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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).

血壓(BP)作為生命體征之一，在麻醉和手術(shù)患者中至少每5分鐘使用無創(chuàng)袖帶方法測(cè)量一次。在許多情況下，血壓實(shí)際上是使用有創(chuàng)傳感器方法逐次監(jiān)測(cè)的。在圍手術(shù)期護(hù)理中常規(guī)和定期監(jiān)測(cè)血壓的基本原理是基于以下論點(diǎn)：(1)血壓可能非常不穩(wěn)定，(2)異常血壓與不良結(jié)局相關(guān)，(3)BP易于處理，(4)基于少數(shù)隨機(jī)對(duì)照試驗(yàn)(RCT)的方案指導(dǎo)的BP管理改善了預(yù)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

盡管在圍手術(shù)期護(hù)理中必須進(jìn)行頻繁的血壓監(jiān)測(cè)，但目前對(duì)于接受麻醉和手術(shù)患者的適當(dāng)血壓目標(biāo)幾乎沒有達(dá)成共識(shí)。這種情況與初級(jí)保健中的慢性高血壓形成對(duì)比。最近修訂的指南將高血壓的收縮壓(SBP)和舒張壓(DBP)的臨界值分別定義為130 mmHg和80 mmHg。值得注意的是，盡管在初級(jí)保健中檢查血壓的頻率要低得多，間隔從幾天到幾周或幾個(gè)月不等，但初級(jí)保健已經(jīng)為可能是醫(yī)療保健中最大的患者群體之一建立了治療性血壓目標(biāo)。有趣的是，是否可以在圍術(shù)期護(hù)理中建立類似的治療性血壓目標(biāo)，并在全球每年進(jìn)行超過3億次的外科手術(shù)。

Why Is There a Lack of Consensus on BP Targets in Perioperative Care?

為什么在圍手術(shù)期護(hù)理中對(duì)BP目標(biāo)缺乏共識(shí)？

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.

雖然在圍手術(shù)期護(hù)理中強(qiáng)制并定期監(jiān)測(cè)血壓，但對(duì)于不同手術(shù)患者群體的明確血壓目標(biāo)缺乏共識(shí)。潛在原因是多方面的(圖S1)。首先，以前的研究針對(duì)的患者群體和手術(shù)類型都是不同的。在確定BP目標(biāo)的過程中，不同的患者和手術(shù)涉及不同的關(guān)注事項(xiàng)和優(yōu)先事項(xiàng)。第二，不同且復(fù)雜的血壓分析方法，包括收縮期、均數(shù)、舒張期、絕對(duì)值、相對(duì)變化值、各種閾值、閾值以下的面積、平均值、時(shí)間加權(quán)平均值、最小值、最小持續(xù)時(shí)間等，再加上不同RCT使用的不同的治療血壓靶點(diǎn)，使得統(tǒng)一成為一項(xiàng)艱巨的任務(wù)。最后，不同研究評(píng)估的結(jié)果也是不同的，這增加了證據(jù)收集的難度。

Provisional Considerations During the Determination of BP Targets for an Individual Surgical Patient

確定個(gè)體化外科患者血壓指標(biāo)時(shí)的暫定注意事項(xiàng)

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.

在確定單個(gè)外科患者的血壓目標(biāo)時(shí)，需要實(shí)事求是的循證考慮。然而，在這個(gè)時(shí)候，對(duì)于大多數(shù)臨床相關(guān)的方面，高質(zhì)量的證據(jù)往往是缺乏的、有限的或不容易適用于個(gè)別患者的護(hù)理?；诂F(xiàn)有的最佳證據(jù)和臨床經(jīng)驗(yàn)，我們提出以下暫定的注意事項(xiàng)，以促進(jìn)圍手術(shù)期血壓目標(biāo)的確定(圖3)。表中列出了這些注意事項(xiàng)的類別和證據(jù)水平。

圖3 根據(jù)現(xiàn)有的最佳證據(jù)和臨床經(jīng)驗(yàn)，在圍手術(shù)期護(hù)理中確定血壓(BP)目標(biāo)時(shí)的暫定注意事項(xiàng)。主要考慮的是手術(shù)類型、患者的基礎(chǔ)血壓以及器官缺血和手術(shù)出血的風(fēng)險(xiǎn)。插圖突顯了平衡相互沖突的風(fēng)險(xiǎn)的重要性。有關(guān)更多詳細(xì)信息，請(qǐng)參閱正文。CPB表示體外循環(huán)；DBP表示舒張壓；MAP表示平均動(dòng)脈壓；SBP表示收縮壓。

Differentiating the Type of Surgery

區(qū)分手術(shù)類型

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.

