Though intraoperative hypotension (IOH) is common in surgical patients, numerous studies indicate that it is strongly associated with risk—myocardial Injury (MI), acute kidney Injury (AKI), and mortality.1,2 The risks associated with IOH expand with an increase in the severity of hypotension.3

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IOH is common

88% of patients continuously monitored with an arterial line still experienced hypotension, defined as MAP <65 for 1 minute.4

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IOH may elevate risks

Research has revealed strong associations between IOH and increased risk of MI and AKI in noncardiac surgical patients.1,5,6

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IOH can be reduced

Acumen Hypotension Prediction Index (HPI) software is effective in detecting hemodynamic instability and substantially reducing the amount of intraoperative hypotension during noncardiac surgery, as demonstrated in a clinical study comparing to a historic control.7

IOH is common

Frequency and duration are high

IOH is a frequent side effect of general anesthesia and is presumed to have unfavorable outcomes for the patient.8 In a multi-center study of over 22k noncardiac 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

In a recent study of 11 hospitals across the U.S., 88% of noncardiac cases encountered at least one hypotensive event (defined as MAP <65 mmHg for at least 1 min.).4

Duration

28.2 minutes (SD 42.6 min) was the mean cumulative duration of hypotension in noncardiac surgery cases (n = 19,446) which had at least 1 minute of hypotension, defined as a MAP <65 mmHg.4

IOH may elevate risks

IOH may elevate risks

Myocardial injury after noncardiac surgery (MINS)

MINS is one of the most common causes of death within 30 days of 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 myocardial and kidney injury in noncardiac surgical patients.5

IOH may elevate risks

Acute kidney injury (AKI)

AKI is a major public health concern linked to poor outcomes, both in terms of health and the patient experience.10 In a recent study of 22k patients, 11.75% experienced AKI. Several studies also indicate AKI is expensive and consumes considerable healthcare resources.10-12 They also suggest greater severity of AKI is associated with incremental increases in length of stay.11-12

Depth and duration matter

MAP less than 65 mmHg for greater than or equal to 13 min (characterizing 50% of the patients studied) was associated with significantly higher odds of myocardial and kidney injury.1 A recent study characterized hypotension exposure by the lowest MAP maintained for various durations and by time under various MAP thresholds. This systematic review of IOH studies suggests that lower MAP thresholds and longer duration of IOH increases risk of AKI, MI, and mortality.8

Wesselink et al. also found the following blood pressure ranges were reported to be associated with overall organ injury, which reported as a combination of outcomes of mortality, AKI, MI, stroke, and delirium:8

Depth and duration matter

Multiple studies have suggested that maintaining intraoperative MAP above 65 mmHg may reduce the risk of AKI and myocardial injury.1

IOH may elevate risks

Additional research

For an extensive review of the associations between IOH and risk of adverse clinical outcomes, see the list of published studies below.

