Intraoperative arterial pressure management: knowns and unknowns

Karamchandani, Kunal; Dave, Siddharth; Hoffmann, Ulrich; Khanna, Ashish K.; Saugel, Bernd

doi:10.1016/j.bja.2023.05.027

Cited by 5 publications

(2 citation statements)

References 50 publications

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“…This may be explained by the fact that the MAP, rather than the SBP, affects the collateral perfusion pressure, maintaining penumbral blood supply and preventing its conversion to an infarct core [24]. This could point to the conclusion that careful fluid management and the use of vasopressors may halt the ischemic core volume progression [26,27].…”

Section: Discussionmentioning

confidence: 99%

Association between Transient-Continuous Hypotension during Mechanical Thrombectomy for Acute Ischemic Stroke and Final Infarct Volume in Patients with Proximal Anterior Circulation Large Vessel Occlusion

Wiącek,

Tomaszewska-Lampart,

Dziedzic

et al. 2024

JCM

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Background/Objectives: Periprocedural blood pressure changes in stroke patients with a large vessel occlusion are a known modifiable risk factor of unfavorable treatment outcomes. We aimed to evaluate the association between pre-revascularization hypotension and the final infarct volume. Methods: In our retrospective analysis, we included 214 consecutive stroke patients with an anterior circulation large vessel occlusion that underwent mechanical thrombectomy under general anesthesia. Noninvasively obtained blood pressure values prior to symptomatic vessel recanalization were analyzed as a predictor of post-treatment infarct size. Linear logistic regression models adjusted for predefined factors were used to investigate the association between blood pressure parameters and the final infarct volume. Results: In our cohort, higher baseline systolic blood pressure (aβ = 8.32, 95% CI 0.93–15.7, p = 0.027), its maximal absolute drop (aβ = 6.98, 95% CI 0.42–13.55, p = 0.037), and >40% mean arterial pressure decrease (aβ = 41.77, CI 95% 1.93–81.61, p = 0.040) were independently associated with higher infarct volumes. Similarly, continuous hypotension measured as intraprocedural cumulative time spent below either 100 mmHg (aβ = 3.50 per 5 min, 95% CI 1.49–5.50, p = 0.001) or 90 mmHg mean arterial pressure (aβ = 2.91 per 5 min, 95% CI 0.74–5.10, p = 0.010) was independently associated with a larger ischemia size. In the subgroup analysis of 151 patients with an M1 middle cerebral artery occlusion, two additional factors were independently associated with a larger ischemia size: systolic blood pressure maximal relative drop and >40% drop from pretreatment value (aβ = 1.36 per 1% lower than baseline, 95% CI 0.04–2.67, p = 0.043, and aβ = 43.01, 95% CI 2.89–83.1, p = 0.036, respectively). No associations between hemodynamic parameters and post-treatment infarct size were observed in the cohort of intracranial internal carotid artery occlusion. Conclusions: In patients with ischemic stroke due to a proximal middle cerebral artery occlusion, higher pre-thrombectomy treatment systolic blood pressure is associated with a larger final infarct size. In patients treated under general anesthesia, hypotension prior to the M1 portion of middle cerebral artery recanalization is independently correlated with the post-treatment infarct volume. In this group, every 5 min spent below the mean arterial pressure threshold of 100 mmHg is associated with a 4 mL increase in ischemia volume on a post-treatment NCCT. No associations between blood pressure and final infarct volume were present in the subgroup of patients with an intracranial internal carotid artery occlusion.

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Section: Discussionmentioning

confidence: 99%

Association between Transient-Continuous Hypotension during Mechanical Thrombectomy for Acute Ischemic Stroke and Final Infarct Volume in Patients with Proximal Anterior Circulation Large Vessel Occlusion

Wiącek,

Tomaszewska-Lampart,

Dziedzic

et al. 2024

JCM

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“…In contrast to blood pressure management during CPB, which is primarily pump flow driven, MAP regulation of the patients from induction of anesthesia until surgical opening and during resuscitation after removal of the pump is generally attributable to anesthesiologic management [ 50 , 51 ]. In this period, the anesthetists could control the blood pressure as much as possible above the target threshold and avoid prolonged hypotension by resorting to strategies such as enhancing cardiac function, maintaining electrolyte balance, addressing anemia, and eliminating allergies [ 52 ]. Therefore, giving anesthetists more specific advice on maintaining intraoperative blood pressure is essential for successful early prophylactic intervention for AKI.…”

Section: Discussionmentioning

confidence: 99%

Incorporating intraoperative blood pressure time-series variables to assist in prediction of acute kidney injury after type a acute aortic dissection repair: an interpretable machine learning model

Dai,

Zhou,

Jiang

et al. 2023

Annals of Medicine

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Background Acute kidney injury (AKI) is a common and serious complication after the repair of Type A acute aortic dissection (TA-AAD). However, previous models have failed to account for the impact of blood pressure fluctuations on predictive performance. This study aims to develop machine learning (ML) models combined with intraoperative medicine and blood pressure time-series data to improve the accuracy of early prediction for postoperative AKI risk. Methods Indicators reflecting the duration and depth of hypotension were obtained by analyzing continuous mean arterial pressure (MAP) monitored intraoperatively with multiple thresholds (<65, 60, 55, 50) set in the study. The predictive features were selected by logistic regression and the least absolute shrinkage and selection operator (LASSO), and 4 ML models were built based on the above features. The performance of the models was evaluated by area under receiver operating characteristic curve (AUROC), calibration curve and decision curve analysis (DCA). Shapley additive interpretation (SHAP) was used to explain the prediction models. Results Among the indicators reflecting intraoperative hypotension, 65 mmHg showed a statistically superior difference to other thresholds in patients with or without AKI ( p < .001). Among 4 models, the extreme gradient boosting (XGBoost) model demonstrated the highest AUROC: 0.800 (95% 0.683–0.917) and sensitivity: 0.717 in the testing set and was verified the best-performing model. The SHAP summary plot indicated that intraoperative urine output, cumulative time of mean arterial pressure lower than 65 mmHg outside cardiopulmonary bypass (OUT_CPB_MAP_65 time), autologous blood transfusion, and smoking were the top 4 features that contributed to the prediction model. Conclusion With the introduction of intraoperative blood pressure time-series variables, we have developed an interpretable XGBoost model that successfully achieve high accuracy in predicting the risk of AKI after TA-AAD repair, which might aid in the perioperative management of high-risk patients, particularly for intraoperative hemodynamic regulation.

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PRO: Vasopressors Can Be Administered Safely via a Peripheral Intravenous Catheter

Darwish,

Karamchandani

2024

Journal of Cardiothoracic and Vascular Anesthesia

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Intraoperative arterial pressure management: knowns and unknowns

Cited by 5 publications

References 50 publications

Association between Transient-Continuous Hypotension during Mechanical Thrombectomy for Acute Ischemic Stroke and Final Infarct Volume in Patients with Proximal Anterior Circulation Large Vessel Occlusion

Association between Transient-Continuous Hypotension during Mechanical Thrombectomy for Acute Ischemic Stroke and Final Infarct Volume in Patients with Proximal Anterior Circulation Large Vessel Occlusion

Incorporating intraoperative blood pressure time-series variables to assist in prediction of acute kidney injury after type a acute aortic dissection repair: an interpretable machine learning model

PRO: Vasopressors Can Be Administered Safely via a Peripheral Intravenous Catheter

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