1
|
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
Collapse
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
| |
Collapse
|
2
|
Saugel B, Fletcher N, Gan TJ, Grocott MPW, Myles PS, Sessler DI. PeriOperative Quality Initiative (POQI) international consensus statement on perioperative arterial pressure management. Br J Anaesth 2024:S0007-0912(24)00264-2. [PMID: 38839472 DOI: 10.1016/j.bja.2024.04.046] [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: 12/19/2023] [Revised: 03/09/2024] [Accepted: 04/05/2024] [Indexed: 06/07/2024] Open
Abstract
Arterial pressure monitoring and management are mainstays of haemodynamic therapy in patients having surgery. This article presents updated consensus statements and recommendations on perioperative arterial pressure management developed during the 11th POQI PeriOperative Quality Initiative (POQI) consensus conference held in London, UK, on June 4-6, 2023, which included a diverse group of international experts. Based on a modified Delphi approach, we recommend keeping intraoperative mean arterial pressure ≥60 mm Hg in at-risk patients. We further recommend increasing mean arterial pressure targets when venous or compartment pressures are elevated and treating hypotension based on presumed underlying causes. When intraoperative hypertension is treated, we recommend doing so carefully to avoid hypotension. Clinicians should consider continuous intraoperative arterial pressure monitoring as it can help reduce the severity and duration of hypotension compared to intermittent arterial pressure monitoring. Postoperative hypotension is often unrecognised and might be more important than intraoperative hypotension because it is often prolonged and untreated. Future research should focus on identifying patient-specific and organ-specific hypotension harm thresholds and optimal treatment strategies for intraoperative hypotension including choice of vasopressors. Research is also needed to guide monitoring and management strategies for recognising, preventing, and treating postoperative hypotension.
Collapse
Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, UK
| | - Tong J Gan
- Division of Anesthesiology and Perioperative Medicine, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
3
|
Kim J, Lee S, Choi J, Ryu DK, Woo S, Park M. Effect of continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers on the day of surgery on myocardial injury after non-cardiac surgery: A retrospective cohort study. J Clin Anesth 2024; 94:111401. [PMID: 38330844 DOI: 10.1016/j.jclinane.2024.111401] [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: 08/08/2023] [Revised: 01/17/2024] [Accepted: 01/23/2024] [Indexed: 02/10/2024]
Abstract
STUDY OBJECTIVE To evaluate the effect of continuing of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) prescriptions 24 h before surgery on postoperative myocardial injury and blood pressure in patients undergoing non-cardiac surgery. DESIGN A single-center, retrospective study. SETTING Operating room and perioperative care area. PATIENTS 42,432 patients who had been taking chronic ACEI/ARB underwent non-cardiac surgery from January 2012 to June 2022. INTERVENTIONS Patients who discontinued ACEI/ARB 24 h before surgery (withheld group, n=31,055) and those who continued ACEI/ARB 24 h before surgery (continued group, n=11,377). MEASUREMENTS Primary outcome was myocardial injury after non-cardiac surgery (MINS) within 7 days postoperatively. MINS was defined as an elevated postoperative cardiac troponin measurement above the 99th percentile of the upper reference limit with a rise/fall pattern. Perioperative blood pressure and clinical outcomes were secondary outcomes. MAIN RESULTS Among 42,432 patients, MINS occurred in 2848 patients (6.7%) and was the all-cause of death within 30 days in 122 patients (0.3%). Incidence of MINS was significantly higher in the continued group than the withheld group (847/11,377 [7.4%] vs. 2001/31,055 [6.4%]; OR [95% CI] 1.17 [1.07-1.27]; P<0.001). After 1:1 propensity score matching, 11,373 patients were included in each group. There was still a significant difference for the occurrence of MINS between two groups in matched cohort (7.4% vs. 6.6%, OR [95% CI] 1.14 [1.03-1.26]; P=0.015). Time-average weight of mean arterial pressure <65 mmHg during surgery was significantly higher in the continued group (mean 0.11 vs. 0.09 [95% CI of mean difference] [0.01-0.03]; P<0.001). However, there was no significant difference in other clinical outcomes and mortality. CONCLUSIONS Withholding ACEI/ARB before surgery was associated with a reduced risk of intraoperative hypotension and postoperative myocardial injury, but it did not affect overall clinical outcomes in patients undergoing non-cardiac surgery.
Collapse
Affiliation(s)
- Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seungwon Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jisun Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dae Kyun Ryu
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seunghyeon Woo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - MiHye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
4
|
Kouz K, Thiele R, Michard F, Saugel B. Haemodynamic monitoring during noncardiac surgery: past, present, and future. J Clin Monit Comput 2024; 38:565-580. [PMID: 38687416 PMCID: PMC11164815 DOI: 10.1007/s10877-024-01161-2] [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: 01/31/2024] [Accepted: 04/02/2024] [Indexed: 05/02/2024]
Abstract
During surgery, various haemodynamic variables are monitored and optimised to maintain organ perfusion pressure and oxygen delivery - and to eventually improve outcomes. Important haemodynamic variables that provide an understanding of most pathophysiologic haemodynamic conditions during surgery include heart rate, arterial pressure, central venous pressure, pulse pressure variation/stroke volume variation, stroke volume, and cardiac output. A basic physiologic and pathophysiologic understanding of these haemodynamic variables and the corresponding monitoring methods is essential. We therefore revisit the pathophysiologic rationale for intraoperative monitoring of haemodynamic variables, describe the history, current use, and future technological developments of monitoring methods, and finally briefly summarise the evidence that haemodynamic management can improve patient-centred outcomes.
Collapse
Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Robert Thiele
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | | | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
| |
Collapse
|
5
|
Galouzis N, Khawam M, Alexander EV, Khreiss MR, Luu C, Mesropyan L, Riall TS, Kwass WK, Dull RO. Pilot Study to Optimize Goal-directed Hemodynamic Management During Pancreatectomy. J Surg Res 2024; 300:173-182. [PMID: 38815516 DOI: 10.1016/j.jss.2024.04.035] [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: 12/01/2023] [Revised: 04/15/2024] [Accepted: 04/24/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Intraoperative goal-directed hemodynamic therapy (GDHT) is a cornerstone of enhanced recovery protocols. We hypothesized that use of an advanced noninvasive intraoperative hemodynamic monitoring system to guide GDHT may decrease intraoperative hypotension (IOH) and improve perfusion during pancreatic resection. METHODS The monitor uses machine learning to produce the Hypotension Prediction Index to predict hypotensive episodes. A clinical decision-making algorithm uses the Hypotension Prediction Index and hemodynamic data to guide intraoperative fluid versus pressor management. Pre-implementation (PRE), patients were placed on the monitor and managed per usual. Post-implementation (POST), anesthesia teams were educated on the algorithm and asked to use the GDHT guidelines. Hemodynamic data points were collected every 20 s (8942 PRE and 26,638 POST measurements). We compared IOH (mean arterial pressure <65 mmHg), cardiac index >2, and stroke volume variation <12 between the two groups. RESULTS 10 patients were in the PRE and 24 in the POST groups. In the POST group, there were fewer minimally invasive resections (4.2% versus 30.0%, P = 0.07), more pancreaticoduodenectomies (75.0% versus 20.0%, P < 0.01), and longer operative times (329.0 + 108.2 min versus 225.1 + 92.8 min, P = 0.01). After implementation, hemodynamic parameters improved. There was a 33.3% reduction in IOH (5.2% ± 0.1% versus 7.8% ± 0.3%, P < 0.01, a 31.6% increase in cardiac index >2.0 (83.7% + 0.2% versus 63.6% + 0.5%, P < 0.01), and a 37.6% increase in stroke volume variation <12 (73.2% + 0.3% versus 53.2% + 0.5%, P < 0.01). CONCLUSIONS Advanced intraoperative hemodynamic monitoring to predict IOH combined with a clinical decision-making tree for GDHT may improve intraoperative hemodynamic parameters during pancreatectomy. This warrants further investigation in larger studies.
Collapse
Affiliation(s)
| | - Maria Khawam
- Department of Surgery, University of Arizona, Tucson, Arizona
| | | | | | - Carrie Luu
- Department of Surgery, University of Arizona, Tucson, Arizona
| | | | - Taylor S Riall
- Department of Surgery, University of Arizona, Tucson, Arizona.
| | - William K Kwass
- Department of Anesthesia, University of Arizona, Tucson, Arizona
| | - Randal O Dull
- Department of Anesthesia, University of Arizona, Tucson, Arizona
| |
Collapse
|
6
|
Flick M, Lohr A, Weidemann F, Naebian A, Hoppe P, Thomsen KK, Krause L, Kouz K, Saugel B. Post-anesthesia care unit hypotension in low-risk patients recovering from non-cardiac surgery: a prospective observational study. J Clin Monit Comput 2024:10.1007/s10877-024-01176-9. [PMID: 38758404 DOI: 10.1007/s10877-024-01176-9] [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: 02/08/2024] [Accepted: 05/06/2024] [Indexed: 05/18/2024]
Abstract
Intraoperative hypotension is common and associated with organ injury. Hypotension can not only occur during surgery, but also thereafter. After surgery, most patients are treated in post-anesthesia care units (PACU). The incidence of PACU hypotension is largely unknown - presumably in part because arterial pressure is usually monitored intermittently in PACU patients. We therefore aimed to evaluate the incidence, duration, and severity of PACU hypotension in low-risk patients recovering from non-cardiac surgery. In this observational study, we performed blinded continuous non-invasive arterial pressure monitoring with finger-cuffs (ClearSight system; Edwards Lifesciences, Irvine, CA, USA) in 100 patients recovering from non-cardiac surgery in the PACU. We defined PACU hypotension as a mean arterial pressure (MAP) < 65 mmHg. Patients had continuous finger-cuff monitoring for a median (25th percentile, 75th percentile) of 64 (44 to 91) minutes. Only three patients (3%) had PACU hypotension for at least one consecutive minute. These three patients had 4, 4, and 2 cumulative minutes of PACU hypotension; areas under a MAP of 65 mmHg of 17, 9, and 9 mmHg x minute; and time-weighted averages MAP less than 65 mmHg of 0.5, 0.3, and 0.2 mmHg. The median volume of crystalloid fluid patients were given during PACU treatment was 200 (100 to 400) ml. None was given colloids or a vasopressor during PACU treatment. In low-risk patients recovering from non-cardiac surgery, the incidence of PACU hypotension was very low and the few episodes of PACU hypotension were short and of modest severity.
Collapse
Affiliation(s)
- Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anneke Lohr
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Weidemann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ashkan Naebian
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
| |
Collapse
|
7
|
Bar S, Moussa MD, Descamps R, El Amine Y, Bouhemad B, Fischer MO, Lorne E, Dupont H, Diouf M, Guinot PG. Determinants of postoperative complications in high-risk noncardiac surgery patients optimized with hemodynamic treatment strategies: A post-hoc analysis of a randomized multicenter clinical trial. J Clin Anesth 2024; 93:111325. [PMID: 37992534 DOI: 10.1016/j.jclinane.2023.111325] [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: 04/06/2023] [Revised: 10/23/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023]
Abstract
STUDY OBJECTIVE This post-hoc analysis of a randomized controlled trial was undertaken to establish the determinants of postoperative complications and acute kidney injury in high-risk noncardiac surgery patients supported with hemodynamic treatment strategies. DESIGN We conducted a post-hoc analysis of patients enrolled in the OPtimization Hemodynamic Individualized by the respiratory QUotiEnt (OPHIQUE) trial. SETTING Operating rooms in four university medical centers and one non-university hospital from December 26, 2018, to September 9, 2021. PATIENTS We enrolled 350 patients with a high risk of postoperative complications undergoing high-risk noncardiac surgery lasting 2 h or longer under general anesthesia. INTERVENTIONS All patients were treated according to hemodynamic treatment strategies which included cardiac output optimization by titration of fluid challenge and targeted systolic blood pressure to remain within ±10% of the reference value. MEASUREMENTS We assessed the association between pre-operative and intra-operative exposure of interest with a composite primary outcome of major complications or death within seven days following surgery using a multivariable logistic regression model. We also assessed the association between these exposures of interest and acute kidney injury. MAIN RESULTS The data of 341 patients were analyzed. In multivariate analysis, the factors independently associated with the primary outcome were age (OR = 1.04 (1.01-1.06), P = 0.002), preoperative hemoglobin concentration (OR = 0.85 (0.75-0.96), P = 0.012), non-vascular surgery (OR = 0.30 (0.17-0.53), P < 0.0001), and intraoperative surgical complications (OR = 2.08 (1.02-4.24), P = 0.046). The factors independently associated with postoperative acute kidney injury were age (OR = 1.04 (1.01-1.08), P = 0.008), preoperative creatinine concentration (OR = 1.01 (1.00-1.01), P = 0.049), non-vascular surgery (OR = 0.36 (0.20-0.66), P = 0.001), and intraoperative surgical complications (OR = 3.36 (1.50-7.55), P = 0.031). CONCLUSIONS Surgical complications, a lower preoperative hemoglobin concentration, age, and vascular surgery were associated with postoperative complications in a high-risk noncardiac surgery population supported with hemodynamic treatment strategies.
