【罂粟摘要】内镜逆行胰胆管造影术全麻与镇静效果比较
内镜逆行胰胆管造影术全麻与镇静效果比较
贵州医科大学 高鸿教授课题组
翻译：牛振瑛 编辑：佟睿 审校：曹莹
验证全身麻醉与镇静相比可增加内镜逆行胰胆管造影术(ERCP)术后不良结果(住院死亡率或再入专业护理或医疗机构)易感性的假设。
在本项回顾性队列研究中纳入了在三级医疗机构接受ERCP的成年患者，他们分别在全身麻醉或镇静的情况下接受ERCP。使用基于提供者偏好的工具变量分析计算接受全麻和镇静的患者之间校正后的绝对风险差异。同时，使用中介分析来确定全麻术中低血压是否为产生不良结果的影响因素。
在2007年至2018年接受ERCP的17538名患者中，16238名接受了镇静治疗，1300名接受了GA治疗。镇静后不良结果的发生率为5.8%(n=938)，全麻后为16.2%(n=210)。使用与提供者相关的变异性进行工具变量分析，结果显示，与镇静剂相比，接受全身麻醉者的不良结果发生风险增加了8.6%(95%可信区间，4.5-12.6%；P<0.001)。术中低血压事件在全麻期间发生的频率更高，并介导了23.8%(95%可信区间，3.9-43.7%：P=0.019)的主要作用。
这些结果表明，在ERCP中使用镇静剂有助于减少全身麻醉适应证不明确的患者的不良结果发生率。ERCP全麻术中低血压部分介导了不良结果易感性的增加。
Althoff FC, Agnihotri A, Grabitz SD, Outcomes after endoscopic retrograde cholangiopancreatography with general anaesthesia versus sedation[J]. Br J Anaesth. 2021 Jan;126(1):191-200. doi: 10.1016/j.bja.2020.08.057.
Outcomes after endoscopic retrograde cholangiopancreatography
with general anaesthesia versus sedation
Background: We tested the primary hypothesis that use of general anaesthesia vs sedation increases vulnerability to adverse discharge (in-hospital mortality or new discharge to a nursing facility) after endoscopic retrograde chol-angiopancreatography (ERCP).
Methods: In this retrospective cohort study, adult patients undergoing ERCP with general anaesthesia or sedation at atertiary care hospital were included. We calculated adjusted absolute risk differences between patients receiving general anaesthesia vs sedation using provider preference-based instrumental variable analysis. We also used mediation analysis to determine whether intraoperative hypotension during general anaesthesia mediated its effect on adverse discharge.
Results: Among 17 538 patients undergoing ERCP from 2007 through 2018, 16 238 received sedation and 1300 received GA.Rates of adverse discharge were 5.8% (n=938) after sedation and 16.2% (n=210) after general anaesthesia. Providers’ adjusted mean predicted probabilities of using general anaesthesia for ERCP ranged from 0.2% to 63.2% of individual caseloads. Utilising provider-related variability in the use of general anaesthesia for instrumental variable analysis resulted in an 8.6% risk increase (95% confidence interval, 4.5-12.6%; P<0.001) in adverse discharge among patients receiving general anaesthesia vs sedation. Intraoperative hypotensive events occurred more often during general anaesthesia and mediated 23.8% (95% confidence interval, 3.9-43.7%: P=0.019) of the primary association.
Conclusions: These results suggest that use of sedation during ERCP facilitates reduced adverse discharge for patients for whom general anaesthesia is not clearly indicated. Intraoperative hypotension during general anaesthesia for ERCP partly mediates the increased vulnerability to adverse discharge.