Blood pressure variability in surgical and intensive care patients: Is there a potential for closed-loop vasopressor administration?

Rinehart, Joseph; Ma, Michael W.; Calderon, Michael-David; Bardaji, Aurélie; Hafiane, Reda; Linden, Philippe Van der; Joosten, Alexandre

doi:10.1016/j.accpm.2018.11.009

Cited by 28 publications

(37 citation statements)

References 7 publications

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“…Thus, the fluid regimen was tailored strictly to the patients’ needs and requirements. It is therefore obvious that precise monitoring of BP lability could facilitate the maintenance of well-balanced perioperative fluid and vasopressor therapy, decreasing the risk of adverse effects of higher-than-needed vasopressor dosage [27]. We believe that inappropriate tissue oxygenation, regardless of its origin, gives similar effects in terms of increasing mortality in the perioperative period.…”

Section: Discussionmentioning

confidence: 99%

Intraoperative Blood Pressure Variability Predicts Postoperative Mortality in Non-Cardiac Surgery—A Prospective Observational Cohort Study

Wiórek

Krzych

2019

IJERPH

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Little is known about the clinical importance of blood pressure variability (BPV) during anesthesia in non-cardiac surgery. We sought to investigate the impact of intraoperative BPV on postoperative mortality in non-cardiac surgery subjects, taking into account patient- and procedure-related variables. This prospective observational study covered 835 randomly selected patients who underwent gastrointestinal (n = 221), gynecological (n = 368) and neurosurgical (n = 246) procedures. Patient’s and procedure’s risks were assessed according to the validated tools and guidelines. Blood pressure (systolic, SBP, and diastolic, DBP) was recorded in five-minute intervals during anesthesia. Mean arterial pressure (MAP) was assessed. Individual coefficients of variation (Cv) were calculated. Postoperative 30-day mortality was considered the outcome. Median SBP_Cv was 11.2% (IQR 8.4–14.6), DBP_Cv was 12.7% (IQR 9.8–16.3) and MAP_Cv was 10.96% (IQR 8.26–13.86). Mortality was 2%. High SBP_Cv (i.e., ≥11.9%) was associated with increased mortality by 4.5 times (OR = 4.55; 95% CI 1.48–13.93; p = 0.008). High DBP_Cv (i.e., ≥22.4%) was associated with increased mortality by nearly 10 times (OR = 9.73; 95% CI 3.26–28.99; p < 0.001). High MAP_Cv (i.e., ≥13.6%) was associated with increased mortality by 3.5 times (OR = 3.44; 95% CI 1.34–8.83; p = 0.01). In logistic regression, it was confirmed that the outcome was dependent on both SBPV and DBPV, after adjustment for perioperative variables, with AUCSBP_Cv = 0.884 (95% CI 0.859–0.906; p < 0.001) and AUCDBP_Cv = 0.897 (95% CI 0.873–0.918; p < 0.001). Therefore, intraoperative BPV may be considered a prognostic factor for the postoperative mortality in non-cardiac surgery, and DBPV seems more accurate in outcome prediction than SBPV.

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Section: Discussionmentioning

confidence: 99%

Intraoperative Blood Pressure Variability Predicts Postoperative Mortality in Non-Cardiac Surgery—A Prospective Observational Cohort Study

Wiórek

Krzych

2019

IJERPH

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“…30 Our own study showed similar times out of range in both the OR and ICU. 31 In fact, when MAP targets in even strictly defined clinical protocols are compared with observed values in the actual study results, we see that providers often overshoot the target by as much as 20 mm Hg while simultaneously missing sustained periods of hypotension. [32][33][34][35][36][37][38] The original protocol proposed by Rivers et al for management of septic shock targeted a MAP of 65 mm Hg.…”

Section: Current Blood Pressure Managementmentioning

confidence: 73%

Automated Blood Pressure Control

Rinehart

Lee

Saugel

et al. 2020

Semin Respir Crit Care Med

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Arterial pressure management is a crucial task in the operating room and intensive care unit. In high-risk surgical and in critically ill patients, sustained hypotension is managed with continuous infusion of vasopressor agents, which most commonly have direct α agonist activity like phenylephrine or norepinephrine. The current standard of care to guide vasopressor infusion is manual titration to an arterial pressure target range. This approach may be improved by using automated systems that titrate vasopressor infusions to maintain a target pressure. In this article, we review the evidence behind blood pressure management in the operating room and intensive care unit and discuss current and potential future applications of automated blood pressure control.