Collapse
Affiliation(s)
- Stéphane Bar
- Department of Anesthesiology and Critical Care Medicine, Amiens University Medical Centre, Amiens, France; SSPC UPJV 7518 (Simplifications des Soins Patients Chirurgicaux Complexes - Simplification of Care of Complex Surgical Patients) Clinical Research Unit, Jules Verne University of Picardie, Amiens, France.
| | - Mouhamed Djahoum Moussa
- Department of Anesthesiology and Critical Care Medicine, Lille University Medical Centre, Lille, France
| | - Richard Descamps
- Department of Anesthesiology and Critical Care Medicine, Caen University Medical Center, Caen, France
| | - Younes El Amine
- Department of Anesthesiology and Critical Care Medicine, Valenciennes Medical Center, Valenciennes, France
| | - Belaid Bouhemad
- Department of Anesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, Dijon, France
| | | | - Emmanuel Lorne
- Department of Anesthesia and Critical Care Medicine, Millénaire Clinic, Montpellier, France
| | - Hervé Dupont
- Department of Anesthesiology and Critical Care Medicine, Amiens University Medical Centre, Amiens, France; SSPC UPJV 7518 (Simplifications des Soins Patients Chirurgicaux Complexes - Simplification of Care of Complex Surgical Patients) Clinical Research Unit, Jules Verne University of Picardie, Amiens, France
| | - Momar Diouf
- Biostatistical Unit, Direction de la Recherche Clinique, University Hospital of Amiens Picardy, Amiens, France
| | - Pierre Grégoire Guinot
- Department of Anesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, Dijon, France
| |
Collapse
|
8
|
Krone S, Bokoch MP, Kothari R, Fong N, Tallarico RT, Sturgess-DaPrato J, Pirracchio R, Zarbock A, Legrand M. Association between peripheral perfusion index and postoperative acute kidney injury in major noncardiac surgery patients receiving continuous vasopressors: a post hoc exploratory analysis of the VEGA-1 trial. Br J Anaesth 2024; 132:685-694. [PMID: 38242802 DOI: 10.1016/j.bja.2023.11.054] [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: 05/16/2023] [Revised: 10/26/2023] [Accepted: 11/24/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND The peripheral perfusion index is the ratio of pulsatile to nonpulsatile static blood flow obtained by photoplethysmography and reflects peripheral tissue perfusion. We investigated the association between intraoperative perfusion index and postoperative acute kidney injury in patients undergoing major noncardiac surgery and receiving continuous vasopressor infusions. METHODS In this exploratory post hoc analysis of a pragmatic, cluster-randomised, multicentre trial, we obtained areas and cumulative times under various thresholds of perfusion index and investigated their association with acute kidney injury in multivariable logistic regression analyses. In secondary analyses, we investigated the association of time-weighted average perfusion index with acute kidney injury. The 30-day mortality was a secondary outcome. RESULTS Of 2534 cases included, 8.9% developed postoperative acute kidney injury. Areas and cumulative times under a perfusion index of 3% and 2% were associated with an increased risk of acute kidney injury; the strongest association was observed for area under a perfusion index of 1% (adjusted odds ratio [aOR] 1.32, 95% confidence interval [CI] 1.00-1.74, P=0.050, per 100%∗min increase). Additionally, time-weighted average perfusion index was associated with acute kidney injury (aOR 0.82, 95% CI 0.74-0.91, P<0.001) and 30-day mortality (aOR 0.68, 95% CI 0.49-0.95, P=0.024). CONCLUSIONS Larger areas and longer cumulative times under thresholds of perfusion index and lower time-weighted average perfusion index were associated with postoperative acute kidney injury in patients undergoing major noncardiac surgery and receiving continuous vasopressor infusions. CLINICAL TRIAL REGISTRATION NCT04789330.
Collapse
Affiliation(s)
- Sina Krone
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA; Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Michael P Bokoch
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Rishi Kothari
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Nicholas Fong
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Roberta T Tallarico
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Jillene Sturgess-DaPrato
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Romain Pirracchio
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Matthieu Legrand
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA; INI-CRCT Network, Nancy, France.
| |
Collapse
|
9
|
Bao X, Kumar SS, Shah NJ, Penning D, Weinstein M, Malhotra G, Rose S, Drover D, Pennington MW, Domino K, Meng L, Treggiari M, Clavijo C, Wagener G, Chitilian H, Maheshwari K. AcumenTM hypotension prediction index guidance for prevention and treatment of hypotension in noncardiac surgery: a prospective, single-arm, multicenter trial. Perioper Med (Lond) 2024; 13:13. [PMID: 38439069 PMCID: PMC10913612 DOI: 10.1186/s13741-024-00369-9] [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: 08/06/2023] [Accepted: 02/25/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Intraoperative hypotension is common during noncardiac surgery and is associated with postoperative myocardial infarction, acute kidney injury, stroke, and severe infection. The Hypotension Prediction Index software is an algorithm based on arterial waveform analysis that alerts clinicians of the patient's likelihood of experiencing a future hypotensive event, defined as mean arterial pressure < 65 mmHg for at least 1 min. METHODS Two analyses included (1) a prospective, single-arm trial, with continuous blood pressure measurements from study monitors, compared to a historical comparison cohort. (2) A post hoc analysis of a subset of trial participants versus a propensity score-weighted contemporaneous comparison group, using external data from the Multicenter Perioperative Outcomes Group (MPOG). The trial included 485 subjects in 11 sites; 406 were in the final effectiveness analysis. The post hoc analysis included 457 trial participants and 15,796 comparison patients. Patients were eligible if aged 18 years or older, American Society of Anesthesiologists (ASA) physical status 3 or 4, and scheduled for moderate- to high-risk noncardiac surgery expected to last at least 3 h. MEASUREMENTS minutes of mean arterial pressure (MAP) below 65 mmHg and area under MAP < 65 mmHg. RESULTS Analysis 1: Trial subjects (n = 406) experienced a mean of 9 ± 13 min of MAP below 65 mmHg, compared with the MPOG historical control mean of 25 ± 41 min, a 65% reduction (p < 0.001). Subjects with at least one episode of hypotension (n = 293) had a mean of 12 ± 14 min of MAP below 65 mmHg compared with the MPOG historical control mean of 28 ± 43 min, a 58% reduction (p< 0.001). Analysis 2: In the post hoc inverse probability treatment weighting model, patients in the trial demonstrated a 35% reduction in minutes of hypotension compared to a contemporaneous comparison group [exponentiated coefficient: - 0.35 (95%CI - 0.43, - 0.27); p < 0.001]. CONCLUSIONS The use of prediction software for blood pressure management was associated with a clinically meaningful reduction in the duration of intraoperative hypotension. Further studies must investigate whether predictive algorithms to prevent hypotension can reduce adverse outcomes. TRIAL REGISTRATION Clinical trial number: NCT03805217. Registry URL: https://clinicaltrials.gov/ct2/show/NCT03805217 . Principal investigator: Xiaodong Bao, MD, PhD. Date of registration: January 15, 2019.
Collapse
Affiliation(s)
- Xiaodong Bao
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Sathish S Kumar
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Nirav J Shah
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Donald Penning
- Department of Anesthesiology, Henry Ford Health System, Detroit, MI, USA
| | - Mitchell Weinstein
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gaurav Malhotra
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sydney Rose
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - David Drover
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Matthew W Pennington
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Karen Domino
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Lingzhong Meng
- Department of Anesthesiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mariam Treggiari
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Claudia Clavijo
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gebhard Wagener
- Department of Anesthesiology, College of Physicians & Surgeons of Columbia University, New York, NY, USA
| | - Hovig Chitilian
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kamal Maheshwari
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
10
|
Kant M, van Klei WA, Hollmann MW, Veelo DP, Kappen TH. The effect of proactive versus reactive treatment of hypotension on postoperative disability and outcome in surgical patients under anaesthesia (PRETREAT): clinical trial protocol and considerations. BJA OPEN 2024; 9:100262. [PMID: 38440053 PMCID: PMC10910055 DOI: 10.1016/j.bjao.2024.100262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/30/2024] [Indexed: 03/06/2024]
Abstract
Background Intraoperative hypotension has been extensively studied for its association with adverse outcomes. However, small sample sizes and methodological issues limit the causal inference that can be drawn. Methods In this multicentre, adaptive, randomised controlled trial, we will include 5000 adult inpatients scheduled for elective non-cardiac surgery under general or central neuraxial anaesthesia. Patients will be either randomly allocated to the intervention or care-as-usual group using computer-generated blocks of four, six, or eight, with an allocation ratio of 1:1. In the intervention arm patients will be divided into low-, intermediate-, and high-risk groups based on their likelihood to experience intraoperative hypotension, with resulting mean blood pressure targets of 70, 80, and 90 mm Hg, respectively. Anaesthesia teams will be provided with a clinical guideline on how to keep patients at their target blood pressure. During the first 6 months of the trial the intervention strategy will be evaluated and further revised in adaptation cycles of 3 weeks if necessary, to improve successful impact on the clinical process. The primary outcome is postoperative disability after 6 months measured with the World Health Organization Disability Assessment Score (WHODAS) 2.0 questionnaire. Ethics and dissemination This study protocol has been approved by the Medical Ethics Committee of the University Medical Centre Utrecht (20-749) and all protocol amendments will be communicated to the Medical Ethics Committee. The study protocol is in adherence with the Declaration of Helsinki and the guideline of Good Clinical Practice. Dissemination plans include publication in a peer-reviewed journal. Clinical trial registration The Dutch Trial Register, NL9391. Registered on 22 March 2021.
Collapse
Affiliation(s)
- Matthijs Kant
- Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Wilton A. van Klei
- Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Markus W. Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centre, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Denise P. Veelo
- Department of Anaesthesiology, Amsterdam University Medical Centre, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Teus H. Kappen
- Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| |
Collapse
|
11
|
Saugel B, Annecke T, Bein B, Flick M, Goepfert M, Gruenewald M, Habicher M, Jungwirth B, Koch T, Kouz K, Meidert AS, Pestel G, Renner J, Sakka SG, Sander M, Treskatsch S, Zitzmann A, Reuter DA. Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies. J Clin Monit Comput 2024:10.1007/s10877-024-01132-7. [PMID: 38381359 DOI: 10.1007/s10877-024-01132-7] [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: 01/18/2024] [Accepted: 01/25/2024] [Indexed: 02/22/2024]
Abstract
Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).
Collapse
Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Thorsten Annecke
- Department of Anesthesiology and Intensive Care Medicine, Cologne Merheim Medical Center, Hospital of the University of Witten/Herdecke, Cologne, Germany
| | - Berthold Bein
- Department for Anaesthesiology, Asklepios Hospital Hamburg St. Georg, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Goepfert
- Department of Anaesthesiology and Intensive Care Medicine, Alexianer St. Hedwigkliniken Berlin, Berlin, Germany
| | - Matthias Gruenewald
- Department of Anaesthesiology and Intensive Care Medicine, Evangelisches Amalie Sieveking Krankenhaus, Hamburg, Germany
| | - Marit Habicher
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Bettina Jungwirth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Tilo Koch
- Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Marburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Agnes S Meidert
- Department of Anaesthesiology, University Hospital LMU Munich, Munich, Germany
| | - Gunther Pestel
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jochen Renner
- Department of Anesthesiology and Intensive Care Medicine, Municipal Hospital Kiel, Kiel, Germany
| | - Samir G Sakka
- Department of Intensive Care Medicine, Gemeinschaftsklinikum Mittelrhein gGmbH, Academic Teaching Hospital of the Johannes Gutenberg University Mainz, Koblenz, Germany
| | - Michael Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Amelie Zitzmann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
| | - Daniel A Reuter
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
| |
Collapse
|
12
|
Noto A, Chalkias A, Madotto F, Ball L, Bignami EG, Cecconi M, Guarracino F, Messina A, Morelli A, Princi P, Sanfilippo F, Scolletta S, Tritapepe L, Cortegiani A. Continuous vs intermittent Non-Invasive blood pressure MONitoring in preventing postoperative organ failure (niMON): study protocol for an open-label, multicenter randomized trial. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:7. [PMID: 38321507 PMCID: PMC10845743 DOI: 10.1186/s44158-024-00142-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/18/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Blood pressure has become one of the most important vital signs to monitor in the perioperative setting. Recently, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) recommended, with low level of evidence, continuous monitoring of blood pressure during the intraoperative period. Continuous monitoring allows for early detection of hypotension, which may potentially lead to a timely treatment. Whether the ability to detect more hypotension events by continuous noninvasive blood pressure (C-NiBP) monitoring can improve patient outcomes is still unclear. Here, we report the rationale, study design, and statistical analysis plan of the niMON trial, which aims to evaluate the effect of intraoperative C-NiBP compared with intermittent (I-NiBP) monitoring on postoperative myocardial and renal injury. METHODS The niMon trial is an investigator-initiated, multicenter, international, open-label, parallel-group, randomized clinical trial. Eligible patients will be randomized in a 1:1 ratio to receive C-NiBP or I-NiBP as an intraoperative monitoring strategy. The proportion of patients who develop myocardial injury in the first postoperative week is the primary outcome; the secondary outcomes are the proportions of patients who develop postoperative AKI, in-hospital mortality rate, and 30 and 90 postoperative days events. A sample size of 1265 patients will provide a power of 80% to detect a 4% absolute reduction in the rate of the primary outcome. CONCLUSIONS The niMON data will provide evidence to guide the choice of the most appropriate intraoperative blood pressure monitoring strategy. CLINICAL TRIAL REGISTRATION Clinical Trial Registration: NCT05496322, registered on the 5th of August 2023.
