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

车璐; 余佳文; 张越伦; 许力; 黄宇光

doi:10.24920/004202

Your Location：

Home >

Browse articles >

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

中国医学科学杂志（英文） 2023年38卷第4期页码：257-264

论著 | Updated：2024-05-21

- 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
- Affiliations：
  
  Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
- Author bio：
  
  *pumchxuli@163.com
- Funds：
  
  2022年北京协和医院中央高水平医院临床研究专项
- DOI：10.24920/004202
  中图分类号：
- 收稿日期：2022-12-22，
  
  录用日期：2023-07-12，
  
  网络出版日期：2023-09-06，
  
  纸质出版日期：2023-12-30
- Accepted：
Scan QR Code
车璐, 余佳文, 张越伦, 等. 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[J]. 中国医学科学杂志（英文）, 2023,38(4):257-264.

Lu Che, Jia-Wen Yu, Yue-Lun Zhang, et al. 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.
车璐, 余佳文, 张越伦, 等. 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[J]. 中国医学科学杂志（英文）, 2023,38(4):257-264. DOI： 10.24920/004202.

Lu Che, Jia-Wen Yu, Yue-Lun Zhang, et al. 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. DOI： 10.24920/004202.

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%

：0.278，0.761；

= 0.003）。GDFT对术后并发症的总效应为-0.18（95%

: -0.28，-0.07，

0.01）；中介效应作用为-0.08（95%

：-0.15，-0.04；

0.01），直接效应为-0.09（95%

：-0.20，0.03；

= 0.17）。中介效应在总效应中占比为49.9%（95%

：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。

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%

: 0.278

0.761;

= 0.003). The total effect of GDFT on postoperative complications was -0.18 (95%

: -0.28

-0.07;

0.01). The average causal mediation effect was -0.08 (95%

: -0.15

-0.04;

0.01). The average direct effect was -0.09 (95%

: -0.20

0.03;

= 0.17). The proportion mediated was 49.9% (95%

: 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.

关键词

Keywords

references

Messina A , Robba C , Calabrò L , et al . Association between perioperative fluid administration and postoperative outcomes: a 20-year systematic review and a meta-analysis of randomized goal-directed trials in major visceral/noncardiac surgery . Crit Care 2021 ; 25 ( 1 ): 43 . doi: 10.1186/s13054-021-03464-1 https://dx.doi.org/10.1186/s13054-021-03464-1 .

Calvo-Vecino JM , Ripollés-Melchor J , Mythen MG , et al . Effect of goal-directed haemodynamic therapy on postoperative complications in low-moderate risk surgical patients: a multicentre randomised controlled trial (FEDORA trial) . Br J Anaesth 2018 ; 120 ( 4 ): 734 - 44 . doi: 10.1016/j.bja.2017.12.018 https://dx.doi.org/10.1016/j.bja.2017.12.018 .

Che L , Zhang XH , Li X , et al . Outcome impact of individualized fluid management during spine surgery: a before-after prospective comparison study . BMC Anesthesiol 2020 ; 20 ( 1 ): 181 . doi: 10.1186/s12871-020-01092-w https://dx.doi.org/10.1186/s12871-020-01092-w .

Park S , Lee HC , Jung CW , et al . Intraoperative arterial pressure variability and postoperative acute kidney injury . Clin J Am Soc Nephrol 2020 ; 15 ( 1 ): 35 - 46 . doi: 10.2215/cjn.06620619 https://dx.doi.org/10.2215/cjn.06620619 . https://journals.lww.com/10.2215/CJN.06620619 https://journals.lww.com/10.2215/CJN.06620619

Wiórek A , Krzych Ł J . Intraoperative blood pressure variability predicts postoperative mortality in non-cardiac surgery—a Prospective Observational Cohort Study . Int J Environ Res Public Health 2019 ; 16 ( 22 ): 4380 . doi: 10.3390/ijerph16224380 https://dx.doi.org/10.3390/ijerph16224380 . https://www.mdpi.com/1660-4601/16/22/4380 https://www.mdpi.com/1660-4601/16/22/4380

Li J , Zhao Y , Zhao M , et al . High variance of intraoperative blood pressure predicts early cerebral infarction after revascularization surgery in patients with Moyamoya disease . Neurosurg Rev 2020 ; 43 ( 2 ): 759 - 69 . doi: 10.1007/s10143-019-01118-z https://dx.doi.org/10.1007/s10143-019-01118-z .

