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Risk Factors for Postoperative Nausea and Vomiting in Surgical Patients Undergoing Patient Controlled Intravenous Analgesia
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摘要:
目的 分析手术患者接受患者自控静脉镇痛(patient controlled intravenous analgesia，PCIA)期间发生术后恶心呕吐(postoperative nausea and vomiting，PONV)的危险因素。 方法 本研究为回顾性队列研究，纳入2023年7月1日—10月31日在北京协和医院接受外科手术且术后接受PCIA的患者。通过电子病历系统获取患者的一般资料、既往史、手术信息、术中用药信息、术后镇痛随访信息。根据接受PCIA期间PONV的发生情况，将患者分为PCIA-PONV组和非PCIA-PONV组；根据是否发生术后呕吐(postoperative vomiting，POV)，将其分为PCIA-POV组和非PCIA-POV组。采用多因素Logistic回归分析法筛选PCIA-PONV和PCIA-POV的危险因素。 结果 共纳入1373例患者，其中PCIA-PONV组676例，PCIA-PONV的发生率为49.2%；PCIA-POV组285例，PCIA-POV的发生率为20.8%。多因素Logistic回归分析显示，女性(OR=2.134，95% CI：1.590~2.865，P＜0.001)、腹部手术(OR=1.655，95% CI：1.253~2.186，P＜0.001)是手术患者接受PCIA期间出现PONV的危险因素，而年龄增长(OR=0.990，95% CI：0.982~0.998，P=0.019)、体质量指数增加(OR=0.961，95% CI：0.932~0.991，P=0.012)则是其保护因素；女性(OR=2.646，95% CI：1.754~3.992，P＜0.001)、全麻史(OR=1.372，95% CI：1.042~1.806，P=0.024)、术中使用大剂量阿片类药物(OR=1.607，95% CI：1.206~2.142，P=0.001)是手术患者接受PCIA期间出现POV的危险因素，而术中未使用肌松拮抗剂(OR=0.393，95% CI：0.237~0.651，P＜0.001)则是其保护因素。 结论 本研究初步揭示了手术患者接受PCIA期间发生PONV的危险因素，完善的术前评估及合理的围术期管理策略对于预防PCIA-PONV具有重要意义。 Abstract:Objective To identify the risk factors for postoperative nausea and vomiting (PONV) in surgical patients undergoing patient controlled intravenous analgesia (PCIA). Methods Our study was a retrospective cohort study, including patients who underwent surgery at Peking Union Medical College Hospital from July 1 to October 31, 2023 and received PCIA after surgery. Patient characteristics, medical history, surgical information, intraoperative medication information, postoperative analgesia follow-up information were obtained through the electronic medical record system. The patients were divided into PCIA-PONV group and non-PCIA-PONV group, depending on the occurrence of PONV during PCIA, and all patients were also divided into PCIA-POV group and non-PCIA-POV according to whether postoperative vomiting (POV) occurred. Multivariate Logistic regression analysis was used to identify the risk factors for PCIA-PONV and PCIA-POV. Results A total of 1373 patients were included in this study, with 676 cases in PCIA-PONV group. The incidence of PCIA-PONV was 49.2%. There were 285 patients in PCIA-POV group, and the incidence of PCIA-POV was 20.8%. The results of multivariate Logistic regression analysis showed that female (OR=2.134, 95% CI: 1.590-2.865, P < 0.001) and