动脉调转术术前护理变异与大动脉转位患者结局的相关性。
Association Between Variation in Preoperative Care Before Arterial Switch Operation and Outcomes in Patients With Transposition of the Great Arteries.
机构信息
Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania.
Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.).
出版信息
Circulation. 2018 Nov 6;138(19):2119-2129. doi: 10.1161/CIRCULATIONAHA.118.036145.
BACKGROUND
The arterial switch operation (ASO) is the gold standard operative correction of neonates with transposition of the great arteries and intact ventricular septum, with excellent operative survival. The associations between patient and surgeon characteristics and outcomes are well understood, but the associations between variation in preoperative care and outcomes are less well studied.
METHODS
A multicenter retrospective cohort study of infants undergoing neonatal ASO between January 2010 and September 2015 at hospitals contributing data to the Pediatric Health Information Systems database was performed. The association between preoperative care (timing of ASO, preoperative use of balloon atrial septostomy, prostaglandin infusion, mechanical ventilation, and vasoactive agents) and operative outcomes (mortality, length of stay, and cost) was studied with multivariable mixed-effects models.
RESULTS
Over the study period, 2159 neonates at 40 hospitals were evaluated. Perioperative mortality was 2.8%. Between hospitals, the use of adjuvant therapies and timing of ASO varied broadly. At the subject level, older age at ASO was associated with higher mortality risk (age >6 days: odds ratio, 1.90; 95% CI, 1.11-3.26; P=0.02), cost, and length of stay. Receipt of a balloon atrial septostomy was associated with lower mortality risk (odds ratio, 0.32; 95% CI, 0.17-0.59; P<0.001), cost, and length of stay. Later hospital median age at ASO was associated with higher odds of mortality (odds ratio, 1.15 per day; 95% CI, 1.02-1.29; P=0.03), longer length of stay ( P<0.004), and higher cost ( P<0.001). Other hospital factors were not independently associated with the outcomes of interest.
CONCLUSIONS
There was significant variation in preoperative care between hospitals. Some potentially modifiable aspects of perioperative care (timing of ASO and septostomy) were significantly associated with mortality, length of stay, and cost. Further research on the perioperative care of neonates is necessary to determine whether modifying practice on the basis of the observed associations translates into improved outcomes.
背景
动脉调转术（ASO）是治疗完全性大动脉转位伴室间隔完整的新生儿的金标准手术矫正方法，手术存活率非常高。患者和外科医生特征与手术结果之间的关联已得到充分了解，但术前护理与手术结果之间的关联研究较少。
方法
本研究对 2010 年 1 月至 2015 年 9 月期间在参与儿科健康信息系统数据库的医院接受新生儿 ASO 的患儿进行了一项多中心回顾性队列研究。使用多变量混合效应模型研究了术前护理（ASO 时机、术前使用球囊房间隔造口术、前列腺素输注、机械通气和血管活性药物）与手术结果（死亡率、住院时间和费用）之间的关系。
结果
在研究期间，评估了 40 家医院的 2159 例新生儿。围手术期死亡率为 2.8%。各医院之间，辅助治疗和 ASO 时机的使用差异很大。在个体水平上，ASO 时的年龄越大，死亡率风险越高（年龄>6 天：比值比，1.90；95%置信区间，1.11-3.26；P=0.02），费用和住院时间也越长。接受球囊房间隔造口术与死亡率降低相关（比值比，0.32；95%置信区间，0.17-0.59；P<0.001），费用和住院时间也更短。ASO 时医院中位年龄较晚与死亡率升高相关（比值比，每天增加 1.15；95%置信区间，1.02-1.29；P=0.03），住院时间延长（P<0.004），费用增加（P<0.001）。其他医院因素与研究结果无显著关联。
结论
各医院之间术前护理存在显著差异。一些潜在可改变的围手术期护理方面（ASO 时机和房间隔造口术）与死亡率、住院时间和费用显著相关。需要进一步研究新生儿的围手术期护理，以确定根据观察到的关联改变实践是否能改善结果。
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