Collapse
Affiliation(s)
- Alberto Noto
- Division of Anesthesia and Intensive Care, Department of Human Pathology of the Adult and Evolutive Age "Gaetano Barresi", Policlinico "G. Martino", University of Messina, Messina, Italy.
| | - Athanasios Chalkias
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104-5158, USA
- Outcomes Research Consortium, Cleveland, OH, 44195, USA
| | - Fabiana Madotto
- Dipartimento Area Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Elena Giovanna Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, 20089, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Moltancini 4, Pieve Emanuele, Milan, 20072, Italy
| | - Fabio Guarracino
- Cardiothoracic and Vascular Anesthesia and Intensive Care, Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, 20089, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Moltancini 4, Pieve Emanuele, Milan, 20072, Italy
| | - Andrea Morelli
- Department Clinical Internal, Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza," Policlinico Umberto Primo, Rome, Italy
| | - Pietro Princi
- Consiglio Nazionale Delle Ricerche, CNR-IPCF, Messina, Italy
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy
| | - Sabino Scolletta
- Department of Medicine, Surgery and Neuroscience, Anesthesia and Intensive Care Unit, University of Siena, Siena, Italy
| | - Luigi Tritapepe
- Unit of Anesthesia and Intensive Care, San Camillo-Forlanini Hospital, Rome, Italy
| | - Andrea Cortegiani
- Department of Surgical Oncological and Oral Science, University of Palermo, Palermo, Italy
- Department of Anesthesia Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| |
Collapse
|
13
|
Gore P, Liu H, Bohringer C. Can Currently Available Non-invasive Continuous Blood Pressure Monitors Replace Invasive Measurement With an Arterial Catheter? Cureus 2024; 16:e54707. [PMID: 38529464 PMCID: PMC10961923 DOI: 10.7759/cureus.54707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/27/2024] Open
Abstract
Deviations from normal blood pressure (BP) during general anesthesia have been clearly linked to several adverse outcomes. Measuring BP accurately is therefore critically important for producing excellent outcomes in health care. Normal BP does not necessarily guarantee adequate organ perfusion however and adverse events have occurred even when BP seemed adequate. Invasive blood pressure monitoring has recently evolved beyond merely measuring BP. Arterial line-derived pulse contour analysis is used now to assess both cardiac output and stroke volume variation as indices of adequate intravascular volume. Confirmation of acceptable cardiac output with data derived from invasive intra-arterial catheters has become very important when managing high-risk patients. Newer devices that measure BP continuously and non-invasively in the digital arteries via a finger cuff have also become available. Many clinicians contemplate now if these new devices are ready to replace invasive monitoring with an arterial catheter. Unlike non-invasive devices, intra-arterial catheters allow frequent blood sampling. This makes it possible to assess vital parameters like pH, hemoglobin concentration, ionized calcium, potassium, glucose, and arterial partial pressure of oxygen and carbon dioxide frequently. Non-invasive continuous BP measurement has been found to be unreliable in critically ill patients, the elderly, and patients with calcified arteries. Pulse contour-derived estimates of cardiac output and stroke volume variation have been validated better with data derived from arterial lines than that from the newer finger cuff monitors. Significant advances have been recently made with non-invasive continuous BP monitors. Invasive monitoring with an arterial line however remains the gold standard for measuring BP and assessing pulse contour analysis-derived hemodynamic variables in critically ill patients. In the future, non-invasive continuous BP monitors will likely replace intermittent oscillometers in the operating room and the postoperative period. They will however not eliminate the need for arterial catheterization in critically ill patients.
Collapse
Affiliation(s)
- Payton Gore
- Anesthesiology, University of California Davis Medical Center, Sacramento, USA
| | - Hong Liu
- Anesthesiology, University of California Davis Medical Center, Sacramento, USA
| | - Christian Bohringer
- Anesthesiology, University of California Davis Medical Center, Sacramento, USA
| |
Collapse
|
14
|
Michard F, Joosten A, Futier E. Intraoperative blood pressure: could less be more? Br J Anaesth 2023; 131:810-812. [PMID: 37778938 DOI: 10.1016/j.bja.2023.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/03/2023] Open
Abstract
Retrospective observational studies have reported a significant association between intraoperative hypotension and postoperative morbidity. However, association does not imply causation, and whether preventing intraoperative hypotension can improve patient outcome remains to be demonstrated. In this issue of the British Journal of Anaesthesia, D'Amico and colleagues meta-analysed 10 prospective randomised trials comparing low (≤60 mm Hg) and higher mean arterial pressure targets during anaesthesia and surgery. They did not observe an increase in postoperative morbidity and mortality in the low target group. In contrast, they reported a statistically significant (but not clinically relevant) reduction in postoperative cardiac arrhythmia and hospital length of stay when targeting mean arterial pressure ≤60 mm Hg. These findings suggest that during most surgical cases, intraoperative hypotension is a marker of the severity, frailty, or both rather than a mediator of postoperative complications.
Collapse
Affiliation(s)
| | - Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Villejuif, France
| | - Emmanuel Futier
- Department of Anesthesia and Critical Care, Université Clermont Auvergne, Hopital d'Estaing, Clermont-Ferrand, France
| |
Collapse
|
15
|
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.
Collapse
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.
| |
Collapse
|
16
|
Mol KHJM, Liem VGB, van Lier F, Stolker RJ, Hoeks SE. Intraoperative hypotension in noncardiac surgery patients with chronic beta-blocker therapy: A matched cohort analysis. J Clin Anesth 2023; 89:111143. [PMID: 37216803 DOI: 10.1016/j.jclinane.2023.111143] [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: 09/06/2022] [Revised: 04/19/2023] [Accepted: 05/01/2023] [Indexed: 05/24/2023]
Abstract
STUDY OBJECTIVE To explore the incidence of intraoperative hypotension in patients with chronic beta-blocker therapy, expressed as time spent, area and time-weighted average under predefined mean arterial pressure thresholds. DESIGN Retrospective analysis of a prospective observational cohort registry. SETTING Patients ≥60 years undergoing intermediate- to high-risk noncardiac surgery with routine postoperative troponin measurements on the first three days after surgery. PATIENTS 1468 matched sets of patients (1:1 ratio with replacement) with and without chronic beta-blocker treatment. INTERVENTIONS None. MEASUREMENTS The primary outcome was the exposure to intraoperative hypotension in beta-blocker users vs. non-users. Time spent, area and time-weighted average under predefined mean arterial pressure thresholds (55-75 mmHg) were calculated to express the duration and severity of exposure. Secondary outcomes included incidence of postoperative myocardial injury and thirty-day mortality, myocardial infarction (MI) and stroke. Furthermore, analyses for patient subgroup and beta-blocker subtype were conducted. MAIN RESULTS In patients with chronic beta-blocker therapy, no increased exposure to intraoperative hypotension was observed for all characteristics and thresholds calculated (all P > .05). Beta-blocker users had lower heart rate before, during and after surgery (70 vs. 74, 61 vs. 65 and 68 vs. 74 bpm, all P < .001, respectively). Postoperative myocardial injury (13.6% vs. 11.6%, P = .269) and thirty-day mortality (2.5% vs. 1.4%, P = .055), MI (1.4% vs. 1.5%, P = .944) and stroke (1.0% vs 0.7%, P = .474) rates were comparable. The results were consistent in subtype and subgroup analyses. CONCLUSIONS In this matched cohort analysis, chronic beta-blocker therapy was not associated with increased exposure to intraoperative hypotension in patients undergoing intermediate- to high-risk noncardiac surgery. Furthermore, differences in patient subgroups and postoperative adverse cardiovascular events as a function of treatment regimen could not be demonstrated.
Collapse
Affiliation(s)
- Kristin H J M Mol
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Victor G B Liem
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Felix van Lier
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Robert Jan Stolker
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Sanne E Hoeks
- Department of Anesthesia, Erasmus University Medical Center, Rotterdam, the Netherlands.
| |
Collapse
|
17
|
Kouz K, Weidemann F, Naebian A, Lohr A, Bergholz A, Thomsen KK, Krause L, Petzoldt M, Moll-Khosrawi P, Sessler DI, Flick M, Saugel B. Continuous Finger-cuff versus Intermittent Oscillometric Arterial Pressure Monitoring and Hypotension during Induction of Anesthesia and Noncardiac Surgery: The DETECT Randomized Trial. Anesthesiology 2023; 139:298-308. [PMID: 37265355 DOI: 10.1097/aln.0000000000004629] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Finger-cuff methods allow noninvasive continuous arterial pressure monitoring. This study aimed to determine whether continuous finger-cuff arterial pressure monitoring helps clinicians reduce hypotension within 15 min after starting induction of anesthesia and during noncardiac surgery. Specifically, this study tested the hypotheses that continuous finger-cuff-compared to intermittent oscillometric-arterial pressure monitoring helps clinicians reduce the area under a mean arterial pressure of 65 mmHg within 15 min after starting induction of anesthesia and the time-weighted average mean arterial pressure less than 65 mmHg during noncardiac surgery. METHODS In this single-center trial, 242 noncardiac surgery patients were randomized to unblinded continuous finger-cuff arterial pressure monitoring or to intermittent oscillometric arterial pressure monitoring (with blinded continuous finger-cuff arterial pressure monitoring). The first of two hierarchical primary endpoints was the area under a mean arterial pressure of 65 mmHg within 15 min after starting induction of anesthesia; the second primary endpoint was the time-weighted average mean arterial pressure less than 65 mmHg during surgery. RESULTS Within 15 min after starting induction of anesthesia, the median (interquartile range) area under a mean arterial pressure of 65 mmHg was 7 (0, 24) mmHg × min in 109 patients assigned to continuous finger-cuff monitoring versus 19 (0.3, 60) mmHg × min in 113 patients assigned to intermittent oscillometric monitoring (P = 0.004; estimated location shift: -6 [95% CI: -15 to -0.3] mmHg × min). During surgery, the median (interquartile range) time-weighted average mean arterial pressure less than 65 mmHg was 0.04 (0, 0.27) mmHg in 112 patients assigned to continuous finger-cuff monitoring and 0.40 (0.03, 1.74) mmHg in 115 patients assigned to intermittent oscillometric monitoring (P < 0.001; estimated location shift: -0.17 [95% CI: -0.41 to -0.05] mmHg). CONCLUSIONS Continuous finger-cuff arterial pressure monitoring helps clinicians reduce hypotension within 15 min after starting induction of anesthesia and during noncardiac surgery compared to intermittent oscillometric arterial pressure monitoring. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Weidemann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ashkan Naebian
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anneke Lohr
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Parisa Moll-Khosrawi
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; and Outcomes Research Consortium, Cleveland, Ohio
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and Outcomes Research Consortium, Cleveland, Ohio
| |
Collapse
|
18
|
Michard F, Futier E. Predicting intraoperative hypotension: from hope to hype and back to reality. Br J Anaesth 2023; 131:199-201. [PMID: 36997473 DOI: 10.1016/j.bja.2023.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/30/2023] Open
Abstract
The analysis of arterial pressure waveforms with machine learning algorithms has been proposed to predict intraoperative hypotension. The ability to forecast arterial hypotension 5-15 min ahead of the fall in blood pressure allows clinicians to be pro-active instead of reactive, and could potentially decrease postoperative morbidity. However, the predictive value of machine learning algorithms has been overestimated due to selection bias in several clinical studies, and they might not be superior to mere observation of arterial pressure. Continuous blood pressure monitoring enables immediate detection of hypotension, and giving fluid, vasopressors or inotropes to patients who are not yet (and might never become) hypotensive based on an algorithm is questionable. Finally, recent prospective interventional studies suggest that reducing intraoperative hypotension does not improve postoperative outcomes.
Collapse
Affiliation(s)
| | - Emmanuel Futier
- Department of Anesthesia and Critical Care, Université Clermont Auvergne, Hopital d'Estaing, Clermont-Ferrand, France
| |
Collapse
|
19
|
Yoon HK, Kim YJ, Lee HS, Seo JH, Kim HS. A randomised controlled trial of the analgesia nociception index for intra-operative remifentanil dose and pain after gynaecological laparotomy. Anaesthesia 2023; 78:988-994. [PMID: 36960477 DOI: 10.1111/anae.16008] [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] [Accepted: 02/25/2023] [Indexed: 03/25/2023]
Abstract
We aimed to investigate the effect of the analgesia nociception index on postoperative pain. We randomly allocated 170 women scheduled for gynaecological laparotomy and analysed results from 159: in 80 women, remifentanil was infused to maintain analgesia nociception indices 50-70; and in 79 women, remifentanil was infused to maintain systolic blood pressure < 120% of baseline values. The primary outcome was the proportion of women with pain scores ≥ 5 (scale 0-10) within 40 min of admission to recovery. The proportion of women with pain scores ≥ 5 was 62/80 (78%) vs. 64/79 (81%), p = 0.73. Mean (SD) doses of fentanyl in recovery were 53.6 (26.9) μg vs. 54.8 (20.8) μg, p = 0.74. Intra-operative remifentanil doses were 0.124 (0.050) μg.kg-1 .min-1 vs. 0.129 (0.044) μg.kg-1 .min-1 , p = 0.55.
