Maile Michael D, Engoren Milo C, Tremper Kevin K, Tremper Theodore T, Jewell Elizabeth S, Kheterpal Sachin
From the Department of Anesthesiology, Division of Critical Care Medicine, University of Michigan, Ann Arbor, Michigan.
Anesth Analg. 2016 Mar;122(3):608-615. doi: 10.1213/ANE.0000000000000803.
Intraoperative electrocardiographic monitoring is considered a standard of care. However, there are no evidence-based algorithms for using intraoperative ST segment data to identify patients at high risk for adverse perioperative cardiac events. Therefore, we performed an exploratory study of statistical measures summarizing intraoperative ST segment values determine whether the variability of these measurements was associated with adverse postoperative events. We hypothesized that elevation, depression, and variability of ST segments captured in an anesthesia information management system are associated with postoperative serum troponin elevation.
We conducted a single-institution, retrospective study of intraoperative automated ST segment measurements from leads I, II, and III, which were recorded in the electronic anesthesia record of adult patients undergoing noncardiac surgery. The maximum, minimum, mean, and SD of ST segment values were entered into logistic regression models to find independent associations with myocardial injury, defined as an elevated serum troponin concentration during the 7 days after surgery. Performance of these models was assessed by measuring the area under the receiver operator characteristic curve. The net reclassification improvement was calculated to quantify the amount of information that the ST segment values analysis added regarding the ability to predict postoperative troponin elevation.
Of 81,011 subjects, 4504 (5.6%) had postoperative myocardial injury. After adjusting for patient characteristics, the ST segment maximal depression (e.g., lead I: odds ratio [OR], 1.66; 95% confidence interval [CI], 1.26-2.19; P = 0.0004), maximal elevation (e.g., lead I: OR, 1.70; 95% CI, 1.34-2.17; P < 0.0001), and SD (e.g., lead I: OR, 0.16; 95% CI, 0.06-0.42; P = 0.0002) were found to have statistically significant associations with myocardial injury. Increased SD was associated with decreased risk when accounting for the maximal amount of ST segment depression and elevation and for patient characteristics. The ST segment summary statistics model had fair discrimination, with an area under the receiver operator characteristic curve of 0.71 (95% CI, 0.68-0.73). Addition of ST segment data produced a net reclassification improvement of 0.0345 (95% CI, 0.00016-0.0591; P = 0.0474).
Analysis of automated ST segment values obtained during anesthesia may be useful for improving the prediction of postoperative troponin elevation.
术中心电图监测被视为一种标准治疗手段。然而，目前尚无基于证据的算法可利用术中ST段数据来识别围手术期心脏不良事件的高危患者。因此，我们开展了一项探索性研究，采用统计方法总结术中ST段值，以确定这些测量值的变异性是否与术后不良事件相关。我们假设麻醉信息管理系统中记录的ST段抬高、压低及变异性与术后血清肌钙蛋白升高有关。
我们对一家机构的成年非心脏手术患者电子麻醉记录中I、II、III导联的术中自动ST段测量值进行了回顾性研究。将ST段值的最大值、最小值、平均值和标准差纳入逻辑回归模型，以寻找与心肌损伤的独立关联，心肌损伤定义为术后7天内血清肌钙蛋白浓度升高。通过测量受试者工作特征曲线下面积来评估这些模型的性能。计算净重新分类改善值，以量化ST段值分析在预测术后肌钙蛋白升高能力方面所增加的信息量。
在81011名受试者中，4504名（5.6%）发生了术后心肌损伤。在对患者特征进行调整后，发现ST段最大压低（例如，I导联：比值比[OR]，1.66；95%置信区间[CI]，1.26 - 2.19；P = 0.0004）、最大抬高（例如，I导联：OR，1.70；95% CI，1.34 - 2.17；P < 0.0001）和标准差（例如，I导联：OR，0.16；95% CI，0.06 - 0.42；P = 0.0002）与心肌损伤具有统计学显著关联。在考虑ST段最大压低和抬高量以及患者特征时，标准差增加与风险降低相关。ST段汇总统计模型具有中等鉴别能力，受试者工作特征曲线下面积为0.71（95% CI，0.68 - 0.73）。添加ST段数据后净重新分类改善值为0.0345（95% CI，0.00016 - 0.0591；P = 0.0474）。
分析麻醉期间获得的自动ST段值可能有助于改善对术后肌钙蛋白升高的预测。
