Persistent severe post‐operative hypotension after pancreaticoduodenectomy is related to increased inflammatory response

Abstract

Background: Hypotension during major surgery is frequent, resulting in increased need for observation in the post-anaesthesia care unit and treatment including vasopressors and fluids. However, although severe hypotension in the immediate postoperative recovery phase after major surgery is suggested to be related to increased morbidity and mortality, the underlying risk factors are not well described, hindering advancements in prevention and treatment. Methods: We performed a retrospective study assessing factors (age, gender, bodymass index, cardiac co-morbidity, haemoglobin, absolute and increase in c-reactive protein on the first post-operative day, bleeding, fluid balance at the end of surgery and the first post-operative day) related to severe persistent hypotension (SPH) (SPH: need for noradrenaline to maintain a mean arterial blood pressure (MAP) >65.0 mm Hg on the morning after surgery) and occurrence of other early (24 hours) complications. One hundred patients undergoing pancreaticoduodenectomy (PD) with preoperative high-dose glucocorticoid and goal-directed fluid therapy were enrolled and perioperative data collected from anaesthetic and medical records. Results: Forty-five patients had SPH, who had a significantly higher increase in CRP levels the morning after surgery (median 50 mg L −1 vs 41 mg L −1 , SPH vs non-SPH, respectively, P = .028), and a significantly more positive fluid balance at discharge (median 1457 ml vs 1031 ml, respectively, P = .027) vs patients without SPH. Conclusions: Severe persistent hypotension after PD was associated with significantly increased inflammatory response and increased need for fluids. Future studies should investigate the effect of further inflammatory control in PD to improve haemodynamics and morbidity.

Risk factors associated with intraoperative persistent hypotension in pancreaticoduodenectomy

“…In the present retrospective cohort study, we found that the risk factors associated with IPH during PD were age, prolonged surgical procedures, more blood loss, and even more notably, decreased arterial Ca 2+ concentration. The incidence of IPH during PD was 41.42; similar to the report by Pitter and colleagues[ 11 ]. Our study confirms findings from previous studies, which indicated a close relationship of prolonged surgery and increased blood loss to intraoperative hypotension[ 4 , 16 , 17 ].…”

“…The small arteries located anterior to the capillaries predominantly determine peripheral vascular resistance, which is influenced by the autonomic nervous system, self-regulation, endothelial-cell-derived molecules and inflammatory factors[ 10 ]. The increased inflammatory markers, such as C-reactive protein, can increase the risk for severe hypotension and vasopressor dependency during postoperative day 1 after PD[ 11 ]. A more positive fluid balance commonly seen in PD implicates inadequate circulating blood volume in the risk of IPH.…”

Elevated preoperative suPAR is a strong and independent risk marker for postoperative complications in high-risk patients undergoing major non-cardiac surgery (SPARSE)

“…22,23 Consequently, the preoperative inflammatory status can be a major contributor to postoperative organ injury and therefore it is very important for risk stratification. 22,24 In addition, preoperative neuroendocrine responses to stress can modify the immune function and are associated with adverse outcomes, 25-28 while several drugs may induce inflammation or exert significant anti-inflammatory properties. 29-31 Therefore, preoperative suPAR levels may also assist in measuring inflammation, identifying a proinflammatory, inflammatory, or an immuno-suppressive status, which can influence short- and long-term outcome and/or disease progression.…”

Preoperative TruCulture® whole blood cytokine response predicts post‐operative inflammation in pancreaticoduodenectomy patients—A pilot cohort study

“…Blood loss was substituted with HA 5% or with blood transfusion if haemoglobin < 8.1 g/dL, according to national guidelines. 14 During the post-anaesthesia care unit (PACU) stay, the epidural infusion continued together with the GDT protocol, and NA if needed to maintain a MAP > 65 mmHg. PACU discharge followed standardized criteria.…”