Collapse
Affiliation(s)
- H-K Yoon
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Y J Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - H S Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - J-H Seo
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - H-S Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
20
|
Bergholz A, Greiwe G, Kouz K, Saugel B. Continuous Blood Pressure Monitoring in Patients Having Surgery: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1299. [PMID: 37512110 PMCID: PMC10385393 DOI: 10.3390/medicina59071299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/11/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Abstract
Hypotension can occur before, during, and after surgery and is associated with postoperative complications. Anesthesiologists should thus avoid profound and prolonged hypotension. A crucial part of avoiding hypotension is accurate and tight blood pressure monitoring. In this narrative review, we briefly describe methods for continuous blood pressure monitoring, discuss current evidence for continuous blood pressure monitoring in patients having surgery to reduce perioperative hypotension, and expand on future directions and innovations in this field. In summary, continuous blood pressure monitoring with arterial catheters or noninvasive sensors enables clinicians to detect and treat hypotension immediately. Furthermore, advanced hemodynamic monitoring technologies and artificial intelligence-in combination with continuous blood pressure monitoring-may help clinicians identify underlying causes of hypotension or even predict hypotension before it occurs.
Collapse
Affiliation(s)
- Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Gillis Greiwe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| |
Collapse
|
21
|
Fuchita M, Pattee J, Russell DW, Driver BE, Prekker ME, Barnes CR, Brewer JM, Doerschug KC, Gaillard JP, Gandotra S, Ghamande S, Gibbs KW, Hughes CG, Janz DR, Khan A, Mitchell SH, Page DB, Rice TW, Self WH, Smith LM, Stempek SB, Trent SA, Vonderhaar DJ, West JR, Whitson MR, Williamson K, Semler MW, Casey JD, Ginde AA. Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials. Crit Care Explor 2023; 5:e0946. [PMID: 37457916 PMCID: PMC10344527 DOI: 10.1097/cce.0000000000000946] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Hypotension affects approximately 40% of critically ill patients undergoing emergency intubation and is associated with an increased risk of death. The objective of this study was to examine the association between prophylactic vasopressor administration and the incidence of peri-intubation hypotension and other clinical outcomes. DESIGN A secondary analysis of two multicenter randomized clinical trials. The clinical effect of prophylactic vasopressor administration was estimated using a one-to-one propensity-matched cohort of patients with and without prophylactic vasopressors. SETTING Seven emergency departments and 17 ICUs across the United States. PATIENTS One thousand seven hundred ninety-eight critically ill patients who underwent emergency intubation at the study sites between February 1, 2019, and May 24, 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was peri-intubation hypotension defined as a systolic blood pressure less than 90 mm Hg occurring between induction and 2 minutes after tracheal intubation. A total of 187 patients (10%) received prophylactic vasopressors prior to intubation. Compared with patients who did not receive prophylactic vasopressors, those who did were older, had higher Acute Physiology and Chronic Health Evaluation II scores, were more likely to have a diagnosis of sepsis, had lower pre-induction systolic blood pressures, and were more likely to be on continuous vasopressor infusions prior to intubation. In our propensity-matched cohort, prophylactic vasopressor administration was not associated with reduced risk of peri-intubation hypotension (41% vs 32%; p = 0.08) or change in systolic blood pressure from baseline (-12 vs -11 mm Hg; p = 0.66). CONCLUSIONS The administration of prophylactic vasopressors was not associated with a lower incidence of peri-intubation hypotension in our propensity-matched analysis. To address potential residual confounding, randomized clinical trials should examine the effect of prophylactic vasopressor administration on peri-intubation outcomes.
Collapse
Affiliation(s)
- Mikita Fuchita
- Department of Anesthesiology, Division of Critical Care, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jack Pattee
- Department of Biostatistics & Informatics, Center for Innovative Design & Analysis, Colorado School of Public Health, Aurora, CO
| | - Derek W Russell
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
- Pulmonary Section, Birmingham Veterans Affairs Medical Center, Birmingham, AL
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Christopher R Barnes
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Joseph M Brewer
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, MS
| | | | - John P Gaillard
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Anesthesiology, Section on Critical Care, Wake Forest School of Medicine, Winston-Salem, NC
| | - Sheetal Gandotra
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Shekhar Ghamande
- Department of Medicine, Division of Pulmonary Disease and Critical Care Medicine, Baylor Scott & White Medical Center, Temple, TX
| | - Kevin W Gibbs
- Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest School of Medicine, Winston-Salem, NC
| | - Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - David R Janz
- University Medical Center New Orleans, New Orleans, LA
- Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA
| | - Akram Khan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University School of Medicine, Portland, OR
| | - Steven H Mitchell
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - David B Page
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Lane M Smith
- Department of Internal Medicine, University of Iowa, Iowa City, IA
| | - Susan B Stempek
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA
| | - Stacy A Trent
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
| | - Derek J Vonderhaar
- Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, LA
| | - Jason R West
- Department of Emergency Medicine, NYC Health + Hospitals | Lincoln, Bronx, NY
| | - Micah R Whitson
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Kayla Williamson
- Department of Biostatistics & Informatics, Center for Innovative Design & Analysis, Colorado School of Public Health, Aurora, CO
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Jonathan D Casey
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| |
Collapse
|
22
|
Puliyanda D, Barday Z, Barday Z, Freedman A, Todo T, Chen AKC, Davidson B. Children Are Not Small Adults: Similarities and Differences in Renal Transplantation Between Adults and Pediatrics. Semin Nephrol 2023; 43:151442. [PMID: 37949683 DOI: 10.1016/j.semnephrol.2023.151442] [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] [Indexed: 11/12/2023]
Abstract
Kidney transplantation is the treatment of choice for all patients with end-stage kidney disease, including pediatric patients. Graft survival in pediatrics was lagging behind adults, but now is comparable with the adult cohort. Although many of the protocols have been adopted from adults, there are issues unique to pediatrics that one should be aware of to take care of this population. These issues include recipient size consideration, increased incidence of viral infections, problems related to growth, common occurrence of underlying urological issues, and psychosocial issues. This article addresses the similarities and differences in renal transplantation, from preparing a patient for transplant, the transplant process, to post-transplant complications.
Collapse
Affiliation(s)
- Dechu Puliyanda
- Pediatric Nephrology and Comprehensive Transplant Program, Cedars Sinai Medical Center, Los Angeles, CA.
| | - Zibya Barday
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Zunaid Barday
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Andrew Freedman
- Pediatric Nephrology and Comprehensive Transplant Program, Cedars Sinai Medical Center, Los Angeles, CA
| | - Tsuyoshi Todo
- Pediatric Nephrology and Comprehensive Transplant Program, Cedars Sinai Medical Center, Los Angeles, CA
| | - Allen Kuang Chung Chen
- Pediatric Nephrology and Comprehensive Transplant Program, Cedars Sinai Medical Center, Los Angeles, CA
| | - Bianca Davidson
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
23
|
Szabó M, Pleck AP, Soós SÁ, Keczer B, Varga B, Széll J. A preoperative ultrasound-based protocol for optimisation of fluid therapy to prevent early intraoperative hypotension: a randomised controlled study. Perioper Med (Lond) 2023; 12:30. [PMID: 37370150 DOI: 10.1186/s13741-023-00320-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Intraoperative hypotension is a risk factor for postoperative complications. Preoperative dehydration is a major contributor, although it is difficult to estimate its severity. Point-of-care ultrasound offers several potential methods, including measurements of the inferior vena cava. The addition of lung ultrasound may offer a safety limit. We aimed to evaluate whether the implication of an ultrasound-based preoperative fluid therapy protocol can decrease the incidence of early intraoperative hypotension. METHODS Randomised controlled study in a tertiary university department involves elective surgical patients of ASA 2-3 class, scheduled for elective major abdominal surgery under general anaesthesia with intubation. We randomised 40-40 patients; 38-38 were available for analysis. Conventional fluid therapy was ordered on routine preoperative visits. Ultrasound-based protocol evaluated the collapsibility index of inferior vena cava and lung ultrasound profiles. Scans were performed twice: 2 h and 30 min before surgery. A high collapsibility index (≥ 40%) indicated a standardised fluid bolus, while the anterior B-profile of the lung ultrasound contraindicated further fluid. The primary outcome was the incidence of postinduction and early intraoperative (0-10 min) hypotension (MAP < 65 mmHg and/or ≥ 30% of decrease from baseline). Secondary endpoints were postoperative lactate level, urine output and lung ultrasound score at 24 h. RESULTS The absolute criterion of postinduction hypotension was fulfilled in 12 patients in the conventional group (31.6%) and 3 in the ultrasound-based group (7.9%) (p = 0.0246). Based on composite criteria of absolute and/or relative hypotension, we observed 17 (44.7%) and 7 (18.4%) cases, respectively (p = 0.0136). The incidence of early intraoperative hypotension was also lower: HR for absolute hypotension was 2.10 (95% CI 1.00-4.42) in the conventional group (p = 0.0387). Secondary outcome measures were similar in the study groups. CONCLUSION We implemented a safe and effective point-of-care ultrasound-based preoperative fluid replacement protocol into perioperative care. TRIAL REGISTRATION The study was registered to ClinicalTrials.gov on 10/12/2021, registration number: NCT05171608 (registered prospectively on 10/12/2021).
Collapse
Affiliation(s)
- Marcell Szabó
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary.
| | | | - Sándor Árpád Soós
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Bánk Keczer
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Balázs Varga
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - János Széll
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| |
Collapse
|
24
|
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: 3.0] [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.
Collapse
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
| |
Collapse
|
25
|
Kouz K, Monge García MI, Cerutti E, Lisanti I, Draisci G, Frassanito L, Sander M, Ali Akbari A, Frey UH, Grundmann CD, Davies SJ, Donati A, Ripolles-Melchor J, García-López D, Vojnar B, Gayat É, Noll E, Bramlage P, Saugel B. Intraoperative hypotension when using hypotension prediction index software during major noncardiac surgery: a European multicentre prospective observational registry (EU HYPROTECT). BJA OPEN 2023; 6:100140. [PMID: 37588176 PMCID: PMC10430826 DOI: 10.1016/j.bjao.2023.100140] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/19/2023] [Accepted: 03/28/2023] [Indexed: 08/18/2023]
Abstract
Background Intraoperative hypotension is associated with organ injury. Current intraoperative arterial pressure management is mainly reactive. Predictive haemodynamic monitoring may help clinicians reduce intraoperative hypotension. The Acumen™ Hypotension Prediction Index software (HPI-software) (Edwards Lifesciences, Irvine, CA, USA) was developed to predict hypotension. We built up the European multicentre, prospective, observational EU HYPROTECT Registry to describe the incidence, duration, and severity of intraoperative hypotension when using HPI-software monitoring in patients having noncardiac surgery. Methods We enrolled 749 patients having elective major noncardiac surgery in 12 medical centres in five European countries. Patients were monitored using the HPI-software. We quantified hypotension using the time-weighted average MAP <65 mm Hg (primary endpoint), the proportion of patients with at least one ≥1 min episode of a MAP <65 mm Hg, the number of ≥1 min episodes of a MAP <65 mm Hg, and duration patients spent below a MAP of 65 mm Hg. Results We included 702 patients in the final analysis. The median time-weighted average MAP <65 mm Hg was 0.03 (0.00-0.20) mm Hg. In addition, 285 patients (41%) had no ≥1 min episode of a MAP <65 mm Hg; 417 patients (59%) had at least one. The median number of ≥1 min episodes of a MAP <65 mm Hg was 1 (0-3). Patients spent a median of 2 (0-9) min below a MAP of 65 mm Hg. Conclusions The median time-weighted average MAP <65 mm Hg was very low in patients in this registry. This suggests that using HPI-software monitoring may help reduce the duration and severity of intraoperative hypotension in patients having noncardiac surgery.
Collapse
Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Elisabetta Cerutti
- Department of Anesthesia, Transplant and Surgical Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Ivana Lisanti
- Department of Anesthesia, Transplant and Surgical Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Gaetano Draisci
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Luciano Frassanito
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Michael Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Amir Ali Akbari
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Ulrich H. Frey
- Department of Anesthesiology, Intensive Care, Pain and Palliative Care, Marien Hospital Herne, Ruhr-University Bochum, Bochum, Germany
| | - Carla Davina Grundmann
- Department of Anesthesiology, Intensive Care, Pain and Palliative Care, Marien Hospital Herne, Ruhr-University Bochum, Bochum, Germany
| | - Simon James Davies
- York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
- Centre for Health and Population Sciences, Hull York Medical School, York, UK
| | - Abele Donati
- Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Javier Ripolles-Melchor
- Anesthesia and Critical Care Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Daniel García-López
- Department of Anaesthesiology and Reanimation, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Benjamin Vojnar
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany
| | - Étienne Gayat
- Université Paris Cité, INSERM, Paris, France
- Department of Anesthesia and Critical Care Medicine, Hôpital Lariboisière, Paris, France
| | - Eric Noll
- Department of Anesthesiology and Intensive Care, Hôpital de Hautepierre, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| |
Collapse
|
26
|
Frassanito L, Giuri PP, Vassalli F, Piersanti A, Garcia MIM, Sonnino C, Zanfini BA, Catarci S, Antonelli M, Draisci G. Hypotension Prediction Index guided Goal Directed therapy and the amount of Hypotension during Major Gynaecologic Oncologic Surgery: a Randomized Controlled clinical Trial. J Clin Monit Comput 2023:10.1007/s10877-023-01017-1. [PMID: 37119322 PMCID: PMC10372133 DOI: 10.1007/s10877-023-01017-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 04/14/2023] [Indexed: 05/01/2023]
Abstract
Intraoperative hypotension (IOH) is associated with increased morbidity and mortality. Hypotension Prediction Index (HPI) is a machine learning derived algorithm that predicts IOH shortly before it occurs. We tested the hypothesis that the application of the HPI in combination with a pre-defined Goal Directed Therapy (GDT) hemodynamic protocol reduces IOH during major gynaecologic oncologic surgery. We enrolled women scheduled for major gynaecologic oncologic surgery under general anesthesia with invasive arterial pressure monitoring. Patients were randomized to a GDT protocol aimed at optimizing stroke volume index (SVI) or hemodynamic management based on HPI guidance in addition to GDT. The primary outcome was the amount of IOH, defined as the timeweighted average (TWA) mean arterial pressure (MAP) < 65 mmHg. Secondary outcome was the TWA-MAP < 65 mmHg during the first 20 min after induction of GA. After exclusion of 10 patients the final analysis included 60 patients (30 in each group). The median (25-75th IQR) TWA-MAP < 65 mmHg was 0.14 (0.04-0.66) mmHg in HPI group versus 0.77 (0.36-1.30) mmHg in Control group, P < 0.001. During the first 20 min after induction of GA, the median TWA-MAP < 65 mmHg was 0.53 (0.06-1.8) mmHg in the HPI group and 2.15 (0.65-4.2) mmHg in the Control group, P = 0.001. Compared to a GDT protocol aimed to SVI optimization, a machine learning-derived algorithm for prediction of IOH combined with a GDT hemodynamic protocol, reduced IOH and hypotension after induction of general anesthesia in patients undergoing major gynaecologic oncologic surgery.Trial registration number: NCT04547491. Date of registration: 10/09/2020.
