Intraoperative Hypotension and 1-Year Mortality after Noncardiac Surgery (original) (raw)
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Anesthesiology, 2015
Although deviations in intraoperative blood pressure are assumed to be associated with postoperative mortality, critical blood pressure thresholds remain undefined. Therefore, the authors estimated the intraoperative thresholds of systolic blood pressure (SBP), mean blood pressure (MAP), and diastolic blood pressure (DBP) associated with increased risk-adjusted 30-day mortality. This retrospective cohort study combined intraoperative blood pressure data from six Veterans Affairs medical centers with 30-day outcomes to determine the risk-adjusted associations between intraoperative blood pressure and 30-day mortality. Deviations in blood pressure were assessed using three methods: (1) population thresholds (individual patient sum of area under threshold [AUT] or area over threshold 2 SDs from the mean of the population intraoperative blood pressure values), (2). absolute thresholds, and (3) percent change from baseline blood pressure. Thirty-day mortality was associated with (1) popu...
Intraoperative Hypotension Is Associated With Adverse Clinical Outcomes After Noncardiac Surgery
Anesthesia & Analgesia
Is there an association between intraoperative hypotension and postoperative major adverse cardiac or cerebrovascular events (MACCE)? • Findings: This multicenter retrospective analysis of 368,222 surgical procedures demonstrated that regardless of how hypotension exposure was defined (ie, mean arterial pressure [MAP] ≤75, ≤65, ≤55 mm Hg), intraoperative hypotension is significantly associated with MACCE in a "dose-dependent" manner. • Meaning: Intraoperative hypotension is a potentially avoidable hazard that appears to be associated with clinically significant morbidity regardless of age group; it remains to be demonstrated whether avoidance of hypotension reduces the incidence of MACCE, and if so, whether the way normotension is maintained matters. BACKGROUND: Intraoperative hypotension (IOH) occurs frequently during surgery and may be associated with organ ischemia; however, few multicenter studies report data regarding its associations with adverse postoperative outcomes across varying hemodynamic thresholds. Additionally, no study has evaluated the association between IOH exposure and adverse outcomes among patients by various age groups. METHODS: A multicenter retrospective cohort study was conducted between 2008 and 2017 using intraoperative blood pressure data from the US electronic health records database to examine postoperative outcomes. IOH was assessed in 368,222 noncardiac surgical procedures using 5 methods: (a) absolute maximum decrease in mean arterial pressure (MAP) during surgery, (b) time under each absolute threshold, (c) total area under each threshold, (d) timeweighted average MAP under each threshold, and (e) cumulative time under the prespecified relative MAP thresholds. MAP thresholds were defined by absolute limits (≤75, ≤65, ≤55 mm Hg) and by relative limits (20% and 40% lower than baseline). The primary outcome was major adverse cardiac or cerebrovascular events; secondary outcomes were all-cause 30-and 90-day mortality, 30-day acute myocardial injury, and 30-day acute ischemic stroke. Residual confounding was minimized by controlling for observable patient and surgical factors. In addition, we stratified patients into age subgroups (18-40, 41-50, 51-60, 61-70, 71-80, >80) to investigate how the association between hypotension and the likelihood of major adverse cardiac or cerebrovascular events and acute kidney injury differs in these age subgroups. RESULTS: IOH was common with at least 1 reading of MAP ≤75 mm Hg occurring in 39.5% (145,743) of cases; ≤65 mm Hg in 19.3% (70,938) of cases, and ≤55 mm Hg in 7.5% (27,473) of cases. IOH was significantly associated with the primary outcome for all age groups. For an absolute maximum decrease, the estimated odds of a major adverse cardiac or cerebrovascular events in the 30-day postsurgery was increased by 12% (95% confidence interval [CI], 11-14) for ≤75 mm Hg; 17.0% (95% CI, 15-19) for ≤65 mm Hg; and by 26.0% (95% CI, 22-29) for ≤55 mm Hg. CONCLUSIONS: IOH during noncardiac surgery is common and associated with increased 30-day major adverse cardiac or cerebrovascular events. This observation is magnified with increasing hypotension severity. The potentially avoidable nature of the hazard, and the extent of the exposed population, makes hypotension in the operating room a serious public health issue that should not be ignored for any age group.
