Mean arterial pressure versus cardiac index for haemodynamic management and myocardial injury after hepatopancreatic surgery: A randomised controlled trial.
Taner Abdullah,Hürü Ceren Gökduman,İşbara Alp Enişte,İlyas Kudaş,Achmet Ali,Erdem Kınacı,İlgin Özden,Funda Gümüş Özcan
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引用次数: 0
Abstract
BACKGROUND
Myocardial injury after noncardiac surgery (MINS) frequently complicates the peri-operative period and is associated with increased mortality.
OBJECTIVES
We hypothesised that cardiac index (CI) based haemodynamic management reduces peri-operative high-sensitive troponin-T (hsTnT) elevation and MINS incidence in patients undergoing hepatic/pancreatic surgery compared to mean arterial pressure.
DESIGN
A randomised controlled study.
SETTING
A single-centre study conducted in a university-affiliated tertiary hospital between June 2022 and March 2023.
PATIENTS
Ninety-one patients, who were ≥ 65 years old or ≥ 45 years old with a history of at least one cardiac risk factor were randomised to either mean arterial pressure (MAP) based (n = 45) or CI-based (n = 46) management groups, and completed the study.
INTERVENTIONS
In group-MAP, patients received fluid boluses and/or a noradrenaline infusion to maintain MAP above the predefined threshold. In group-CI, patients received fluid boluses and/or dobutamine infusion to keep CI above the predefined threshold. When a low MAP was observed despite a normal CI, a noradrenaline infusion was started.
MAIN OUTCOME MEASURES
The primary outcome was peri-operative hsTnT elevation. The secondary outcomes were MINS incidence and 90-day mortality.
RESULTS
The median absolute troponin elevation was 4.3 ng l-1 (95% CI 3.4 to 6) for the CI-based group, and 9.4 ng l-1 (95% CI 7.7 to 12.7) for the MAP-based group (median difference: 5.1 ng l-1, 95% CI 3 to 7; P < 0.001). MINS occurred in 8 (17.4%) patients in the CI-based group and 17 (37.8%) patients in the MAP-based group (relative risk: 0.46, 95% CI: 0.22 to 0.96; P = 0.029). Two patients in group-MAP died from cardiovascular-related causes. One patient in group-CI and two in group-MAP died from sepsis-related complications (for all-cause mortality: χ2 = 1.98, P = 0.16). MAP-AUC and CI-AUC values of the CI- and MAP-based groups were 147 vs. 179 min × mmHg (P = 0.85) and 8.4 vs. 43.2 l m-2 min-1 × min (P < 0.001), respectively.
CONCLUSIONS
CI-based haemodynamic management assures sufficient flow and consequently is associated with peri-operative hsTnT elevation and the incidence of MINS compared to MAP.
TRIAL REGISTRATION
Clinicaltrials.gov identifier: NCT05391087.
期刊介绍:
The European Journal of Anaesthesiology (EJA) publishes original work of high scientific quality in the field of anaesthesiology, pain, emergency medicine and intensive care. Preference is given to experimental work or clinical observation in man, and to laboratory work of clinical relevance. The journal also publishes commissioned reviews by an authority, editorials, invited commentaries, special articles, pro and con debates, and short reports (correspondences, case reports, short reports of clinical studies).