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.

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

Association between Intraoperative Hypotension and Myocardial Injury after Vascular Surgery

2016 ◽  
Vol 124 (1) ◽  
pp. 35-44 ◽  
Author(s):  
Judith A. R. van Waes ◽  
Wilton A. van Klei ◽  
Duminda N. Wijeysundera ◽  
Leo van Wolfswinkel ◽  
Thomas F. Lindsay ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Vascular Surgery ◽  
Arterial Blood Pressure ◽  
Mean Arterial Blood Pressure ◽  
Myocardial Injury ◽  
Arterial Blood ◽  
Intraoperative Hypotension ◽  
Cumulative Duration

Abstract Background Postoperative myocardial injury occurs frequently after noncardiac surgery and is strongly associated with mortality. Intraoperative hypotension (IOH) is hypothesized to be a possible cause. The aim of this study was to determine the association between IOH and postoperative myocardial injury. Methods This cohort study included 890 consecutive patients aged 60 yr or older undergoing vascular surgery from two university centers. The occurrence of myocardial injury was assessed by troponin measurements as part of a postoperative care protocol. IOH was defined by four different thresholds using either relative or absolute values of the mean arterial blood pressure based on previous studies. Either invasive or noninvasive blood pressure measurements were used. Poisson regression analysis was used to determine the association between IOH and postoperative myocardial injury, adjusted for potential clinical confounders and multiple comparisons. Results Depending on the definition used, IOH occurred in 12 to 81% of the patients. Postoperative myocardial injury occurred in 131 (29%) patients with IOH as defined by a mean arterial pressure less than 60 mmHg, compared with 87 (20%) patients without IOH (P = 0.001). After adjustment for potential confounding factors including mean heart rates, a 40% decrease from the preinduction mean arterial blood pressure with a cumulative duration of more than 30 min was associated with postoperative myocardial injury (relative risk, 1.8; 99% CI, 1.2 to 2.6, P < 0.001). Shorter cumulative durations (less than 30 min) were not associated with myocardial injury. Postoperative myocardial infarction and death within 30 days occurred in 26 (6%) and 17 (4%) patients with IOH as defined by a mean arterial pressure less than 60 mmHg, compared with 12 (3%; P = 0.08) and 15 (3%; P = 0.77) patients without IOH, respectively. Conclusions In elderly vascular surgery patients, IOH defined as a 40% decrease from the preinduction mean arterial blood pressure with a cumulative duration of more than 30 min was associated with postoperative myocardial injury.

scholarly journals Intraoperative Arterial Pressure Variability and Postoperative Acute Kidney Injury

2019 ◽  
Vol 15 (1) ◽  
pp. 35-46 ◽  
Author(s):  
Sehoon Park ◽  
Hyung-Chul Lee ◽  
Chul-Woo Jung ◽  
Yunhee Choi ◽  
Hyung Jin Yoon ◽  
...  
Keyword(s):  
Arterial Pressure ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Validation Cohort ◽  
Kidney Injury ◽  
Noncardiac Surgery ◽  
Discovery Cohort ◽  
Intraoperative Hypotension ◽  
Average Real Variability ◽  
Postoperative Aki

Background and objectivesHigh BP variability may cause AKI because of inappropriate kidney perfusion. This study aimed to investigate the association between intraoperative BP variability and postoperative AKI in patients who underwent noncardiac surgery.Design, setting, participants, & measurementsWe performed a cohort study of adults undergoing noncardiac surgery in hospitals in South Korea. We studied three cohorts using the following recording windows for intraoperative BP: discovery cohort, 1-minute intervals; first validation cohort, 5-minute intervals; and second validation cohort, 2-second intervals. We calculated four variability parameters (SD, coefficient of variation, variation independent of mean, and average real variability) based on the measured mean arterial pressure values. The primary outcomes were postoperative AKI (defined by the Kidney Disease Improving Global Outcomes serum creatinine cutoffs) and critical AKI (consisting of stage 2 or higher AKI and post-AKI death or dialysis within 90 days).ResultsIn the three cohorts, 45,520, 29,704, and 7435 patients were analyzed, each with 2230 (443 critical), 1552 (444 critical), and 300 (91 critical) postoperative AKI events, respectively. In the discovery cohort, all variability parameters were significantly associated with risk of AKI, even after adjusting for intraoperative hypotension. For example, average real variability was associated with higher risks of postoperative AKI (adjusted odds ratio, 1.13 per 1 SD increment; 95% CI, 1.07 to 1.19) and critical AKI (adjusted odds ratio, 1.13 per 1 SD increment; 95% CI, 1.02 to 1.26). Associations were evident predominantly among patients who also experienced intraoperative hypotension. In the validation analysis with 5-minute-interval BP records, all four variability parameters were associated with the risk of postoperative AKI or critical AKI. In the validation cohort with 2-second-interval BP records, average real variability was the only significant variability parameter.ConclusionsHigher intraoperative BP variability is associated with higher risks of postoperative AKI after noncardiac surgery, independent of hypotension and other clinical characteristics.

