Massachusetts Institute of Technology Critical Data, Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Cambridge, Massachusetts; Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Big Data Department, Regional Ministry of Health of Andalucia, Seville, Spain.
Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Anesthesiology. 2022 Jun 1;136(6):927-939. doi: 10.1097/ALN.0000000000004175.
In cardiac surgery, the association between hypotension during specific intraoperative phases or vasopressor-inotropes with adverse outcomes remains unclear. This study's hypothesis was that intraoperative hypotension duration throughout the surgery or when separated into hypotension during and outside cardiopulmonary bypass may be associated with postoperative major adverse events.
This retrospective observational cohort study included data for adults who had cardiac surgery between 2008 and 2016 in a tertiary hospital. Intraoperative hypotension was defined as mean arterial pressure of less than 65 mmHg. The total duration of hypotension was divided into three categories based on the fraction of overall hypotension duration that occurred during cardiopulmonary bypass (more than 80%, 80 to 60%, and less than 60%). The primary outcome was a composite of stroke, acute kidney injury, or mortality during the index hospitalization. The association with the composite outcome was evaluated for duration of hypotension during the entire surgery, outside cardiopulmonary bypass, and during cardiopulmonary bypass and the fraction of hypotension during cardiopulmonary bypass adjusting for vasopressor-inotrope dose, milrinone dose, patient, and surgical factors.
The composite outcome occurred in 256 (5.1%) of 4,984 included patient records; 66 (1.3%) patients suffered stroke, 125 (2.5%) had acute kidney injury, and 109 (2.2%) died. The primary outcome was associated with total duration of hypotension (adjusted odds ratio, 1.05; 95% CI, 1.02 to 1.08; P = 0.032), hypotension outside cardiopulmonary bypass (adjusted odds ratio, 1.06; 95% CI, 1.03 to 1.10; P = 0.001) per 10-min exposure to mean arterial pressure of less than 65 mmHg, and fraction of hypotension duration during cardiopulmonary bypass of less than 60% (reference greater than 80%; adjusted odds ratio, 1.67; 95% CI, 1.10 to 2.60; P = 0.019) but not with each 10-min period hypotension during cardiopulmonary bypass (adjusted odds ratio, 1.04; 95% CI, 0.99 to 1.09; P = 0.118), fraction of hypotension during cardiopulmonary bypass of 60 to 80% (adjusted odds ratio, 1.45; 95% CI, 0.97 to 2.23; P = 0.082), or total vasopressor-inotrope dose (adjusted odds ratio, 1.00; 95% CI, 1.00 to 1.00; P = 0.247).
This study confirms previous single-center findings that intraoperative hypotension throughout cardiac surgery is associated with an increased risk of acute kidney injury, mortality, or stroke.
在心脏外科手术中，特定手术阶段的低血压或血管加压素-正性肌力药物与不良结局之间的关系仍不清楚。本研究的假设是，手术过程中整个低血压持续时间或分为体外循环期间和体外循环外的低血压持续时间与术后主要不良事件有关。
本回顾性观察队列研究纳入了 2008 年至 2016 年期间在一家三级医院接受心脏手术的成年人的数据。术中低血压定义为平均动脉压低于 65mmHg。根据体外循环期间发生的总体低血压持续时间的分数，将低血压的总持续时间分为三个类别（超过 80%、80%至 60%和低于 60%）。主要结局是指数住院期间发生的中风、急性肾损伤或死亡率的复合。评估了整个手术期间、体外循环外和体外循环期间低血压持续时间与体外循环期间低血压分数与血管加压素-正性肌力药物剂量、米力农剂量、患者和手术因素的复合结局之间的关系。
4984 例患者记录中，复合结局发生在 256 例（5.1%）；66 例（1.3%）患者发生中风，125 例（2.5%）发生急性肾损伤，109 例（2.2%）死亡。主要结局与总低血压持续时间（调整后的优势比，1.05；95%置信区间，1.02 至 1.08；P = 0.032）、体外循环外低血压（调整后的优势比，1.06；95%置信区间，1.03 至 1.10；P = 0.001）每 10 分钟暴露于平均动脉压低于 65mmHg 有关，以及体外循环期间低血压持续时间小于 60%的分数（参考值大于 80%；调整后的优势比，1.67；95%置信区间，1.10 至 2.60；P = 0.019），但与体外循环期间每 10 分钟的低血压时间无关（调整后的优势比，1.04；95%置信区间，0.99 至 1.09；P = 0.118），体外循环期间低血压持续时间为 60%至 80%（调整后的优势比，1.45；95%置信区间，0.97 至 2.23；P = 0.082）或总血管加压素-正性肌力药物剂量（调整后的优势比，1.00；95%置信区间，1.00 至 1.00；P = 0.247）。
本研究证实了先前的单中心研究结果，即整个心脏手术过程中的术中低血压与急性肾损伤、死亡率或中风的风险增加有关。
