先天性⼼脏病⼿术患⼉⽓管插管径路实⾏状况的研究： ⽓管插管径路对围术期结局的影响-胸外科医师协会先天性⼼脏病麻醉学分会数据库分析
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A Study of Practice Behavior for Endotracheal Intubation Site for Children With Congenital Heart Disease Undergoing Surgery: Impact of Endotracheal Intubation Site on Perioperative Outcomes-An Analysis of the Society of Thoracic Surgeons Congenital Cardiac Anesthesia Society Database
背景与目的
在接受体外循环⼿术的成⼈中，因可以降低⿐窦炎和感染的⻛险，经⼝腔插管通常优于经⿐插管。在⼉童中，⿐插管更常⻅，有时更受⻘睐，因为需要的术后镇静剂量较少，意外拔管的⻛险较低。本研究旨在描述在接受体外循环⼿术的⼉科⼈群中进⾏⿐插管的情况，并⽐较⿐腔与⼝腔途径的⻛险/益处。
方 法
2010年1⽉⾄2015年12⽉期间在胸外科学会先天性⼼脏病⼿术数据库中，包括＜18岁的患者在内。排除术前⽓管插管，⽓管切开术或已知⽓道异常的患者。多变量建模⽤于评估⽓管插管途径与感染⻛险（伤⼝感染，纵隔炎，败⾎症，肺炎和⼼内膜炎）的综合测量之间的关联。包括协变量以调整重要的患者特征（例如体重、年龄、合并症），病例复杂性和中⼼效应。次要结果包括插管时间、住院时间和⽓道并发症，包括意外拔管。我们还对⾼容量中⼼（>100例/年）＜12个⽉的⼉童进⾏了亚组分析，检查感染⻛险在⼿术时如何随年龄⽽变化。
结 果
在新⽣⼉⼿术中使⽤⿐插管占41%，婴⼉占38%，学龄⼉童占15%，⻘少年占2%。⿐插管仅对新⽣⼉的意外拔管有保护作⽤（P=0.02）。婴⼉和新⽣⼉的多变量分析显示，插管的⿐腔途径与复合感染⽆关（相对⻛险[RR]，0.84，95%CI，0.59-1.18）与较短的住院时间⽆关（RR，0.992，95%CI，0.947-1.039），但与较短的插管时间相关（RR，0.929，95%CI，0.869-0.992）。对⾼容量中⼼的限制显示年龄和插管途径之间存在显著的相互作⽤，感染的⻛险变化发⽣在⼤约6-12个⽉之间（P=0.003）。
结 论
虽然接受⿐插管的年⻓⼉感染⻛险增加的趋势与成年相似，但新⽣⼉和婴⼉的⿐插管似乎没有类似的⻛险。新⽣⼉和婴⼉的⿐插管也可能与较短的插管时间相关，但不会缩短住院时间。需要进⾏前瞻性研究以更好地了解这些复杂的相关内容。
原始文献摘要
Greene NH, Jooste EH, Thibault DP. A Study of Practice Behavior for Endotracheal Intubation Site for Children With Congenital Heart Disease Undergoing Surgery: Impact of Endotracheal Intubation Site on Perioperative Outcomes-An Analysis of the Society of Thoracic Surgeons Congenital Cardiac Anesthesia Society Database. Anesth Analg. 2018 Sep 5. doi: 10.1213/ANE.0000000000003594. [Epub ahead of print] PubMed PMID: 30198928.
Background: In adults undergoing cardiopulmonary bypass surgery, oral intubation is typically preferred over nasal intubation due to reduced risk of sinusitis and infection. In children,nasal intubation is more common and sometimes preferred due to perceived benefits of less postoperative sedation and a lower risk for accidental extubation. This study sought to describe the practice of nasal intubation in the pediatric population undergoing cardiopulmonary bypass surgery and assess the risks/benefits of anasal route against an oral one.
Methods: Patients <18 years of age in the Society of Thoracic Surgeons Congenital Heart Surgery Database between January 2010 and December 2015 were included. Patients with a preoperative endotracheal tube, tracheostomy, or known airway anomalies were excluded. Multivariable modeling was used to assess the association between route of tracheal intubation and a composite measure of infection risk (wound infection, mediastinitis, septicemia, pneumonia, and endocarditis). Covariates were included to adjust for important patient characteristics (eg, weight, age,comorbidities), case complexity, and center effects. Secondary outcomes included length of intubation, hospital length of stay, and airway complications including accidental extubations. We also performed a subanalysis in children <12 months of age in high-volume centers (>100 cases/y) examining how infection risk may change with age at the time of surgery.
Results: Nasal intubation was used in 41% of operations in neonates, 38% in infants, 15% in schoolaged children, and 2% in adolescents. Nasal intubation appeared protective for accidental extubation only in neonates (P = .02). Multivariable analysis in infants and neonates showed that the nasal route of intubation was not associated with the infection composite (relative risk [RR], 0.84; 95% CI, 0.59-1.18) or a shorter length of stay (RR, 0.992; 95% CI, 0.947-1.039), but was associated with a shorter intubation length (RR, 0.929; 95% CI, 0.869-0.992). Restricting to high-volume centers showed a significant interaction between age and intubation route with a risk change for infection occurring between approximately 6-12 months of age (P = .003).
Conclusion: While older children undergoing nasal intubation trend similar to the adult population with an increased risk of infection, nasal intubation in neonates and infants does not appear to carry a similar risk. Nasal intubation in neonates and infants may also be associated with a shorter intubation length but not a shorter length of stay. Prospective studies are required to better understand these complex associations.
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