严重创伤患者全身麻醉期间阿片类药物给药与生存的关联:PROPPR研究的预先计划二次分析

贵州医科大学麻醉与心脏电生理课题组

翻译 : 柏雪 

编辑 : 严旭  

审校 : 曹莹

背景: 对接受麻醉的急性创伤患者使用阿片类药物后的临床结果缺乏报道。我们分析了实用、随机、最佳血小板和血浆比率(PROPPR)研究的数据，以检验阿片类药物剂量和死亡率。我们假设麻醉期间较高剂量阿片类药物与严重受伤患者的较低死亡率相关。

方法:PROPPR检查了北美12个一级创伤中心680名出血性创伤患者的血液成分比率。确定接受紧急手术麻醉的受试者，并计算阿片类药物剂量(吗啡毫克当量[MMEs])/小时）。将未接受阿片类药物治疗的受试者(第一组)分离后，其余受试者按阿片类药物低至高剂量范围分为4组（4个大小相等的四分位数，每个四分位数的阿片类药物剂量具有不同的临床相关范围）。主要结果采用广义线性混合模型评估阿片类药物剂量在6 小时、24 小时和 30 天对死亡率影响，次要结果为对其他发病率的影响，控制损伤类型、严重程度和休克指数作为固定影响因素，控制部位作为随机影响因素。

结果：在 680 名受试者中，579 名有需要麻醉的急诊手术，526 名有完整的麻醉数据。接受任何阿片类药物治疗的患者6小时死亡率较低（比值比 [ORs]，0.02–0.04；[置信区间 {CIs}，0.003–0.1]），该结果是与24 小时（ORs，0.01–0.03；[CIs，0.003–0.09]）死亡率较低]) 、 30 天 (ORs, 0.04–0.08; [CIs, 0.01–0.18]) 和未接受治疗的患者相比得出(均P < 0.001)。在对存活24小时的患者进行分析后，任何阿片类药物剂量组的30天死亡率都较低(P < 0.001)。校正分析显示，与无阿片类药物组相比，最低阿片类药物组与较高的呼吸机相关性肺炎(VAP)发生率相关(P = 0.02)，而在存活24小时的患者中，第三组阿片类药物剂量组与无阿片类药物组相比，肺部并发症发生率较低(P = 0.03)。阿片类药物剂量与其他发病率结果之间没有其他一致的关联。

结论:这些结果表明，尽管非阿片类药物组损伤更严重，血流动力学不稳定，但在全身麻醉时给药阿片类药物可提高严重损伤患者的生存率。由于这是一个预先计划的事后分析，阿片类药物剂量不是随机的，因此需要前瞻性研究。这些来自大型、多机构研究的发现可能与临床实践相关。

原始文献来源 ： 

Dominique T., Levy BS, Colleen E. Livingston, BS, Sepideh Saroukhani, MD, PhD, et, al. Association of Opioid Administration During General Anesthesia and Survival for Severely Injured Trauma Patients: A Preplanned Secondary Analysis of the PROPPR Study. ANESTHESIA&ANALGESIA,DOI:10.1213/ANE.0000000000006456

英文原文

Association of Opioid Administration During General Anesthesia and Survival for Severely Injured Trauma Patients: A Preplanned Secondary Analysis of the PROPPR Study

BACKGROUND: There is a lack of reported clinical outcomes after opioid use in acute trauma patients undergoing anesthesia. Data from the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study were analyzed to examine opioid dose and mortality. We hypothesized that higher dose opioids during anesthesia were associated with lower mortality in severely injured patients.

METHODS: PROPPR examined blood component ratios in 680 bleeding trauma patients at 12 level 1 trauma centers in North America. Subjects undergoing anesthesia for an emergency procedure were identified, and opioid dose was calculated (morphine milligram equivalents [MMEs])/h. After separation of those who received no opioid (group 1), remaining subjects were divided into 4 groups of equal size with low to high opioid dose ranges. A generalized linear mixed model was used to assess impact of opioid dose on mortality (primary outcome, at 6 hours, 24 hours, and 30 days) and secondary morbidity outcomes, controlling for injury type, severity, and shock index as fixed effect factors and site as a random effect factor.

RESULTS: Of 680 subjects, 579 had an emergent procedure requiring anesthesia, and 526 had complete anesthesia data. Patients who received any opioid had lower mortality at 6 hours (odds ratios [ORs], 0.02–0.04; [confidence intervals {CIs}, 0.003–0.1]), 24 hours (ORs, 0.01–0.03; [CIs, 0.003–0.09]), and 30 days (ORs, 0.04–0.08; [CIs, 0.01–0.18]) compared to those who received none (all P < .001) after adjusting for fixed effect factors. The lower mortality at 30 days in any opioid dose group persisted after analysis of those patients who survived >24 hours (P < .001).Adjusted analyses demonstrated an association with higher ventilator-associated pneumonia (VAP) incidence in the lowest opioid dose group compared to no opioid (P = .02), and lung complications were lower in the third opioid dose group compared to no opioid in those surviving 24 hours (P = .03). There were no other consistent associations of opioid dose with other morbidity outcomes.

CONCLUSIONS: These results suggest that opioid administration during general anesthesia for severely injured patients is associated with improved survival, although the no-opioid group was more severely injured and hemodynamically unstable. Since this was a preplanned post hoc analysis and opioid dose not randomized, prospective studies are required. These findings from a large, multi-institutional study may be relevant to clinical practice. (Anesth Analg 2023;136:905–12)

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