scholarly journals Hypotension Prediction Index for Prevention of Hypotension during Moderate- to High-risk Noncardiac Surgery

2020 ◽  
Vol 133 (6) ◽  
pp. 1214-1222 ◽  
Author(s):  
Kamal Maheshwari ◽  
Tetsuya Shimada ◽  
Dongsheng Yang ◽  
Sandeep Khanna ◽  
Jacek B. Cywinski ◽  
...  
Keyword(s):  
Mean Arterial Pressure ◽  
High Risk ◽  
Arterial Pressure ◽  
Pilot Trial ◽  
Treatment Algorithm ◽  
Weighted Average ◽  
Noncardiac Surgery ◽  
Intraoperative Hypotension ◽  
Time Weighted Average ◽  
Alert Threshold

Background The Hypotension Prediction Index is a commercially available algorithm, based on arterial waveform features, that predicts hypotension defined as mean arterial pressure less than 65 mmHg for at least 1 min. We therefore tested the primary hypothesis that index guidance reduces the duration and severity of hypotension during noncardiac surgery. Methods We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized to hemodynamic management with or without index guidance. Clinicians caring for patients assigned to guidance were alerted when the index exceeded 85 (range, 0 to 100) and a treatment algorithm based on advanced hemodynamic parameters suggested vasopressor administration, fluid administration, inotrope administration, or observation. Primary outcome was the amount of hypotension, defined as time-weighted average mean arterial pressure less than 65 mmHg. Secondary outcomes were time-weighted mean pressures less than 60 and 55 mmHg. Results Among 214 enrolled patients, guidance was provided for 105 (49%) patients randomly assigned to the index guidance group. The median (first quartile, third quartile) time-weighted average mean arterial pressure less than 65 mmHg was 0.14 (0.03, 0.37) in guided patients versus 0.14 (0.03, 0.39) mmHg in unguided patients: median difference (95% CI) of 0 (–0.03 to 0.04), P = 0.757. Index guidance therefore did not reduce amount of hypotension less than 65 mmHg, nor did it reduce hypotension less than 60 or 55 mmHg. Post hoc, guidance was associated with less hypotension when analysis was restricted to episodes during which clinicians intervened. Conclusions In this pilot trial, index guidance did not reduce the amount of intraoperative hypotension. Half of the alerts were not followed by treatment, presumably due to short warning time, complex treatment algorithm, or clinicians ignoring the alert. In the future we plan to use a lower index alert threshold and a simpler treatment algorithm that emphasizes prompt treatment. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Intraoperative Mean Arterial Pressure Variability and 30-day Mortality in Patients Having Noncardiac Surgery

2015 ◽  
Vol 123 (1) ◽  
pp. 79-91 ◽  
Author(s):  
Edward J. Mascha ◽  
Dongsheng Yang ◽  
Stephanie Weiss ◽  
Daniel I. Sessler
Keyword(s):  
Blood Pressure ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Blood Pressure Variability ◽  
Postoperative Mortality ◽  
Weighted Average ◽  
Noncardiac Surgery ◽  
Cumulative Duration ◽  
Time Weighted Average ◽  
Average Real Variability

Abstract Background: Little is known about the relationship between intraoperative blood pressure variability and mortality after noncardiac surgery. Therefore, the authors tested the hypothesis that blood pressure variability, independent from absolute blood pressure, is associated with increased 30-day mortality. Methods: Baseline and intraoperative variables plus 30-day mortality were obtained for 104,401 adults having noncardiac surgery lasting 60 min or longer. In confounder-adjusted models, the authors evaluated the associations between 30-day mortality and both time-weighted average intraoperative mean arterial pressure (TWA-MAP) and measures of intraoperative MAP variability—including generalized average real variability of MAP (ARV-MAP) and SD of MAP (SD-MAP). Results: Mean ± SD TWA-MAP was 84 ± 10 mmHg, and ARV-MAP was 2.5 ± 1.3 mmHg/min. TWA-MAP was strongly related to 30-day mortality, which more than tripled as TWA-MAP decreased from 80 to 50 mmHg. ARV-MAP was only marginally related to 30-day mortality (P = 0.033) after adjusting for TWA-MAP. Compared with median ARV-MAP, odds ratio (95% CI) for 30-day mortality was 1.14 (1.03 to 1.25) for low ARV-MAP (first quartile) and 0.94 (0.88 to 0.99) for high ARV-MAP (third quartile). Odds of 30-day mortality decreased as five-level categorized ARV-MAP increased (0.92; 0.87 to 0.99 for one category increase; P = 0.015). Secondarily, cumulative duration of MAP less than 50, 55, 60, 70, and 80 mmHg was associated with increased odds of 30-day mortality (all P < 0.001). Conclusion: Although lower mean arterial pressure is strongly associated with mortality, lower intraoperative blood pressure variability per se is only mildly associated with postoperative mortality after noncardiac surgery.

