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Daher M, Balmaceno-Criss M, Liu J, Singh M, Kuharski MJ, Daniels AH, Cohen EM. Anticoagulation in patients with atrial fibrillation undergoing inpatient total knee arthroplasty: A matched analysis. J Orthop 2025; 63:82-86. [PMID: 39564088 PMCID: PMC11570692 DOI: 10.1016/j.jor.2024.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Accepted: 10/31/2024] [Indexed: 11/21/2024] Open
Abstract
Background Patients with atrial fibrillation (AF) often require lifetime anticoagulation using drugs such as Warfarin and Direct-acting Oral Anticoagulants (DOAC). It is important to assess the impact that prior anticoagulant use has on the post-operative complications in patients with AF undergoing TKA. Methods This is a retrospective analysis of the PearlDiver database querying all patients who underwent an inpatient TKA. Patients who had AF and filled a prescription for at least 30 days of either Warfarin or a DOAC were matched to control cohorts. Medical and surgical complications 30 and 90 days post-operatively were compared between the two groups. Results 4396 patients made up the group with AF on warfarin, while 5383 patients made up the cohort with AF on DOAC and their corresponding controls. Patients on anticoagulation had more AKI (OR 2.70, OR: 2.37), pneumonia (OR: 2.89, OR: 2.46), MI (OR: 2.70, OR: 3.14), transfusion (OR: 6.94, OR: 3.16), sepsis (OR: 2.47, OR: 1.96), and aseptic loosening at 90 days (OR: 17.06, OR:7.01). However, PE (OR: 3.32) and hematoma (OR: 1.71) were only higher in the warfarin cohort. TKA instability was higher in the DOAC cohort (OR: 6.00). Conversely, patients in the control group exhibited more wound dehiscence compared to the warfarin group (OR: 0.28), and higher rates of revision surgery compared to both the DOAC (OR:0.27) and Warfarin (OR:0.31) groups at 90 days. Conclusion Patients on DOAC and Warfarin for AF, and undergoing TKA are exposed to a higher risk of post-operative complications.
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Affiliation(s)
- Mohammad Daher
- Department of Orthopedics, Brown University, Providence, RI, USA
| | | | - Jonathan Liu
- Department of Orthopedics, Brown University, Providence, RI, USA
| | - Manjot Singh
- Department of Orthopedics, Brown University, Providence, RI, USA
| | | | - Alan H Daniels
- Department of Orthopedics, Brown University, Providence, RI, USA
| | - Eric M Cohen
- Department of Orthopedics, Brown University, Providence, RI, USA
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Szrama J, Gradys A, Woźniak A, Nowak Z, Bartkowiak T, Lohani A, Zwoliński K, Koszel T, Kusza K. The Hypotension Prediction Index in Free Flap Transplant in Head and Neck Surgery: Protocol of a Prospective Randomized Controlled Trial. Life (Basel) 2025; 15:400. [PMID: 40141745 PMCID: PMC11943565 DOI: 10.3390/life15030400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2024] [Revised: 02/09/2025] [Accepted: 02/27/2025] [Indexed: 03/28/2025] Open
Abstract
INTRODUCTION Microvascular free flap surgery is a treatment method for patients with head and neck cancer requiring reconstruction surgery. Patients undergoing this complex, long-lasting surgery are prone to prolonged episodes of intraoperative hypotension, which is associated with increased incidence of postoperative mortality, morbidity, and free flap failure. A new technology recently approved, named the Hypotension Prediction Index (HPI), allows precise hemodynamic monitoring of patients under general anesthesia, with a significant reduction of intraoperative hypotension events. This study aims to assess the impact of the Hypotension Prediction Index (HPI) on the incidence and severity of intraoperative hypotension in patients undergoing free flap surgery. METHODS AND ANALYSIS Eligible patients will be randomly assigned to one of two groups: Group A, receiving invasive blood pressure monitoring with standard medical therapy, or Group B, undergoing hemodynamic monitoring using the Hypotension Prediction Index (HPI) software. The primary outcome is the time-weighted average (TWA) of mean arterial pressure (MAP) < 65 mmHg. Secondary outcomes include free flap viability and perioperative complications. ETHICS AND DISSEMINATION Ethics approval was obtained from the Poznan University of Medical Sciences Ethics Committee (KB-560/22; date 1 July 2022). Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT05738603.
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Affiliation(s)
- Jakub Szrama
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland; (A.G.); (A.W.); (Z.N.); (T.B.); (A.L.); (K.Z.); (T.K.); (K.K.)
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Sicova M, McGinn R, Emerson S, Perez P, Gonzalez R, Li Y, Famure O, Randall I, Mina DS, Santema M, Wijeysundera DN, Van Klei W, Kim SJ, McCluskey SA. Association of Intraoperative Hypotension With Delayed Graft Function Following Kidney Transplant: A Single Centre Retrospective Cohort Study. Clin Transplant 2024; 38:e70000. [PMID: 39460628 DOI: 10.1111/ctr.70000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 07/28/2024] [Accepted: 10/01/2024] [Indexed: 10/28/2024]
Abstract
BACKGROUND Intraoperative hypotension is associated with acute kidney injury after surgery. However, the definition (duration and magnitude) of hypotension during kidney transplantation (KT) surgery on early graft function remains unclear. METHODS We conducted a retrospective cohort study of KT recipients from December 1, 2009, to December 31, 2019. Exposure to intraoperative hypotension was characterized as the duration (minutes) of mean arterial pressure (MAP) <55, <65, <75, and <85 mmHg. Our co-primary outcomes were DGF-creatinine reduction ratio (DGF-CRR, <30% creatinine reduction, postoperative days 1 and 2), and DGF-dialysis (DGF-D, required dialysis within the week of KT for deceased donor recipients). Logistic regression models were fitted to assess this relationship between MAP and DGF. RESULTS We included 1602 KT (939 deceased donors, 663 living donors) and 23 were excluded. DGF-CRR occurred in 33% of patients. DGF-CRR was associated with MAP < 65 (>5 min: OR 1.77, 95% confidence interval [CI]: 1.39-2.30; 6-10 min: OR 1.67, 95% CI: 0.97-2.86; 11-20 min: OR 2.18, 95% CI: 1.31-3.63) in unadjusted and <55 mmHg (5 min: OR 1.85, 95% CI: 1.47-2.32; 5-10 min: OR 2.41, 95% CI: 1.65-3.53; 11-20 min: OR 2.36, 95% CI: 1.60, 3.48) in adjusted models. There was also a signal for increased risk of DGF-CRR at MAP < 75 (>5 min: OR 1.69, 95% CI: 1.02-2.80). DGF-D (incidence 35%) in deceased donor KT was not associated with hypotension. CONCLUSIONS We found an association between intraoperative hypotension and DGF-CRR at a threshold MAP of 55 mmHg, with a consistent signal toward increased risk at both 65 and 75 mmHg, as indicated by unadjusted models.
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Affiliation(s)
- Marc Sicova
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada
| | - Ryan McGinn
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada
| | - Sophia Emerson
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada
| | - Paula Perez
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Roberto Gonzalez
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yanhong Li
- Department of Medicine (Nephrology) and the Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Olusegum Famure
- Department of Medicine (Nephrology) and the Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ian Randall
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Santa Mina
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Michael Santema
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Anesthesia, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
| | - Wilton Van Klei
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S Joseph Kim
- Department of Medicine (Nephrology) and the Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Wanner PM, Filipovic M. Intraoperative hypotension: New answers, but the same old questions. J Clin Anesth 2024; 96:111373. [PMID: 38191276 DOI: 10.1016/j.jclinane.2023.111373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 12/20/2023] [Accepted: 12/28/2023] [Indexed: 01/10/2024]
Affiliation(s)
- Patrick M Wanner
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
| | - Miodrag Filipovic
- Division of Perioperative Intensive Care Medicine, Kantonsspital St.Gallen, St.Gallen, Switzerland
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Martins Lima P, Ferreira L, Dias AL, Rodrigues D, Abelha F, Mourão J. Postoperative Acute Kidney Injury After Intraoperative Hypotension in Major Risk Procedures. Cureus 2024; 16:e64579. [PMID: 39144846 PMCID: PMC11323959 DOI: 10.7759/cureus.64579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 08/16/2024] Open
Abstract
Background Reportedly prevalent, intraoperative hypotension (IOH) is linked to kidney injury and increased risk of mortality. In this study, we aimed to assess IOH incidence in high-risk non-cardiac surgery and its correlation with postoperative acute kidney injury (PO-AKI) and 30-day postoperative mortality. Methodology This retrospective cohort study included adult inpatients who underwent elective, non-cardiac, high-risk European Society of Anaesthesiology/European Society of Cardiology surgery from October to November of 2020, 2021, and 2022, excluding cardiac, intracranial, or emergency surgery. IOH was primarily defined by the 2022 Anesthesia Quality Institute. PO-AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours, the need for dialysis in dialysis-naïve patients, or the documentation of AKI in clinical records. For univariate analysis, the Mann-Whitney U test and chi-square or Fisher's exact tests were performed, as appropriate. Logistic regression was used to test risk factors for IOH in univariate analysis (p < 0.1). The significance level considered in multivariate analysis was 5%. Results Of the 197 patients included, 111 (56.3%) experienced IOH. After adjustment, surgical time >120 minutes remained associated with higher odds of IOH (odds ratio (OR) = 9.62, 95% confidence interval (CI) = 2.49-37.13), as well as combined general + locoregional (vs. general OR = 3.41, 95 CI% = 1.38-8.43, p = 0.008; vs. locoregional OR = 6.37, 95% CI = 1.48-27.47). No association was found between IOH and 30-day postoperative mortality (p = 0.565) or PO-AKI (p = 0.09). The incidence of PO-AKI was 14.9% (27 patients), being significantly associated with higher 30-day postoperative mortality (p = 0.018). Conclusions Our study highlights the high prevalence of IOH in high-risk non-cardiac surgical procedures. Its impact on PO-AKI and 30-day postoperative mortality appears less pronounced compared to the significant implications of PO-AKI, emphasizing the need for PO-AKI screening and renal protection strategies.
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Affiliation(s)
| | - Luana Ferreira
- Department of Anesthesiology, Unidade Local de Saúde São João, Porto, PRT
| | - Ana Lídia Dias
- Center for Research in Health Technologies and Health Systems (CINTESIS), Faculty of Medicine of Porto, Porto, PRT
- Department of Anesthesiology, Unidade Local de Saúde São João, Porto, PRT
| | - Diana Rodrigues
- Department of Anesthesiology, Unidade Local de Saúde São João, Porto, PRT
| | - Fernando Abelha
- Department of Anesthesiology, Unidade Local de Saúde São João, Porto, PRT
| | - Joana Mourão
- Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, PRT
- Department of Anesthesiology, Unidade Local de Saúde São João, Porto, PRT
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Barboi C, Stapelfeldt WH. Mortality following noncardiac surgery assessed by the Saint Louis University Score (SLUScore) for hypotension: a retrospective observational cohort study. Br J Anaesth 2024; 133:33-41. [PMID: 38702236 PMCID: PMC11213987 DOI: 10.1016/j.bja.2024.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/07/2024] [Accepted: 03/13/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND The Saint Louis University Score (SLUScore) was developed to quantify intraoperative blood pressure trajectories and their associated risk for adverse outcomes. This study examines the prevalence and severity of intraoperative hypotension described by the SLUScore and its relationship with 30-day mortality in surgical subtypes. METHODS This retrospective analysis of perioperative data included surgical cases performed between January 1, 2010, and December 31, 2020. The SLUScore is calculated from cumulative time-periods for which the mean arterial pressure is below a range of hypotensive thresholds. After calculating the SLUScore for each surgical procedure, we quantified the prevalence and severity of intraoperative hypotension for each surgical procedure and the association between intraoperative hypotension and 30-day mortality. We used binary logistic regression to quantify the potential contribution of intraoperative hypotension to mortality. RESULTS We analysed 490 982 cases (57.7% female; mean age 57 yr); 33.2% of cases had a SLUScore>0, a median SLUScore of 13 (inter-quartile range [IQR] 7-21), with 1.19% average mortality. The SLUScore was associated with mortality in 12/14 surgical groups. The increases in the odds ratio for death within 30 days of surgery per SLUScore increment were: all surgery types 3.5% (95% confidence interval [95% CI] 3.2-3.9); abdominal/transplant surgery 6% (95% CI 1.5-10.7); thoracic surgery1.5% (95% CI 1-3.3); vascular surgery 3.01% (95% CI 1.9-4.05); spine/neurosurgery 1.1% (95% CI 0.1-2.1); orthopaedic surgery 1.4% (95% CI 0.7-2.2); gynaecological surgery 6.3% (95% CI 2.5-10.1); genitourinary surgery 4.84% (95% CI 3.5-6.15); gastrointestinal surgery 5.2% (95% CI 3.9-6.4); gastroendoscopy 5.5% (95% CI 4.4-6.7); general surgery 6.3% (95% CI 5.5-7.1); ear, nose, and throat surgery 1.6% (95% CI 0-3.27); and cardiac electrophysiology (including pacemaker procedures) 6.6% (95% CI 1.1-12.4). CONCLUSIONS The SLUScore was independently, but variably, associated with 30-day mortality after noncardiac surgery.
