目的:评估主要为癌症的大型非心脏手术后老年患者术中低血压与长期生存的关系。
方法:对三个长期随访随机试验的数据库进行二次分析。
方法:基础试验在中国17家三级医院进行。
方法:将60-90岁在单个中心接受大型非心脏胸或腹部手术(≥2小时)的患者纳入分析。
方法:使用限制性三次样条模型来确定可能对长期生存有害的最低平均动脉压(MAP)阈值。根据MAP阈值下的累积持续时间或面积,将患者任意分为三组。使用Cox比例风险回归模型分析术中低血压暴露与长期生存之间的关系。
方法:我们的主要终点是总生存期。次要终点包括无复发和无事件生存率。
结果:总共2664名患者(平均年龄69.0岁,34.9%的女性,92.5%的癌症手术)包括在最终分析中。术中低血压的阈值为MAP<60mmHg。根据MAP<60mmHg(<1分钟,1-10分钟,和>10分钟)或MAP<60mmHg(<1mmHg·min,1-30mmHg·min,且>30mmHg·min)。在调整混杂因素后,与<1min的患者相比,MAP<60mmHg·min>10min的持续时间与总生存期缩短相关(调整后的风险比[HR]1.31,95%置信区间[CI]1.09至1.57,P=0.004);与<1mmHg·min的患者相比,MAP<60mmHg·min的面积与总生存期缩短相关(调整后的HR1.40,95%CI<1.68,P=0.001)。MAP<60mmHg>10分钟的持续时间或MAP<60mmHg>30mmHg·min的面积与无复发或无事件生存率之间存在类似的关联。
结论:在主要因癌症而接受非心脏大手术的老年患者中,术中低血压与整体恶化有关,无复发,和无事件生存。
OBJECTIVE: To assess the association of intraoperative
hypotension with long-term survivals in older patients after major noncardiac surgery mainly for cancer.
METHODS: A secondary analysis of databases from three randomized trials with long-term follow-up.
METHODS: The underlying trials were conducted in 17 tertiary hospitals in China.
METHODS: Patients aged 60 to 90 years who underwent major noncardiac thoracic or abdominal surgeries (≥ 2 h) in a single center were included in this analysis.
METHODS: Restricted cubic spline models were employed to determine the lowest mean arterial pressure (MAP) threshold that was potentially harmful for long-term survivals. Patients were arbitrarily divided into three groups according to the cumulative duration or area under the MAP threshold. The association between intraoperative
hypotension exposure and long-term survivals were analyzed with the Cox proportional hazard regression models.
METHODS: Our primary endpoint was overall survival. Secondary endpoints included recurrence-free and event-free survivals.
RESULTS: A total of 2664 patients (mean age 69.0 years, 34.9% female sex, 92.5% cancer surgery) were included in the final analysis. MAP < 60 mmHg was adopted as the threshold of intraoperative
hypotension. Patients were divided into three groups according to duration under MAP < 60 mmHg (<1 min, 1-10 min, and > 10 min) or area under MAP <60 mmHg (< 1 mmHg⋅min, 1-30 mmHg⋅min, and > 30 mmHg⋅min). After adjusting confounders, duration under MAP < 60 mmHg for > 10 min was associated with a shortened overall survival when compared with the < 1 min patients (adjusted hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.09 to 1.57, P = 0.004); area under MAP < 60 mmHg for > 30 mmHg⋅min was associated with a shortened overall survival when compared with the < 1 mmHg⋅min patients (adjusted HR 1.40, 95% CI 1.16 to 1.68, P < 0.001). Similar associations exist between duration under MAP < 60 mmHg for > 10 min or area under MAP < 60 mmHg for > 30 mmHg⋅min and recurrence-free or event-free survivals.
CONCLUSIONS: In older patients who underwent major noncardiac surgery mainly for cancer, intraoperative
hypotension was associated with worse overall, recurrence-free, and event-free survivals.