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再置換膝関節全摘術を受けた患者における麻酔の種類と術後成績および合併症との関連
Association of Anesthesia Type with Postoperative Outcome and Complications in Patients Undergoing Revision Total Knee Arthroplasty.
PMID: 32663884 DOI: 10.1055/s-0040-1713776.
抄録
再置換膝関節形成術（TKA）は、ますます一般的になってきており、変形性膝関節症の治療に有効であるが、一次TKAよりも合併症の発生率が高い。麻酔選択には周術期リスクがあり、一次TKAでは広範囲に研究されており、全身麻酔と比較して局所麻酔で良好な結果を示している。再置換TKAにおける麻酔薬選択の影響はあまり研究されていない。American College of Surgeons National Surgical Quality Improvement Programのデータベースを用いてレトロスペクティブコホート研究が行われた。2014年から2017年の間に再置換TKAを受けた患者を3つの麻酔コホートに分けた。(1)全身麻酔、(2)局所麻酔、(3)全身麻酔と局所麻酔の併用。一変量解析と多変量解析を用いて、患者の特徴と術後30日の転帰を解析した。解析にはボンフェローニ補正を適用した。合計8,820人の患者が同定された。そのうち全身麻酔が3,192例、局所麻酔が3,474例、複合麻酔が2,154例であった。多変量解析の結果、局所麻酔は全身麻酔と比較して合併症（=0.008）、周術期輸血（<0.001）、入院期間延長（<0.001）のオッズが減少した。また、局所麻酔は併用麻酔と比較して周術期輸血（<0.001）と在院期間延長（=0.006）のオッズが減少した。しかし、多変量解析の結果、局所麻酔は創傷、肺、腎、尿路、血栓塞栓症、心臓合併症のオッズの減少とは関連せず、手術室への復帰、入院期間の延長、軽度および重度の合併症、死亡率とは関連していなかった。大規模な手術データベースのレトロスペクティブ分析から、全身麻酔を受けている患者は、局所麻酔を受けている患者と比較して、術後に有害な転帰を起こす可能性が高いことが示唆されている。これらの知見を検証するために、プロスペクティブで対照的な試験を実施すべきである。
Revision total knee arthroplasty (TKA) is an increasingly common procedure and is effective in treating knee osteoarthritis, but it has higher complication rates than primary TKA. Anesthetic choice poses perioperative risk that has been extensively studied in primary TKA, showing favorable results for regional anesthesia compared with general anesthesia. The impact of anesthetic choice in revision TKAs is not well studied. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent revision TKAs between 2014 and 2017 were divided into three anesthesia cohorts: (1) general anesthesia, (2) regional anesthesia, and (3) combined general-regional anesthesia. Univariate and multivariate analyses were used to analyze patient characteristics and 30-day postoperative outcomes. Bonferroni correction was applied for analysis. In total, 8,820 patients were identified. Of whom, 3,192 patients underwent general anesthesia, 3,474 patients underwent regional anesthesia, and 2,154 patients underwent combined anesthesia. After multivariate analyses, regional anesthesia was associated with decreased odds for any complication ( = 0.008), perioperative blood transfusion ( < 0.001), and extended length of stay ( < 0.001) compared with general anesthesia. In addition, regional anesthesia was associated with decreased odds for perioperative blood transfusion ( < 0.001) and extended length of stay ( = 0.006) compared with combined anesthesia. However, following multivariate analysis, regional anesthesia was not associated with decreased odds of wound, pulmonary, renal, urinary tract, thromboembolic, and cardiac complications, and was not associated with return to operating room, extended length of stay, minor and major complications, and mortality. Retrospective analysis of a large surgical database suggests that patients receiving general anesthesia have increased likelihood for developing adverse postoperative outcomes relative to patients receiving regional anesthesia. Prospective and controlled trials should be conducted to verify these findings.
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