成人肝移植术中心脏骤停：美国 7 家学术中心的发生率和危险因素分析。
Intraoperative Cardiac Arrest During Adult Liver Transplantation: Incidence and Risk Factor Analysis From 7 Academic Centers in the United States.
机构信息
From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York.
Department of Anesthesiology, Hospital for Special Surgery, New York City, New York.
出版信息
Anesth Analg. 2021 Jan;132(1):130-139. doi: 10.1213/ANE.0000000000004734.
BACKGROUND
Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks.
METHODS
Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18-80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes.
RESULTS
ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2-4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI) <20 (odds ratio [OR]: 2.04, 95% CI, 1.05-3.98; P = .0386), BMI ≥40 (2.16 [1.12-4.19]; P = .022), Model for End-Stage Liver Disease (MELD) score: (MELD 30-39: 1.75 [1.09-2.79], P = .02; MELD ≥40: 2.73 [1.53-4.85], P = .001), postreperfusion syndrome (PRS) (3.83 [2.75-5.34], P < .001), living donors (2.13 [1.16-3.89], P = .014), and reoperation (1.87 [1.13-3.11], P = .015). Overall 30-day and 1-year mortality were 4.18% and 11.0%, respectively. After ICA, 30-day and 1-year mortality were 43.9% and 52%, respectively, compared to 2.6% and 9.3% without ICA.
CONCLUSIONS
We established a 3.7% incidence of ICA and a 1.2% incidence of intraoperative mortality in liver transplantation and confirmed previously identified risk factors for ICA including BMI, MELD score, PRS, and reoperation and identified new risk factors including living donor and length of surgery in this multicenter retrospective cohort. ICA, while rare, is associated with high intraoperative mortality, and future research must focus on therapy to reduce the incidence of ICA.
背景
术中心脏骤停（intraoperative cardiac arrest，ICA）的发生率据报道为每 10000 例麻醉 1 例，但在原位肝移植（orthotopic liver transplantation，OLT）中估计发病率要高得多。OLT 中 ICA 的单中心研究受到样本量小的限制，无法对风险进行多变量回归分析。
方法
我们利用来自 7 个学术医疗中心的数据，对 2000 年至 2017 年间 5296 例成年肝移植受者（18-80 岁）进行了回顾性、观察性研究，以确定 ICA 的发生率、相关危险因素和结局。
结果
196 例（3.7% 95%置信区间 [CI]，3.2-4.2）发生了 ICA，62 例（1.2%）死亡。经历 ICA 的患者术中死亡率为 31.6%。在多变量广义线性混合模型中，ICA 与体重指数（body mass index，BMI）<20（比值比 [odds ratio，OR]：2.04，95%CI，1.05-3.98；P=.0386）、BMI≥40（2.16 [1.12-4.19]；P=.022）、终末期肝病模型（Model for End-Stage Liver Disease，MELD）评分：（MELD 30-39：1.75 [1.09-2.79]，P=.02；MELD≥40：2.73 [1.53-4.85]，P<.001）、再灌注后综合征（postreperfusion syndrome，PRS）（3.83 [2.75-5.34]，P<.001）、活体供体（living donors，2.13 [1.16-3.89]，P=.014）和再次手术（reoperation，1.87 [1.13-3.11]，P=.015）相关。总体 30 天和 1 年死亡率分别为 4.18%和 11.0%。发生 ICA 后，30 天和 1 年死亡率分别为 43.9%和 52%，而无 ICA 时分别为 2.6%和 9.3%。
结论
我们确定了肝移植中 ICA 的发生率为 3.7%，术中死亡率为 1.2%，并证实了之前确定的 ICA 危险因素，包括 BMI、MELD 评分、PRS 和再次手术，以及新的危险因素，包括活体供体和手术时间，这是一项多中心回顾性队列研究。虽然 ICA 很罕见，但它与术中高死亡率相关，未来的研究必须集中在减少 ICA 发生率的治疗方法上。
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