scholarly journals The Use of the Hypotension Prediction Index Integrated in an Algorithm of Goal Directed Hemodynamic Treatment during Moderate and High-Risk Surgery

2021 ◽  
Vol 10 (24) ◽  
pp. 5884
Author(s):  
Marina Tsoumpa ◽  
Aikaterini Kyttari ◽  
Stamo Matiatou ◽  
Maria Tzoufi ◽  
Panayota Griva ◽  
...  
Keyword(s):  
High Risk ◽  
Arterial Pressure ◽  
Intervention Group ◽  
Treatment Protocol ◽  
Group Versus ◽  
Weighted Average ◽  
Standard Of Care ◽  
Noncardiac Surgery ◽  
Control Group ◽  
Intraoperative Hypotension

(1) Background: The Hypotension Prediction Index (HPI) is an algorithm that predicts hypotension, defined as mean arterial pressure (MAP) less than 65 mmHg for at least 1 min, based on arterial waveform features. We tested the hypothesis that the use of this index reduces the duration and severity of hypotension during noncardiac surgery. (2) Methods: We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized 1:1 to standard of care or hemodynamic management with HPI guidance with a goal directed hemodynamic treatment protocol. The trigger to initiate treatment (with fluids, vasopressors, or inotropes) was a value of HPI of 85 (range, 0–100) or higher in the intervention group. Primary outcome was the amount of hypotension, defined as time-weighted average (TWA) MAP less than 65 mmHg. Secondary outcomes were time spent in hypertension defined as MAP more than 100 mmHg for at least 1 min; medication and fluids administered and postoperative complications. (3) Results: We obtained data from 99 patients. The median (IQR) TWA of hypotension was 0.16 mmHg (IQR, 0.01–0.32 mmHg) in the intervention group versus 0.50 mmHg (IQR, 0.11–0.97 mmHg) in the control group, for a median difference of −0.28 (95% CI, −0.48 to −0.09 mmHg; p = 0.0003). We also observed an increase in hypertension in the intervention group as well as a higher weight-adjusted administration of phenylephrine in the intervention group. (4) Conclusions: In this single-center prospective study of patients undergoing elective noncardiac surgery, the use of this prediction model resulted in less intraoperative hypotension compared with standard care. An increase in the time spent in hypertension in the treatment group was also observed, probably as a result of overtreatment. This should provide an insight for refining the use of this prediction index in future studies to avoid excessive correction of blood pressure.

Relationship between Chronic Intermittent Hypoxia and Intraoperative Mean Arterial Pressure in Obstructive Sleep Apnea Patients Having Laparoscopic Bariatric Surgery

2015 ◽  
Vol 122 (1) ◽  
pp. 64-71 ◽  
Author(s):  
Alparslan Turan ◽  
Jing You ◽  
Cameron Egan ◽  
Alex Fu ◽  
Ignazia Gazmuri ◽  
...  
Keyword(s):  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Weighted Average ◽  
Sleep Time ◽  
Laparoscopic Bariatric Surgery ◽  
Obstructive Sleep ◽  
Time Weighted Average ◽  
Absolute Decrease

