行乳房游离皮瓣手术患者发生症状性低血压： Enhanced recovery after surgery（加速康复外科）要背锅吗？
Occurrence of Symptomatic Hypotension in Patients Undergoing Breast Free Flaps: Is Enhanced Recovery after Surgery to Blame?
机构信息
From the Division of Plastic, Maxillofacial, and Oral Surgery, Department of General Surgery, and the Department of Anesthesia, Duke University Hospital; Duke University School of Medicine; and the Department of Biostatistics and Bioinformatics, Duke University Medical Center.
出版信息
Plast Reconstr Surg. 2020 Mar;145(3):606-616. doi: 10.1097/PRS.0000000000006537.
BACKGROUND
Enhanced recovery after surgery (ERAS) initiatives improve postoperative function and expedite recovery, leading to a decrease in length of stay. The authors noted a high rate of postoperative symptomatic hypotension in patients undergoing abdominal free flap breast reconstruction and wished to explore this observation.
METHODS
Subjects undergoing abdominal free flap breast reconstruction at the authors' institution from 2013 to 2017 were identified. The ERAS protocol was initiated in 2015 at the authors' hospital; thus, 99 patients underwent traditional management and 138 patients underwent ERAS management. Demographics and perioperative data were collected and analyzed. Postoperative symptomatic hypotension was defined as mean arterial pressure below 80 percent of baseline with symptoms requiring evaluation.
RESULTS
A significantly higher rate of postoperative symptomatic hypotension was observed in the ERAS cohort compared with the traditional management cohort (4 percent versus 22 percent; p < 0.0001). Patients in the ERAS cohort received significantly less intraoperative intravenous fluid (4467 ml versus 3505 ml; p < 0.0001) and had a significantly increased amount of intraoperative time spent with low blood pressure (22 percent versus 32 percent; p =0.002). Postoperatively, the ERAS cohort had significantly lower heart rate (77 beats per minute versus 88 beats per minute; p < 0.0001) and mean arterial pressure (71 mmHg versus 78 mmHg; p < 0.0001), with no difference in urine output or adverse events.
CONCLUSIONS
The authors report that ERAS implementation in abdominal free flap breast reconstruction may result in a unique physiologic state with low mean arterial pressure, low heart rate, and normal urine output, resulting in postoperative symptomatic hypotension. Awareness of this early postoperative finding can help better direct fluid resuscitation and prevent episodes of symptomatic hypotension.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
背景
手术后加速康复（ERAS）方案可改善术后功能并加快康复速度，从而减少住院时间。作者注意到行腹部游离皮瓣乳房再造术的患者术后发生症状性低血压的比例较高，因此希望对此现象进行探讨。
方法
作者所在机构于 2013 年至 2017 年期间行腹部游离皮瓣乳房再造术的患者纳入研究。作者所在医院于 2015 年开始实施 ERAS 方案，因此 99 例患者接受传统治疗，138 例患者接受 ERAS 治疗。收集并分析患者的人口统计学资料和围手术期数据。术后发生症状性低血压定义为平均动脉压低于基础值的 80%，并伴有需要评估的症状。
结果
与传统治疗组相比，ERAS 组患者术后发生症状性低血压的比例显著更高（4%比 22%；p<0.0001）。ERAS 组患者术中接受的静脉输液量显著更少（4467 ml 比 3505 ml；p<0.0001），且低血压时间明显更长（22%比 32%；p=0.002）。术后，ERAS 组患者的心率显著更低（77 次/分比 88 次/分；p<0.0001），平均动脉压显著更低（71 mmHg 比 78 mmHg；p<0.0001），但尿量和不良事件无差异。
结论
作者报告称，腹部游离皮瓣乳房再造术中实施 ERAS 方案可能会导致一种独特的生理状态，即平均动脉压、心率较低，而尿量正常，从而导致术后发生症状性低血压。认识到这一早期术后发现有助于更好地指导液体复苏并预防症状性低血压的发生。
临床问题/证据水平：治疗性，III 级。
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