小柯机器人

近日，丹麦新西兰大学医院Sarah Ekeloef课题组，研究了远端缺血预处理对急诊髋部骨折手术心肌损伤的影响。2019年12月4日，《英国医学杂志》在线发表了这项成果。

2015-2017年，研究组在丹麦的三所大学医院进行了一项临床2期、多中心、随机、观察者盲的试验。招募了648名有心血管危险因素的髋部骨折患者，其中286名接受远端缺血预处理（RIPC），即术前在上臂使用止血带，前臂缺血5分钟，再灌注5分钟，共进行4个周期；287名接受手术标准操作（对照组）。心肌损伤定义为缺血引起的血浆肌钙蛋白I峰值浓度超过45ng/L，校正后的心肌损伤添加了高敏肌钙蛋白I浓度超过24ng/L。

术后4天，RIPC组的168名患者中有25名（15%）发生心肌损伤，显著低于对照组（158名中有45名，28%）。RIPC组的286名患者中有57名（20%）发生校正后的心肌损伤，显著低于对照组（287例中有90例，31%）。RIPC组中发生10例心肌梗死（3%），对照组发生21例（7%），差异显著。两组间其他临床指标均无显著性差异。

结果表明，RIPC降低了急诊髋部骨折术后心肌损伤和梗死的风险。但不能断言，RIPC可全面预防术后心血管事件的发生，仍需大规模研究来进一步验证。

附：英文原文

Title: The effect of remote ischaemic preconditioning on myocardial injury in emergency hip fracture surgery (PIXIE trial): phase II randomised clinical trial

Author: Sarah Ekeloef, Morten Homilius, Maiken Stilling, Peter Ekeloef, Seda Koyuncu, Anna-Marie Bloch Münster, Christian S Meyhoff, Ossian Gundel, Julie Holst-Knudsen, Ole Mathiesen, Ismail Ggenur

Issue&Volume: 2019/12/04

Abstract:

Objective To investigate whether remote ischaemic preconditioning (RIPC) prevents myocardial injury in patients undergoing hip fracture surgery.

Design Phase II, multicentre, randomised, observer blinded, clinical trial.

Setting Three Danish university hospitals, 2015-17.

Participants 648 patients with cardiovascular risk factors undergoing hip fracture surgery. 286 patients were assigned to RIPC and 287 were assigned to standard practice (control group).

Intervention The RIPC procedure was initiated before surgery with a tourniquet applied to the upper arm and consisted of four cycles of forearm ischaemia for five minutes followed by reperfusion for five minutes.

Main outcome measures The original primary outcome was myocardial injury within four days of surgery, defined as a peak plasma cardiac troponin I concentration of 45 ng/L or more caused by ischaemia. The revised primary outcome was myocardial injury within four days of surgery, defined as a peak plasma cardiac troponin I concentration of 45 ng/L or more or high sensitive troponin I greater than 24 ng/L (the primary outcome was changed owing to availability of testing). Secondary outcomes were peak plasma troponin I and total troponin I release during the first four days after surgery (cardiac and high sensitive troponin I), perioperative myocardial infarction, major adverse cardiovascular events, and all cause mortality within 30 days of surgery, length of postoperative stay, and length of stay in the intensive care unit. Several planned secondary outcomes will be reported elsewhere.

Results 573 of the 648 randomised patients were included in the intention-to-treat analysis (mean age 79 (SD 10) years; 399 (70%) women). The primary outcome occurred in 25 of 168 (15%) patients in the RIPC group and 45 of 158 (28%) in the control group (odds ratio 0.44, 95% confidence interval 0.25 to 0.76; P=0.003). The revised primary outcome occurred in 57 of 286 patients (20%) in the RIPC group and 90 of 287 (31%) in the control group (0.55, 0.37 to 0.80; P=0.002). Myocardial infarction occurred in 10 patients (3%) in the RIPC group and 21 patients (7%) in the control group (0.46, 0.21 to 0.99; P=0.04). Statistical power was insufficient to draw firm conclusions on differences between groups for the other clinical secondary outcomes (major adverse cardiovascular events, 30 day all cause mortality, length of postoperative stay, and length of stay in the intensive care unit).

Conclusions RIPC reduced the risk of myocardial injury and infarction after emergency hip fracture surgery. It cannot be concluded that RIPC overall prevents major adverse cardiovascular events after surgery. The findings support larger scale clinical trials to assess longer term clinical outcomes and mortality.

DOI: 10.1136/bmj.l6395

Source: https://www.bmj.com/content/367/bmj.l6395

BMJ-British Medical Journal:《英国医学杂志》，创刊于1840年。隶属于BMJ出版集团，最新IF：93.333
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