Intraoperative Hypotension Is Associated With Adverse Clinical Outcomes After Noncardiac Surgery

Abstract

BACKGROUND: Intraoperative hypotension (IOH) occurs frequently during surgery and may be associated with organ ischemia; however, few multicenter studies report data regarding its associations with adverse postoperative outcomes across varying hemodynamic thresholds. Additionally, no study has evaluated the association between IOH exposure and adverse outcomes among patients by various age groups. METHODS: A multicenter retrospective cohort study was conducted between 2008 and 2017 using intraoperative blood pressure data from the US electronic health records database to examine postoperative outcomes. IOH was assessed in 368,222 noncardiac surgical procedures using 5 methods: (a) absolute maximum decrease in mean arterial pressure (MAP) during surgery, (b) time under each absolute threshold, (c) total area under each threshold, (d) time-weighted average MAP under each threshold, and (e) cumulative time under the prespecified relative MAP thresholds. MAP thresholds were defined by absolute limits (≤75, ≤65, ≤55 mm Hg) and by relative limits (20% and 40% lower than baseline). The primary outcome was major adverse cardiac or cerebrovascular events; secondary outcomes were all-cause 30- and 90-day mortality, 30-day acute myocardial injury, and 30-day acute ischemic stroke. Residual confounding was minimized by controlling for observable patient and surgical factors. In addition, we stratified patients into age subgroups (18–40, 41–50, 51–60, 61–70, 71–80, >80) to investigate how the association between hypotension and the likelihood of major adverse cardiac or cerebrovascular events and acute kidney injury differs in these age subgroups. RESULTS: IOH was common with at least 1 reading of MAP ≤75 mm Hg occurring in 39.5% (145,743) of cases; ≤65 mm Hg in 19.3% (70,938) of cases, and ≤55 mm Hg in 7.5% (27,473) of cases. IOH was significantly associated with the primary outcome for all age groups. For an absolute maximum decrease, the estimated odds of a major adverse cardiac or cerebrovascular events in the 30-day postsurgery was increased by 12% (95% confidence interval [CI], 11-14) for ≤75 mm Hg; 17.0% (95% CI, 15-19) for ≤65 mm Hg; and by 26.0% (95% CI, 22-29) for ≤55 mm Hg. CONCLUSIONS: IOH during noncardiac surgery is common and associated with increased 30-day major adverse cardiac or cerebrovascular events. This observation is magnified with increasing hypotension severity. The potentially avoidable nature of the hazard, and the extent of the exposed population, makes hypotension in the operating room a serious public health issue that should not be ignored for any age group.

Relationship among Preoperative, Pre and Postinduction Blood Pressure in Normotensive and Hypertensive Patients

“…Changes in intraoperative blood pressure (BP) are frequent, especially hypotension, during noncardiac and cardiac surgery with general anesthesia. Adverse intra and postoperative outcomes involving postoperative myocardial ischemia and myocardial infarction, ischemic renal injury, stroke, postoperative cognitive decline, and death are related to intraoperative hypotension [1][2][3][4][5][6][7][8][9]. Although hypertension alone is not regularly correlated with perioperative cardiovascular complications, it may induce intra-operative hypotension The BPpre-ind was the BP at the time of the patient's arrival in the operating room before anesthesia induction [14].…”

The burden of perioperative hypertension/hypotension: A systematic review

“…In addition, an association between the threshold and the increased odds for 30-day and 90-day mortality has been recently demonstrated: the lower the MAP the higher the odds, as reported by Gregory et al . [ 23 ].…”

Red cell distribution width/albumin ratio and 90-day mortality after burn surgery

“…In addition, intraoperative hypotensive events were common and significantly associated with cerebrovascular or major adverse cardiac events for all age groups. Cerebrovascular or major adverse cardiac events in the first 30 postoperative days were elevated by 12% for ≤75 mmHg, 17.0% for ≤65 mmHg and 26.0% for ≤55 mmHg [ 28 ]. Therefore, reducing the chance of blood transfusion and intraoperative hypotension would improve morbidity and mortality in burn patients.…”