小儿肝移植术后在手术室拔管：一项回顾性队列研究。

Extubation in the operating room after pediatric liver transplant: A retrospective cohort study.

作者信息

Gurnaney Harshad G, Cook-Sather Scott D, Shaked Abraham, Olthoff Kim M, Rand Elizabeth B, Lingappan Arul M, Rehman Mohamed A

机构信息

Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

The Department of Surgery, Division of Transplant Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

出版信息

Paediatr Anaesth. 2018 Feb;28(2):174-178. doi: 10.1111/pan.13313. Epub 2018 Jan 8.

DOI:10.1111/pan.13313

PMID:29316006

Abstract

BACKGROUND

Early extubation immediately following liver transplantation is increasingly common in adult practice. Some pediatric institutions have begun to adopt this strategy. Careful patient selection is essential in minimizing risk.

METHODS

This retrospective cohort study evaluated infants and children who underwent liver transplantation between July 2011 and December 2014. Our primary objective was to determine early extubation rate. Secondary objectives were to identify clinical factors associated with successful early extubation compared with delayed extubation and to examine significant postoperative complications, intensive care unit length of stay, and hospital length of stay.

RESULTS

The early extubation rate was 57.8% (37/64, confidence interval [CI] 44.8%-70.1%) over this 3.5-year period, increasing from 42% in 2012 to 58% by the end of 2014. The patients in the early extubation group were more likely to be older than the delayed extubation group (mean [SD], 7 [5.3] years vs 3.5 [5.5] years, difference between the mean [95% CI], 3.5 [0.8, 6.2] years); were to have come from home on the day of surgery (78.4% vs 25.9%); and were less likely to be listed as United Network for Organ Sharing status 1A (2.7% vs 25.9%). The early extubation group received less packed red blood cell volume (mean [SD], 9 [13.2] mL/kg vs 40.6 [48.5] mL/kg, difference between the mean [95% CI], 31.6 [95% CI 14.9, 48.3] mL/kg) and fresh-frozen plasma (mean 2.7 [SD 9.5] vs 13.3 [SD15.1], difference between the mean [95% CI], 10.5 [4.4,16.7] mL/kg). None of the patients in the early extubation group required reintubation in the first 24 hours following transplant and none experienced hepatic artery thrombosis. The early extubation group had a shorter average postoperative PICU stay (mean 3.8 [SD 2.1] days vs 17.6 [SD 31.3] days, difference between the mean [95% CI], 9.5 [4.3, 14.7] days) and a shorter postoperative hospital stay overall (mean 10.7 [SD 4.3] days vs 29.7 [SD 43.1] days, difference between the mean [95% CI], 19.1 [8.6, 29.6] days).

CONCLUSION

More than half of our pediatric liver transplant patients were successfully extubated in the operating room immediately following surgery. We believe early extubation to be safe when employed in selected subpopulations of pediatric patients undergoing liver transplantation.

摘要

背景

在成人肝移植实践中，术后立即早期拔管越来越普遍。一些儿科机构也已开始采用这一策略。谨慎选择患者对于将风险降至最低至关重要。

方法

这项回顾性队列研究评估了2011年7月至2014年12月期间接受肝移植的婴幼儿及儿童。我们的主要目标是确定早期拔管率。次要目标是确定与延迟拔管相比，与成功早期拔管相关的临床因素，并检查术后严重并发症、重症监护病房住院时间及住院总时长。

结果

在这3.5年期间，早期拔管率为57.8%（37/64，置信区间[CI] 44.8%-70.1%），从2012年的42%增至2014年底的58%。早期拔管组患者的年龄比延迟拔管组更大（平均[标准差]，7[5.3]岁对3.5[5.5]岁，平均差值[95% CI]，3.5[0.8, 6.2]岁）；手术当天来自家中的可能性更高（78.4%对25.9%）；被列为器官共享联合网络1A状态的可能性更低（2.7%对25.9%）。早期拔管组接受的浓缩红细胞量更少（平均[标准差]，9[13.2] mL/kg对40.6[48.5] mL/kg，平均差值[95% CI]，31.6[95% CI 14.9, 48.3] mL/kg）以及新鲜冰冻血浆更少（平均2.7[标准差9.5]对13.3[标准差15.1]，平均差值[95% CI]，10.5[4.4,16.7] mL/kg）。早期拔管组中无一例患者在移植后首24小时内需要再次插管，也无一例发生肝动脉血栓形成。早期拔管组术后在儿科重症监护病房的平均住院时间更短（平均3.8[标准差2.1]天对17.6[标准差31.3]天，平均差值[95% CI]，9.5[4.3, 14.7]天），且术后总体住院时间也更短（平均10.7[标准差4.3]天对29.7[标准差43.1]天，平均差值[95% CI]，19.1[8.6, 29.6]天）。