Perioperative hypertension: defining at-risk patients and their management

An audit of postoperative haemodynamic stability after intraoperative labetalol administration in non-cardiac surgery patients

Anaesthesiologists commonly use intravenous labetalol to adjust patient haemodynamics during surgical procedures. Cases of profound hypotension after continuous labetalol infusions have been reported; however, there is limited evidence regarding the safety of intraoperative labetalol boluses. This audit examined the frequency of postoperative hypotension and bradycardia in 292 adult non-cardiac surgery patients treated with intraoperative labetalol boluses. Blood pressure and heart rate data were collected from the post-anaesthesia care unit and on the floor units for 24 hours after surgery. The median total intraoperative labetalol dose was 10mg. A total of 30/292 patients had all-cause postoperative hypotension within 24 hours of surgery, 26 of which had other medical or surgical precipitants. Fifteen patients developed bradycardia. There were no deaths or intensive care unit admissions attributed to labetalol. This audit demonstrates a low risk of all-cause postoperative hypotension (10%) and bradycardia (5%) after the use of small IV doses of intraoperative labetalol.

Proposal of a Modified Classification of Hypertensive Crises: Urgency, Impending Emergency, and Emergency

Systemic arterial hypertension (HTN) is the main cause of morbidity and mortality, and HTN crises contribute significantly to an unfavourable clinical course. For decades, HTN crises have been dichotomized into hypertensive emergency (HTN-E) and hypertensive urgency (HTN-U). The main difference between the two is the presence of acute hypertension-mediated organ damage (HMOD) - if HMOD is present, HTN crisis is HTN-E; if not, it is HTN-U. Patients with HTN-E are in a life-threatening situation. They are hospitalized and receive antihypertensive drugs intravenously (IV). On the other hand, patients with HTN-U are usually not hospitalized and receive their antihypertensives orally. We suggest a modification of the current risk stratification scheme for patients with HTN crises. The new category would be the intermediate risk group, more precisely the 'impending HTN-E' group, with a higher risk in comparison to HTN-U and a lower risk than HTN-E. 'Impending HMOD' means that HMOD has not occurred (yet), and the prognosis is, therefore, better than in patients with ongoing HMOD. There are three main reasons to classify patients as having impending HTN-E: excessively elevated BP, high-risk comorbidities, and ongoing bleeding/high bleeding risk. Their combinations are probable. This approach may enable us to prevent some HTNEs by avoiding acute HMOD using a timely blood pressure treatment. This treatment should be prompt but controlled.

Nomogram for predicting early complications after distal gastrectomy

BACKGROUND

Reducing or preventing postoperative morbidity in patients with gastric cancer (GC) is particularly important in perioperative treatment plans.

AIM

To identify risk factors for early postoperative complications of GC post-distal gastrectomy and to establish a nomogram prediction model.

METHODS

This retrospective study included 131 patients with GC who underwent distal gastrectomy at the Second Hospital of Shandong University between January 2019 and February 2023. The factors influencing the development of complications after distal gastrectomy in these patients were evaluated using univariate and multivariate logistic regression analysis. Based on the results obtained, a predictive nomogram was established. The nomogram was validated using internal and external (n = 45) datasets. Its sensitivity and specificity were established by receiver operating characteristic curve analysis. Decision curve (DCA) analysis was used to determine its clinical benefit and ten-fold overfitting was used to establish its accuracy and stability.

RESULTS

Multivariate logistic regression analysis showed that hypertension, diabetes, history of abdominal surgery, and perioperative blood transfusion were independent predictors of postoperative complications of distal gastrectomy. The modeling and validation sets showed that the area under the curve was 0.843 [95% confidence interval (CI): 0.746-0.940] and 0.877 (95%CI: 0.719-1.000), the sensitivity was 0.762 and 0.778, respectively, and the specificity was 0.809 and 0.944, respectively, indicating that the model had good sensitivity and specificity. The C-indexes of the modeling and validation datasets were 0.843 (95%CI: 0.746-0.940) and 0.877 (95%CI: 0.719-1.000), respectively. The calibration curve (Hosmer Lemeshow test: χ2 = 7.33) showed that the model had good consistency. The results of the DCA analysis indicated that this model offered good clinical benefits. The accuracy of 10-fold cross-validation was 0.878, indicating that the model had good accuracy and stability.

