Charlson M E, MacKenzie C R, Gold J P, Ales K L, Topkins M, Shires G T
Department of Medicine, Cornell University Medical College, New York, NY 10021.
Ann Surg. 1990 Jul;212(1):66-81. doi: 10.1097/00000658-199007000-00010.
We prospectively studied patients with hypertension and diabetes undergoing elective noncardiac surgery with general anesthesia to test the hypothesis that patients at high risk for prognostically significant intraoperative hemodynamic instability could be identified by their preoperative characteristics. Specifically we hypothesized that patients with a low functional capacity, decreased plasma volume, or significant cardiac comorbidity would be at high risk for intraoperative hypotension and those with a history of severe hypertension would be at risk for intraoperative hypertension. Patients who had a preoperative mean arterial pressure (MAP) greater than or equal to 110, a walking distance of less than 400 m, or a plasma volume less than 3000 cc were at increased risk of intraoperative hypotension (i.e., more than 1 hour of greater than or equal to 20 mmHg decreases in the MAP). Hypotension was also more common among patients having intra-abdominal or vascular surgery, and among those who had operations longer than 2 hours. Patients older than 70 years or with a decreased plasma volume were at increased risk of having more than 15 minutes of intraoperative elevations of greater than or equal to 20 mmHg over the preoperative MAP in combination with intraoperative hypotension; this was also more common when surgery lasted more than 2 hours. Patients who had intraoperative hypotension tended to have an immediate decrease in MAP at the onset of anesthesia and were often purposefully maintained at MAPs less than their usual level during surgery with fentanyl and neuromuscular blocking agents. Patients who had intraoperative hyper/hypotension tended to have repeated elevations in MAP above their preoperative levels during the course of surgery, and such elevations precipitated interventions with neuromuscular blocking agents and/or fentanyl. Neither pattern was more common among patients who developed net intraoperative negative fluid balances. Both hypotension and hyper/hypotension were associated with increased renal and cardiac complications after operation. Patients with cardiac disease, especially diabetics, and those with negative fluid balances also had increased complications. Preoperative characteristics influence the susceptibility to intraoperative hypotension and hypertension, which are related to postoperative complications.
我们对接受全身麻醉下择期非心脏手术的高血压和糖尿病患者进行了前瞻性研究，以检验以下假设：可通过术前特征识别出具有预后显著术中血流动力学不稳定高风险的患者。具体而言，我们假设功能能力低下、血浆量减少或有明显心脏合并症的患者术中低血压风险高，而有严重高血压病史的患者术中高血压风险高。术前平均动脉压（MAP）大于或等于110、步行距离小于400米或血浆量小于3000立方厘米的患者术中低血压风险增加（即MAP降低大于或等于20 mmHg超过1小时）。低血压在接受腹部或血管手术的患者以及手术时间超过2小时的患者中也更常见。70岁以上或血浆量减少的患者发生术中MAP比术前升高大于或等于20 mmHg超过15分钟并伴有术中低血压的风险增加；当手术持续超过2小时时这种情况也更常见。术中发生低血压的患者在麻醉开始时MAP往往立即下降，并且在手术期间经常有意地用芬太尼和神经肌肉阻滞剂维持MAP低于其通常水平。术中发生高血压/低血压的患者在手术过程中MAP往往反复高于术前水平升高，并且这种升高促使使用神经肌肉阻滞剂和/或芬太尼进行干预。在出现术中净负液体平衡的患者中，这两种模式都不更常见。低血压和高血压/低血压都与术后肾脏和心脏并发症增加有关。患有心脏病的患者，尤其是糖尿病患者，以及有负液体平衡的患者并发症也增加。术前特征影响对术中低血压和高血压的易感性，而这与术后并发症有关。
