肝硬化患者内镜检查中麻醉服务相关并发症。
Complications Associated With Anesthesia Services in Endoscopic Procedures Among Patients With Cirrhosis.
机构信息
Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina (UNC) Health Care, Chapel Hill, NC.
Department of Anesthesiology, University of North Carolina (UNC) Health Care, Chapel Hill, NC.
出版信息
Hepatology. 2020 Dec;72(6):2109-2118. doi: 10.1002/hep.31224.
BACKGROUND AND AIMS
Anesthesia services for endoscopic procedures have proliferated with the promise of increased comfort and safety. Cirrhosis patients are higher risk for sedation, yet limited data are available describing anesthesia complications in this population.
APPROACH AND RESULTS
This cross-sectional study utilized the National Anesthesia Clinical Outcomes Registry, a multicenter quality-improvement database from 2010 to 2015. Patients with cirrhosis undergoing an endoscopy were identified by International Classification of Diseases, Ninth Revision (ICD-9)/Current Procedures Terminology (CPT) codes. The outcome of interest was serious anesthesia-related complication defined as cardiovascular, respiratory, neurological, drug related, patient injury, death, or unexpected admission. A mixed-effects multivariate logistic regression model determined odds ratios (ORs) between variables and serious complications, adjusting for potential confounders. In total, 9,007 endoscopic procedures were performed among patients with cirrhosis; 92% were esophagogastroduodenoscopies. The majority (81%) were American Society of Anesthesiologists (ASA) class ≥3, and 72% had a history of hepatic encephalopathy, ascites, varices, hepatorenal syndrome, or spontaneous bacterial peritonitis identified by ICD-9/CPT codes. In total, 87 complications were reported, 33 of which were serious. Frequency of serious complications was 0.4% or 378.6 per 100,000 procedures (95% confidence interval [CI], 260.8, 531.3). The majority of serious complications were cardiovascular (21 of 33), including 15 cardiac arrests. Serious complications were significantly associated with ASA 4/5 (OR, 3.84; 95% CI, 1.09, 13.57) and general anesthesia (OR, 4.71; 95% CI, 1.20, 18.50), adjusting for age, sex, ASA class, anesthesia type, inpatient status, portal hypertension history, and variable complication reporting practices.
CONCLUSIONS
Anesthesia complications among endoscopic procedures in cirrhosis are rare overall. Serious complications were predominantly cardiac and associated with sicker patients undergoing general anesthesia. The complexity of end-stage liver disease may warrant more intensive care during endoscopic procedures, including anesthesia monitoring.
背景和目的
内镜手术的麻醉服务随着舒适度和安全性的提高而迅速发展。肝硬化患者镇静风险更高，但目前可用的数据有限，无法描述该人群中的麻醉并发症。
方法和结果
本横断面研究利用了国家麻醉临床结果登记处（National Anesthesia Clinical Outcomes Registry），这是一个 2010 年至 2015 年的多中心质量改进数据库。通过国际疾病分类第 9 版（ICD-9）/当前操作术语（CPT）代码识别出接受内镜检查的肝硬化患者。感兴趣的结局是严重的麻醉相关并发症，定义为心血管、呼吸、神经、药物相关、患者损伤、死亡或意外入院。混合效应多变量逻辑回归模型确定了变量与严重并发症之间的比值比（OR），并对潜在混杂因素进行了调整。共对 9007 例肝硬化患者的内镜手术进行了分析；其中 92%为食管胃十二指肠镜检查。大多数患者（81%）为美国麻醉医师协会（ASA）分级≥3，72%的患者有肝性脑病、腹水、静脉曲张、肝肾综合征或自发性细菌性腹膜炎的病史，这些信息是通过 ICD-9/CPT 代码识别的。共报告了 87 例并发症，其中 33 例为严重并发症。严重并发症的发生率为 0.4%或每 100000 例 378.6 例（95%置信区间 [CI]，260.8，531.3）。大多数严重并发症为心血管并发症（21/33），包括 15 例心脏骤停。严重并发症与 ASA 4/5（OR，3.84；95%CI，1.09，13.57）和全身麻醉（OR，4.71；95%CI，1.20，18.50）显著相关，调整了年龄、性别、ASA 分级、麻醉类型、住院状态、门静脉高压病史和变量并发症报告实践。
结论
总体而言，肝硬化患者内镜手术中的麻醉并发症很少见。严重并发症主要是心脏相关的，与接受全身麻醉的病情较重的患者有关。终末期肝病的复杂性可能需要在内镜手术期间进行更密集的监护，包括麻醉监测。
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