CONCLUSION

The nomogram prediction model based on independent risk factors related to postoperative complications of distal gastrectomy can facilitate perioperative intervention for high-risk populations and reduce the incidence of postoperative complications.

Consequences of Preoperative Oral Carbohydrate Consumption in Septal Deviation Patients Undergoing Endoscopic Septoplasty: A Retrospective Cohort Study

PURPOSE

Multiple reports have demonstrated the benefits of preoperative oral carbohydrates (CHO) in patients receiving open abdominal, thoracic, and orthopedic surgeries. However, thus far, no reports have investigated the benefits of CHO in patients undergoing nasal endoscopic surgery. Our goal was to evaluate the outcome of preoperative oral of administration of CHO in septal deviation patients, undergoing endoscopic septoplasty, under general anesthesia.

DESIGN

A retrospective cohort study from a prospectively collected database.

METHODS

Consecutive 400 septal deviation patients, undergoing endoscopic septoplasty, were randomly assigned to receive CHO or plain water (80 CHO cohort vs. 320 control cohort) before general anesthesia. The primary outcome was the risk of acute postoperative hypertension (APH). The secondary outcomes included length of hospital stay (LOS), hospitalization cost, sleep time the day before surgery, fluid infusion volume on surgical day, as well the incidence of postoperative nausea and vomiting (PONV) and aspiration.

FINDINGS

Patients in the CHO cohort experienced a lower risk of both diastolic blood pressure (DBP)-based APH (OR, 0.49; 95% CI, 0.25 to 0.96; P = 0.0375) and total APH (OR, 0.49; 95% CI, 0.26 to 0.92; P = 0.0258), lower LOS, lower hospitalization cost, longer sleep time and less fluid infusion volume after adjusting for gender, age, BMI, preoperative blood pressure and pulse. Besides, data showed no significant differences in the incidence of (P = 0.4173) and aspiration (P > 0.99).

CONCLUSIONS

Preoperative CHO administration can reduce APH risk in patients undergoing endoscopic septoplasty under general anesthesia. Besides, preoperative CHO administration can improve other clinical outcomes, such as, LOS, hospitalization cost, sleep time, and fluid infusion volume. Moreover, CHO safety was confirmed in our study. In the future, additional investigation is necessary to confirm our results.

Prediction of blood pressure changes associated with abdominal pressure changes during robotic laparoscopic low abdominal surgery using deep learning

Background

Intraoperative hypertension and blood pressure (BP) fluctuation are known to be associated with negative patient outcomes. During robotic lower abdominal surgery, the patient’s abdominal cavity is filled with CO₂, and the patient’s head is steeply positioned toward the floor (Trendelenburg position). Pneumoperitoneum and the Trendelenburg position together with physiological alterations during anesthesia, interfere with predicting BP changes. Recently, deep learning using recurrent neural networks (RNN) was shown to be effective in predicting intraoperative BP. A model for predicting BP rise was designed using RNN under special scenarios during robotic laparoscopic surgery and its accuracy was tested.

Methods

Databases that included adult patients (over 19 years old) undergoing low abdominal da Vinci robotic surgery (ovarian cystectomy, hysterectomy, myomectomy, prostatectomy, and salpingo-oophorectomy) at Soonchunhyang University Bucheon Hospital from October 2018 to March 2021 were used. An RNN-based model was designed using Python3 language with the PyTorch packages. The model was trained to predict whether hypertension (20% increase in the mean BP from baseline) would develop within 10 minutes after pneumoperitoneum.

Results

Eight distinct datasets were generated and the predictive power was compared. The macro-average F1 scores of the datasets ranged from 68.18% to 72.33%. It took only 3.472 milliseconds to obtain 39 prediction outputs.

Conclusions

A prediction model using the RNN may predict BP rises during robotic laparoscopic surgery.

