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Dana E, Dana HK, De Castro C, Bueno Rey L, Li Q, Tomlinson G, Khan JS. Inferior vena cava ultrasound to predict hypotension after general anesthesia induction: a systematic review and meta-analysis of observational studies. Can J Anaesth 2024; 71:1078-1091. [PMID: 38961000 DOI: 10.1007/s12630-024-02776-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 07/05/2024] Open
Abstract
PURPOSE Hypotension after induction of general anesthesia is common and is associated with significant adverse events. Identification of patients at high risk can inform the use of preoperative mitigation strategies. We conducted a systematic review and meta-analysis to assess the diagnostic accuracy of the inferior vena cava collapsibility index (IVC-CI) and maximal diameter (dIVCmax) in predicting postinduction hypotension and to identify their predictive performance across different threshold ranges. METHODS We searched MEDLINE, PubMed®, and Embase from inception to March 2023 for prospective observational studies exploring the performance of IVC-CI and dIVCmax in predicting postinduction hypotension in adults presenting for elective surgery under general anesthesia. We excluded studies reporting on IVC parameters predicting postinduction hypotension in the obstetric patient population or exclusively in patients with obesity. Trials screening and data extraction were conducted independently. We performed meta-analyses to identify the performance of IVC parameters in predicting postinduction hypotension, followed by subgroup analyses that sought the IVC-CI range with the highest hierarchical summary receiver-operating characteristic area under the curve (HSROC-AUC). We used a bivariate random effects model to calculate summary estimates. We evaluated study quality using Newcastle-Ottawa scores and certainty of evidence using the GRADE framework. RESULTS We included 14 studies involving 1,166 patients. Pooled sensitivity and specificity of the IVC-CI to predict postinduction hypotension was 0.68 (95% confidence interval [CI], 0.55 to 0.79; coverage probability, 0.91) and 0.78 (95% CI, 0.69 to 0.85; coverage probability, 0.9), respectively, with an HSROC-AUC of 0.80 (95% CI, 0.68 to 0.85, high quality of evidence). An IVC-CI threshold range of 40-45% had an HSROC-AUC of 0.86 (95% CI, 0.69 to 0.93, high quality of evidence). CONCLUSIONS Preoperative IVC-CI is a strong predictor of postinduction hypotension. We recommend that future studies use an IVC-CI threshold of 40-45% (low certainty of evidence). Future studies are needed to establish whether ultrasound-guided preoperative optimization improves outcomes in high-risk patients. STUDY REGISTRATION PROSPERO ( CRD42022316140 ); first submitted 10 March 2022.
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Affiliation(s)
- Elad Dana
- Department of Anesthesia, Intensive Care and Pain Medicine, Meir Medical Center, Kfar Saba, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Mount Sinai Hospital, Toronto, ON, Canada.
| | - Hadas K Dana
- Division of Emergency Medicine, The Hospital for Sick Children (SickKids), Toronto, ON, Canada
- Pediatric Emergency Department, Meir Medical Center, Kfar-Saba, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Charmaine De Castro
- Sidney Liswood Health Sciences Library, Sinai Health System, Toronto, ON, Canada
| | - Luz Bueno Rey
- Mount Sinai Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Qixuan Li
- Biostatistics Department, University Health Network, University of Toronto, Toronto, ON, Canada
| | - George Tomlinson
- Biostatistics Department, University Health Network, University of Toronto, Toronto, ON, Canada
| | - James S Khan
- Mount Sinai Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
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Liu C, An R, Liu H. Preoperative Ultrasound for the Prediction of Postinduction Hypotension: A Systematic Review and Meta-Analysis. J Pers Med 2024; 14:452. [PMID: 38793034 PMCID: PMC11122148 DOI: 10.3390/jpm14050452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
Postinduction hypotension (PIH) is closely associated with postoperative adverse outcomes. Preoperative hypovolemia is a key risk factor, and many parameters are available from ultrasound to detect hypovolemia, but the accuracy of PIH from ultrasound remains unclear. This systematic review and meta-analysis aimed to evaluate the commonly used measurements from ultrasound to predict PIH. We searched the PubMed, Cochrane Library, Embase, CNKI, and Web of Science databases from their inception to December 2023. Thirty-six studies were included for quantitative analysis. The pooled sensitivities for the inferior vena cava collapsibility index (IVC-CI), maximum inferior vena cava diameter (DIVCmax), minimum inferior vena cava diameter (DIVCmin), and carotid artery corrected flow time (FTc) were 0.73 (95% CI = 0.65, 0.79), 0.66 (95% CI = 0.54, 0.77), 0.74 (95% CI = 0.60, 0.85), and 0.81 (95% CI = 0.72, 0.88). The pooled specificities for the IVC-CI, DIVCmax, DIVCmin, and carotid artery FTc were 0.82 (95% CI = 0.75, 0.87), 0.75 (95% CI = 0.66, 0.82), 0.76 (95% CI = 0.65, 0.84), and 0.87 (95% CI = 0.77, 0.93). The AUC for the IVC-CI, DIVCmax, DIVCmin, and carotid artery FTc were 0.84 (95% CI = 0.81, 0.87), 0.77 (95% CI = 0.73, 0.81), 0.82 (95% CI = 0.78, 0.85), and 0.91 (95% CI = 0.88, 0.93). Our study demonstrated that ultrasound indices are reliable predictors for PIH. The carotid artery FTc is probably the optimal ultrasound measurement for identifying patients who will develop PIH in our study.
