行择期非心脏手术的老年患者发生全身麻醉诱导后低血压的危险因素分析与预测模型建立

Risk factors and prediction model establishment for hypotension induced by general anesthesia in elderly patients undergoing elective noncardiac surgery

目的 探究行择期非心脏手术的老年患者接受全身麻醉(简称全麻)诱导后发生低血压的危险因素,并建立预测模型。方法 选取2019年2月—2021年5月在复旦大学附属中山医院青浦分院行择期非心脏手术并接受全麻的407例患者资料。按照既往文献中的低血压标准,将研究对象分为2组,即全麻诱导后血压水平较基础水平下降幅度>30%或平均动脉压(MAP)<60 mmHg(1 mmHg=0.133 kPa)的患者,纳入低血压组;而血压水平下降幅度≤30%且MAP≥60 mmHg的患者,纳入对照组。记录包括年龄、身高、体重、BMI、是否有高血压病史、是否有糖尿病病史、是否罹患冠心病、NYHA心功能分级的患者一般资料。记录入手术室后5 min(记为T_(0)点)的患者基础MAP值(即MAP_(T0)),以及全麻诱导后气管插管前(记为T_(1)点)的患者MAP值(即MAP_(T1))。同时,记录手术前获得的患者包括血糖、TG、TC、低密度脂蛋白(LDL)、高密度脂蛋白(HDL)水平等指标;收集患者的麻醉药物诱导剂量(丙泊酚和舒芬太尼),ASA分级,是否合并使用依托咪酯诱导,以及诱导后心率下降的幅度(即ΔHR)。采用单因素分析和多因素logistic逐步回归分析研究对象发生全麻诱导后低血压的危险因素。应用危险因素及其系数建立预测模型。结果 407例患者中有211例(51.84%)发生全麻诱导后低血压。与对照组比较,低血压组身高值、体重值均显著较低(P=0.007、0.017),女性患者的占比显著较高(P=0.038),LDL、TC水平显著较高(P=0.019、0.004),合并使用依托咪酯的患者占比、患者MAP_(T0)、ΔHR均显著较高(P=0.022、0.015、<0.001)。将单因素分析中P<0.1的变量纳入多因素logistic逐步回归分析,结果显示,年龄、TC、舒芬太尼诱导剂量、MAP_(T0)、ΔHR为行非心脏择期手术的老年患者在全麻诱导期间发生低血压的危险因素。所建立的预测模型的ROC曲线的AUC为0.705, 95%CI为0.655~0.756,P<0.001,提示该模型具有较好的预测准确性。结论年龄、TC、舒芬太尼诱导剂量、MAP_(T0)、ΔHR为行非心脏择期手术的老年患者接受全麻诱导后发生低血压的危险因素,据其建立的预测模型具有较好的预测准确性。

Objective To explore the risk factors of hypotension induced by general anesthesia after elective noncardiac surgery in elderly patients and to establish a prediction model.Methods The clinical data of 407 elderly patients who underwent general anesthesia for elective noncardiac surgery in Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University from February 2019 to May 2021 were retrospectively analyzed.The patients were divided into hypotensive group(blood pressure decreased by>30%compared with the basic level after induction of general anesthesia or mean arterial pressure[MAP]<60 mmHg[1 mmHg=0.133 kPa])and control group(blood pressure decreased by≤30%and MAP≥60 mmHg).The general information such as age,height,weight,body mass index(BMI),hypertension,diabetes,coronary heart disease,and NYHA classification were collected.MAP at 5 min after entering operation room(MAP_(T0)),MAP before intubation(MAP_(T1)),preoperative blood glucose,triglyceride(TG),cholesterol(TC),low density lipoprotein(LDL)and high density lipoprotein(HDL),induction dose of propofol and sufentanil,ASA classification,the use of etomidate,and the magnitude of induced heart rate decline(ΔHR)were also recorded.Univariate and multivariate logistic regression analyses were performed to investigate the risk factors of hypotension induced by general anesthesia after elective noncardiac surgery in elderly patients.A predictive model was established on the basis of the risk factors and their coefficients.Results Among the 407 patients,211(51.84%)had hypotension induced by general anesthesia.The height and weight in the hypotensive group were significantly lower than those in the control group(P=0.007 and 0.017).The proportion of females,LDL,TC,the proportion of patients receiving etomidate,MAP_(T0) andΔHR in the hypotensive group were significantly higher than those in the control group(P=0.019,0.004,0.022,0.015,and<0.001).Variables with P<0.1 in univariate analysis were included in logistic regression analysis,and the result showed that age,TC,sufentanil induction dose,MAP_(T0),andΔHR were risk factors for hypotension during induction of general anesthesia in elderly patients undergoing noncardiac surgery.ROC curve was used to evaluate the accuracy of the model,with an AUC of 0.705(95%CI:0.655-0.756,P<0.001).Conclusion Age,TC,sufentanil induction dose,MAP_(T0),andΔHR are risk factors for hypotension during induction of general anesthesia in elderly patients undergoing noncardiac elective surgery,and the prediction model based on these risk factors has a good accuracy in predicting hypotension.