A dynamic risk factor assessment for myocardial infarction and cardiac arrest in patients undergoing pancreatectomy

BACKGROUND

To identify pancreatectomy specific risk factors for myocardial infarction and cardiac arrest (MICA) and to assess whether addition of new information obtained during the hospitalization changes these risk factors.

METHODS

Analysis was performed on elective pancreatectomy data from the ACS-NSQIP database (2014-2019). Risk factors were grouped into pre-operative, intra-operative, and postoperative phases. Factors were selected using a bootstrap resampling procedure to determine MICA association. Independent significance was assessed by logistic regression.

RESULTS

In the first 30 days post-op, 650 of 39779 patients (1.88%) developed MICA. Some of the surgery specific, intra- and post-operative factors that were identified are: delayed gastric emptying (OR: 2.61; 95% CI: 2.12-3.21), total pancreatectomy (OR: 2.16; 95% CI: 1.29-3.42), pancreatic fistula (OR: 1.54; 95% CI: 1.25-1.90), post-operative transfusion (OR: 1.28; 95% CI: 1.03-1.58), and open approach (OR: 1.36; 95% CI: 1.05-1.77). Adding new variables improved statistical model performance and the c-statistic improved from 0.69 to 0.76 in the final analysis.

CONCLUSION

Surgery specific, intra-, and post-operative factors were associated with MICA. Addition of new information during the hospital course changed risk factors and the statistical prediction of MICA risk improved.

The association between nondipper pattern and perioperative hypertension in patients with controlled hypertension

BACKGROUND

Perioperative hypertension is a frequent complication even in preoperatively normotensive or controlled hypertensive patients and there is a lack of data regarding the effect of nondipping pattern on perioperative hypertension.

OBJECTIVE

In this study, we aimed to investigate the possible effect of nondipping blood pressure pattern on the risk of perioperative hypertension.

MATERIALS AND METHODS

234 hypertensive patients who underwent surgery with general anesthesia were evaluated prospectively. The study enrolled patients with well-controlled preoperative blood pressure. The 24-h ambulatory blood pressure monitoring results were used to classify patients as dippers and nondippers. Perioperative hypertension is defined as a systolic/diastolic arterial blood pressure greater than or equal to 160/90 mmHg or systolic blood pressure elevated by more than 20% from the patient's baseline level for more than 15 min perioperatively.

RESULTS

There were 61 (26%) nondipper patients [mean age: 62.1 ± 7.1 years, 25 (40.9%) men] and 173 (74%) dipper patients [mean age: 61.4 ± 8.1 years, 83 (47.9%) men]. In the nondipper group, perioperative hypertension was observed in 31 (51.3%) patients, whereas in the dipper group, 33 (19.3%) patients experienced a hypertensive attack (P < 0.001). The independent predictors of perioperative hypertension were the presence of the nondipping pattern [odds ratio (OR) 3.084; 95% confidence interval (CI) 1.831-5.195; P < 0.001], the presence of diabetes mellitus (OR 2.059; 95% CI 1.215-3.490; P = 0.007), and the number of drugs (OR 2.317; 95% CI 1.102-5.097; P = 0.027).

CONCLUSION

The frequency of perioperative hypertension was higher in preoperative normotensive and known hypertensive patients who were identified as nondippers. In addition, diabetes mellitus and number of drugs were found to be predictors of perioperative hypertension.

The burden of perioperative hypertension/hypotension: A systematic review

Study objective

Our goal is to review the outcomes of acute hypertensive/hypotensive episodes from articles published in the past 10 years that assessed the short- and long-term impact of acute hypertensive/hypotensive episodes in the perioperative setting.

Methods

We conducted a systematic peer review based upon PROSPERO and Cochrane Handbook protocols. The following study characteristics were collected: study type, author, year, population, sample size, their definition of acute hypertension, hypotension or other measures, and outcomes (probabilities, odds ratio, hazard ratio, and relative risk) and the p-values; and they were classified according to the type of surgery (cardiac and non-cardiac).