abdominal surgery (OR=1.655, 95% CI: 1.253-2.186, P < 0.001) were risk factors for PCIA-PONV, whereas the increase of age (OR=0.990, 95% CI: 0.982-0.998, P=0.019) and the increase of BMI (OR=0.961, 95% CI: 0.932-0.991, P=0.012) were protective factors for PCIA-PONV. Female (OR=2.646, 95% CI: 1.754-3.992, P < 0.001), history of general anesthesia (OR=1.372, 95% CI: 1.042-1.806, P=0.024), and intraoperative use of high-dose opioids (OR=1.607, 95% CI: 1.206-2.142, P=0.001) were risk factors for PCIA-POV, whereas no intraoperative use of neuromuscular blocking antagonists (OR=0.393, 95% CI: 0.237-0.651, P < 0.001) was protective factor for PCIA-POV. Conclusions Our study reveals the risk factors for PONV in surgical patients undergoing PCIA, and shows that comprehensive preoperative assessment and reasonable perioperative management strategies are significant in the prevention of PCIA-PONV. 作者贡献：吴觉伦负责研究设计、数据收集、数据处理、统计分析及论文撰写；田园、聂卫华负责数据收集与数据处理；张越伦负责统计分析与论文修改；申乐负责研究设计、统计分析与论文修改。利益冲突：所有作者均声明不存在利益冲突 -
表 1 1373例接受PCIA患者的基线情况(根据PCIA-PONV分组)[n(%)]
Table 1. Baseline of 1373 patients receiving PCIA(grouping based on PCIA-PONV) [n(%)]
变量 PCIA-PONV
(n=676)非PCIA-PONV
(n=697)P值 年龄(x±s，岁) 51.2±15.1 54.3±15.0 ＜0.001 性别 ＜0.001 男性 132(19.5) 255(36.6) 女性 544(80.5) 442(63.4) BMI(x±s，kg/m2) 23.5±3.6 24.3±3.9 ＜0.001 ASA分级 0.128 Ⅰ~Ⅱ 603(89.2) 603(86.5) ≥Ⅲ 73(10.8) 94(13.5) 吸烟史 0.001 有 35(5.2) 71(10.2) 无 641(94.8) 626(89.8) 饮酒史 0.001 有 22(3.3) 52(7.5) 无 654(96.7) 645(92.5) 高血压史 0.033 有 121(17.9) 157(22.5) 无 555(82.1) 540(77.5) 糖尿病史 0.240 有 52(7.7) 66(9.5) 无 624(92.3) 631(90.5) 全麻史 0.731 有 278(41.1) 293(42.0) 无 398(58.9) 404(58.0) 手术种类 0.267 择期手术 666(98.5) 681(97.7) 急诊手术 10(1.5) 16(2.3) 手术方式 ＜0.001 腹部手术 515(76.2) 417(59.8) 非腹部手术 161(23.8) 280(40.2) 手术时长 0.011 ＜3 h 290(42.9) 347(49.8) ≥3 h 386(57.1) 350(50.2) 术中麻醉维持方式 0.079 全静脉麻醉 150(22.2) 183(26.3) 静吸复合麻醉 526(77.8) 514(73.7) 阿片类药物用量 0.026 ＜400 μg 325(48.1) 377(54.1) ≥400 μg 351(51.9) 520(45.9) 地塞米松 0.711 有 633(93.6) 656(94.1) 无 43(6.4) 41(5.9) 昂丹司琼 0.008 有 456(67.5) 422(60.5) 无 220(32.5) 275(39.5) 肌松拮抗剂 0.014 新斯的明 293(43.3) 335(48.1) 舒更葡糖钠 276(40.8) 228(32.7) 无拮抗 96(14.2) 116(16.6) PCIA(patient controlled intravenous analgesia)：患者自控静脉镇痛；PONV(postoperative nausea and vomiting)：术后恶心呕吐；BMI(body mass index)：体质量指数；ASA(American Society of Anesthesiologists)：美国麻醉医师协会 
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表 2 1373例接受PCIA患者的基线情况(根据PCIA-POV分组)[n(%)]
Table 2. Baseline of 1373 patients receiving PCIA(grouping based on PCIA-POV) [n(%)]
