肝癌术后重症患者围手术期低血压的危险因素分析

王斌; 梁汉生; 冯艺; 安友仲

doi:10.3969/j.issn.1001-5256.2022.03.015

肝癌术后重症患者围手术期低血压的危险因素分析

DOI: 10.3969/j.issn.1001-5256.2022.03.015

王斌^a,
梁汉生^b,
冯艺^b, , ,,
安友仲^a, , ,

a.
北京大学人民医院重症医学科, 北京 100044
b.
北京大学人民医院麻醉疼痛医学科, 北京 100044

基金项目:

国家重点研发计划 (2018YFC2001905)

伦理学声明：本研究方案于2021年2月7日经由北京大学人民医院伦理委员会审批通过，批号：2021FHB024-001。

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：王斌、安友仲、冯艺负责研究设计；王斌、梁汉生负责收集分析研究数据；王斌负责起草、修改文章关键内容。

详细信息

通信作者:
冯艺, E-mail: doctor_yifeng@sina.com

安友仲, E-mail: bjicu@163.com

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出版历程
- 收稿日期: 2021-11-03
- 录用日期: 2021-12-05
- 出版日期: 2022-03-20

Risk factors for perioperative hypotension in severe patients after liver cancer surgery

Bin WANG^a,
Hansheng LIANG^b,
Yi FENG^{b
, ,
,},
Youzhong AN^{a
, ,
,}

a.
Department of Critical Care Medicine, Peking University People's Hospital, Beijing 100044, China
b.
Department of Anesthesia and Pain Medicine, Peking University People's Hospital, Beijing 100044, China

Research funding:

National Key Research and Development Program of China (2018YFC2001905)

More Information

Corresponding author: FENG Yi, doctor_yifeng@sina.com (ORCID: 0000-0002-3952-1351); AN Youzhong, bjicu@163.com (ORCID: 0000-0003-4344-3699)