Abstract Background: Recurrent nocturnal hypoxemia in obstructive sleep apnea enhances sympathetic function, decreases baroreceptor sensitivity, and weakens peripheral vascular responses to adrenergic signals. The authors hypothesized that the percentage of total sleep time spent at oxyhemoglobin saturation (Sao2) less than 90% and minimum nocturnal Sao2 on preoperative polysomnography are associated with decreased intraoperative mean arterial pressure. Methods: The authors examined the records of all patients who had laparoscopic bariatric surgery at Cleveland Clinic between 2005 and 2009 and an available polysomnography study. The authors assessed the relationships between the percentage of total sleep time spent at Sao2 less than 90% and minimum nocturnal Sao2, and the time-weighted average of mean arterial pressure. The authors used multivariable regression models to adjust for prespecified clinical confounders. Results: Two hundred eighty-one patients were included in the analysis. The average change in the time-weighted average of mean arterial pressure was −0.02 (97.5% CI, −0.08, 0.04) mmHg for each 1% absolute increase in the percentage of sleep time spent at Sao2 less than 90% (P = 0.50). The average change was −0.13 (97.5% CI, −0.27, 0.01) mmHg, for each 1% absolute decrease in the minimum Sao2 (P = 0.04 > significance criterion of 0.025, Bonferroni correction). An unplanned analysis estimated 1% absolute decrease in minimum Sao2 was associated with −0.22 (98.75% CI, −0.39, −0.04) mmHg, change in mean arterial pressure (P = 0.002) in the time period between endotracheal intubation and trocar insertion. Conclusion: Recurrent nocturnal hypoxemia in obstructive sleep apnea is not a risk marker for intraoperative hypotension.

CHARACTERISTICS OF 24-HOUR BLOOD PRESSURE INDICATORS IN PATIENTS WITH HYPERTENSION AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE

2020 ◽  
pp. 31-41
Author(s):  
M.A. Bubnova ◽  
O.N. Kryuchkova
Keyword(s):  
Blood Pressure ◽  
Chronic Obstructive Pulmonary Disease ◽  
Mean Arterial Pressure ◽  
High Risk ◽  
Arterial Pressure ◽  
Pulmonary Disease ◽  
Comparison Group ◽  
Cardiovascular Complications ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease

Patients with hypertension (HT) and chronic obstructive pulmonary disease (COPD) have a high risk of cardiovascular complications. Up to now, there is no optimal strategy for combined antihypertensive therapy. Still, the data of 24-hour blood pressure monitoring (BPM) are important while choosing treatment tactics. The aim of the paper is to study the features of indicators in patients with arterial hypertension (AH) and COPD. Materials and methods. 130 patients with HT were included in the study. The main group (n=90) included comorbid patients with HT and COPD, their average age was 61.30±1.01; the comparison group (n=40) consisted of patients with HT, their average age was 59.10±1.53. All patients underwent 24-hour BPM. Results. Comorbid patients revealed an increase in the mean 24-hour and night systolic and mean arterial pressure values as well as a significant increase in the load index of systolic, diastolic and mean arterial pressure. Also, comorbid patients demonstrated higher blood pressure in contrast to the patients of the comparison group. They had increased systolic, diastolic and mean blood pressure variability and a quicker rate of morning blood pressure rise. According to 24-hour blood pressure dynamics, pathological types of the 24-hour blood pressure curve, a higher frequency of the night-peaker profile dominated in patients with COPD if compared to patients with HT. Conclusion. The obtained data indicated a high risk of cardiovascular complications in comorbid patients, early target organ damage and an unfavorable disease prognosis. It means that both further study of hypertension clinical course in such patients and personalization of antihypertensive therapy are relevant. Keywords: hypertension, chronic obstructive pulmonary disease, 24-hour monitoring, blood pressure. Пациенты с артериальной гипертензией (АГ) и хронической обструктивной болезнью легких (ХОБЛ) имеют высокий риск возникновения кардиоваскулярных осложнений. В настоящее время в лечении не определена наиболее оптимальная стратегия комбинированной антигипертензивной терапии. Для выбора тактики терапии важную роль играют показатели суточного мониторирования артериального давления (СМАД). Цель. Изучить особенности показателей СМАД у пациентов с АГ на фоне ХОБЛ. Материалы и методы. В исследование включено 130 пациентов с АГ. В основную группу (n=90) вошли пациенты с АГ и ХОБЛ (средний возраст – 61,30±1,01 года), в группу сравнения (n=40) – больные только АГ (средний возраст – 59,10±1,53 года). Всем пациентам проведено СМАД. Результаты. У пациентов с коморбидностью выявлены следующие особенности суточных показателей артериального давления: увеличение значений среднесуточных и средненочных показателей систолического и среднего артериального давления; существенное повышение индекса нагрузки систолическим, диастолическим и средним артериальным давлением. Также эти больные отличались от пациентов группы сравнения более высокими значениями пульсового давления, имели повышенную вариабельность систолического, диастолического и среднего артериального давления, у них наблюдалось увеличение скорости утреннего подъема артериального давления. Суточная динамика артериального давления у пациентов с ХОБЛ характеризовалась преобладанием патологических типов суточной кривой АД, более высокой частотой профиля night-peaker по сравнению с больными только АГ. Выводы. Выявленные особенности свидетельствуют о высоком риске сердечно-сосудистых осложнений у пациентов с коморбидностью, раннем поражении органов-мишеней и неблагоприятном прогнозе заболевания, что требует дальнейшего изучения особенностей клинического течения АГ у таких больных и индивидуализации антигипертензивной терапии. Ключевые слова: артериальная гипертензия, хроническая обструктивная болезнь легких, суточное мониторирование, артериальное давление.