Collapse
Affiliation(s)
- Luciano Frassanito
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, Rome, Italy.
| | - Pietro Paolo Giuri
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Francesco Vassalli
- Department of Critical Care and Perinatal Medicine, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genova, Italy
| | - Alessandra Piersanti
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, Rome, Italy
| | | | - Chiara Sonnino
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Bruno Antonio Zanfini
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Stefano Catarci
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Massimo Antonelli
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Gaetano Draisci
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, Rome, Italy
| |
Collapse
|
27
|
Bello C, Rössler J, Shehata P, Smilowitz NR, Ruetzler K. Perioperative strategies to reduce risk of myocardial injury after non-cardiac surgery (MINS): A narrative review. J Clin Anesth 2023; 87:111106. [PMID: 36931053 DOI: 10.1016/j.jclinane.2023.111106] [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: 01/03/2023] [Revised: 02/06/2023] [Accepted: 03/03/2023] [Indexed: 03/17/2023]
Abstract
Myocardial injury is a frequent complication of surgical patients after having non-cardiac surgery that is strongly associated with perioperative mortality. While intraoperative anesthesia-related deaths are exceedingly rare, about 1% of patients undergoing non-cardiac surgery die within the first 30 postoperative days. Given the number of surgeries performed annually, death following surgery is the second leading cause of death in the United States. Myocardial injury after non-cardiac surgery (MINS) is defined as an elevation in troponin concentrations within 30 days postoperatively. Although typically asymptomatic, patients with MINS suffer myocardial damage and have a 10% risk of death within 30 days after surgery and excess risks of mortality that persist during the first postoperative year. Many factors for the development of MINS are non-modifiable, such as preexistent coronary artery disease. Preventive measures, systematic approaches to surveillance and treatment standards are still lacking, however many factors are modifiable and should be considered in clinical practice: the importance of hemodynamic control, adequate oxygen supply, metabolic homeostasis, the use of perioperative medications such as statins, anti-thrombotic agents, beta-blockers, or anti-inflammatory agents, as well as some evidence regarding the choice of sedative and analgesic for anesthesia are discussed. Also, as age and complexity in comorbidities of the surgical patient population increase, there is an urgent need to identify patients at risk for MINS and develop prevention and treatment strategies. In this review, we provide an overview of current screening standards and promising preventive options in the perioperative setting and address knowledge gaps requiring further investigation.
Collapse
Affiliation(s)
- Corina Bello
- Department of Anaesthesiology and Pain Medicine, Inselspital Bern, University Hospital, University of Bern, Switzerland
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Peter Shehata
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, United States of America; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, New York, NY, United States of America
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America.
| |
Collapse
|
28
|
Lee CT, Lin CP, Chan KC, Wu YL, Teng HC, Wu CY. Effects of Goal-Directed Hemodynamic Therapy Using a Noninvasive Finger-Cuff Monitoring Device on Intraoperative Cerebral Oxygenation and Early Delayed Neurocognitive Recovery in Patients Undergoing Beach Chair Position Shoulder Surgery: A Randomized Controlled Trial. Anesth Analg 2023; 136:355-364. [PMID: 36135341 DOI: 10.1213/ane.0000000000006200] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Perioperative cerebral desaturation events (CDEs) and delayed neurocognitive recovery are common among patients undergoing beach chair position (BCP) shoulder surgery and may be caused by cerebral hypoperfusion. This study tested the hypothesis that the application of goal-directed hemodynamic therapy (GDHT) would attenuate these conditions. METHODS We randomly assigned 70 adult patients undergoing BCP shoulder surgery to GDHT group or control at a 1:1 ratio. Cerebral oxygenation was monitored using near-infrared spectroscopy, and GDHT was administered using the ClearSight pulse wave analysis system. The primary outcome was CDE duration, whereas the secondary outcomes were CDE occurrence, delayed neurocognitive recovery occurrence, and Taiwanese version of the Quick Mild Cognitive Impairment (Qmci-TW) test score on the first postoperative day (T 2 ) adjusted for the baseline score (on the day before surgery; T 1 ). RESULTS CDE duration was significantly shorter in the GDHT group (0 [0-0] vs 15 [0-75] min; median difference [95% confidence interval], -8 [-15 to 0] min; P = .007). Compared with the control group, fewer patients in the GDHT group experienced CDEs (23% vs 51%; relative risk [95% confidence interval], 0.44 [0.22-0.89]; P = .025) and mild delayed neurocognitive recovery (17% vs 40%; relative risk [95% confidence interval], 0.60 [0.39-0.93]; P = .034). The Qmci-TW scores at T 2 adjusted for the baseline scores at T 1 were significantly higher in the GDHT group (difference in means: 4 [0-8]; P = .033). CONCLUSIONS Implementing GDHT using a noninvasive finger-cuff monitoring device stabilizes intraoperative cerebral oxygenation and is associated with improved early postoperative cognitive scores in patients undergoing BCP shoulder surgery.
Collapse
Affiliation(s)
- Chen-Tse Lee
- From the Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Peng Lin
- From the Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Cheng Chan
- From the Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Luen Wu
- Department of Medical Education, National Taiwan University, Taipei, Taiwan
| | - Hsiao-Chun Teng
- From the Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Yu Wu
- From the Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
29
|
Subramani Y, Rajarathinam M, Veldhoven K, Taneja N, Querney J, Fatima N, Nagappa M. Comparison of hemodynamic stability with continuous noninvasive blood pressure monitoring and intermittent oscillometric blood pressure monitoring in hospitalized patients: A systematic review and meta-analysis. Anesth Essays Res 2023. [DOI: 10.4103/aer.aer_119_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
|
30
|
Terwindt LE, Schuurmans J, van der Ster BJP, Wensing CAGCL, Mulder MP, Wijnberge M, Cherpanath TGV, Lagrand WK, Karlas AA, Verlinde MH, Hollmann MW, Geerts BF, Veelo DP, Vlaar APJ. Incidence, Severity and Clinical Factors Associated with Hypotension in Patients Admitted to an Intensive Care Unit: A Prospective Observational Study. J Clin Med 2022; 11:jcm11226832. [PMID: 36431308 PMCID: PMC9696980 DOI: 10.3390/jcm11226832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/19/2022] [Accepted: 11/15/2022] [Indexed: 11/22/2022] Open
Abstract
Background: The majority of patients admitted to the intensive care unit (ICU) experience severe hypotension which is associated with increased morbidity and mortality. At present, prospective studies examining the incidence and severity of hypotension using continuous waveforms are missing. Methods: This study is a prospective observational cohort study in a mixed surgical and non-surgical ICU population. All patients over 18 years were included and continuous arterial pressure waveforms data were collected. Mean arterial pressure (MAP) below 65 mmHg for at least 10 s was defined as hypotension and a MAP below 45 mmHg as severe hypotension. The primary outcome was the incidence of hypotension. Secondary outcomes were the severity of hypotension expressed in time-weighted average (TWA), factors associated with hypotension, the number and duration of hypotensive events. Results: 499 patients were included. The incidence of hypotension (MAP < 65 mmHg) was 75% (376 out of 499) and 9% (46 out of 499) experienced severe hypotension. Median TWA was 0.3 mmHg [0−1.0]. Associated clinical factors were age, male sex, BMI and cardiogenic shock. There were 5 (1−12) events per patients with a median of 52 min (5−170). Conclusions: In a mixed surgical and non-surgical ICU population the incidence of hypotension is remarkably high.
Collapse
Affiliation(s)
- Lotte E. Terwindt
- Department of Anesthesiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - Jaap Schuurmans
- Department of Intensive Care, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - Björn J. P. van der Ster
- Department of Anesthesiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - Carin A. G. C. L. Wensing
- Department of Anesthesiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - Marijn P. Mulder
- Cardiovascular and Respiratory Physiology Group, Technical Medical Center, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - Marije Wijnberge
- Department of Anesthesiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - Thomas G. V. Cherpanath
- Department of Intensive Care, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - Wim K. Lagrand
- Department of Intensive Care, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - Alain A. Karlas
- Department of Anesthesiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - Mark H. Verlinde
- Department of Anesthesiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - Markus W. Hollmann
- Department of Anesthesiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - Bart F. Geerts
- Department of Anesthesiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - Denise P. Veelo
- Department of Anesthesiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-(0)20-562-7421
| | - Alexander P. J. Vlaar
- Department of Intensive Care, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1105 AZ Amsterdam, The Netherlands
| |
Collapse
|
31
|
Zhu T, Zhao X, Sun M, An Y, Kong W, Ji F, Wang G. Opioid-reduced anesthesia based on esketamine in gynecological day surgery: a randomized double-blind controlled study. BMC Anesthesiol 2022; 22:354. [PMCID: PMC9667678 DOI: 10.1186/s12871-022-01889-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 10/26/2022] [Indexed: 11/18/2022] Open
Abstract
Background Opioid-reduced anesthesia may accelerate postoperative rehabilitation by reducing opioid-related side effects. The objective was to investigate the feasibility of opioid-reduced general anesthesia based on esketamine and to observe postoperative nausea and vomiting (PONV), postoperative pain, hemodynamics and other adverse reactions in gynecological day surgery compared with the traditional opioid-based anesthesia program. Method This study was conducted as a prospective parallel-group randomized controlled trial. A total of 141 adult women undergoing gynecological day surgery were included. Patients were randomly assigned to receive traditional opioid-based anesthesia (Group C) with alfentanil, or opioid-reduced anesthesia (a moderate-opioid group (Group MO) and low-opioid group (Group LO) with esketamine and alfentanil). For anesthesia induction, the three groups received 20, 20, 10 μg/kg alfentanil respectively and Group LO received an additional 0.2 mg/kg esketamine. For maintenance of anesthesia, the patients in Group C received 40 μg/kg/h alfentanil, and those in Group MO and Group LO received 0.5 mg/kg/h esketamine. Results Patients in the three groups had comparable clinical and surgical data. A total of 33.3% of patients in Group C, 18.4% of patients in Group MO and 43.2% of patients in Group LO met the primary endpoint (p = 0.033), and the incidence of nausea within 24 hours after surgery in Group MO was lower than in Group LO (p < 0.05). The extubation time, median length of stay in the hospital after surgery and visual analog scale (VAS) of postoperative pain were equivalent in the three groups. The frequencies of adverse hemodynamic events in the MO 1(0, 2) and LO 0(0, 1) groups were significantly decreased (p < 0.05). Compared with Group C, the median length of stay in the postanesthesia care unit (PACU) in Group LO was increased, 60.0 (36.25, 88.75) vs. 42.5 (25, 73.75) minutes (p < 0.05). Conclusions Opioid-reduced anesthesia based on esketamine is feasible and provides effective analgesia for patients. Esketamine provided a positive analgesic effect and the opioid-reduced groups showed more stable hemodynamics. However, less or no use of opioids did not result in a more comfortable prognosis. Trial registration This study was registered at Chictr.org.cn (NO. ChiCTR2100053153); November 13, 2021.
