Blood Pressure Targets in Perioperative Care
Provisional Considerations Based on a Comprehensive Literature Review
围手术期血压指标
基于综合文献回顾的暂定注意事项
Lingzhong Meng, Weifeng Y u, Tianlong Wang, Lina Zhang, Paul M. Heerdt, Adrian W. Gelb
翻译 by 苏洋
As one of the vital signs, blood pressure (BP) is measured at least once every 5 minutes using a noninvasive cuff method in patients having anesthesia and surgery, and in many instances, BP is actually monitored beat to beat using an invasive transducing method. The rationale for routine and regular BP monitoring in perioperative care is based on the following arguments: (1) BP can be exceedingly volatile, (2) abnormal BP and unfavorable outcomes are associated, (3) BP can be readily treated, and (4) protocol-guided BP management improves outcomes based on a few randomized controlled trials (RCTs).
血压(BP)作为生命体征之一，在麻醉和手术患者中至少每5分钟使用无创袖带方法测量一次。在许多情况下，血压实际上是使用有创传感器方法逐次监测的。在围手术期护理中常规和定期监测血压的基本原理是基于以下论点：(1)血压可能非常不稳定，(2)异常血压与不良结局相关，(3)BP易于处理，(4)基于少数随机对照试验(RCT)的方案指导的BP管理改善了预后。
Although diligent BP monitoring is mandatory in perioperative care, there is currently little consensus on the appropriate BP target for an individual patient receiving anesthesia and surgery. This situation is in contrast to that of chronic hypertension in primary care. The recently revised guideline newly defines the cutoffs for systolic BP (SBP) and diastolic BP (DBP) for hypertension as 130 and 80 mm Hg, respectively.1 It is conspicuous that although BP is much less-frequently checked in primary care, with an interval ranging from days to weeks or months, primary care has established therapeutic BP targets for probably one of the largest patient populations in health care. It is intriguing to ask whether similar therapeutic BP targets can be established in perioperative care and used for >300 million surgical procedures performed every year globally.2
尽管在围手术期护理中必须进行频繁的血压监测，但目前对于接受麻醉和手术患者的适当血压目标几乎没有达成共识。这种情况与初级保健中的慢性高血压形成对比。最近修订的指南将高血压的收缩压(SBP)和舒张压(DBP)的临界值分别定义为130 mmHg和80 mmHg。值得注意的是，尽管在初级保健中检查血压的频率要低得多，间隔从几天到几周或几个月不等，但初级保健已经为可能是医疗保健中最大的患者群体之一建立了治疗性血压目标。有趣的是，是否可以在围术期护理中建立类似的治疗性血压目标，并在全球每年进行超过3亿次的外科手术。
Why Is There a Lack of Consensus on BP Targets in Perioperative Care?
为什么在围手术期护理中对BP目标缺乏共识？
Although BP is mandatorily and regularly monitored in perioperative care, a consensus on explicit BP targets for different surgical patient populations is lacking. The potential causes are multifold (Figure S1). First, the patient population and type of surgery targeted by previous studies are both heterogeneous. Different patients and surgeries involve different concerns and priorities during the determination of BP targets. Second, the different and often sophisticated methods of BP analyses, including systolic, mean, diastolic, absolute values, relative change, various threshold, area under the threshold, average, timeweighted average, minimum, duration of the minimum, etc, in addition to the different therapeutic BP targets used by different RCTs, make unification an arduous task. Lastly, the outcomes being assessed by different studies are also heterogeneous, which escalates the difficulty in evidence aggregation.
