非心脏手术术中低血压与术后谵妄的关系

非心脏手术术中低血压与术后谵妄的关系：一项回顾性多中心队列研究                            

贵州医科大学    麻醉与心脏电生理课题组

翻译：胡廷菊  编辑：潘志军  审校：曹莹

背景：

术中低血压与术后谵妄是否有关尚不清楚。我们假设临床上常观察到的术中一定范围内低血压与术后谵妄发生率增加有关。

方法：

此项回顾性队列研究纳入2005-2017年2个学术医学中心全麻下接受非心脏手术的成年患者。主要暴露为术中低血压，定义为术中平均动脉压(MAP) <55 mmHg的累积时间，术中低血压持续时间分类为短时(<15分钟;中位数[四分位数间距{IQR}]， 2[1-4]分钟)和长时(≥15分钟;中位数(四分位数间距),21[17-31]分钟)。主要结局是术后30天内新发生的谵妄。我们在二次分析中评价了血压相对基线值下降大于30%与术后谵妄的关系。使用多变量logistic回归分析调整病人和手术相关的因素，包括人口统计学资料，合并症和手术严重程度的指标。                       

结果：

在316717例患者中，2183例（0.7%）术后30天内诊断谵妄。短时间和长时间MAP小于55mmHg的患者分别为41.7% 和2.6%。与未发生低血压相比，MAP小于55mmHg与术后谵妄发生有关(MAP小于55mmHg的短时段；调整后的优势比ORadj1.22；95%CI 1.11-1.33；P< 0.001以及MAP小于55mmHg的长时段；ORadj1.57；95%CI 1.27-1.94；P< 0.001）。与MAP小于55mmHg的短时段相比，MAP小于55mmHg的长时段术后发生谵妄的比率更高（ORadj1.29；95%CI 1.05-1.58；P=0.016）。术中低血压和术后谵妄之间的关系是时间依赖性的（MAP <55 mm Hg每累计10min,ORadj 1.06；95% CI, 1.02–1.09; P =0.001) 。手术时间长的病人这种作用更明显( 手术时间 >3 h 患者中MAP <55 mm Hg 与没有发生MAP <55 mm Hg患者交互作用P =0 .046;ORadj, 1.40; 95% CI, 1.23–1.61; P < 0.001)。与没有发生低血压相比，MAP下降大于基线30%与术后谵妄无关，当额外调整MAP <55 mm Hg累积时间也是这样( MAP 下降>30%短时间: ORadj, 1.13; 95% CI, 0.91–1.40; P =0 .262 ；MAP 下降>30%长时间: ORadj, 1.19; 95% CI, 0.95–1.49; P =0 .141)。

结论：

在非心脏外科手术患者中， MAP < 55mmHg与术后谵妄发生的几率呈时间依赖性增加。这种关联在接受长时间手术的患者中更明显。

原始文献来源：

Wachtendorf LJ, Azimaraghi O, Santer P, et al. Association Between Intraoperative Arterial Hypotension and Postoperative Delirium After Noncardiac Surgery: A Retrospective Multicenter Cohort Study. Anesth Analg. 2022 Apr 1;134(4):822-833.

Association Between Intraoperative Arterial Hypotension

and Postoperative Delirium After Noncardiac Surgery:

A Retrospective Multicenter Cohort Study

Abstract

Background: It is unclear whether intraoperative arterial hypotension is associated with postoperative delirium. We hypothesized that intraoperative hypotension within a range frequently observed in clinical practice is associated with increased odds of delirium after surgery.

Methods: Adult noncardiac surgical patients undergoing general anesthesia at 2 academic medical centers between 2005 and 2017 were included in this retrospective cohort study. The primary exposure was intraoperative hypotension, defined as the cumulative duration of an intraoperative mean arterial pressure (MAP) <55 mm Hg, categorized into and short (<15 minutes;

median [interquartile range {IQR}], 2 [1–4] minutes) and prolonged (≥15 minutes; median [IQR], 21 [17–31] minutes) durations of intraoperative hypotension. The primary outcome was a new diagnosis of delirium within 30 days after surgery. In secondary analyses, we assessed the association between a MAP decrease of >30% from baseline and postoperative delirium. Multivariable logistic regression adjusted for patient- and procedure-related factors, including demographics, comorbidities, and markers of procedural severity, was used.

Results: Among 316,717 included surgical patients, 2183 (0.7%) were diagnosed with delirium within 30 days after surgery; 41.7% and 2.6% of patients had a MAP <55 mm Hg for a short and a prolonged duration, respectively. A MAP <55 mm Hg was associated with postoperative delirium compared to no hypotension (short duration of MAP <55 mm Hg: adjusted odds ratio [ORadj], 1.22; 95% confidence interval [CI], 1.11–1.33; P < 0.001 and prolonged duration of MAP <55 mmHg: ORadj, 1.57; 95% CI, 1.27–1.94; P <0 .001). Compared to a short duration of a MAP <55 mmHg, a prolonged duration of a MAP <55 mm Hg was associated with greater odds of postopera

tive delirium (ORadj, 1.29; 95% CI, 1.05–1.58; P =0 .016). The association between intraoperative hypotension and postoperative delirium was duration-dependent (ORadj for every 10 cumulative minutes of MAP <55 mm Hg: 1.06; 95% CI, 1.02–1.09; P =0.001) and magnified in patients who

underwent surgeries of longer duration (P for interaction =0 .046; MAP <55 mm Hg versus no MAP <55 mm Hg in patients undergoing surgery of >3 hours: ORadj, 1.40; 95% CI, 1.23–1.61; P <0 .001). A MAP decrease of >30% from baseline was not associated with postoperative delirium compared to no hypotension, also when additionally adjusted for the cumulative duration of a

MAP <55 mm Hg (short duration of MAP decrease >30%: ORadj, 1.13; 95% CI, 0.91–1.40; P =0 .262 and prolonged duration of MAP decrease >30%: ORadj, 1.19; 95% CI, 0.95–1.49; P =0 .141).

Conclusions: In patients undergoing noncardiac surgery, a MAP <55 mm Hg was associated with a duration-dependent increase in odds of postoperative delirium. This association was magnified in patients who underwent surgery of long duration.

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