  • Gregory A, et al. Intraoperative hypotension is associated with adverse clinical outcomes after noncardiac surgery. Anesth Analg. 2021;132(6):1654-1665.
  • Wesselink EM, et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: A systematic review. Br J Anaesth. 2018;121(4):706-721. doi: 10.1016/j.bja.2018.04.036
  • 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.
  • Futier E, et al. Effect of individualized vs standard blood pressure management strategies on postoperative organ dysfunction among high-risk patients undergoing major surgery: A randomized clinical trial. JAMA. 2017;318(14):1346-1357.
  • Smeltz AM, et al. Elevated pulse pressure, intraoperative hemodynamic perturbations, and acute kidney injury after coronary artery bypass grafting surgery. J Cardiothorac Vasc Anesth. 2018;32(3):1214-1224..
  • Hallqvist L, et al. Intraoperative hypotension is associated with acute kidney injury in noncardiac surgery: An observational study. Eur J Anaesthesiol. 2018;35(4):273-279.
  • Vernooij LM, et al. Different methods of modelling intraoperative hypotension and their association with postoperative complications in patients undergoing non-cardiac surgery. Br J Anaesth. 2018;120(5):1080-1089.
  • Abbott TEF, et al. A prospective international multicentre cohort study of intraoperative heart rate and systolic blood pressure and myocardial injury after noncardiac surgery: Results of the VISION study. Anesth Analg. 2018;126(6):1936-1945.
  • Maheshwari K, et al. The association of hypotension during non-cardiac surgery, before and after skin incision, with postoperative acute kidney injury: A retrospective cohort analysis. Anaesthesia. 2018;73(10):1223-1228.
  • Sun LY, et al. Defining an intraoperative hypotension threshold in association with stroke in cardiac surgery. Anesthesiology. 2018;129(3);440-447.
  • Saugel B, et al. Automated ambulatory blood pressure measurements and intraoperative hypotension in patients having noncardiac surgery with general anesthesia: A prospective observational study. Anesthesiology. 2019;131(1):74-83.
  • Mathis MR, et al. Preoperative risk and the association between hypotension and postoperative acute kidney injury. Anesthesiology. 2020;132(3):461-475.
  • Naylor AJ, et al. Arterial catheters for early detection and treatment of hypotension during major noncardiac surgery: A randomized trial. Anesth Analg. 2020;131(5):1540-1550.
  • Ahuja S, et al. Associations of intraoperative radial arterial systolic, diastolic, mean, and pulse pressures with myocardial and acute kidney injury after noncardiac surgery: A retrospective cohort analysis. Anesthesiology. 2020;132(2):291-306.
  • Sessler DI, et al. Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth. 2019;122(5):563-574.
  • https://qpp.cms.gov/about/resource-library Measure ID: EPREOP31 – Full description in Appendix
  • Ono, Hogue, et al. Blood pressure excursions below the cerebral autoregulation threshold during cardiac surgery are associated with acute kidney injury. Crit Care Med. 2013;41(2):464-471.
  • Ono M, et al. Duration and magnitude of blood pressure below cerebral autoregulation threshold during cardiopulmonary bypass is associated with major morbidity and operative mortality. J Thorac Cardiovasc Surg. 2014;147(1):483-489.
  • Hori D, et al. Arterial pressure above the upper cerebral autoregulation limit during cardiopulmonary bypass is associated with postoperative delirium. Br J Anaesth. 2014;113(6):1009-1017.
  • Hori D, et al. Hypotension after cardiac surgery based on autoregulation monitoring leads to brain cellular injury. Ann Thorac Surg. 2015;100(2):487-493.
  • Chuan A, et al. Is cerebrovascular autoregulation associated with outcomes after major noncardiac surgery? A prospective observational pilot study. Acta Anaesthesiol Scand. 2019;63(1):8-17.
  • Brady KM, et al. Personalizing the definition of hypotension to protect the brain. Anesthesiology. 2020;132(1):170-179.
  • Chan B, Aneman A. A prospective, observational study of cerebrovascular autoregulation and its association with delirium following cardiac surgery. Anaesthesia. 2019;74(1):33-44.
  • Brown CH 4th, et al. Effect of targeting mean arterial pressure during cardiopulmonary bypass by monitoring cerebral autoregulation on postsurgical delirium among older patients: A nested randomized clinical trial. JAMA Surg. 2019;154(9):819-826.

IOH can be reduced

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 Several smaller studies on Acumen HPI software found similar results.13-15

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%, (with the results ranging from 23% to 72% mean IOH reduction).‡7 Several smaller studies on Acumen HPI software found similar results.13-15

Acumen HPI software is effective in detecting hemodynamic instability and substantially reducing the amount of IOH.*7 It’s the first-of-its-kind predictive decision support software that provides you with information regarding the likelihood of a patient trending toward hypotension. Acumen HPI software can be unlocked with the noninvasive Acumen IQ cuff or minimally-invasive Acumen IQ sensor.

Stay ahead of IOH »

IOH can be reduced

*When used in surgical patients who require intraoperative hemodynamic monitoring during noncardiac 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.

Understanding IOH in your practice

IOH can be reduced

Acumen Analytics software enables you to retrospectively view and analyze hemodynamic parameters including mean arterial pressure, providing you insights into the frequency, duration, and prevalence of intraoperative hypotension in your practice.

Learn about Acumen Analytics software »

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References
  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 Anest. 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.
  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.
  12. Alshaikh HN, et al. Financial impact of acute kidney injury after cardiac operations in the United States. Ann Thorac Surg. 2018;105(2):469-475.
  13. Wijnberge, M., et al. (2020) Effect of a Machine Learning-Derived Early Warning System for Intraoperative Hypotension vs Standard Care on Depth and Duration of Intraoperative Hypotension During Elective Noncardiac Surgery: The HYPE Randomized Clinical Trial. JAMA Online, February 17, 2020.
  14. Schneck, E., et al. (2019) Hypotension Prediction Index based protocolized haemodynamic management reduces the incidence and duration of intraoperative hypotension in primary total hip arthroplasty: a single centre feasibility randomized blinded prospective interventional trial. Journal of Clinical Monitoring and Computing online, November 29, 2019.
  15. Maheshwari K, Shimada T, Yang D, Khanna S, Cywinski JB, Irefin SA, Ayad S, Turan A, Ruetzler K, Qiu Y, Saha P, Mascha EJ, Sessler DI. Hypotension Prediction Index for Prevention of Hypotension during Moderate- to High-risk Noncardiac Surgery. Anesthesiology. 2020 Dec 1;133(6):1214-1222.

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