虽然在围手术期护理中强制并定期监测血压，但对于不同手术患者群体的明确血压目标缺乏共识。潜在原因是多方面的(图S1)。首先，以前的研究针对的患者群体和手术类型都是不同的。在确定BP目标的过程中，不同的患者和手术涉及不同的关注事项和优先事项。第二，不同且复杂的血压分析方法，包括收缩期、均数、舒张期、绝对值、相对变化值、各种阈值、阈值以下的面积、平均值、时间加权平均值、最小值、最小持续时间等，再加上不同RCT使用的不同的治疗血压靶点，使得统一成为一项艰巨的任务。最后，不同研究评估的结果也是不同的，这增加了证据收集的难度。
Provisional Considerations During the Determination of BP Targets for an Individual Surgical Patient
确定个体化外科患者血压指标时的暂定注意事项
Evidence-based considerations that are pragmatic during the determination of BP targets for an individual surgical patient are needed. However, at this time, for most clinically relevant aspects, quality evidence is often lacking, limited, or not readily applicable to the care of an individual patient. Based on the best available evidence and clinical experience, we propose the following provisional considerations to facilitate the determination of perioperative BP targets (Figure 3). The class of these considerations and the level of evidence are specified in the Table.
在确定单个外科患者的血压目标时，需要实事求是的循证考虑。然而，在这个时候，对于大多数临床相关的方面，高质量的证据往往是缺乏的、有限的或不容易适用于个别患者的护理。基于现有的最佳证据和临床经验，我们提出以下暂定的注意事项，以促进围手术期血压目标的确定(图3)。表中列出了这些注意事项的类别和证据水平。
图3 根据现有的最佳证据和临床经验，在围手术期护理中确定血压(BP)目标时的暂定注意事项。主要考虑的是手术类型、患者的基础血压以及器官缺血和手术出血的风险。插图突显了平衡相互冲突的风险的重要性。有关更多详细信息，请参阅正文。CPB表示体外循环；DBP表示舒张压；MAP表示平均动脉压；SBP表示收缩压。
Differentiating the Type of Surgery
区分手术类型
Different surgeries target different patient populations and have different impacts on BP and organ perfusion. Because of the frequent use of CPB and impact of surgical maneuvers on circulation, cardiac surgery is distinguished from noncardiac surgery. Cardiac surgery during CPB is different from that before and after CPB. Carotid artery or cerebrovascular surgery threatens cerebral perfusion during temporary occlusion of the internal carotid artery or temporary clipping of the feeding artery to an aneurysm. Therefore, it is prudent to differentiate the type of surgery as the first step.
不同的手术针对不同的患者群体，并且对血压和器官灌注有不同的影响。由于体外循环的频繁使用和手术操作对循环的影响，心脏手术与非心脏手术不同。心脏手术体外循环期间与体外循环前后不同。颈内动脉或脑血管手术会在颈内动脉暂时阻断或动脉瘤供血动脉暂时夹闭期间威胁脑灌注。因此，首先要慎重区分手术类型。
Classifying Baseline BP
基础BP分类
Whether a normotensive patient and a hypertensive patient would equally benefit from the same BP target is a critical question, which clearly challenges the one-size-fits-all practice. The wide interindividual difference in baseline BP makes BP management based on reference to the baseline measurement judicious and in accordance with the results of the recent RCT discussed above.48 In light of these considerations, we propose a trichotomy that classifies baseline BP as low (SBP , <90 mm Hg, or DBP , <50 mm Hg), normal (SBP , 90–129 mm Hg, and DBP , 50–79 mm Hg), and high (SBP , ≥130 mm Hg, or DBP , ≥80 mm Hg). Baseline BP is the average of multiple measurements taken with the patient unstressed, pain free, and awake (or lightly sedated). Because of the diversity of the BP forms (ie, SBP versus DBP versus mean BP) used by the previous studies, it is difficult to unify different forms of BP measurements into one form.