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Affiliation(s)
- Cristina Barboi
- Indiana University School of Medicine, Department of Anesthesiology, Indianapolis, IN, USA.
| | - Wolf H Stapelfeldt
- Indiana University School of Medicine, Department of Anesthesiology, Indianapolis, IN, USA; Richard L. Roudebush VA Medical Centre, Department of Anesthesiology, Indianapolis, IN, USA
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Wang XJ, Xuan XC, Sun ZC, Shen S, Yu F, Li NN, Chu XC, Yin H, Hu YL. Risk factors associated with intraoperative persistent hypotension in pancreaticoduodenectomy. World J Gastrointest Surg 2024; 16:1582-1591. [PMID: 38983354 PMCID: PMC11230017 DOI: 10.4240/wjgs.v16.i6.1582] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/27/2024] [Accepted: 05/16/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Intraoperative persistent hypotension (IPH) during pancreaticoduodenectomy (PD) is linked to adverse postoperative outcomes, yet its risk factors remain unclear. AIM To clarify the risk factors associated with IPH during PD, ensuring patient safety in the perioperative period. METHODS A retrospective analysis of patient records from January 2018 to December 2022 at the First Affiliated Hospital of Nanjing Medical University identified factors associated with IPH in PD. These factors included age, gender, body mass index, American Society of Anesthesiologists classification, comorbidities, medication history, operation duration, fluid balance, blood loss, urine output, and blood gas parameters. IPH was defined as sustained mean arterial pressure < 65 mmHg, requiring prolonged deoxyepinephrine infusion for > 30 min despite additional deoxyepinephrine and fluid treatments. RESULTS Among 1596 PD patients, 661 (41.42%) experienced IPH. Multivariate logistic regression identified key risk factors: increased age [odds ratio (OR): 1.20 per decade, 95% confidence interval (CI): 1.08-1.33] (P < 0.001), longer surgery duration (OR: 1.15 per additional hour, 95%CI: 1.05-1.26) (P < 0.01), and greater blood loss (OR: 1.18 per 250-mL increment, 95%CI: 1.06-1.32) (P < 0.01). A novel finding was the association of arterial blood Ca2+ < 1.05 mmol/L with IPH (OR: 2.03, 95%CI: 1.65-2.50) (P < 0.001). CONCLUSION IPH during PD is independently associated with older age, prolonged surgery, increased blood loss, and lower plasma Ca2+.
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Affiliation(s)
- Xing-Jun Wang
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Xi-Chen Xuan
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Zhao-Chu Sun
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Shi Shen
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Fan Yu
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Na-Na Li
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Xue-Chun Chu
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - Hui Yin
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
| | - You-Li Hu
- Department of Anesthesia and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu Province, China
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Lee S, Islam N, Ladha KS, van Klei W, Wijeysundera DN. Intraoperative Hypotension in Patients Having Major Noncardiac Surgery Under General Anesthesia: A Systematic Review of Blood Pressure Optimization Strategies. Anesth Analg 2024:00000539-990000000-00845. [PMID: 38870081 DOI: 10.1213/ane.0000000000007074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Intraoperative hypotension is associated with increased risks of postoperative complications. Consequently, a variety of blood pressure optimization strategies have been tested to prevent or promptly treat intraoperative hypotension. We performed a systematic review to summarize randomized controlled trials that evaluated the efficacy of blood pressure optimization interventions in either mitigating exposure to intraoperative hypotension or reducing risks of postoperative complications. METHODS Medline, Embase, PubMed, and Cochrane Controlled Register of Trials were searched from database inception to August 2, 2023, for randomized controlled trials (without language restriction) that evaluated the impact of any blood pressure optimization intervention on intraoperative hypotension and/or postoperative outcomes. RESULTS The review included 48 studies (N = 46,377), which evaluated 10 classes of blood pressure optimization interventions. Commonly assessed interventions included hemodynamic protocols using arterial waveform analysis, preoperative withholding of antihypertensive medications, continuous blood pressure monitoring, and adjuvant agents (vasopressors, anticholinergics, anticonvulsants). These same interventions reduced intraoperative exposure to hypotension. Conversely, low blood pressure alarms had an inconsistent impact on exposure to hypotension. Aside from limited evidence that higher prespecified intraoperative blood pressure targets led to a reduced risk of complications, there were few data suggesting that these interventions prevented postoperative complications. Heterogeneity in interventions and outcomes precluded meta-analysis. CONCLUSIONS Several different blood pressure optimization interventions show promise in reducing exposure to intraoperative hypotension. Nonetheless, the impact of these interventions on clinical outcomes remains unclear. Future trials should assess promising interventions in samples sufficiently large to identify clinically plausible treatment effects on important outcomes. KEY POINTS
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Affiliation(s)
- Sandra Lee
- From the Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nehal Islam
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Karim S Ladha
- From the Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St. Michael's Hospital - Unity Health Toronto, Toronto, Ontario, Canada
| | - Wilton van Klei
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Toronto, Ontario, Canada
- Division of Anaesthesiology, Intensive Care, and Emergency Medicine, University Medical Center Utrecht, Utrecht, Netherlands
| | - Duminda N Wijeysundera
- From the Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St. Michael's Hospital - Unity Health Toronto, Toronto, Ontario, Canada
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Schuurmans J, van Rossem BTB, Rellum SR, Tol JTM, Kurucz VC, van Mourik N, van der Ven WH, Veelo DP, Schenk J, Vlaar APJ. Hypotension during intensive care stay and mortality and morbidity: a systematic review and meta-analysis. Intensive Care Med 2024; 50:516-525. [PMID: 38252288 PMCID: PMC11018652 DOI: 10.1007/s00134-023-07304-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024]
Abstract
PURPOSE The aim of this study is to provide a summary of the existing literature on the association between hypotension during intensive care unit (ICU) stay and mortality and morbidity, and to assess whether there is an exposure-severity relationship between hypotension exposure and patient outcomes. METHODS CENTRAL, Embase, and PubMed were searched up to October 2022 for articles that reported an association between hypotension during ICU stay and at least one of the 11 predefined outcomes. Two independent reviewers extracted the data and assessed the risk of bias. Results were gathered in a summary table and studies designed to investigate the hypotension-outcome relationship were included in the meta-analyses. RESULTS A total of 122 studies (176,329 patients) were included, with the number of studies varying per outcome between 0 and 82. The majority of articles reported associations in favor of 'no hypotension' for the outcomes mortality and acute kidney injury (AKI), and the strength of the association was related to the severity of hypotension in the majority of studies. Using meta-analysis, a significant association was found between hypotension and mortality (odds ratio: 1.45; 95% confidence interval (CI) 1.12-1.88; based on 13 studies and 34,829 patients), but not for AKI. CONCLUSION Exposure to hypotension during ICU stay was associated with increased mortality and AKI in the majority of included studies, and associations for both outcomes increased with increasing hypotension severity. The meta-analysis reinforced the descriptive findings regarding mortality but did not yield similar support for AKI.
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Affiliation(s)
- Jaap Schuurmans
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Intensive Care, Meibergdreef 9, Amsterdam, The Netherlands
| | - Benthe T B van Rossem
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Santino R Rellum
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Intensive Care, Meibergdreef 9, Amsterdam, The Netherlands
| | - Johan T M Tol
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Vincent C Kurucz
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Niels van Mourik
- Amsterdam UMC location University of Amsterdam, Intensive Care, Meibergdreef 9, Amsterdam, The Netherlands
| | - Ward H van der Ven
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Denise P Veelo
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Jimmy Schenk
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Intensive Care, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Epidemiology and Data Science, Amsterdam Public Health, Meibergdreef 9, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Amsterdam UMC location University of Amsterdam, Intensive Care, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
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Schmidt G, Frieling N, Schneck E, Habicher M, Koch C, Rubarth K, Balzer F, Aßmus B, Sander M. Preoperative routine measurement of NT-proBNP predicts postoperative morbidity after non-cardiac surgery with intermediate or high surgical risk: an observational study. BMC Anesthesiol 2024; 24:113. [PMID: 38521898 PMCID: PMC10960410 DOI: 10.1186/s12871-024-02488-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/11/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Chronic heart failure (HF) is a common clinical condition associated with adverse outcomes in elderly patients undergoing non-cardiac surgery. This study aimed to estimate a clinically applicable NT-proBNP cut-off that predicts postoperative 30-day morbidity in a non-cardiac surgical cohort. METHODS One hundred ninety-nine consecutive patients older than 65 years undergoing elective non-cardiac surgery with intermediate or high surgical risk were analysed. Preoperative NT-proBNP was measured, and clinical events were assessed up to postoperative day 30. The primary endpoint was the composite morbidity endpoint (CME) consisting of rehospitalisation, acute decompensated heart failure (ADHF), acute kidney injury (AKI), and infection at postoperative day 30. Secondary endpoints included perioperative fluid balance and incidence, duration, and severity of perioperative hypotension. RESULTS NT-proBNP of 443 pg/ml had the highest accuracy in predicting the composite endpoint; a clinical cut-off of 450 pg/ml was implemented to compare clinical endpoints. Although 35.2% of patients had NT-proBNP above the threshold, only 10.6% had a known history of HF. The primary endpoint was the composite morbidity endpoint (CME) consisting of rehospitalisation, acute decompensated heart failure (ADHF), acute kidney injury (AKI), and infection. Event rates were significantly increased in patients with NT-proBNP > 450 pg/ml (70.7% vs. 32.4%, p < 0.001), which was due to the incidence of cardiac rehospitalisation (4.4% vs. 0%, p = 0.018), ADHF (20.1% vs. 4.0%, p < 0.001), AKI (39.8% vs. 8.3%, p < 0.001), and infection (46.3% vs. 24.4%, p < 0.01). Perioperative fluid balance and perioperative hypotension were comparable between groups. Preoperative NT-proBNP > 450 pg/ml was an independent predictor of the CME in a multivariable Cox regression model (hazard ratio 2.92 [1.72-4.94]). CONCLUSIONS Patients with NT-proBNP > 450 pg/ml exhibited profoundly increased postoperative morbidity. Further studies should focus on interdisciplinary approaches to improve outcomes through integrated interventions in the perioperative period. TRIAL REGISTRATION German Clinical Trials Register: DRKS00027871, 17/01/2022.
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Affiliation(s)
- Götz Schmidt
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany.
| | - Nora Frieling
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Emmanuel Schneck
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Marit Habicher
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Christian Koch
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - Kerstin Rubarth
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Birgit Aßmus
- Department of Cardiology and Angiology, Justus Liebig University of Giessen, Klinikstrasse 33, 35392, Giessen, Germany
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
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11
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Szrama J, Gradys A, Bartkowiak T, Woźniak A, Nowak Z, Zwoliński K, Lohani A, Jawień N, Smuszkiewicz P, Kusza K. The Incidence of Perioperative Hypotension in Patients Undergoing Major Abdominal Surgery with the Use of Arterial Waveform Analysis and the Hypotension Prediction Index Hemodynamic Monitoring-A Retrospective Analysis. J Pers Med 2024; 14:174. [PMID: 38392607 PMCID: PMC10889918 DOI: 10.3390/jpm14020174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
Intraoperative hypotension (IH) is common in patients receiving general anesthesia and can lead to serious complications such as kidney failure, myocardial injury and increased mortality. The Hypotension Prediction Index (HPI) algorithm is a machine learning system that analyzes the arterial pressure waveform and alerts the clinician of an impending hypotension event. The purpose of the study was to compare the frequency of perioperative hypotension in patients undergoing major abdominal surgery with different types of hemodynamic monitoring. The study included 61 patients who were monitored with the arterial pressure-based cardiac output (APCO) technology (FloTrac group) and 62 patients with the Hypotension Prediction Index algorithm (HPI group). Our primary outcome was the time-weighted average (TWA) of hypotension below < 65 mmHg. The median TWA of hypotension in the FloTrac group was 0.31 mmHg versus 0.09 mmHg in the HPI group (p = 0.000009). In the FloTrac group, the average time of hypotension was 27.9 min vs. 8.1 min in the HPI group (p = 0.000023). By applying the HPI algorithm in addition to an arterial waveform analysis alone, we were able to significantly decrease the frequency and duration of perioperative hypotension events in patients who underwent major abdominal surgery.
