肌松剂与术后麻醉后肺部并发症：多中心前瞻性观察研究
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Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study
背景与目的
前期回顾性研究结果表明，全身麻醉期间使用神经肌肉阻滞剂可能与术后肺部并发症有关。因此，本研究旨在评估使用神经肌肉阻滞剂是否与术后肺部并发症有关。
方 法
我们进行了一项多中心前瞻性观察队列研究。从28个欧洲国家的211家医院中征集患者，收集接受全身麻醉的除心脏手术以外的任何住院手术患者（年龄≥18岁）。患者特征、手术和麻醉细节、出院时的病历回顾用2周进行前瞻性收集。此外，每名患者术后3天内进行体检，观察是否发生肺部不良事件。观察指标为从手术结束到术后28天的肺部并发症的发生率。对手术因素和患者术前身体状况进行逻辑回归分析，提供调整后的优势比(ORadj) 和调整后的绝对风险下降率(ARRadj)。
结 果
2014年6月16日至2015年4月29日之间共收集了22803名患者的数据。神经肌肉阻滞剂的使用与全身麻醉患者术后肺部并发症的发生率增加有关(21694例中有1658例 [7.6%] ); ORadj：1.86, 95% CI：1.53~2.26; ARRadj：-4.4%, 95% CI：-5.5~ -3.2)。只有2.3%的高危手术患者和呼吸状况不佳的患者未使用神经肌肉阻滞剂进行麻醉。神经肌肉监测仪(ORadj：1.31, 95% CI：1.15~1.49; ARRadj：-2.6%, 95% CI：-3.9 ~ -1.4) 和拮抗剂(1.23, 1.07~1.41; -1.9%, -3.2 ~ -0.7) 的使用与术后肺部并发症的发生风险降低无关。用舒更葡糖代替新斯的明拮抗(ORadj：1.03, 95% CI：0.85~1.25; ARRadj：-0.3%, 95% CI：-2.4 ~ 1.5) 或在TOF值为0.9或更大时拔管(1.03, 0.82~1.31; -0.4%, -3.5~2.2)均与良好的肺部预后无关。
结 论
本研究发现神经肌肉阻滞剂在全身麻醉中的应用与术后肺部并发症发生风险增加有关。麻醉医师需要权衡神经肌肉阻断后的潜在益处与术后肺部并发症发生风险增加之间的利弊。
原始文献摘要
Kirmeier Eva, Eriksson Lars I, Lewald Heidrun, et al. Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study[J]. Lancet Respir Med 2019,7(2):129-140. DOI: 10.1016/s2213-2600(18)30294-7.
Background：Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications.
Methods：We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients’ preoperative physical status, providing adjusted odds ratios (ORadj) and adjusted absolute risk reduction (ARRadj). This study is registered with ClinicalTrials.gov, number NCT01865513.
Findings：Between June 16, 2014, and April 29, 2015, data from 22803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7·6%] of 21694); ORadj 1·86, 95% CI 1·53–2·26; ARRadj –4·4%, 95% CI –5·5 to –3·2). Only 2·3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (ORadj 1·31, 95% CI 1·15–1·49; ARRadj –2·6%, 95% CI –3·9 to –1·4) and the administration of reversal agents (1·23, 1·07–1·41; –1·9%, –3·2 to –0·7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (ORadj 1·03, 95% CI 0·85–1·25; ARRadj –0·3%, 95% CI –2·4 to 1·5) nor extubation at a train-of-four ratio of 0·9 or more (1·03, 0·82–1·31; –0·4%, –3·5 to 2·2) was associated with better pulmonary outcomes.
Interpretation：We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：冯玉蓉 编辑：何幼芹 审校：王贵龙