Collapse
Affiliation(s)
- Teng Zhu
- grid.268079.20000 0004 1790 6079School of Anesthesiology, WeiFang Medical University, WeiFang, 261053 China
| | - Xiaoyong Zhao
- grid.268079.20000 0004 1790 6079School of Anesthesiology, WeiFang Medical University, WeiFang, 261053 China
| | - Meiyan Sun
- grid.268079.20000 0004 1790 6079School of Anesthesiology, WeiFang Medical University, WeiFang, 261053 China
| | - Yan An
- grid.268079.20000 0004 1790 6079School of Anesthesiology, WeiFang Medical University, WeiFang, 261053 China
| | - Wenwen Kong
- grid.268079.20000 0004 1790 6079School of Anesthesiology, WeiFang Medical University, WeiFang, 261053 China
| | - Fanceng Ji
- Department of Anesthesiology, WeiFang, People’ Hospital, WeiFang, 261000 China
| | - Guizhi Wang
- grid.268079.20000 0004 1790 6079School of Anesthesiology, WeiFang Medical University, WeiFang, 261053 China
| |
Collapse
|
32
|
Flick M, Bergholz A, Kouz K, Breitfeld P, Nitzschke R, Flotzinger D, Saugel B. A new noninvasive finger sensor (NICCI system) for continuous blood pressure and pulse pressure variation monitoring: A method comparison study in patients having neurosurgery. Eur J Anaesthesiol 2022; 39:851-857. [PMID: 36155392 DOI: 10.1097/eja.0000000000001754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The NICCI system (Getinge, Gothenburg, Sweden) is a new noninvasive haemodynamic monitoring system using a finger sensor. OBJECTIVES We aimed to investigate the performance of the NICCI system to measure blood pressure and pulse pressure variation compared with intra-arterial measurements. DESIGN A prospective method comparison study. SETTING University Medical Center Hamburg-Eppendorf, Hamburg, Germany. PATIENTS Forty-seven neurosurgery patients. MAIN OUTCOME MEASURES We performed a method comparison study in 47 neurosurgery patients to compare NICCI blood pressure measurements (BP NICCI ) with intra-arterial blood pressure measurements (BP ART ) (Bland-Altman analysis, four-quadrant plot, error grid analysis) and NICCI pulse pressure variation measurements (PPV NICCI ) with pulse pressure variation calculated manually from the intra-arterial blood pressure waveform (PPV ART ) (Bland-Altman analysis, predictive agreement, Cohen's kappa). RESULTS The mean of the differences ± standard deviation (95% limits of agreement) between BP NICCI and BP ART was 11 ± 10 mmHg (-8 to 30 mmHg) for mean blood pressure (MBP), 3 ± 12 mmHg (-21 to 26 mmHg) for systolic blood pressure (SBP) and 12 ± 10 mmHg (-8 to 31 mmHg) for diastolic blood pressure (DBP). In error grid analysis, 54% of BP NICCI and BP ART MBP measurement pairs were classified as 'no risk', 43% as 'low risk', 3% as 'moderate risk' and 0% as 'significant risk' or 'dangerous risk'. The mean of the differences between PPV NICCI and PPV ART was 1 ± 3% (-4 to 6%). The predictive agreement between PPV NICCI and PPV ART was 80% and Cohen's kappa was 0.55. CONCLUSIONS The absolute agreement between BP NICCI and BP ART was not clinically acceptable. We recommend not using the current version of the NICCI system for blood pressure monitoring during surgery. The absolute agreement between PPV NICCI and PPV ART was clinically acceptable with moderate predictive agreement regarding pulse pressure variation categories. The NICCI system needs to be further developed and re-evaluated when an improved version is available. TRIAL REGISTRATION The study was registered in the German Clinical Trials Register (DRKS00023188) on 2 October 2020.
Collapse
Affiliation(s)
- Moritz Flick
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (MF, AB, KK, PB, RN, BS), CNSystems Medizintechnik, Graz, Austria (DF), the Outcomes Research Consortium, Cleveland, Ohio, USA (BS)
| | | | | | | | | | | | | |
Collapse
|
33
|
Hypotension Prediction Index Software to Prevent Intraoperative Hypotension during Major Non-Cardiac Surgery: Protocol for a European Multicenter Prospective Observational Registry (EU-HYPROTECT). J Clin Med 2022; 11:jcm11195585. [PMID: 36233455 PMCID: PMC9571548 DOI: 10.3390/jcm11195585] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/17/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Intraoperative hypotension is common in patients having non-cardiac surgery and associated with postoperative acute myocardial injury, acute kidney injury, and mortality. Avoiding intraoperative hypotension is a complex task for anesthesiologists. Using artificial intelligence to predict hypotension from clinical and hemodynamic data is an innovative and intriguing approach. The AcumenTM Hypotension Prediction Index (HPI) software (Edwards Lifesciences; Irvine, CA, USA) was developed using artificial intelligence—specifically machine learning—and predicts hypotension from blood pressure waveform features. We aimed to describe the incidence, duration, severity, and causes of intraoperative hypotension when using HPI monitoring in patients having elective major non-cardiac surgery. Methods: We built up a European, multicenter, prospective, observational registry including at least 700 evaluable patients from five European countries. The registry includes consenting adults (≥18 years) who were scheduled for elective major non-cardiac surgery under general anesthesia that was expected to last at least 120 min and in whom arterial catheter placement and HPI monitoring was planned. The major objectives are to quantify and characterize intraoperative hypotension (defined as a mean arterial pressure [MAP] < 65 mmHg) when using HPI monitoring. This includes the time-weighted average (TWA) MAP < 65 mmHg, area under a MAP of 65 mmHg, the number of episodes of a MAP < 65 mmHg, the proportion of patients with at least one episode (1 min or more) of a MAP < 65 mmHg, and the absolute maximum decrease below a MAP of 65 mmHg. In addition, we will assess causes of intraoperative hypotension and investigate associations between intraoperative hypotension and postoperative outcomes. Discussion: There are only sparse data on the effect of using HPI monitoring on intraoperative hypotension in patients having elective major non-cardiac surgery. Therefore, we built up a European, multicenter, prospective, observational registry to describe the incidence, duration, severity, and causes of intraoperative hypotension when using HPI monitoring in patients having elective major non-cardiac surgery.
Collapse
|
34
|
Wesselink EM, Wagemakers SH, van Waes JAR, Wanderer JP, van Klei WA, Kappen TH. Associations between intraoperative hypotension, duration of surgery and postoperative myocardial injury after noncardiac surgery: a retrospective single-centre cohort study. Br J Anaesth 2022; 129:487-496. [PMID: 36064492 DOI: 10.1016/j.bja.2022.06.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/16/2022] [Accepted: 06/05/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Studies of intraoperative hypotension typically specify a blood pressure threshold associated with adverse outcomes. Such thresholds are likely to be study-biased, investigator-biased, or both. We hypothesised that a newly developed modelling method without a threshold, which is biologically more plausible than a threshold-based approach, would reveal a continuous association between exposure to intraoperative hypotension and adverse outcomes. METHODS Single-centre, retrospective cohort study of subjects ≥60 yr old undergoing noncardiac surgery. We modelled intraoperative hypotension using three different approaches: (1) unweighted, (2) weighted for degree of hypotension (depth), and (3) weighted for duration of hypotension. The primary outcome was myocardial injury, defined as elevated troponin I (>60 ng L-1) measured during the first 3 days after surgery. The associations between the three models, postoperative myocardial injury, and mortality (secondary outcome) were reported as penalised adjusted odds ratios (ORs) scaled between the 75th and 25th percentiles. RESULTS Myocardial injury occurred in 1812/15 452 (12%) procedures, with 554/15 452 (3.6%) procedures resulting in death before discharge from hospital. The unweighted lower blood pressure measure (OR: 0.26, 95% confidence interval [CI]: 0.12-0.53) and the depth-weighted measure (OR: 4.4, 95% CI: 2.6-7.4) were associated with myocardial injury. The duration-weighted measure was not associated with myocardial injury (OR: 0.89, 95% CI: 0.61-1.3). The unweighted measure (OR 0.08, 95% CI: 0.01-0.40) and the depth-weighted measure (OR: 12, 95% CI, 3.8-35) were associated with in-hospital mortality, but not the duration-weighted measure (OR: 1.3, 95% CI: 0.53-3.0). CONCLUSIONS Intraoperative hypotension appears to have a graded association with postoperative myocardial injury and mortality, with depth appearing to contribute more than duration.
Collapse
Affiliation(s)
- Esther M Wesselink
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sjors H Wagemakers
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jonathan P Wanderer
- Departments of Anesthesiology and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Teus H Kappen
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| |
Collapse
|
35
|
‘If you don't take a temperature, you can't find a fever’: relevance to continuous arterial pressure monitoring. Br J Anaesth 2022; 129:464-468. [DOI: 10.1016/j.bja.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022] Open
|
36
|
Qiu Y, Yu F, Yao F, Wu J. The efficacy of high-frequency jet ventilation on intraoperative oxygen saturation compared to cross-field ventilation in patients undergoing carinal resection and reconstruction. J Thorac Dis 2022; 14:3197-3204. [PMID: 36245598 PMCID: PMC9562552 DOI: 10.21037/jtd-22-355] [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: 03/19/2022] [Accepted: 06/24/2022] [Indexed: 01/18/2023]
Abstract
Background Cross-field ventilation is used as a conventional choice during carinal resection and anastomosis, but may interfere with surgical procedures. High-frequency jet ventilation (HFJV) allows for control of oxygenation in the open airways; nevertheless, there is a paucity of data to support its benefits versus cross-field ventilation. Herein, we aimed to investigate the efficacy of HFJV on intraoperative oxygen saturation compared with cross-field ventilation in patients undergoing carinal surgeries. Methods We conducted a retrospective analysis of 82 adults who underwent carinal resection and reconstruction (CRR) for benign or malignant diseases and received cross-field ventilation or HFJV at Shanghai Chest Hospital between January 2018 and September 2021. Patients were excluded when they had emergency surgeries or critical airway stenosis requiring extracorporeal life support, or limited resection without the need for cross-field ventilation or HFJV. Patients were classified into two groups based on the airway approach: cross-field ventilation group and HFJV group. The primary outcome was the area under the curve (AUC) of intraoperative hypoxemia defined as peripheral oxygen saturation (SpO2) below 90% lasting at least 1 minute. The secondary outcomes included cumulative time of SpO2 below 90%, AUC and cumulative time of severe intraoperative hypoxemia (defined as SpO2 below 80% lasting at least 1 minute), and AUC and cumulative time of suboptimal SpO2 (defined as SpO2 below 95% lasting at least 1 minute). Results Thirty-two patients were included in the final analysis, with 22 patients in cross-field ventilation group and 10 patients in HFJV group. The two groups did not differ in the severity and duration of intraoperative hypoxemia (P=0.366). The median (IQR) AUC of SpO2 below 90% was 21.92 (4.28, 54.48) min in cross-field ventilation group and 28.93 (10.78, 199.89) min in HFJV group. The cumulative time of SpO2 <90% was 16.67 (4.46, 37.11) min in cross-field ventilation group and 19.32 (7.50, 121.24) min in HFJV group, without statistical difference between groups (P>0.05). Severe intraoperative hypoxemia did not occur in either group. Conclusions This retrospective case series demonstrates that HFJV can be adopted to maintain oxygenation in CRR, without the interruption of surgical procedure.
Collapse
Affiliation(s)
- Yuwei Qiu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Fenghao Yu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Feng Yao
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
37
|
Kouz K, Wegge M, Flick M, Bergholz A, Moll-Khosrawi P, Nitzschke R, Trepte CJC, Krause L, Sessler DI, Zöllner C, Saugel B. Continuous intra-arterial versus intermittent oscillometric arterial pressure monitoring and hypotension during induction of anaesthesia: the AWAKE randomised trial. Br J Anaesth 2022; 129:478-486. [PMID: 36008202 DOI: 10.1016/j.bja.2022.06.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Hypotension during induction of anaesthesia is associated with organ injury. Continuous arterial pressure monitoring might help reduce hypotension. We tested the hypothesis that continuous intra-arterial compared with intermittent oscillometric arterial pressure monitoring reduces hypotension during induction of anaesthesia in noncardiac surgery patients. METHODS In this single-centre randomised trial, 242 noncardiac surgery patients in whom intra-arterial arterial pressure monitoring was planned were randomised to unblinded continuous intra-arterial or to intermittent oscillometric arterial pressure monitoring (with blinded intra-arterial arterial pressure monitoring) during induction of anaesthesia. The primary endpoint was the area under a mean arterial pressure (MAP) of 65 mm Hg within the first 15 min of induction of anaesthesia. Secondary endpoints included areas under MAP values of 60, 50, and 40 mm Hg and durations of MAP values <65, <60, <50, and <40 mm Hg. RESULTS There were 224 subjects available for analysis. The median (25th-75th percentile) area under a MAP of 65 mm Hg was 15 (2-36) mm Hg • min in subjects assigned to continuous intra-arterial monitoring and 46 (7-111) mm Hg • min in subjects assigned to intermittent oscillometric monitoring (P<0.001). Subjects assigned to continuous intra-arterial monitoring had smaller areas under MAP values of 60, 50, and 40 mm Hg and shorter durations of MAP values <65, <60, <50, and <40 mm Hg than subjects assigned to intermittent oscillometric monitoring. CONCLUSION Continuous intra-arterial arterial pressure monitoring reduces hypotension during induction of anaesthesia compared with intermittent oscillometric arterial pressure monitoring in noncardiac surgery patients. In patients for whom an arterial catheter is planned, clinicians might therefore consider inserting the arterial catheter before rather than after induction of anaesthesia. CLINICAL TRIALS REGISTRATION NCT04894019.
