阻塞性睡眠呼吸暂停综合征不是病态肥胖患者困难气管插管的危险因素

背景 病态肥胖症(morbid obesity,MO)、阻塞性睡眠呼吸暂停综合征(obstructive sleep apnea,OSA)、颈围(neck circumference,NC)被广泛认为是困难气管插管的独立危险因素.在本研究中,我们试图确定这些因素是否和减肥手术患者困难气管插管风险增加相关.研究的预测性因...     

肝移植患者术后气管导管延迟拔管的危险因素

目的 探讨行肝移植手术患者术后气管导管延迟拔管的危险因素。方法 回顾性分析2018年1月至2021年10月于全麻下行肝移植手术患者339例,男264例,女75例,年龄18～80岁,BMI 14～35 kg/m²,ASAⅡ—Ⅴ级。根据术后24 h内是否拔除气管导管分为两组：正常拔管组和延迟拔管组。采用单因素分析延迟拔管相关的影响因素,多因素Logistic回归分析筛选肝移植术后延迟拔管的独立危险因素。结果 有60例(17.7%)患者术后延迟拔管。与正常拔管组比较,延迟拔管组终末期肝病模型(MELD)评分明显升高(P<0.05),手术时间、冷缺血时间明显延长(P<0.05),术中严重低血压发生率明显升高(P<0.05),术中6%羟乙基淀粉输入量、浓缩红细胞输入量、血浆输入量明显增多,(P<0.05)。多因素Logistic回归分析显示,MELD评分≥17分(OR=1.829,95%CI 1.004～3.333,P=0.049)、浓缩红细胞输入量>4 U(OR=3.264,95%CI 1.650～7.271,P=0.001)和冷缺血时间≥4...     

病态肥胖患者胃减容术的麻醉管理

病态肥胖症（morbid obesity,MO）,特别是合并阻塞性睡眠呼吸暂停综合征（obstructive sleep apnea syndrome,OSAS）患者的麻醉给麻醉医师提出了诸多挑战。充分的术前评估和围术期准备是患者平稳渡过围手术期的关键。MO影响多个重要器官,麻醉前评估除了病史及体格检查外,应着重了解循环和呼吸系统的问题,MO患者气管插管可能更困难,应详细评估气道,制定插管备选策略。此外,不同的药代动力学和药效学,围手术期及术后的管理也同样棘手。现通过1例MO患者的病例,讨论分析此类患者适合的麻醉方法和管理技术。     

肾移植术后气管导管延迟拔管的危险因素分析

目的 探讨肾移植患者术后气管导管延迟拔管的危险因素及对预后的影响。
方法 回顾性分析2017年1月至2020年12月全麻下肾移植手术患者的电子病历资料366例,男261例,女105例,年龄18～64岁。根据拔除气管导管时间是否超过1 h分为两组：常规组和延迟组。采用单因素分析和多因素Logistic回归分析筛选肾移植术后延迟拔管的危险因素。
结果 有80例（21.9%）患者发生延迟拔管。与常规组比较,延迟组男性比例、亲属活体移植例数明显减少（P<0.05）,术前Hb、术前血钙明显降低（P<0.05）,冷缺血时间、麻醉时间明显延长（P<0.05）,诱导使用罗库溴铵和术中输血例数明显增加（P<0.05）,液体总入量、出血量明显增多（P<0.05）,拔管时间、PACU停留时间明显延长（P<0.05）。多因素Logistic回归分析显示,肾移植术后延迟拔管的独立危险因素为：术前Hb<113 g/L（OR=1.847,95%CI 1.076~3.171,P=0.026）、术前血钙<2.48 mmol/L（OR=2.293,95%CI 1.258~4.179,P=0.007）、冷缺血时间>10.5 h（OR=1.986,95%CI 1.139~3.464,P=0.016）和液体总入量>1 975 ml（OR=3.092,95%CI 1.795~5.324,P<0.001）。
结论 术前Hb<113 g/L、术前血钙<2.48 mmol/L、冷缺血时间>10.5 h、液体总入量>1 975 ml是肾移植术后延迟拔管的独立危险因素。     

