Perioperative optimal blood pressure as determined by ultrasound tagged near infrared spectroscopy and its association with postoperative acute kidney injury in cardiac surgery patients
Perioperative optimal blood pressure as determined by ultrasound tagged near infrared spectroscopy and its association with postoperative acute kidney injury in cardiac surgery patients
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DOI：
10.1093/icvts/ivv371
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发表时间：
2016-04-01
影响因子：
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通讯作者：
Mandal, Kaushik
中科院分区：
文献类型：
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作者：
Hori, Daijiro;Hogue, Charles;Mandal, Kaushik
目的：通过脑血流自动调节监测来确定个体化的最佳血压，以达到围手术期血压管理的目的，可确保足够的肾血流灌注。本研究的目的是评估在体外循环(CPB)期间和重症监护病房(ICU)术后早期测定的个体患者的最佳血压的变化。第二个目的是检查ICU中低于理想血压的漂移是否与心脏手术相关的急性肾损伤(CsA-AKI)相关。方法：110例心脏手术患者在体外循环期间和术后3h内使用一种新技术-超声标记近红外光谱(UT-NIRS)监测脑血流。计算相关血流指数(CFX)，作为UT-NIRS测量的脑血流指数与平均动脉压(MAP)之间的直线相关系数。最佳血压定义为CFX最低的MAP。观察围术期最佳血压的变化，分析低于最佳血压[曲线下面积和最优MAP mm Hgxh]的血压漂移(幅度和持续时间)与CsA-AKI(根据肾脏疾病：改善全球预后标准定义)的发生率之间的关系。结果：ICU早期和体外循环期间的最佳血压相关(r=0.46，P<；0.0001)，但ICU组明显高于CPB期间(75+/-8.7vs71+/-10.3 mm Hg，P=0.0002)。术后48h内发生CsA-AKI 30例(27.3%)。AUC<；OptMAP与CsA-AKI相关[中位数13.27 mm Hgxh，四分位数范围(IQR)，4.63~20.14 vs Medium，6.05 mm Hgxh，IQR3.03~12.40，P=0.008]，ICU中AUC；OptMAP与CsA-AKI相关(13.72 mm Hgxh，IQR5.09~25.54vs5.65 mm Hgxh，IQR1.71~13.07，P=0.022)。围手术期血压低于最佳血压(AUC<；OptMAP，MmHgXh)与CSA-AKI相关。围手术期基于脑自动调节监测的个体化血压管理有助于改善CSA-AKI相关预后。
OBJECTIVES: Perioperative blood pressure management by targeting individualized optimal blood pressure, determined by cerebral blood flow autoregulation monitoring, may ensure sufficient renal perfusion. The purpose of this study was to evaluate changes in the optimal blood pressure for individual patients, determined during cardiopulmonary bypass (CPB) and during early postoperative period in intensive care unit (ICU). A secondary aim was to examine if excursions below optimal blood pressure in the ICU are associated with risk of cardiac surgery-associated acute kidney injury (CSA-AKI).METHODS: One hundred and ten patients undergoing cardiac surgery had cerebral blood flow monitored with a novel technology using ultrasound tagged near infrared spectroscopy (UT-NIRS) during CPB and in the first 3 h after surgery in the ICU. The correlation flow index (CFx) was calculated as a moving, linear correlation coefficient between cerebral flow index measured using UT-NIRS and mean arterial pressure (MAP). Optimal blood pressure was defined as the MAP with the lowest CFx. Changes in optimal blood pressure in the perioperative period were observed and the association of blood pressure excursions (magnitude and duration) below the optimal blood pressure [area under the curve (AUC) < OptMAP mmHgxh] with incidence of CSA-AKI (defined using Kidney Disease: Improving Global Outcomes criteria) was examined.RESULTS: Optimal blood pressure during early ICU stay and CPB was correlated (r = 0.46, P < 0.0001), but was significantly higher in the ICU compared with during CPB (75 +/- 8.7 vs 71 +/- 10.3 mmHg, P = 0.0002). Thirty patients (27.3%) developed CSA-AKI within 48 h after the surgery. AUC < OptMAP was associated with CSA-AKI during CPB [median, 13.27 mmHgxh, interquartile range (IQR), 4.63-20.14 vs median, 6.05 mmHgxh, IQR 3.03-12.40, P = 0.008], and in the ICU (13.72 mmHgxh, IQR 5.09-25.54 vs 5.65 mmHgxh, IQR 1.71-13.07, P = 0.022).CONCLUSIONS: Optimal blood pressure during CPB and in the ICU was correlated. Excursions below optimal blood pressure (AUC < OptMAP mmHgXh) during perioperative period are associated with CSA-AKI. Individualized blood pressure management based on cerebral autoregulation monitoring during the perioperative period may help improve CSA-AKI-related outcomes.