腹部大手术中低血压的模型：一项观察性队列研究的回溯性机器学习分析

贵州医科大学 麻醉与心脏电生理课题组

翻 译：佟睿  编 辑：柏雪   审 校：曹莹

背景：术中低血压与心肌损伤、急性肾损伤和死亡有关。在常规操作中，术中低血压的具体原因往往不清楚。对术中低血压潜在的血流动力学改变有更详细的了解，可以确定具体的治疗方法。因此，我们的目标是使用机器学习，特别是采用分级聚类法来识别导致腹部大手术患者术中低血压的潜在血流动力学变化。具体地说，我们测试了术中低血压存在不同模型的假设，这可能有助于改进治疗干预措施。 

方法：我们对100例全麻下腹部大手术患者的术中血流动力学测量进行了二次分析，这些数据来自前瞻性观察研究。我们使用每搏输出量指数、心率、心脏指数、全身血管阻力指数和脉压变化测量。术中低血压定义为平均动脉压65mmHg或平均动脉压在66至75mmHg之间，去甲肾上腺素需要输注速率超过0.1μg·kg-1·min-1。为了确定术中低血压的模型，我们使用了分层聚类法(Ward’s方法)。 

结果：共有82例患者(其中46例为女性，中位年龄：64[57-73岁])发生了615次术中低血压，手术的平均持续时间为270(195-335)分钟。分层聚类法显示了6种不同的术中低血压模型。根据其临床特点，我们将其分为(1)心肌抑制、(2)心动过缓、(3)血管扩张伴心脏指数升高、(4)血管扩张但心脏指数未升高、(5)血容量减少、(6)混合型。 

结论：分层聚类法确定了术中低血压的六种分型。如果得到证实，考虑到这些术中低血压模型可能使术中低血压的因果治疗成为可能。 

原始文献来源：Karim Kouz, Lennart Brockmann, Lea Malin Timmermann, et al. Endotypes of intraoperative hypotension during major abdominal surgery: a retrospective machine learning analysis of an observational cohort study.[J]Br J Anae, doi: 10.1016/j.bja.2022.07.056.   

英文原文：

Endotypes of intraoperative hypotension during major abdominal surgery: a retrospective machine learning analysis of an observational cohort study

Abstract   Background: :Intraoperative hypotension is associated with myocardial injury, acute kidney injury, and death. In routine practice, specific causes of intraoperative hypotension are often unclear. A more detailed understanding of underlying haemodynamic alterations of intraoperative hypotension may identify specific treatments. We thus aimed to use machine learning e specifically, hierarchical clustering e to identify underlying haemodynamic alterations causing intraoperative hypotension in major abdominal surgery patients. Specifically, we tested the hypothesis that there are distinct endotypes of intraoperative hypotension, which may help refine therapeutic interventions.  

Method: We conducted a secondary analysis of intraoperative haemodynamic measurements from a prospective observational study in 100 patients who had major abdominal surgery under general anaesthesia. We used stroke volume index, heart rate, cardiac index, systemic vascular resistance index, and pulse pressure variation measurements. Intraoperative hypotension was defined as any mean arterial pressure 65 mm Hg or a mean arterial pressure between 66 and 75 mm Hg requiring a norepinephrine infusion rate exceeding 0.1 μg kg-1 min-1 . To identify endotypes of intraoperative hypotension, we used hierarchical clustering (Ward’s method). 

Results: A total of 615 episodes of intraoperative hypotension occurred in 82 patients (46 [56%] female; median age: 64 [57, 73] yr) who had surgery of a median duration of 270 (195, 335) min. Hierarchical clustering revealed six distinct intraoperative hypotension endotypes. Based on their clinical characteristics, we labelled these endotypes as (1) myocardial depression, (2) bradycardia, (3) vasodilation with cardiac index increase, (4) vasodilation without cardiac index increase, (5) hypovolaemia, and (6) mixed type. 

Conclusion: Hierarchical clustering identified six endotypes of intraoperative hypotension. If validated, considering these intraoperative hypotension endotypes may enable causal treatment of intraoperative hypotension.  

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文中所涉及药物使用、疾病诊疗等内容仅供医学专业人士参考。

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编辑：MiSuper.米超

校对：Michel.米萱

来源 | 健康界

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