成人双瓣膜置换术后延迟拔管的危险因素

目的 探讨术前及术中影响成人主动脉瓣、二尖瓣双瓣置换术后延迟拔管(PMV)的危险因素.方法 行双瓣置换术及同期其他手术患者2026例,延迟拔管组230例,对照组1796例.应用统计学方法比较两组患者术后早期结果,筛选导致延迟拔管的术前及术中危险因素.结果 延迟拔管组患者术后并发症发生率较高,住院病死率明显高于对照组(33.5％对0.2％,P＜0.01).年龄＞60岁、糖尿病史、活动期感染性心内膜炎、心功能NYHA分级≥Ⅲ级、术前危重状态、左心室射血分数≤0.50、血肌酐＞ 110 μmol/L、体外循环＞180 min及围手术期应用主动脉球囊反搏是患者双瓣置换术后PMV的危险因素.结论 双瓣置换术后PMV的患者具有较高的住院病死率及并发症发生率,通过危险因素分析可于术前筛选出高危患者,更好地进行围手术期准备,提高患者生存质量.     

影响肝移植术后早期拔管的危险因素分析

目的 肝移植术后延迟拔管原因不明确,本研究旨在开发一种预测影响肝移植术后早期拔管危险因素的风险模型,为提高肝移植患者早期拔除气管插管提供依据。方法 回顾性分析安徽医科大学第一附属医院器官移植中心2018年1月至2021月5月收治的93例成人肝移植患者资料。根据术后24小时是否拔除气管插管分为早期拔管组(58例)和延迟拔管组(35例)。通过单因素和Logistic多因素分析出影响患者早期拔管的因素。结果 对影响肝移植术后患者早期拔管因素进行单因素和logistic多因素分析,评估得出术前Child-Pugh评分和手术时间是影响肝移植术后患者早期拔管的独立危险因素,术前Child-Pugh评分OR 1.542(95%CI 1.029～2.309),P=0.036,手术时间OR 2.059(95%CI 1.160～3.653),P=0.014。由术前Child-Pugh评分和手术时间组成模型和常用的肝移植患者的严重程度评分进行ROC分析,模型AUC 0.791;术前Child-Pugh评分AUC 0.743,术前MELD评分AUC 0.709,与这两个评分相比,预测模型在预测肝移植术后早期拔...     

非心脏手术后延迟拔管的危险因素分析及预测模型建立

目的 探讨非心脏手术后延迟拔管的危险因素并建立预测模型。
方法 回顾性分析2020年9—10月接受非心脏手术且术后于PACU进行麻醉苏醒的1 009例患者临床资料。根据术后是否出现延迟拔管将患者分为两组：延迟拔管组（拔管时间＞1 h）和非延迟拔管组（拔管时间≤1 h）。采用LASSO回归和多因素Logistic回归建立预测模型,受试者工作特征（ROC）曲线、曲线下面积（AUC）和决策曲线分析评估该预测模型对非心脏手术后延迟拔管的预测价值。
结果 发生延迟拔管253例（25.1%）。多因素Logistic回归分析
结果 显示,ACCI评分（≥3分）、BMI（≤22.66 kg/m²）、术中罗库溴铵的使用、术中输血、手术时间（≥166 min）、留置导尿管、PACU内丙泊酚的使用和PACU内血管活性药物的使用是术后延迟拔管的独立危险因素（P＜0.05）。预测模型的AUC为0.730（95%CI 0.695～0.765, P<0.001）,敏感性81.4%,特异性55.4%。决策曲线分析显示,该预测模型对延迟拔管的预测具有重要临床价值。
结论 ACCI评分（≥3分）、BMI（≤22.66 kg/m²）、术中罗库溴铵的使用、术中输血、手术时间（≥166 min）、留置导尿管、PACU内丙泊酚的使用和PACU内血管活性药物的使用是非心脏手术后延迟拔管的危险因素,基于以上危险因素建立的模型具有较好的预测价值。     