血压正常的患者和高血压患者是否会从相同的血压目标中同样受益是一个关键问题，这显然是对一刀切做法的挑战。个体间基础血压的巨大差异使得基于基础测量的血压管理是明智的，并与上述近期随机对照试验的结果一致。鉴于这些考虑，我们提出了一种三分法，将基础血压分为低血压(SBP <90 mmHg，或DBP <50 mmHg)、正常血压(SBP 90-129 mmHg，和DBP 50-79 mmHg)和高血压(SBP ≥130 mmHg，或DBP ≥80 mmHg)。基础血压是在患者无压力、无疼痛、清醒(或轻度镇静)的情况下进行多次测量的平均值。由于以往研究使用的BP形式(即SBP、DBP或平均BP)各不相同，很难将不同形式的BP测量统一为一种形式。
Considerations for Noncardiac Surgical Patients With a Low Baseline BP (SBP, <90 mm Hg, or DBP, <50 mm Hg)
低基础血压(SBP<90 mmHg或DBP<50 mmHg)的非心脏手术患者应注意的问题
The targets for patients with a low baseline BP may be to maintain MAP ≥60 mm Hg and BP within 100% to 120% of baseline. This consideration is based on multiple studies that have consistently shown that MAP <60 mm Hg during surgery is associated with various unfavorable outcomes.8,24,26–28Although the baseline BP was not specified in these studies, it is prudent to err on the side of caution by maintaining MAP ≥60 mm Hg even in patients with a low baseline BP . The highest baseline BP in this patient population is ≈90/50 mm Hg, giving a MAP of ≈63 mm Hg. For the allowable BP increase, it is prudent to keep it at ≤20% (instead of 10%) of the baseline because the highest allowable MAP will be ≈76 mm Hg for the highest baseline MAP of ≈63 mm Hg in this patient population (63 mm Hg×120%=76 mm Hg). Clinically, a MAP of 76 mm Hg is common and deemed normal. It is also prudent to maintain the BP no lower than baseline in this patient population, implying that the allowable BP decrease is 0% because if keeping MAP ≥60 mm Hg is a prerequisite, there will be almost no space for a further BP decrease even for a patient with the highest baseline MAP of ≈63 mm Hg in this population. It can be inferred that for patients with a baseline MAP <60 mm Hg, there will be no chance to obtain a perioperative MAP less than baseline because the overriding consideration is to maintain MAP ≥60 mm Hg.
低基础血压患者的目标可能是将MAP≥60 mmHg和BP维持在基础值的100%到120%之间。这一考虑是基于多项研究，这些研究一致表明，术中MAP<60 mmHg与各种不利的结果相关。虽然这些研究没有指定基础血压，但慎重的做法是维持MAP≥60 mmHg，宁可过于谨慎也不要冒风险，即使在基础血压较低的患者中也是如此。该患者群体中最高基础血压约为90/50 mmHg，MAP约为63 mmHg。对于允许的血压增加，谨慎的做法是将其保持在基础血压的20%(而不是10%)，因为在该患者群体中，最高基础MAP为63 mmHg，最高允许的MAP将是76 mm Hg (63 mm Hg×120%=76 mmHg)。临床上，MAP为76 mmHg是常见的，被认为是正常的。在这一人群中保持血压不低于基础血压也是谨慎的，这意味着允许的血压降幅为0%，因为如果保持MAP≥60 mmHg是先决条件，即使是该人群中最高基础血压为63 mmHg的患者，也几乎没有进一步降低血压的空间。可以推断，对于基础MAP<60 mmHg的患者，由于最重要的考虑是维持MAP≥为60 mmHg，围手术期MAP将不会低于基础值。
Considerations for Noncardiac Surgical Patients With a Normal Baseline BP (SBP, 90–129 mm Hg, and DBP, 50–79 mm Hg)
基础血压正常(SBP 90-129 mmHg和DBP 50-79 mmHg)的非心脏手术患者应注意的问题
The targets for patients with a normal baseline BP may be to maintain BP within 90% to 110% of baseline and MAP within ≈65 to 95 mm Hg. The 10% rule, that is, the allowable BP change of ≤10% baseline, is based on a recent RCT performed in patients having major abdominal surgery.48 Although this trial has limitations and did not differentiate the baseline BPs of the study participants, it is prudent to adopt the 10% rule in patients with a normal baseline BP . The MAP range of ≈65 to 95 mm Hg comes from the fact that the lowest and highest baseline BPs of this patient population are 90/50 and 130/80 mm Hg, which correspond to a MAP of ≈63 and ≈97 mm Hg, respectively.