Intraoperative hypotension and complications after vascular surgery: A scoping review
Surgery
Background: Intraoperative hypotension (IOH) during major surgery is associated with adverse health outcomes. This phenomenon represents a potentially important therapeutic target for vascular surgery patients, who may be uniquely vulnerable to IOH. This review summarizes current evidence regarding the impact of IOH on postoperative complications in patients undergoing vascular surgery, focusing on potentially modifiable procedure-and patient-specific risk factors. Methods: A scoping review of the literature from Embase, MEDLINE, and PubMed databases was conducted from inception to December 2019 to identify articles related to the effects of IOH on patients undergoing vascular surgery. Results: Ninety-two studies met screening criteria; nine studies met quality and inclusion criteria. Among the nine studies that defined IOH objectively, there were nine different definitions. Accordingly, the reported incidence of IOH ranged from 8 to 88% (when defined as a fall in SBP of >30 mmHg or MAP <65). The results demonstrated that IOH is an independent risk factor for longer hospital length of stay, myocardial injury, acute kidney injury, postoperative mechanical ventilation, and early mortality. Vascular surgery patients with comorbid conditions that confer increased vulnerability to hypoperfusion and ischemia appear to be susceptible to the adverse effects of IOH. Conclusions: There is no validated, consensus definition of IOH or other hemodynamic parameters associated with increased risk for adverse outcomes. Despite these limitations, the
Incidence of Intraoperative Hypotension as a Function of the Chosen Definition
Anesthesiology, 2007
Background Intraoperative hypotension (IOH) is a common side effect of general anesthesia and has been reported to be associated with adverse perioperative outcomes. These associations were found using different definitions for IOH. It is unknown whether the incidences of IOH found with those different definitions are comparable. The authors aimed to describe the relation between the chosen definition and incidence of IOH. Methods First, a systematic literature search was performed to identify recent definitions of IOH that have been used in the anesthesia literature. Subsequently, these definitions were applied to a cohort of 15,509 consecutive adult patients undergoing noncardiac surgery during general anesthesia. The incidence of IOH according to the different threshold values was calculated, and the effect of a defined minimal duration of a hypotensive episode was studied. Results Many different definitions of IOH were found. When applied to a cohort of patients, these different...
Critical Care
BackgroundThe postoperative period is critical for a patient’s recovery, and postoperative hypotension, specifically, is associated with adverse clinical outcomes and significant harm to the patient. However, little is known about the association between postoperative hypotension in patients in the intensive care unit (ICU) after non-cardiac surgery, and morbidity and mortality, specifically among patients who did not experience intraoperative hypotension. The goal of this study was to assess the impact of postoperative hypotension at various absolute hemodynamic thresholds (≤ 75, ≤ 65 and ≤ 55 mmHg), in the absence of intraoperative hypotension (≤ 65 mmHg), on outcomes among patients in the ICU following non-cardiac surgery.MethodsThis multi-center retrospective cohort study included specific patient procedures from Optum® healthcare database for patients without intraoperative hypotension (MAP ≤ 65 mmHg) discharged to the ICU for ≥ 48 h after non-cardiac surgery with valid mean ar...
Anesthesiology
Background The Hypotension Prediction Index is a commercially available algorithm, based on arterial waveform features, that predicts hypotension defined as mean arterial pressure less than 65 mmHg for at least 1 min. We therefore tested the primary hypothesis that index guidance reduces the duration and severity of hypotension during noncardiac surgery. Methods We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized to hemodynamic management with or without index guidance. Clinicians caring for patients assigned to guidance were alerted when the index exceeded 85 (range, 0 to 100) and a treatment algorithm based on advanced hemodynamic parameters suggested vasopressor administration, fluid administration, inotrope administration, or observation. Primary outcome was the amount of hypotension, defined as time-weighted average mean arterial pressure less than 65 mmHg. Secondary outcomes were...