肥胖患者腹腔镜胃减容术后早期低氧血症危险因素分析

目的探讨肥胖患者腹腔镜胃减容术(LSG)后早期低氧血症的危险因素。方法回顾性分析2017年1月—2021年12月全身麻醉下行LSG的271例肥胖患者资料, 美国麻醉医师协会(ASA)分级Ⅰ～Ⅲ级、体重指数(BMI)≥35 kg/m2、性别不限、年龄18～50岁。根据患者入麻醉后监测治疗室(PACU)30 min是否出现低氧血症, 分为低氧血症组[动脉氧分压/吸入氧浓度(PaO2/FiO2)≤300 mmHg(1 mmHg=0.133 kPa), 93例]和非低氧血症组(PaO2/FiO2>300 mmHg, 178例)。单因素分析两组患者一般情况、术前吸烟史及合并基础病史、术前检查、手术和麻醉相关因素, 将两组差异有统计学意义的因素纳入多因素logistic回归分析, 分析肥胖患者LSG后早期低氧血症的危险因素。结果纳入患者术后早期低氧血症发生率为34.7%。与非低氧血症组比较, 低氧血症组男性占比、体重、BMI、有阻塞性睡眠呼吸暂停低通气综合征(OSAHS)病史比例、术中舒芬太尼用量等较高(均P<0.05), 手术时间较长(P<0.05), 术前第1秒用力呼气量(F...     

吸入氧浓度对行腹腔镜胃减容术的病态肥胖患者肺氧合和呼吸力学的影响

目的探讨不同FiO2对行腹腔镜胃减容术的病态肥胖患者肺氧合和呼吸力学的影响。方法选择择期行腹腔镜胃减容术的病态肥胖患者99例。采用随机数字表法分为3组,全身麻醉插管后维持FiO240%(L组,33例)、FiO260%(M组,33例)、FiO280%(H组,33例),直至手术结束。于未吸氧前(T0)、达目标氧浓度后5 min(T1)、气腹后1 h(T4)、气腹结束后5 min(T5)、入PACU后10 min(T6)、出PACU时(T7)采集桡动脉血进行血气分析,记录并计算氧合指数(oxygenation index,PaO2/FiO2)、动脉肺泡氧分压比(arterial/alveolar oxygen partial pressure ratio,a/APO2)、PaCO2;记录T1、气腹后5 min(T2)、气腹后30 min(T3)、T4、T5时刻气道平台压(plateau airway pressure,Pplat)、气道峰压(peak airway pressure,Ppeak)、动态肺顺应性(dynamic lung compliance,Cdyn);记录停药开始到拔管的时间、PACU停留时间、高氧血症(术中PaO2>300 mmHg,1 mmHg=0.133 kPa)和去氧饱和发生情况(术中SpO2<95%的例数、拔管后5 min SpO2下降至92%的例数及时长、PACU内SpO2<92%的例数)、不良事件发生情况(PACU内恶心呕吐、需应用口咽通气道或无创正压通气)、术后住院天数。结果3组患者一般资料差异无统计学意义(P>0.05)。与M组比较,L组、H组PACU停留时间延长(P<0.05),其余临床特征资料差异无统计学意义(P>0.05);H组T6、T7时点PaO2/FiO2较L组、M组降低(P<0.05),T4时点PaO2/FiO2、T6时点PaCO2较L组升高,T5时点Cdyn较L组降低(P<0.05),高氧血症的发生率较L组、M组升高(P<0.05);3组T0、T1、T5时点PaO2/FiO2、PaCO2,T0、T1、T4~T7时点a/APO2,T1~T4时点Cdyn,T1~T5时点Pplat、Ppeak差异无统计学意义(P>0.05)。与T0时点比较,3组T1、T4、T6、T7时点及L组T5时点PaO2/FiO2降低(P<0.05),3组T1、T4~T7时点a/APO2降低、PaCO2升高(P<0.05)。与T6时点比较,3组T7时点PaO2/FiO2、a/APO2、PaCO2差异无统计学意义(P>0.05)。与T1时点比较,3组T2~T5时点Pplat、Ppeak升高(P<0.05),Cdyn降低(P<0.05);与T4时点比较,3组T5时点Pplat、Ppeak降低(P<0.05),Cdyn升高(P<0.05)。3组去氧饱和及不良事件的发生情况差异无统计学意义(P>0.05)。结论与40%、80%的FiO2相比,行腹腔镜胃减容术的病态肥胖患者术中给予60%的FiO2对肺氧合和呼吸力学的优化是有效的,同时能够降低高氧血症的发生率且不增加去氧饱和及不良事件的发生风险。     