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Affiliation(s)
- Jakub Szrama
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Agata Gradys
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Tomasz Bartkowiak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Amadeusz Woźniak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Zuzanna Nowak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Krzysztof Zwoliński
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Ashish Lohani
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Natalia Jawień
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Piotr Smuszkiewicz
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Krzysztof Kusza
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
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12
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Stasiowski MJ, Lyssek-Boroń A, Zmarzły N, Marczak K, Grabarek BO. The Adequacy of Anesthesia Guidance for Vitreoretinal Surgeries with Preemptive Paracetamol/Metamizole. Pharmaceuticals (Basel) 2024; 17:129. [PMID: 38256962 PMCID: PMC10819548 DOI: 10.3390/ph17010129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/09/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
Despite the possibility of postoperative pain occurrence, in some patients, vitreoretinal surgeries (VRSs) require performance of general anesthesia (GA). The administration of intraoperative intravenous rescue opioid analgesics (IROA) during GA constitutes a risk of perioperative adverse events. The Adequacy of Anesthesia (AoA) concept consists of an entropy electroencephalogram to guide the depth of GA and surgical pleth index (SPI) to optimize the titration of IROA. Preemptive analgesia (PA) using cyclooxygenase-3 (COX-3) inhibitors is added to GA to minimize the demand for IROA and reduce postoperative pain. The current analysis evaluated the advantage of PA using COX-3 inhibitors added to GA with AoA-guided administration of IROA on the rate of postoperative pain and hemodynamic stability in patients undergoing VRS. A total of 165 patients undergoing VRS were randomly allocated to receive either GA with AoA-guided IROA administration with intravenous paracetamol/metamizole or with preemptive paracetamol or metamizole. Preemptive paracetamol resulted in a reduction in the IROA requirement; both preemptive metamizole/paracetamol resulted in a reduced rate of postoperative pain as compared to metamizole alone. We recommend using intraoperative AOA-guided IROA administration during VRS to ensure hemodynamic stability alongside PA using both paracetamol/metamizole to reduce postoperative pain.
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Affiliation(s)
- Michał Jan Stasiowski
- Chair and Department of Emergency Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
- Department of Anaesthesiology and Intensive Care, 5th Regional Hospital, Trauma Centre, 41-200 Sosnowiec, Poland;
| | - Anita Lyssek-Boroń
- Department of Ophthalmology with Paediatric Unit, 5th Regional Hospital, Trauma Centre, 41-200 Sosnowiec, Poland;
- Department of Ophthalmology, Faculty of Medicine, Academy of Silesia, 40-055 Katowice, Poland
| | - Nikola Zmarzły
- Collegium Medicum, WSB University, 41-300 Dabrowa Gornicza, Poland; (N.Z.); (B.O.G.)
| | - Kaja Marczak
- Department of Anaesthesiology and Intensive Care, 5th Regional Hospital, Trauma Centre, 41-200 Sosnowiec, Poland;
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Fujii T, Takakura M, Taniguchi T, Tamura T, Nishiwaki K. Intraoperative hypotension affects postoperative acute kidney injury depending on the invasiveness of abdominal surgery: A retrospective cohort study. Medicine (Baltimore) 2023; 102:e36465. [PMID: 38050260 PMCID: PMC10695494 DOI: 10.1097/md.0000000000036465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/13/2023] [Indexed: 12/06/2023] Open
Abstract
Intraoperative hypotension (IOH) or highly invasive surgery adversely affects postoperative clinical outcomes. It is, however, unclear whether IOH affects postoperative acute kidney injury (AKI) depending on the invasiveness of abdominal surgery. We speculated that IOH in highly invasive abdominal surgery is a significant risk factor for postoperative AKI. We retrospectively reviewed the data of 448 patients who underwent abdominal surgery. Patients were divided into 3 groups: highly (such as pancreaticoduodenectomy and hepatectomy), moderately (open abdominal surgery), and minimally (laparoscopic surgery) invasive surgeries. The association between the time-weighted average (TWA) of mean arterial pressure (MAP) values (≤60 and ≤ 55 mm Hg) and AKI occurrences in each group was assessed. Postoperative AKI occurred after highly, moderately, and minimally invasive surgeries in 33 of 222 (14.9%), 14 of 110 (12.7%), and 12 of 116 (10.3%) cases, respectively (P = .526). The median [interquartile range] of TWA-MAP ≤ 60 mm Hg, as an IOH parameter, was 0.94 [0.33-2.08] mm Hg in highly, 0.54 [0.16-1.46] mm Hg in moderately, and 0.14 [0.03-0.57] mm Hg in minimally invasive surgeries (P < 0001). In addition, there was a significant association between TWA-MAP and AKI in highly invasive surgery, unlike in moderately and minimally invasive surgery, with adjusted odds ratios (95% confidence interval) for TWA-MAP ≤ 60 and ≤ 55 mm Hg associated with AKI of 1.23 [1.00-1.52] (P = .049) and 1.55 [1.02-2.36] (P = .041), respectively. Intraoperative MAP ≤ 60 mm Hg in highly invasive abdominal surgery is associated with postoperative AKI, compared to moderately and minimally invasive surgeries. Additionally, low MAP thresholds in highly invasive surgery increase postoperative AKI risk.
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Affiliation(s)
- Tasuku Fujii
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Masashi Takakura
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Tomoya Taniguchi
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Takahiro Tamura
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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14
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Saasouh W, Christensen AL, Chappell D, Lumbley J, Woods B, Xing F, Mythen M, Dutton RP. Intraoperative hypotension in ambulatory surgery centers. J Clin Anesth 2023; 90:111181. [PMID: 37454554 DOI: 10.1016/j.jclinane.2023.111181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 05/19/2023] [Accepted: 06/04/2023] [Indexed: 07/18/2023]
Abstract
STUDY OBJECTIVES To measure the incidence of intraoperative hypotension (IOH) during surgery in ambulatory surgery centers (ASCs) and describe associated characteristics of patients and procedures. DESIGN Retrospective analysis. SETTING 20 ASCs. PATIENTS 16,750 patients having non-emergent, non-cardiac surgery; ASA physical status 2 through 4. INTERVENTIONS None. MEASUREMENTS We assessed incidence of IOH using the definition from the Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS)-mean arterial pressure (MAP) < 65 mmHg for at least 15 cumulative minutes-and three secondary definitions: minutes of MAP <65 mmHg, area under MAP of 65 mmHg, and time-weighted average MAP <65 mmHg. MAIN RESULTS 30.9% of ASC cases had a MAP <65 mmHg for at least 15 min. The incidence of IOH varied significantly, and was higher among younger adults (age 18-39; 36.2%), females (35.2%), and patients with ASA physical status 2 (32.8%). IOH increased with increasing surgery length, even when time-weighted, and was higher among low complexity (30.6%) than moderate complexity (28.8%) procedures, and highest among high complexity procedures (44.1%). CONCLUSIONS There was substantial occurrence of IOH in ASCs, similar to that described in academic hospital settings in previous literature. We hypothesize that this may reflect clinician preference not to intervene in perceived healthy patients or assumptions about ability to tolerate lower blood pressures on behalf of these patients. Future research will determine whether IOH in ACSs is associated with adverse outcomes to the same extent as described in more complex hospital-based surgeries.
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Affiliation(s)
- Wael Saasouh
- Detroit Medical Center, Department of Anesthesiology, 3990 John R, Office 2941, Detroit, MI 48201, USA; NorthStar Anesthesia, 6225 State Hwy 161 #200, Irving, TX 75038, USA; Outcomes Research Consortium, The Cleveland Clinic, 9500 Euclid Ave -- P77, Cleveland, OH 44195, USA.
| | | | - Desirée Chappell
- NorthStar Anesthesia, 6225 State Hwy 161 #200, Irving, TX 75038, USA; Middle Tennessee School of Anesthesia, 315 Hospital Drive, Madison, TN 37115, USA.
| | - Josh Lumbley
- NorthStar Anesthesia, 6225 State Hwy 161 #200, Irving, TX 75038, USA.
| | - Brian Woods
- NorthStar Anesthesia, 6225 State Hwy 161 #200, Irving, TX 75038, USA.
| | - Fei Xing
- Mathematica, 1100 1st St NE, Washington, DC 20002, USA.
| | - Monty Mythen
- University College London, Gower Street, London WC1E 6BT, UK.
| | - Richard P Dutton
- US Anesthesia Partners, 12222 Merit Drive, Dallas, TX 75351, USA; Texas A&M College of Medicine, 8447 Riverside Pkwy, Bryan, TX 77807, USA.
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15
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Katsuragawa T, Mimuro S, Sato T, Aoki Y, Doi M, Katoh T, Nakajima Y. Effect of remimazolam versus sevoflurane on intraoperative hemodynamics in noncardiac surgery: a retrospective observational study using propensity score matching. JA Clin Rep 2023; 9:70. [PMID: 37880547 PMCID: PMC10600086 DOI: 10.1186/s40981-023-00661-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/13/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND This study compared the effects of remimazolam and sevoflurane on intraoperative hemodynamics including intraoperative hypotension (IOH). RESULTS This study involved adult patients undergoing noncardiac surgery using remimazolam (Group R) or sevoflurane (Group S) for maintenance anesthesia, and invasive arterial pressure measurements, from September 2020 to March 2023 at our hospital. IOH was defined as a mean blood pressure < 65 mmHg occurring for a cumulative duration of at least 10 min. A 1:1 propensity score-matching method was used. The primary endpoint was the occurrence of IOH, and the secondary endpoints were the cumulative hypotensive time, incidence of vasopressor use, and dose of vasopressor used (ephedrine, phenylephrine, dopamine, and noradrenaline). Group R comprised 169 patients, Group S comprised 393 patients, and a matched cohort of 141 patients was created by propensity score matching. There was no significant difference in the incidence of IOH between the two groups (85.1% in Group R vs. 91.5% in Group S, p = 0.138). Patients in Group R had a significantly lower cumulative hypotension duration (55 [18-119] vs. 83 [39-144] min, p = 0.005), vasopressor use (81.6% vs. 91.5%, p = 0.023), and dose of ephedrine (4 [0-8] vs. 12 [4-20] mg, p < 0.001) than those in Group S. There were no significant differences in the doses of other vasopressors between groups. CONCLUSIONS Compared with sevoflurane, the maintenance of anesthesia with remimazolam was not associated with a decreased incidence of IOH; however, it reduced the cumulative hypotension time, incidence of vasopressor use, and dose of ephedrine.
