From the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina.
Department of Anesthesiology and Pediatrics, Duke University School of Medicine, Durham, North Carolina.
Anesth Analg. 2019 Oct;129(4):1061-1068. doi: 10.1213/ANE.0000000000003594.
In adults undergoing cardiopulmonary bypass surgery, oral intubation is typically preferred over nasal intubation due to reduced risk of sinusitis and infection. In children, nasal intubation is more common and sometimes preferred due to perceived benefits of less postoperative sedation and a lower risk for accidental extubation. This study sought to describe the practice of nasal intubation in the pediatric population undergoing cardiopulmonary bypass surgery and assess the risks/benefits of a nasal route against an oral one.
Patients <18 years of age in the Society of Thoracic Surgeons Congenital Heart Surgery Database between January 2010 and December 2015 were included. Patients with a preoperative endotracheal tube, tracheostomy, or known airway anomalies were excluded. Multivariable modeling was used to assess the association between route of tracheal intubation and a composite measure of infection risk (wound infection, mediastinitis, septicemia, pneumonia, and endocarditis). Covariates were included to adjust for important patient characteristics (eg, weight, age, comorbidities), case complexity, and center effects. Secondary outcomes included length of intubation, hospital length of stay, and airway complications including accidental extubations. We also performed a subanalysis in children <12 months of age in high-volume centers (>100 cases/y) examining how infection risk may change with age at the time of surgery.
Nasal intubation was used in 41% of operations in neonates, 38% in infants, 15% in school-aged children, and 2% in adolescents. Nasal intubation appeared protective for accidental extubation only in neonates (P = .02). Multivariable analysis in infants and neonates showed that the nasal route of intubation was not associated with the infection composite (relative risk [RR], 0.84; 95% CI, 0.59-1.18) or a shorter length of stay (RR, 0.992; 95% CI, 0.947-1.039), but was associated with a shorter intubation length (RR, 0.929; 95% CI, 0.869-0.992). Restricting to high-volume centers showed a significant interaction between age and intubation route with a risk change for infection occurring between approximately 6-12 months of age (P = .003).
While older children undergoing nasal intubation trend similar to the adult population with an increased risk of infection, nasal intubation in neonates and infants does not appear to carry a similar risk. Nasal intubation in neonates and infants may also be associated with a shorter intubation length but not a shorter length of stay. Prospective studies are required to better understand these complex associations.
在接受心肺旁路手术的成年人中，由于鼻窦炎和感染风险降低，通常首选经口插管而非经鼻插管。在儿童中，由于术后镇静作用减少和意外拔管风险较低，经鼻插管更为常见，有时也更受欢迎。本研究旨在描述在接受心肺旁路手术的儿科人群中经鼻插管的情况，并评估经鼻途径相对于经口途径的风险/益处。
纳入 2010 年 1 月至 2015 年 12 月期间胸外科医师学会先天性心脏病数据库中年龄<18 岁的患者。排除术前有气管内导管、气管造口术或已知气道异常的患者。多变量建模用于评估气管插管途径与感染风险综合指标（伤口感染、纵隔炎、败血症、肺炎和心内膜炎）之间的关联。纳入协变量以调整重要的患者特征（如体重、年龄、合并症）、病例复杂性和中心效应。次要结局包括插管时间、住院时间和包括意外拔管在内的气道并发症。我们还在高容量中心（>100 例/年）中对<12 个月大的儿童进行了亚分析，研究手术时的年龄如何改变感染风险。
鼻插管在新生儿中占手术的 41%，在婴儿中占 38%，在学龄儿童中占 15%，在青少年中占 2%。鼻插管似乎仅对新生儿意外拔管有保护作用（P=.02）。婴儿和新生儿的多变量分析显示，经鼻插管途径与感染综合指标（相对风险 [RR]，0.84；95%置信区间，0.59-1.18）或住院时间缩短（RR，0.992；95%置信区间，0.947-1.039）无关，但与插管时间缩短有关（RR，0.929；95%置信区间，0.869-0.992）。限制在高容量中心显示年龄与插管途径之间存在显著交互作用，大约在 6-12 个月龄时感染风险发生变化（P=.003）。
虽然接受经鼻插管的大龄儿童的感染风险趋势与成人相似，但风险增加，而新生儿和婴儿的经鼻插管似乎没有带来类似的风险。新生儿和婴儿的经鼻插管可能与插管时间缩短有关，但与住院时间缩短无关。需要前瞻性研究来更好地理解这些复杂的关联。
