Changes in Anesthetic and Postoperative Sedation-Analgesia Practice Associated With Early Extubation Following Infant Cardiac Surgery: Experience From the Pediatric Heart Network Collaborative Learning Study*
Changes in Anesthetic and Postoperative Sedation-Analgesia Practice Associated With Early Extubation Following Infant Cardiac Surgery: Experience From the Pediatric Heart Network Collaborative Learning Study*
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DOI：
10.1097/pcc.0000000000002005
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发表时间：
2019-10-01
影响因子：
4.1
通讯作者：
Nicolson, Susan C.
中科院分区：
文献类型：
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作者：
Amula, Venu;Vener, David F.;Nicolson, Susan C.
目的：儿科心脏网络赞助了一项多中心协作学习研究，该研究实施了一项临床实践指南，以促进孤立性主动脉缩窄和法洛四联症修复后婴儿的早期拔管。我们试图比较手术室的麻醉实践和ICU的镇静-镇痛管理之前和之后的指南，导致早期拔管。设计：对2013年1月至2015年4月的多中心研究数据进行二次分析。在指南实施前后比较了麻醉剂、镇静剂和镇痛剂暴露的预定变量。使用倾向评分加权逻辑回归分析确定术中右美托咪定给药对早期拔管的独立影响。地点：5家儿童医院。患者：共240例接受主动脉缩窄或法洛四联症修复术的研究受试者（119例指南实施前和121例指南实施后）。干预：无。测量和主要结果：临床实践指南的实施伴随着阿片类药物术中中位总剂量的减少（芬太尼当量为49.7 vs 24.0 μ g/kg，p < 0.001）和苯二氮卓类药物（1.0 vs 0.4 mg/kg咪达唑仑当量，p < 0.001），但中位挥发性麻醉剂暴露量无变化（1.3 vs 1.5最小肺泡浓度hr，p = 0.25）。当调整其他协变量时，术中右美托咪定给药与早期拔管相关（比值比2.5，95% CI，1.02-5.99，p = 0.04）。在ICU中，更多患者接受右美托咪定治疗（43% vs 75%），但指南实施后伴随苯二氮卓类药物暴露的频率（66% vs 57%，p < 0.001）和累积中位剂量（0.5 vs 0.3 mg/kg ME，p = 0.003）均降低。结论：早期拔管临床实践指南的实施导致阿片类药物和苯二氮卓类药物的剂量减少，而手术室使用的挥发性麻醉剂没有变化。术中右美托咪定给药与早期拔管独立相关。术后早期苯二氮卓类药物的总暴露量降低。
Objectives: The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation. Design: Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation. Setting: Five children's hospitals. Patients: A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation). Interventions: None. Measurements and Main Results: Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 mu g/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4 mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02-5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3 mg/kg of ME, p = 0.003) postguideline implementation. Conclusions: The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period.