手术室头高足低位的评估及其对术后低氧血症、误吸和住院时间的影响：对连续患者的回顾性研究

Evaluation of operating room reverse Trendelenburg positioning and its effect on postoperative hypoxemia, aspiration, and length of stay: a retrospective study of consecutive patients.

作者信息

Michael Dunham C, Hileman Barbara M, Hutchinson Amy E, Antonaccio Tamara, Chance Elisha A, Huang Gregory S, Szmaj Gregory, Calabro Kristen, Bishop Cynthia, Schrickel Tyson T

机构信息

Trauma, Critical Care, and General Surgery Services, St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44501 USA.

Trauma and Neurosciences Research Department, St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44501 USA.

出版信息

Perioper Med (Lond). 2017 Aug 22;6:10. doi: 10.1186/s13741-017-0067-2. eCollection 2017.

DOI:10.1186/s13741-017-0067-2

PMID:28852473

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC5568354/

Abstract

BACKGROUND

In 2014, this group published an investigation of surgical patients from 2012 who had substantial rates of postoperative hypoxemia (POH) and perioperative pulmonary aspiration (POPA). Therefore, we investigated whether intraoperative reverse Trendelenburg positioning (RTP) decreases POH and POPA rates.

METHODS

Consecutive ASA I-IV surgical patients who had preoperative pulmonary stability requiring general anesthesia with endotracheal intubation were evaluated. Using pulse oximetry, hypoxemia was documented intraoperatively and during the 48 h following PACU discharge. POPA was the presence of a pulmonary infiltrate with hypoxemia. In early 2015, a multifaceted effort was undertaken to enhance anesthesiologist and operating nurse awareness of RTP to potentially decrease POH and POPA rates. Analyses included (1) combining 2012 and 2015 cohorts to assess risk conditions, (2) comparing post-campaign 2015 (increased RTP) and 2012 cohorts, and (3) comparing 2015 patients with audit-documented RTP during surgery to the other 2015 patients.

RESULTS

Combining the 500 patients in 2012 with the 1000 in 2015 showed that POH had increased mortality (2.3%), compared to no POH (0.2%; = 0.0004). POH had increased postoperative length of stay (LOS) (4.6 days), compared to no POH (2.0 days; < 0.0001). POPA had increased mortality (7.7%) and LOS (8.8 days), compared to no POPA (0.4%; = 0.0004; 2.3 days; < 0.0001). Open aortic, cranial, laparotomy, and neck procedures had greater POH (41.3%) and LOS (4.0 days), compared to other procedures (16.3%; < 0.0001; 2.2 days; < 0.0001). Glycopyrrolate on induction had lower POH (17.4%) and LOS (1.9 days), compared to no glycopyrrolate (21.6%; = 0.0849; 2.7 days; < 0.0001). POH was lower (18.1%) in 2015, than in 2012 (25.6%; = 0.0007). POPA was lower with RTP in 2015 (0.6%), than in 2012 (4.8%; = 0.0088). For the 2015 patients, LOS was lower with audit-documented RTP (2.2 days), compared to other patients (2.7 days; = 0.0246).

CONCLUSIONS

These findings are only hypothesis-generating. A randomized clinical trial is needed to confirm whether RTP has an inverse association with POH and POPA, and if RTP and glycopyrrolate are associated with improved outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02984657.

摘要

背景

2014年，该研究团队发表了一项针对2012年手术患者的调查，这些患者术后低氧血症（POH）和围手术期肺误吸（POPA）发生率较高。因此，我们研究了术中头低脚高位反向体位（RTP）是否能降低POH和POPA的发生率。

方法

对连续的ASA I-IV级手术患者进行评估，这些患者术前肺部功能稳定，需要全身麻醉并气管插管。使用脉搏血氧饱和度仪，记录术中及术后麻醉恢复室（PACU）出院后48小时内的低氧血症情况。POPA定义为存在伴有低氧血症的肺部浸润。2015年初，我们开展了多方面的工作，以提高麻醉医生和手术护士对RTP的认识，从而有可能降低POH和POPA的发生率。分析包括：（1）合并2012年和2015年的队列以评估风险状况；（2）比较2015年活动后（增加RTP使用）和2012年的队列；（3）比较2015年手术中有审计记录RTP的患者与其他2015年患者。

结果

将2012年的500例患者与2015年的1000例患者合并分析显示，与无POH的患者（0.2%；P = 0.0004）相比，POH患者的死亡率增加（2.3%）。与无POH的患者（2.0天；P < 0.0001）相比，POH患者的术后住院时间（LOS）增加（4.6天）。与无POPA的患者（0.4%；P = 0.0004；2.3天；P < 0.0001）相比，POPA患者的死亡率增加（7.7%），LOS增加（8.8天）。与其他手术（16.3%；P < 0.0001；2.2天；P < 0.0001）相比，开放性主动脉、颅脑、剖腹和颈部手术的POH发生率更高（41.3%），LOS更长（4.0天）。诱导时使用格隆溴铵的患者POH发生率较低（17.4%），LOS较短（1.9天），而未使用格隆溴铵患者的POH发生率为21.6%（P = 0.0849；2.7天；P < 0.0001）。2015年的POH发生率（18.1%）低于2012年（25.6%；P = 0.0007）。2015年采用RTP的患者POPA发生率（0.6%）低于2012年（4.8%；P = 0.0088）。对于2015年的患者，有审计记录RTP的患者LOS较短（2.2天），而其他患者为2.7天（P = 0.0246）。