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Affiliation(s)
| | | | - Hongliang Liu
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing 400030, China; (C.L.); (R.A.)
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Fathy MM, Wahdan RA, Salah AAA, Elnakera AM. Inferior vena cava collapsibility index as a predictor of hypotension after induction of general anesthesia in hypertensive patients. BMC Anesthesiol 2023; 23:420. [PMID: 38114949 PMCID: PMC10729554 DOI: 10.1186/s12871-023-02355-y] [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: 09/27/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Hypertensive patients are more susceptible to develop hypotension after the induction of general anesthesia (GA), most likely due to hypovolemia. An inferior vena cava collapsibility index (IVCCI) > 40-50% can predict hypotension after the induction of GA in the general population by variable accuracies. The current study aimed to investigate IVCCI% as a predictor of postinduction hypotension in hypertensive patients undergoing noncardiac surgery. METHODS Ultrasound IVCCI % was assessed for all controlled hypertensive patients immediately before induction of GA. After induction of GA, patients were diagnosed with postinduction hypotension if their systolic arterial pressure (SAP) dropped by ≥ 30% of the baseline value and/or mean arterial pressure (MAP) dropped to < 65 mmHg up to 15 min after intubation. The receiver operating characteristic (ROC) curve of IVCCI% was compared to patients' classification either developing hypotension after induction of GA or not as a gold standard. RESULTS Of the 153 patients who completed the study, 62 (40.5%) developed hypotension after the induction of GA, and 91 (59.5%) did not. An IVCCI > 39% predicted the occurrence of postinduction hypotension with high accuracy (84%) (AUC 0.908, P < 0.001). The area of uncertainty (by gray zone analysis) of IVCCI lies at values from 39 to 45%. This gray zone included 21 patients (13.7% of all patients). CONCLUSION An inferior vena cava collapsibility index > 39% before anesthetic induction can be a simple noninvasive reliable predictor of hypotension after the induction of GA for hypertensive patients not treated with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) and undergoing noncardiac surgery. TRIAL REGISTRATION This clinical trial was approved by the Institutional Review Board (IRB) at Zagazig University (ZUIRB #9424 dated 03/04/2022), and patients' informed consent for participation in the study was obtained during the period from May 2022 to May 2023. All study procedures were carried out in accordance with the ethical standards of the Helsinki Declaration of 2013.
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Affiliation(s)
- Mohamed Metwaly Fathy
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Rehab A Wahdan
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
| | - Amal Abdul Azeem Salah
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Abeer M Elnakera
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Hu JH, Xu N, Bian Z, Shi HJ, Ji FH, Peng K. Protocol for development and validation of a prediction model for post-induction hypotension in elderly patients undergoing non-cardiac surgery: a prospective cohort study. BMJ Open 2023; 13:e074181. [PMID: 37734882 PMCID: PMC10514608 DOI: 10.1136/bmjopen-2023-074181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/31/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION Post-induction hypotension (PIH) is a common event in elderly surgical patients and is associated with increased postoperative morbidity and mortality. This study aims to develop and validate a PIH prediction model for elderly patients undergoing elective non-cardiac surgery to identify potential PIH in advance and help to take preventive measures. METHODS AND ANALYSIS A total of 938 elderly surgical patients (n=657 for development and internal validation, n=281 for temporal validation) will be continuously recruited at The First Affiliated Hospital of Soochow University in Suzhou, China. The main outcome is PIH during the first 15 min after anaesthesia induction or before skin incision (whichever occurs first). We select candidate predictors based on published literature, professional knowledge and clinical expertise. For model development, we will use the least absolute shrinkage and selection operator regression analysis and multivariable logistic regression. For internal validation, we will apply the bootstrapping technique. After model development and internal validation, temporal validation will be conducted in patients recruited in another time period. We will use the discrimination, calibration and max-rescaled Brier score in the temporal validation cohort. Furthermore, the clinical utility of the prediction model will be assessed using the decision curve analysis, and the results will be presented in a nomogram and a web-based risk calculator. ETHICS AND DISSEMINATION Ethical approval was obtained from the Ethics Committee of the First Affiliated Hospital of Soochow University (Approval No. 2023-012). This PIH risk prediction model will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ChiCTR2200066201.
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Affiliation(s)
- Jing-Hui Hu
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Ning Xu
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Zhen Bian
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Hai-Jing Shi
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Fu-Hai Ji
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Ke Peng
- Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
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