胃减容术治疗肥胖症

肥胖是全球的高发病之一,它可引起高血压、2型糖尿病、冠心病、脂肪肝、睡眠呼吸暂停综合征等多种并发症,严重影响病人的生存时间和生活质量。饮食控制、体育锻炼、药物等保守治疗对轻度肥胖有效,但对重度肥胖效果不佳,手术是唯一长期有效的治疗方法。笔者结合在减肥手术中的临床实践,对现今流行的胃减容术作一介绍。一、减肥手术的原理及主要术式所有的减肥手术都基于两种不同的原理:减少食物吸收或/和限制食物摄入。1.减少吸收型手术:减少吸收型手术主要通过类似于短肠综合征的吸收不良效果来达到减肥的目的,包括空结肠旁路术、空回肠旁路…     

Impaired skeletal muscle mitochondrial function in morbidly obese patients is normalized one year after bariatric surgery

BackgroundObesity and type 2 diabetes are associated with impaired skeletal muscle mitochondrial metabolism. As an intrinsic characteristic of an individual, skeletal muscle mitochondrial dysfunction could be a risk factor for weight gain and obesity-associated co-morbidities, such as type 2 diabetes. On the other hand, impaired skeletal muscle metabolism could be a consequence of obesity. We hypothesize that marked weight loss after bariatric surgery recovers skeletal muscle mitochondrial function.MethodsSkeletal muscle mitochondrial function as assessed by high-resolution respirometry was measured in 8 morbidly obese patients (body mass index [BMI], 41.3±4.7 kg/m²; body fat, 48.3%±5.2%) before and 1 year after bariatric surgery (mean weight loss: 35.0±8.6 kg). The results were compared with a lean (BMI 22.8±1.1 kg/m²; body fat, 15.6%±4.7%) and obese (BMI 33.5±4.2 kg/m²; body fat, 34.1%±6.3%) control group.ResultsBefore surgery, adenosine diphosphate (ADP)-stimulated (state 3) respiration on glutamate/succinate was decreased compared with lean patients (9.5±2.4 versus 15.6±4.4 O₂ flux/mtDNA; P<.05). One year after surgery, mitochondrial function was comparable to that of lean controls (after weight loss, 12.3±5.5; lean, 15.6±4.4 O₂ flux/mtDNA). In addition, we observed an increased state 3 respiration on a lipid substrate after weight loss (10.0±3.2 versus 14.0±6.6 O₂ flux/mtDNA; P< .05).ConclusionWe conclude that impaired skeletal muscle mitochondrial function is a consequence of obesity that recovers after marked weight loss.     

Obesity hypoventilation syndrome in bariatric surgery patients: an underestimated disease

BackgroundObesity is a known risk factor for obesity hypoventilation syndrome (OHS). However, study on the prevalence and clinical characteristics of OHS among bariatric surgery patients is scarce.ObjectivesTo investigate the prevalence of OHS in bariatric surgery patients and to identify its related predictors.SettingThe study was conducted at a bariatric surgery center in a tertiary university hospital.MethodsA cross sectional analysis was performed in the patients undergoing bariatric surgery between March 2017 and January 2020. Anthropometric, laboratory, pulmonary function, blood gas analysis, and polysomnographic data was collected and analyzed.ResultsOf 522 patients, the overall prevalence of OHS was 15.1%, with men (22.8 %) having a greater frequency than women (9.4%) (P < .001). The prevalence increases with obesity severity, from 4.1% in those with body mass index (BMI) <35 kg/m² to 39.1% in those with BMI ≥50 kg/m². Of 404 patients with obstructive sleep apnea (OSA), OHS was present in 17.3%, with 9.8% in mild OSA, 10.0% in moderate OSA, and 27.3%in severe OSA. Only 11.4% of patients diagnosed with OHS had no OSA. On logistic regression, BMI (odds ratio [OR]: 1.10; 95% confidence interval [CI], 1.01–1.21; P = .033), neck circumference (OR: 1.15; 95% CI, 1.03–1.28; P = .014), serum bicarbonate (OR: 1.39; 95% CI, 1.20–1.61; P = .000), C-reactive protein (CRP) (OR: 1.04; 95% CI, 1.00–1.07; P = .034) were independently associated with OHS.ConclusionIn bariatric surgery patients, OHS presented a high prevalence, especially in men. Higher levels of BMI, neck circumference, serum bicarbonate, and CRP indicated higher risk of OHS.     

