【罂粟摘要】中高危患者行非心脏手术的低血压预测指标
中高危患者行非心脏手术的低血压预测指标
背景：低血压预测指数是一种基于动脉波形特征的商用算法，它能够判断平均动脉压低于65mmHg且持续至少1分钟的低血压。因此，我们验证了最初的假设，即应用该指数指导可以减少非心脏手术期间低血压的持续时间和严重程度。
方法：我们招募了术中行有创动脉压监测的中高风险非心脏手术的成年患者。参与试验的患者被随机分成两组，分别在有或没有指数指导的情况下进行血流动力学治疗。当指数超过85(范围从0到100)时，指数指导组的临床医生会收到警示，并基于先进的血流动力学治疗算法推荐使用血管升压药、液体治疗、正性肌力药或进行观察。主要观察指标是低血压发生量，定义为时间加权平均动脉压低于65 mmHg。次要观察指标是时间加权平均动脉压小于60和55 mmHg。
结果：在214名入选患者中，有105名(49%)患者被随机分配到指数指导组进行指导。平均动脉压中位数(25%，75%)时间加权平均动脉压低于65mmHg的指数指导患者为0.14(0.03，0.37)，非指数指导组患者为0.14 (0.03，0.39)，中位数差(95%CI)为0(-0.03~0.04)，P=0.757。因此，指数指导不能降低低于65 mmHg的低血压的发生率，也不能降低低于60或55 mmHg的低血压的发生率。试验后回顾发现，当临床医生进行干预时，指数指导才与降低低血压发生率相关。
结论：在这项前期试验中，指数指导并不能减少术中低血压的发生。发出警示之后半数的患者没有接受到治疗，可能是因为警示的时间过短，治疗算法复杂，或者临床医生忽视了警报。在未来，我们计划使用较低的指数警报阈值和更简单的、强调及时治疗的新的治疗算法解决这一问题。
Kamal Maheshwari, Tetsuya Shimada,Dongsheng Yang,Sandeep Khanna, et al.Hypotension Prediction Index for Prevention of Hypotension during
Moderate-to High-risk Noncardiac Surgery.ANESTHESIOLOGY 2020;133:1214–22.
Hypotension Prediction Index for Prevention of Hypotension during Moderate- to High-risk Noncardiac Surgery
ABSTRACT
Background: The Hypotension Prediction Index is a commercially available algorithm, based on arterial waveform features, that predicts hypotension
defined as mean arterial pressure less than 65 mmHg for at least 1min. We therefore tested the primary hypothesis that index guidance reduces the dura
tion and severity of hypotension during noncardiac surgery.
Methods: We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were
randomized to hemodynamic management with or without index guidance.Clinicians caring for patients assigned to guidance were alerted when the
index exceeded 85 (range, 0 to 100) and a treatment algorithm based on advanced hemodynamic parameters suggested vasopressor administration,
fluid administration, inotrope administration, or observation. Primary outcome was the amount of hypotension, defined as time-weighted average mean arterial pressure less than 65 mmHg. Secondary outcomes were time-weighted mean pressures less than 60 and 55 mmHg.
Results: Among 214 enrolled patients, guidance was provided for 105(49%) patients randomly assigned to the index guidance group. The median(first quartile, third quartile) time-weighted average mean arterial pressure less than 65 mmHg was 0.14 (0.03, 0.37) in guided patients versus 0.14(0.03, 0.39) mmHg in unguided patients: median difference (95% CI) of 0
(–0.03 to 0.04), P = 0.757. Index guidance therefore did not reduce amount of hypotension less than 65 mmHg, nor did it reduce hypotension less than
60 or 55 mmHg. Post hoc, guidance was associated with less hypotension when analysis was restricted to episodes during which clinicians intervened.
Conclusions: In this pilot trial, index guidance did not reduce the amount of intraoperative hypotension. Half of the alerts were not followed by treatment,
presumably due to short warning time, complex treatment algorithm, or clinicians ignoring the alert. In the future we plan to use a lower index alert threshold and a simpler treatment algorithm that emphasizes prompt treatment.
翻译：任文鑫 佟睿
编辑：冯玉蓉 佟睿
审校：曹莹