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自然气道替代气管插管用于小儿内镜食管异物取出：326例患者的回顾性队列研究
贵州医科大学 麻醉与心脏电生理课题组
翻译：文春雷 编辑：田明德 审校：曹莹
背景：儿童内镜下食管异物（EFB）取出时需要麻醉。过去，气管插管一直是这些病例气道管理的金标准。然而，随着越来越多的选择性内镜手术可在丙泊酚镇静下采用自然气道进行，针对需要内镜下取出EFB的特定患者，逐渐转向使用监护麻醉（MAC）。
方法：在这项单中心回顾性队列研究中，我们比较了使用MAC或气管插管的内镜下EFB取出情况。描述性统计总结了按初始气道选择分层的因素，包括麻醉中和麻醉后并发症以及最初使用MAC的患者术中转换为气管插管的频率。为了展示这些因素与麻醉医生气道选择之间关联，我们采用了单变量Firth逻辑回归和分位数回归来估计比值比（95% CI）和β系数（95% CI）。
结果：我们在搜索结果中确定了326名患者。其中，23%（n=75）计划进行插管，77%（n=251）计划进行MAC。三名（0.9%）计划使用MAC的患者在诱导后转为气管插管。其中两名（0.6%）儿童在手术后住院并接受持续气道反应治疗。无患者出现胃内容物反流或异物移位至气管，也没有患者需要使用血管活性药物或心肺复苏。如果异物是硬币（OR，3.3；CI，1.9–5.7，p<.001）或禁食时间超过6小时，麻醉医生选择使用MAC的几率更高。插管患者的中位总手术时间比非插管患者多15分钟（11分钟 vs 26分钟, p< .001）。
结论：本研究表明，MAC可用于选择接受内镜下异物取出的儿童患者，特别是那些吞入硬币、没有反应性气道、禁食超过6小时，并且预计内镜手术将短暂且简单的患者，需要前瞻性的多地点研究来证实这些发现。
原始文献来源：Hannah Lonsdale, Kurt Rodriguez, Ryan Shargo, et al. Natural airway as an alternative to intubation for pediatric endoscopic esophageal foreign body removal: A retrospective cohort study of 326 patients.[J]. Pediatric Anesthesia. 2024;34(7):628-637.
Natural airway as an alternative to intubation for pediatric endoscopic esophageal foreign body removal: A retrospective cohort study of 326 patients
Background: Anesthesia is required for endoscopic removal of esophageal foreign bodies (EFBs) in children. Historically, endotracheal intubation has been the de facto gold standard for airway management in these cases. However, as more elective endoscopic procedures are now performed under propofol sedation with natural airway, there has been a move toward using similar Monitored Anesthesia Care (MAC) for select patients who require endoscopic removal of an EFB.
Methods: In this single-center retrospective cohort study, we compared endoscopic EFB removal with either MAC or endotracheal intubation. Descriptive statistics summarized factors stratified by initial choice of airway technique, including intraand postanesthesia complications and the frequency of mid-procedure conversion to endotracheal intubation in those initially managed with MAC. To demonstrate the magnitude of associations between these factors and the anesthesiologist's choice of airway technique, univariable Firth logistic and quantile regressions were used to estimate odds ratios (95% CI) and beta coefficients (95% CI).
Results:From the initial search, 326 patients were identified. Among them, 23% (n= 75) were planned for intubation and 77% (n= 251) were planned for MAC. Three patients (0.9%) who were initially planned for MAC required conversion to endotracheal intubation after induction. Two (0.6%) of these children were admitted to the hospital after the procedure and treated for ongoing airway reactivity. No patient experienced reflux of gastric contents to the mouth or dislodgement of the foreign body to the airway, and no patient required administration of vasoactive medications or cardiopulmonary resuscitation. Patients had higher odds that the anesthesiologist chose to utilize MAC if the foreign body was a coin (OR, 3.3; CI, 1.9–5.7, p< .001) or if their fasting time was >6 h. Median total operating time was 15 min greater in intubated patients (11 vs. 26 min, p< .001).
Conclusions: This study demonstrates that MAC may be considered for select pediatric patients undergoing endoscopic removal of EFB, especially those who have ingested coins, who do not have reactive airways, who have fasted for >6 h, and in whom the endoscopic procedure is expected to be short and uncomplicated. Prospective multisite studies are needed to confirm these findings.