Lizano-Díez I , Poteet S , Burniol-Garcia A , et al . The burden of perioperative hypertension/hypotension: a systematic review . PLoS One 2022 ; 17 ( 2 ): e0263737 . doi: 10.1371/journal.pone.0263737 https://dx.doi.org/10.1371/journal.pone.0263737 . https://dx.plos.org/10.1371/journal.pone.0263737 https://dx.plos.org/10.1371/journal.pone.0263737

Lee H , Cashin A , Lamb S , et al . A Guideline for Reporting Mediation Analyses of Randomized Trials and Observational Studies: The AGReMA Statement . JAMA 2021 ; 326 ( 11 ): 1045 - 56 . doi: 10.1001/jama.2021.14075 https://dx.doi.org/10.1001/jama.2021.14075 .

Chen X , Zhu Y , Geng S , et al . Association of blood pressure variability and intima-media thickness with white matter hyperintensities in hypertensive patients . Front Aging Neurosci 2019 ; 11 : 192 . doi: 10.3389/fnagi.2019.00192 https://dx.doi.org/10.3389/fnagi.2019.00192 .

Hansen TW , Thijs L , Li Y , et al . Prognostic value of reading-to-reading blood pressure variability over 24 hours in 8938 subjects from 11 populations . Hypertension 2010 ; 55 ( 4 ): 1049 - 57 . doi: 10.1161/hypertensionaha.109.140798 https://dx.doi.org/10.1161/hypertensionaha.109.140798 .

Buis ML . Direct and indirect effects in a logit model . Stata J 2010 ; 10 ( 1 ): 11 - 29 .

Imai K , Keele L , Tingley D . A general approach to causal mediation analysis . Psychol Methods 2010 ; 15 ( 4 ): 309 - 34 . doi: 10.1037/a0020761 https://dx.doi.org/10.1037/a0020761 .

Valente MJ , Rijnhart JJM , Smyth HL , et al . Causal mediation programs in R, Mplus, SAS, SPSS, and Stata . Struct Equ Modeling 2020 ; 27 ( 6 ): 975 - 84 . doi: 10.1080/10705511.2020.1777133 https://dx.doi.org/10.1080/10705511.2020.1777133 . https://www.tandfonline.com/doi/full/10.1080/10705511.2020.1777133 https://www.tandfonline.com/doi/full/10.1080/10705511.2020.1777133

Schoemann AM , Boulton AJ , Short SD . Determining power and sample size for simple and complex mediation models . Soc Psychol Personal Sci 2017 ; 8 ( 4 ): 379 - 86 . doi: 10.1177/1948550617715068 https://dx.doi.org/10.1177/1948550617715068 . http://journals.sagepub.com/doi/10.1177/1948550617715068 http://journals.sagepub.com/doi/10.1177/1948550617715068

Luo MS . Perioperative goal-directed therapy in high-risk abdominal surgery . J Clin Anesth 2022 ; 78 : 110637 . doi: 10.1016/j.jclinane.2021.110637 https://dx.doi.org/10.1016/j.jclinane.2021.110637 . https://linkinghub.elsevier.com/retrieve/pii/S0952818021004803 https://linkinghub.elsevier.com/retrieve/pii/S0952818021004803

Zorrilla-Vaca A , Cata JP , Brown JK , et al . Goal-directed fluid therapy does not have an impact on renal outcomes in an enhanced recovery program . Ann Thorac Surg 2022 ; 114 ( 6 ): 2059 - 65 . doi: 10.1016/j.athoracsur.2022.03.070 https://dx.doi.org/10.1016/j.athoracsur.2022.03.070 .