Transnasal small-caliber esophagogastroduodenoscopy for preoperative evaluation of the high-risk morbidly obese patient

Background Esophagogastroduodenoscopy (EGD) is an important facet of the preoperative evaluation for bariatric surgery. Morbidly obese patients are at high risk for airway complications during this procedure, and an attractive alternative is transnasal EGD. This report describes a series of patients evaluated successfully using this technique. Methods All patients undergoing preoperative transnasal small-caliber EGD for morbid obesity surgery between September 2004 and June 2005 at a Veterans Affairs Hospital were included in the analysis. The variables assessed were the adequacy of the examination, patient tolerance, the need for sedation, and the ability to perform interventions. Results The study enrolled 25 patients (17 men and 8 women) with an average age of 55 years (range, 44–63 years) and an average body mass index (BMI) of 47 kg/m² (range, 38–69 kg/m²). All the patients met the 1991 National Institutes of Health (NIH) Consensus Conference Criteria for bariatric surgery and were undergoing preoperative evaluation. The most common comorbidities were hypertension (82%), diabetes mellitus (80%), and obstructive sleep apnea (68%). All 25 patients had successful cannulation of the duodenum’s second portion with excellent tolerance. There were no sedation requirements for 23 (92%) of the 25 patients. Significant pathology was found in 14 (56%) of the 25 patients, including hiatal hernia (28%), gastritis (16%), esophageal intestinal metaplasia (16%), esophagitis (12%), gastric polyps (8%), gastric ulcer (4%) and esophageal varices (4%). Biopsies were indicated for 12 patients and successful for all 12 (100%). Conclusion Transnasal small-caliber EGD is a feasible and safe alternative to conventional EGD for the preoperative evaluation of patients undergoing bariatric surgery. It requires minimal to no sedation in a population at high risk for complications in this setting. In addition, this technique is effective in identifying pathology that requires preoperative treatment and offers a complete examination with biopsy capabilities. This technique should be considered for all morbidly obese patients at high risk for airway compromise during EGD.     

Leveling the learning curve for laparoscopic bariatric surgery

Background The learning curve for laparoscopic bariatric surgery is associated with increased morbidity and mortality.Methods The study included the first 100 patients undergoing laparoscopic Roux-en-Y gastric bypass (LGB) by a designated surgical team. Surgeon A operated as primary surgeon, with surgeon B assisting (Stage 1). Surgeon B learned LGB in stages: exposure and jejunojejunostomy (stage 2), gastric pouch (stage 3), gastrojejunostomy (stage 4), and sequence all steps (stage 5).Results Surgeon A achieved confidence with LGB after 20 cases and surgeon B after 25 cases (stage 2), 18 cases (stage 3), 21 cases (stage 4), and 16 cases (stage 5). Complications (8%) included small bowel obstruction (three); pulmonary embolus (two), and leak, stomal stenosis, and gastrogastric fistula (one each). There was a decreasing trend for operative duration, length of stay, and complications across the five stages (p < 0.05).Conclusions By transferring skills in stages, a laparoscopic bariatric program can be established with minimal morbidity and mortality.     

Using the preoperative psychological evaluation to determine psychosocial risk factors for CPAP nonadherence among bariatric surgery candidates