Increasing mean arterial pressure during cardiac surgery does not reduce the rate of postoperative acute kidney injury

Perfusion ◽  
2014 ◽  
Vol 29 (6) ◽  
pp. 496-504 ◽  
Author(s):  
A Azau ◽  
P Markowicz ◽  
JJ Corbeau ◽  
C Cottineau ◽  
X Moreau ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Cardiac Surgery ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Kidney Injury

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 Association of Intraoperative Hypotension with Acute Kidney Injury after Noncardiac Surgery in Patients Younger than 60 Years Old

2019 ◽  
Vol 44 (2) ◽  
pp. 211-221 ◽  
Author(s):  
Yongzhong Tang ◽  
Chaonan Zhu ◽  
Jiabin Liu ◽  
Anli Wang ◽  
Kaiming Duan ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Primary Outcome ◽  
Kidney Injury ◽  
Noncardiac Surgery ◽  
Intraoperative Hypotension ◽  
Outcome Relationship ◽  
Increased Risk ◽  
Interaction Factor ◽  
Surgical Duration ◽  
Postoperative Aki

Background/Aims: Intraoperative hypotension (IOH) may be associated with surgery-related acute kidney injury (AKI). However, the duration of hypotension that triggers AKI is poorly understood. The incidence of AKI with various durations of IOH and mean arterial pressures (MAPs) was investigated. Materials: A retrospective cohort study of 4,952 patients undergoing noncardiac surgery (2011 to 2016) with MAP monitoring and a length of stay of one or more days was performed. The exclusion criteria were a preoperative estimated glomerular filtration (eGFR) ≤60 mL min–1 1.73 m2–1, a preoperative MAP less than 65 mm Hg, dialysis dependence, urologic surgery, age older than 60 years, and a surgical duration of less than 60 min. The primary exposure was IOH, and the primary outcome was AKI (50% or 0.3 mg dL–1 increase in creatinine) during the first 7 postoperative days. Multivariable logistic regression was used to model the exposure-outcome relationship. Results: AKI occurred in 186 (3.76%) noncardiac surgery patients. The adjusted odds ratio for surgery-related AKI for a MAP of less than 55 mm Hg was 14.11 (95% confidence interval: 5.02–39.69) for an exposure of more than 20 min. Age was not an interaction factor between AKI and IOH. Conclusion: There was a considerably increased risk of postoperative AKI when intraoperative MAP was less than 55 mm Hg for more than 10 min. Strict blood pressure management is recommended even for patients younger than 60 years old.

A Non-inferiority Trial: Safety and Efficacy of Topical 1:1000 versus 1:10 000 Epinephrine in Sino-nasal Surgeries

2020 ◽  
pp. 000348942096282
Author(s):  
Cassie L. Dow ◽  
Anders W. Sideris ◽  
Ravjit Singh ◽  
Mitchell H. Giles ◽  
Catherine Banks ◽  
...  
Keyword(s):  
Heart Rate ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Nasal Passage ◽  
Hemodynamic Parameters ◽  
Hemodynamic Stability ◽  
Absolute Change ◽  
Significant Difference ◽  
Blood Pressures ◽  
Surgical Conditions

Objective: This study aimed to test the non-inferiority of topical 1:1000 epinephrine compared to topical 1:10 000 with regard to intraoperative hemodynamic stability, and to determine whether it produced superior visibility conditions. Methods: A single-blinded, prospective, cross-over non-inferiority trial was performed. Topical 1:1000 or topical 1:10 000 was placed in 1 nasal passage. Hemodynamic parameters (heart rate, systolic and diastolic blood pressures, and mean arterial pressure) were measured prior to insertion then every minute for 10 minutes. This was repeated in the contralateral nasal passage of the same patient with the alternate concentration. The surgeon graded the visualization of each passage using the Boezaart Scale. The medians of the greatest absolute change in parameters were compared using a Wilcoxon Rank-Signed test and confidence intervals were calculated using a Hodges-Lehman test. The non-inferiority margin was pre-determined at 10 bpm for heart rate and 10 mmHg for blood pressures. A Wilcoxon Rank-Signed test was used to assess superiority in visualization. Results: Thirty-two patients were enrolled and after exclusions, nineteen were assessed (mean age = 35.63 ± 12.49). Differences in means of greatest absolute change between the 2 concentrations were calculated (heart rate = 2.49 ± 1.20; systolic = −1.51 ± 2.16; diastolic = 2.47 ± 1.47; mean arterial pressure = 0.07 ± 1.83). In analyses of medians, 1:1000 was non-inferior to the 1:10 000. There was a significant difference (–0.58 ± 0.84; P = .012) in visualization in favor of topical 1:1000. Conclusion: Topical 1:1000 epinephrine provides no worse intraoperative hemodynamic stability compared to topical 1:10 000 but affords superior visualization and should be used to optimize surgical conditions.

Association between decreased blood pressure and azotaemia in canine babesiosis

2014 ◽  
Vol 17 (1) ◽  
pp. 173-175 ◽  
Author(s):  
W. Zygner ◽  
O. Gójska-Zygner
Keyword(s):  
Blood Pressure ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Serum Creatinine ◽  
Renal Damage ◽  
Systolic Arterial Pressure ◽  
Babesia Canis ◽  
Canine Babesiosis ◽  
Tubular Necrosis ◽  
Blood Pressures

Abstract Acute tubular necrosis (ATN) was described in canine babesiosis. Hypotension is considered as one of the factors which influence the development of hypoxic renal damage. In this study hypotension defined as mean arterial pressure (MAP) < 80 mmHg was detected in 7 out of 48 dogs (14.6%) infected with Babesia canis. Lower systolic arterial pressure (SAP), diastolic arterial pressure (DAP) and MAP were detected in azotaemic dogs infected with B. canis. Statistically significant negative correlations between blood pressures (SAP, DAP and MAP) and serum creatinine and urea concentrations showed the influence of decreased blood pressure on the development of azotaemia and is probably also associated with ATN in canine babesiosis.

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