| Objective:To investigate the causes of severe hypotension in patients with chronic deep sternal infection(DSWI)after general anesthesia,and to investigate whether preoperative angiotensin II(ATⅡ)can be used as an early warning indicator for vasodilatory shock after anesthesia in patients with chronic deep sternal infection.Methods:A total of 21 patients with deep sternal infection who underwent debridement from July 2019 to February 2021 were collected,including 10 males and 11 females.All patients underwent sternal lesion removal under general anesthesia,and the following indexes were recorded:(1)General characteristics :height,weight,age,gender,BMI,type of heart surgery,infection time,preoperative complications,heart function,ejection fraction,ASA classification,preoperative angiotensin Ⅱ(ATⅡ)levels,the preoperative mean arterial pressure(MAP);(2)Characteristics of patients during operation:blood pressure(BP),MAP,heart rate(HR),cardiac output(CO),stroke volume variation(SVV)of patients after induction(T1),5 min after intubation(T2),removal of necrotic sternum/costal cartilage(T3),end of operation(T4)and 5 min after extubation(T5)were recorded respectively.The type and dosage of vasoactive drugs during operation,operation time,fluid consumption during operation and the extubation time were recorded;5ml venous blood was collected during operation to measure ATⅡ levels;The incidence of intraoperative adverse cardiovascular events was recorded.(3)The ATII levels of 1 day before discharge after postoperative infection status disappear,the mortality rate of 30 days after operation,the adverse events within 30 days and the total length of hospitalization were recorded.The patients were divided into two groups:hypotension after general anesthesia(MAP≤65mmhg or blood pressure drop > basal value 20%),excluding anesthesia or surgery factors,and volume resuscitation according to target-directed fluid therapy,the need for continuous administration of vasoactive drugs to maintain hemodynamic stability was defined as severe hypotension caused by infection(group A),otherwise it was defined as control group(group B).The general and intraoperative characteristics,ATⅡ levels at different time points,total hospital stay,30-day mortality and adverse events within 30 days were compared between the two groups;The preoperative and introperative ATII levels of the two groups were compared within the group,the preoperative and postoperative ATII levels of the two groups were compared within the group.The incidence of intraoperative hypotension was calculated and some significant preoperative factors between groups were included in binary Logistic regression analysis,and the risk factors of severe intraoperative hypotension were statistically analyzed.The ROC curve was drawn according to the preoperative angiotensin II levels of the patients in the hypotension group,and the cut-off value of the patients with intraoperative hypotension was determined.Results:(1)General characteristics:A total of 21 patients were included in this study,including 10 males and 11 females,5 patients in hypotension group(group A)and 16 patients in control group(group B).The incidence of intraoperative hypotension was23.8%.The duration of infection in group A was significantly shorter than that in group B(P<0.05).There was no significant difference in other indexes between the two groups.(2)The preoperative and perioperative ATⅡ levels in group A higher than that of group B(P<0.05),but there was no difference in two groups of postoperative ATⅡlevels.Compared with preoperative,the introperative and postoperative ATⅡ levels of group A decreased significantly(P< 0.05).In group B,the introperative ATⅡ levels were lower than preoperative(P<0.05),but there was no statistical difference between preoperative and postoperative.MAP of group A was significantly lower than that of group B at time points T1,T2 and T3(P< 0.05),but there was no difference at other time points;There was no significant difference in CO and SVV between the two groups at any time point.Patients in group A were more likely to use catecholamines such as norepinephrine and dopamine,and the incidence of intraoperative cardiovascular adverse events was also higher than that in group B(P<0.05).There was a significant difference in hospital stay between the two groups.The hospitalization time of patients in the hypotension group was relatively longer(P<0.05).There was no difference in 30-day mortality between the two groups,and no serious adverse events occurred.(3)The results of binary Logistic regression analysis showed that preoperative ATⅡ value(OR 0.95,95%CI 0.876～1.042,P=0.298),infection time(OR 1.024,95%CI0.995～1.054,P=0.108)all P > 0.05,preoperative ATII levels and duration of infection had no significant effect on intraoperative hypotension.(4)ROC curve analysis showed that when the preoperative ATⅡ levels were57.6pg/ml,the Jordan index was the highest,with a sensitivity of 100% and a specificity of 66.7%.The area under the AUC curve was 0.827,indicating a certain accuracy of diagnosis.Conclusion:The patients with high preoperative ATⅡ levels of sternal infection were more likely to develop hypotension after general anesthesia,and the cut-off value is approximately57.6 pg/ml.However,a larger sample size is still needed to confirm it. |
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