麻醉诱导前血压与术前评估时血压的关系
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Relationship Between Preoperative Evaluation Blood Pressure and Preinduction Blood Pressure: A Cohort Study in Patients Undergoing General Anesthesia
背景与目的
相关研究表明术中血压波动是影响患者预后的重要因素之一，是否能够简单地以患者诱导前的血压作为基础血压参考值仍存在较大争议。本研究主要探讨术前评估时的血压和入室后诱导前的血压之间的关系。
方 法
该研为观察性的队列研究，纳入对象为全麻下行择期非心脏手术且年龄在60岁及以上的患者，共4408名患者。主要结果为诱导前平均血压（Mean Blood Pressure, MAP）和术前评估时平均血压的差值，若差值≥10mmHg则认为有临床意义。次要结果是入手术室前和诱导前收缩压（Systolic Blood Pressure, SBP）及舒张压(Diastolic Blood Pressure, DBP)的差别，使用配对t检验比较组间差别，使用线性回归分析获得患者一般资料、合并症、药物治疗、手术类型和术前血压校正后的MBP差值和术前血压关系的估计值。
结 果
最终有3660例(83%)患者符合入选标准并完成了相关研究。其中2228例(61%)患者诱导前和术前评估MBP的差值≥10mmHg。总体来说，诱导前血压较术前血压增加。两组血压MAP、SBP、DBP的差值均数分别为11mmHg、14mmHg、2.6mmHg。52%的患者诱导前MAP较术前升高至少10mmHg，39%的患者两者之间的差值在±10mmHg之间，9%的患者诱导前血压反而降低了10mmHg以上。术前MAP和诱导前MAP有显著的正线性相关关系，相关系数0.43，但是术前MAP与术前和诱导前MAP的差值呈负相关，术前MBP越高的患者该差值越小。
结 论
诱导前血压通常高于术前评估血压，这可能与患者术前焦虑有关。为获得研究中的最佳血压参考值或临床围术期血压控制的最佳目标值，需要考虑患者自身的因素和不同患者之间的体质差异。
原始文献摘要
van Klei W A, van Waes J A, Pasma W, et al. Relationship Between Preoperative Evaluation Blood Pressure and Preinduction Blood Pressure: A Cohort Study in Patients Undergoing General Anesthesia[J]. Anesthesia & Analgesia, 2017, 124(2):431.
BACKGROUND: For outcomes research where changes in intraoperative blood pressure are a possible causative factor, it is important to determine an appropriate source for a reference value. We studied to what extent preinduction blood pressure values in the operating room differ from those obtained during preoperative evaluation outside the operating room.
METHODS: Cohort study including 4408 patients aged 60 years or older undergoing noncardiac surgery. The outcome was the difference between the preinduction mean blood pressure (MBP) and the MBP obtained during preoperative evaluation. A difference of ≥10 mm Hg was considered clinically relevant. A paired samples t test was used to estimate the difference. Linear regression was used to obtain estimates adjusted for patient characteristics, comorbidity, medications, type of surgery, and preoperative blood pressure.
RESULTS: Complete data were available for 3660 (83%) patients. There were 2228 (61%) patients with a difference of ≥10 mm Hg between the preinduction and preoperative MBP. The overall mean difference between both MBPs was 11 mm Hg (95% confidence interval, 10–11) with important variability among individuals. Patients with higher preoperative MBP values had smaller differences. After adjusting for patient characteristics, comorbidity, medications, type of surgery, and preoperative blood pressure, the difference decreased an estimated 5.0 mm Hg (95% confidence interval, 4.7–5.4) for every increase of 10 mm Hg in preoperative MBP. Patient characteristics, comorbidity, type of surgery, or medication were not strongly associated with the difference.
CONCLUSIONS: The average preinduction blood pressure was higher than the preoperative blood pressure. This difference between the measurements can be explained by stress-induced effects and regression to the mean. To define an optimal reference value for research purposes or to arrive at a clinical perioperative blood pressure target, one should consider that there is important variability both within and between patients.
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