Results

A total of 3,680 articles were identified, and 66 articles fulfilled the criteria for data extraction. For the perioperative setting, the number of articles varies by outcome: 20 mortality, 16 renal outcomes, 6 stroke, 7 delirium and 34 other outcomes. Hypotension was reported to be associated with mortality (OR 1.02–20.826) as well as changes from the patient’s baseline blood pressure (BP) (OR 1.02–1.36); hypotension also had a role in the development of acute kidney injury (AKI) (OR 1.03–14.11). Postsurgical delirium was found in relation with BP lability (OR 1.018–1.038) and intra- and postsurgical hypotension (OR 1.05–1.22), and hypertension (OR 1.44–2.34). Increased OR (37.67) of intracranial hemorrhage was associated to postsurgical systolic BP >130 mmHg. There was a wide range of additional diverse outcomes related to hypo-, hypertension and BP lability.

Conclusions

The perioperative management of BP influences short- and long-term effects of surgical procedures in cardiac and non-cardiac interventions; these findings support the burden of BP fluctuations in this setting.

Rationale for the Concept of Impending Hypertension-Mediated Organ Damage

Background:

The number of patients with hypertension urgencies (HTN-Us) and emergencies (HTN-Es) in the emergency department is relatively constant despite improved detection, awareness and control of arterial hypertension.

Objective:

This study analyses the precision of the often-used definition of HTN-E, particularly the phrase ‘with the evidence of impending or progressive hypertension-mediated organ damage (HMOD)’. We then provide a rationale for the concept of impending HMOD.

MethodS:

We searched PubMed, Science Direct, Springer, Oxford Press, Wiley, SAGE and Google Scholar and analysed the relevant definition.

Results:

The definition of HTN-E is suboptimal and requires a consensus on whether to include the phrase ‘impending hypertensive HMOD’ in the definition.

Conclusion:

A consensus on the principles of treating the ‘impending hypertensive HMOD’ does not exist, making its use inconsistent in emergency departments worldwide. In this paper, we present a rationale for the concept of ‘impending HMOD’.

Comparative Study of Clevidipine to Nicardipine for Perioperative Hypertension in Patients Undergoing Cardiac Surgery

OBJECTIVE

The primary objective of this study was to compare the efficacy of clevidipine to nicardipine in the treatment of perioperative acute hypertension in patients undergoing cardiac surgery.

METHODS

This was a single-center retrospective study which included patients who received either clevidipine or nicardipine. Patients were followed for the duration of study drug infusion or for a maximum of 48 hours. Outcomes assessed included the percent of time spent within patient specific goal blood pressure, incidence of hypertensive events per patient, safety outcomes, and cost of medication treatment.

RESULTS

There were 201 cardiac surgeries performed between August 2018-January 2019 and July 2019-February 2020. Sixty-seven patients met our inclusion criteria of receiving either clevidipine (n = 29) or nicardipine (n = 38). The median percent of time spent within goal blood pressure range for clevidipine was 55.2% compared to 36.4% for nicardipine treatment (P = .036). The median number of hypertensive episodes per patient was 3 for clevidipine and 2 for nicardipine (P = .211). There were no identified differences in safety outcomes such as hypotension, vasopressor use, serum creatinine elevation, tachycardia, and atrial fibrillation. The median cost of treatment required for the observed 48-hour period with clevidipine was $128.58 compared to $55.74 for nicardipine (P < .001).

CONCLUSION

Our findings suggest that patients undergoing cardiac surgery on clevidipine had better perioperative blood pressure control compared to nicardipine, with a negligible increase in cost, and no observed difference in safety.

Preoperative Evaluation Before Noncardiac Surgery

The medical complexity of surgical patients is increasing and medical specialties are frequently asked to assist with the perioperative management surgical patients. Effective pre-anesthetic medical evaluations are a valuable tool in providing high-value, patient-centered surgical care and should systematically address risk assessment and identify areas for risk modification. This review outlines a structured approach to the pre-anesthetic medical evaluation, focusing on the asymptomatic patient. It discusses the evidence supporting the use of perioperative risk calculation tools and focused preoperative testing. We also introduce important key topics that will be explored in greater detail in upcoming reviews in this series.