scholarly journals Preoperative and Intraoperative Predictors of Cardiac Adverse Events after General, Vascular, and Urological Surgery

2009 ◽  
Vol 110 (1) ◽  
pp. 58-66 ◽  
Author(s):  
Sachin Kheterpal ◽  
Michael O’Reilly ◽  
Michael J. Englesbe ◽  
Andrew L. Rosenberg ◽  
Amy M. Shanks ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Mean Arterial Pressure ◽  
Adverse Events ◽  
Arterial Pressure ◽  
Univariate Analysis ◽  
Noncardiac Surgery ◽  
University Hospital ◽  
Improvement Program ◽  
Urological Surgery ◽  
Cardiac Adverse Events

Background The authors sought to determine the incidence and risk factors for perioperative cardiac adverse events (CAEs) after noncardiac surgery using detailed preoperative and intraoperative hemodynamic data. Methods The authors conducted a prospective observational study at a single university hospital from 2002 to 2006. All American College of Surgeons-National Surgical Quality Improvement Program patients undergoing general, vascular, and urological surgery were included. The CAE outcome definition included cardiac arrest, non-ST elevation myocardial infarction, Q-wave myocardial infarction, and new clinically significant cardiac dysrhythmia within the first 30 postoperative days. Results Four years of data demonstrated that of 7,740 noncardiac operations, 83 patients (1.1%) experienced a CAE within 30 days. Nine independent predictors were identified (P < or = 0.05): age > or = 68, body mass index > or = 30, emergent surgery, previous coronary intervention or cardiac surgery, active congestive heart failure, cerebrovascular disease, hypertension, operative duration > or = 3.8 h, and the administration of 1 or more units of packed red blood cells intraoperatively. The c-statistic of this model was 0.81 +/- 0.02. Univariate analysis demonstrated that high-risk patients experiencing a CAE were more likely to experience an episode of mean arterial pressure < 50 mmHg (6% vs. 24%, P = 0.02), experience an episode of 40% decrease in mean arterial pressure (26% vs. 53%, P = 0.01), and an episode of heart rate > 100 (22% vs. 34%, P = 0.05). Conclusions In comparison with current risk stratification indices, the inclusion of intraoperative elements improves the ability to predict a perioperative CAE after noncardiac surgery.

scholarly journals Targeting low-normal or high-normal mean arterial pressure after cardiac arrest and resuscitation: a randomised pilot trial

2018 ◽  
Vol 44 (12) ◽  
pp. 2091-2101 ◽  
Author(s):  
Pekka Jakkula ◽  
◽  
Ville Pettilä ◽  
Markus B. Skrifvars ◽  
Johanna Hästbacka ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Pilot Trial ◽  
Normal Mean

Defining an Intraoperative Hypotension Threshold in Association with Stroke in Cardiac Surgery

2018 ◽  
Vol 129 (3) ◽  
pp. 440-447 ◽  
Author(s):  
Louise Y. Sun ◽  
Amy M. Chung ◽  
Michael E. Farkouh ◽  
Sean van Diepen ◽  
Jesse Weinberger ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Bypass Graft ◽  
Perioperative Stroke ◽  
Intraoperative Hypotension ◽  
Tertiary Center

