D'Amico Filippo, Fominskiy Evgeny V, Turi Stefano, Pruna Alessandro, Fresilli Stefano, Triulzi Margherita, Zangrillo Alberto, Landoni Giovanni
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
Br J Anaesth. 2023 Nov;131(5):823-831. doi: 10.1016/j.bja.2023.08.026. Epub 2023 Sep 20.
Intraoperative hypotension is associated with adverse postoperative outcomes; however these findings are supported only by observational studies. The aim of this meta-analysis of randomised trials was to compare the postoperative effects permissive management with targeted management of intraoperative blood pressure.
We searched PubMed, Cochrane, and Embase up to June 2023 for studies comparing permissive (mean arterial pressure ≤60 mm Hg) with targeted (mean arterial pressure >60 mm Hg) intraoperative blood pressure management. Primary outcome was all-cause mortality at the longest follow-up available. Secondary outcomes were atrial fibrillation, myocardial infarction, acute kidney injury, delirium, stroke, number of patients requiring transfusion, time on mechanical ventilation, and length of hospital stay.
We included 10 randomised trials including a total of 9359 patients. Mortality was similar between permissive and targeted blood pressure management groups (89/4644 [1.9%] vs 99/4643 [2.1%], odds ratio 0.88, 95% confidence interval [CI], 0.65-1.18, P=0.38, I=0% with nine studies included). Atrial fibrillation (102/3896 [2.6%] vs 130/3887 [3.3%] odds ratio 0.71, 95% CI 0.53-0.96, P=0.03, I=0%), and length of hospital stay (mean difference -0.20 days, 95% CI -0.26 to -0.13, P<0.001, I=0%) were reduced in the permissive management group. No significant differences were found in subgroup analysis for cardiac and noncardiac surgery.
Pooled randomised evidence shows that a target intraoperative mean arterial pressure ≤60 mm Hg is not associated with increased mortality; nevertheless it is surprisingly associated with a reduced rate of atrial fibrillation and of length of hospital stay.
PROSPERO CRD42023393725.
术中低血压与术后不良结局相关；然而，这些发现仅得到观察性研究的支持。这项随机试验的荟萃分析旨在比较术中血压的允许性管理与目标性管理的术后效果。
我们检索了截至2023年6月的PubMed、Cochrane和Embase数据库，以查找比较允许性（平均动脉压≤60 mmHg）与目标性（平均动脉压>60 mmHg）术中血压管理的研究。主要结局是最长随访期内的全因死亡率。次要结局包括心房颤动、心肌梗死、急性肾损伤、谵妄、中风、需要输血的患者数量、机械通气时间和住院时间。
我们纳入了10项随机试验，共9359例患者。允许性血压管理组和目标性血压管理组的死亡率相似（89/4644 [1.9%] 对99/4643 [2.1%]，比值比0.88，95%置信区间[CI]，0.65 - 1.18，P = 0.38，纳入9项研究时I² = 0%）。允许性管理组的心房颤动（102/3896 [2.6%] 对130/3887 [3.3%]，比值比0.71，95% CI 0.53 - 0.96，P = 0.03，I² = 0%）和住院时间（平均差 -0.20天，95% CI -0.26至 -0.13，P < 0.001，I² = 0%）有所降低。在心脏手术和非心脏手术的亚组分析中未发现显著差异。
汇总的随机证据表明，术中目标平均动脉压≤60 mmHg与死亡率增加无关；然而，令人惊讶的是，它与心房颤动发生率降低和住院时间缩短有关。
PROSPERO CRD42023393725。