Simultaneous Quantitation of a Novel α₁/β₁-Blocker TJ0711 and Its Two Metabolites in Dog Plasma Using LC-MS/MS and Its Application to a Pharmacokinetic Study after Intravenous Infusion

TJ0711∙HCl, which is a novel α₁/β₁ adrenoceptor blocking agent with a ratio of 1:1 for α₁/β₁, is designed to treat and prevent perioperative hypertension. M1 and M3 were identified as important metabolites in vitro for either antihypertension activity or the major metabolite production. In order to obtain a pharmacokinetic profile of both TJ0711 and its metabolites, a rapid, selective, and reliable LC-MS/MS method was developed and validated for simultaneous determination of TJ0711 and two metabolites in beagle dog plasma via efficiently separating two interferential metabolites M16 and M4 from M1 and M3, respectively. Chromatographic separation was achieved on a Waters CORTECS C18⁺ column (2.1 × 100 mm, 2.7 μm). The mass spectrometric detection was carried out in positive ion MRM mode with ESI⁺ source. Protein precipitation was used in sample preparation and provided good recovery without a matrix effect. Good linearity was observed at the ranges of 0.5–100 ng/mL for TJ0711 and M3, 0.1–20 ng/mL for M1. Additional validation results were within the acceptance limits followed U.S. FDA guidelines for bioanalytical method validation. This method was successfully applied to an intravenous infusion pharmacokinetic study of TJ0711 at dosing rates of 3, 6, and 12 µg/kg/min in anesthetized beagle dogs for the first time. TJ0711 and its two metabolites exhibited effective proportionality in the dosage of 3 to 12 µg/kg/min. Neither TJ0711 nor its metabolites showed significant differences in pharmacokinetic parameters such as t_1/2, CL, and V_ss among three dose groups.

Predictors of hypertension urgency in primary aldosteronism patients during the first 24 hours after surgery

Study about blood pressure variation in the first 24 hours post-operation is limited in patients with adrenal aldosterone-producing adenoma. We aim to evaluate the potential predictors for postoperative hypertension urgency during the first 24 hours after laparoscopic adrenalectomy in patients with aldosterone-producing adenoma. Clinical data of 177 patients with aldosterone-producing adenoma were retrospectively collected from January 2009 to December 2015 and the potential factors that may influence postoperative blood pressure during the first 24 hours after surgery were analyzed. The factors included gender, age, body mass index, preoperative maximum systolic blood pressure, number of antihypertensive medicines, preoperative spironolactone treatment, duration of hypertension, surgical method and approach, adenoma diameter, preoperative proteinuria, estimated glomerular filtration rate, serum potassium and serum aldosterone. Univariate and multivariate regression analyses were used to evaluate the relationship between the above variables and postoperative hypertension urgency. We found that the proportion of patients with a higher systolic blood pressure ≥ 160 mmHg and ≥ 180 mmHg were significantly increased post-operation (both p < 0.001). In multivariate analysis, the maximum systolic blood pressure was an independent predictor of postoperative hypertension urgency, and the cut-off point was 157 mmHg with the sensitivity of 66% and specificity of 82%. Multivariable analysis also showed that preoperative maximum systolic blood pressure and number of antihypertensive medicines were independent risk factors for higher postoperative systolic blood pressure. This study was derived from a high volume adrenal tumor center, and these data may provide a potential tool to guide preoperative counseling.

Therapeutic experience of 289 elderly patients with biliary diseases

AIM

To present clinical characteristics, diagnosis and treatment strategies in elderly patients with biliary diseases.

METHODS

A total of 289 elderly patients with biliary diseases were enrolled in this study. The clinical data relating to these patients were collected in our hospital from June 2013 to May 2016. Patient age, disease type, coexisting diseases, laboratory examinations, surgical methods, postoperative complications and therapeutic outcomes were analyzed.

