A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching
A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching
复制标题
使用倾向评分匹配对神经肌肉阻滞药物使用和通气技术对儿科困难插管登记处并发症的影响进行回顾性分析
DOI：
10.1213/ane.0000000000004393
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发表时间：
2019
影响因子：
5.7
通讯作者：
Cheryl Gooden
中科院分区：
文献类型：
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作者：
Annery G. Garcia‐Marcinkiewicz;H. D. Adams;H. Gurnaney;Vikram Patel;N. Jagannathan;N. Burjek;J. Mensinger;Bingqing Zhang;Kenneth N. Peeples;P. Kovatsis;J. Fiadjoe;B. V. von Ungern;D. Sommerfield;Chris Holmes;Stefano Sabato;Niroop R Ravula;Christine Jette;Samuel Mireles;Clyde Matava;Simon Whyte;Eduardo Vega;Lei Yang;P. Echeverry;Carolina Pérez‐Pradilla;D. Polaner;E. Starker;J. Zieg;J. Szolnoki;Angela Lee;E. Heitmiller;Mohamed A. Rehman;Allison Fernandez;Jonathan Meserve;John McCloskey;Nicholas M. Dalesio;Rahul Koka;Robert Greenberg;Raymond Park;J. Peyton;Solmaletha Bhattacharya;Paul Reynolds;Ian Lewis;B. Haydar;Megan Therrian;L. Sarmiento;Martina Richtsfeld;Kumar Belani;Sara Robertson;Kumar Sathyamoorthy;Charles Schrock;Jurgen de Graaff;Codruta N. Soneru;Neeta Singh;Franklin Chiao;B. Taicher;Thomas Templeton;Pilar Castro;N. Ricardo Riveros Perez;Vidya T. Raman;Ralph Beltran;Tarun Bhalla;P. Stricker;J. Lockman;Jorge A. Gálvez;Rebecca S Isserman;Brian Struyk;Christopher Ward;Grace Hsu;A. Nishisaki;Ramesh Kodavatiganti;Luis Sequera Ramos;Eric Scheu;S. Watkins;Tally Goldfarb;P. Olomu;P. Szmuk;Paul Hopkins;Chris Glover;Kim Nguyen;O. Olutoye;Ranu Jain;M. Matuszczak;Agnes I Hunyady;A. Bosenberg;See Tham;Daniel Low;Guelay Bilen Rosas;James Fehr;Lisa K. Lee;Ihab Iyah;Roshan Patel;Cheryl Gooden
背景：通气在气道管理中至关重要，失败可能致命。气道困难儿童气管内插管的最佳通气方法仍存在争议。儿科插管困难（PeDI）注册是一个国际多中心注册，收集插管困难儿童的插管数据。登记记录了初始（诱导时）和最终通气技术（插管时）、神经肌肉阻断药物（NMBDs）的使用、插管期间气道反应性和并发症。我们分析了PeDI Registry中的数据，以确定各种通气技术的使用频率和相关并发症。由于自发呼吸患者在插管过程中需要通气，我们假设自发通气与其他方法相比并发症更少。方法：我们查询了2012年9月至2016年2月间来自16家儿童医院的PeDI注册病例。我们将主治麻醉师的通气计划分为3组：自发通气、给予NMBD后控制通气和未给予NMBD时控制通气。采用二项家族分布和logit链接的广义估计方程（GEE）模型来确定通气技术与并发症风险之间的关系，并考虑站点内聚类。进一步应用倾向评分匹配来平衡各通气组的预处理特征。结果：在1289例预期插管困难患者中，507例（39%）采用自主通气，453例（35%）采用NMBD控制通气，329例（26%）采用无NMBD控制通气。242例（18.8%；95%可信区间[CI]， 16.6%-20.9%）患者出现并发症。其中218例（16.9%）不严重，24例（1.9%）严重。自发通气组非严重并发症114例（22.5%，标准化残余[Std.Res] = 4.29），高于NMBD为60的控制通气组（13.3%,Std.Res = - 2.58）和NMBD为44的控制通气组（13.4%,Std.Res = - 1.98）， P < 0.001。最邻近匹配卡尺宽度等于倾向评分logit标准差（SD）的0.2也表明，与控制通气技术相比，自动通气患者发生并发症的几率更大：优势比(OR) = 2.07 （95% CI, 1.36-3.15; P = 0.001）。结论：与控制通气技术相比，在气道困难的儿童插管时，自发通气与低氧血症和喉痉挛等非严重并发症相关。麻醉深度不足可能导致并发症增加。
BACKGROUND: Ventilation is critical in airway management, and failure can be fatal. The optimal ventilation approach for endotracheal intubation in children with difficult airways remains controversial. The Pediatric Difficult Intubation (PeDI) Registry is an international multicenter registry that collects intubation data in difficult to intubate children. The registry captures the initial (at induction) and final ventilation technique (at intubation), the use of neuromuscular blocking drugs (NMBDs), airway reactivity during intubation, and complications. We analyzed data in the PeDI Registry to determine the frequency of use of various ventilation techniques and associated complications. Because spontaneously breathing patients ventilate throughout intubation, we hypothesized that spontaneous ventilation would be associated with fewer complications than other approaches. METHODS: We queried the PeDI Registry for cases entered between September 2012 and February 2016, from 16 children’s hospitals. We categorized the attending anesthesiologist’s ventilation plan into 3 groups: spontaneous ventilation, controlled ventilation after administering an NMBD, and controlled ventilation without administering an NMBD. Generalized Estimating Equation (GEE) model, with a binomial family distribution and logit link, was used to determine the association between ventilation technique and the risk of complications, as well as to account for within-site clustering. Propensity score matching was further applied to balance pretreatment characteristics of ventilation groups. RESULTS: Of 1289 anticipated difficult intubations, 507 (39%) were managed with spontaneous ventilation, 453 (35%) controlled ventilation with an NMBD, and 329 (26%) controlled ventilation without an NMBD. Complications occurred in 242 (18.8%; 95% confidence interval [CI], 16.6%–20.9%) patients. Of these, 218 (16.9%) were nonsevere, and 24 (1.9%) were severe. The spontaneous ventilation group had 114 (22.5%, standardized residual [Std.Res] = 4.29) nonsevere complications, which was higher than the controlled ventilation with an NMBD 60 (13.3%, Std.Res = −2.58), and controlled ventilation without an NMBD 44 (13.4%, Std.Res = −1.98), P < .001. Nearest neighbor matching with caliper width equal to 0.2 of the standard deviation (SD) of the logit of the propensity score also demonstrated that patients with spontaneous ventilation had greater odds of complications compared to controlled ventilation techniques: odds ratio (OR) = 2.07 (95% CI, 1.36–3.15; P = .001). CONCLUSIONS: Spontaneous ventilation is associated with more nonsevere complications, such as hypoxemia and laryngospasm, than controlled ventilation techniques during intubation of children with difficult airways. Inadequate anesthetic depth may contribute to increased complications.