Collapse
Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mirja Wegge
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Parisa Moll-Khosrawi
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Nitzschke
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Constantin J C Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Krause
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| |
Collapse
|
38
|
Qiu Y, Gu W, Zhao M, Zhang Y, Wu J. The hemodynamic stability of remimazolam compared with propofol in patients undergoing endoscopic submucosal dissection: A randomized trial. Front Med (Lausanne) 2022; 9:938940. [PMID: 36004376 PMCID: PMC9394743 DOI: 10.3389/fmed.2022.938940] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveHypotension is common in propofol anesthesia. Whether remimazolam could reduce intraoperative hypotension remains unknown. We therefore tested the primary hypothesis that remimazolam reduces the incidence of intraoperative hypotension compared with propofol in adult patients undergoing endoscopic submucosal dissection (ESD) surgery.Materials and methodsWe conducted a prospective trial to compare patients who received either remimazolam or propofol bolus induction and thereafter intravenous infusion. The hemodynamic parameters were measured using CNAP® Monitor 500 system. Our primary analysis was to compare the incidence of hypotension defined as systolic blood pressure below 90 mmHg between remimazolam and propofol during the whole anesthesia period.ResultsThe incidence of hypotension decreased by 50%, from 67.9% in propofol group to 32.1% in remimazolam group (p < 0.01). Patients received less amount of intraoperative phenylephrine in the remimazolam group than the propofol group (0 [0–40] μg vs. 80 [0–200] μg, p < 0.01). Time-weighted average and cumulative time of hypotension was lower in remimazolam group compared with propofol group (p < 0.05). Cardiac output continuously measured by CNAP was preserved much better in remimazolam group compared with propofol group (p = 0.01), while systemic vascular resistance did not differ between the groups. The median time from discontinuation until full alertness was 4 [3–11.8] min in the remimazolam group compared with 15 [12.0–19.8] min in the propofol group (p < 0.01).ConclusionRemimazolam has better hemodynamic stability than propofol in adult patients undergoing ESD surgery. The benefits of remimazolam on hemodynamic stability and hypotension prevention may be partly contributed to its better preservation of cardiac output.Clinical Trial Registration[http://www.chictr.org.cn/com/25/showproj.aspx?proj=61104], identifier [ChiCTR2000037975].
Collapse
Affiliation(s)
- Yuwei Qiu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
- Outcomes Research Consortium, Cleveland, OH, United States
| | - Wei Gu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Mingye Zhao
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yunyun Zhang
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
- Outcomes Research Consortium, Cleveland, OH, United States
- *Correspondence: Jingxiang Wu,
| |
Collapse
|
39
|
Helmer P, Helf D, Sammeth M, Winkler B, Hottenrott S, Meybohm P, Kranke P. The Use of Non-Invasive Continuous Blood Pressure Measuring (ClearSight®) during Central Neuraxial Anaesthesia for Caesarean Section—A Retrospective Validation Study. J Clin Med 2022; 11:jcm11154498. [PMID: 35956113 PMCID: PMC9369920 DOI: 10.3390/jcm11154498] [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: 06/24/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 11/23/2022] Open
Abstract
The close monitoring of blood pressure during a caesarean section performed under central neuraxial anaesthesia should be the standard of safe anaesthesia. As classical oscillometric and invasive blood pressure measuring have intrinsic disadvantages, we investigated a novel, non-invasive technique for continuous blood pressure measuring. Methods: In this monocentric, retrospective data analysis, the reliability of continuous non-invasive blood pressure measuring using ClearSight® (Edwards Lifesciences Corporation) is validated in 31 women undergoing central neuraxial anaesthesia for caesarean section. In addition, patients and professionals evaluated ClearSight® through questioning. Results: 139 measurements from 11 patients were included in the final analysis. Employing Bland–Altman analyses, we identified a bias of −10.8 mmHg for systolic, of −0.45 mmHg for diastolic and of +0.68 mmHg for mean arterial blood pressure measurements. Pooling all paired measurements resulted in a Pearson correlation coefficient of 0.7 for systolic, of 0.67 for diastolic and of 0.75 for mean arterial blood pressure. Compensating the interindividual differences in linear regressions of the paired measurements provided improved correlation coefficients of 0.73 for systolic, of 0.9 for diastolic and of 0.89 for mean arterial blood pressure measurements. Discussion: Diastolic and mean arterial blood pressure are within an acceptable range of deviation from the reference method, according to the Association for the Advancement of Medical Instrumentation (AAMI) in the patient collective under study. Both patients and professionals prefer ClearSight® to oscillometric blood pressure measurement in regard of comfort and handling.
Collapse
Affiliation(s)
- Philipp Helmer
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Germany; (P.H.); (D.H.); (M.S.); (B.W.); (S.H.); (P.M.)
| | - Daniel Helf
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Germany; (P.H.); (D.H.); (M.S.); (B.W.); (S.H.); (P.M.)
| | - Michael Sammeth
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Germany; (P.H.); (D.H.); (M.S.); (B.W.); (S.H.); (P.M.)
- Department of Applied Sciences, Coburg University, Friedrich-Streib-Str. 2, 96450 Coburg, Germany
| | - Bernd Winkler
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Germany; (P.H.); (D.H.); (M.S.); (B.W.); (S.H.); (P.M.)
| | - Sebastian Hottenrott
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Germany; (P.H.); (D.H.); (M.S.); (B.W.); (S.H.); (P.M.)
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Germany; (P.H.); (D.H.); (M.S.); (B.W.); (S.H.); (P.M.)
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, Germany; (P.H.); (D.H.); (M.S.); (B.W.); (S.H.); (P.M.)
- Correspondence:
| |
Collapse
|
40
|
The Effect of Intermittent versus Continuous Non-Invasive Blood Pressure Monitoring on the Detection of Intraoperative Hypotension, a Sub-Study. J Clin Med 2022; 11:jcm11144083. [PMID: 35887844 PMCID: PMC9321987 DOI: 10.3390/jcm11144083] [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: 05/30/2022] [Revised: 06/26/2022] [Accepted: 07/01/2022] [Indexed: 02/01/2023] Open
Abstract
Intraoperative hypotension is associated with postoperative complications. However, in the majority of surgical patients, blood pressure (BP) is measured intermittently with a non-invasive cuff around the upper arm (NIBP-arm). We hypothesized that NIBP-arm, compared with a non-invasive continuous alternative, would result in missed events and in delayed recognition of hypotensive events. This was a sub-study of a previously published cohort study in adult patients undergoing surgery. The detection of hypotension (mean arterial pressure below 65 mmHg) was compared using two non-invasive methods; intermittent oscillometric NIBP-arm versus continuous NIBP measured with a finger cuff (cNIBP-finger) (Nexfin, Edwards Lifesciences). cNIBP-finger was used as the reference standard. Out of 350 patients, 268 patients (77%) had one or more hypotensive events during surgery. Out of the 286 patients, 72 (27%) had one or more missed hypotensive events. The majority of hypotensive events (92%) were detected with NIBP-arm, but were recognized at a median of 1.2 (0.6–2.2) minutes later. Intermittent BP monitoring resulted in missed hypotensive events and the hypotensive events that were detected were recognized with a delay. This study highlights the advantage of continuous monitoring. Future studies are needed to understand the effect on patient outcomes.
Collapse
|
41
|
Wijeysundera DN, Duncan D, Moreno Garijo J, Jerath A, Meineri M, Parotto M, Wąsowicz M, McCluskey SA. A randomised controlled feasibility trial of a clinical protocol to manage hypotension during major non-cardiac surgery. Anaesthesia 2022; 77:795-807. [PMID: 37937943 DOI: 10.1111/anae.15715] [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: 02/01/2022] [Revised: 02/15/2022] [Accepted: 02/28/2022] [Indexed: 11/09/2023]
Abstract
Intra-operative hypotension is a risk factor for postoperative morbidity and mortality. Minimally invasive monitors that derive other haemodynamic parameters, such as stroke volume, may better inform the management of hypotension. As a prelude to a multicentre randomised controlled trial, we conducted a single-centre feasibility trial of a protocol to treat hypotension as informed by minimally invasive haemodynamic monitoring during non-cardiac surgery. We recruited adults aged ≥40 years with cardiovascular risk factors who underwent non-cardiac surgery requiring invasive arterial pressure monitoring. Participants were randomly allocated to usual care, or a clinical protocol informed by an arterial waveform contour analysis monitor. Participants, outcome assessors, clinicians outside operating theatres and analysts were blinded to treatment allocation. Feasibility was evaluated based on: consent rate; recruitment rate; structured feedback from anaesthesia providers; and between-group differences in blood pressure, processes-of-care and outcomes. The consent rate among eligible patients was 33%, with 30 participants randomly allocated to the protocol and 30 to usual care. Anaesthesia providers rated the protocol to be feasible and acceptable. The protocol was associated with reduced fluid balance and hypotension exposure in the peri-operative setting. Postoperative complications included: acute myocardial injury in 18 (30%); acute kidney injury in 17 (28%); and surgical site infection in 7 (12%). The severity of complications was rated as moderate or severe in 25 (42%) participants. In summary, this single-centre study confirmed the feasibility of a multicentre trial to assess the efficacy and safety of a physiologically guided treatment protocol for intra-operative hypotension based on minimally invasive haemodynamic monitors.
Collapse
Affiliation(s)
- D N Wijeysundera
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - D Duncan
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - J Moreno Garijo
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - A Jerath
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - M Meineri
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
- Department of Anaesthesia and Intensive Care, Heart Centre Leipzig, Germany
| | - M Parotto
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - M Wąsowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - S A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| |
Collapse
|
42
|
Prediction of intraoperative hypotension from the linear extrapolation of mean arterial pressure. Eur J Anaesthesiol 2022; 39:574-581. [PMID: 35695749 DOI: 10.1097/eja.0000000000001693] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hypotension prediction index (HPI) software is a proprietary machine learning-based algorithm used to predict intraoperative hypotension (IOH). HPI has shown superiority in predicting IOH when compared to the predictive value of changes in mean arterial pressure (ΔMAP) alone. However, the predictive value of ΔMAP alone, with no reference to the absolute level of MAP, is counterintuitive and poor at predicting IOH. A simple linear extrapolation of mean arterial pressure (LepMAP) is closer to the clinical approach. OBJECTIVES Our primary objective was to investigate whether LepMAP better predicts IOH than ΔMAP alone. DESIGN Retrospective diagnostic accuracy study. SETTING Two tertiary University Hospitals between May 2019 and December 2019. PATIENTS A total of 83 adult patients undergoing high risk non-cardiac surgery. DATA SOURCES Arterial pressure data were automatically extracted from the anaesthesia data collection software (one value per minute). IOH was defined as MAP < 65 mmHg. ANALYSIS Correlations for repeated measurements and the area under the curve (AUC) from receiver operating characteristics (ROC) were determined for the ability of LepMAP and ΔMAP to predict IOH at 1, 2 and 5 min before its occurrence (A-analysis, using the whole dataset). Data were also analysed after exclusion of MAP values between 65 and 75 mmHg (B-analysis). RESULTS A total of 24 318 segments of ten minutes duration were analysed. In the A-analysis, ROC AUCs to predict IOH at 1, 2 and 5 min before its occurrence by LepMAP were 0.87 (95% confidence interval, CI, 0.86 to 0.88), 0.81 (95% CI, 0.79 to 0.83) and 0.69 (95% CI, 0.66 to 0.71) and for ΔMAP alone 0.59 (95% CI, 0.57 to 0.62), 0.61 (95% CI, 0.59 to 0.64), 0.57 (95% CI, 0.54 to 0.69), respectively. In the B analysis for LepMAP these were 0.97 (95% CI, 0.9 to 0.98), 0.93 (95% CI, 0.92 to 0.95) and 0.86 (95% CI, 0.84 to 0.88), respectively, and for ΔMAP alone 0.59 (95% CI, 0.53 to 0.58), 0.56 (95% CI, 0.54 to 0.59), 0.54 (95% CI, 0.51 to 0.57), respectively. LepMAP ROC AUCs were significantly higher than ΔMAP ROC AUCs in all cases. CONCLUSIONS LepMAP provides reliable real-time and continuous prediction of IOH 1 and 2 min before its occurrence. LepMAP offers better discrimination than ΔMAP at 1, 2 and 5 min before its occurrence. Future studies evaluating machine learning algorithms to predict IOH should be compared with LepMAP rather than ΔMAP.
Collapse
|
43
|
Lorente JV, Jimenez I, Ripollés-Melchor J, Becerra A, Wesselink W, Reguant F, Mojarro I, Fuentes MDLA, Abad-Motos A, Agudelo E, Herrero-Machancoses F, Callejo P, Bosch J, Monge MI. Intraoperative haemodynamic optimisation using the Hypotension Prediction Index and its impact on tissular perfusion: a protocol for a randomised controlled trial. BMJ Open 2022; 12:e051728. [PMID: 35654467 PMCID: PMC9163532 DOI: 10.1136/bmjopen-2021-051728] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/30/2022] Open
Abstract
INTRODUCTION Intraoperative arterial hypotension is associated with poor postoperative outcomes. The Hypotension Prediction Index (HPI) developed using machine learning techniques, allows the prediction of arterial hypotension analysing the arterial pressure waveform. The use of this index may reduce the duration and severity of intraoperative hypotension in adults undergoing non-cardiac surgery. This study aims to determine whether a treatment protocol based on the prevention of arterial hypotension using the HPI algorithm reduces the duration and severity of intraoperative hypotension compared with the recommended goal-directed fluid therapy strategy and may improve tissue oxygenation and organ perfusion. METHODS AND ANALYSIS We will conduct a multicentre, randomised, controlled trial (N=80) in high-risk surgical patients scheduled for elective major abdominal surgery. All participants will be randomly assigned to a control or intervention group. Haemodynamic management in the control group will be based on standard haemodynamic parameters. Haemodynamic management of patients in the intervention group will be based on functional haemodynamic parameters provided by the HemoSphere platform (Edwards Lifesciences), including dynamic arterial elastance, dP/dtmax and the HPI. Tissue oxygen saturation will be recorded non-invasively and continuously by using near-infrared spectroscopy technology. Biomarkers of acute kidney stress (cTIMP2 and IGFBP7) will be obtained before and after surgery. The primary outcome will be the intraoperative time-weighted average of a mean arterial pressure <65 mm Hg. ETHICS AND DISSEMINATION Ethics committee approval was obtained from the Ethics Committee of Hospital Gregorio Marañón (Meeting of 27 July 2020, minutes 18/2020, Madrid, Spain). Findings will be widely disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT04301102.
