麻醉方式与下肢创伤性骨折患者术后临床结局的关系
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Anesthesia Type Is Not Associated With Postoperative Complications in the Care of Patients With Lower Extremity Traumatic Fractures
背景与目的
在骨科创伤手术中下肢骨折固定术是常见的且占绝大多数。尽管如此，很少有研究调查在这一手术患者中使用局部麻醉或神经阻滞麻醉(RA/NA)与全身麻醉(GA)对患者临床结局的对比。本研究旨在探讨RA/NA的情况，以及RA/NA与GA相比是否与下肢骨科创伤患者的死亡率和发病率更低相关。
方 法
我们对住院患者进行了倾向性匹配的回顾性队列研究。我们使用美国外科医师学会国家外科质量改进项目（ACS-NSQIP）数据库来确定2011年至2016年期间接受手术矫正的骨科下肢创伤患者。根据麻醉类型将患者分为2组（RA / NA）与GA）。主要结果是30天死亡率。次要结果包括返回手术室，无法脱离呼吸机，插管，肺炎，急性肾损伤，心肌梗塞，输血，静脉血栓栓塞（VTE），尿路感染，败血症，住院时间，手术至出院天数，并发症的数量和意外再入院
结 果
我们确定了18467例接受下肢骨折手术修复的患者。大约9.58%的患者使用RA/NA, 89.9%的患者使用GA作为主要麻醉。经过1:1倾向性匹配，最终队列有3254名患者。我们的分析没有发现两组之间30天死亡率的差异。次要结果也没有显著差异。
结 论
尽管RA/NA具有潜在的优势，但在我们的分析中，对下肢创伤的利用程度较低;RA/NA组患者仅占9.58%，大部分患者接受脊髓麻醉。这可能是由于考虑到这些创伤病例的紧急性，以及有利于外科医生在术后监测神经损伤和骨筋膜综合征或一些后勤因素导致的。RA/NA与GA对下肢骨折患者30天死亡率及术后并发症无显著差异。麻醉的选择是多因素的，可能是由病人和医生在这些手术中的偏好决定的。
原始文献摘要
Brovman EY,et al;Anesthesia Type Is Not Associated With Postoperative Complications in the Care of Patients With Lower Extremity Traumatic Fractures..[J] Anesth Analg 2019;00:1–9.
BACKGROUND:
Lower extremity fracture fixation is commonplace and represents the majority of orthopedic trauma surgical volume. Despite this, few studies have examined the use of regional anesthesia or neuraxial anesthesia (RA/NA) versus general anesthesia (GA) in this surgical population. We aimed to determine the overall rates of RA/NA use and whether RA/NA was associated with lower mortality and morbidity versus GA for patients with lower extremity orthopedic trauma.
Methed:
We conducted a propensity-matched, retrospective cohort study of hospitalized patients. We used the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) dataset to identify patients undergoing surgical correction of low velocity orthopedic lower extremity traumas between 2011 and 2016. Patients were separated into 2 groups based on anesthesia type (RA/NA versus GA). The primary outcome was 30-day mortality. Secondary outcomes included return to the operating room, failure to wean from the ventilator, intubation, pneumonia, acute kidney injury, myocardial infarction, transfusion, venous thromboembolism (VTE), urinary tract infection, sepsis, length of stay, days from operation to discharge, number of complications, and unplanned readmission.
Results：
We identified 18,467 patients undergoing surgical repair of lower extremity fractures. Approximately 9.58% had RA/NA and 89.9% had GA as their primary anesthetic. After 1:1 propensity matching, the final cohort had 3254 patients. Our analysis did not find a difference in 30-day mortality between the 2 groups. There were also no significant differences in secondary outcomes.
Conclusion:
Despite the potential advantages of RA/NA, utilization for lower extremity trauma was low in our analysis; only 9.58% of patients were in the RA/NA group, with the majority receiving spinal anesthesia. This may be due to surgeon preference to allow for postoperative monitoring for neurologic injury and compartment syndrome or logistical factors given the urgent nature of these trauma cases. No significant differences in 30-day mortality and postoperative complications were found between RA/NA and GA for patients with lower extremity orthopedic fractures. The choice of anesthesia is multifactorial and may be driven by patient and provider preferences in these operations.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：唐剑 编辑：何幼芹 审校：王贵龙