高危患者腰椎手术中脊椎麻醉与全身麻醉：围手术期血液动力学稳定性、并发症和成本。

Spinal versus general anesthesia for lumbar spine surgery in high risk patients: Perioperative hemodynamic stability, complications and costs.

机构信息

Department of Orthopedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.

Division of Anesthesiology, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.

出版信息

J Clin Anesth. 2018 May;46:3-7. doi: 10.1016/j.jclinane.2018.01.004. Epub 2018 Jan 6.

DOI:10.1016/j.jclinane.2018.01.004

PMID:29316474

Abstract

OBJECTIVE

More stable perioperative hemodynamic conditions, lower costs and a lower perioperative complication rate were reported in young healthy patients undergoing lumbar spine surgery in spinal anesthesia (SA) compared to general anesthesia (GA). However, the benefits of SA in high risk patients (ASA≥II suffering from cardiovascular and/or pulmonary pathologies) undergoing this surgery are unclear. Our objective was to analyze whether SA leads to an improved perioperative hemodynamic stability and to a more cost-effective management compared to GA in high risk patients undergoing this surgery.

METHODS

In a retrospective analysis 146 ASA II-III patients who underwent lumbar spine surgery in SA were compared with 292 ASA I-III patients who were operated in GA between 2000 and 2014. Hemodynamic effects, hospitalization times, complications, and costs according to the Swiss billing system were assessed. The data extraction was conducted according to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative for cohort studies.

RESULTS

The patients in the SA group were older (75years (±9.6) vs 69 (±11.5), p<0.001), had a lower BMI (25.8kg/m2 (±4.8) vs 27.2 (±4.7), p=0.003) and showed a higher ASA score (3 vs 2, p<0.001). However, SA was associated with significantly better perioperative hemodynamic stability with less need for intraoperative vasopressors (15% vs 57%, p<0.001), volume supplementation (1113ml ±458 vs 1589±644, p<0.001) and transfusions (0% vs 4%, p<0.001). Additionally, the number of hypotension episodes was lower in the SA group (15% vs 47%, p<0.001). Furthermore, the SA group showed a significantly shorter duration of surgery (70min (±1.2) vs 91 (±41), p<0.001), lower postoperative nausea and vomiting (PONV) (4% vs 28%, p<0.001) and pain in the post anesthesia care unit (PACU) (visual analogue scale (VAS) 2.3 (±1.1) vs 0.8 (±0.8), p<0.001), whereas pain after 24h did not differ (VAS 0.9 (±1) vs 0.8 (±1.1), p=ns). The postoperative complication (7% vs 5%, p=0.286) and revision rates (4% vs 5%, p=0.626) were similar in both groups. Total costs (United States Dollars (USD) 6377 (±2332) vs 7018 (±4056), p=0.003) and PACU time were significantly lower in the SA group (35min (±12) vs 109 (±173), p<0.001).

CONCLUSIONS

Lumbar spine surgery in cardiovascular high risk patients with SA is safe, allows good perioperative hemodynamic stability and might lead to lower health care costs. Further prospective studies are needed to confirm these findings.

摘要

目的

与全身麻醉（GA）相比，年轻健康患者在接受腰椎手术时，椎管内麻醉（SA）可使围手术期血流动力学更稳定，降低成本，减少围手术期并发症发生率。然而，对于接受这种手术的高危患者（ASA≥II 级，患有心血管和/或肺部疾病），SA 的益处尚不清楚。我们的目的是分析在接受这种手术的高危患者中，与 GA 相比，SA 是否会导致围手术期血流动力学更稳定，并且更具成本效益。

方法

回顾性分析了 2000 年至 2014 年间接受 SA 的 146 例 ASA II-III 级患者和接受 GA 的 292 例 ASA I-III 级患者。评估了围手术期的血流动力学效应、住院时间、并发症和按瑞士计费系统计算的成本。根据观察性研究的 STROBE 倡议（Strengthening the Reporting of Observational Studies in Epidemiology），进行了数据提取。

结果

SA 组患者年龄较大（75 岁（±9.6）vs 69 岁（±11.5），p<0.001），BMI 较低（25.8kg/m2（±4.8）vs 27.2（±4.7），p=0.003），ASA 评分较高（3 级 vs 2 级，p<0.001）。然而，SA 与围手术期血流动力学更稳定显著相关，术中需要使用血管加压药的比例较低（15% vs 57%，p<0.001），需要补充的液体量较少（1113ml±458 vs 1589±644，p<0.001），输血也较少（0% vs 4%，p<0.001）。此外，SA 组低血压发作的次数也较少（15% vs 47%，p<0.001）。此外，SA 组的手术时间明显缩短（70min（±1.2）vs 91min（±41），p<0.001），术后恶心和呕吐（PONV）（4% vs 28%，p<0.001）和麻醉后护理病房（PACU）疼痛（视觉模拟评分（VAS）2.3（±1.1）vs 0.8（±0.8），p<0.001）均较低，而 24 小时后的疼痛无差异（VAS 0.9（±1）vs 0.8（±1.1），p=ns）。两组的术后并发症（7% vs 5%，p=0.286）和翻修率（4% vs 5%，p=0.626）相似。SA 组的总费用（美元 6377（±2332）vs 7018（±4056），p=0.003）和 PACU 时间明显较低（35min（±12）vs 109min（±173），p<0.001）。