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Affiliation(s)
- Takayuki Katsuragawa
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Soichiro Mimuro
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan.
| | - Tsunehisa Sato
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Takasumi Katoh
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yoshiki Nakajima
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, Shizuoka, 431-3192, Japan
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16
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Zhang NR, Zheng ZN, Wang K, Li H. Incidence, characteristics and risk factors for alveolar recruitment maneuver-related hypotension in patients undergoing laparoscopic colorectal cancer resection. World J Gastrointest Surg 2023; 15:1454-1464. [PMID: 37555120 PMCID: PMC10405128 DOI: 10.4240/wjgs.v15.i7.1454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/09/2023] [Accepted: 05/31/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Alveolar recruitment maneuvers (ARMs) may lead to transient hypotension, but the clinical characteristics of this induced hypotension are poorly understood. We investigated the characteristics of ARM-related hypotension in patients who underwent laparoscopic colorectal cancer resection. AIM To investigate the characteristics of ARM-related hypotension in patients who underwent laparoscopic colorectal cancer resection. METHODS This was a secondary analysis of the PROtective Ventilation using Open Lung approach Or Not trial and included 140 subjects. An ARM was repeated every 30 min during intraoperative mechanical ventilation. The primary endpoint was ARM-related hypotension, defined as a mean arterial pressure (MAP) < 60 mmHg during an ARM or within 5 min after an ARM. The risk factors for hypotension were identified. The peri-ARM changes in blood pressure were analyzed for the first three ARMs (ARM1,2,3) and the last ARM (ARMlast). RESULTS Thirty-four subjects (24.3%) developed ARM-related hypotension. Of all 1027 ARMs, 37 (3.61%) induced hypotension. More ARMs under nonpneumoperitoneum (33/349, 9.46%) than under pneumoperitoneum conditions (4/678, 0.59%) induced hypotension (P < 0.01). The incidence of hypotension was higher at ARM1 points than at non-ARM1 points (18/135, 13.3% vs 19/892, 2.1%; P < 0.01). The median percentage decrease in the MAP at ARM1 was 14%. Age ≥ 74 years, blood loss ≥ 150 mL and peak inspiratory pressure under pneumoperitoneum < 24 cm H2O were risk factors for ARM-related hypotension. CONCLUSION When the ARM was repeated intraoperatively, a quarter of subjects developed ARM-related hypotension, but only 3.61% of ARMs induced hypotension. ARM-related hypotension most occurred in a hemodynamically unstable state or a hypovolemic state, and in elderly subjects. Fortunately, ARMs that were performed under pneumoperitoneum conditions had less impact on blood pressure.
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Affiliation(s)
- Nan-Rong Zhang
- Department of Anesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Zhi-Nan Zheng
- Department of Anesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Kai Wang
- Department of Anesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
| | - Hong Li
- Department of Anesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
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17
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Saasouh W, Christensen AL, Xing F, Chappell D, Lumbley J, Woods B, Mythen M, Dutton RP. Incidence of intraoperative hypotension during non-cardiac surgery in community anesthesia practice: a retrospective observational analysis. Perioper Med (Lond) 2023; 12:29. [PMID: 37355641 DOI: 10.1186/s13741-023-00318-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/15/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Intraoperative hypotension (IOH) is well-described in the academic setting but not in community practice. IOH is associated with risk of postoperative morbidity and mortality. This is the first report of IOH in the community setting using the IOH measure definition from the Centers for Medicare and Medicaid Services Merit-based Incentive Payment System program. OBJECTIVES To describe the incidence of IOH in the community setting; assess variation in IOH by patient-, procedure-, and facility-level characteristics; and describe variation in risk-adjusted IOH across clinicians. METHODS Design Cross-sectional descriptive analysis of retrospective data from anesthesia records in 2020 and 2021. Setting Forty-five facilities affiliated with two large anesthesia providers in the USA. Participants Patients aged 18 years or older having non-emergent, non-cardiac surgery under general, neuraxial, or regional anesthesia. Cases were excluded based on criteria for the IOH measure: baseline mean arterial pressure (MAP) below 65 mmHg prior to anesthesia induction; American Society of Anesthesiologists (ASA) physical status classification of I, V, or VI; monitored anesthesia care only; deliberate induced hypotension; obstetric non-operative procedures; liver or lung transplant; cataract surgery; non-invasive gastrointestinal cases. Main outcomes IOH, using four definitions. Primary definition: binary assessment of whether the case had MAP < 65 mmHg for 15 min or more. Secondary definitions: total number of minutes of MAP < 65 mmHg, total area under MAP of 65 mmHg, time-weighted average MAP < 65 mmHg. RESULTS Among 127,095 non-emergent, non-cardiac cases in community anesthesia settings, 29% had MAP < 65 mmHg for at least 15 min cumulatively, with an overall mean of 12.4 min < 65 mmHg. IOH was slightly more common in patients who were younger, female, and ASA II (versus III or IV); in procedures that were longer and had higher anesthesia base units; and in ambulatory surgery centers. Incidence of IOH varied widely across individual clinicians in both unadjusted and risk-adjusted analyses. CONCLUSION Intraoperative hypotension is common in community anesthesia practice, including among patients and settings typically considered "low risk." Variation in incidence across clinicians remains after risk-adjustment, suggesting that IOH is a modifiable risk worth pursuing in quality improvement initiatives.
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Affiliation(s)
- Wael Saasouh
- Department of Anesthesiology, Detroit Medical Center, Detroit, MI, USA.
- NorthStar Anesthesia, Irving, TX, USA.
- Outcomes Research Consortium, The Cleveland Clinic, Cleveland, OH, USA.
| | | | - Fei Xing
- Mathematica, Washington, DC, USA
| | | | | | | | | | - Richard P Dutton
- US Anesthesia Partners, Dallas, TX, USA
- Texas A&M College of Medicine, Bryant, TX, USA
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Cai J, Tang M, Wu H, Yuan J, Liang H, Wu X, Xing S, Yang X, Duan XD. Association of intraoperative hypotension and severe postoperative complications during non-cardiac surgery in adult patients: A systematic review and meta-analysis. Heliyon 2023; 9:e15997. [PMID: 37223701 PMCID: PMC10200862 DOI: 10.1016/j.heliyon.2023.e15997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/25/2023] Open
Abstract
Background Intraoperative hypotension (IOH) is a common side effect of non-cardiac surgery that might induce poor postoperative outcomes. The relationship between the IOH and severe postoperative complications is still unclear. Thus, we summarized the existing literature to evaluate whether IOH contributes to developing severe postoperative complications during non-cardiac surgery. Methods We conducted a comprehensive search of PubMed, Embase, Cochrane Library, Web of Science, and the CBM from inception to 15 September 2022. The primary outcomes were 30-day mortality, acute kidney injury (AKI), major adverse cardiac events (myocardial injury or myocardial infarction), postoperative cognitive dysfunction (POCD), and postoperative delirium (POD). Secondary outcomes included surgical-site infection (SSI), stroke, and 1-year mortality. Results 72 studies (3 randomized; 69 non-randomized) were included in this study. Low-quality evidence showed IOH resulted in an increased risk of 30-day mortality (OR, 1.85; 95% CI, 1.30-2.64; P < .001), AKI (OR, 2.69; 95% CI, 2.15-3.37; P < .001), and stroke (OR, 1.33; 95% CI, 1.21-1.46; P < .001) after non-cardiac surgery than non-IOH. Very low-quality evidence showed IOH was associated with a higher risk of myocardial injury (OR, 2.00; 95% CI, 1.17-3.43; P = .01), myocardial infarction (OR, 2.11; 95% CI, 1.41-3.16; P < .001), and POD (OR, 2.27; 95% CI, 1.53-3.38; P < .001). Very low-quality evidence showed IOH have a similar incidence of POCD (OR, 2.82; 95% CI, 0.83-9.50; P = .10) and 1-year-mortality (OR, 1.66; 95% CI, 0.65-4.20; P = .29) compared with non-IOH in non-cardiac surgery. Conclusion Our results suggest IOH was associated with an increased risk of severe postoperative complications after non-cardiac surgery than non-IOH. IOH is a potentially avoidable hazard that should be closely monitored during non-cardiac surgery.
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Affiliation(s)
- Jianghui Cai
- Department of Pharmacy, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Mi Tang
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
- Office of Good Clinical Practice, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Huaye Wu
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Jing Yuan
- Department of Information, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, 611731, China
| | - Hua Liang
- Department of Pharmacy, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xuan Wu
- Department of Epidemiology and Biostatistics and West China-PUMC C. C. Chen Institute of Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Shasha Xing
- Office of Good Clinical Practice, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xiao Yang
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xiao-Dong Duan
- Department of Rehabilitation Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China
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Szrama J, Gradys A, Bartkowiak T, Woźniak A, Kusza K, Molnar Z. Intraoperative Hypotension Prediction—A Proactive Perioperative Hemodynamic Management—A Literature Review. Medicina (B Aires) 2023; 59:medicina59030491. [PMID: 36984493 PMCID: PMC10057151 DOI: 10.3390/medicina59030491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/19/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Intraoperative hypotension (IH) is a frequent phenomenon affecting a substantial number of patients undergoing general anesthesia. The occurrence of IH is related to significant perioperative complications, including kidney failure, myocardial injury, and even increased mortality. Despite advanced hemodynamic monitoring and protocols utilizing goal directed therapy, our management is still reactive; we intervene when the episode of hypotension has already occurred. This literature review evaluated the Hypotension Prediction Index (HPI), which is designed to predict and reduce the incidence of IH. The HPI algorithm is based on a machine learning algorithm that analyzes the arterial pressure waveform as an input and the occurrence of hypotension with MAP <65 mmHg for at least 1 min as an output. There are several studies, both retrospective and prospective, showing a significant reduction in IH episodes with the use of the HPI algorithm. However, the level of evidence on the use of HPI remains very low, and further studies are needed to show the benefits of this algorithm on perioperative outcomes.
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Affiliation(s)
- Jakub Szrama
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
- Correspondence: ; Tel.: +48-618-691-856
| | - Agata Gradys
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Tomasz Bartkowiak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Amadeusz Woźniak
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Krzysztof Kusza
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
| | - Zsolt Molnar
- Department of Anesthesiology, Intensive Therapy and Pain Management, Poznan University of Medical Sciences, 60-355 Poznan, Poland
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
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Bladder paraganglioma: basic characteristics and new perspectives on perioperative management. World J Urol 2022; 40:2807-2816. [PMID: 36205740 DOI: 10.1007/s00345-022-04166-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/24/2022] [Indexed: 10/10/2022] Open
Abstract
PURPOSE Paraganglioma and pheochromocytoma are rare neuroendocrine tumors with severe metabolic and cardiovascular complications. Bladder PGLs are rare, and their clinical management is not precise. Here, we discuss the basic characteristics and perioperative management of bladder PGLs. METHODS We retrospectively reviewed 20 bladder PGL cases diagnosed at Sun Yat-sen University Cancer Center. Case notes were reviewed, clinical presentations, therapies, and outcomes were collected, and data analysis was performed. RESULTS Ten male and ten female patients with a median age of 47.5 years (range 14-69 years) were included. Most patients (65%) had no symptoms, and PGL was detected incidentally during medical checkups. All patients were treated surgically; 4 (20%) underwent transurethral resection of bladder tumor (TURBT), and 16 (80%) underwent partial cystectomy. Strong intraoperative blood pressure fluctuations were observed in 13 patients (65%). Two patients who were treated preoperatively with α-receptor blockers also experienced severe intraoperative blood pressure fluctuations. Postoperative measurements of troponin I were available for 3 patients, and all were significantly elevated. All patients were diagnosed with bladder PGL on postoperative pathological examination. The median follow-up time was 51 months (range 2-147 months), and 2 patients were lost to follow-up at 1 and 3 months; 16 (88.9%) survived without recurrence, 2 patients (11.1%) experienced recurrence, and 1 patient died. CONCLUSION Most bladder paragangliomas are easily mistaken for bladder urothelial carcinoma, and robust hemodynamic instability during surgery might be a challenge for urologists. Postoperative monitoring of troponin I, regardless of the presence of clinical symptoms, is recommended for patients with bladder PGL.
