Cassina Tiziano, Putzu Alessandro, Santambrogio Luisa, Villa Michele, Licker Marc Joseph
Department of Cardiac Anesthesia and Intensive Care, Cardiocentro Ticino Foundation, 6900 Lugano, Switzerland.
Department of Anesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University Hospital of Geneva, 1206 Geneva, Switzerland.
Ann Card Anaesth. 2016 Jul-Sep;19(3):425-32. doi: 10.4103/0971-9784.185524.
Active mobilization is a key component in fast-track surgical strategies. Following major surgery, clinicians are often reluctant to mobilize patients arguing that circulatory homeostasis would be impaired as a result of myocardial stunning, fluid shift, and autonomic dysfunction.
We examined the feasibility and safety of a mobilization protocol 12-24 h after elective cardiac surgery.
This observational study was performed in a tertiary nonacademic cardiovascular Intensive Care Unit.
Over a 6-month period, we prospectively evaluated the hemodynamic response to a two-staged mobilization procedure in 53 consecutive patients. Before, during, and after the mobilization, hemodynamics parameters were recorded, including the central venous oxygen saturation (ScvO 2 ), lactate concentrations, mean arterial pressure (MAP), heart rate (HR), right atrial pressure (RAP), and arterial oxygen saturation (SpO 2 ). Any adverse events were documented.
All patients successfully completed the mobilization procedure. Compared with the supine position, mobilization induced significant increases in arterial lactate (34.6% [31.6%, 47.6%], P = 0.0022) along with reduction in RAP (-33% [-21%, -45%], P < 0.0001) and ScvO 2 (-7.4% [-5.9%, -9.9%], P = 0.0002), whereas HR and SpO 2 were unchanged. Eighteen patients (34%) presented a decrease in MAP > 10% and nine of them (17%) required treatment. Hypotensive patients experienced a greater decrease in ScvO 2 (-18 ± 5% vs. -9 ± 4%, P = 0.004) with similar changes in RAP and HR. All hemodynamic parameters, but arterial lactate, recovered baseline values after resuming the horizontal position.
Early mobilization after cardiac surgery appears to be a safe procedure as far as it is performed under close hemodynamic and clinical monitoring in an intensive care setting.
主动活动是快速康复外科策略的关键组成部分。在大手术后，临床医生往往不愿意让患者活动，认为心肌顿抑、液体转移和自主神经功能障碍会导致循环稳态受损。
我们研究了择期心脏手术后12 - 24小时活动方案的可行性和安全性。
本观察性研究在一家三级非学术性心血管重症监护病房进行。
在6个月的时间里，我们前瞻性评估了53例连续患者对两阶段活动程序的血流动力学反应。在活动前、活动期间和活动后，记录血流动力学参数，包括中心静脉血氧饱和度（ScvO₂）、乳酸浓度、平均动脉压（MAP）、心率（HR）、右心房压（RAP）和动脉血氧饱和度（SpO₂）。记录任何不良事件。
所有患者均成功完成活动程序。与仰卧位相比，活动导致动脉乳酸显著增加（34.6% [31.6%，47.6%]，P = 0.0022），同时RAP降低（-33% [-21%，-45%]，P < 0.0001）和ScvO₂降低（-7.4% [-5.9%，-9.9%]，P = 0.0002），而HR和SpO₂不变。18例患者（34%）MAP下降> 10%，其中9例（17%）需要治疗。低血压患者ScvO₂下降幅度更大（-18 ± 5% 对 -9 ± 4%，P = 0.004），RAP和HR有类似变化。除动脉乳酸外，所有血流动力学参数在恢复平卧位后恢复到基线值。
在重症监护环境中，只要在密切的血流动力学和临床监测下进行，心脏手术后早期活动似乎是一种安全的程序。
