夜间手术对术后死亡率和发病率的影响：一项多中心队列研究。

Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study.

机构信息

Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.

出版信息

BMJ Qual Saf. 2021 Aug;30(8):678-688. doi: 10.1136/bmjqs-2020-011684. Epub 2020 Oct 7.

DOI:10.1136/bmjqs-2020-011684

PMID:33028658

Abstract

BACKGROUND

Surgery at night (incision time 17:00 to 07:00 hours) may lead to increased postoperative mortality and morbidity. Mechanisms explaining this association remain unclear.

METHODS

We conducted a multicentre retrospective cohort study of adult patients undergoing non-cardiac surgery with general anaesthesia at two major, competing tertiary care hospital networks. In primary analysis, we imputed missing data and determined whether exposure to night surgery affects 30-day mortality using a mixed-effects model with individual anaesthesia and surgical providers as random effects. Secondary outcomes were 30-day morbidity and the mediating effect of blood transfusion rates and provider handovers on the effect of night surgery on outcomes. We further tested for effect modification by surgical setting.

RESULTS

Among 350 235 participants in the primary imputed cohort, the mortality rate was 0.9% (n=2804/322 327) after day and 3.4% (n=940/27 908) after night surgery. Night surgery was associated with an increased risk of mortality (OR 1.26, 95% CI 1.15 to 1.38, p<0.001). In secondary analyses, night surgery was associated with increased morbidity (OR 1.41, 95% CI 1.33 to 1.48, p<0.001). The proportion of patients receiving intraoperative blood transfusion and anaesthesia handovers were higher during night-time, mediating 9.4% (95% CI 4.7% to 14.2%, p<0.001) of the effect of night surgery on 30-day mortality and 8.4% (95% CI 6.7% to 10.1%, p<0.001) of its effect on morbidity. The primary association was modified by the surgical setting (p-for-interaction<0.001), towards a greater effect in patients undergoing ambulatory/same-day surgery (OR 1.81, 95% CI 1.39 to 2.35) compared with inpatients (OR 1.17, 95% CI 1.02 to 1.34).

CONCLUSIONS

Night surgery was associated with an increased risk of postoperative mortality and morbidity. The effect was independent of case acuity and was mediated by potentially preventable factors: higher blood transfusion rates and more frequent provider handovers.

摘要

背景

夜间手术（17:00 至 07:00 时间段进行的手术）可能导致术后死亡率和发病率增加。但解释这种关联的机制仍不清楚。

方法

我们对在两家主要的、竞争激烈的三级护理医院网络中接受全身麻醉的非心脏手术的成年患者进行了一项多中心回顾性队列研究。在主要分析中，我们对缺失数据进行了插补，并使用包含个体麻醉和外科医生的混合效应模型来确定夜间手术是否会影响 30 天死亡率，其中将个体麻醉和外科医生作为随机效应。次要结果是 30 天发病率以及输血率和医生交接对夜间手术对结果影响的中介作用。我们还进一步测试了手术环境的调节作用。

结果

在主要插补队列的 350235 名参与者中，日间手术后的死亡率为 0.9%（2804/322327），夜间手术后的死亡率为 3.4%（940/27908）。夜间手术与死亡率升高相关（OR 1.26，95%CI 1.15 至 1.38，p<0.001）。在次要分析中，夜间手术与发病率升高相关（OR 1.41，95%CI 1.33 至 1.48，p<0.001）。夜间手术期间接受术中输血和麻醉交接的患者比例较高，介导了夜间手术对 30 天死亡率的 9.4%（95%CI 4.7% 至 14.2%，p<0.001）和对发病率的 8.4%（95%CI 6.7% 至 10.1%，p<0.001）的影响。主要关联受到手术环境的调节（p 交互<0.001），在日间/当天手术患者中（OR 1.81，95%CI 1.39 至 2.35），该关联大于住院患者（OR 1.17，95%CI 1.02 至 1.34）。