基础血压正常的患者的目标可能是将血压维持在基础值的90%至110%，并将MAP控制在65至95 mmHg范围内。10%的规则，即允许血压变化≤基础值10%，是基于最近在接受重大腹部手术的患者中进行的随机对照试验。虽然这项试验有局限性，并且没有区分研究参与者的基础血压，但在基础血压正常的患者中采用10%规则是谨慎的。65-95 mmHg的MAP范围来自于该患者群体的最低和最高基础血压，分别为90/50和130/80 mmHg，它们分别对应63和97 mmHg的MAP。
Considerations for Noncardiac Surgical Patients With a High Baseline BP (SBP, ≥130 mm Hg, or DBP, ≥80 mm Hg)
高基础血压(SBP，≥130 mmHg或DBP，≥80 mmHg)的非心脏手术患者应注意的问题
The targets for patients with a high baseline BP may be to maintain BP within 80% to 110% of baseline and SBP <160 mm Hg. This patient population is notorious for BP volatility in the perioperative environment. For the allowable BP decrease, it is prudent to keep it at ≤20%, instead of 10%, of baseline, based on the consideration that a cutoff of 10%, compared with 20%, may lead to an unwarranted high BP . For example, the lowest allowable SBP is ≈170 and ≈150 mm Hg, based on the 10% and 20% rule, respectively, for a baseline SBP of 190 mm Hg. For this patient, most clinicians would prefer to keep the SBP at 150 mm Hg, instead of 170 mm Hg, on most occasions if given these 2 options. The 20% rule is supported by multiple nonrandomized studies.26,29,40,44 In contrast, for the allowable BP increase, it may be prudent to follow the 10% rule, that is, ≤10% baseline.48 We additionally recommend to keep SBP <160 mm Hg based on the result of 1 retrospective study45 and 1 prospective study.9
高基础血压患者的目标可能是将血压维持在基础值的80%-110%，SBP<160 mmHg。这一患者群体因围手术期环境中的血压易变性而著称。对于允许的BP下降，谨慎的做法是将其保持在基础的20%以内，而不是10%，因为考虑到与20％相比，10％的临界值可能会导致不适当的高血压。例如，基础收缩压为190mmHg时，根据10%和20%的规则，允许的最低收缩压分别为170和150 mmHg。对于这名患者，如果给予这两种选择，大多数临床医生在大多数情况下更愿意将SBP保持在150 mmHg，而不是170 mmHg。20%的规则得到了多项非随机研究的支持。相反，对于允许的血压增加，遵循10%的规则可能是谨慎的，即不超过基础值的10%。此外，基于1项回顾性研究和1项前瞻性研究的结果，我们建议将SBP值保持在160 mmHg以下。
Considerations for Patients Having Cardiac Surgery
心脏手术患者应注意的问题
Evidence related to BP targets before and after CPB during cardiac surgery is lacking. At this time, it is prudent to use the considerations for noncardiac surgery as a reference. For BP targets during CPB, it is judicious to maintain MAP within 70 to 100 mm Hg based on the aggregation of the results of 5 RCTs.61–65 Among these RCTs, 2 studies demonstrated favorable effects associated with a higher perfusion pressure,61,62 whereas 3 did not find an outcome difference between a high versus a low BP target.63–65 It is thus judicious to maintain a higher perfusion pressure during CPB because although not every line of evidence shows a favorable effect, there is no evidence showing an unfavorable effect when the perfusion pressure is maintained at a higher level. The MAP target of 70 to 100 mm Hg is still a wide range. Specific MAP targets during CPB for an individual patient should be determined based on the baseline measurement and the monitoring of end-organ perfusion, when available.
