夜间拔管不会增加重新插管、住院时间和死亡的⻛险： ⼤ 型城市教学医院经验
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Nighttime Extubation Does Not Increase Risk of Reintubation, Length of Stay, or Mortality: Experience of a Large, Urban, Teaching Hospital.
背景与目的
在重症监护病房（ICU），拔管失败与更⼤的资源利⽤率和临床结果恶化有关。
最近，据报道夜间拔管（NTE）是ICU和住院死亡率增加的危险因素。 我们假设，在⼀
个⼤型的城市⼤学附属医院进⾏拔管的多学科评估，严格协议拔管算法，⽓道管理专家
24⼩时评估有⾼⻛险的拔管，保障NTE不会带来引起不良临床后果的额外⻛险。
方 法
这是⼀项针对⼤学附属医院成⼈机械通⽓的回顾性队列研究。 NTE被定义为在
下午7:00到第⼆天6:59之间的拔管。 所有数据均来⾃该机构的电⼦病历。 多变量回归
分析⽤于评估NTE和再插管，ICU和住院时间（LOS），以及⼈⼝统计学和⾸先定义好
的临床 协变量进⾏调整的死亡率之间的关联。 在灵敏性分析中排除了姑息性，⾮计划性和常规性术后拔管。
结 果
在2241名患者中，2241名患者中有204名（9.1％）接受了NTE治疗。 再插管率
（NTE 6.9％对⽐⽩天拔管[DTE] 12.4％;调整后的⽐值[95％置信区间{CI}]，0.78
[0.43-1.41]; P = .41）和院内死亡率（NTE 3.4） ％与DTE 5.9％;调整后的⽐值
[95％CI]，0.72 [0.28-1.84]; P = .49）未发现差异。 与DTE相⽐，NTE与较短的机械
通⽓持续时间相关（中位数[四分位距]，1 [0-1]天vs 2 [1-4]天;调整后的⼏何平均值
[RGMs] [95％CI] ，0.64 [0.54-0.70]; P <.001），ICU（2 [1-5]天vs 4 [2-10]天;调
整后的RGM [95％CI]，0.65 [0.57-0.75]; P <。 001）和住院时间（6 [3-18]天vs
13 [6-25]天;调整后的RGM [95％CI]，0.64 [0.56-0.74]; P <.001）。 这些结果在灵
敏度分析中没有变化。
结 论
接受NTE的患者不会增加再次插管和院内死亡的⻛险。 此外，NTE还可以缩短机
械通⽓时间和住院时间。 在具有类似重症监护服务模式的医疗保健系统中，NTE可以⽤于合适的患者以减少资源的利⽤。
原始文献摘要
BACKGROUND:
In the intensive care unit (ICU), extubation failure has been associated with greater resource utilization and worsened clinical outcomes. Most recently, nighttime extubation (NTE) has been reported as a risk factor for increased ICU and hospital mortality. We
hypothesized that, in a large, urban, university-affiliated hospital with multidisciplinary assessment for extubation, rigorously protocolized extubation algorithms, and expert airway managers available at all times of day for assessment of high-risk extubations,
NTE would not confer additional risk of adverse clinical outcomes.
METHODS: This was a retrospective cohort study of mechanically ventilated adults at a single university-affiliated hospital. NTE was defined as occurring between 7:00 PM and 6:59 AM the following day. All data were extracted from the institution's electronic medical
record. Multi-vari-able regression analyses were used to assess associations between NTE and reintubation, ICU and hospital length of stay (LOS), and mortality with adjustments for demographic and clinical covariates defined a priori. Palliative, unplanned, and routine postoperative extubations were excluded in sensitivity analyses.
RESULTS: Of 2241 patients, 204 of 2241 (9.1%) underwent NTE. The rates of reintubation (NTE 6.9% versus daytime extubation [DTE] 12.4%; adjusted odds ratio [95% confidence interval {CI}], 0.78 [0.43-1.41]; P = .41) and in-hospital mortality (NTE 3.4% versus DTE
5.9%; adjusted odds ratio [95% CI], 0.72 [0.28-1.84]; P = .49) were not found to differ.NTE, compared to DTE, was associated with shorter duration of mechanical ventilation (median [interquartile range], 1 [0-1] days vs 2 [1-4] days; adjusted ratio of geometric
means [RGMs] [95% CI], 0.64 [0.54-0.70]; P < .001), ICU (2 [1-5] days vs 4 [2-10] days; adjusted RGMs [95% CI], 0.65 [0.57-0.75]; P < .001), and hospital LOS (6 [3-18] days vs 13 [6-25] days; adjusted RGMs [95% CI], 0.64 [0.56-0.74]; P < .001). These results were unchanged in sensitivity analyses.
CONCLUSIONS:Patients who underwent NTE were not at increased risk of reintubation or in-hospital mortality. In addition, NTE was associated with a shortened duration of mechanical ventilation and hospital LOS. In health care systems with similar critical care delivery
models, NTE may coincide with reduced resource utilization in appropriately selected patients.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
编辑：符校魁 审校：余晓旭