变量 PCIA-POV
(n=285)非PCIA-POV
(n=1088)P值 年龄(x±s，岁) 50.6±15.2 53.3±15.1 0.007 性别 ＜0.001 男性 40(14.0) 347(31.9) 女性 245(86.0) 741(68.1) BMI(x±s，kg/m2) 23.4±3.7 24.0±3.7 0.012 ASA分级 0.249 Ⅰ~Ⅱ 256(89.8) 950(87.3) ≥ Ⅲ 29(10.2) 138(12.7) 吸烟史 ＜0.001 有 8(2.8) 98(9.0) 无 277(97.2) 990(91.0) 饮酒史 0.001 有 4(1.4) 70(6.4) 无 281(98.6) 1018(93.6) 高血压史 0.345 有 52(18.2) 226(20.8) 无 233(81.8) 862(79.2) 糖尿病史 0.024 有 15(5.3) 103(9.5) 无 270(94.7) 985(90.5) 全麻史 0.092 有 131(46.0) 440(40.4) 无 154(54.0) 648(59.6) 手术种类 0.495 择期手术 281(98.6) 1066(98.0) 急诊手术 4(1.4) 22(2.0) 手术方式 0.008 腹部手术 212(74.4) 720(66.2) 非腹部手术 73(25.6) 368(33.8) 手术时长 0.614 ＜3 h 136(47.7) 501(46.0) ≥3 h 149(52.3) 587(54.0) 术中麻醉维持方式 0.342 全静脉麻醉 63(22.1) 270(24.8) 静吸复合麻醉 222(77.9) 818(75.2) 阿片类药物用量 0.050 ＜400 μg 131(46.0) 571(52.5) ≥400 μg 154(54.0) 517(47.5) 地塞米松 0.876 有 267(93.7) 1022(93.9) 无 18(6.3) 66(6.1) 昂丹司琼 0.136 有 193(67.5) 685(63.0) 无 92(32.5) 403(37.0) 肌松拮抗剂 0.006 新斯的明 130(45.6) 498(45.8) 舒更葡糖钠 123(43.2) 381(35.0) 无拮抗 27(9.5) 185(17.0) PCIA、BMI、ASA：同表 1；POV(postoperative vomiting)：术后呕吐
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表 3 PCIA-PONV与术后疼痛及胃肠道功能的关系[n(%)]
Table 3. The relationship between PCIA-PONV and postoperative pain and gastrointestinal function[n(%)]
变量 PCIA-PONV
(n=676)非PCIA-PONV
(n=697)P值 术后第1天疼痛NRS评分 ＜0.001 0~3分 269(39.8) 435(62.4) ≥4分 407(60.2) 262(37.6) 术后第1天胃肠功能 ＜0.001 未排气 487(72.0) 348(49.9) 已排气 189(28.0) 349(50.1) PCIA、PONV：同表 1；NRS(numerical rating scale)：数字评定量表
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表 4 PCIA-POV与术后疼痛及胃肠道功能的关系[n(%)]
Table 4. The relationship between PCIA-POV and postoperative pain and gastrointestinal function[n(%)]
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表 5 PCIA-PONV单因素Logistic回归分析结果
Table 5. PCIA-PONV univariate Logistic regression analysis results
变量 OR值 95% CI P值 年龄(连续变量) 0.986 0.980~0.994 ＜0.001 女性(与男性相比) 2.378 1.861~3.037 ＜0.001 BMI(连续变量) 0.942 0.915~0.969 ＜0.001 ASA分级≥Ⅲ(与ASA分级Ⅰ~Ⅱ相比) 0.777 0.561~1.076 0.128 吸烟史(与无吸烟史相比) 0.481 0.316~0.732 ＜0.001 饮酒史(与无饮酒史相比) 0.417 0.251~0.695 ＜0.001 高血压史(与无高血压史相比) 0.750 0.575~0.977 0.033 糖尿病史(与无糖尿病史相比) 0.797 0.545~1.165 0.241 全麻史(与无全麻史相比) 0.963 0.777~1.194 0.731 急诊手术(与择期手术相比) 0.639 0.288~1.418 0.271 腹部手术(与非腹部手术相比) 2.148 1.702~2.711 ＜0.001 手术时长≥3 h(与手术时长＜3 h相比) 1.320 1.067~1.632 0.011 静吸复合麻醉(与全静脉麻醉相比) 1.248 0.975~1.599 0.079 阿片类药物用量≥400 μg(与＜400 μg相比) 1.272 1.029~1.573 0.026 术中使用地塞米松(与未使用相比) 0.920 0.592~1.431 0.711 术中使用昂丹司琼(与未使用相比) 1.351 1.083~1.685 0.008 术中使用舒更葡糖钠(与新斯的明相比) 1.384 1.094~1.751 0.007 术中未使用肌松拮抗剂(与新斯的明相比) 0.946 0.692~1.293 0.729 PCIA、PONV、BMI、ASA：同表 1
