University of Glasgow Academic Unit of Anaesthesia, Pain and Critical Care Medicine, Glasgow, UK.
London School of Hygiene and Tropical Medicine, London, UK.
Anaesthesia. 2019 Sep;74(9):1121-1129. doi: 10.1111/anae.14649. Epub 2019 Apr 8.
Unplanned intensive care admission is a devastating complication of lung resection and is associated with significantly increased mortality. We carried out a two-year retrospective national multicentre cohort study to investigate the influence of anaesthetic and analgesic technique on the need for unplanned postoperative intensive care admission. All patients undergoing lung resection surgery in 16 thoracic surgical centres in the UK in the calendar years 2013 and 2014 were included. We defined critical care admission as the unplanned need for either tracheal intubation and mechanical ventilation or renal replacement therapy, and sought an association between mode of anaesthesia (total intravenous anaesthesia vs. volatile) and analgesic technique (epidural vs. paravertebral) and need for intensive care admission. A total of 253 out of 11,208 patients undergoing lung resection in the study period had an unplanned admission to intensive care in the postoperative period, giving an incidence of intensive care unit admission of 2.3% (95%CI 2.0-2.6%). Patients who had an unplanned admission to intensive care unit had a higher mortality (29.00% vs. 0.03%, p < 0.001), and hospital length of stay was increased (26 vs. 6 days, p < 0.001). Across univariate, complete case and multiple imputation (multivariate) models, there was a strong and significant effect of both anaesthetic and analgesic technique on the need for intensive care admission. Patients receiving total intravenous anaesthesia (OR 0.50 (95%CI 0.34-0.70)), and patients receiving epidural analgesia (OR 0.56 (95%CI 0.41-0.78)) were less likely to have an unplanned admission to intensive care after thoracic surgery. This large retrospective study suggests a significant effect of both anaesthetic and analgesic technique on outcome in patients undergoing lung resection. We must emphasise that the observed association does not directly imply causation, and suggest that well-conducted, large-scale randomised controlled trials are required to address these fundamental questions.
计划性重症监护病房入院是肺切除术的一种毁灭性并发症，与死亡率显著增加有关。我们进行了一项为期两年的回顾性全国多中心队列研究，以调查麻醉和镇痛技术对术后计划外重症监护病房入院的影响。所有在英国 16 个胸外科中心于 2013 年和 2014 年接受肺切除术的患者均纳入研究。我们将重症监护病房入院定义为计划外需要气管插管和机械通气或肾脏替代治疗，并探讨麻醉方式（全凭静脉麻醉与挥发性麻醉）和镇痛技术（硬膜外与椎旁）与重症监护病房入院之间的关联。在研究期间，共有 253 例（2.3%[95%CI 2.0-2.6%]）计划外接受肺切除术的患者在术后期间被转入重症监护病房。转入重症监护病房的患者死亡率更高（29.00%比 0.03%，p<0.001），住院时间延长（26 天比 6 天，p<0.001）。在单变量、完全病例和多重插补（多变量）模型中，麻醉和镇痛技术对重症监护病房入院的需求均有强烈且显著的影响。接受全凭静脉麻醉的患者（OR 0.50[95%CI 0.34-0.70]）和接受硬膜外镇痛的患者（OR 0.56[95%CI 0.41-0.78]）在接受胸部手术后计划外入住重症监护病房的可能性较小。这项大型回顾性研究表明，麻醉和镇痛技术对接受肺切除术的患者的结局有显著影响。我们必须强调，观察到的关联并不直接意味着因果关系，并建议需要进行精心设计的大规模随机对照试验来解决这些基本问题。
