明确心脏手术中与卒中相关的术中低血压阈值
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Defining an Intraoperative Hypotension Threshold in Association with Stroke in Cardiac Surgery
背景与目的
卒中是接受心脏手术的患者发病率、死亡率和残疾的主要原因。明确可避免的围手术期卒中危险因素可能会改善患者的预后。本文评估了心脏手术患者术中低血压的严重程度和持续时间与术后卒中之间的关系。
方 法
本项回顾性队列研究对于2009年11月1日至2015年3月31日期间在三级医院进行体外循环心脏手术的成年患者进行了回顾性研究。主要结局为术后缺血性卒中。术中低血压定义为在体外循环之前、期间和之后平均动脉压小于55、55至64和65至74 mmHg数分钟。通过使用逻辑回归来分析卒中和低血压之间的关联。
结 果
本研究纳入了7457例患者，其中111（1.5%）例患者术后诊断为卒中。卒中与体外循环期间持续平均动脉压低于64 mmHg密切相关（校正OR值为1.13; 95％CI，每10分钟平均动脉压在55至64 mmHg的比值为1.05-1.21；校正OR值为 1.16; 95％CI，每10分钟平均动脉压小于55 mmHg 的比值为1.08至1.23）。与卒中独立相关的其他因素包括年龄较大，高血压，联合冠状动脉旁路移植/瓣膜手术，急诊手术，延长的心肺分流持续时间和术后新发心房颤动。
结 论
低血压是围手术期卒中的潜在的可避免的危险因素。该研究的结果表明，平均动脉压可能是一项对术中血流动力学重要的治疗性靶点，可降低接受体外循环患者的卒中发生率。
原始文献摘要
Sun LY, Chung AM, Farkouh ME, van Diepen S, Weinberger J, Bourke M, Ruel M. Defining an Intraoperative Hypotension Threshold in Association with Stroke in Cardiac Surgery. Anesthesiology. 2018 Sep;129(3):440-447. doi: 10.1097/ALN.0000000000002298.
Background and Objectives:Stroke is a leading cause of morbidity, mortality, and disability in patients undergoing cardiac surgery. Identifying modifiable perioperative stroke risk factors may lead to improved patient outcomes. The association between the severity and duration of intraoperative hypotension and postoperative stroke in patients undergoing cardiac surgery was evaluated.
Methods: A retrospective cohort study was conducted of adult patients who underwent cardiac surgery requiring cardiopulmonary bypass at a tertiary center between November 1, 2009, and March 31, 2015. The primary outcome was postoperative ischemic stroke. Intraoperative hypotension was defined as the number of minutes spent within mean arterial pressure bands of less than 55, 55 to 64, and 65 to 74 mmHg before, during, and after cardiopulmonary bypass. The association between stroke and hypotension was examined by using logistic regression with propensity score adjustment.
Results:Among the 7,457 patients included in this analysis, 111 (1.5%) had a confirmed postoperative diagnosis of stroke. Stroke was strongly associated with sustained mean arterial pressure of less than 64 mmHg during cardiopulmonary bypass (adjusted odds ratio 1.13; 95% CI, 1.05 to 1.21 for every 10 min of mean arterial pressure between 55 and 64 mmHg; adjusted odds ratio 1.16; 95% CI, 1.08 to 1.23 for every 10 min of mean arterial pressure less than 55 mmHg). Other factors that were independently associated with stroke were older age, hypertension, combined coronary artery bypass graft/valve surgery, emergent operative status, prolonged cardiopulmonary bypass duration, and postoperative new-onset atrial fibrillation.
Conclusions:Hypotension is a potentially modifiable risk factor for perioperative stroke. The study's findings suggest that mean arterial pressure may be an important intraoperative therapeutic hemodynamic target to reduce the incidence of stroke in patients undergoing cardiopulmonary bypass.
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