【原】鞘內(nèi)注射嗎啡與阻塞性睡眠呼吸暫?；颊哧P(guān)節(jié)置換術(shù)后肺部并發(fā)癥的關(guān)系：回顧性隊列研究

罌粟花anesthGH 2021-07-21

展開全文

本公眾號每天分享一篇最新一期Anesthesia & Analgesia等SCI雜志的摘要翻譯，敬請關(guān)注并提出寶貴意見

Intrathecal Morphine and Pulmonary Complications after Arthroplasty in Patients with Obstructive Sleep Apnea: A Retrospective Cohort Study

背景與目的

鞘內(nèi)注射嗎啡常用于關(guān)節(jié)置換術(shù)后鎮(zhèn)痛，但與延遲性呼吸抑制有關(guān)。阻塞性睡眠呼吸暫?；颊咝g(shù)后肺部并發(fā)癥發(fā)生的風(fēng)險可能較高。然而，關(guān)于鞘內(nèi)注射嗎啡在此種接受關(guān)節(jié)置換人群中安全性的數(shù)據(jù)是有限的。

方法

這項回顧性隊列研究旨在評估鞘內(nèi)注射嗎啡在1326例確診或懷疑患有阻塞性睡眠呼吸暫停且接受髖關(guān)節(jié)或膝關(guān)節(jié)置換術(shù)患者中安全性。進(jìn)行回顧性分析以確定臨床特征、圍手術(shù)期事件和術(shù)后結(jié)局。所有患者均接受低劑量（100μg）鞘內(nèi)嗎啡（暴露組）或不含阿片類藥物（對照組）的椎管內(nèi)麻醉。主要觀察指標(biāo)是任何術(shù)后肺部并發(fā)癥，包括：（1）需要納洛酮的呼吸抑制；（2）肺炎；（3）需要與重癥監(jiān)護(hù)反應(yīng)小組協(xié)商的急性呼吸事件；（4）呼吸衰竭需要插管/機(jī)械通氣；（5）計劃外進(jìn)入重癥監(jiān)護(hù)室進(jìn)行呼吸支持；（6）因呼吸原因死亡。作者假設(shè)鞘內(nèi)注射嗎啡會增加術(shù)后并發(fā)癥發(fā)生的風(fēng)險。

結(jié) 果

1326例患者中，1042例（78.6%）接受鞘內(nèi)嗎啡治療?；颊咂骄挲g為65±9歲，體重指數(shù)為34.7±7.0kg/m²。在1326例患者中，622名(46.9%)懷疑患有阻塞性睡眠呼吸暫停(打鼾、困倦、別人注意到的呼吸暫停、高血壓、體重指數(shù)、年齡、頸圍、性別[Stop-Bang量表]評分≥3)，而1326名患者中有704名(53.1%)有多導(dǎo)睡眠圖診斷。術(shù)后，1322例患者中有20例（1.5%）出現(xiàn)肺部并發(fā)癥，其中暴露組1039例中有14例（1.3%），對照組283例中有6例（2.1%）（P=0.345）?？偟膩碚f，1322例中有6例（0.5%）發(fā)生呼吸抑制，1322例中有18例（1.4%）發(fā)生呼吸事件需要重癥監(jiān)護(hù)反應(yīng)小組會診，1322例中有4例（0.3%）非計劃進(jìn)入重癥監(jiān)護(hù)室病房；兩組之間以上情況發(fā)生比率無顯著性差異。校正混雜因素后，鞘內(nèi)注射嗎啡與術(shù)后肺部并發(fā)癥無顯著相關(guān)性[調(diào)整比值比（OR），0.60 [95% CI，0.24-1.67]；P=0.308]。

結(jié) 論

低劑量鞘內(nèi)注射嗎啡聯(lián)合多模式鎮(zhèn)痛與阻塞性睡眠呼吸暫停患者行關(guān)節(jié)置換術(shù)后肺部并發(fā)癥無相關(guān)性。

原始文獻(xiàn)摘要

Bai JW, Singh M, Short A, et al. Intrathecal Morphine and Pulmonary Complications after Arthroplasty in Patients with Obstructive Sleep Apnea: A Retrospective Cohort Study.[J] .Anesthesiology, 2020, undefined: undefined.

Background: Intrathecal morphine is commonly and effectively used for analgesia after joint arthroplasty, but has been associated with delayed respiratory depression. Patients with obstructive sleep apnea may be at higher risk of postoperative pulmonary complications. However, data is limited regarding the safety of intrathecal morphine in this population undergoing arthroplasty.
Methods: This retrospective cohort study aimed to determine the safety of intrathecal morphine in 1,326 patients with documented or suspected obstructive sleep apnea undergoing hip or knee arthroplasty. Chart review was performed to determine clinical characteristics, perioperative events, and postoperative outcomes. All patients received neuraxial anesthesia with lowdose (100 μg) intrathecal morphine (exposure) or without opioids (control). The primary outcome was any postoperative pulmonary complication including: (1) respiratory depression requiring naloxone; (2) pneumonia; (3) acute respiratory event requiring consultation with the critical care response team; (4) respiratory failure requiring intubation/mechanical ventilation; (5) unplanned admission to the intensive care unit for respiratory support; and (6) death from a respiratory cause. The authors hypothesized that intrathecal morphine would be associated with increased postoperative complications.
Results: In 1,326 patients, 1,042 (78.6%) received intrathecal morphine. The mean age of patients was 65 ± 9 yr and body mass index was 34.7 ± 7.0 kg/m2. Of 1,326 patients, 622 (46.9%) had suspected obstructive sleep apnea (Snoring, Tired, Observed, Pressure, Body Mass Index, Age, Neck size, Gender [STOP-Bang] score greater than 3), while 704 of 1,326 (53.1%) had documented polysomnographic diagnosis. Postoperatively, 20 of 1,322 (1.5%) patients experienced pulmonary complications, including 14 of 1,039 (1.3%) in the exposed and 6 of 283 (2.1%) in the control group (P = 0.345). Overall, there were 6 of 1 322 (0.5%) cases of respiratory depression, 18 of 1,322 (1.4%) respiratory events requiring critical care team consultation, and 4 of 1,322 (0.3%) unplanned intensive care unit admissions; these rates were similar between both groups. After adjustment for confounding, intrathecal morphine was not significantly associated with postoperative pulmonary complication (adjusted odds ratio, 0.60 [95% CI, 0.24 to 1.67]; P = 0.308).
Conclusions: Low-dose intrathecal morphine, in conjunction with multimodal analgesia, was not reliably associated with postoperative pulmonary complications in patients with obstructive sleep apnea undergoing joint arthroplasty.

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