Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
Departments of Anesthesiology and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
Br J Anaesth. 2022 Oct;129(4):487-496. doi: 10.1016/j.bja.2022.06.034. Epub 2022 Sep 5.
Studies of intraoperative hypotension typically specify a blood pressure threshold associated with adverse outcomes. Such thresholds are likely to be study-biased, investigator-biased, or both. We hypothesised that a newly developed modelling method without a threshold, which is biologically more plausible than a threshold-based approach, would reveal a continuous association between exposure to intraoperative hypotension and adverse outcomes.
Single-centre, retrospective cohort study of subjects ≥60 yr old undergoing noncardiac surgery. We modelled intraoperative hypotension using three different approaches: (1) unweighted, (2) weighted for degree of hypotension (depth), and (3) weighted for duration of hypotension. The primary outcome was myocardial injury, defined as elevated troponin I (>60 ng L) measured during the first 3 days after surgery. The associations between the three models, postoperative myocardial injury, and mortality (secondary outcome) were reported as penalised adjusted odds ratios (ORs) scaled between the 75th and 25th percentiles.
Myocardial injury occurred in 1812/15 452 (12%) procedures, with 554/15 452 (3.6%) procedures resulting in death before discharge from hospital. The unweighted lower blood pressure measure (OR: 0.26, 95% confidence interval [CI]: 0.12-0.53) and the depth-weighted measure (OR: 4.4, 95% CI: 2.6-7.4) were associated with myocardial injury. The duration-weighted measure was not associated with myocardial injury (OR: 0.89, 95% CI: 0.61-1.3). The unweighted measure (OR 0.08, 95% CI: 0.01-0.40) and the depth-weighted measure (OR: 12, 95% CI, 3.8-35) were associated with in-hospital mortality, but not the duration-weighted measure (OR: 1.3, 95% CI: 0.53-3.0).
Intraoperative hypotension appears to have a graded association with postoperative myocardial injury and mortality, with depth appearing to contribute more than duration.
术中低血压的研究通常会指定与不良后果相关的血压阈值。这些阈值很可能存在研究偏倚、研究者偏倚或两者兼而有之。我们假设一种新开发的无阈值建模方法，该方法在生物学上比基于阈值的方法更合理，它将揭示术中低血压暴露与不良后果之间的连续关联。
这是一项单中心、回顾性队列研究，纳入了年龄≥60 岁行非心脏手术的患者。我们使用三种不同的方法来对术中低血压进行建模：（1）未加权；（2）按低血压程度（深度）加权；（3）按低血压持续时间加权。主要结局是术后心肌损伤，定义为手术后前 3 天测量的肌钙蛋白 I 升高（＞60ng/L）。报告了三种模型与术后心肌损伤和死亡率（次要结局）之间的关联，报告为经调整后在第 75 百分位到第 25 百分位之间缩放的惩罚后调整比值比（OR）。
15452 例手术中有 1812 例（12%）发生心肌损伤，其中 554 例（3.6%）在出院前死亡。未加权的较低血压测量值（OR：0.26，95%CI：0.12-0.53）和深度加权测量值（OR：4.4，95%CI：2.6-7.4）与心肌损伤相关。持续时间加权测量值与心肌损伤无关（OR：0.89，95%CI：0.61-1.3）。未加权测量值（OR：0.08，95%CI：0.01-0.40）和深度加权测量值（OR：12，95%CI：3.8-35）与院内死亡率相关，但持续时间加权测量值（OR：1.3，95%CI：0.53-3.0）无关。
术中低血压似乎与术后心肌损伤和死亡率呈分级关联，深度似乎比持续时间的影响更大。
