椎管内麻醉后低血压是老年患者心功能受损的预测因素吗？
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Is postspinal hypotension a sign of impaired cardiac performance in the elderly? An observational mechanistic study
背景与目的
研究表明大多数髋部骨折老年患者麻醉前后每搏量减少，本研究的目的主要为观察腰麻下行髋部或膝关节手术的老年患者心功能各项指标。
方 法
本研究为前瞻性观察试验，纳入对象为年龄≥65岁行择期关节置换术的老年患者。分别于术前、麻醉前以及麻醉后使用LiDCOplusTM进行指标监测及记录,椎管内麻醉后低血压定义为收缩压＜100mmHg或低于术前基线值得30%。使用逻辑回归分析进行统计学处理。
结 果
共纳入20例患者，平均年龄74岁（66～89岁）；麻醉前，休克指数下降了14%（95%CI：9.3～19%）；对椎管内麻醉后是否出现低血压患者进行分类分析：麻醉后低血压患者心排量下降，而非低血压患者其为代偿性增加的；麻醉后低血压与心排量指下降关系较大（OR=0.79,95%CI：0.60～0.91），那么心排量可作为腰麻后低血压的预测因素。
结 论
心排量下降可作为老年患者腰麻后低血压的重要预测因素。
原始文献摘要
Jakobsson J, Kalman S H, Lindeberg-Lindvet M, et al. Is postspinal hypotension a sign of impaired cardiac performance in the elderly? An observational mechanistic study[J]. British Journal of Anaesthesia, 2017, 119(6):1178-1185.
Background. We have previously reported that stroke volume is reduced in a majority of elderly patients undergoing surgical repair of hip fracture before and after intrathecal injection of anaesthetic. We aimed to investigate these observations further in a prospective study of elderly patients undergoing elective hip or knee arthroplasty under spinal anaesthesia.
Methods. Patients _65 yr undergoing elective arthroplasty were monitored with LiDCOplusTM preoperatively (baseline),before and continuously for 45min after spinal anaesthesia. Postspinal hypotension was defined as systolic blood pressure(bp)<100mmHg or>30% decrease from baseline. Associations between post-spinal hypotension and haemodynamic changes before (i.e. between baseline and before injection) spinal anaesthesia were analysed by logistic regression analysis.
Results. Twenty patients with a mean age of 74 (range 66–89) yr were included. Stroke volume index decreased by 14% (95%CI 9.3%–19%) before spinal anaesthesia. When patients were categorised according to post-spinal hypotension (Y/N) the patterns of haemodynamic changes differed. In the hypotensive patients, cardiac index progressively decreased whereas it increased initially in the non-hypotensive patients. Reduction of cardiac index from baseline before spinal anaesthesia was associated with increased risk of hypotension: OR 0.79 (95% CI 0.60, 0.91). The predictive value of reduced cardiac index was good (AUC under ROC curve 0.91).
Conclusions. A decrease in cardiac output from baseline before spinal anaesthesia and an inability to increase it after induction may be important features of postspinal hypotension in elderly patients.
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