不同的手術(shù)針對(duì)不同的患者群體，并且對(duì)血壓和器官灌注有不同的影響。由于體外循環(huán)的頻繁使用和手術(shù)操作對(duì)循環(huán)的影響，心臟手術(shù)與非心臟手術(shù)不同。心臟手術(shù)體外循環(huán)期間與體外循環(huán)前后不同。頸內(nèi)動(dòng)脈或腦血管手術(shù)會(huì)在頸內(nèi)動(dòng)脈暫時(shí)阻斷或動(dòng)脈瘤供血?jiǎng)用}暫時(shí)夾閉期間威脅腦灌注。因此，首先要慎重區(qū)分手術(shù)類型。

Classifying Baseline BP

基礎(chǔ)BP分類

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.

血壓正常的患者和高血壓患者是否會(huì)從相同的血壓目標(biāo)中同樣受益是一個(gè)關(guān)鍵問題，這顯然是對(duì)一刀切做法的挑戰(zhàn)。個(gè)體間基礎(chǔ)血壓的巨大差異使得基于基礎(chǔ)測(cè)量的血壓管理是明智的，并與上述近期隨機(jī)對(duì)照試驗(yàn)的結(jié)果一致。鑒于這些考慮，我們提出了一種三分法，將基礎(chǔ)血壓分為低血壓(SBP <90 mmHg，或DBP <50 mmHg)、正常血壓(SBP 90-129 mmHg，和DBP 50-79 mmHg)和高血壓(SBP ≥130 mmHg，或DBP ≥80 mmHg)?；A(chǔ)血壓是在患者無壓力、無疼痛、清醒(或輕度鎮(zhèn)靜)的情況下進(jìn)行多次測(cè)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，很難將不同形式的BP測(cè)量統(tǒng)一為一種形式。

Considerations for Noncardiac Surgical Patients With a Low Baseline BP (SBP, <90 mm Hg, or DBP, <50 mm Hg)

低基礎(chǔ)血壓(SBP<90 mmHg或DBP<50 mmHg)的非心臟手術(shù)患者應(yīng)注意的問題

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.

低基礎(chǔ)血壓患者的目標(biāo)可能是將MAP≥60 mmHg和BP維持在基礎(chǔ)值的100%到120%之間。這一考慮是基于多項(xiàng)研究，這些研究一致表明，術(shù)中MAP<60 mmHg與各種不利的結(jié)果相關(guān)。雖然這些研究沒有指定基礎(chǔ)血壓，但慎重的做法是維持MAP≥60 mmHg，寧可過于謹(jǐn)慎也不要冒風(fēng)險(xiǎn)，即使在基礎(chǔ)血壓較低的患者中也是如此。該患者群體中最高基礎(chǔ)血壓約為90/50 mmHg，MAP約為63 mmHg。對(duì)于允許的血壓增加，謹(jǐn)慎的做法是將其保持在基礎(chǔ)血壓的20%(而不是10%)，因?yàn)樵谠摶颊呷后w中，最高基礎(chǔ)MAP為63 mmHg，最高允許的MAP將是76 mm Hg (63 mm Hg×120%=76 mmHg)。臨床上，MAP為76 mmHg是常見的，被認(rèn)為是正常的。在這一人群中保持血壓不低于基礎(chǔ)血壓也是謹(jǐn)慎的，這意味著允許的血壓降幅為0%，因?yàn)槿绻３諱AP≥60 mmHg是先決條件，即使是該人群中最高基礎(chǔ)血壓為63 mmHg的患者，也幾乎沒有進(jìn)一步降低血壓的空間。可以推斷，對(duì)于基礎(chǔ)MAP<60 mmHg的患者，由于最重要的考慮是維持MAP≥為60 mmHg，圍手術(shù)期MAP將不會(huì)低于基礎(chǔ)值。

Considerations for Noncardiac Surgical Patients With a Normal Baseline BP (SBP, 90–129 mm Hg, and DBP, 50–79 mm Hg)

基礎(chǔ)血壓正常(SBP 90-129 mmHg和DBP 50-79 mmHg)的非心臟手術(shù)患者應(yīng)注意的問題

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. 