心脏手术期间CPB前后血压指标的相关证据缺乏。此时，谨慎地使用非心脏手术的注意事项作为参考。对于CPB期间的血压目标，基于5个随机对照试验的结果的汇总，将MAP维持在70到100 mmHg是明智的。在这些随机对照试验中，2项研究显示出与较高的灌注压相关的有利影响，而3项研究没有发现高和低血压指标之间的结果差异。因此，在CPB期间保持较高的灌注压是明智的，因为虽然不是每条证据都显示有利的影响，但没有证据表明当灌注压保持在较高的水平时会产生不利的影响。70至100 mmHg的MAP目标仍是一个较大范围。CPB期间个别患者的特定MAP目标应根据基础值测量和终末器官灌注监测(如果可用)来确定。
Considerations for Patients Receiving Carotid Artery or Cerebrovascular Surgery
颈动脉或脑血管手术患者应注意的问题
During carotid endarterectomy, the BP target during temporary occlusion of the internal carotid artery may be ≥120% of baseline based on a nonrandomized study with early cognitive dysfunction as the end point.67 During cerebrovascular surgery, BP targets may be to maintain SBP >90 mm Hg and MAP >70 mm Hg based on 2 nonrandomized studies.71 It is prudent to maintain BP ≥baseline during temporary clipping of the feeding artery to the aneurysm, based on expert opinion.73
在颈动脉内膜切除术期间，基于一项以早期认知功能障碍为终点的非随机研究，颈内动脉临时阻断期间的血压目标可能是基础值的120%。基于两项非随机研究，脑血管手术期间的血压目标可能是维持SBP >90 mmHg和MAP >70 mmHg。根据专家的意见，在临时夹闭动脉瘤供血动脉期间维持BP≥基础值是谨慎的。
Balancing Hypotension-Related Organ Ischemia Versus Hypertension-Related Surgical Bleeding
平衡低血压相关器官缺血与高血压相关手术出血
Two common modifiers to BP targets in perioperative care are risks of organ ischemia and BP-related surgical bleeding. BP should be maintained at the upper allowable range when risk of organ ischemia is high; otherwise, it should be maintained at the lower allowable range when BP-related bleeding risk is significant.75,76 Risk-benefit decision-making should be applied when these 2 risks coexist.
在围手术期护理中，BP目标的两个常见调整因素是器官缺血和BP相关手术出血的风险。当器官缺血风险较高时，血压应维持在较高允许范围内；否则，当与血压相关的出血风险较大时，血压应维持在较低允许范围内。当这两种风险并存时，应采用风险-效益决策。
BP Management Guided by Tissue Oxygenation Monitoring
以组织氧合监测为指导的血压管理
Hemodynamics is a ladder composed of multiple interrelated steps (Figure 4). BP is a step positioned in the middle, whereas tissue oxygenation is a step positioned upward on the ladder. Tissue oxygenation measured by near infrared spectroscopy, such as cerebral tissue oxygen saturation, represents the balance between tissue oxygen consumption and supply. Tissue oxygen supply is determined by multiple downward steps on the ladder, with BP as just one of these determinants. As a result, the relationship between tissue oxygenation and BP is inconsistent and needs to be interpreted in a clinical context.77,78 The optimal BP management guided by tissue oxygenation monitoring remains both a promise and challenge and deserves further exploration.
