2026 年第 2 期 第 21 卷

破裂腹主动脉瘤术中低血压负荷与术后7天复合不良结局的关系

Relationship between intraoperative hypotension load and 7 d postoperative composite adverse outcomes in patients with ruptured abdominal aortic aneurysm

作者：周晓瑞1张京岚2寇镭3徐雪峰2陈尧2王晟1

英文作者：Zhou Xiaorui1 Zhang Jinglan2 Kou Lei3 Xu Xuefeng2 Chen Yao2 Wang Sheng1

单位：1首都医科大学附属北京安贞医院麻醉手术中心，北京100029；2首都医科大学附属北京安贞医院综合外科重症监护室，北京100029；3首都医科大学附属北京安贞医院血管外科，北京100029

英文单位：1Anesthesia and Surgery Center Beijing Anzhen Hospital Capital Medical University Beijing 100029 China; 2Comprehensive Surgical Intensive Care Unit Beijing Anzhen Hospital Capital Medical University Beijing 100029 China; 3Department of Vascular Surgery Beijing Anzhen Hospital Capital Medical University Beijing 100029 China

关键词：破裂腹主动脉瘤；开放修补术；低血压负荷；多器官功能障碍

英文关键词：Rupturedabdominalaorticaneurysm;Opensurgicalrepair;Hypotensionload;Multipleorgandysfunction

• 摘要：

• 目的 探讨破裂腹主动脉瘤（rAAA）开放修补术（OSR）患者术中低血压负荷（HL）与术后7 d复合不良结局［MOFD-7，即术后第7天仍需机械通气（有创或无创）、血管活性药物维持血流动力学或连续性肾脏替代治疗中任1项，或术后7 d内死亡］的关系。方法 回顾性分析2005年8月至2020年11月在首都医科大学附属北京安贞医院接受OSR治疗的rAAA患者50例。以平均动脉压（MAP）＜65 mmHg（1 mmHg=0.133 kPa）的累积面积定义HL。根据是否有MOFD-7发生分为无MOFD-7组（30例）和发生MOFD-7组（20例）。以MOFD-7为主要结局，采用Logistic回归方法及受试者工作特征曲线分析HL与MOFD-7的关系。结果 50例rAAA OSR患者中MOFD-7发生率为40.0%（20/50），术后30 d全因死亡率为10.0%（5/50），全部死亡均在发生MOFD-7组。发生MOFD-7组术前失血性休克比例高于无MOFD-7组，术前血肌酐和血乳酸水平高于无MOFD-7组（均P<0.05）。围手术期管理方面，HL水平、去甲肾上腺素当量、术后首次血乳酸水平明显高于无MOFD-7组，术中输液量、术中出血量和术中输血量（包括术中输红细胞量、术中输血浆量）多于无MOFD-7组，差异均有统计学意义（均P<0.05）。多因素Logistic回归分析结果显示，在调整年龄、性别及术前血肌酐、术前血乳酸后，HL（每增加100 mmHg·min）仍与MOFD-7独立相关（比值比=1.298，95%置信区间：1.034～1.630，P=0.025）。HL单指标及多因素模型预测MOFD-7的曲线下面积分别为0.770和0.870。限制性立方样条分析提示，HL与MOFD-7发生风险之间呈近乎单调递增关系，当HL超过约75 mmHg·min后，不良结局风险随HL进一步升高而明显增加。结论 在rAAA OSR患者中，术中HL越大，MOFD-7风险越高。围手术期应尽量减少HL，以期改善早期预后。

• Objective To investigate the relationship between intraoperative hypotension load (HL) and 7 d postoperative composite adverse outcomes ［MOFD-7, defined as the requirement for mechanical ventilation (invasive or non-invasive), hemodynamic support with vasoactive agents, or continuous renal replacement therapy on the 7th postoperative day, or death within 7 d after surgery］ in patients undergoing open surgical repair (OSR) for ruptured abdominal aortic aneurysm (rAAA). Methods A retrospective analysis was conducted on 50 patients with rAAA who underwent OSR in Beijing Anzhen Hospital, Capital Medical University from August 2005 to November 2020. HL was defined as the cumulative area under the curve of mean arterial pressure (MAP) <65 mmHg (1 mmHg=0.133 kPa). Patients were divided into the non-MOFD-7 group (30 cases) and the MOFD-7 development group (20 cases) according to the occurrence of MOFD-7. Logistic regression analysis and receiver operating characteristic (ROC) curve were used to analyze the relationship between HL and MOFD-7, with MOFD-7 as the primary outcome. Results The incidence of MOFD-7 was 40.0%(20/50) among the 50 rAAA patients undergoing OSR, and the 30 d all-cause mortality was 10.0%(5/50), and all deaths occurred in the MOFD-7 development group. The proportion of preoperative hemorrhagic shock, preoperative serum creatinine and lactic acid levels in the MOFD-7 development group were significantly higher than those in the non-MOFD-7 group (all P<0.05). In terms of perioperative management, HL, norepinephrine equivalent, and the first postoperative lactic acid level in the MOFD-7 development group were significantly higher than those in the non-MOFD-7 group; intraoperative fluid infusion volume, intraoperative blood loss, and intraoperative blood transfusion volume (including intraoperative red blood cell transfusion volume and intraoperative plasma transfusion volume) in the MOFD-7 development group were significantly greater than those in the non-MOFD-7 group (all P<0.05). Multivariate Logistic regression analysis showed that after adjusting for age, gender, preoperative serum creatinine and preoperative lactic acid, HL (per 100 mmHg·min increase) was still independently associated with MOFD-7 (odds ratio=1.298, 95% confidence interval: 1.034-1.630, P=0.025). The area under the curve of HL alone and the multivariate model for predicting MOFD-7 were 0.770 and 0.870, respectively. Restricted cubic spline analysis indicated an approximately monotonic increasing relationship between HL and the risk of MOFD-7; when HL exceeded approximately 75 mmHg·min, the risk of adverse outcomes increased significantly with further elevation of HL. Conclusion In patients undergoing OSR for rAAA, a higher intraoperative HL is associated with an increased risk of MOFD-7. Perioperative management should aim to minimize HL to improve early prognosis.