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表 6 PCIA-PONV多因素Logistic回归分析结果
Table 6. PCIA-PONV multivariate Logistic regression analysis results
变量 校正OR值 95% CI P值 年龄(连续变量) 0.990 0.982~0.998 0.019 女性(与男性相比) 2.134 1.590~2.865 ＜0.001 BMI(连续变量) 0.961 0.932~0.991 0.012 ASA分级≥Ⅲ(与ASA分级Ⅰ~Ⅱ相比) 0.983 0.689~1.402 0.926 吸烟史(与无吸烟史相比) 1.025 0.585~1.795 0.931 饮酒史(与无饮酒史相比) 0.735 0.381~1.416 0.357 高血压史(与无高血压史相比) 1.105 0.813~1.502 0.523 腹部手术(与非腹部手术相比) 1.655 1.253~2.186 ＜0.001 手术时长≥3 h(与手术时长＜3 h相比) 1.265 0.978~1.636 0.073 静吸复合麻醉(与全静脉麻醉相比) 1.014 0.765~1.343 0.925 阿片类药物用量≥400 μg(与＜400 μg相比) 1.220 0.942~1.581 0.132 术中使用昂丹司琼(与未使用相比) 1.019 0.790~1.314 0.886 术中使用舒更葡糖钠(与新斯的明相比) 1.176 0.899~1.537 0.237 术中未使用肌松拮抗剂(与新斯的明相比) 0.704 0.486~1.020 0.063 PCIA、PONV、BMI、ASA：同表 1
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表 7 PCIA-POV单因素Logistic回归分析结果
Table 7. PCIA-POV univariate Logistic regression analysis results
变量 OR值 95% CI P值 年龄(连续变量) 0.988 0.980~0.997 0.007 女性(与男性相比) 2.868 2.006~4.102 ＜0.001 BMI(连续变量) 0.955 0.921~0.990 0.012 ASA分级≥Ⅲ(与ASA分级Ⅰ~Ⅱ相比) 0.780 0.511~1.191 0.250 吸烟史(与无吸烟史相比) 0.292 0.140~0.607 ＜0.001 饮酒史(与无饮酒史相比) 0.207 0.075~0.572 0.002 高血压史(与无高血压史相比) 0.851 0.609~1.189 0.345 糖尿病史(与无糖尿病史相比) 0.531 0.304~0.928 0.026 全麻史(与无全麻史相比) 1.253 0.964~1.629 0.092 急诊手术(与择期手术相比) 0.690 0.236~2.018 0.498 腹部手术(与非腹部手术相比) 1.484 1.106~1.992 0.008 手术时长≥3 h(与手术时长＜3 h相比) 0.935 0.720~1.214 0.615 静吸复合麻醉(与全静脉麻醉相比) 1.163 0.852~1.589 0.342 阿片类药物用量≥400 μg(与＜400 μg相比) 1.298 1.000~1.687 0.050 术中使用地塞米松(与未使用相比) 0.958 0.559~1.641 0.876 术中使用昂丹司琼(与未使用相比) 1.234 0.935~1.628 0.137 术中使用舒更葡糖钠(与新斯的明相比) 1.237 0.934~1.637 0.137 术中未使用肌松拮抗剂(与新斯的明相比) 0.559 0.357~0.875 0.011 PCIA、BMI、ASA：同表 1；POV：同表 2
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表 8 PCIA-POV多因素Logistic回归分析结果
Table 8. PCIA-POV multivariate Logistic regression analysis results
变量 校正OR值 95% CI P值 年龄(连续变量) 0.993 0.984~1.003 0.166 女性(与男性相比) 2.646 1.754~3.992 ＜0.001 BMI(连续变量) 0.966 0.930~1.003 0.073 吸烟史(与无吸烟史相比) 0.815 0.333~1.996 0.655 饮酒史(与无饮酒史相比) 0.475 0.145~1.554 0.218 糖尿病史(与无糖尿病史相比) 0.596 0.331~1.073 0.085 全麻史(与无全麻史相比) 1.372 1.042~1.806 0.024 腹部手术(与非腹部手术相比) 1.145 0.820~1.600 0.426 阿片类药物用量≥400 μg(与＜400 μg相比) 1.607 1.206~2.142 0.001 术中使用昂丹司琼(与未使用相比) 0.830 0.605~1.141 0.252 术中使用舒更葡糖钠(与新斯的明相比) 1.149 0.839~1.574 0.386 术中未使用肌松拮抗剂(与新斯的明相比) 0.393 0.237~0.651 ＜0.001 PCIA、BMI、ASA：同表 1；POV：同表 2
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