hypotension matters
Intraoperative hypotension and
outcomes after noncardiac surgery
outcomes

Recent studies show associations between intraoperative hypotension and increased risk of acute kidney injury (AKI) and myocardial injury 1-3 — the leading cause of post-operative mortality.1

Prolonged exposures below mean arterial pressure (MAP) thresholds of 65 mmHg and lower are associated with increased risk of myocardial injury and AKI after noncardiac surgery.1

outcomes

Studies also show an increased risk of mortality associated with hypotension after noncardiac surgery.4,5

If it were considered its own category, post-operative mortality would be the third leading cause of death in the United States.6

Hypotension study findings
point to increased risk

Highlights from 2017 Salmasi, et al.1

Publication in Anesthesiology: “Relationship Between Intraoperative Hypotension, Defined by Either Reduction From Baseline or Absolute Thresholds, and Acute Kidney and Myocardial Injury After Noncardiac Surgery”

In a study conducted by the Cleveland Clinic, researchers found that intraoperative hypotension is associated with clinical outcomes after noncardiac surgery.

Mean arterial pressure (MAP) below absolute thresholds of 65 mmHg and lower or relative thresholds of 20% or more below baseline were progressively related to both myocardial and acute kidney injury (AKI). At any given threshold, prolonged exposure was associated with increased odds.

Absolute and relative MAP thresholds had comparable ability to discriminate patients with myocardial or kidney injury from those without. These results suggest that maintaining intraoperative MAP greater than 65 mmHg may reduce the risk of AKI and myocardial injury.

Lowest mean arterial pressure (MAP) thresholds for myocardial injury
after noncardiac surgery (MINS)

Univariable and multivariable relationship between MINS and absolute and relative lowest MAP thresholds. (A) and (C) Estimated probability of MINS were from the univariable moving-window with the width of 10% data; (B) and (D) were from multivariable logistic regression smoothed by restricted cubic spline with three degrees and knots at 10th, 50th, and 90th percentiles of given exposure variable. Multivariable models adjusted for covariates in the table below. (A) and (B) show that there was a change point (i.e., decreases steeply up and then flattens) around 65 mmHg, but 20% was not a change point from (C) and (D).

Lowest mean arterial pressure (MAP) thresholds for acute kidney injury (AKI) after noncardiac surgery

Univariable and multivariable relationship between AKI and absolute and relative lowest MAP thresholds. (A) and (C) Estimated probability of AKI were from the univariable moving-window with the width of 10% data; (B) and (D) were from multivariable logistic regression smoothed by restricted cubic spline with three degrees and knots at 10th, 50th, and 90th percentiles of given exposure variable. (A) and (B) show that there was a change point (i.e., decreases steeply up and then flattens) around 65 mmHg, but 20% was not a change point from (C) and (D).

MINS
AKI
MINS

Lowest mean arterial pressure (MAP) thresholds for acute kidney injury (AKI) after noncardiac surgery

Univariable and multivariable relationship between AKI and absolute and relative lowest MAP thresholds. (A) and (C) Estimated probability of AKI were from the univariable moving-window with the width of 10% data; (B) and (D) were from multivariable logistic regression smoothed by restricted cubic spline with three degrees and knots at 10th, 50th, and 90th percentiles of given exposure variable. (A) and (B) show that there was a change point (i.e., decreases steeply up and then flattens) around 65 mmHg, but 20% was not a change point from (C) and (D).

AKI

Further Reading

Physiology of perfusion:
pressure and flow
adequate perfusion

Adequate perfusion requires adequate arterial pressure and cardiac output (CO)

cardiac output

Cardiac Output (CO) =
Stroke Volume x Heart Rate

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education

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References

  1. Salmasi, V., Maheshwari, K., Yang, G., Mascha, E.J., Singh, A., Sessler, D.I., & Kurz, A. (2017). Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney injury and myocardial injury. Anesthesiology, 126(1), 47-65.
  2. Sun, L.Y., Wijeysundera, D.N., Tait, G.A., & Beattie, W.S. (2015). Association of Intraoperative Hypotension with Acute Kidney Injury after Elective Noncardiac Surgery. Anesthesiology, 123(3), 515-523.
  3. Walsh, M., Devereaux, P.J., Garg, A.X., Kurz, A., Turan, A., Rodseth, R.N., Cywinski, J., Thabane, L., &Sessler, D.I. (2013). Relationship between Intraoperative Mean Arterial Pressure and Clinical Outcomes after Noncardiac Surgery. Anesthesiology, 119(3), 507-515.
  4. Mascha, E.J., Yang, D., Weiss, S., & Sessler, D.I. (2015). Intraoperative Mean Arterial Pressure Variability and 30-day Mortality in Patients Having Noncardiac Surgery. Anesthesiology, 123(1), 79-91.
  5. Monk, T.G., Bronsert, M.R., Henderson, W.G., Mangione, M.P., Sum-Ping, S.T.J., Bentt, D.R., Nguyen, J.D., Richman, J.S., Meguid, R.A., Hammermeister, K.A., (2015). Association between Intraoperative Hypotension and Hypertension and 30-day Postoperative Mortality in Noncardiac Surgery. Anesthesiology, 123(2), 307-319.
  6. Devereaux, P.J., Sessler, D.I., (2015). Cardiac Complications in Patients Undergoing Major Noncardiac Surgery, N Engl J Med, 373(23), 2258-2269.

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