Computer-assisted Individualized Hemodynamic Management Reduces Intraoperative Hypotension in Intermediate- and High-risk Surgery: A Randomized Controlled Trial.
Computer-assisted Individualized Hemodynamic Management Reduces Intraoperative Hypotension in Intermediate- and High-risk Surgery: A Randomized Controlled Trial.
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DOI：
10.1097/aln.0000000000003807
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发表时间：
2021-08-01
期刊：
影响因子：
8.8
通讯作者：
Duranteau J
中科院分区：
文献类型：
--
作者：
Joosten A;Rinehart J;Van der Linden P;Alexander B;Penna C;De Montblanc J;Cannesson M;Vincent JL;Vicaut E;Duranteau J
手术期间个体化血流动力学管理依赖于血管加压剂和液体的准确滴定。在这种情况下，已经开发了计算机系统来协助麻醉提供者提供这些干预措施。我们验证了计算机辅助个体化血流动力学管理可以减少中高风险手术患者术中低血压的假设。这项单中心、平行、双臂、前瞻性随机对照单盲优势研究纳入了38例接受腹部或骨科手术的患者。所有纳入的患者在麻醉诱导后插入桡动脉导管，并连接未校准的脉搏轮廓监测装置。在手动调整目标导向治疗组（N=19）中，个体化血流动力学管理包括手动滴注去甲肾上腺素以维持患者平均动脉压（MAP）在基线值的10%以内，以及微流体挑战以最大化卒中容积指数（SVI）。在计算机辅助组（N=19）中，采用相同的方法，使用闭环系统进行去甲肾上腺素调节，并使用决策支持系统输注微流体挑战（100ml）。主要结局是术中低血压，定义为术中MAP <患者基线值90%的患者时间百分比，在术前筛查中测量。次要结果为轻微术后并发症的发生率。所有患者均纳入分析。计算机辅助组术中低血压为1.2%[0.4-2.0%]，而人工调节目标定向治疗组为21.5%[14.5-31.8%](差异为- 21.1 (95% CI - 15.9 - 27.6%)；p < 0.001)。术后轻微并发症发生率组间无差异（42% vs 58%, p=0.330）。计算机辅助组的平均SVI和心脏指数均显著高于人工调节目标导向治疗组（p<0.001）。在接受中高风险手术的患者中，计算机辅助的个体化血流动力学管理与人工控制的目标导向方法相比，可显著降低术中低血压。
Individualized hemodynamic management during surgery relies on accurate titration of vasopressors and fluids. In this context, computer systems have been developed to assist anesthesia providers in delivering these interventions. We tested the hypothesis that computer-assisted individualized hemodynamic management could reduce intraoperative hypotension in patients undergoing intermediate to high-risk surgery. This single-center, parallel, two-arm, prospective randomized controlled single blinded superiority study included 38 patients undergoing abdominal or orthopedic surgery. All included patients had a radial arterial catheter inserted after anesthesia induction and connected to an uncalibrated pulse contour monitoring device. In the manually adjusted goal directed therapy group (N=19), the individualized hemodynamic management consisted of manual titration of norepinephrine infusion to maintain mean arterial pressure (MAP) within 10% of the patient’s baseline value, and mini-fluid challenges to maximize stroke volume index (SVI). In the computer-assisted group (N=19), the same approach was applied using a closed-loop system for norepinephrine adjustments and a decision-support system for the infusion of mini-fluid challenges (100ml). The primary outcome was intraoperative hypotension defined as the percentage of intraoperative case time patients spent with a MAP < 90% of the patient’s baseline value, measured during the preoperative screening. Secondary outcome was the incidence of minor postoperative complications. All patients were included in the analysis. Intraoperative hypotension was 1.2% [0.4-2.0%] in the computer-assisted group compared to 21.5% [14.5-31.8%] in the manually adjusted goal directed therapy group (difference −21.1 (95% CI −15.9 to −27.6%); p<0.001). The incidence of minor postoperative complications was not different between groups (42 versus 58%, p=0.330). Mean SVI and cardiac index were both significantly higher in the computer-assisted group than in the manually adjusted goal directed therapy group (p<0.001). In patients having intermediate to high-risk surgery, computer-assisted individualized hemodynamic management significantly reduces intraoperative hypotension compared to a manually controlled goal directed approach.