低血压预测指数在机器人辅助腹腔镜膀胱切除术患者血流动力学管理中应用1例报告及文献复习

doi:10.13481/j.1671-587X.20240428

摘要/Abstract

摘要：

目的分析在机器人辅助腹腔镜膀胱切除术患者应用低血压预测指数（HPI）进行术中血流动力学管理的经过，为同类型大手术的麻醉监测和血流动力学管理提供参考。方法回顾性分析1例采用HPI进行术中血流动力学管理的接受机器人辅助腹腔镜膀胱切除术患者的临床资料、术中血流动力学资料、血管活性药物用法用量和临床效果，并结合相关文献进行分析。结果患者，女性，72岁，因肉眼血尿5个月伴尿痛3个月入院。膀胱镜检查，膀胱三角区右侧可见7 cm×7 cm×5 cm肿物，近膀胱颈可见大小约4 cm×3 cm×3 cm肿物。正电子发射/计算机断层扫描（PET/CT）检查，膀胱右后壁增厚伴高代谢，初步诊断为膀胱恶性肿瘤。进行麻醉前评估后拟行机器人辅助腹腔镜膀胱切除术。患者入室后常规监测，同时采用搭载HPI软件的监护仪指导术中血流动力学管理。常规麻醉诱导后，使用可视喉镜进行气管插管。患者术中共发生低血压事件（IOH）6次，平均动脉压（MAP）<65 mmHg累计时间为13.7 min，占麻醉时长的4.4%，MAP<65 mmHg时间加权平均数为0.28 mmHg。HPI≥85的时间范围与MAP<65 mmHg大致重叠且包含后者。146个HPI≥85的时间点，68.5%（100/146）MAP>65 mmHg；47个MAP<65 mmHg的时间点，97.9%（46/47）均出现HPI≥85。患者术后第1天超敏肌钙蛋白I<0.01 μg·L^-1，未发生围术期不良事件，第8天顺利出院。结论 HPI可及时并准确地预警机器人辅助腹腔镜膀胱切除术患者IOH的发生。术中使用基于HPI的低血压纠正策略可将患者MAP<65 mmHg的时间加权平均数维持在较低水平。

关键词: 低血压, 低血压预测指数, 机器学习, 血流动力学管理, 病例报告

Abstract:

Objective To analyze the intraoperative hemodynamic management by hypotension prediction index （HPI） in one patient underwent robot-assisted laparoscopic cystectomy， and to provide the reference for anesthesia monitoring and hemodynamic management in the similar major surgery. Methods The clinical data， intraoperative hemodynamic data， usage and dosage of vasoactive drugs， and clinical outcomes of one patient underwent robot-assisted laparoscopic cystectomy with HPI-guided intraoperative hemodynamic management were retrospectively analyzed， and the relevant literatures were reviewed. Results The patient， a 72-year-old female， was admitted due to macroscopic hematuria for 5 months accompanied by dysuria for 3 months. The cystoscope results showed a 7 cm×7 cm×5 cm mass on the right side of the bladder trigone and a 4 cm×3 cm×3 cm mass near the bladder neck. The positron emission tomography/computed tomography （PET/CT） results showed thickening of the right posterior bladder wall with high metabolism， and the preliminary diagnosis was bladder malignancy. After preoperative anesthesia evaluation， the robot-assisted laparoscopic cystectomy was planned. After entering the operating room， the routine monitoring was conducted， and the monitor equipped with HPI software was used to guide intraoperative hemodynamic management. After routine anesthesia induction， the tracheal intubation was performed by video laryngoscope. The patient experienced intraoperative hypotension （IOH） for six times， the cumulative time of mean arterial pressure （MAP）<65 mmHg was 13.7 min， accounting for 4.40% of the anesthesia duration， and the time-weighted average of MAP<65 mmHg was 0.28 mmHg. The time range with HPI≥85 roughly overlapped with and included the period of MAP<65 mmHg. At 146 time points with HPI≥85，the MAP remained greater than 65 mmHg at 68.5% （100/146） of the points. At 47 time points with MAP<65 mmHg， HPI≥85 occurred at 97.9% （46/47） of the points. On the first postoperative day， the patient’s hypersensitive cardiac troponin I was <0.01 μg·L^-1， and no perioperative adverse events occurred. The patient was discharged on the eighth day. Conclusion HPI can promptly and accurately predict the occurrence of IOH in the patients undergoing robot-assisted laparoscopic cystectomy. The use of HPI-based hypotension correction strategies during surgery can maintain the time-weighted average of MAP<65 mmHg at a lower level.

Key words: Hypotension, Hypotension prediction index, Machine learning, Hemodynamic management, Case report

中图分类号:

R614.2

阮文青,付泽润,黄逸,李龙云,孙耀,李凯. 低血压预测指数在机器人辅助腹腔镜膀胱切除术患者血流动力学管理中应用1例报告及文献复习[J]. 吉林大学学报(医学版), 2024, 50(4): 1130-1136.

Wenqing RUAN,Zerun FU,Yi HUANG,Longyun LI,Yao SUN,Kai LI. Application of hypotension prediction index in intraoperative hemodynamic management of robot-assisted laparoscopic cystectomy：A case report and literature review[J]. Journal of Jilin University(Medicine Edition), 2024, 50(4): 1130-1136.