Jessen MK , Vallentin MF , Holmberg MJ , et al . Goal-directed haemodynamic therapy during general anaesthesia for noncardiac surgery: a systematic review and meta-analysis . Br J Anaesth 2022 ; 128 ( 3 ): 416 - 33 . doi: 10.1016/j.bja.2021.10.046 https://dx.doi.org/10.1016/j.bja.2021.10.046 . https://linkinghub.elsevier.com/retrieve/pii/S0007091221007339 https://linkinghub.elsevier.com/retrieve/pii/S0007091221007339

Wei FF , Li Y , Zhang L , et al . Beat-to-beat, reading-to-reading, and day-to-day blood pressure variability in relation to organ damage in untreated Chinese . Hypertension 2014 ; 63 ( 4 ): 790 - 6 . doi: 10.1161/hypertensionaha.113.02681 https://dx.doi.org/10.1161/hypertensionaha.113.02681 . https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.113.02681 https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.113.02681

Sachdeva R , Nightingale TE , Krassioukov AV . The blood pressure pendulum following spinal cord injury: implications for vascular cognitive impairment . Int J Mol Sci 2019 ; 20 ( 10 ): 2464 . doi: 10.3390/ijms20102464 https://dx.doi.org/10.3390/ijms20102464 . https://www.mdpi.com/1422-0067/20/10/2464 https://www.mdpi.com/1422-0067/20/10/2464

Leibowitz A , Grossman E , Berkovitch A , et al . The effect of head and neck radiotherapy on blood pressure and orthostatic hypotension in patients with head and neck tumors . Am J Hypertens 2018 ; 31 ( 2 ): 235 - 9 . doi: 10.1093/ajh/hpx158 https://dx.doi.org/10.1093/ajh/hpx158 .

Putowski Z , Czok M , Krzych Ł . The impact of intraoperative blood pressure variability on the risk of postoperative adverse outcomes in non-cardiac surgery: a systematic review . J Anes 2022 ; 36 ( 2 ): 316 - 22 . doi: 10.1007/s00540-022-03035-w https://dx.doi.org/10.1007/s00540-022-03035-w .

Südfeld S , Brechnitz S , Wagner J , et al . Post-induction hypotension and early intraoperative hypotension associated with general anaesthesia . Br J Anaes 2017 ; 119 ( 1 ): 57 - 64 . doi: 10.1093/bja/aex127 https://dx.doi.org/10.1093/bja/aex127 . https://linkinghub.elsevier.com/retrieve/pii/S000709121733739X https://linkinghub.elsevier.com/retrieve/pii/S000709121733739X

Zhao JB , Li YL , Xia DY , et al . Protective effect of targeted fluid therapy on patients with one-lung ventilation . Evid Based Complement Alternat Med 2022 ; 2022 : 7850031 . doi: 10.1155/2022/7850031 https://dx.doi.org/10.1155/2022/7850031 .

Chirnoaga D , Coeckelenbergh S , Ickx B , et al . Impact of conventional vs . goal-directed fluid therapy on urethral tissue perfusion in patients undergoing liver surgery: a pilot randomised controlled trial . Eur J Anaesthesiol 2022 ; 39 ( 4 ): 324 - 32 . doi: 10.1097/eja.0000000000001615 https://dx.doi.org/10.1097/eja.0000000000001615 . https://journals.lww.com/10.1097/EJA.0000000000001615 https://journals.lww.com/10.1097/EJA.0000000000001615

Wang DD , Li Y , Hu XW , et al . Comparison of restrictive fluid therapy with goal-directed fluid therapy for postoperative delirium in patients undergoing spine surgery: a randomized controlled trial . Perioper Med (Lond) 2021 ; 10 ( 1 ): 48 . doi: 10.1186/s13741-021-00220-5 https://dx.doi.org/10.1186/s13741-021-00220-5 .

Khan AI , Fischer M , Pedoto AC , et al . The impact of fluid optimisation before induction of anaesthesia on hypotension after induction . Anaesthesia 2020 ; 75 ( 5 ): 634 - 41 . doi: 10.1111/anae.14984 https://dx.doi.org/10.1111/anae.14984 .

Fontanarosa P . Reporting findings from mediation analyses . JAMA 2021 ; 326 ( 11 ): 1057 . doi: 10.1001/jama.2021.15786 https://dx.doi.org/10.1001/jama.2021.15786 .

浏览量

382

Downloads

CSCD

文章被引用时，请邮件提醒。

Submit

关联资源

Possible Risk Factors for Severe Complications Occurring after Primary Total Knee Arthroplasty