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非心臟手術后無術中低血壓患者的術后低血壓和不良臨床結局

背景
術后低血壓（POH）與重大不良事件有關 。 然而 ， 對于普通護理病房術后無術中低血壓（IOH）患者血壓閾值與預后的關系 ， 目前尚不清楚 。 我們評估了無IOH患者POH與主要不良心腦血管事件（MACCE）的關系 。
方法回顧性分析了2008-2017年67968例非心臟病患者的手術 ， 選取這些患者出院后的平均動脈壓（MAP）數據為術后≥48小時且沒有IOH的跡象的 。 主要觀察指標是術后30天的MACCE通過MAP閾值進行評估：≤75、≤65和≤55 mmHg(POH定義為閾值以下的單次測量) 。 次要觀察指標包括全因死亡率(30-90天)、30天急性心肌梗死、30天急性缺血性中風、30天再住院和7天急性腎損傷 。 POH和不良事件之間的相關性也在16,034名接受IOH(術中MAP≤為65毫米汞柱)手術的患者隊列(#2)中進行了評估 。
結果在無IOH的患者中 ， POH暴露與MACCE無關（P<0.016被認為是顯著的：≤75mmHg ， 危險比[HR]1.18[98.4%置信區間{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 ， 與無POH的患者相比,在所有MAP閾值下觀察到急性腎損傷和30天再入院與 MAP≤65mmHg時30-/90-天死亡率及MAP≤55mmHg時 90天死亡率的有相關性 。 在任何MAP閾值下 ， POH與急性缺血性卒中或急性心肌梗死的次要觀察指標之間均未發現關聯 。 在包括所有患者在內的數據集中 ， 無論IOH狀態如何 ， 我們評估POH與IOH之間的相關性時 ， 未發現POH與IOH之間的相互作用（相互作用項的P值無意義） 。 當使用相互作用項時 ， 無IOH的POH與MACCE的相關性在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])時顯著 ， MAP≤55 mmHg時不顯著 。 隊列2(POH和IOH)在MACCE方面顯示出大致相似的結果：MAP≤75和≤65 mmHg時無顯著意義 ， 但MAP≤55 mmHg時顯著(HR1.53[1.05-2.22] ， P=0.006) 。
結論在所研究的所有MAP中 ， 無IOH患者的POH與MACCE無關 。 POH和IOH之間沒有相互作用 。 大型前瞻性隨機試驗是必要的 ， 以發展更好的證據 ， 并告知臨床醫生術后血壓管理的價值 。
原始文獻來源：
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.

非心臟手術后無術中低血壓患者的術后低血壓和不良臨床結局
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READINGPostoperative 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).

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