血流动力学是由多个相互关联的步骤组成的阶梯(图4)。BP是位于中间的台阶，而组织氧合是位于梯子上部的台阶。近红外光谱学测量的组织氧合，如脑组织氧饱和度，代表了组织氧消耗和供应之间的平衡。组织供氧是由阶梯上的多个下部台阶决定的，而血压只是其中一个决定因素。因此，组织氧合和血压之间的关系是不一致的，需要在临床环境中加以解释。由组织氧合监测指导的最佳血压管理仍然是一种前景和挑战，值得进一步探索。
图4 假设的血流动力学阶梯，包括血管内容量、前负荷、心输出量(CO)、血压(BP)、器官灌注、氧气输送(DO2)、组织氧合和患者预后。阶梯下方突出显示了不同步骤之间的关系。阶梯上方突出了基于不同血流动力学方面的血流动力学管理的现状。EP表示诱发电位；GDFT表示目标导向液体疗法；HR表示心率；PCWP表示肺毛细血管楔压；SaO2表示动脉血氧饱和度；SmvO2表示混合静脉血氧饱和度；SVR表示全身血管阻力；UOP表示尿量
Precise Treatment of Hypotension: a Proposal
低血压的精准治疗：一个建议
Precise treatment of perioperative hypotension should be based on a reference to the patient’s baseline measurements of BP , cardiac output, stroke volume, heart rate, and systemic vascular resistance (Figure 5). BP is determined by the product of cardiac output and systemic vascular resistance. If cardiac output reduction is responsible for hypotension, the cause of the change in cardiac output, that is, stroke volume decrement versus heart rate decrement, should be determined. Stroke volume decrement can be secondary to either inadequate intravascular volume or decreased myocardial contractility. If the patient is fluid responsive, that is, exhibits a relatively large increase in stroke volume (eg, ≥10%) following a fluid bolus, the indicated therapy is volume replacement; otherwise, positive inotropes are indicated.79 Positive chronotropes are indicated if heart rate decrement is responsible for cardiac output reduction. Decreased systemic vascular resistance can be treated by either anesthetic depth adjustment or vasopressor administration or both. The execution of this proposal demands advanced hemodynamic monitoring that assesses volume and flow. This proposal should be validated by RCTs.
围手术期低血压的精准治疗应参考患者的血压、心输出量、每搏量、心率和全身血管阻力的基础测量值(图5)。血压由心输出量和全身血管阻力的乘积决定。如果心输出量减少是低血压的原因，应该确定心输出量变化的原因，即每搏量减少与心率减慢。每搏量减少可能继发于血管内容量不足或心肌收缩力降低。如果患者对液体有反应，也就是说，在推注液体后表现出较大的每搏量增加(例如，≥10%)，指示的是容量替代治疗；否则，表明是正性变力治疗。如果心率减慢是导致心输出量减少的原因，则表明是正性变时治疗。降低的全身血管阻力可以通过调整麻醉深度或应用血管加压剂或两者共同实施来治疗。这项建议的实施需要先进的血流动力学监测，以评估容量和流量。这项建议应该得到RCT的验证。
图5
围手术期低血压的鉴别诊断和治疗。血压(BP)、心输出量(CO)、每搏量(SV)、心率(HR)和全身血管阻力(SVR)的基础测量值被用作决策的参考。↓表示减少或不足；↑表示增加；(−)表示无变化或稳定。应该注意的是，大多数用于治疗低血压的血管活性药物都会产生多种心血管效应，包括动脉血管收缩、静脉收缩、正性/负性变力和变时性作用。
Importance of BP Management After Surgery
手术后血压管理的重要性
The aforementioned considerations are for the determination of BP targets during, not after, surgery. However, BP can be fragile postoperatively. Orthostatic hypotension is common after general anesthesia for minor surgery.80 Hemodynamic instability after surgery is associated with increased perioperative and 1-year morbidity and mortality after carotid endarterectomy.69,81 One recent retrospective study showed that hypotension defined as SBP <90 mm Hg and requiring treatment during each of the perioperative phases, that is, surgery, the remaining day of surgery, and postoperative day 1 to 4, is significantly associated with a combination of myocardial infarction and death.17 The protocol of an RCT that showed a beneficial effect associated with a personalized BP target (90%–110% baseline) covers the duration of surgery and the first 4 hours after surgery.48Therefore, continuous BP management after surgery deserves further exploration.