The Association Between Mild Intraoperative Hypotension and Stroke in General Surgery Patients
Anesthesia and analgesia, 2016
Intraoperative hypotension may contribute to perioperative strokes. We therefore tested the hypothesis that intraoperative hypotension is associated with perioperative stroke. After institutional review board approval for this case-control study, we identified patients who had nonneurological, noncardiac, and noncarotid surgery under general anesthesia at the Cleveland Clinic between 2005 and 2011 and experienced a postoperative stroke. Control patients not experiencing postoperative stroke were matched in a 4-to-1 ratio using propensity scores and restriction to the same procedure type as stroke patients. The association between intraoperative hypotension, measured as time-integrated area under a mean arterial pressure (MAP) of 70 mm Hg, and postoperative stroke was assessed using zero-inflated negative binomial regression. Among 106 337 patients meeting inclusion criteria, we identified 120 who had confirmed postoperative stroke events based on manual chart review. Four-to-one pro...
Intraoperative arterial hypotension: clinical reasoning in the absence of definitive data
intensetimes ABSTRACT For many years it was impossible to demonstrate a relationship between intraoperative arterial hypotension (IOAH) and worse postoperative outcome. This was related to both problems with the definition of IOAH (that still persist) and the relatively low number of patients (thousands) providing insufficient statistical power. The recent widespread availability of electronic anaesthesia records has corrected that lack of statistical power, but many problems still persist, the most important one being the lack of studies that demonstrate a causal effect of IOAH on worse postoperative outcome. In this essay we critically analyse the different definition criteria for IOAH, summarize the most recent data that statistically link IOAH with worse postoperative outcome and attempt to build up clinical reasoning on the management of IOAH. The main message is that the complexity of IOAH will not allow simplistic corrective measures (i.e. the prescription of vasoconstrictors...
Journal of Anesthesia
Purpose Intraoperative hypotension (IOH) is associated with organ hypoperfusion. There are different underlying causes of IOH depending on the phase of surgery. Post-induction hypotension (PIH) and early-intraoperative hypotension tend to be frequently differentiated. We aimed to explore further different phases of IOH and verify whether they are differently associated with postoperative complications. Methods Patients undergoing abdominal surgery between October 2018 and July 2019 in a university hospital were screened. Post-induction hypotension was defined as MAP ≤ 65 mmHg between the induction of anaesthesia and the onset of surgery. Hypotension during surgery (IOH) was defined as MAP ≤ 65 mmHg occurring between the onset of surgery and its completion. Acute kidney injury, stroke or transient ischaemic attack, delirium, and myocardial infarction were considered as the outcome. Results We enrolled 508 patients (219 males, median age 62 years). 158 subjects (31.1%) met PIH, 171 (3...
National Journal of Health Sciences, 2022
Introduction: Intraoperative hypotension in cardiac surgery could be complicated by acute kidney injury (AKI), cardiac arrest and death due to poor organ perfusion. We studied intraoperative hypotension (IOH) and its immediate and short term relationship with post-operative mortality. Materials & Methods: A retrospective study of participants, 16-86 years old who underwent cardiac and vascular surgery at Tristate Heart and Vascular Center, Ilishan-Remo, Nigeria, a high dependency cardiac and vascular surgical center between January 2015 and March 2021. Study participants were grouped into three cohorts and primary outcome was all-cause post-operative death. Results: The records of four hundred and fifteen (258 males and 157 females) cohorts were studied, with mean age of 56.6 ± 5.4 years, 14.69% of the participants were 65 years or older. The surgeries were coronary artery bypass graft (CABG) alone (26.03%), CABG with valve surgery (38.31%) and, valves surgery alone (35.66%). The mean arterial pressure (MAP) pre-induction, and intra-operative and immediate post-op were 71.37 ± 14 09 mmHg, 68.6 ± 11.24 mmHg and 72.24 ± 33 mmHg respectively. The incidence of IOH was 86.30%, prevalence of background kidney dysfunction was 29.40% and incidence of AKI was 25.54%. Eleven (2.65%) participants died, all (100%) had IOH, 1 (9.09%) was intradialytic.