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21
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Effectiveness of Prophylactic Bolus Ephedrine Versus Norepinephrine for Management of Postspinal Hypotension during Elective Caesarean Section in Resource Limited Setting: A Prospective Cohort Study. Anesthesiol Res Pract 2022; 2022:7170301. [PMID: 36225250 PMCID: PMC9550498 DOI: 10.1155/2022/7170301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background. Spinal anaesthesia for caesarean section is the preferred technique since it provides better maternal safety and neonatal outcome compared to general anaesthesia. Hypotension is the most common complication after spinal anaesthesia. The study aims to determine the effectiveness of a prophylactic bolus dose of norepinephrine and ephedrine on the management of postspinal hypotension during caesarean section. Method. An institutional-based prospective cohort study was conducted on 84 pregnant women undergoing elective caesarean section. Based on the responsible anaesthetist’s postspinal hypotension management plan, patients were divided into two groups. Those patients who received ephedrine are grouped into the ephedrine (EPH, n = 42) group, and patients who received norepinephrine are grouped under the norepinephrine group (NE, n = 42) by data collectors. After aseptic technique, spinal anaesthesia was administered with 0.5% (3 ml) bupivacaine using a 23G spinal needle. During spinal anaesthesia, a prophylactic bolus dose of 10 mg (2 ml) EPH or 16 g (2 ml) NE was given based on management plan of the shift anaesthetist. Mean arterial pressure (MAP), the heart rate (HR), number of boluses of vasopressor used, incidence of nausea and vomiting, and the Apgar score of babies at 1 and 5 min between the groups were recorded. Results. The norepinephrine group had a statistically significant higher MAP compared to the ephedrine group in the first 10 and 15 min (
) of the study period. Thereafter, there was no statistically significant difference in MAP between the groups until the end of the study period (
). The ephedrine group had a statistically significant higher heart rate throughout the procedure compared to the norepinephrine group (
). The norepinephrine group required a lower bolus number of vasopressors compared to the ephedrine group to maintain blood pressure. The Apgar scores of all babies at 1 and 5 min were above seven. Significant differences regarding maternal complications (nausea and vomiting) between the groups were not detected (nausea,
and vomiting,
). Conclusion. Norepinephrine can be used instead of ephedrine to keep a pregnant mother’s blood pressure stable during a caesarean section under spinal anaesthesia without causing harm to the mother or baby. Trial registration. ClinicalTrials.gov Identifier: NCT05522088 (Date of registration: 30/08/22).
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Huff S, Henningsen J, Schneider A, Hijji F, Froehle A, Krishnamurthy A. Differences between intertrochanteric and femoral neck fractures in resuscitative status and mortality rates. Orthop Traumatol Surg Res 2022; 108:103231. [PMID: 35124249 DOI: 10.1016/j.otsr.2022.103231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/17/2021] [Accepted: 09/02/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Hip fracture mortality remains a challenge for orthopedic surgeons. The purpose of this study was to compare resuscitative mean arterial pressures (MAPs), intravenous fluid (IVF) administration, and mortality rates between intertrochanteric (IT) and femoral neck (FN) fracture patients. HYPOTHESIS We hypothesized that IT fracture patients would receive less aggressive fluid resuscitation than FNF patients given the perceived less invasive nature of intra-medullary nails compared with hemiarthroplasty. MATERIALS AND METHODS An institutional database was queried to identify all hip fractures managed surgically over a 2-year period. Preoperative and intraoperative MAPs and IVF administration, as measures of resuscitation, were compared between IT fracture patients treated with open reduction internal fixation and FN fracture patients treated with hemiarthroplasty. RESULTS Six hundred and ninety-eight hip fractures, including 531 IT and 167 FN fractures, were analyzed. There were no differences between IT and FN fracture cohorts for age, sex distribution, or Charlson Comorbidity Index scores. IT fracture patients were found to have lower MAP upon admission (103.7±20.1 vs. 107.8±18.4mmHg; p=0.026), and lower average, minimum, and maximum MAP values preoperatively and intraoperatively. Despite lower MAPs, IT fracture patients received less total IVF (581.9±472.5 vs. 832.9±496.5cc; p<0.001) and lower IVF rates intraoperatively (306.5±256.8 vs. 409.8±251.0 cc/h; p<0.001). IT fracture patients experienced higher 30-day (7.9% vs. 3.6%; p=0.040) and 90-day (10.6% vs. 5.4%; p=0.035) mortality rates and trended towards higher inpatient mortality (3.0% vs. 0.6%; p=0.088). Multivariate regression demonstrated IT pattern to be independently predictive of 30-day mortality with 2.459 increased odds relative to FN fracture (p=0.039). DISCUSSION IT fracture patterns are associated with decreased perioperative MAP values, yet received lower perioperative IVF rates. IT fracture patients suffered higher 30- and 90-day mortality rates, despite similar age and comorbidities. LEVEL OF EVIDENCE III; retrospective cohort study.
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Affiliation(s)
- Scott Huff
- Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435, USA.
| | - Joseph Henningsen
- Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435, USA
| | - Andrew Schneider
- Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435, USA
| | - Fady Hijji
- Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435, USA
| | - Andrew Froehle
- Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH 45435, USA
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Yang X, Qin Z, Li Y, Deng Y, Li M. Hypotension following hip fracture surgery in patients aged 80 years or older: A prospective cohort study. Heliyon 2022; 8:e10202. [PMID: 36033291 PMCID: PMC9404332 DOI: 10.1016/j.heliyon.2022.e10202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 04/30/2022] [Accepted: 08/04/2022] [Indexed: 11/02/2022] Open
Abstract
Background Hip fractures occurring in older patients often result in significant anemia, even hemodynamic disorders and hypoperfusion. The present study aims to investigate the general characteristics of hypotension following hip fracture surgery (HFHFS) and its effect on clinical outcomes. Methods A total of 168 patients aged ≥80 years who underwent hip fracture surgery at a tertiary orthopaedic hospital from January 1, 2020 to August 31, 2020 were enrolled and followed up for one year. Patients were divided into HFHFS and non-HFHFS cohorts according to blood pressure within 24 h after surgery. General difference comparison, univariate and multivariate regression, and survival analysis were applied to investigate the association between HSHSF and in-hospital and one-year clinical outcomes. Results The incidence of HFHFS was 23.8% (40/168), with a median time to onset of 8.0 (5.0-12.0) hours after surgery. The HFHFS group had more chronic heart disease before injury and experienced more positive fluid balance on the day of surgery (P values were 0.032 and 0.028, respectively). After adjustment for potential confounders, HFHFS was associated with prolonged length of hospital stay (B 2.66, 95% CI 0.22, 5.10; P = 0.033), postoperative cardiac dysfunction (OR 2.92, 95% CI 1.05, 8.11; P = 0.039), and postoperative brain dysfunction (OR 3.51, 95% CI 1.50, 8.23; P = 0.004). HFHFS had no effect on one-year modified Rankin Scale (mRS) (B 0.28, 95% CI -0.28, 0.84; P = 0.322) and one-year mortality (HR 1.07, 95% CI 0.29, 3.96; P = 0.917). Conclusion Many older patients develop hypotension several hours after hip fracture surgery, which may be related with preexisting decline in cardiac reserve in addition to postoperative hidden blood loss. Patients who experienced HFHFS were more likely to have postoperative cardiac and brain dysfunction and longer hospital stay. However, HFHFS had no significant effect on mRS and mortality at one year.
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Affiliation(s)
- Xi Yang
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, Sichuan Province, China
| | - Zhijun Qin
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, Sichuan Province, China
| | - Yi Li
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, Sichuan Province, China
| | - Yang Deng
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, Sichuan Province, China
| | - Man Li
- Department of Anesthesia, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, Sichuan Province, China
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Song Q, Li J, Jiang Z. Provisional Decision-Making for Perioperative Blood Pressure Management: A Narrative Review. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:5916040. [PMID: 35860431 PMCID: PMC9293529 DOI: 10.1155/2022/5916040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
Blood pressure (BP) is a basic determinant for organ blood flow supply. Insufficient blood supply will cause tissue hypoxia, provoke cellular oxidative stress, and to some extent lead to organ injury. Perioperative BP is labile and dynamic, and intraoperative hypotension is common. It is unclear whether there is a causal relationship between intraoperative hypotension and organ injury. However, hypotension surely compromises perfusion and causes harm to some extent. Because the harm threshold remains unknown, various guidelines for intraoperative BP management have been proposed. With the pending definitions from robust randomized trials, it is reasonable to consider observational analyses suggesting that mean arterial pressures below 65 mmHg sustained for more than 15 minutes are associated with myocardial and renal injury. Advances in machine learning and artificial intelligence may facilitate the management of hemodynamics globally, including fluid administration, rather than BP alone. The previous mounting studies concentrated on associations between BP targets and adverse complications, whereas few studies were concerned about how to treat and multiple factors for decision-making. Hence, in this narrative review, we discussed the way of BP measurement and current knowledge about baseline BP extracting for surgical patients, highlighted the decision-making process for BP management with a view to providing pragmatic guidance for BP treatment in the clinical settings, and evaluated the merits of an automated blood control system in predicting hypotension.
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Affiliation(s)
- Qiliang Song
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Jipeng Li
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Zongming Jiang
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
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25
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Intraoperative Hypotension and Acute Kidney Injury, Stroke, and Mortality during and outside Cardiopulmonary Bypass: A Retrospective Observational Cohort Study. Anesthesiology 2022; 136:927-939. [PMID: 35188970 DOI: 10.1097/aln.0000000000004175] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In cardiac surgery, the association between hypotension during specific intraoperative phases or vasopressor-inotropes with adverse outcomes remains unclear. This study's hypothesis was that intraoperative hypotension duration throughout the surgery or when separated into hypotension during and outside cardiopulmonary bypass may be associated with postoperative major adverse events. METHODS This retrospective observational cohort study included data for adults who had cardiac surgery between 2008 and 2016 in a tertiary hospital. Intraoperative hypotension was defined as mean arterial pressure of less than 65 mmHg. The total duration of hypotension was divided into three categories based on the fraction of overall hypotension duration that occurred during cardiopulmonary bypass (more than 80%, 80 to 60%, and less than 60%). The primary outcome was a composite of stroke, acute kidney injury, or mortality during the index hospitalization. The association with the composite outcome was evaluated for duration of hypotension during the entire surgery, outside cardiopulmonary bypass, and during cardiopulmonary bypass and the fraction of hypotension during cardiopulmonary bypass adjusting for vasopressor-inotrope dose, milrinone dose, patient, and surgical factors. RESULTS The composite outcome occurred in 256 (5.1%) of 4,984 included patient records; 66 (1.3%) patients suffered stroke, 125 (2.5%) had acute kidney injury, and 109 (2.2%) died. The primary outcome was associated with total duration of hypotension (adjusted odds ratio, 1.05; 95% CI, 1.02 to 1.08; P = 0.032), hypotension outside cardiopulmonary bypass (adjusted odds ratio, 1.06; 95% CI, 1.03 to 1.10; P = 0.001) per 10-min exposure to mean arterial pressure of less than 65 mmHg, and fraction of hypotension duration during cardiopulmonary bypass of less than 60% (reference greater than 80%; adjusted odds ratio, 1.67; 95% CI, 1.10 to 2.60; P = 0.019) but not with each 10-min period hypotension during cardiopulmonary bypass (adjusted odds ratio, 1.04; 95% CI, 0.99 to 1.09; P = 0.118), fraction of hypotension during cardiopulmonary bypass of 60 to 80% (adjusted odds ratio, 1.45; 95% CI, 0.97 to 2.23; P = 0.082), or total vasopressor-inotrope dose (adjusted odds ratio, 1.00; 95% CI, 1.00 to 1.00; P = 0.247). CONCLUSIONS This study confirms previous single-center findings that intraoperative hypotension throughout cardiac surgery is associated with an increased risk of acute kidney injury, mortality, or stroke. EDITOR’S PERSPECTIVE
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Ariyarathna D, Bhonsle A, Nim J, Huang CKL, Wong GH, Sim N, Hong J, Nan K, Lim AKH. Intraoperative vasopressor use and early postoperative acute kidney injury in elderly patients undergoing elective noncardiac surgery. Ren Fail 2022; 44:648-659. [PMID: 35403562 PMCID: PMC9009951 DOI: 10.1080/0886022x.2022.2061997] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
| | - Ajinkya Bhonsle
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Joseph Nim
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Colin K. L. Huang
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Gabriella H. Wong
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Nicholle Sim
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Joy Hong
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Kirrolos Nan
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
| | - Andy K. H. Lim
- Department of General Medicine, Monash Health, Clayton, Victoria, Australia
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
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Lankadeva YR, May CN, Bellomo R, Evans RG. Role of perioperative hypotension in postoperative acute kidney injury: a narrative review. Br J Anaesth 2022; 128:931-948. [DOI: 10.1016/j.bja.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/17/2022] [Accepted: 03/01/2022] [Indexed: 12/20/2022] Open
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Mohammed S, Syal R, Bhatia P, Chhabra S, Chouhan RS, Kamal M. Prediction of post-induction hypotension in young adults using ultrasound-derived inferior vena cava parameters: An observational study. Indian J Anaesth 2021; 65:731-737. [PMID: 34898699 PMCID: PMC8607854 DOI: 10.4103/ija.ija_1514_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/26/2021] [Accepted: 08/28/2021] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Inferior vena cava (IVC) diameter and its respiratory variability have been shown to predict post-induction hypotension with high specificity in a mixed population of patients. We assessed whether these parameters could be as reliable in healthy adult patients as in a mixed patient population. Methods In the present prospective observational study, 110 patients of either sex, aged between 18 and 50 years, belonging to American Society of Anesthesiologists class I and II, fasted as per the institutional protocol and scheduled for elective surgery under general anaesthesia were enroled. Prior to induction, ultrasound examination of IVC was done and variation in IVC diameter with respiration was assessed. Maximum and minimum IVC diameters [(dIVCmax) and (dIVCmin), respectively] over a single respiratory cycle were measured and collapsibility index (CI) was calculated. Vitals were recorded just before induction and at every minute after induction for 10 min. Episodes of hypotension (mean arterial pressure [MAP] <65 mmHg or fall in MAP >30% from baseline) during the observation period were recorded. The receiver operating characteristic (ROC) curve was constructed for determining optimum cut-off with sensitivity and specificity of IVC diameters and CI for development of hypotension. Results IVC was not visualised in 22 patients. Out of the remaining 88 patients, 17 (19.3%) patients developed hypotension after induction. The dIVCmax, dIVCmin and CI were comparable between patients who developed and who did not develop hypotension. The area under curve of ROC for CI, dIVCmax and dIVCmin was 0.51, 0.55 and 0.52, respectively, with optimum cut-off value of 0.46, 1.42 and 0.73, respectively. Conclusion Ultrasound-derived IVC parameters demonstrate poor diagnostic accuracy for prediction of hypotension after induction in healthy adult patients.
