体外循环期间和脱机期间的术中低血压和急性肾损伤、卒中和死亡率：一项回顾性队列观察研究

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体外循环期间和脱机期间的术中低血压和急性肾损伤、卒中和死亡率：一项回顾性队列观察研究 

                     贵州医科大学  麻醉与心脏电生理课题组

                     翻译：易菁   编辑：马艳燕  审校：曹莹

背景：在心脏手术中，特定术中阶段的低血压或血管活性药物与不良结局之间的关联仍不清楚。本项研究假设术中低血压持续时间或在体外循环期间和脱机期间的低血压可能与术后主要不良事件的发生有关。

方法：这项回顾性队列观察研究纳入了2008 -2016年期间在一家三级医院接受心脏手术的成年人数据。术中低血压定义为平均动脉压低于 65 mmHg。根据体外循环期间发生的总低血压持续时间的占比，将低血压分为三类（超过 80%、60%-80% 和＜ 60%）。主要结局指标是住院期间卒中、急性肾损伤或死亡率的占比。校正了血管活性药物剂量、米力农剂量、患者和手术因素，评估了手术期间、体外循环脱机期间和体外循环期间低血压的持续时间以及体外循环期间低血压的比例。

结果 ：4,984 例患者中 256 例（占比5.1%）发生不良事件；其中66 人（占1.3%）中风，125 人（占2.5%）急性肾损伤，109 人（占比2.2%）死亡。主要结局与低血压的总持续时间（校正比值比，1.05；95% CI，1.02 - 1.08；P = 0.032）、每 10 分钟暴露于低于 65 mmHg 的平均动脉压时体外循环脱机期间的低血压（校正比值比，1.06；95% CI，1.03 - 1.10；P = 0.001) ，体外循环期间低血压持续时间的分数低于 60%（参考值大于 80%；校正比值比，1.67；95% CI，1.10 -2.60；P= 0.019）有关，但与体外循环期间每 10 分钟的低血压（校正比值比，1.04；95% CI，0.99 -1.09；P = 0.118），体外循环期间低血压的比例为 60% - 80%（校正比值比, 1.45; 95% CI, 0.97 -2.23; P = 0.082)，或总血管活性药物剂量（校正比值比，1.00；95% CI，1.00 -1.00；P = 0.247）无关。

      结论：这项研究证实了先前的单中心研究结果，即整个心脏手术过程中的术中低血压与急性肾损伤、死亡或中风的风险增加有关。 

Recruitment 英文原文    

Intraoperative Hypotension and Acute Kidney Injury, Stroke, and Mortality during and outside Cardiopulmonary Bypass: A Retrospective Observational Cohort Study

Background

In cardiac surgery, the association between hypotension during specific intraoperative phases or vasopressor-inotropes with adverse outcomes remains unclear. This study’s hypothesis was that intraoperative hypotension duration throughout the surgery or when separated into hypotension during and outside cardiopulmonary bypass may be associated with postoperative major adverse events.

Methods

This retrospective observational cohort study included data for adults who had cardiac surgery between 2008 and 2016 in a tertiary hospital. Intraoperative hypotension was defined as mean arterial pressure of less than 65 mmHg. The total duration of hypotension was divided into three categories based on the fraction of overall hypotension duration that occurred during cardiopulmonary bypass (more than 80%, 80 to 60%, and less than 60%). The primary outcome was a composite of stroke, acute kidney injury, or mortality during the index hospitalization. The association with the composite outcome was evaluated for duration of hypotension during the entire surgery, outside cardiopulmonary bypass, and during cardiopulmonary bypass and the fraction of hypotension during cardiopulmonary bypass adjusting for vasopressor-inotrope dose, milrinone dose, patient, and surgical factors.

Results

The composite outcome occurred in 256 (5.1%) of 4,984 included patient records; 66 (1.3%) patients suffered stroke, 125 (2.5%) had acute kidney injury, and 109 (2.2%) died. The primary outcome was associated with total duration of hypotension (adjusted odds ratio, 1.05; 95% CI, 1.02 to 1.08; P = 0.032), hypotension outside cardiopulmonary bypass (adjusted odds ratio, 1.06; 95% CI, 1.03 to 1.10; P = 0.001) per 10-min exposure to mean arterial pressure of less than 65 mmHg, and fraction of hypotension duration during cardiopulmonary bypass of less than 60% (reference greater than 80%; adjusted odds ratio, 1.67; 95% CI, 1.10 to 2.60; P = 0.019) but not with each 10-min period hypotension during cardiopulmonary bypass (adjusted odds ratio, 1.04; 95% CI, 0.99 to 1.09; P = 0.118), fraction of hypotension during cardiopulmonary bypass of 60 to 80% (adjusted odds ratio, 1.45; 95% CI, 0.97 to 2.23; P = 0.082), or total vasopressor-inotrope dose (adjusted odds ratio, 1.00; 95% CI, 1.00 to 1.00; P = 0.247).

Conclusions

This study confirms previous single-center findings that intraoperative hypotension throughout cardiac surgery is associated with an increased risk of acute kidney injury, mortality, or stroke.

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