摘要

摘要: 目的探讨肝癌术后重症患者围手术期低血压相关危险因素及其对预后的影响。方法回顾性分析2014年1月—2019年12月于北京大学人民医院因原发性肝癌或转移性肝癌行手术治疗后转入ICU的422例患者的临床资料。将术中或术后需要持续泵入血管活性药物（去甲肾上腺素、多巴胺、苯肾上腺素、肾上腺素）维持血压者纳入低血压组（n=107），不需泵入血管活性药物维持血压者纳入非低血压组（n=315）。收集所有患者性别、年龄、BMI、肝脏手术史、合并症、肝脏基础疾病、术前实验室检查、外科和麻醉情况等临床资料。比较两组患者预后相关指标（院内病死率，ICU住院时间、总住院时间、机械通气时间、急性肾损伤、低氧血症、肺部感染、心肌损伤）。符合正态分布的计量资料两组间比较采用独立样本t检验；不符合正态分布和方差齐的计量资料两组间比较采用Mann-Whitney U检验。计数资料两组间比较采用χ²检验。将P < 0.1的临床指标纳入二元logistic多因素回归分析低血压危险因素。结果肝癌术后重症患者总体病死率为1.9%，低血压组病死率为3.7%，非低血压病死率为1.3%。相较于非低血压组，低血压组ICU住院时间更长（Z=-6.440，P < 0.001），机械通气时间更长（Z=-6.082，P < 0.001），术后急性肾损伤、低氧血症、肺部感染者更多（χ²值分别为25.661、25.409、20.126，P值均＜0.001）。将两组比较P < 0.1的临床指标（合并冠心病、腹水，术前Alb、血小板和纤维蛋白原水平，手术和肝门阻断时间，开腹手术，失血量）纳入二元logistic多因素回归分析，结果显示，手术时间（OR=1.004，95%CI: 1.002~1.006，P < 0.05）和失血量（OR=1.151，95%CI: 1.009~1.313，P < 0.05）是肝癌手术患者发生低血压的独立危险因素，更高的术前Alb水平（OR=0.950，95%CI: 0.907~0.995，P < 0.05）是其保护性因素。结论肝癌术后重症患者围手术期低血压发生率较高，更长的手术时间和更多的失血量是低血压的独立危险因素，而较高的术前Alb水平是其保护性因素。
- 肝肿瘤 /
- 肝切除术 /
- 低血压 /
- 危险因素
Abstract: Objective To investigate the risk factors for perioperative hypotension in severe patients after liver cancer surgery and its influence on prognosis. Methods A retrospective analysis was performed for the clinical data of 422 patients who underwent surgical treatment due to primary liver cancer or metastatic liver cancer and were then admitted to the intensive care unit (ICU) of Peking University People's Hospital from January 2014 to December 2019. The 107 patients requiring continuous intraoperative or postoperative pumping of vasoactive drugs (norepinephrine, dopamine, phenylephrine, and epinephrine) to maintain blood pressure were included in the hypotension group, and the 315 patients who did not require the pumping of vasoactive drugs to maintain blood pressure were included in the non-hypotension group. Related clinical data were collected from all patients, including sex, age, body mass index, history of liver surgery, comorbidities, underlying liver diseases, preoperative laboratory examinations, surgical data, and anesthesia, and the two groups were compared in terms of related prognostic indicators (in-hospital mortality, length of ICU stay, length of hospital stay, duration of mechanical ventilation, acute kidney injury, hypoxemia, pulmonary infection, and myocardial injury). The independent samples t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups. The clinical indices with P < 0.1 were included in the binary logistic regression analysis to investigate the risk factors for hypotension. Results The overall mortality rate was 1.9% for the severe patients after liver cancer surgery, with a mortality rate of 3.7% in the hypotension group and 1.3% in the non-hypotension group. Compared with the non-hypotension group, the hypotension group had a significantly longer length of ICU stay (Z=-6.440, P < 0.001), a significantly longer duration of mechanical ventilation (Z=-6.082, P < 0.001), and a significantly higher proportion of patients with acute kidney injury, hypoxemia, and pulmonary infection after surgery (χ²=25.661, 25.409, and 20.126, all P < 0.001). The clinical indices with P < 0.1 between the two groups (coronary heart disease, ascites, preoperative levels of albumin/platelets/fibrinogen, time of operation and hepatic portal occlusion, laparotomy, blood loss) were included in the binary logistic regression analysis, and the results showed that time of operation (odds ratio [OR]=1.004, 95% confidence interval [CI]: 1.002-1.006, P < 0.05) and blood loss (OR=1.151, 95%CI: 1.009-1.313, P < 0.05) were independent risk factors for hypotension in patients undergoing liver cancer surgery, while preoperative albumin level (OR=0.950, 95%CI: 0.907-0.995, P < 0.05) was a protective factor. Conclusion There is a relatively high incidence rate of hypotension among severe patients after liver cancer surgery, and a longer time of operation and greater blood loss are independent risk factors for hypotension, while a higher preoperative albumin level is a protective factor.
- Liver Neoplasms /
- Hepatectomy /
- Hypotension /
- Risk Factors

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表 1 两组患者预后指标比较

预后指标	低血压组（n=107）	非低血压组（n=315）	统计值	P值
院内病死率[例(%)]	4（3.7）	4（1.3）	χ²=2.617	0.106
ICU住院时间（d）	3（2~5）	2（2~2）	Z=-6.440	< 0.001
总住院时间（d）	17（14~25）	17（13~22）	Z=-1.899	0.058
机械通气时间（h）	11.0（5.8~35.0）	5.5（3.0~11.0）	Z=-6.082	< 0.001
急性肾损伤[例（%）]	23（21.5）	16（5.1）	χ²=25.661	< 0.001
低氧血症[例（%）]	57（53.3）	84（26.7）	χ²=25.409	< 0.001
肺部感染[例（%）]	26（24.3）	25（7.9）	χ²=20.126	< 0.001
心肌损伤[例（%）]	44（41.1）	107（34.0）	χ²=1.779	0.182

