非心脏手术后低血压与心肌损伤的关系
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非心脏手术后低血压与心肌损伤的关系
翻译：唐剑 编辑：冯玉蓉 审校：曹莹
背景：术中低血压与术后发病率和早期死亡率有关。然而，术后低血压的研究较少。本研究假设术后低血压的严重程度和持续时间都与心肌损伤有关。
方法：本项单中心观察队列研究纳入1710名60岁或60岁以上接受中到高风险非心脏手术的患者。记录患者术后24小时内血流动力学的监测情况。多重平均动脉压(MAP)绝对阈值(50~75 mmHg)用于定义低血压，其标准为MAP下的累计分钟数、持续时间和时间加权平均值。主要评价指标是术后前3天的心肌损伤程度(高敏肌钙蛋白T峰值为50 ng/L或更高)。
结果：术后低血压常见，其中血压累计2小时低于60 mmHg者144例(8%)，血压累计4小时小于75 mmHg者824例(48%)。混杂因子调整后，患者术后血压低于75 mmHg且时间长于635min与心肌损伤相关。多阈值比较，MAP阈值低于60 mmHg累计2~4h，MAP阈值小于65 mmHg和70 mmHg超过4h也与心肌损伤相关。在调整了术中低血压后，相关性仍然显著，因此术中低血压作为独立因素与心肌损伤无关。
结论：在本研究中，术后低血压是常见的，并且与心肌损伤独立相关。
文献来源： Liem VGB, Hoeks SE, Mol KHJM, et al. Postoperative Hypotension after Noncardiac Surgery and the Association with Myocardial Injury.Anesthesiology, 2020, 09;133(3).
Postoperative Hypotension after Noncardiac Surgery and the Association with Myocardial Injury
Abstract
Background: Intraoperative hypotension has been associated with postoperative morbidity and early mortality. Postoperative hypotension, however, has been less studied. This study examines postoperative hypotension, hypothesizing that both the degree of hypotension severity and longer durations would be associated with myocardial injury.
METHODS: This single-center observational cohort was comprised of 1,710 patients aged 60 yr or more undergoing intermediate- to high-risk noncardiac surgery. Frequent sampling of hemodynamic monitoring on a postoperative high-dependency ward during the first 24 h after surgery was recorded. Multiple mean arterial pressure (MAP) absolute thresholds (50 to 75 mmHg) were used to define hypotension characterized by cumulative minutes, duration, area, and time-weighted-average under MAP. Zero time spent under a threshold was used as the reference group. The primary outcome was myocardial injury (a peak high-sensitive troponin T measurement 50 ng/l or greater) during the first 3 postoperative days.
Results: Postoperative hypotension was common, e.g., 2 cumulative hours below a threshold of 60 mmHg occurred in 144 (8%) patients while 4 h less than 75 mmHg occurred in 824 (48%) patients. Patients with myocardial injury had higher prolonged exposures for all characterizations. After adjusting for confounders, postoperative duration below a threshold of 75 mmHg for more than 635min was associated with myocardial injury (adjusted odds ratio, 2.68; 95% CI, 1.46 to 5.07, P = 0.002). Comparing multiple thresholds, cumulative durations of 2 to 4 h below a MAP threshold of 60 mmHg (adjusted odds ratio, 3.26; 95% CI, 1.57 to 6.48, P = 0.001) and durations of more than 4 h less than 65 mmHg (adjusted odds ratio, 2.98; 95% CI, 1.78 to 4.98, P < 0.001) and 70 mmHg (adjusted odds ratio, 2.18; 95% CI, 1.37 to 3.51, P < 0.001) were also associated with myocardial injury. Associations remained significant after adjusting for intraoperative hypotension, which independently was not associated with myocardial injury.
CONCLUSIONS:In this study, postoperative hypotension was common and was independently associated with myocardial injury.
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