Ziegler D W, Wright J G, Choban P S, Flancbaum L
Department of Surgery, Ohio State University College of Medicine, Columbus, USA.
Surgery. 1997 Sep;122(3):584-92. doi: 10.1016/s0039-6060(97)90132-x.
Previous investigations have suggested that preoperative invasive hemodynamic monitoring with "optimization" of cardiovascular function may favorably affect the outcome among patients undergoing peripheral vascular surgery. The purpose of this study was to evaluate the effect of preoperative optimization of hemodynamic parameters on outcome in patients undergoing aortic reconstruction (AR) or limb salvage procedures (LSP) in a randomized, prospective clinical trial.
All 72 patients who consented to participate in this study were admitted to the intensive care unit at least 12 hours before operation for placement of a pulmonary artery catheter (PAC). Patients who were randomized to the treatment group (n = 32) were "optimized" by adjusting their hemoglobin concentration, oxygen saturation (SaO2), cardiac output, or afterload until the mixed venous O2 saturation (SvO2) was at least 65%. The control group (n = 40) underwent placement of a PAC and had oxygen transport parameters measured without any attempt to optimize SvO2.
There were no significant differences between the treatment and control groups with respect to age, gender, type of operation, initial Acute Physiology and Chronic Health Evaluation (APACHE) II score, SvO2, pulmonary artery occlusion pressure, or cardiac index. All treatment patients achieved an SvO2 of at least 65% before operation. Comparing the treatment and control groups, postoperative cardiovascular complications occurred in 25% versus 27%, intraoperative complications in 28% versus 20%, and death in 9% versus 5%, respectively. None of these differences was statistically significant as a whole or within the subgroups undergoing AR or LSP.
These data suggest that preoperative optimization of cardiovascular function by using achievement of SvO2 above 65% as the end point does not result in any reduction of intraoperative or perioperative cardiac complications in patients undergoing PVS. Further studies with alternative assessments and manipulation of different cardiopulmonary parameters may yield additional information.
先前的研究表明，术前进行有创血流动力学监测并“优化”心血管功能可能会对接受外周血管手术的患者的预后产生有利影响。本研究的目的是在一项随机、前瞻性临床试验中评估术前优化血流动力学参数对接受主动脉重建术（AR）或肢体挽救手术（LSP）患者预后的影响。
所有同意参与本研究的72例患者在手术前至少12小时入住重症监护病房，以便放置肺动脉导管（PAC）。随机分配到治疗组（n = 32）的患者通过调整血红蛋白浓度、氧饱和度（SaO2）、心输出量或后负荷进行“优化”，直到混合静脉血氧饱和度（SvO2）至少达到65%。对照组（n = 40）放置了PAC并测量了氧输送参数，但未试图优化SvO2。
治疗组和对照组在年龄、性别、手术类型、初始急性生理与慢性健康状况评估（APACHE）II评分、SvO2、肺动脉闭塞压或心脏指数方面无显著差异。所有治疗组患者在手术前SvO2均至少达到65%。比较治疗组和对照组，术后心血管并发症发生率分别为25%和27%，术中并发症发生率分别为28%和20%，死亡率分别为9%和5%。这些差异总体上或在接受AR或LSP的亚组中均无统计学意义。
这些数据表明，以SvO2高于65%为终点进行术前心血管功能优化并不能降低接受外周血管手术患者的术中或围手术期心脏并发症。采用其他评估方法并操纵不同心肺参数的进一步研究可能会提供更多信息。