图/表 2

参考文献 23

1	高云鹏，王志峰，刘洁，等. 达芬奇机器人辅助腹腔镜在泌尿外科手术中应用研究进展［J］. 中华实用诊断与治疗杂志， 2023， 37（4）： 354-356.
2	薛小云，徐成，韩小莉，等. 不同剂量瑞马唑仑用于老年患者喉罩全麻诱导时对血流动力学参数影响的双盲随机对照研究［J］. 同济大学学报（医学版）， 2023，44（4）： 574-579.
3	VAN WAES J A， VAN KLEI W A， WIJEYSUNDERA D N， et al. Association between intraoperative hypotension and myocardial injury after vascular surgery［J］. Anesthesiology， 2016， 124（1）： 35-44.
4	SUN L Y， WIJEYSUNDERA D N， TAIT G A， et al. Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery［J］. Anesthesiology， 2015， 123（3）： 515-523.
5	HALLQVIST L， GRANATH F， HULDT E， et al. Intraoperative hypotension is associated with acute kidney injury in noncardiac surgery： an observational study［J］. Eur J Anaesthesiol， 2018， 35（4）： 273-279.
6	MONK T G， BRONSERT M R， HENDERSON W G， et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery［J］. Anesthesiology， 2015， 123（2）： 307-319.
7	BIJKER J B， VAN KLEI W A， VERGOUWE Y， et al. Intraoperative hypotension and 1-year mortality after noncardiac surgery［J］. Anesthesiology， 2009， 111（6）： 1217-1226.
8	RADINOVIC K， MARKOVIC DENIC L， MILAN Z， et al. Impact of intraoperative blood pressure， blood pressure fluctuation， and pulse pressure on postoperative delirium in elderly patients with hip fracture： a prospective cohort study［J］. Injury， 2019， 50（9）： 1558-1564.
9	MAHESHWARI K， TURAN A， MAO G， et al. The association of hypotension during non-cardiac surgery， before and after skin incision， with postoperative acute kidney injury： a retrospective cohort analysis［J］. Anaesthesia， 2018， 73（10）： 1223-1228.
10	李王宇，胡周婷，李凯. 低血压预测指数的研究进展［J］. 中华麻醉学杂志， 2021， 41（10）： 1274-1277.
11	TSOUMPA M， KYTTARI A， MATIATOU S， et al. The use of the hypotension prediction index integrated in an algorithm of goal directed hemodynamic treatment during moderate and high-risk surgery［J］. J Clin Med， 2021， 10（24）： 5884.
12	HATIB F， JIAN Z P， BUDDI S， et al. Machine-learning algorithm to predict hypotension based on high-fidelity arterial pressure waveform analysis［J］. Anesthesiology， 2018， 129（4）： 663-674.
13	WIJNBERGE M， GEERTS B F， HOL L， et al. Effect of a machine learning-derived early warning system for intraoperative hypotension vs standard care on depth and duration of intraoperative hypotension during elective noncardiac surgery： the HYPE randomized clinical trial［J］. JAMA， 2020， 323（11）： 1052-1060.
14	MAHESHWARI K， SHIMADA T， YANG D S， et al. Hypotension prediction index for prevention of hypotension during moderate- to high-risk noncardiac surgery［J］. Anesthesiology， 2020， 133（6）： 1214-1222.
15	KOUZ K， MONGE GARCÍA M I， CERUTTI E， et al. Intraoperative hypotension when using hypotension prediction index software during major noncardiac surgery： a European multicentre prospective observational registry （EU HYPROTECT）［J］. BJA Open， 2023， 6： 100140.
16	SCHNECK E， SCHULTE D， HABIG L， et al. Hypotension prediction index based protocolized haemodynamic management reduces the incidence and duration of intraoperative hypotension in primary total hip arthroplasty： a single centre feasibility randomised blinded prospective interventional trial［J］. J Clin Monit Comput， 2020， 34（6）： 1149-1158.
17	LI W Y， HU Z T， YUAN Y X， et al. Effect of hypotension prediction index in the prevention of intraoperative hypotension during noncardiac surgery： a systematic review［J］. J Clin Anesth， 2022， 83： 110981.
18	ZHOU X Y， PAN W H， CHEN B X， et al. Predictive performance of dynamic arterial elastance for arterial pressure response to fluid expansion in mechanically ventilated hypotensive adults： a systematic review and meta-analysis of observational studies［J］. Ann Intensive Care， 2021， 11（1）： 119.
19	MURABITO P， ASTUTO M， SANFILIPPO F， et al. Proactive management of intraoperative hypotension reduces biomarkers of organ injury and oxidative stress during elective non-cardiac surgery： a pilot randomized controlled trial［J］. J Clin Med， 2022， 11（2）： 392.
20	中华医学会麻醉学分会α 1 激动剂围术期应用专家组. α1肾上腺素能受体激动剂围术期应用专家共识（2017版）［J］. 临床麻醉学杂志， 2017， 33（2）： 186-192.
21	OVERGAARD C B， DZAVÍK V. Inotropes and vasopressors： review of physiology and clinical use in cardiovascular disease［J］. Circulation， 2008， 118（10）： 1047-1056.
22	MONGE GARCÍA M I， GIL CANO A， GRACIA ROMERO M. Dynamic arterial elastance to predict arterial pressure response to volume loading in preload-dependent patients［J］. Crit Care， 2011， 15（1）： R15.
23	LORENTE J V， JIMENEZ I， RIPOLLÉS-MELCHOR J， et al. Intraoperative haemodynamic optimisation using the Hypotension Prediction Index and its impact on tissular perfusion： a protocol for a randomised controlled trial［J］. BMJ Open， 2022， 12（6）： e051728.

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