鞘内注射吗啡与阻塞性睡眠呼吸暂停患者关节置换术后肺部并发症的关系：回顾性队列研究
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Intrathecal Morphine and Pulmonary Complications after Arthroplasty in Patients with Obstructive Sleep Apnea: A Retrospective Cohort Study
背景与目的
鞘内注射吗啡常用于关节置换术后镇痛，但与延迟性呼吸抑制有关。阻塞性睡眠呼吸暂停患者术后肺部并发症发生的风险可能较高。然而，关于鞘内注射吗啡在此种接受关节置换人群中安全性的数据是有限的。
方 法
这项回顾性队列研究旨在评估鞘内注射吗啡在1326例确诊或怀疑患有阻塞性睡眠呼吸暂停且接受髋关节或膝关节置换术患者中安全性。进行回顾性分析以确定临床特征、围手术期事件和术后结局。所有患者均接受低剂量（100μg）鞘内吗啡（暴露组）或不含阿片类药物（对照组）的椎管内麻醉。主要观察指标是任何术后肺部并发症，包括：（1）需要纳洛酮的呼吸抑制；（2）肺炎；（3）需要与重症监护反应小组协商的急性呼吸事件；（4）呼吸衰竭需要插管/机械通气；（5） 计划外进入重症监护室进行呼吸支持；（6）因呼吸原因死亡。作者假设鞘内注射吗啡会增加术后并发症发生的风险。
结 果
1326例患者中，1042例（78.6%）接受鞘内吗啡治疗。患者平均年龄为65±9岁，体重指数为34.7±7.0kg/m2。在1326例患者中，622名(46.9%)怀疑患有阻塞性睡眠呼吸暂停(打鼾、困倦、别人注意到的呼吸暂停、高血压、体重指数、年龄、颈围、性别[Stop-Bang量表]评分≥3)，而1326名患者中有704名(53.1%)有多导睡眠图诊断。术后，1322例患者中有20例（1.5%）出现肺部并发症，其中暴露组1039例中有14例（1.3%），对照组283例中有6例（2.1%）（P=0.345）。总的来说，1322例中有6例（0.5%）发生呼吸抑制，1322例中有18例（1.4%）发生呼吸事件需要重症监护反应小组会诊，1322例中有4例（0.3%）非计划进入重症监护室病房；两组之间以上情况发生比率无显著性差异。校正混杂因素后，鞘内注射吗啡与术后肺部并发症无显著相关性[调整比值比（OR），0.60 [95% CI，0.24-1.67]；P=0.308]。
结 论
低剂量鞘内注射吗啡联合多模式镇痛与阻塞性睡眠呼吸暂停患者行关节置换术后肺部并发症无相关性。
原始文献摘要
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.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：何幼芹 编辑：冯玉蓉 审校：王贵龙