背景:血压监测在危重患者的院前管理中很重要。通常使用非侵入式血压(NIBP)测量,但是标准示波袖带装置的准确性可能受到运输期间的极端生理机能和不利状况(例如振动)的影响。这项研究旨在量化需要院前重症监护的患者中NIBP测量的准确性。
方法:使用2020年5月1日至2023年4月30日院前危重组治疗的患者数据进行了一项回顾性队列研究,这些患者在测量NIBP的同时进行有创血压(IBP)动脉测压。收缩压(SBP)和舒张压(DBP)的可接受差异被先验地确定为<20mmHg,平均动脉压(MAP)<10mmHg。主要结果是“成对协议”,即在此可接受性范围内的成对观测值的比例。Bland-Altman地块与95%的一致性极限一起构建,以可视化数据对之间的差异。与患者年龄有关,重症监护的原因,运输状态,血流动力学休克,严重的高血压,在单因素分析和拟合多变量逻辑回归模型中探索动脉导管位置。
结果:从221名中位年龄为57岁的患者中进行了2,359个配对测量。运输的最常见原因是心脏骤停(79,35.7%)。Bland-Altman分析表明,与NIBP在低血压期间高估SBP和MAP以及在高血压期间低估这些值的一致性具有不可接受的广泛界限。血流动力学休克(SBP<90mmHg)与SBP的成对一致性降低独立相关(调整后比值比[aOR]0.52,95%CI0.35~0.77),DBP(aOR0.65,95%CI0.42至0.99)和MAP(aOR0.53,95%CI0.36至0.78)和重度高血压(SBP>160mmHg),SBP的成对一致性降低(aOR0.17,95%CI0.11至0.27)。患者转运与SBP方法之间的协议之间没有关联,DBP,或MAP。
结论:在院前重症监护环境中,无创血压测量通常不准确,尤其是血流动力学不稳定的患者。临床医生在解释NIBP测量时应谨慎,并在情况允许时考虑直接监测动脉压。
BACKGROUND: Blood pressure monitoring is important in the pre-hospital management of critically ill patients. Non-invasive blood pressure (NIBP) measurements are commonly used but the accuracy of standard oscillometric cuff devices may be affected by extremes of physiology and adverse conditions (e.g. vibration) during transport. This study aimed to quantify the accuracy of NIBP measurements amongst patients requiring pre-hospital critical care.
METHODS: A retrospective cohort study was undertaken using data from patients treated by a pre-hospital critical team between 1st May 2020 and 30th April 2023 that had NIBP measured concurrently with invasive blood pressure (IBP) arterial manometry. An acceptable difference was determined a priori to be < 20mmHg for systolic blood pressure (SBP) and diastolic blood pressure (DBP), and < 10mmHg for mean arterial pressure (MAP). The primary outcome was \"pairwise agreement\", i.e. the proportion of paired observations that fell within this range of acceptability. Bland-Altman plots were constructed together with 95% limits of agreement to visualise differences between pairs of data. Associations with patient age, reason for critical care, transport status, haemodynamic shock, severe hypertension, and arterial catheter position were explored in univariate analyses and by fitting multivariable logistic regression models.
RESULTS: There were 2,359 paired measurements from 221 individual patients with a median age of 57. The most frequent reason for transport was cardiac arrest (79, 35.7%). Bland-Altman analyses suggested unacceptably wide limits of agreement with NIBP overestimating both SBP and MAP during hypotension and underestimating these values during hypertension. Haemodynamic shock (SBP < 90mmHg) was independently associated with reduced pairwise agreement for SBP (adjusted odds ratio [aOR] 0.52, 95% CI 0.35 to 0.77), DBP (aOR 0.65, 95% CI 0.42 to 0.99) and MAP (aOR 0.53, 95% CI 0.36 to 0.78) and severe hypertension (SBP > 160mmHg) with reduced pairwise agreement for SBP (aOR 0.17, 95% CI 0.11 to 0.27). There was no association between patient transport and agreement between the methods for SBP, DBP, or MAP.
CONCLUSIONS: Non-invasive blood pressure measurements are often inaccurate in the pre-hospital critical care setting, particularly in patients with haemodynamic instability. Clinicians should be cautious when interpreting NIBP measurements and consider direct arterial pressure monitoring when circumstances allow.