脊柱大手术患者术中血压波动在目标导向液体治疗与患者术后并发症之间发挥中介作用

doi:10.24920/004202

摘要/Abstract

摘要：

目的目标导向液体治疗（goal-directed fluid therapy，GDFT）能有效降低术后并发症的发生率，但其潜在机制尚不清楚。本研究探讨了术中血流动力学波动在GDFT与脊柱大手术患者术后并发症发生率之间的中介作用。此外，我们使用血流动力学指标平均动脉压对这种中介作用进行了分层分析。

方法在一项比较GDFT和常规液体管理模式对脊柱大手术患者术后并发症发生率影响的非随机对照研究的基础上，我们采用中介分析探讨血流动力学波动是否在GDFT与术后并发症之间发挥中介作用。数据分析时，以血压平均真实变异率代表血流动力学波动，应用R软件的中介包（3.1.2版），在调整协变量后，对5,000个自举样本进行二次分析。

结果在纳入的300例患者中，40%（120/300）在术后30天内出现术后并发症。结果显示：校正混杂因素后，GDFT与术后30天并发症减少相关（odds ratio：0.460，95% CI：0.278，0.761；P = 0.003）。GDFT对术后并发症的总效应为-0.18（95% CI: -0.28，-0.07，P < 0.01）；中介效应作用为-0.08（95% CI：-0.15，-0.04；P < 0.01），直接效应为-0.09（95% CI：-0.20，0.03；P = 0.17）。中介效应在总效应中占比为49.9%（95% CI：18.3%，140.0%）。

结论术中血压波动在GDFT与术后并发症发生之间发挥中介作用。降低本术血压波动是否能预防术后并发症需要进一步研究证实。

关键词: 目标导向液体治疗, 中介因素分析, 术后并发症, 血流动力学

Abstract:

Objective Although goal-directed fluid therapy (GDFT) has been proven to be effective in reducing the incidence of postoperative complications, the underlying mechanisms remain unknown. The aim of this study was to examine the mediating role of intraoperative hemodynamic lability in the association between GDFT and the incidence of postoperative complications. We further tested the role of this mediation effect using mean arterial pressure, a hemodynamic indicator.

Methods This secondary analysis used the dataset of a completed nonrandomized controlled study to investigate the effect of GDFT on the incidence of postoperative complications in patients undergoing posterior spine arthrodesis. We used a simple mediation model to test whether there was a mediation effect of average real variability between the association of GDFT and postoperative complications. We conducted mediation analysis using the mediation package in R (version 3.1.2), based on 5,000 bootstrapped samples, adjusting for covariates.

Results Among the 300 patients in the study, 40% (120/300) developed postoperative complications within 30 days. GDFT was associated with fewer 30-day postoperative complications after adjustment for confounders (odds ratio: 0.460, 95% CI: 0.278, 0.761; P = 0.003). The total effect of GDFT on postoperative complications was -0.18 (95% CI: -0.28, -0.07; P < 0.01). The average causal mediation effect was -0.08 (95% CI: -0.15, -0.04; P < 0.01). The average direct effect was -0.09 (95% CI: -0.20, 0.03; P = 0.17). The proportion mediated was 49.9% (95% CI: 18.3%, 140.0%).

Conclusions The intraoperative blood pressure lability mediates the relationship between GDFT and the incidence of postoperative complications. Future research is needed to clarify whether actively reducing intraoperative blood pressure lability can prevent postoperative complications.

Key words: goal-directed fluid therapy, mediation analysis, postoperative complications, hemodynamic stability

Lu Che,Jia-Wen Yu,Yue-Lun Zhang,Li Xu,Yu-Guang Huang. Intraoperative Blood Pressure Lability Acts as a Key Mediator in the Impacts of Goal-Directed Fluid Therapy on Postoperative Complications in Patients Undergoing Major Spine Surgery[J].Chinese Medical Sciences Journal, 2023, 38(4): 257-264.

图/表 3

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Variables	GDFT group (n = 150)	Control group (n = 150)	P value
Age (yrs, mean ± SD)	57.8 ± 17.2	59.2 ± 13.8	0.448
Sex, male [n (%)]	61 (40.7)	63 (42.0)	0.725
BMI (kg/m², mean ± SD )	25.4 ± 3.8	25.4 ± 3.3
ASA score [n (%)]			0.971
≤ Ⅱ	141 (94.0)	144 (91.0)
> Ⅱ	9 (6.0)	6 (9.0)
Comorbidity [n (%)]
Hypertension	66 (44.0)	61 (40.7)	0.514
Coronary artery disease	10 (6.7)	10 (6.7)	0.987
Diabetes mellitus type Ⅱ	21 (14.0)	25 (16.8)	0.521
Baseline Hb (g·L^-1, mean ± SD)	136.0 ± 13.2	134.7 ± 19.4	0.486
Baseline HR (bpm, mean ± SD)	77.0 ± 9.2	79.0 ± 10.5	0.162
Baseline SBP (mmHg, mean ± SD)	129.5 ± 15.9	132.3 ± 15.3	0.121
Baseline creatinine (μg·ml^-1, mean ± SD)	67.9 ± 19.3	67.1 ± 12.8	0.657
Infused crystalloids [ml·kg^-1·h^-1, median (IQR)]	7.2 (4.6-9.8)	7.4 (5.1-9.7)	0.398
Infused colloids [ml·kg^-1·h^-1, median (IQR)]	1.6 (0.3-2.9)	1.6 (0.3-2.9)	0.893
Vasopressor [n (%)]	7 (4.67)	20 (13.33)	0.009
Operation time [min, median (IQR))	184 (153-220)	193 (156-225)	0.404
ARV (mmHg·min^-1, median (IQR))	0.87 (0.53-1.25)	1.73 (1.16-2.49)	<0.001
TWA_MAP (mmHg, mean ± SD)	82.7 ± 7.7	82.3 ± 9.5	0.219

Items	Crude			Adjusted*
Items	OR	95% CI	P value	OR	95% CI	P value
GDFT	0.510	0.319, 0.815	0.005	0.460	0.278, 0.761	0.003
TWA_MAP	0.922	0.892, 0.953	<0.001	0.928	0.897, 0.960	<0.001
ARV (mmHg·min^-1)	1.687	1.338, 2.126	<0.001	1.634	1.278, 2.090	<0.001

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