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表 2 两组患者临床资料比较

指标	低血压组（n=107）	非低血压组（n=315）	统计值	P值
性别（例）			χ²=0.693	0.405
男	68	214
女	39	101
年龄（岁）	60.38±10.95	60.46±12.59	t=-0.054	0.957
BMI（kg/m²）	24.71±3.63	24.45±3.88	t=0.591	0.555
肝脏手术史[例（%）]	16（15.0）	46（14.7）	χ²=0.006	0.939
合并症[例（%）]
糖尿病	19（17.8）	66（21.0）	χ²=0.507	0.476
高血压	35（33.0）	104（33.1）	χ²=0.985	0.985
冠心病	5（4.7）	31（9.8）	χ²=2.734	0.098
慢性肾功能不全	2（1.9）	8（2.5）	χ²=0.694	0.694
肝脏基础疾病[例（%）]
乙型肝炎	39（36.4）	123（39.0）	χ²=0.228	0.633
丙型肝炎	5（4.7）	8（2.5）	χ²=1.204	0.272
肝硬化	28（26.2）	79（25.1）	χ²=0.050	0.823
脾大	18（16.8）	48（15.2）	χ²=0.152	0.697
腹水	17（15.9）	30（9.5）	χ²=3.268	0.071
脂肪肝	3（2.8）	8（2.5）	χ²=0.022	0.882
术前实验室检查
Alb（g/L）	38.61±5.63	39.90±7.16	t=-1.688	0.092
WBC（×10⁹/L）	5.87±2.40	6.00±2.15	t=-0.514	0.608
Hb（g/L）	130.06±23.42	131.61±20.99	t=-0.642	0.521
PLT（×10⁹/L）	171.53±85.12	195.78±93.13	t=-2.377	0.018
PT（s）	12.10±1.52	11.94±1.20	t=1.068	0.286
APTT（s）	31.89±3.86	31.79±3.42	t=0.252	0.801
纤维蛋白原水平（mg/dL）	299.60±88.63	322.46±98.24	t=-2.131	0.034
手术情况
手术时间（min）	389.21±135.21	310.19±120.87	t=5.665	< 0.001
开腹手术[例（%）]	104（97.2）	291（92.4）	χ²=3.092	0.079
腹腔镜手术[例（%）]	14（13.1）	51（16.2）	χ²=0.591	0.442
肝门阻断时间（min）	0（0~18）	0（0~7）	Z=-1.880	0.060
多部位手术[例（%）]	43（40.2）	102（32.4）	χ²=2.158	0.142
麻醉情况
ASA分级（例）			χ²=2.364	0.124
1~2级	78	252
3~4级	29	63
全凭静脉麻醉[例（%）]	12（11.2）	35（11.1）	χ²=0.001	0.976
麻醉诱导后低血压[例（%）]	55（51.4）	160（50.8）	χ²=0.012	0.913
术中最低体温（℃）	35.89±0.67	35.85±2.19	t=0.191	0.849
失血量（L）	2.00（1.00~3.50）	1.00（0.50~1.85）	Z=-5.476	< 0.001

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表 3 肝癌术后患者围手术期发生低血压的多因素分析

指标	Β值	Wald	OR值	95%CI	P值
冠心病	-0.539	1.035	0.583	0.206~1.649	0.309
腹水	0.498	1.851	1.645	0.803~3.371	0.174
Alb	-0.052	4.766	0.950	0.907~0.995	0.029
PL	-0.002	2.222	0.998	0.994~1.001	0.136
纤维蛋白原	-0.003	2.641	0.997	0.994~1.001	0.104
手术时间	0.004	12.406	1.004	1.002~1.006	0
开腹手术	0.814	1.346	2.256	0.571~8.892	0.246
肝门阻断时间	0.009	1.621	1.009	0.995~1.022	0.203
失血量	0.141	4.395	1.151	1.009~1.313	0.036

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