低收入和中等收入国家腹部手术后死亡的机制和原因:FALCON 试验的二次分析。

IF 19.9 1区 医学 Q1 PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH
Lancet Global Health Pub Date : 2024-11-01 Epub Date: 2024-09-05 DOI:10.1016/S2214-109X(24)00318-8
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引用次数: 0

摘要

背景:手术后死亡对患者、家庭和社区都是巨大的打击,但在低收入和中等收入国家(LMICs)仍很常见。我们的目标是利用现有全球随机试验的高质量数据来描述低收入和中等收入国家术后死亡的原因和机制。为此,我们开发了一个新颖的框架,既借鉴了现有的分类系统,又在数据分析过程中获得了新的见解:本研究是对 FALCON 试验的一项预先计划的二次分析,该试验在 7 个低收入、中等收入国家/地区(贝宁、加纳、印度、墨西哥、尼日利亚、卢旺达和南非)的 54 家医院进行。FALCON 是一项务实的 2 × 2 因式随机对照试验,比较了两种备皮(10% 聚维酮碘水溶液与 2% 洗必泰酒精)和缝合(三氯生涂层与无涂层)干预措施的效果。未进行手术或失去随访的患者被排除在外(231 人)。本次分析的主要结果是手术后 30 天内的死亡机制和原因,根据严重不良事件报告采用改良的口头尸检策略确定。通过混合效应 Cox 比例危险模型探讨了与死亡率相关的因素。FALCON试验已在ClinicalTrials.gov上注册,编号为NCT03700749.研究结果:FALCON试验的这项预先计划的二次分析纳入了5558名接受腹部手术的患者,其中4248名(76-4%)患者在三级转诊中心接受了手术,1310名(23-6%)患者在一级转诊医院(即地区或农村医院)接受了手术。5558 例手术中有 3704 例(66-7%)为急诊手术。5558名患者中有306名(5-5%)在术后30天内死亡。306 例死亡病例中有 226 例(74%)死于循环系统衰竭,其中 173 例(57%)死于败血症,29 例(9%)死于低血容量休克,包括出血。47人(15%)死于呼吸衰竭。306 名患者中有 60 人(20%)死于无明确死因:45(15%)名患者死于原因不明的败血症,15(5%)名患者死因不明。306例患者中有46例(15%)在术后24小时内死亡,111例(36%)在术后24小时至72小时内死亡,57例(19%)在术后72小时以上至168小时内死亡,92例(30%)在术后1周以上死亡。306名患者中有248人(81%)死于住院,58人(19%)死于院外。调整后的 Cox 回归模型确定了年龄(危险比 1-01,95% CI 1-01-1-02;pFunding:国家健康与护理研究所全球健康研究组。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Mechanisms and causes of death after abdominal surgery in low-income and middle-income countries: a secondary analysis of the FALCON trial.

Background: Death after surgery is devasting for patients, families, and communities, but remains common in low-income and middle-income countries (LMICs). We aimed to use high-quality data from an existing global randomised trial to describe the causes and mechanisms of postoperative mortality in LMICs. To do so, we developed a novel framework, learning from both existing classification systems and emerging insights during data analysis.

Methods: This study was a preplanned secondary analysis of the FALCON trial in 54 hospitals across seven LMICs (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa). FALCON was a pragmatic, 2 × 2 factorial, randomised controlled trial that compared the effectiveness of two types of interventions for skin preparation (10% aqueous povidone-iodine vs 2% alcoholic chlorhexidine) and sutures (triclosan-coated vs uncoated). Patients who did not have surgery or were lost to follow-up were excluded (n=231). The primary outcomes of the present analysis were the mechanism and cause of death within 30-days of surgery, determined using a modified verbal autopsy strategy from serious adverse event reports. Factors associated with mortality were explored in a mixed-effects Cox proportional hazards model. The FALCON trial is registered with ClinicalTrials.gov, NCT03700749.

Findings: This preplanned secondary analysis of the FALCON trial included 5558 patients who underwent abdominal surgery, of whom 4248 (76·4%) patients underwent surgery in tertiary, referral centres and 1310 (23·6%) underwent surgery in primary referral (ie, district or rural) hospitals. 3704 (66·7%) of 5558 surgeries were emergent. 306 (5·5%) of 5558 patients died within 30 days of surgery. 226 (74%) of 306 deaths were due to circulatory system failure, which included 173 (57%) deaths from sepsis and 29 (9%) deaths from hypovolaemic shock including bleeding. 47 (15%) deaths were due to respiratory failure. 60 (20%) of 306 patients died without a clear cause of death: 45 (15%) patients died with sepsis of unknown origin and 15 (5%) patients died of an unknown cause. 46 (15%) of 306 patients died within 24 h, 111 (36%) between 24 h and 72 h, 57 (19%) between >72 h and 168 h, and 92 (30%) more than 1 week after surgery. 248 (81%) of 306 patients died in hospital and 58 (19%) patients died out of hospital. The adjusted Cox regression model identified age (hazard ratio 1·01, 95% CI 1·01-1·02; p<0·0001), ASA grade III-V (4·93, 3·45-7·03; p<0·0001), presence of diabetes (1·47, 1·04-2·41; p=0·033), being an ex-smoker (1·59, 1·10-2·30; p=0·013), emergency surgery (2·08, 1·45-2·98; p<0·0001), cancer (1·98, 1·42-2·76; p<0·0001), and major surgery (3·94, 2·30-6·75; p<0·0001) as risk factors for postoperative mortality INTERPRETATION: Circulatory failure leads to most deaths after abdominal surgery, with sepsis accounting for almost two-thirds. Variability in timing of death highlights opportunities to intervene throughout the perioperative pathway, including after hospital discharge. A high proportion of patients without a clear cause of death reflects the need to improve capacity to rescue and cure by strengthening perioperative systems.

Funding: National Institute for Health and Care Research Global Health Research Unit.

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来源期刊
Lancet Global Health
Lancet Global Health PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH-
CiteScore
44.10
自引率
1.20%
发文量
763
审稿时长
10 weeks
期刊介绍: The Lancet Global Health is an online publication that releases monthly open access (subscription-free) issues.Each issue includes original research, commentary, and correspondence.In addition to this, the publication also provides regular blog posts. The main focus of The Lancet Global Health is on disadvantaged populations, which can include both entire economic regions and marginalized groups within prosperous nations.The publication prefers to cover topics related to reproductive, maternal, neonatal, child, and adolescent health; infectious diseases (including neglected tropical diseases); non-communicable diseases; mental health; the global health workforce; health systems; surgery; and health policy.
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