RESULTS

The average age of the 289 patients with biliary diseases was 73.9 ± 8.5 years (range, 60-102 years). One hundred and thirty-one patients (45.3%) had one of 10 different biliary diseases, such as gallbladder stones, common bile duct stones, and cholangiocarcinoma. The remaining patients (54.7%) had two types of biliary diseases. One hundred and seventy-nine patients underwent 9 different surgical treatments, including pancreaticoduodenectomy, radical resection of hilar cholangiocarcinoma and laparoscopic cholecystectomy. Ten postoperative complications occurred with an incidence of 39.3% (68/173), and hypopotassemia showed the highest incidence (33.8%, 23/68). One hundred and sixteen patients underwent non-surgical treatments, including anti-infection, symptomatic and supportive treatments. The cure rate was 97.1% (168/173) in the surgical group and 87.1% (101/116) in the non-surgical group. The difference between these two groups was statistically significant (χ² = 17.227, P < 0.05).

CONCLUSION

Active treatment of coexisting diseases, management of indications and surgical opportunities, appropriate selection of surgical procedures, improvements in perioperative therapy, and timely management of postoperative complications are key factors in enhancing therapeutic efficacy in elderly patients with biliary diseases.

Preoperative β-blockade and hypertension in the first hour of functional endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Local anesthetic with epinephrine is commonly injected into the nasal mucosa during functional endoscopic sinus surgery (FESS). Systemic absorption of epinephrine following local injection may occur, resulting in a mild sympathetic response. This study seeks to determine whether an exaggerated sympathetic response to epinephrine is demonstrated in patients undergoing FESS treated preoperatively with established pharmacologic beta (β) adrenoceptor blockade.

STUDY DESIGN

A retrospective analysis of adult patients undergoing FESS at a tertiary care university hospital.

METHODS

The primary outcome was the occurrence of an exaggerated hypertensive response within the first hour of surgical time defined by a relative increase (>20%) in the first measured intraoperative systolic blood pressure (SBP) prior to induction of anesthesia, or a single SBP value above 200 mm Hg. A mixed effects logistic regression model was developed to identify independent predictors of an exaggerated hypertensive response and describe the variance in the outcome attributable to the surgeon and anesthesiologist.

RESULTS

There were 2,051 patients identified. Independent predictors of an exaggerated intraoperative hypertensive event included: preoperative β-blocker use (adjusted odds ratio [AOR]: 3.33), female gender (AOR: 1.92), body mass index (AOR: 1.03), lower baseline SBP (AOR: 0.93), and advanced age (AOR: 1.03). The C statistic for the model was 0.8881.

CONCLUSIONS

Preoperative β-blocker use is an independent predictor of an exaggerated hypertensive response within the first hour of operative time. An exaggerated hypertensive effect should be anticipated in patients presenting for FESS with established pharmacologic β-blockade, and caution should be applied to use of epinephrine-containing solutions.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1496-1505, 2017.

Hemodynamic Parameters during Laryngoscopic Procedures in the Office and in the Operating Room

Objective

Previous research has shown that office-based laryngoscopic procedures can induce hemodynamic changes, including tachycardia and severe hypertension, calling into question the safety of these procedures. However, comparison between office and operating room (OR) procedures has not been carried out. Therefore, we prospectively measured hemodynamic variables in both settings to compare hemodynamic changes between office and OR procedures.

Study Design

Prospective cohort study.

Setting

Single academic center.

Subjects and Methods

Subjects undergoing office and OR laryngoscopic procedures were prospectively identified, and 92 OR and 70 office subjects were included. Heart rate and blood pressure were measured at established time points before, during, and after the procedures. Descriptive and comparative statistical analyses were conducted.

Results

Severe hemodynamic events, either tachycardia or severe hypertension (blood pressure >180 mm Hg systolic or >110 mm Hg diastolic), occurred significantly more frequently in OR than office procedures (41% vs 20%; P = .006). OR severe hemodynamic events occurred more commonly than previously reported rates in the office (41% vs 28%; P = .012). Regression analyses showed that the odds of having a severe hemodynamic event were 3.66 times higher in OR versus office procedures.

Conclusion

Severe hemodynamic events are more likely to occur in the OR than in the office during laryngologic procedures. While larger studies will be required to establish rates of dangerous cardiovascular events in laryngoscopic procedures, hemodynamic parameters indicate that office-based procedures have a safety benefit for procedures that can be conducted in either setting.

