Mandell M S, Lockrem J, Kelley S D
Department of Anesthesiology, University of Colorado Health Sciences Center, Denver 80262, USA.
Anesth Analg. 1997 Feb;84(2):249-53. doi: 10.1097/00000539-199702000-00003.
Early tracheal extubation has been safely performed after large operative procedures, questioning the need for routine postoperative ventilation. Because immediate postoperative tracheal extubation of liver transplantation patients has not been previously reported, we performed preliminary studies at two institutions to evaluate potential risk and cost benefit. At the University of Colorado (UC), extubation criteria were derived from the retrospective analysis of patients who were ventilated less than 8 h and experienced an intensive care unit stay less than 48 h in 1994. Preoperative criteria for age, severity of illness, and absence of encephalopathy and coexistent disease were used in a subsequent prospective study in 1995. Donor graft function, blood use, hemodynamic stability, and alveolar-arterial oxygen gradient served as intraoperative criteria. Cost of intensive care services was compared for the 1994 ventilated patients and the 1995 patients whose tracheas were extubated immediately postoperatively. At the second institution, University of California at San Francisco (UCSF), patients were tracheally extubated immediately postoperatively, based on clinical judgment by the anesthesiologist. A retrospective analysis was then completed. Sixteen of 67 patients at UC and 25 of 106 patients at UCSF were tracheally extubated. There were no reintubations at UC, while 2 of 25 patients at UCSF required reintubation. Prior encephalopathy, poor donor liver function, and an increased alveolar-arterial oxygen gradient were present in the patients who suffered perioperative respiratory failure. Seventeen of 25 patients at UCSF did not have all criteria used at UC but did not require reintubation. Wider limits on age and severity of illness did not preclude successful extubation. Cost analysis at UC showed a significant reduction in intensive care unit services and associated cost for extubated patients. We conclude that immediate postoperative tracheal extubation of selected liver transplantation patients is safe and cost effective.
在大型手术操作后已安全实施早期气管拔管，这对术后常规通气的必要性提出了质疑。由于此前尚未有关于肝移植患者术后立即气管拔管的报道，我们在两家机构进行了初步研究，以评估潜在风险和成本效益。在科罗拉多大学（UC），拔管标准源自对1994年通气时间少于8小时且重症监护病房停留时间少于48小时的患者的回顾性分析。在随后于1995年进行的前瞻性研究中，采用了术前年龄、疾病严重程度、无脑病及并存疾病的标准。供体移植物功能、血液使用情况、血流动力学稳定性及肺泡-动脉氧分压差作为术中标准。对1994年通气患者与1995年术后立即气管拔管患者的重症监护服务成本进行了比较。在第二家机构，即加利福尼亚大学旧金山分校（UCSF），患者根据麻醉医生的临床判断在术后立即进行气管拔管。然后完成了一项回顾性分析。UC的67例患者中有16例、UCSF的106例患者中有25例进行了气管拔管。UC没有再次插管的情况，而UCSF的25例患者中有2例需要再次插管。围手术期呼吸衰竭患者存在既往脑病、供体肝功能差及肺泡-动脉氧分压差增加的情况。UCSF的25例患者中有17例未满足UC所采用的所有标准，但无需再次插管。对年龄和疾病严重程度放宽限制并不妨碍成功拔管。UC的成本分析显示，拔管患者的重症监护服务及相关成本显著降低。我们得出结论，对部分肝移植患者术后立即气管拔管是安全且具有成本效益的。