上述考虑是为了在手术期间而非手术后确定BP目标。然而，BP在手术后可能会变得脆弱。在小手术的全身麻醉后，直立性低血压是常见的。手术后的血流动力学不稳定与增加的围手术期以及颈动脉内膜切除术后一年的发病率和死亡率有关。最近的一项回顾性研究表明，低血压定义为SBP<90 mmHg，在围手术期的每个阶段，即手术、手术剩余日和术后第1至4天，需要治疗的低血压与心肌梗死和死亡都显著相关。一项RCT方案显示，个性化血压目标(基础值的90%-110%)的有益效果，涵盖了手术期间和术后最初4小时。因此，术后持续BP管理值得进一步探讨。
Considerations Are Not Judgments of Malpractice
注意事项不是对医疗差错的判断
It is well known that, as one of the most volatile physiological variables, BP can readily go beyond the targeted range in the perioperative environment. However, an extreme change in BP is not a deviation from the standard of care but rather a signal for action.82 Evidence shows that hypotension during anesthesia induction is neither a reliable nor a useful quality measure for comparing anesthesiologist performance.83 As long as corrective measures are promptly instituted based on diligent monitoring, there is normally no-to-minimal and reversible harm based on clinical experience. This finding agrees with the knowledge that BP-related injuries depend on not only the magnitude but also the duration of the change in BP . The considerations herein proposed are meant to facilitate the determination of BP targets in perioperative care, not to be used as judgments of malpractice. These proposals are provisional and must be revised when new evidence becomes available.
众所周知，血压作为最易波动的生理变量之一，在围手术期环境中很容易超出目标范围。然而，血压的极端变化并不是偏离护理标准，而是行动的信号。证据表明，麻醉诱导期间的低血压既不是比较麻醉医师表现的可靠的质量指标，也不是有用的质量指标。只要在勤于监测的基础上及时采取纠正措施，根据临床经验，通常是无伤害或最小的和可逆的伤害。这一发现与BP相关的损伤不仅取决于BP变化的幅度，而且取决于BP变化的持续时间这一认识是一致的。本文提出的注意事项是为了便于在围手术期护理中确定BP目标，而不是用来作为医疗差错的判断。这些建议是暂时性的，当有新的证据出现时，必须加以修订。
BP Management in Perioperative Versus Primary Care
围手术期与初级保健血压管理的比较
The differences in BP management between perioperative and primary care are notable. BP is much more volatile during perioperative than primary care. Hypotension, although there is a lack of consensus on its definition,84 is a prominent concern in perioperative but not primary care. The management model of chronic hypertension in primary care, with therapeutic targets defined by explicit absolute values for an exceedingly large population, may not be replicable in perioperative care. Therapeutic BP targets in perioperative care should be determined based on the integration of the results of clinical research and individualized evaluation of each patient. Intensive BP management guided by a personalized target is possible in perioperative care because, at least during surgery, an anesthesiologist is with the patient at all times and checks the BP at least every 5 minutes, which is not possible in primary care.
围手术期和初级保健在血压管理上的差异是显著的。围手术期的血压波动比初级保健大得多。尽管对低血压的定义缺乏共识，但它是围手术期而不是初级保健的一个突出问题。初级保健中的慢性高血压的管理模式，其治疗目标由极其庞大人群的明确绝对值定义，在围手术期护理中可能无法可复制。围术期治疗血压指标的确定应综合临床研究结果和每个患者的个体化评价。在围手术期护理中，由个性化目标指导的强化血压管理是可能的，因为至少在手术期间，麻醉医师时刻陪伴着患者，并至少每5分钟检查一次血压，这在初级保健中是不可能的。
Summary
总结
There is a close relationship between BP and outcome in perioperative care based on abundant nonrandomized studies. Maintaining a higher BP compared with a lower BP does not lead to worse outcomes and on the contrary may lead to improved outcomes, based on 3 RCTs performed in noncardiac surgical patients and 5 RCTs conducted in cardiac surgical patients. In contrast to the management of chronic hypertension in primary care, BP management in perioperative care needs to be personalized. The setup in perioperative care, for example, the at least 1:1 ratio between the patient and caregiver throughout surgery, makes intensive BP management possible. The determination of BP targets in perioperative care needs to take the type of surgery, patient’s baseline BP , and risks of hypotension-related organ ischemia and hypertension-related bleeding into consideration, as a minimum. Because of the lack of robust evidence and the volatility of BP in perioperative care, the considerations herein proposed should be used as a provisional facilitator for clinical decision-making, not a judgment of malpractice. More research, especially quality outcome-oriented RCTs, is urgently needed.