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Affiliation(s)
- Sadik Mohammed
- Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
| | - Rashmi Syal
- Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
| | - Pradeep Bhatia
- Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
| | - Swati Chhabra
- Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
| | - Ravindra S Chouhan
- Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
| | - Manoj Kamal
- Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
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Targeting Higher Intraoperative Blood Pressures Does Not Reduce Adverse Cardiovascular Events Following Noncardiac Surgery. J Am Coll Cardiol 2021; 78:1753-1764. [PMID: 34711333 DOI: 10.1016/j.jacc.2021.08.048] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/02/2021] [Accepted: 08/17/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Intraoperative arterial hypotension is strongly associated with postoperative major adverse cardiovascular events (MACE); however, whether targeting higher intraoperative mean arterial blood pressures (MAPs) may prevent adverse events remains unclear. OBJECTIVES This study sought to determine whether targeting higher intraoperative MAP lowers the incidence of postoperative MACE. METHODS This single-center randomized controlled trial assigned adult patients at cardiovascular risk undergoing major noncardiac surgery to an intraoperative MAP target of ≥60 mm Hg (control) or ≥75 mm Hg (MAP ≥75). The primary outcome was acute myocardial injury on postoperative days 0-3 and/or 30-day MACE/acute kidney injury (AKI) (acute coronary syndrome, congestive heart failure, coronary revascularization, stroke, AKI, and all-cause mortality). The secondary outcome was 1-year MACE. RESULTS In total, 458 patients were randomized (intention-to-treat population: 451). The cumulative intraoperative duration with MAP <65 mm Hg was significantly shorter in the MAP ≥75 group (median 9 minutes [interquartile range: 3 to 24 minutes] vs 23 minutes [interquartile range: 8-49 minutes]; P < 0.001). The primary outcome incidence was 48% for MAP ≥75 and 52% for control (risk difference -4.2%; 95% CI: -13% to +5%), the primary contributor being AKI (incidence 44%). Acute myocardial injury occurred in 15% (MAP ≥75) and 19% (control) of patients. The secondary outcome incidence was 17% for MAP ≥75 and 15% for control (risk difference +2.7; 95% CI: -4% to +9.5%). CONCLUSIONS These findings do not support universally targeting higher intraoperative blood pressures to reduce postoperative complications. Despite a 60% reduction in hypotensive time with MAP <65 mm Hg, no significant reductions in acute myocardial injury or 30-day MACE/AKI could be found. (Biomarkers, Blood Pressure, BIS: Risk Stratification/Management of Patients at Cardiac Risk in Major Noncardiac Surgery [BBB]; NCT02533128).
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Fundamentals of Arthroscopy Fluid Management and Strategies to Safely Improve Visualization. J Am Acad Orthop Surg 2021; 29:862-871. [PMID: 34623341 DOI: 10.5435/jaaos-d-20-01057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 06/18/2021] [Indexed: 02/01/2023] Open
Abstract
Arthroscopy has become increasingly relevant to various subspecialties within the orthopaedic surgery. From a patient safety standpoint and surgical efficiency standpoint, it is critical to know the fundamental concepts of fluid management such as those related to the fluid, pressure, and flow. A satisfactory field of view during arthroscopy can be achieved with the use of gravity-dependent or automated fluid management systems. Fluid management parameters and their physiological impact on the patient should be continuously monitored to avoid morbidity or delayed recovery. Local and systemic complications can occur from careless use of techniques that improve visualization such as tourniquet, epinephrine-diluted irrigation, and controlled hypotensive anesthesia. The purpose of this article is to review the fundamental concepts of fluid management in arthroscopy and the techniques to safely improve arthroscopic visualization.
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Zhao B, Chen X, Chen Q, Li G, Chen Z, Yang Z, Gu L, Xiao X, Wang Z, Ning J, Yi B, Lu K, Zhang H, Gu J. Intraoperative Hypotension and Related Risk Factors for Postoperative Mortality After Noncardiac Surgery in Elderly Patients: A Retrospective Analysis Report. Clin Interv Aging 2021; 16:1757-1767. [PMID: 34621121 PMCID: PMC8491785 DOI: 10.2147/cia.s327311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/15/2021] [Indexed: 11/25/2022] Open
Abstract
Background Blood pressure fluctuation is very common during non-cardiac surgery in elderly. This retrospective study was to analyse whether intraoperative hypotension in elderly and other risk factors relate to the postoperative mortality. Methods A total of 118 cases (Observational group), who underwent noncardiac surgery in three medical centers between September 2014 and March 2017, and died in the hospital after the noncardiac surgery. With 1:2 ratio of propensity matching, 236 survival cases (Control group) were selected for comparison analyses with the death cases. Intraoperative blood pressure and perioperative parameters from both groups were collected from electronic anaesthesia charts. Data were analysed with univariate logistic regression analysis where variables with p values less than 0.05 were analysed with multivariate logistic regression analysis. The receiver operating characteristic (ROC) curve was constructed. Results There are five risk factors related to postoperative death in elderly patients: ASA grade, COPD, emergency surgery, general anesthesia, 60 < MAP ≤ 65mmHg (OR > 1), and one factor may reduce the risk of postoperative mortality, which is PACU therapy (OR < 1). Compared with the Control group, the Observational group had a higher proportion of cerebral hernia, kidney injury and trauma (p < 0.001). The intraoperative blood transfusion volume and intraoperative blood loss volume were higher in the Observational group than the Control group (p < 0.001). The proportion of using vasoactive drugs was higher in the Observational group (p < 0.001), and there was more urine output during the operation in the Observational group (p = 0.005). Conclusion The intraoperative MAP of geriatric patients lower than 65mmHg is highly related to the postoperative mortality. Elderly patients with emergency surgery, high ASA grade and a history of COPD have an increased risk of postoperative mortality. General anesthesia is a risk factor for postoperative death in elderly patients, and the PACU therapy is a protective factor to avoid postoperative death. Trial Registration This study has been retrospectively registered in the Chinese Clinical Trials Registry (ChiCTR2000038912, 10/10/2020).
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Affiliation(s)
- Benhui Zhao
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Xingtong Chen
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Qian Chen
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China.,Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London, UK
| | - Gaoming Li
- Department of Health Statistics, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Zhe Chen
- Quality Management and Control Department, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Ziheng Yang
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Li Gu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Xudong Xiao
- Department of Anesthesiology, Xinqiao Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | | | - Jiaolin Ning
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Bin Yi
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Kaizhi Lu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Hongyan Zhang
- Hospital Office, Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Jianteng Gu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
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Czajka S, Putowski Z, Krzych ŁJ. Intraoperative hypotension and its organ-related consequences in hypertensive subjects undergoing abdominal surgery: a cohort study. Blood Press 2021; 30:348-358. [PMID: 34323131 DOI: 10.1080/08037051.2021.1947777] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Purpose. Intraoperative hypotension is associated with organ hypoperfusion, which is deleterious to vital organs. Little is known about the prevalence and consequences of intraoperative hypotension in subjects with arterial hypertension (AH). The primary goal of this study was to investigate the prevalence and determinants of hypoperfusion-related clinical consequences of intraoperative hypotension, taking into account the role of AH, in a homogeneous cohort of patients undergoing abdominal surgery.Materials and methods. We enrolled 508 patients (219 males, median age 62 years). Intraoperative hypotension was defined as systolic blood pressure (SBP) <90 mmHg for at least 10 min or mean arterial pressure (MAP) <65 mmHg for at least 10 min or a need for noradrenaline infusion of at least 0.05 μg/kg/min for ≥10 min or intraoperative MAP drop of at least 30% from the baseline value for at least 10 min, regardless of the time of surgery. Acute kidney injury, stroke or transient ischaemic attack, delirium, and myocardial infarction were considered as the outcome.Results. AH concerned 234 (46%) individuals. The prevalence of intraoperative hypotension varied from 19.9 to 59.4%. Patients with AH were more likely to experience MAP drop of >30% than non-hypertensive patients (OR = 1.53; 95%CI 1.07-2.19; p = 0.02). The outcome was diagnosed in 38 (7.5%) patients. AH was a significant predictor of hypoperfusion-related events, regardless of the intraoperative hypotension definition applied (logOR 2.80 ÷ 3.22; p < 0.05 for all). Only intraoperative hypotension defined as 'MAP < 65mmHg' was found to be a determinant of negative outcome (logOR = 2.85; 95%CI 1.35-5.98; p < 0.01), with AUROC = 0.83 (95%CI 0.0-0.86); p < 0.01.Conclusion. AH is a significant predictor of hypoperfusion-related events, regardless of the intraoperative hypotension definition applied. In hypertensive patients, hypoperfusion-related clinical consequences are more frequent in high-risk and long-lasting procedures. MAP < 65 mmHg lasting for >10 min during surgery was identified as most associated with the negative outcome.
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Affiliation(s)
- Szymon Czajka
- Department of Anaesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Zbigniew Putowski
- Department of Anaesthesiology and Intensive Care, School of Medicine in Katowice, Students' Scientific Society, Medical University of Silesia, Katowice, Poland
| | - Łukasz J Krzych
- Department of Anaesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
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Awad H, Alcodray G, Raza A, Boulos R, Essandoh M, Bhandary S, Dalton R. Intraoperative Hypotension-Physiologic Basis and Future Directions. J Cardiothorac Vasc Anesth 2021; 36:2154-2163. [PMID: 34218998 DOI: 10.1053/j.jvca.2021.05.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 05/26/2021] [Accepted: 05/30/2021] [Indexed: 02/05/2023]
Abstract
Intraoperative hypotension (IOH) is a major concern to the anesthesiologist. Its appropriate identification and management require an understanding of the physiology of blood pressure regulation, prudent blood pressure monitoring, and treatment. Even short durations of low mean arterial pressure have been associated with adverse postoperative clinical outcomes. The challenge is for the clinician to respond proactively, address the specific etiology of IOH, and keep in mind any changes to the patient's physiology. Predictive technology, such as the Hypotension Prediction Index, offers the clinician new insight into IOH. It has been shown to predict hypotension up to 15 minutes before occurrence. It also calculates stroke volume variation, dynamic arterial elastance, and left ventricular contractility, which can inform the anesthesiologist of the etiology of IOH to direct management. This new technology has the potential to reduce duration or even prevent IOH. In the authors' opinion, it is an example of how human-machine interaction will contribute to future advances in medicine. Additional studies should evaluate the effects of its use on postoperative outcomes.