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“…In a recent editorial , Biais and Pearce acknowledge the barriers to implementing recommendations on intra‐operative blood pressure management, citing data that suggests patients may spend less than half their time within recommended limits . They confirmed the uncertainty, discussed above, around which monitors, vasopressors and fluids to use, and how frequently blood pressure measurements should be taken.…”

Section: Discussionmentioning

confidence: 98%

Pre‐incision hypotension and the association with postoperative acute kidney injury – an opportunity to improve peri‐operative outcomes?

El‐Ghazali

Pandit

2019

Anaesthesia

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It is well established that intra-operative hypotension is associated with acute kidney injury (AKI), which is in turn associated with postoperative mortality. Recently, Maheshwari et al. investigated the influence of hypotension following induction of anaesthesia, and before the first surgical incision, on the incidence of postoperative AKI [1].From a large retrospective database analysis of more than 42,000 cases, the authors concluded that one-third of hypotensive readings occurred before incision which is arguably a time period under direct control of the anaesthetist. These readings were four times more frequently observed than after the first surgical incision.Hypotension at any time was associated with postoperative AKI. Before anaesthetists change their practice, this instalment of 'Clinical Consequences' will critique and explore the impact of this evidence in depth.The incidence of postoperative AKI can vary depending on the type of surgery, but up to 40% of hospital-acquired AKI may occur in surgical patients [2]. Postoperative AKI is associated with increased mortality, as well as increased financial costs and other complications, such as the need for long-term renal replacement therapy [3][4][5]. Since postoperative AKI is easy to define and measure, perioperative strategies for its prevention seem to be a reasonable target for intervention. The question is, should we place more focus on better monitoring blood pressure and optimising haemodynamic parameters during the period between induction of anaesthesia and the first surgical incision? Renal perfusionIn 2012, the Kidney Disease Improving Global Outcomes (KDIGO) group released their AKI clinical practice guidelines [6]. Acute kidney injury is classified in stages by the degree of increase in serum creatinine and reduction in urine output. It follows that renal function is not a dichotomous (normal vs. deranged), but a continuous parameter. Similarly, the decrease in blood pressure preincision (or specifically the drop in renal perfusion pressure) is also continuous. Yet, logistic regression analysisthe method used by Maheshwari et al. to analyse their datasetrequires that both are converted to binary (dichotomous) measures. They define hypotension as a mean arterial pressure (MAP < 65 mmHg and AKI as KDIGO stage one or higher. It would have perhaps been interesting to inspect the plot of serum creatinine against the actual decrease in pre-induction MAP to look for any suggestion of correlation across the whole range of values, but this was not reported.The blood pressure required to maintain adequate blood flow to vital organs will vary between patients. Blood flow to most organs in health is governed by autoregulatory mechanisms, which are well understood. What is less well established is the lower limit of MAP beyond which autoregulation breaks down, and when flow becomes directly proportional to the perfusion pressure. Our understanding is currently based on studies of animals [7], but there appears to be no clear point at which autoregulation...

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Blood pressure variability in surgical and intensive care patients: Is there a potential for closed-loop vasopressor administration?

Cited by 28 publications

References 7 publications

Intraoperative Blood Pressure Variability Predicts Postoperative Mortality in Non-Cardiac Surgery—A Prospective Observational Cohort Study

Intraoperative Blood Pressure Variability Predicts Postoperative Mortality in Non-Cardiac Surgery—A Prospective Observational Cohort Study

Automated Blood Pressure Control

Pre‐incision hypotension and the association with postoperative acute kidney injury – an opportunity to improve peri‐operative outcomes?

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