Collapse
Affiliation(s)
- Juan Victor Lorente
- Anesthesia and Critical Care, Hospital Juan Ramon Jimenez, Huelva, Spain
- School of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Ignacio Jimenez
- Anesthesia and Critical Care, Virgen del Rocio University Hospital, Sevilla, Spain
| | | | - Alejandra Becerra
- Anesthesia and Critical Care, Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain
| | | | - Francesca Reguant
- School of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
- Anesthesia, Fundacio Althaia de Manresa, Manresa, Spain
| | - Irene Mojarro
- Anesthesia and Critical Care, Hospital Juan Ramon Jimenez, Huelva, Spain
| | | | - Ane Abad-Motos
- Anesthesia and Critical Care, Infanta Leonor University Hospital, Madrid, Spain
| | - Elizabeth Agudelo
- Anesthesia and Critical Care, Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain
| | | | | | - Joan Bosch
- School of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Manuel Ignacio Monge
- Intensive Care Unit, Hospital Universitario de Jerez de la Frontera, Jerez de la Frontera, Spain
| |
Collapse
|
44
|
Lai CJ, Shih CC, Huang HH, Chien MH, Wu MS, Cheng YJ. Detecting Volemic, Cardiac, and Autonomic Responses From Hypervolemia to Normovolemia via Non-Invasive ClearSight Hemodynamic Monitoring During Hemodialysis: An Observational Investigation. Front Physiol 2022; 13:775631. [PMID: 35574491 PMCID: PMC9095841 DOI: 10.3389/fphys.2022.775631] [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: 11/11/2021] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Unstable hemodynamics are not uncommon during hemodialysis (HD), which involves a rapid volume depletion, taking the patient from hypervolemia toward euvolemia. Since uremic patients commonly have cardiovascular comorbidities, hemodynamic changes during HD may reflect interactions among the volemic, cardiac, and autonomic responses to gradual volume depletion during ultrafiltration. Accurate identification of inappropriate responses helps with precisely managing intradialytic hypotension. Recently, the non-invasive ClearSight was reported to be able to detect causes of intraoperative hypotension. In this prospective observational study, we aimed to determine whether ClearSight could be used to detect patterns in stroke volemic, cardiac, and vasoreactive responses during HD. Methods: ClearSight was used to monitor chronic stable patients receiving maintenance HD. Data of mean arterial blood pressure (MAP), heart rate (HR), stroke volume index (SVI), cardiac index (CI), and calculated systemic vascular resistance index (SVRI) were obtained and analyzed to examine patterns in volemic, cardiac, and vasoreactive changes from T0 (before HD) until T8 in 30-min intervals (total 4 h). Results: A total of 56 patients with a mean age of 60.5 years were recruited, of which 40 of them were men. The average ultrafiltration volume at T8 was 2.1 ± 0.8 L. The changes in MAP and HR from T0 to T8 were non-significant. SVI at T7 was significantly lower than that at T1, T2, and T3. CI at T4 to T8 was significantly lower than that at T0. SVRI was significantly higher at T3 to T8 than at T0. Pearson's correlation coefficients between SVI and CI and between SVRI and MAP were positive at all time points. The correlation coefficients between SVRI and SVI and between CI and SVRI were significant and negative for all time points. Conclusion: ClearSight was able to detect patterns in hypervolemia during HD and was well tolerated for 4 h. CI decreased significantly after T4, with slightly decreased SVI. Ultrafiltration volume was not correlated with changes in SVI or CI. The vascular tone increased significantly, and this counteracted the reduced cardiac output after T4. With simultaneous monitoring on SVI, CI, and SVRI during HD, therefore, hypotension could be detected and managed by reducing the filtration rate or administering inotrope or vasopressors. Trial Registration: clinicaltrials.gov, ID: NCT03901794.
Collapse
Affiliation(s)
- Chih-Jun Lai
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan.,Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Chih Shih
- Department of Anesthesiology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Hsing-Hao Huang
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Hung Chien
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Shiou Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Jung Cheng
- Department of Anesthesiology, National Taiwan University Cancer Center, Taipei, Taiwan
| |
Collapse
|
45
|
Hansen J, Pohlmann M, Beckmann JH, Klose P, Gruenewald M, Renner J, Lorenzen U, Elke G. Comparison of oscillometric, non-invasive and invasive arterial pressure monitoring in patients undergoing laparoscopic bariatric surgery – a secondary analysis of a prospective observational study. BMC Anesthesiol 2022; 22:83. [PMID: 35346046 PMCID: PMC8962134 DOI: 10.1186/s12871-022-01619-3] [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: 12/01/2021] [Accepted: 03/17/2022] [Indexed: 11/18/2022] Open
Abstract
Background Oscillometric, non-invasive blood pressure measurement (NIBP) is the first choice of blood pressure monitoring in the majority of low and moderate risk surgeries. In patients with morbid obesity, however, it is subject to several limitations. The aim was to compare arterial pressure monitoring by NIBP and a non-invasive finger-cuff technology (Nexfin®) with the gold-standard invasive arterial pressure (IAP). Methods In this secondary analysis of a prospective observational, single centre cohort study, systolic (SAP), diastolic (DAP) and mean arterial pressure (MAP) were measured at 16 defined perioperative time points including posture changes, fluid bolus administration and pneumoperitoneum (PP) in patients undergoing laparoscopic bariatric surgery. Absolute arterial pressures by NIBP, Nexfin® and IAP were compared using correlation and Bland Altman analyses. Interchangeability was defined by a mean difference ≤ 5 mmHg (SD ≤8 mmHg). Percentage error (PE) was calculated as an additional statistical estimate. For hemodynamic trending, concordance rates were analysed according to the Critchley criterion. Results Sixty patients (mean body mass index of 49.2 kg/m2) were enrolled and data from 56 finally analysed. Pooled blood pressure values of all time points showed a significant positive correlation for both NIPB and Nexfin® versus IAP. Pooled PE for NIBP versus IAP was 37% (SAP), 35% (DAP) and 30% (MAP), for Nexfin versus IAP 23% (SAP), 26% (DAP) and 22% (MAP). Correlation of MAP was best and PE lowest before induction of anesthesia for NIBP versus IAP (r = 0.72; PE 24%) and after intraoperative fluid bolus administration for Nexfin® versus IAP (r = 0.88; PE: 17.2%). Concordance of MAP trending was 90% (SAP 85%, DAP 89%) for NIBP and 91% (SAP 90%, DAP 86%) for Nexfin®. MAP trending was best during intraoperative ATP positioning for NIBP (97%) and at induction of anesthesia for Nexfin® (97%). Conclusion As compared with IAP, interchangeability of absolute pressure values could neither be shown for NIBP nor Nexfin®, however, NIBP showed poorer overall correlation and precision. Overall trending ability was generally high with Nexfin® surpassing NIBP. Nexfin® may likely render individualized decision-making in the management of different hemodynamic stresses during laparoscopic bariatric surgery, particularly where NIBP cannot be reliably established. Trial registration The non-interventional, observational study was registered retrospectively at (NCT03184285) on June 12, 2017.
Collapse
|
46
|
Vokuhl C, Briesenick L, Saugel B. [Intraoperative Hemodynamic Monitoring and Management]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:104-114. [PMID: 35172341 DOI: 10.1055/a-1390-3569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Postoperative deaths are a consequence of postoperative complications - including acute kidney injury and myocardial injury. Postoperative complications are associated with non-modifiable patient-specific risk factors (i.e., age, medical history), but also with potentially modifiable risk factors - including intraoperative hypotension and compromised intraoperative blood flow. Based on patient- and surgery-specific risk factors, the intraoperative hemodynamic monitoring strategy needs to be selected. Intraoperative hypotension is associated with postoperative organ failure and should thus be avoided. To optimize intraoperative hemodynamics, cardiac output-guided hemodynamic management has been proposed. Cardiac output-guided hemodynamic management aims at optimizing oxygen delivery using fluids, vasopressors, and inotropes. Cardiac output-guided hemodynamic management has been shown to reduce postoperative complications compared to routine hemodynamic management in high-risk patients having major surgery.
Collapse
|
47
|
The Use of the Hypotension Prediction Index Integrated in an Algorithm of Goal Directed Hemodynamic Treatment during Moderate and High-Risk Surgery. J Clin Med 2021; 10:jcm10245884. [PMID: 34945177 PMCID: PMC8707257 DOI: 10.3390/jcm10245884] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/20/2022] Open
Abstract
(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.
Collapse
|
48
|
Miao Q, Wu DJ, Chen X, Xu M, Sun L, Guo Z, He B, Wu J. Target blood pressure management during cardiopulmonary bypass improves lactate levels after cardiac surgery: a randomized controlled trial. BMC Anesthesiol 2021; 21:309. [PMID: 34879822 PMCID: PMC8653567 DOI: 10.1186/s12871-021-01537-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 12/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background Hyperlactatemia is associated with a poor prognosis in cardiac surgery patients. This study explored the impact of target blood pressure management during cardiopulmonary bypass (CPB) on blood lactate levels after cardiac surgery. Methods Adult patients undergoing cardiac valve surgery between 20/1/2020 and 30/6/2020 at Shanghai Chest Hospital were enrolled. The patients were randomized into a low mean arterial pressure (L-MAP) group (target MAP between 50 and 60 mmHg) or a high mean arterial pressure (H-MAP) group (target MAP between 70 and 80 mmHg), n = 20 for each. Norepinephrine was titrated only during CPB to maintain MAP at the target level. Blood lactate levels in the two groups were detected before the operation (T0), at the end of CPB (T1), at the end of the operation (T2), 1 h after the operation (T3), 6 h after the operation (T4) and 24 h after the operation (T5). The primary outcome was the blood lactate level at the end of the operation (T2). The secondary outcomes included the blood lactate level at T1, T3, T4, and T5 and the dose of epinephrine and dopamine within 24 h after the operation, time to extubation, length of stay in the ICU, incidence of readmission within 30 days, and mortality within 1 year. Results Forty patents were enrolled and analyzed in the study. The lactate level in the H-MAP group was significantly lower than that in the L-MAP group at the end of the operation (3.1 [IQR 2.1, 5.0] vs. 2.1 [IQR 1.7, 2.9], P = 0.008) and at the end of CPB and 1 hour after surgery. The dose of epinephrine within 24 h after the operation, time to extubation and length of stay in the ICU in the L-MAP group were significantly higher than those in the H-MAP group. Conclusions Maintaining a relatively higher MAP during CPB deceased the blood lactate level at the end of surgery, reduced epinephrine consumption, and shortened the time to extubation and length of stay in the ICU after surgery. Trial registration This single-center, prospective, RCT has completed the registration of the Chinese Clinical Trial Center at 8/1/2020 with the registration number ChiCTR2000028941. It was conducted from 20/1/2020 to 30/6/2020 as a single, blinded trial in Shanghai Chest Hospital.
Collapse
Affiliation(s)
- Qing Miao
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China
| | - Dong Jin Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China
| | - Xu Chen
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China
| | - Meiying Xu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China
| | - Lin Sun
- Department of Cardiopulmonary Bypass, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhen Guo
- Department of Cardiopulmonary Bypass, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bin He
- Department of Intensive Care Unit, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 West Huaihai Road, Shanghai, 200030, China.
| |
Collapse
|
49
|
Performance of a machine-learning algorithm to predict hypotension in mechanically ventilated patients with COVID-19 admitted to the intensive care unit: a cohort study. J Clin Monit Comput 2021; 36:1397-1405. [PMID: 34775533 PMCID: PMC8590442 DOI: 10.1007/s10877-021-00778-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/05/2021] [Indexed: 01/08/2023]
Abstract
The Hypotension Prediction Index (HPI) is a commercially available machine-learning algorithm that provides warnings for impending hypotension, based on real-time arterial waveform analysis. The HPI was developed with arterial waveform data of surgical and intensive care unit (ICU) patients, but has never been externally validated in the latter group. In this study, we evaluated diagnostic ability of the HPI with invasively collected arterial blood pressure data in 41 patients with COVID-19 admitted to the ICU for mechanical ventilation. Predictive ability was evaluated at HPI thresholds from 0 to 100, at incremental intervals of 5. After exceeding the studied threshold, the next 20 min were screened for positive (mean arterial pressure (MAP) < 65 mmHg for at least 1 min) or negative (absence of MAP < 65 mmHg for at least 1 min) events. Subsequently, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and time to event were determined for every threshold. Almost all patients (93%) experienced at least one hypotensive event. Median number of events was 21 [7–54] and time spent in hypotension was 114 min [20–303]. The optimal threshold was 90, with a sensitivity of 0.91 (95% confidence interval 0.81–0.98), specificity of 0.87 (0.81–0.92), PPV of 0.69 (0.61–0.77), NPV of 0.99 (0.97–1.00), and median time to event of 3.93 min (3.72–4.15). Discrimination ability of the HPI was excellent, with an area under the curve of 0.95 (0.93–0.97). This validation study shows that the HPI correctly predicts hypotension in mechanically ventilated COVID-19 patients in the ICU, and provides a basis for future studies to assess whether hypotension can be reduced in ICU patients using this algorithm.
Collapse
|
50
|
Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, de Jesus Perez V, Sessler DI, Wijeysundera DN. Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e287-e305. [PMID: 34601955 DOI: 10.1161/cir.0000000000001024] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.
Collapse
|