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Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH.
| | | | - Arwa Raza
- Ohio State University College of Medicine, Columbus, OH
| | - Racha Boulos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael Essandoh
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Sujatha Bhandary
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
| | - Ryan Dalton
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
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Kong Q, Ming WK, Mi XS. Refractive outcomes after intravitreal injection of antivascular endothelial growth factor versus laser photocoagulation for retinopathy of prematurity: a meta-analysis. BMJ Open 2021; 11:e042384. [PMID: 33568373 PMCID: PMC7878142 DOI: 10.1136/bmjopen-2020-042384] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To determine the effects of the intraocular injection of antivascular endothelial growth factor (anti-VEGF) drugs on the refractive status of infants with retinopathy of prematurity (ROP). DESIGN Systematic review and meta-analysis of the refractive status of infants with ROP who receive anti-VEGF drugs. DATA SOURCES The PubMed, Web of Science and Embase databases and the ClinicalTrials.gov website were searched up to June 2020. ELIGIBILITY CRITERIA WHEN SELECTING STUDIES We included randomised controlled trials (RCTs) and observational studies that compared refractive errors between anti-VEGF drug and laser therapies. DATA EXTRACTION AND SYNTHESIS Data extraction and risk-of-bias assessments were conducted by two independent reviewers. We used a random-effect model to pool outcomes. The outcome measures were the spherical equivalents, axial length (AL), anterior chamber depth (ACD) and lens thickness (LT). RESULTS Thirteen studies involving 1850 eyes were assessed: 914 in the anti-VEGF drug group, and 936 in the control (laser) group. Children who received anti-VEGF drug treatment had less myopia than those who received laser therapy (mean difference=1.80 D, 95% CI 0.97 to 2.63, p＜0.0001, I2=78%). The AL, ACD and LT did not reach statistical significance difference between the two groups. The current evidence indicates that the refractive safety in children with ROP is better for anti-VEGF drug treatment than for laser therapy. CONCLUSIONS This meta-analysis indicates that anti-VEGF drug therapy results in less myopia compared with laser therapy. However, there are relatively few published articles on refractive errors in ROP, and so high-quality and powerful RCTs are needed in the future. PROSPERO REGISTRATION NUMBER CRD42020160673.
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Affiliation(s)
- Qihang Kong
- Department of Ophthalmology, the First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Wai-Kit Ming
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, China
- Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Xue-Song Mi
- Department of Ophthalmology, the First Affiliated Hospital of Jinan University, Guangzhou, China
- Changsha Academician Expert Workstation, Aier Eye Hospital Group, Changsha, China
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Wijnberge M, Schenk J, Bulle E, Vlaar AP, Maheshwari K, Hollmann MW, Binnekade JM, Geerts BF, Veelo DP. Association of intraoperative hypotension with postoperative morbidity and mortality: systematic review and meta-analysis. BJS Open 2021; 5:6073395. [PMID: 33609377 PMCID: PMC7893468 DOI: 10.1093/bjsopen/zraa018] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 09/07/2020] [Indexed: 12/21/2022] Open
Abstract
Background Intraoperative hypotension, with varying definitions in literature, may be associated with postoperative complications. The aim of this meta-analysis was to assess the association of intraoperative hypotension with postoperative morbidity and mortality. Methods MEDLINE, Embase and Cochrane databases were searched for studies published between January 1990 and August 2018. The primary endpoints were postoperative overall morbidity and mortality. Secondary endpoints were postoperative cardiac outcomes, acute kidney injury, stroke, delirium, surgical outcomes and combined outcomes. Subgroup analyses, sensitivity analyses and a meta-regression were performed to test the robustness of the results and to explore heterogeneity. Results The search identified 2931 studies, of which 29 were included in the meta-analysis, consisting of 130 862 patients. Intraoperative hypotension was associated with an increased risk of morbidity (odds ratio (OR) 2.08, 95 per cent confidence interval 1.56 to 2.77) and mortality (OR 1.94, 1.32 to 2.84). In the secondary analyses, intraoperative hypotension was associated with cardiac complications (OR 2.44, 1.52 to 3.93) and acute kidney injury (OR 2.69, 1.31 to 5.55). Overall heterogeneity was high, with an I2 value of 88 per cent. When hypotension severity, outcome severity and study population variables were added to the meta-regression, heterogeneity was reduced to 50 per cent. Conclusion Intraoperative hypotension during non-cardiac surgery is associated with postoperative cardiac and renal morbidity, and mortality. A universally accepted standard definition of hypotension would facilitate further research into this topic.
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Affiliation(s)
- M Wijnberge
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - J Schenk
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - E Bulle
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - A P Vlaar
- Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - K Maheshwari
- Department of General Anaesthesiology, Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - M W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - J M Binnekade
- Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - B F Geerts
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - D P Veelo
- Department of Anaesthesiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
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36
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Li N, Kong H, Li SL, Zhu SN, Zhang Z, Wang DX. Intraoperative hypotension is associated with increased postoperative complications in patients undergoing surgery for pheochromocytoma-paraganglioma: a retrospective cohort study. BMC Anesthesiol 2020; 20:147. [PMID: 32532209 PMCID: PMC7291712 DOI: 10.1186/s12871-020-01066-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/08/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Dramatic hemodynamic fluctuation occurs frequently during surgery for pheochromocytoma or paraganglioma. However, the criteria of intraoperative hemodynamic instability vary widely, and most of them were defined arbitrarily but not according to patients' prognosis. The objective was to analyze the relationship between different thresholds and durations of intraoperative hyper-/hypotension and the risk of postoperative complications in patients undergoing surgery for pheochromocytoma or paraganglioma. METHODS This was a retrospective single-center cohort study performed in a tertiary care hospital from January 1, 2005 to December 31, 2017. Three hundred twenty-seven patients who underwent surgery for pheochromocytoma or paraganglioma, of which the diagnoses were confirmed by postoperative pathologic examination, were enrolled. Those who were less than 18 years, underwent surgery involving non-tumor organs, or had incomplete data were excluded. The primary endpoint was a composite of the occurrence of AKI or other complications during hospital stay after surgery. Multivariate Logistic regression models were used to analyze the association between different thresholds and durations of intraoperative hyper-/hypotension and the development of postoperative complications. RESULTS Forty three (13.1%) patients developed complications during hospital stay after surgery. After adjusting for confounding factors, intraoperative hypotension, defined as systolic blood pressure (SBP) of ≤95 mmHg for ≥20 min (OR 3.211; 99% CI 1.081-9.536; P = 0.006), SBP of ≤90 mmHg for ≥20 min (OR 3.680; 98.8% CI 1.107-12.240; P = 0.006), SBP of ≤85 mmHg for ≥10 min (OR 3.975; 98.3% CI 1.321-11.961; P = 0.003), and SBP of ≤80 mmHg for ≥1 min (OR 3.465; 95% CI 1.484-8.093; P = 0.004), were associated with an increased risk of postoperative complications. On the other hand, intraoperative hypertension was not significantly associated with the development of postoperative complications. CONCLUSIONS For patients undergoing surgery for pheochromocytoma or paraganglioma, intraoperative hypotension is associated with increased postoperative complications; and the harmful effects are level- and duration-dependent. The effects of intraoperative hypertension need to be studied further.
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Affiliation(s)
- Nan Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku street, Beijing, 100034, China
| | - Hao Kong
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku street, Beijing, 100034, China
| | - Shuang-Ling Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku street, Beijing, 100034, China
| | - Sai-Nan Zhu
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Zheng Zhang
- Department of Urology, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, No.8 Xishiku street, Beijing, 100034, China.
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Rogers-Smith E, Hammerton R, Mathis A, Allison A, Clark L. Twelve previously healthy non-geriatric dogs present for acute kidney injury after general anaesthesia for non-emergency surgical procedures in the UK. J Small Anim Pract 2020; 61:363-367. [PMID: 32196674 DOI: 10.1111/jsap.13134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To characterise common factors after a suspected increase in the incidence of post-procedure acute kidney injury in healthy dogs presenting for non-emergency surgical procedures. MATERIALS AND METHODS Retrospective analysis of the medical records of 12 dogs that presented for acute kidney injury after general anaesthesia for non-emergency surgical procedures. RESULTS The 12 non-geriatric dogs re-presented with acute kidney injury at a median of 4 days after surgery to four different veterinary centres, including three multidisciplinary referral practices in the UK. All dogs in this case series weighed more than 20 kg and had a median age of 17 months. There was no apparent association with breed, type of surgery, duration of anaesthesia, perioperative drug choice or non-steroidal anti-inflammatory drug administration. CLINICAL SIGNIFICANCE Although well-defined in human medicine, there is very little information regarding the association between general anaesthesia and acute kidney injury in animals. No definitive causal link was found in this case series. Clinicians with similar cases are requested to contact the corresponding author so a more representative incidence rate can be obtained.
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Affiliation(s)
- E Rogers-Smith
- Internal Medicine, Davies Veterinary Specialists, Higham Gobion, SG53HR, UK
| | - R Hammerton
- Internal Medicine, Davies Veterinary Specialists, Higham Gobion, SG53HR, UK
| | - A Mathis
- Anaesthesia, Willows Veterinary Centre and Referral Service, Solihull, B90 4NH, UK
| | - A Allison
- Anaesthesia, Scarsdale Veterinary Group, Derby, DE24 8HX, UK
| | - L Clark
- Internal Medicine, Davies Veterinary Specialists, Higham Gobion, SG53HR, UK
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Boyd-Carson H, Gana T, Lockwood S, Murray D, Tierney GM. A review of surgical and peri-operative factors to consider in emergency laparotomy care. Anaesthesia 2020; 75 Suppl 1:e75-e82. [PMID: 31903572 DOI: 10.1111/anae.14821] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2019] [Indexed: 12/12/2022]
Abstract
Patients undergoing emergency laparotomy are a heterogeneous group with regard to comorbidity, pre-operative physiological state and surgical pathology. There are many factors to consider in the peri-operative period for these patients. Surgical duration should be as short as possible for adequate completion of the procedure. This is of particular importance in the elderly and comorbid population. To date, there are limited data addressing the role of damage control surgery in emergency general surgery. Dual consultant-led care in all stages of emergency laparotomy care is increasing, with increased presence out of hours and also for high-risk patients. The role of the stoma care team should be actively encouraged in all patients who may require a stoma. Due to the emergent and unpredictable nature of surgical emergencies, healthcare teams may need to employ novel strategies to ensure early input from the stoma care team. It is important for all members of the medical teams to ensure that patients have given consent for both anaesthesia and surgery before emergency laparotomy. Small studies suggest that patients and their families are not aware of the high risk of morbidity and mortality following emergency laparotomy before operative intervention. Elderly patients should have early involvement from geriatric specialists and careful attention paid to assessment of frailty due to its association with mortality and morbidity. Additionally, the use of enhanced recovery programmes in emergency general surgery has been shown to have some impact in reducing length of stay in emergency surgical patients. However, the emergent nature of this surgery has been shown to be a detrimental factor in full implementation of enhanced recovery programmes. The use of a national database to collect data on patients undergoing emergency laparotomy and their processes of care has led to reduced mortality and length of stay in the UK. However, internationally, fewer data are available to draw conclusions.
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Affiliation(s)
- H Boyd-Carson
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - T Gana
- Bradford Royal Infirmary, Yorkshire and Humber Deanery, Leeds, UK
| | | | - D Murray
- James Cook University Hospital, Middlesbrough, UK
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Yeh HW, Yeh LT, Chou YH, Yang SF, Ho SW, Yeh YT, Yeh YT, Wang YH, Chan CH, Yeh CB. Risk of Cardiovascular Disease Due to General Anesthesia and Neuraxial Anesthesia in Lower-Limb Fracture Patients: A Retrospective Population-Based Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 17:ijerph17010033. [PMID: 31861460 PMCID: PMC6982192 DOI: 10.3390/ijerph17010033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 11/20/2022]
Abstract
The purpose of this study was to analyze the relationship between elevated cardiovascular disease (CVD) risk and type of anesthesia by using the National Health Insurance Research Database (NHIRD) of Taiwan in a one-year follow-up period. We assessed whether general anesthesia (GA) or neuraxial anesthesia (NA) increased CVD occurrence in lower-limb fracture patients. Approximately 1 million patients were randomly sampled from the NHIRD registry. We identified and enrolled 3437 lower-limb fracture patients who had received anesthesia during operations conducted in the period from 2010 to 2012. Next, patients were divided into two groups, namely GA (n = 1504) and NA (n = 1933), based on the anesthetic technique received during surgery. Our results revealed that those receiving GA did not differ in their risk of CVD relative to those receiving NA, adjusted HR = 1.24 (95% CI: 0.80–1.92). Patients who received GA for more than 2 h also did not differ in their risk of CVD relative to those receiving NA for less than 2 h, adjusted HR = 1.43 (95% CI: 0.81–2.50). Moreover, in the GA group (i.e., patients aged ≥65 years and women), no significant difference for the risk of CVD events was observed. In conclusion, in our study, the difference in the risk of CVD between lower-limb fracture patients receiving NA and GA was not statistically significant. The incidence rate of CVD seemed to be more correlated with patients’ underlying characteristics such as old age, comorbidities, or admission to the intensive care unit. Due to the limited sample size in this study, a database which reviews a whole national population will be required to verify our results in the future.
