From the Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee.
Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
Anesth Analg. 2023 Mar 1;136(3):524-531. doi: 10.1213/ANE.0000000000006205. Epub 2022 Oct 13.
Patients undergoing surgery with general anesthesia and endotracheal intubation are ideally extubated upon case completion, as prolonged postoperative mechanical ventilation (PPMV) has been associated with poor outcomes. However, some patients require PPMV for surgical reasons, such as airway compromise, while others remain intubated at the discretion of the anesthesia provider. Incidence and risk factors for discretionary PPMV (DPPMV) have been described in individual surgical subspecialties and intensive care unit (ICU) populations, but are relatively understudied in a broad surgical cohort. The present study seeks to fill this gap and identify the perioperative risk factors that predict DPPMV.
After obtaining institutional review board (IRB) exemption, existing electronic health record databases at our large referral center were retrospectively queried for adult surgeries performed between January 2018 and December 2020 with general anesthesia, endotracheal intubation, and by surgical services that do not routinely leave patients intubated for surgical reasons. Patients who arrived to the ICU intubated after surgery were identified as experiencing DPPMV. Selection of candidate risk factors was performed with LASSO-regularized logistic regression, and surviving variables were used to generate a multivariable logistic regression model of DPPMV risk.
A total of 32,915 cases met inclusion criteria, of which 415 (1.26%) experienced DPPMV. Compared to extubated patients, those with DPPMV were more likely to have undergone emergency surgery (42.9% versus 3.4%; P < .001), surgery during an existing ICU stay (30.8% versus 2.8%; P < 0.001), and have 20 of the 31 elixhauser comorbidities ( P < .05 for each comparison), among other differences. A risk model with 12 variables, including American Society of Anesthesiologists (ASA) physical classification status, emergency surgery designation, four Elixhauser comorbidities, surgery during an existing ICU stay, surgery duration, estimated number of intraoperative handoffs, and vasopressor, sodium bicarbonate, and albuterol administration, yielded an area under the receiver operating characteristic curve of 0.97 (95% confidence interval, 0.96-0.97) for prediction of DPPMV.
DPPMV was uncommon in this broad surgical cohort but could be accurately predicted using readily available patient-specific and operative factors. These results may be useful for preoperative risk stratification, postoperative resource allocation, and clinical trial planning.
接受全身麻醉和气管插管手术的患者理想情况下应在手术完成后拔管，因为术后长时间机械通气（PPMV）与不良预后有关。然而，一些患者因气道受损等手术原因需要 PPMV，而其他患者则由麻醉提供者决定继续插管。选择性 PPMV（DPPMV）的发生率和危险因素已在个别外科亚专科和重症监护病房（ICU）人群中进行了描述，但在广泛的外科患者群体中研究相对较少。本研究旨在填补这一空白，并确定预测 DPPMV 的围手术期危险因素。
在获得机构审查委员会（IRB）豁免后，我们对大型转诊中心现有的电子健康记录数据库进行了回顾性查询，以获取 2018 年 1 月至 2020 年 12 月期间接受全身麻醉、气管插管和不由外科服务常规因手术原因插管的成人手术。术后被送往 ICU 插管的患者被确定为经历了 DPPMV。候选风险因素的选择采用 LASSO-正则化逻辑回归进行，存活变量用于生成 DPPMV 风险的多变量逻辑回归模型。
共有 32915 例符合纳入标准，其中 415 例（1.26%）经历了 DPPMV。与拔管患者相比，DPPMV 患者更有可能接受急诊手术（42.9%与 3.4%；P<0.001）、在现有 ICU 住院期间接受手术（30.8%与 2.8%；P<0.001）以及有 20 种 31 种 elixhauser 合并症（每项比较均 P<0.05），以及其他差异。一个包含 12 个变量的风险模型，包括美国麻醉师协会（ASA）身体分类状态、急诊手术指定、4 种 elixhauser 合并症、现有 ICU 住院期间手术、手术持续时间、估计术中交接次数以及血管加压药、碳酸氢钠和沙丁胺醇的使用，用于预测 DPPMV，其接受者操作特征曲线下面积为 0.97（95%置信区间，0.96-0.97）。
在这个广泛的外科患者群体中，DPPMV 并不常见，但可以使用现成的患者特定和手术因素准确预测。这些结果可能有助于术前风险分层、术后资源分配和临床试验计划。