基礎(chǔ)血壓正常的患者的目標(biāo)可能是將血壓維持在基礎(chǔ)值的90%至110%，并將MAP控制在65至95 mmHg范圍內(nèi)。10%的規(guī)則，即允許血壓變化≤基礎(chǔ)值10%，是基于最近在接受重大腹部手術(shù)的患者中進(jìn)行的隨機(jī)對(duì)照試驗(yàn)。雖然這項(xiàng)試驗(yàn)有局限性，并且沒有區(qū)分研究參與者的基礎(chǔ)血壓，但在基礎(chǔ)血壓正常的患者中采用10%規(guī)則是謹(jǐn)慎的。65-95 mmHg的MAP范圍來自于該患者群體的最低和最高基礎(chǔ)血壓，分別為90/50和130/80 mmHg，它們分別對(duì)應(yīng)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)

高基礎(chǔ)血壓(SBP，≥130 mmHg或DBP，≥80 mmHg)的非心臟手術(shù)患者應(yīng)注意的問題

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

高基礎(chǔ)血壓患者的目標(biāo)可能是將血壓維持在基礎(chǔ)值的80%-110%，SBP<160 mmHg。這一患者群體因圍手術(shù)期環(huán)境中的血壓易變性而著稱。對(duì)于允許的BP下降，謹(jǐn)慎的做法是將其保持在基礎(chǔ)的20%以內(nèi)，而不是10%，因?yàn)榭紤]到與20％相比，10％的臨界值可能會(huì)導(dǎo)致不適當(dāng)?shù)母哐獕骸＠?，基礎(chǔ)收縮壓為190mmHg時(shí)，根據(jù)10%和20%的規(guī)則，允許的最低收縮壓分別為170和150 mmHg。對(duì)于這名患者，如果給予這兩種選擇，大多數(shù)臨床醫(yī)生在大多數(shù)情況下更愿意將SBP保持在150 mmHg，而不是170 mmHg。20%的規(guī)則得到了多項(xiàng)非隨機(jī)研究的支持。相反，對(duì)于允許的血壓增加，遵循10%的規(guī)則可能是謹(jǐn)慎的，即不超過基礎(chǔ)值的10%。此外，基于1項(xiàng)回顧性研究和1項(xiàng)前瞻性研究的結(jié)果，我們建議將SBP值保持在160 mmHg以下。

Considerations for Patients Having Cardiac Surgery

心臟手術(shù)患者應(yīng)注意的問題

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.

心臟手術(shù)期間CPB前后血壓指標(biāo)的相關(guān)證據(jù)缺乏。此時(shí)，謹(jǐn)慎地使用非心臟手術(shù)的注意事項(xiàng)作為參考。對(duì)于CPB期間的血壓目標(biāo)，基于5個(gè)隨機(jī)對(duì)照試驗(yàn)的結(jié)果的匯總，將MAP維持在70到100 mmHg是明智的。在這些隨機(jī)對(duì)照試驗(yàn)中，2項(xiàng)研究顯示出與較高的灌注壓相關(guān)的有利影響，而3項(xiàng)研究沒有發(fā)現(xiàn)高和低血壓指標(biāo)之間的結(jié)果差異。因此，在CPB期間保持較高的灌注壓是明智的，因?yàn)殡m然不是每條證據(jù)都顯示有利的影響，但沒有證據(jù)表明當(dāng)灌注壓保持在較高的水平時(shí)會(huì)產(chǎn)生不利的影響。70至100 mmHg的MAP目標(biāo)仍是一個(gè)較大范圍。CPB期間個(gè)別患者的特定MAP目標(biāo)應(yīng)根據(jù)基礎(chǔ)值測(cè)量和終末器官灌注監(jiān)測(cè)(如果可用)來確定。

Considerations for Patients Receiving Carotid Artery or Cerebrovascular Surgery

頸動(dòng)脈或腦血管手術(shù)患者應(yīng)注意的問題

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

在頸動(dòng)脈內(nèi)膜切除術(shù)期間，基于一項(xiàng)以早期認(rèn)知功能障礙為終點(diǎn)的非隨機(jī)研究，頸內(nèi)動(dòng)脈臨時(shí)阻斷期間的血壓目標(biāo)可能是基礎(chǔ)值的120%?；趦身?xiàng)非隨機(jī)研究，腦血管手術(shù)期間的血壓目標(biāo)可能是維持SBP >90 mmHg和MAP >70 mmHg。根據(jù)專家的意見，在臨時(shí)夾閉動(dòng)脈瘤供血?jiǎng)用}期間維持BP≥基礎(chǔ)值是謹(jǐn)慎的。

Balancing Hypotension-Related Organ Ischemia Versus Hypertension-Related Surgical Bleeding

平衡低血壓相關(guān)器官缺血與高血壓相關(guān)手術(shù)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.

