Department of Anesthesiology, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Department of Anesthesiology & Critical Care Medicine, Division of Cardiac Anesthesia, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Semin Thorac Cardiovasc Surg. 2021;33(2):429-438. doi: 10.1053/j.semtcvs.2020.09.032. Epub 2020 Nov 10.
The purpose of this study was to determine if setting mean arterial pressure (MAP) targets during cardiopulmonary bypass (CPB) based on individualized cerebral autoregulation data reduces the frequency of neurological complications compared with usual care. Patients (n = 460) ≥ 55 years old at risk for neurological complications were randomized to have MAP targets during CPB to be above the lower limit of transcranial Doppler determined cerebral autoregulation versus usual institutional practices. The primary outcome was the frequency of the composite endpoint of clinical stroke, or new brain magnetic resonance imaging-detected ischemic injury, or cognitive decline 4-6 weeks after surgery from baseline. Secondary outcomes were components of the primary composite outcome and clinically detected delirium. Complete outcome data were available from 194 patients (stroke assessments, n = 460; magnetic resonance imaging data, n = 164; cognitive data n = 336). There was no difference between groups in the frequency of the composite neurological end-point or its components (P = 0.752). Compared with the usual care there was a 45% reduction in the frequency of clinically detected delirium in the autoregulation group (8.2% vs 14.9%, risk ratio = 0.55, 95% confidence interval = 0.32, 0.93, P = 0.035) and improved performance on test of memory 4-6 weeks after surgery from baseline (P = 0.019). Basing MAP during CPB on cerebral autoregulation monitoring did not reduce the frequency of the primary neurological outcome in high-risk patients compared with usual care but it was associated with a reduction in the frequency of delirium and better performance on tests of memory 4-6 weeks after surgery.
本研究旨在确定在体外循环 (CPB) 期间基于个体化脑自动调节数据设定平均动脉压 (MAP) 目标是否与常规护理相比可降低神经并发症的发生频率。高危神经并发症的患者 (n=460) 年龄≥55 岁，随机分为 CPB 期间 MAP 目标高于经颅多普勒确定的脑自动调节下限与常规机构实践组。主要结局是术后 4-6 周从基线开始的临床卒中或新脑磁共振成像检测到的缺血性损伤或认知下降的复合终点的频率。次要结局是主要复合结局和临床发现的谵妄的组成部分。共有 194 例患者（卒中评估，n=460；磁共振成像数据，n=164；认知数据，n=336）获得完整的结局数据。复合神经终点或其组成部分的频率在两组之间无差异 (P=0.752)。与常规护理相比，自动调节组临床发现的谵妄频率降低了 45%（8.2% vs 14.9%，风险比=0.55，95%置信区间=0.32，0.93，P=0.035），术后 4-6 周的记忆测试表现也有所改善（P=0.019）。与常规护理相比，CPB 期间基于脑自动调节监测设定 MAP 并不能降低高危患者的主要神经结局发生频率，但与谵妄频率降低和术后 4-6 周记忆测试表现改善相关。
