From the Department of Anaesthesiology, Istanbul Başakşehir Çam&Sakura City Hospital (TA, HCG, İAE, FGÖ), Department of General Surgery, Istanbul Başakşehir Çam&Sakura City Hospital (İK), Department of Anaesthesiology, Istanbul Medical Faculty, Istanbul University (AA), and Liver Transplantation & Hepatopancreatobiliary Surgery Unit, Department of General Surgery, Istanbul Başakşehir Çam&Sakura City Hospital (EK, İÖ).
Eur J Anaesthesiol. 2024 Nov 1;41(11):831-840. doi: 10.1097/EJA.0000000000002059. Epub 2024 Sep 12.
Myocardial injury after noncardiac surgery (MINS) frequently complicates the peri-operative period and is associated with increased mortality.
We hypothesised that cardiac index (CI) based haemodynamic management reduces peri-operative high-sensitive troponin-T (hsTnT) elevation and MINS incidence in patients undergoing hepatic/pancreatic surgery compared to mean arterial pressure.
A randomised controlled study.
A single-centre study conducted in a university-affiliated tertiary hospital between June 2022 and March 2023.
Ninety-one patients, who were ≥ 65 years old or ≥ 45 years old with a history of at least one cardiac risk factor were randomised to either mean arterial pressure (MAP) based ( n = 45) or CI-based ( n = 46) management groups, and completed the study.
In group-MAP, patients received fluid boluses and/or a noradrenaline infusion to maintain MAP above the predefined threshold. In group-CI, patients received fluid boluses and/or dobutamine infusion to keep CI above the predefined threshold. When a low MAP was observed despite a normal CI, a noradrenaline infusion was started.
The primary outcome was peri-operative hsTnT elevation. The secondary outcomes were MINS incidence and 90-day mortality.
The median absolute troponin elevation was 4.3 ng l -1 (95% CI 3.4 to 6) for the CI-based group, and 9.4 ng l -1 (95% CI 7.7 to 12.7) for the MAP-based group (median difference: 5.1 ng l -1 , 95% CI 3 to 7; P < 0.001). MINS occurred in 8 (17.4%) patients in the CI-based group and 17 (37.8%) patients in the MAP-based group (relative risk: 0.46, 95% CI: 0.22 to 0.96; P = 0.029). Two patients in group-MAP died from cardiovascular-related causes. One patient in group-CI and two in group-MAP died from sepsis-related complications (for all-cause mortality: χ2 = 1.98, P = 0.16). MAP-AUC and CI-AUC values of the CI- and MAP-based groups were 147 vs. 179 min × mmHg ( P = 0.85) and 8.4 vs. 43.2 l m -2 min -1 × min ( P < 0.001), respectively.
CI-based haemodynamic management assures sufficient flow and consequently is associated with less peri-operative hsTnT elevation and lower incidence of MINS compared to MAP.
Clinicaltrials.gov identifier: NCT05391087.
非心脏手术后心肌损伤（MINS）经常在围手术期并发，并与死亡率增加有关。
我们假设与平均动脉压相比，基于心指数（CI）的血流动力学管理可降低接受肝/胰腺手术患者围手术期高敏肌钙蛋白 T（hsTnT）升高和 MINS 的发生率。
一项随机对照研究。
2022 年 6 月至 2023 年 3 月在一所大学附属医院进行的单中心研究。
91 名患者，年龄≥65 岁或≥45 岁，至少有一个心脏危险因素史，被随机分配至平均动脉压（MAP）组（n = 45）或 CI 组（n = 46），并完成了研究。
在 MAP 组中，患者接受液体冲击和/或去甲肾上腺素输注以维持 MAP 高于预设阈值。在 CI 组中，患者接受液体冲击和/或多巴酚丁胺输注以保持 CI 高于预设阈值。当观察到低 MAP 但 CI 正常时，开始给予去甲肾上腺素输注。
主要结局是围手术期 hsTnT 升高。次要结局是 MINS 发生率和 90 天死亡率。
基于 CI 的组的中位绝对肌钙蛋白升高为 4.3ng l -1 （95%CI 3.4 至 6），基于 MAP 的组为 9.4ng l -1 （95%CI 7.7 至 12.7）（中位数差异：5.1ng l -1 ，95%CI 3 至 7；P < 0.001）。基于 CI 的组中 8 名（17.4%）患者发生 MINS，基于 MAP 的组中 17 名（37.8%）患者发生 MINS（相对风险：0.46，95%CI：0.22 至 0.96；P = 0.029）。MAP 组中有 2 名患者死于心血管相关原因。CI 组中有 1 名患者和 MAP 组中有 2 名患者死于脓毒症相关并发症（全因死亡率：χ 2 = 1.98，P = 0.16）。CI 组和 MAP 组的 MAP-AUC 和 CI-AUC 值分别为 147 vs. 179min×mmHg（P = 0.85）和 8.4 vs. 43.2l m -2 min -1 ×min（P < 0.001）。
与 MAP 相比，基于 CI 的血流动力学管理可确保足够的流量，因此与围手术期 hsTnT 升高和 MINS 发生率较低相关。
Clinicaltrials.gov 标识符：NCT05391087。
