全麻下抗胆碱酯酶逆转对术后心血管并发症的影响： 回顾性队列研究
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Effects of Anticholinesterase Reversal Under General Anesthesia on Postoperative Cardiovascular Complications: A Retrospective Cohort Study
背景与目的
抗胆碱酯酶药新斯的明和毒蕈碱抑制剂甘罗溴铵经常合用，以逆转神经肌肉的阻滞。这种做法会导致严重的心动过缓或心动过速，但是否影响心血管并发症的发生尚不清楚。与不逆转抗胆碱酯酶比较，我们假设在成人全麻非心脏手术患者中用新斯的明和甘罗溴铵逆转抗胆碱酯酶会增加术后心血管并发症的风险。
方 法
我们对2007年1月至2015年12月接受全麻手术患者的主要医疗保健网络的医院登记数据进行了预先指定的回顾性分析。主要结果为术后30天内心律失常、急性心力衰竭、短暂性脑缺血发作、缺血性卒中和急性心肌梗死。我们进行了亚组敏感性分析和倾向性评分调整，并探讨了暴露与心血管并发症高危患者亚组预后的关系。
结 果
在接受神经肌肉阻滞的98147例患者中，73181例患者（74.6%）接受了新斯的明和甘罗溴铵，而24966例患者（25.4%）没有。抗胆碱酯酶逆转组5612例患者（7.7%）和对照组1651例患者（6.6%）（P<0.001）出现主要结果。调整临床协变量后，新斯的明和甘罗溴铵的运用与心动过速（调整后的比值比=2.1[95%CI，1.97–2.23]；P<0.001）和心动过缓（调整后的比值比=2.84[95%CI，2.49–3.24]）呈剂量依赖关系（趋势分别为P<0.001）；但不伴有术后心血管并发症（校正比值比=1.03[95%CI，0.97–1.1]；P=0.33）。我们通过高年龄、高风险手术和房颤病史确定了抗胆碱酯酶逆转的显著效果（相互作用P分别为0.002、.001和0.02）。通过使用主要影响和暴露-风险相互作用项的线性组合，我们发现在这些患者的亚组中，抗胆碱酯酶逆转与心血管并发症之间存在较弱的相关性。
结 论
新斯的明和甘罗溴铵逆转神经肌肉阻滞与术中心动过速和心动过缓的发生率增加有关，但与术后30天心血管并发症无关。探索性分析表明，高风险的术后心血管并发症可能改变抗胆碱酯酶逆转对临床相关性的影响。
原始文献摘要
Denys Shaydenfish, Cand Med, Flora T. Scheffenbichler, Cand Med,et al.Effects of Anticholinesterase Reversal Under General Anesthesia on Postoperative Cardiovascular Complications: A Retrospective Cohort Study.Anesth Analg 2020;130:685–95.
BACKGROUND: The anticholinesterase neostigmine and the muscarinic inhibitor glycopyrrolate are frequently coadministered for the reversal of neuromuscular blockade. This practice can precipitate severe bradycardia or tachycardia, but whether it affects the incidence of cardiovascular complications remains unclear. We hypothesized that anticholinesterase reversal with neostigmine and glycopyrrolate versus no anticholinesterase reversal increases the risk of postoperative cardiovascular complications among adult patients undergoing noncardiac surgery with general anesthesia.
METHODS: We conducted a prespecified retrospective analysis of hospital registry data from a major health care network for patients undergoing surgery with general anesthesia from January 2007 to December 2015. The primary outcome was a composite of cardiac dysrhythmia, acute heart failure, transient ischemic attack, ischemic stroke, and acute myocardial infarction within 30 days after surgery. We performed sensitivity analyses in subgroups and propensity score adjustment and explored the association between exposure and outcome in subgroups of patients with high risk of cardiovascular complications.
RESULTS: Of the 98,147 cases receiving neuromuscular blockade, 73,181 (74.6%) received neostigmine and glycopyrrolate, while 24,966 (25.4%) did not. A total of 5612 patients (7.7%) in the anticholinesterase reversal group and 1651 (6.6%) in the control group (P < .001) experienced the primary outcome. After adjustment for clinical covariates, neostigmine and glycopyrrolate exposure was significantly associated in a dose-dependent fashion (P for trend <.001, respectively) with tachycardia (adjusted odds ratio = 2.1 [95% CI, 1.97–2.23]; P < .001) and bradycardia (adjusted odds ratio = 2.84 [95% CI, 2.49–3.24]; P < 0.001) but not with postoperative cardiovascular complications (adjusted odds ratio = 1.03 [95% CI, 0.97–1.1]; P =0 .33). We identified a significant effect modification of anticholinesterase reversal by high age, high-risk surgery, and history of atrial fibrillation (P for interaction = .002, 0.001, and0 .02, respectively). By using linear combinations of main effect and exposure–risk interaction terms, we detected significant associations between anticholinesterase reversal and cardiovascular complications toward a higher vulnerability in these patient subgroups.
CONCLUSIONS: Neuromuscular blockade reversal with neostigmine and glycopyrrolate was associated with an increased incidence of intraoperative tachycardia and bradycardia but not with 30-day postoperative cardiovascular complications. Exploratory analyses suggest that a high postoperative cardiovascular complication risk profile may modify the effects of anticholinesterase reversal toward clinical relevance.
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翻译：任文鑫 编辑：冯玉蓉 审校：王贵龙