BackgroundObstructive sleep apnea (OSA) is prevalent among bariatric surgery candidates and is associated with numerous adverse health conditions, both pre- and postoperatively. Continuous positive airway pressure therapy (CPAP) is the first-line treatment for OSA, but it requires significant behavioral changes. As such, CPAP adherence is a significant problem in OSA treatment. Information from the preoperative psychological evaluation may be used to identify psychosocial risk factors associated with CPAP nonadherence and inform the implementation of more specific and appropriate interventions.ObjectivesExamine the utility of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) behavioral/externalizing dysfunction scale scores to determine personality and psychopathology associations with, and risk for, CPAP nonadherence.SettingAcademic medical center.MethodsPatients who underwent a preoperative psychological evaluation and were diagnosed with OSA (n = 358) were divided into 2 groups: CPAP adherent (n = 271) and CPAP nonadherent (n = 87). Independent samples t tests were computed to examine differences in average MMPI-2-RF scale scores between these groups. Relative risk ratios were computed using multiple MMPI-2-RF substantive scale score cut-offs to determine which MMPI-2-RF scales were associated with increased risk of CPAP nonadherence.ResultsHigher scores on scales measuring behavioral/externalizing dysfunction and family problems were associated with and indicative of risk for CPAP nonadherence.ConclusionsCPAP nonadherence is related to and may be affected by generally higher levels of behavioral/externalizing dysfunction. Using a broadband measure of personality and psychopathology, like the MMPI-2-RF, during the preoperative evaluation can provide important information about co-morbid symptoms that may interfere with CPAP adherence. Considering this information during preoperative treatment planning could increase the likelihood of preoperative CPAP adherence and reduce the likelihood of adverse postoperative outcomes.     

Analysis of the risk factors for perioperative morbidity after laparoscopic revisional bariatric procedures: results from the multicenter Polish Revision Obesity Surgery Study

BackgroundThe growing number of primary bariatric operations has led to an increase in demand for revision surgeries. Higher numbers of revisional operations are also observed in Poland, yet their safety and efficacy remain controversial because of a lack of current recommendations and guidelines.ObjectiveTo review risk factors influencing perioperative morbidity.MethodsA retrospective study was conducted to analyze the results of surgical treatment among 12 Polish bariatric centers. Inclusion criteria were laparoscopic revisional bariatric surgeries and patients ≥18 years of age. The study included 795 patients, of whom 621 were female; the mean age was 47 years (range: 40–55 years).ResultsPerioperative morbidity occurred in 92 patients (11.6%) enrolled in the study, including 76 women (82.6%). The median age was 45 years (range: 39–54 years). Statistically significant risk factors in univariate logistic regression models for perioperative complications were the duration of obesity, revisional surgery after Roux-en-Y gastric bypass (RYGB) or adjustable gastric band (AGB), difference in body mass index before revisional surgery and the lowest achieved after primary surgery, and postoperative morbidity of the primary surgery as the cause for revisional bariatric surgery. These factors were included in the multivariate regression model. Revisional surgery after AGB (odds ratio [OR] = 2.18; 95% confidence interval [CI]: 1.28–3.69; P = .004), revisional surgery performed after RYGB (OR = 6.52; 95% CI: 1.98–21.49; P = .002), and revisions due to complication of the primary surgery (OR = 1.89; 95% CI: 1.06–3.34; P = .030) remained independent risk factors for perioperative morbidity.ConclusionRevisional operations after RYGB or AGB and those performed because of postoperative morbidity after primary surgery as the main cause for revisional surgery were associated with a significantly increased risk of postoperative morbidity.     

Perioperative outcome of esophageal fundoplication for gastroesophageal reflux disease in obese and morbidly obese patients

Background

To determine the perioperative safety of esophageal fundoplication for gastroesophageal reflux disease (GERD) in patients with body mass index (BMI) ≥35 kg/m².

Methods

A retrospective review of 4,231 patients who underwent fundoplication for GERD from 2005 to 2009 was performed. Patients were identified via National Surgical Quality Improvement Program and grouped by BMI < 35 versus BMI ≥ 35 kg/m². Univariate analysis compared 30-day outcomes.

Results

Of the 4,231 patients, 3,496 (83%) had BMI < 35 kg/m² and 735 (17%) had BMI ≥ 35 kg/m². Mean BMI for each cohort was 27.9 versus 39.1, respectively. Patients with BMI ≥ 35 kg/m² had significantly longer operative times (129.7 vs 118 minutes, P < .0001) and increased American Society of Anesthesiologists scores (2.43 vs 2.3, P = .001). The overall complication rate was 1.96%. No difference was demonstrated by BMI in complication rate or hospital length of stay. Increased American Society of Anesthesiologists score, diabetes, black race, longer operative time, and intraoperative transfusion significantly increased postoperative complication rates.

Conclusions

No increased risk is conferred to morbidly obese patients who undergo fundoplication for GERD management. This study identified independent patient risk factors for postoperative complication following esophageal fundoplication.