Abstract What We Already Know about This Topic What This Article Tells Us That Is New Background Stroke is a leading cause of morbidity, mortality, and disability in patients undergoing cardiac surgery. Identifying modifiable perioperative stroke risk factors may lead to improved patient outcomes. The association between the severity and duration of intraoperative hypotension and postoperative stroke in patients undergoing cardiac surgery was evaluated. Methods A retrospective cohort study was conducted of adult patients who underwent cardiac surgery requiring cardiopulmonary bypass at a tertiary center between November 1, 2009, and March 31, 2015. The primary outcome was postoperative ischemic stroke. Intraoperative hypotension was defined as the number of minutes spent within mean arterial pressure bands of less than 55, 55 to 64, and 65 to 74 mmHg before, during, and after cardiopulmonary bypass. The association between stroke and hypotension was examined by using logistic regression with propensity score adjustment. Results Among the 7,457 patients included in this analysis, 111 (1.5%) had a confirmed postoperative diagnosis of stroke. Stroke was strongly associated with sustained mean arterial pressure of less than 64 mmHg during cardiopulmonary bypass (adjusted odds ratio 1.13; 95% CI, 1.05 to 1.21 for every 10 min of mean arterial pressure between 55 and 64 mmHg; adjusted odds ratio 1.16; 95% CI, 1.08 to 1.23 for every 10 min of mean arterial pressure less than 55 mmHg). Other factors that were independently associated with stroke were older age, hypertension, combined coronary artery bypass graft/valve surgery, emergent operative status, prolonged cardiopulmonary bypass duration, and postoperative new-onset atrial fibrillation. Conclusions Hypotension is a potentially modifiable risk factor for perioperative stroke. The study’s findings suggest that mean arterial pressure may be an important intraoperative therapeutic hemodynamic target to reduce the incidence of stroke in patients undergoing cardiopulmonary bypass.

scholarly journals Preoperative Risk and the Association between Hypotension and Postoperative Acute Kidney Injury

2020 ◽  
Vol 132 (3) ◽  
pp. 461-475 ◽  
Author(s):  
Keyword(s):  
Risk Factors ◽  
Acute Kidney Injury ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Validation Cohort ◽  
Kidney Injury ◽  
Preoperative Risk ◽  
Intraoperative Hypotension

Abstract Background Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk. Methods Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline). Results Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort. Conclusions Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Relationship between Intraoperative Mean Arterial Pressure and Clinical Outcomes after Noncardiac Surgery

2013 ◽  
Vol 119 (3) ◽  
pp. 507-515 ◽  
Author(s):  
Michael Walsh ◽  
Philip J. Devereaux ◽  
Amit X. Garg ◽  
Andrea Kurz ◽  
Alparslan Turan ◽  
...  
Keyword(s):  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Myocardial Injury ◽  
Randomized Trials ◽  
Cleveland Clinic ◽  
Kidney Injury ◽  
Intraoperative Hypotension ◽  
Confounding Variables ◽  
Blood Pressures ◽  
Postoperative Aki

Abstract Background: Intraoperative hypotension may contribute to postoperative acute kidney injury (AKI) and myocardial injury, but what blood pressures are unsafe is unclear. The authors evaluated the association between the intraoperative mean arterial pressure (MAP) and the risk of AKI and myocardial injury. Methods: The authors obtained perioperative data for 33,330 noncardiac surgeries at the Cleveland Clinic, Ohio. The authors evaluated the association between intraoperative MAP from less than 55 to 75 mmHg and postoperative AKI and myocardial injury to determine the threshold of MAP where risk is increased. The authors then evaluated the association between the duration below this threshold and their outcomes adjusting for potential confounding variables. Results: AKI and myocardial injury developed in 2,478 (7.4%) and 770 (2.3%) surgeries, respectively. The MAP threshold where the risk for both outcomes increased was less than 55 mmHg. Compared with never developing a MAP less than 55 mmHg, those with a MAP less than 55 mmHg for 1–5, 6–10, 11–20, and more than 20 min had graded increases in their risk of the two outcomes (AKI: 1.18 [95% CI, 1.06–1.31], 1.19 [1.03–1.39], 1.32 [1.11–1.56], and 1.51 [1.24–1.84], respectively; myocardial injury 1.30 [1.06–1.5], 1.47 [1.13–1.93], 1.79 [1.33–2.39], and 1.82 [1.31–2.55], respectively]. Conclusions: Even short durations of an intraoperative MAP less than 55 mmHg are associated with AKI and myocardial injury. Randomized trials are required to determine whether outcomes improve with interventions that maintain an intraoperative MAP of at least 55 mmHg.

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