Kidney transplantation in patients with severe preoperative hypertension

BACKGROUND

Severe systemic hypertension (HTN) is a risk factor for perioperative cardiovascular complications; however, its impact at the time of kidney transplantation (KTX) is not well defined.

METHODS

A retrospective cohort study of adult kidney-only transplant recipients between October 2009 and December 2012 was performed to examine outcomes between patients with (n = 111) and without (n = 98) severe preoperative HTN defined as SBP > 180 or DBP > 110 mmHg.

RESULTS

Recipients with severe HTN were older (56.7 ± 13.0 vs. 53.5 ± 12.4 yr, p = 0.07) and significantly more likely to receive an expanded criteria donor kidney (32.7% vs. 12.2%, p = 0.02). No patients developed hypertensive crisis, intracranial hemorrhage, or life threatening ventricular arrhythmias within 30 d post-transplantation; however, three patients with severe HTN had cardiac events: two with demand ischemia and one with decompensate heart failure. Two patients in the control group had decompensated heart failure. There were no differences between the groups in terms of cardiac event (2.7% vs. 2.0%, p = 0.75), one-yr patient survival (98.2% vs. 98.0%, p = 0.90) or graft survival (90.1% vs. 92.9%, p = 0.48), nadir creatinine > 2 mg/dL (4.6% vs. 6.2%, p = 0.62), length of stay > 6 d (37.8% vs. 35.7%, p = 0.75), and DGF (52.3% vs. 63.3%, p = 0.11).

CONCLUSIONS

Our results suggest that severe preoperative HTN should not be considered an absolute contraindication to kidney transplant in patients who are otherwise clinically stable.

Association between intraoperative blood pressure and postoperative delirium in elderly hip fracture patients

Background

One possible area of intervention to prevent postoperative delirium (PD) is intraoperative blood pressure management. However, the relationship between intraoperative blood pressure and PD is unclear. A secondary analysis of a RCT study examining the PD risk over the range of absolute intraoperative mean arterial blood pressure (MAP) readings and the corresponding relative changes from preoperative baseline level was performed to determine the role of MAP on PD.

Methods

Nonparametric locally weighted quadratic polynomial smoothing (LOESS) regression explored the pattern of PD risk at postoperative day 2 as a function of mean surgery MAP (msMAP) and percent change of msMAP from baseline in 103 elderly hip fracture patients. Segment-linear logistic regression models were then constructed to determine the odds ratios (OR) of PD over the observed range of these msMAP measures, adjusting for potential confounds.

Results

Twenty-three patients (22%) developed PD on day 2. LOESS regression revealed a j-shaped association between absolute levels of msMAP and PD risk. When msMAP was ≥80 mmHg, higher msMAP imparted greater PD risk (OR = 2.28 per 10 mmHg msMAP increase; 95% CI: 1.11–4.70), while higher msMAP was associated with lower PD risk (OR = 0.19 per 10 mmHg increase; CI: 0.05–0.76) if msMAP was <80 mmHg. There was no statistically significant relationship between PD risk and average percent change from baseline in these msMAP measures.

Conclusion

In elderly hip fracture patients, both very high and very low levels of msMAP were associated with significantly increased risk of PD.

Optimal perioperative management of arterial blood pressure

Perioperative blood pressure management is a key factor of patient care for anesthetists, as perioperative hemodynamic instability is associated with cardiovascular complications. Hypertension is an independent predictive factor of cardiac adverse events in noncardiac surgery. Intraoperative hypotension is one of the most encountered factors associated with death related to anesthesia. In the preoperative setting, the majority of antihypertensive medications should be continued until surgery. Only renin-angiotensin system antagonists may be stopped. Hypertension, especially in the case of mild to moderate hypertension, is not a cause for delaying surgery. During the intraoperative period, anesthesia leads to hypotension. Hypotension episodes should be promptly treated by intravenous vasopressors, and according to their etiology. In the postoperative setting, hypertension predominates. Continuation of antihypertensive medications and postoperative care may be insufficient. In these cases, intravenous antihypertensive treatments are used to control blood pressure elevation.