Characteristics and outcomes of rapid response team activations for hypotension in orthopaedic patients

Abstract

Background Hypotension following orthopaedic surgery has been associated with increased morbidity and mortality. Rapid response teams (RRT) review patients on hospital wards with hypotension. Aim To evaluate the epidemiology of hypotensive RRT activations in adult orthopaedic patients to identify contributing factors and areas for future quality improvement. Methods Timing of RRT activations, presumed causes of hypotension and associated treatments were assessed. Results Among 963 RRT activations in 605 patients over 3 years, the first calls of 226 of 605 patients were due to hypotension, and 213 (94.2%) of 226 had sufficient data for analysis. The median age was 79 (interquartile range 66–87) years; 58 (27.2%) were male, and comorbidities were common. Most (68%) surgery was emergent, and 75.1% received intraoperative vasopressors for hypotension. Most activations occurred within 24 h of surgery, and hypovolaemia, infection and arrhythmias were common presumed causes. Fluid boluses occurred in 173 (81.2%), and the time between surgery and RRT activation was 10 (4.0–26.5) h. in cases where fluid boluses were given, compared with 33 (15.5–61.5) h. where they were not (P < 0.001). Blood transfusion (30, 14.1%) and withholding of medications were also common. Hospital mortality was 8.5% (18), and 13.6% (29) were admitted to critical care at some stage. In‐hospital death was associated with older age, functional dependence, arrhythmia and presumed infection. Conclusions Hypotension‐related RRT calls in orthopaedic patients are common. Future interventional studies might focus on perioperative fluid therapy and vaso‐active medications, as well as withholding of anti‐hypertensive medications preoperatively.

Triggers for medical emergency team activation after non-cardiac surgery

“…The dominance of hypotension and tachycardia as triggers for MET calls is consistent with previous work in orthopaedic surgical cohorts. 18,19 These observations suggest that future research could focus on identifying predictive factors for hypotension and tachycardia after surgery, and subsequently potential therapeutic interventions to reduce the risk of deterioration. Additionally, while knowing the most likely trigger for a MET call is helpful, the deterioration syndrome of postoperative hypotension, for example, can be caused by a number of underlying pathological processes.…”

“…17 In surgical patients selected from mixed cohorts, the commonest triggers were hypotension, hypoxia and tachycardia. [18][19][20] Risk factors for MET calls in surgical patients in previous studies included older age, more extensive comorbidity, living with greater degrees of frailty, 21,22 atrial fibrillation, 23 obstructive sleep apnoea (OSA), 24 chronic liver disease, surgical duration, and sedation in PACU. 25 Up to 22% of surgical patients who experience a MET call have more than one activation, 26,27 increasing the risk of mortality compared with a single MET call.…”

Nature and characteristics of orthopaedic medical emergency team (MET) events: a retrospective study of 263 MET calls

“…Frequency and management of MET calls were consistent with that quoted in the literature. [14][15][16][17][18]21 The majority of hypotensive patients in this study required a single fluid bolus to restore normal vital parameters, with few requiring additional management. This may demonstrate the need to reevaluate the response of MET to potentially benign and easily treatable MET triggers, such as asymptomatic hypotension, to allow for more efficient allocation of resources and funding for medical outreach services.…”

“…The most common trigger for MET calls in postoperative patients is hypotension, [14][15][16][17][18] with the most significant occurrences within the first 24 hr after surgery. 14,16,18 Patients with premorbid physiological derangement are at higher risk of deterioration postoperatively.…”

“…The most common trigger for MET calls in postoperative patients is hypotension, [14][15][16][17][18] with the most significant occurrences within the first 24 hr after surgery. 14,16,18 Patients with premorbid physiological derangement are at higher risk of deterioration postoperatively. 19 Management guidelines such as the enhanced recovery after surgery (ERAS) have been implemented to minimize complications, for example minimizing fasting periods and close management of intraoperative and postoperative fluid regimes.…”