【作者】 蒋燕；

【导师】 黄瀚；

【作者基本信息】 四川大学 ， 麻醉学（专业学位）， 2021， 硕士

【摘要】 目的:研究非必要全身麻醉(avoidable general anesthesia,a GA)对剖宫产(Cesarean Delivery,CD)产妇医疗结局的影响,为进一步通过优化麻醉方案,改善产妇远期预后提供依据。材料和方法:通过四川大学华西第二医院HIS系统和麻醉信息系统,回顾性收集了2018年1月1日至2020年5月31日在我院产科行剖宫产手术后出院患者的临床数据。依据病案首页信息,将患者分为椎管内麻醉(neuraxial anesthesia,NA)组与全身麻醉(general anesthesia,GA)组。根据《Chestnut产科麻醉学:理论与实践(第5版)》,美国麻醉医师学会的产科麻醉实践指南及中华医学会麻醉分会中国产科麻醉专家共识,明确了全麻的临床指征。随后,据此将全麻分为必要全麻(unavoidable general anesthesia,un-a GA)组与非必要全麻组。本研究的主要结局指标是术后不良事件的综合发生率,不良事件包括肺部感染(Pulmonary Infection,PI)、肺栓塞(Pulmonary Embolism,PE)、深静脉血栓(Deep Venous Thrombus,DVT)、手术部位感染(Surgical Site Infection,SSI)、死亡(Death)及严重的神经功能障碍(Severe Neurological Dysfunction,SND)。次要结局指标是医疗资源耗损,包括患者的住院天数、术后住院天数、住院费用。通过对使用非必要全麻的相关变量进行了单因素与多因素分析,明确使用非必要全麻的危险因素。结果:本研究纳入了18717例剖宫产患者,包括椎管内麻醉组患者16153例,全麻组患者2564例,其中非必要全麻组患者1146例,必要全麻组患者1418例。椎管内麻醉组与全麻组整体比较后发现:全麻组患者术后不良事件的综合发生率明显高于椎管内麻醉组患者(1.91%vs 0.48%;OR=3.96,95%CI=2.76-5.67;p<0.001);并且全麻组患者术后发生肺部感染(1.09%vs 0.35%;OR=3.12,95%CI=1.98-4.90;p<0.001)、深静脉血栓(0.58%vs 0.09%;OR=6.78,95%CI=3.27-14.27;p<0.001)、肺栓塞(0.15%vs 0.03%;OR=5.04,95%CI=1.35-18.80;p=0.028)的几率也高于椎管内麻醉组患者。对非必要全麻组与椎管内麻醉组应用1:2倾向性评分匹配(Propensity Score Matching,PSM)进行统计分析,结果发现非必要全麻组患者术后不良事件的综合发生率仍高于椎管内麻醉组患者(1.41%vs 0.60%;OR=2.40,95%CI=1.15-5.01;p=0.016),且非必要全麻组患者术后发生肺部感染的危险性较椎管内麻醉组更高(0.97%vs 0.41%;OR=2.38,95%CI=0.98-5.76;p=0.047)。非必要全麻组患者较椎管内麻醉组患者的术后住院天数更长(4[3-5]天vs 4[3-4]天,p<0.001),住院费用更高(16610.88[13358.79-23485.65]元vs 13605.19[11470.58-16707.51]元,p<0.001)。非必要全麻与必要全麻两组患者的术后不良事件综合发生率与医疗资源耗损均不存在统计学差异(p>0.05)。以下因素与非必要全麻增加的可能性显著相关:较长的术前住院天数(OR=1.02,95%CI=1.01-1.04,p<0.001),术前合并胎盘异常(OR=6.69,95%CI=5.04-8.89,p<0.001)、骨骼肌肉系统疾病(OR=70.56,95%CI=14.35-346.90,p<0.001)、神经(精神)系统疾病(OR=11.30,95%CI=5.45-23.39,p<0.001)、风湿免疫性疾病(OR=2.83,95%CI=1.70-4.70,p<0.001)、恶性肿瘤(OR=7.73,95%CI=2.30-27.53,p=0.001)、泌尿系统疾病(OR=3.29,95%CI=1.33-8.15,p=0.010)以及胎儿生长受限(OR=1.91,95%CI=1.01-3.60,p=0.044)。结论:与椎管内麻醉组患者相比,接受非必要全麻患者术后不良事件的综合发生率更高,尤其是术后更容易发生肺部感染;并且接受非必要全麻患者的住院天数、术后住院天数较椎管内麻醉患者更长,住院费用更高。更多还原

【Abstract】 Objective:To investigate the effect of avoidable general anesthesia(a GA)on maternal outcomes following cesarean delivery(CD).Materials and Methods:By extracting data from summary medical sheet via Hospital Information System(HIS)and anesthesia information system of West China Second Hospital of Sichuan University,patients discharged from department of obstetrics after CD from January 1,2018 to May 31,2020 were identified.According to the anesthesia technique received,the patients were divided into neuraxial anesthesia group(neuraxial anesthesia,NA)and general anesthesia(GA)groups.The patients in the GA group were further divided into unavoidable general anesthesia(unavoidable general anesthesia,un-a GA)group and avoidable general anesthesia group,according to standard textbook and clinic guidelines.The primary outcome is the incidence of composite maternal adverse outcomes,which includes pulmonary infection(PI),pulmonary embolism(PE),deep vein thrombosis(Deep Venous Thrombus,DVT),surgical site Infection(Surgical Site Infection,SSI),death(Death),severe neurological dysfunction(Severe Neurological Dysfunction,SND).The secondary outcomes are length of hospital stay,length of postoperative hospital stay days,and total medical expenses.Finally,risk factors associated with avoidable GA were searched.Results:Totally 18,717 patients with CD were included for final analysis,among wich16,153 patients received NA and 2,564 patients received GA.For the GA cases,1146 were identified as a GA while 1418 were as un-a GA.Compared with NA,a GA was associated with significantly increased risk of composite maternal adverse outcomes(adjusted odds ratio,2.40;95% CI,1.15-5.01,p = 0.016),increased length of postoperative hospital stay(4 [3-5] vs 4[3-4])days,p < 0.001),and increased medical expenses(16610.88 [13358.79-23485.65] vs 13605.19 [11470.58-16707.51]RMB,p < 0.001).The following factors were associated with the use of a GA: longer preoperative hospital stay(OR =1.02,95%CI=1.01-1.04,p < 0.001);preoperatively diagnosed with the following diseases: abnormal placenta(OR = 6.69,95% CI = 5.04-8.89,p <0.001),skeletal and muscular system diseases(OR=70.56,95%CI=14.35-346.90,p< 0.001),neurological/psychiatric diseases(OR=11.30,95%CI=5.45-23.39,p <0.001),rheumatic/autoimmune diseases(OR =2.83,95%CI=1.70-4.70,p < 0.001),malignant tumors(OR=7.73,95%CI=2.30-27.53,p = 0.001),urinary system diseases(OR=3.29,95%CI=1.33-8.15,p = 0.010)and fetal growth restriction(OR=1.91,95%CI=1.01-3.60,p = 0.044).Conclusion:Compared with patients in the neuraxial anesthesia group,patients who received avoidable general anesthesia had a higher incidence of maternal adverse events,longer postoperative hospital stay and higher consumption of medical resources.更多还原