基于大量的非随机研究，在围手术期护理中，血压与预后密切相关。根据非心脏手术患者进行的3项随机对照试验(RCT)和心脏手术患者进行的5项随机对照试验(RCT)，维持较高的血压与较低的血压相比并不会导致更差的结果，相反，可能会导致改善的结果。与初级保健中的慢性高血压管理不同，围手术期护理中的BP管理需要个性化。例如，围手术期护理的设置，在整个手术过程中，患者和护理者之间的比例至少为1：1，这使得强化BP管理成为可能。围手术期血压目标的确定至少要考虑手术类型、患者的基础血压以及低血压相关器官缺血和高血压相关出血的风险。由于在围手术期护理中强有力证据的缺乏和BP的波动性，本文提出的注意事项应该被用作临床决策的临时促进器，而不是对医疗差错的判断。迫切需要更多的研究，特别是以质量和结局为导向的随机对照试验。
后台回复“BP”可得原文
●【周五】经典高分文献阅读·有症状性心房颤动的病态肥胖患者 为什么要推迟减肥手术？
●【周五】经典高分文献阅读·超声引导下竖脊肌平面阻滞用于腹腔镜肝切除术术后镇痛 前瞻、随机对照、双盲研究
●【周五】经典高分文献阅读·胃超声评估术前碳水化合物饮料的胃排空:一项随机对照非劣效性研究
●【周三】经典高分文献阅读·至少存在五种类型的急性术后疼痛轨迹，主要由患者因素而不是手术类型和术中药物决定
【周五】经典高分文献阅读·葡萄牙老年患者术前认知能力、局部脑氧饱和度和术后谵妄的相关性
【周五】经典高分文献阅读·术前使用咪达唑仑与术后早期谵妄无关
【周五】经典高分文献阅读·收缩压和灌注状态对急性心力衰竭死亡率的协同影响
【周五】经典高分文献阅读·利多卡因喷雾剂行蝶腭神经节阻滞治疗产科硬膜外穿刺后头痛
【周五】经典高分文献阅读·局部鼻内应用利多卡因不是蝶腭神经节阻滞
【周五】经典高分文献阅读·哪些干预措施可以减少老年人术后谵妄？综合多学科和药物干预数据
【周五】经典高分文献阅读· 阿片类药物相关的院外心脏骤停:独特的临床特征和对医疗和公众的影响
【周五】经典高分文献阅读·睡眠时间可以预测充血性心力衰竭
经典高分文献阅读· 柳叶刀社论反思慢性疼痛 （慢性疼痛系列开篇语）Rethinking chronic pain
【经典高分文献阅读】·类固醇减少谵妄的发生(STRIDE)
【文献阅读】窦性心律中出现休克的瘫痪运动员除颤器植入前自动体外除颤器节律条回收的重要性
【经典高分文献阅读】全髋关节置换术后髋关节囊周围神经阻滞对术后镇痛和功能恢复的影响:一项随机、观察者单盲、对照试验
【经典高分文献阅读】胸神经阻滞用于隆胸手术——一项随机、双盲、双中心对照试验
【经典高分文献阅读】全髋关节置换术中腰方肌阻滞中的作用:一项随机对照试验
【麻醉护理文献阅读】集束化护理干预对 PACU 入室低体温发生率的影响
1
END
1