【罂粟摘要】非心脏手术后无术中低血压患者的术后低血压和不良临床结局
非心脏手术后无术中低血压患者的术后低血压和不良临床结局
贵州医科大学 高鸿教授课题组
翻译：任文鑫 编辑：佟睿 审校：曹莹
术后低血压（POH）与重大不良事件有关。然而，对于普通护理病房术后无术中低血压（IOH）患者血压阈值与预后的关系，目前尚不清楚。我们评估了无IOH患者POH与主要不良心脑血管事件（MACCE）的关系。
回顾性分析了2008-2017年67968例非心脏病患者的手术，选取这些患者出院后的平均动脉压（MAP）数据为术后≥48小时且没有IOH的迹象的。主要观察指标是术后30天的MACCE通过MAP阈值进行评估：≤75、≤65和≤55 mmHg(POH定义为阈值以下的单次测量)。次要观察指标包括全因死亡率(30-90天)、30天急性心肌梗死、30天急性缺血性中风、30天再住院和7天急性肾损伤。POH和不良事件之间的相关性也在16,034名接受IOH(术中MAP≤为65毫米汞柱)手术的患者队列(#2)中进行了评估。
在无IOH的患者中，POH暴露与MACCE无关（P<0.016被认为是显著的：≤75mmHg，危险比[HR]1.18[98.4%置信区间{CI}0.99-1.39]，P=0.023；≤65mmHg，HR 1.18[0.99–1.41]，P=0.028；≤55mmHg，HR 1.23[0.90–1.71]，P=0.121）；然而，与无POH的患者相比,在所有MAP阈值下观察到急性肾损伤和30天再入院与 MAP≤65mmHg时30-/90-天死亡率及MAP≤55mmHg时 90天死亡率的有相关性。在任何MAP阈值下，POH与急性缺血性卒中或急性心肌梗死的次要观察指标之间均未发现关联。在包括所有患者在内的数据集中，无论IOH状态如何，我们评估POH与IOH之间的相关性时，未发现POH与IOH之间的相互作用（相互作用项的P值无意义）。当使用相互作用项时，无IOH的POH与MACCE的相关性在MAP≤75 mmHg(HR1.2 0[1.0 1-1.4 1])和MAP≤6 5 mmHg(HR1.2 1[1.0 2-1.45])时显著，MAP≤55 mmHg时不显著。队列2(POH和IOH)在MACCE方面显示出大致相似的结果：MAP≤75和≤65 mmHg时无显著意义，但MAP≤55 mmHg时显著(HR1.53[1.05-2.22]，P=0.006)。
在所研究的所有MAP中，无IOH患者的POH与MACCE无关。POH和IOH之间没有相互作用。大型前瞻性随机试验是必要的，以发展更好的证据，并告知临床医生术后血压管理的价值。
原始文献来源：
Ashish K. Khanna, Andrew D. Shaw, M Wolf H. Stapelfeldt, et al.Postoperative Hypotension and Adverse Clinical Outcomes in Patients Without Intraoperative Hypotension, After Noncardiac Surgery.Anesth Analg 2021;132:1410–20.
Postoperative Hypotension and Adverse Clinical Outcomes in Patients Without Intraoperative Hypotension, After Noncardiac Surgery
BACKGROUND: Postoperative hypotension (POH) is associated with major adverse events. However, little is known about the association of blood pressure thresholds and outcomes in postoperative patients without intraoperative hypotension (IOH) on the general-care ward. We evaluated the association of POH with major adverse cardiac or cerebrovascular events (MACCE) in patients without IOH.
METHODS: This retrospective analysis included 67,968 noncardiac patient-procedures (2008–2017) for patients discharged to the ward with postoperative mean arterial pressure (MAP) readings, managed for ≥48 hours postsurgery, with no evidence of IOH. The primary outcome was 30-day MACCE evaluated by postoperative MAP thresholds: ≤75, ≤65, and ≤55 mm Hg
(POH defined as a single measurement below threshold). Secondary outcomes included allcause mortality (30-/90-day), 30-day acute myocardial infarction, 30-day acute ischemic stroke, 30-day readmission, 7-day acute kidney injury, and 30-day readmission. Associations between POH and adverse events were also evaluated in a cohort (#2) of 16,034 patient-procedures with IOH (intraoperative MAP ≤65 mm Hg).
RESULTS: In patients without IOH, exposure to POH was not associated with MACCE at any investigated MAP threshold (P < .016 was considered significant: ≤75 mm Hg, hazard ratio [HR] 1.18 [98.4% confidence interval {CI} 0.99-1.39], P = .023; ≤65 mm Hg, HR 1.18 [0.99–1.41], P = .028; ≤55 mm Hg, HR 1.23 [0.90–1.71], P = .121); however, associations were observed at all MAP thresholds for secondary outcomes of acute kidney injury and 30-day readmission, for 30-/90-day mortality for MAP ≤65 mm Hg, and 90-day mortality for MAP ≤55 mm Hg, compared
to those without POH. No associations were detected between POH and secondary outcomes of acute ischemic stroke or acute myocardial infarction at any MAP threshold. No interaction between POH and IOH was found when we evaluated the association of POH on outcomes in the data set including all patients, regardless of IOH status (P values for interaction terms nonsignificant). When the interaction term was utilized, the association between POH without IOH and MACCE was significant for MAP ≤75 mm Hg (HR 1.20 [1.01–1.41]) and MAP ≤65 mm Hg (HR 1.21 [1.02-1.45]), but not MAP ≤55 mm Hg. Cohort #2 (POH with IOH) showed largely similar results for MACCE: not significant for MAP ≤75 and ≤65 mm Hg, but significant for MAP ≤55 mm Hg (HR 1.53 [1.05–2.22], P = .006).
CONCLUSIONS: POH in patients without IOH was not associated with MACCE at any MAP investigated. No interaction was identified between POH and IOH. Large prospective randomized trials are necessary to develop better evidence and inform clinicians the value of postoperative blood pressure management.