在圍手術(shù)期護(hù)理中，BP目標(biāo)的兩個(gè)常見調(diào)整因素是器官缺血和BP相關(guān)手術(shù)出血的風(fēng)險(xiǎn)。當(dāng)器官缺血風(fēng)險(xiǎn)較高時(shí)，血壓應(yīng)維持在較高允許范圍內(nèi)；否則，當(dāng)與血壓相關(guān)的出血風(fēng)險(xiǎn)較大時(shí)，血壓應(yīng)維持在較低允許范圍內(nèi)。當(dāng)這兩種風(fēng)險(xiǎn)并存時(shí)，應(yīng)采用風(fēng)險(xiǎn)-效益決策。

BP Management Guided by Tissue Oxygenation Monitoring

以組織氧合監(jiān)測(cè)為指導(dǎo)的血壓管理

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.

血流動(dòng)力學(xué)是由多個(gè)相互關(guān)聯(lián)的步驟組成的階梯(圖4)。BP是位于中間的臺(tái)階，而組織氧合是位于梯子上部的臺(tái)階。近紅外光譜學(xué)測(cè)量的組織氧合，如腦組織氧飽和度，代表了組織氧消耗和供應(yīng)之間的平衡。組織供氧是由階梯上的多個(gè)下部臺(tái)階決定的，而血壓只是其中一個(gè)決定因素。因此，組織氧合和血壓之間的關(guān)系是不一致的，需要在臨床環(huán)境中加以解釋。由組織氧合監(jiān)測(cè)指導(dǎo)的最佳血壓管理仍然是一種前景和挑戰(zhàn)，值得進(jìn)一步探索。

圖4 假設(shè)的血流動(dòng)力學(xué)階梯，包括血管內(nèi)容量、前負(fù)荷、心輸出量(CO)、血壓(BP)、器官灌注、氧氣輸送(DO2)、組織氧合和患者預(yù)后。階梯下方突出顯示了不同步驟之間的關(guān)系。階梯上方突出了基于不同血流動(dòng)力學(xué)方面的血流動(dòng)力學(xué)管理的現(xiàn)狀。EP表示誘發(fā)電位；GDFT表示目標(biāo)導(dǎo)向液體療法；HR表示心率；PCWP表示肺毛細(xì)血管楔壓；SaO2表示動(dòng)脈血氧飽和度；SmvO2表示混合靜脈血氧飽和度；SVR表示全身血管阻力；UOP表示尿量

Precise Treatment of Hypotension: a Proposal

低血壓的精準(zhǔn)治療：一個(gè)建議

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.

圍手術(shù)期低血壓的精準(zhǔn)治療應(yīng)參考患者的血壓、心輸出量、每搏量、心率和全身血管阻力的基礎(chǔ)測(cè)量值(圖5)。血壓由心輸出量和全身血管阻力的乘積決定。如果心輸出量減少是低血壓的原因，應(yīng)該確定心輸出量變化的原因，即每搏量減少與心率減慢。每搏量減少可能繼發(fā)于血管內(nèi)容量不足或心肌收縮力降低。如果患者對(duì)液體有反應(yīng)，也就是說，在推注液體后表現(xiàn)出較大的每搏量增加(例如，≥10%)，指示的是容量替代治療；否則，表明是正性變力治療。如果心率減慢是導(dǎo)致心輸出量減少的原因，則表明是正性變時(shí)治療。降低的全身血管阻力可以通過調(diào)整麻醉深度或應(yīng)用血管加壓劑或兩者共同實(shí)施來治療。這項(xiàng)建議的實(shí)施需要先進(jìn)的血流動(dòng)力學(xué)監(jiān)測(cè)，以評(píng)估容量和流量。這項(xiàng)建議應(yīng)該得到RCT的驗(yàn)證。

圖5

圍手術(shù)期低血壓的鑒別診斷和治療。血壓(BP)、心輸出量(CO)、每搏量(SV)、心率(HR)和全身血管阻力(SVR)的基礎(chǔ)測(cè)量值被用作決策的參考?！硎緶p少或不足；↑表示增加；(?)表示無變化或穩(wěn)定。應(yīng)該注意的是，大多數(shù)用于治療低血壓的血管活性藥物都會(huì)產(chǎn)生多種心血管效應(yīng)，包括動(dòng)脈血管收縮、靜脈收縮、正性/負(fù)性變力和變時(shí)性作用。

Importance of BP Management After Surgery

手術(shù)后血壓管理的重要性

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.

