IOH is common
88% of patients continuously monitored with an arterial line still experienced hypotension, defined as mean arterial pressure (MAP) <65 for 1 minute.4
Intraoperative hypotension:
Every moment matters
Though intraoperative hypotension (IOH) is common in surgical patients, numerous studies now indicate that it is strongly associated with risk—myocardial Injury (MI), acute kidney Injury (AKI), and mortality.1,2 Recent studies also suggest that no amount of time with a mean arterial pressure (MAP) ≤75 mmHg appears safe for patients undergoing low-risk non-cardiac surgery3
IOH has elevate risks
Research has revealed strong associations between IOH and increased risk of MI and AKI in non-cardiac surgical patients.1,5,6
IOH can be reduced
Acumen Hypotension Prediction Index (HPI) software is effective in detecting haemodynamic instability and substantially reducing the amount of intraoperative hypotension.*7
*When used in surgical patients who require intraoperative haemodynamic monitoring during non-cardiac surgery.
1. Salmasi V, et al. Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney injury and myocardial injury. Anesthesiology. 2017;126(1):47-65.
2. Mascha, EJ, et al. Intraoperative mean arterial pressure variability and 30-day mortality in patients having noncardiac surgery. Anesthesiology. 2015;123(1):79-91.
3. Gregory A, et al. Intraoperative hypotension is associated with adverse clinical outcomes after noncardiac surgery. Anesth Analg. 2021;132(6):1654-1665.
4. Shah NJ, et al. The incidence of intraoperative hypotension in moderate to high risk patients undergoing non-cardiac surgery: A retrospective multicenter observational analysis. J Clin Anesth. 2020;66:109961.
5. Walsh M, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery. Anesthesiology. 2013;119(3):507-515.
6. Sun LY, et al. Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery. Anesthesiology. 2015;132(3):515-523.
7. Edwards Lifesciences LLC. 501(k) Summary: K203224; Acumen Hypotension Prediction Index. U.S. Food and Drug Administration; 2021. Accessed September 29, 2021. https://www.accessdata.fda.gov/ cdrh_docs/pdf20/K203224.pdf.
IOH is common
Frequency and duration are high
IOH is a frequent side effect of general anaesthesia and is presumed to have unfavourable outcomes for the patient.8 In a multi-centre study of over 22,000 non-cardiac surgery cases, where all patients received continuous monitoring through an arterial line, 88% of patients had at least one hypotensive event with a mean cumulative duration of 28.2 minutes.4
Prevalence
88% of non-cardiac surgical cases, in 11 hospitals across the U.S., had at least one hypotensive event of mean arterial pressure (MAP) <65 for at least 1 min.
Duration
28.2 minutes (SD 42.6 min) was the mean cumulative duration of hypotension in non-cardiac surgery cases (n = 19,446) who had at least 1 minute of hypotension, defined as a MAP <65 mmhg 4
4. Shah NJ, et al. The incidence of intraoperative hypotension in moderate to high risk patients undergoing non-cardiac surgery: A retrospective multicenter observational analysis. J Clin Anest. 2020;66:109961.
8. Wesselink EM, et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth. 2018;121(4):706-721.
IOH has elevated risk
Myocardial injury after non-cardiac surgery (MINS)
MINS is the largest cause of people dying within a month after surgery.1 At least 8 million patients worldwide suffer from MINS each year.9 Research is pointing to a strong association between IOH and increased risk of MI and AKI injury in non-cardiac surgical patients.5
Acute kidney injury (AKI)
AKI is a major public health concern linked to both poor outcomes in terms of health and the patient experience.10 In a recent study of 22,000 patients, 11.75% experienced AKI. Several studies also indicate AKI is expensive and consumes considerable healthcare resources.10 They also suggest greater severity of AKI is associated with incremental increases in length of stay.11
Depth and duration matter
A systematic review of literature suggests that lower MAP thresholds and longer duration increases risk of AKI, MI, and mortality.8 A recent study characterised hypotension exposure by the lowest MAP maintained for various durations and by time under various MAP thresholds. MAP less than 65 mmHg for greater than or equal to 13 min (characterising 50% of the patients who ever went less than 65 mmHg) was associated with significantly higher odds of myocardial and kidney injury.
Wesselink et al. found the following blood pressure ranges were reported to be associated with overall organ injury, which was the combined outcomes of mortality, AKI, MI, stroke, and delirium:8
Multiple studies have suggested that maintaining intraoperative MAP above 65 mmHg may reduce the risk of AKI and myocardial injury.1
1. Salmasi V, et al. Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney injury and myocardial injury. Anesthesiology. 2017;126(1):47-65.
5. Walsh M, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery. Anesthesiology. 2013;119(3):507-515.
8. Wesselink EM, et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth. 2018;121(4):706-721.
9. Kahn J, et al. Myocardial injury after noncardiac surgery. Cur Opin Cardiol. 2014;29(4):307-11. doi: 10.1097/HCO.0000000000000069
10. Silver SA, et al. The economic consequences of acute kidney injury. Nephron. 2017;137(4):297-301.
11. Collister D, et al. Health care costs associated with AKI. Clin J Am Soc Nephrol. 2017;12(11):1733-1743.
Additional research
For an extensive review of the associations between IOH and risk of adverse clinical outcomes, see the list of published studies below.
IOH can be reduced
For patients who had a hypotensive event,† Acumen Hypotension Prediction Index (HPI) software has been demonstrated to reduce the duration of IOH by 57%.7
These results demonstrate a substantial reduction in mean IOH that was consistent across most sites. Most sites had a >25% reduction in mean duration of IOH, with all sites but one exceeding 35%, and with the results ranging from 23% to 72% mean IOH reduction.‡7
Acumen HPI detects haemodynamic instability and substantially reduces the amount of IOH.*7 The predictive decision support software provides you with information regarding the likelihood of a patient trending toward hypotension.† Acumen HPI software can be unlocked with the non-invasive Acumen IQ cuff or minimally-invasive Acumen IQ sensor.
Understanding IOH in your practice
Acumen Analytics software enables you to retrospectively view and analyse haemodynamic parameters including mean arterial pressure, providing you insights into the frequency, duration, and prevalence of intraoperative hypotension in your practice.
*When used in surgical patients who require intraoperative haemodynamic monitoring during non-cardiac surgery.
†A hypotensive event is defined as MAP <65 mmhg=for a duration of at least one minute.
‡Single arm, multicenter, prospective-to-historical control where patients received arterial line monitoring.
7. Edwards Lifesciences LLC. 501(k) Summary: K203224; Acumen Hypotension Prediction Index. U.S. Food and Drug Administration; 2021. Accessed September 29, 2021. https://www.accessdata.fda.gov/ cdrh_docs/pdf20/K203224.pdf.
8. Wesselink EM, et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth. 2018;121(4):706-721.
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