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Affiliation(s)
- Han-Wei Yeh
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan;
| | - Liang-Tsai Yeh
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (L.-T.Y.); (Y.-H.C.); (S.-F.Y.)
- Department of Anesthesiology, Changhua Christian Hospital, Changhua 500, Taiwan
| | - Ying-Hsiang Chou
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (L.-T.Y.); (Y.-H.C.); (S.-F.Y.)
- Department of Medical Imaging and Radiological Sciences, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Radiation Oncology, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (L.-T.Y.); (Y.-H.C.); (S.-F.Y.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
| | - Sai-Wai Ho
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan;
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Ying-Tung Yeh
- School of Dentistry, Chung Shan Medical University, Taichung 402, Taiwan; (Y.-T.Y.); (Y.-T.Y.)
- Department of Dentistry, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Ying-Ting Yeh
- School of Dentistry, Chung Shan Medical University, Taichung 402, Taiwan; (Y.-T.Y.); (Y.-T.Y.)
- Department of Dentistry, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
| | - Chi-Ho Chan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
- Department of Microbiology and Immunology, Chung Shan Medical University, Taichung 402, Taiwan
- Correspondence: (C.-H.C.); (C.-B.Y.)
| | - Chao-Bin Yeh
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan;
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Correspondence: (C.-H.C.); (C.-B.Y.)
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Abstract
PURPOSE OF REVIEW Hemodynamic instability is common in the perioperative period because of obligate physiologic changes that occur with surgery. Despite the frequency of such hemodynamic changes and the potential harm associated with them, particularly in the elderly, guidelines to optimize perioperative blood pressure are lacking. The present review examines recent evidence for perioperative blood pressure management in the elderly. RECENT FINDINGS Hypotension has been associated with poor outcomes, particularly renal injury, myocardial injury, and increased mortality, in the perioperative period. Hypertension, tachycardia, frequency of blood pressure monitoring, and management of chronic antihypertensive medications may also affect patient outcomes. Elderly patients may be especially prone to adverse events associated with perioperative hemodynamic instability. SUMMARY Precise and intentional management of hemodynamic parameters, medication regimens, and blood pressure monitoring may reduce adverse events in elderly patients undergoing surgery. Further investigation is required to identify the exact hemodynamic parameters that mitigate risk.
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41
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Abstract
Despite broad availability, extended hemodynamic monitoring is used in practice only in the minority of critical care patients. Pathophysiological reasoning suggests that systemic perfusion pressure (and thereby arterial as well as central venous pressure), cardiac stroke volume, and the systemic oxygen balance are key variables in maintaining adequate organ perfusion. In line with these assumptions, several studies support that a goal-directed optimization of these hemodynamic variables leads to a reduction in morbidity and mortality. The appropriate monitoring modality should be selected following echocardiographic evaluation of biventricular function. Ideally, high-risk patients with limited right ventricular function should be monitored with a pulmonary artery catheter. In patients with preserved right ventricular function, transpulmonary thermodilution with special consideration of extravascular lung water seems to be sufficient to guide hemodynamic therapy.
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An R, Pang QY, Liu HL. Association of intra-operative hypotension with acute kidney injury, myocardial injury and mortality in non-cardiac surgery: A meta-analysis. Int J Clin Pract 2019; 73:e13394. [PMID: 31332896 DOI: 10.1111/ijcp.13394] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 07/01/2019] [Accepted: 07/17/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Intra-operative hypotension might induce poor postoperative outcomes in non-cardiac surgery, and the relationship between the level or duration of Intra-operative hypotension (IOH) and postoperative adverse events is still unclear. In this study, we performed a meta-analysis to determine how IOH could affect acute kidney injury (AKI), myocardial injury and mortality in non-cardiac surgery. METHODS We searched PubMed (Medline), Embase, Springer, The Cochrane Library, Ovid and Google Scholar, and retrieved the related clinical trials on intra-operative hypotension and prognosis in non-cardiac surgery. RESULTS Fifteen observational studies were included. The meta-analysis showed that in non-cardiac surgery, intra-operative hypotension (mean arterial pressure [MAP]) <60 mm Hg for more than 1 minute was associated with an increased risk of postoperative acute kidney injury(AKI) [1-5 minutes: odds ratio (OR) = 1.13, 95% CI (1.04, 1.23), I2 = 0, P = .003; 5-10 minutes: OR = 1.18, 95% CI (1.07, 1.31), I2 = 0, P = .001; >10 minutes: OR = 1.35, 95% CI (1.1, 1.67), I2 = 52.6%, P = .004] and myocardial injury [1-5 minutes: OR = 1.16, 95% CI (1.01, 1.33), I2 = 30.6%, P = .04; 5-10 minutes: OR = 1.34, 95% CI (1.01, 1.77), I2 = 70.4%, P = .046; >10 minutes: OR = 1.43, 95% CI (1.18, 1.72), I2 = 39.4%, P < .0001]. Intra-operative hypotension (MAP < 60 mm Hg) for 1-5 minutes was not associated with postoperative 30-day mortality [OR = 1.15, 95% CI (0.95, 1.4), I2 = 0, P = .154], but intra-operative hypotension (MAP < 60 mm Hg) for more than 5 min was associated with an increased risk of postoperative 30-day mortality [OR = 1.11, 95% CI (1.06, 1.17), I2 = 51.9%, P < .0001]. CONCLUSION Intra-operative hypotension was associated with an increased risk of postoperative AKI, myocardial injury and 30-day mortality in non-cardiac surgery. Intra-operative MAP < 60 mm Hg more than 1 minute should be avoided.
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Affiliation(s)
- Ran An
- Department of Anesthesiology, Chongqing University Cancer Hospital/Chongqing Cancer Institute/Chongqing Cancer Center, Chongqing City, 400030, China
| | - Qian-Yun Pang
- Department of Anesthesiology, Chongqing University Cancer Hospital/Chongqing Cancer Institute/Chongqing Cancer Center, Chongqing City, 400030, China
| | - Hong-Liang Liu
- Department of Anesthesiology, Chongqing University Cancer Hospital/Chongqing Cancer Institute/Chongqing Cancer Center, Chongqing City, 400030, China
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Szabó M, Bozó A, Darvas K, Horváth A, Iványi ZD. Role of inferior vena cava collapsibility index in the prediction of hypotension associated with general anesthesia: an observational study. BMC Anesthesiol 2019; 19:139. [PMID: 31390983 PMCID: PMC6686491 DOI: 10.1186/s12871-019-0809-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 07/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intraoperative hypotension increases 30-day mortality and the risks of myocardial injury and acute renal failure. Patients with inadequate volume reserve before the induction of anesthesia are highly exposed. The identification of latent hypovolemia is therefore crucial. Ultrasonographic measurement of the inferior vena cava collapsibility index (IVCCI) is able to detect volume responsiveness in circulatory shock. No current evidence is available regarding whether preoperative measurement of the IVCCI could identify patients at high risk for hypotension associated with general anesthesia. METHODS A total of 102 patients undergoing elective general surgery under general anesthesia with standardized propofol induction were recruited for this prospective observational study. The IVCCI was measured under spontaneous breathing. A collapsing (IVCCI≧50%) (CI+) and a noncollapsing (CI-) group were formed. Immediate postinduction changes in systolic and mean blood pressure were compared. The performance of the IVCCI as a diagnostic tool for predicting hypotension (systolic pressure < 90 mmHg or a ≥ 30% drop from the baseline) was evaluated by ROC curve analysis. RESULTS A total of 83 patients were available for analysis, with 20 in the CI+ and 63 in the CI- group, we excluded 19 previously eligible patients due to inadequate visualization of the IVC (7 cases), lack of adherence to the protocol (8 cases), missing data (2 cases) or change in anesthesiologic management (2 cases). The mean decrease in systolic pressure in the CI+ group was 53.8 ± 15.3 compared to 35.8 ± 18.1 mmHg in CI- patients (P = 0.0001). The relative mean arterial pressure change medians were 34.1% (IQR 23.2-43.0%) and 24.2% (IQR 17.2-30.2%), respectively (P = 0.0029). The ROC curve analysis for IVCCI showed an AUC of 64.8% (95% CI 52.1-77.5%). The selected 50% level of the IVCCI had a sensitivity of only 45.5% (95% CI 28.1-63.7%), but the specificity was high at 90.0% (78.2-96.7%). The positive predictive value was 75.0% (95% CI 50.9-91.3%), and the negative predictive value was 71.4% (95% CI 58.7-82.1%). CONCLUSION In spontaneously breathing preoperative noncardiac surgical patients, preoperatively detected IVCCI≧50% can predict postinduction hypotension with high specificity but low sensitivity. Despite moderate performance, IVCCI is an easy, noninvasive and attractive option to identify patients at risk and should be explored further.
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Affiliation(s)
- Marcell Szabó
- 1st Department of Surgery, Semmelweis University, Üllői út 78, Budapest, 1082, Hungary. .,Department of Anesthesiology and Intensive Therapy, Semmelweis University, Üllői út 78B, Budapest, 1082, Hungary.
| | - Anna Bozó
- 1st Department of Surgery, Semmelweis University, Üllői út 78, Budapest, 1082, Hungary
| | - Katalin Darvas
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Üllői út 78B, Budapest, 1082, Hungary
| | - Alexandra Horváth
- 1st Department of Surgery, Semmelweis University, Üllői út 78, Budapest, 1082, Hungary
| | - Zsolt Dániel Iványi
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Üllői út 78B, Budapest, 1082, Hungary
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Joosten A, Alexander B, Duranteau J, Taccone FS, Creteur J, Vincent JL, Cannesson M, Rinehart J. Feasibility of closed-loop titration of norepinephrine infusion in patients undergoing moderate- and high-risk surgery. Br J Anaesth 2019; 123:430-438. [PMID: 31255290 DOI: 10.1016/j.bja.2019.04.064] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/09/2019] [Accepted: 05/08/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Vasopressor agents are used to prevent intraoperative hypotension and ensure adequate perfusion. Vasopressors are usually administered as intermittent boluses or manually adjusted infusions, but this practice requires considerable time and attention. We have developed a closed-loop vasopressor (CLV) controller to correct hypotension more efficiently. Here, we conducted a proof-of-concept study to assess the feasibility and performance of CLV control in surgical patients. METHODS Twenty patients scheduled for elective surgical procedures were included in this study. The goal of the CLV system was to maintain MAP within 5 mm Hg of the target MAP by automatically adjusting the rate of a norepinephrine infusion using MAP values recorded continuously from an arterial catheter. The primary outcome was the percentage of time that patients were hypotensive, as defined by a MAP of 5 mm Hg below the chosen target. Secondary outcomes included the total dose of norepinephrine, percentage of time with hypertension (MAP>5 mm Hg of the chosen target), raw percentage "time in target" and Varvel performance criteria. RESULTS The 20 subjects (median age: 64 years [52-71]; male (35%)) underwent elective surgery lasting 154 min [124-233]. CLV control maintained MAP within ±5 mm Hg of the target for 91.6% (85.6-93.3) of the intraoperative period. Subjects were hypotensive for 2.6% of the intraoperative period (range, 0-8.4%). Additional performance criteria for the controller included mean absolute performance error of 2.9 (0.8) and mean predictive error of 0.5 (1.0). No subjects experienced major complications. CONCLUSIONS In this proof of concept study, CLV control minimised perioperative hypotension in subjects undergoing moderate- or high-risk surgery. Further studies to demonstrate efficacy are warranted. TRIAL REGISTRY NUMBER NCT03515161 (ClinicalTrials.gov).
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology and Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium; Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France.
| | - Brenton Alexander
- Department of Anesthesiology, University of California-San Diego, San Diego, CA, USA
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California-Irvine, Irvine, CA, USA
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