上述考慮是為了在手術(shù)期間而非手術(shù)后確定BP目標(biāo)。然而，BP在手術(shù)后可能會(huì)變得脆弱。在小手術(shù)的全身麻醉后，直立性低血壓是常見的。手術(shù)后的血流動(dòng)力學(xué)不穩(wěn)定與增加的圍手術(shù)期以及頸動(dòng)脈內(nèi)膜切除術(shù)后一年的發(fā)病率和死亡率有關(guān)。最近的一項(xiàng)回顧性研究表明，低血壓定義為SBP<90 mmHg，在圍手術(shù)期的每個(gè)階段，即手術(shù)、手術(shù)剩余日和術(shù)后第1至4天，需要治療的低血壓與心肌梗死和死亡都顯著相關(guān)。一項(xiàng)RCT方案顯示，個(gè)性化血壓目標(biāo)(基礎(chǔ)值的90%-110%)的有益效果，涵蓋了手術(shù)期間和術(shù)后最初4小時(shí)。因此，術(shù)后持續(xù)BP管理值得進(jìn)一步探討。

Considerations Are Not Judgments of Malpractice

注意事項(xiàng)不是對(duì)醫(yī)療差錯(cuò)的判斷

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.

眾所周知，血壓作為最易波動(dòng)的生理變量之一，在圍手術(shù)期環(huán)境中很容易超出目標(biāo)范圍。然而，血壓的極端變化并不是偏離護(hù)理標(biāo)準(zhǔn)，而是行動(dòng)的信號(hào)。證據(jù)表明，麻醉誘導(dǎo)期間的低血壓既不是比較麻醉醫(yī)師表現(xiàn)的可靠的質(zhì)量指標(biāo)，也不是有用的質(zhì)量指標(biāo)。只要在勤于監(jiān)測(cè)的基礎(chǔ)上及時(shí)采取糾正措施，根據(jù)臨床經(jīng)驗(yàn)，通常是無傷害或最小的和可逆的傷害。這一發(fā)現(xiàn)與BP相關(guān)的損傷不僅取決于BP變化的幅度，而且取決于BP變化的持續(xù)時(shí)間這一認(rèn)識(shí)是一致的。本文提出的注意事項(xiàng)是為了便于在圍手術(shù)期護(hù)理中確定BP目標(biāo)，而不是用來作為醫(yī)療差錯(cuò)的判斷。這些建議是暫時(shí)性的，當(dāng)有新的證據(jù)出現(xiàn)時(shí)，必須加以修訂。

BP Management in Perioperative Versus Primary Care

圍手術(shù)期與初級(jí)保健血壓管理的比較

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.

圍手術(shù)期和初級(jí)保健在血壓管理上的差異是顯著的。圍手術(shù)期的血壓波動(dòng)比初級(jí)保健大得多。盡管對(duì)低血壓的定義缺乏共識(shí)，但它是圍手術(shù)期而不是初級(jí)保健的一個(gè)突出問題。初級(jí)保健中的慢性高血壓的管理模式，其治療目標(biāo)由極其龐大人群的明確絕對(duì)值定義，在圍手術(shù)期護(hù)理中可能無法可復(fù)制。圍術(shù)期治療血壓指標(biāo)的確定應(yīng)綜合臨床研究結(jié)果和每個(gè)患者的個(gè)體化評(píng)價(jià)。在圍手術(shù)期護(hù)理中，由個(gè)性化目標(biāo)指導(dǎo)的強(qiáng)化血壓管理是可能的，因?yàn)橹辽僭谑中g(shù)期間，麻醉醫(yī)師時(shí)刻陪伴著患者，并至少每5分鐘檢查一次血壓，這在初級(jí)保健中是不可能的。

Summary

總結(jié)