88% of patients experienced intraoperative hypotension during non-cardiac surgery*1

IOH is common icon

IOH is common1,2,6

88%* of non-cardiac surgery patients (19,446/22,109) monitored with an arterial line experienced at least one hypotensive event* for at least 1 minute.1

IOH may elevate risk

IOH may elevate risk1,7,8

A wealth of evidence suggests a link between IOH and the increased risk of adverse outcomes – including MI, AKI, and mortality – after non-cardiac surgery.1,7,8

Acumen IQ cuff icon

IOH can be reduced

Acumen HPI software is effective in detecting haemodynamic instability and substantially reducing^ intraoperative hypotension. When used in surgical patients who require intraoperative haemodynamic monitoring during non-cardiac surgery.

^A single arm, multi-centre, prospective-to-historical control where non-cardiac surgical patients received arterial line monitoring.
*19,446/22,109 non-cardiac surgery patients. In a retrospective multicentre observational study that evaluated moderate-to-high risk (ASA status of 3 or 4) noncardiac surgery patients monitored for hypotension at hospitals that used an invasive arterial line ≥75% of the time. Hypotension/hypertensive event was defined as MAP <65 mmHg for at least one minute1

IOH* is common1,2,6

Frequency and duration during non-cardiac surgery are high.1,6,7,9

88%* of non-cardiac surgery patients (19,446/22,109) monitored with an arterial line experienced at least one hypotensive event* for at least 1 minute and the mean cumulative duration of IOH* was 28.2 minutes (standard deviation 42.6 minutes).1

Frequency

hypotensive event

88%* of patients (19,446/22,109) experienced at least one hypotensive event.*1

Duration

Duration of IOH

Mean cumulative duration of IOH* was 28.2 minutes (standard deviation 42.6 minutes).1

*From a retrospective multi-centre observational study that evaluated moderate- to high-risk (ASA status of 3 or 4) non-cardiac surgery patients monitored for hypotension at hospitals that used an invasive arterial line ≥75% of the time.1
Hypotension/hypotensive event was defined as MAP <65 mmHg for at least one minute.1

IOH may elevate risk1,7,8

IOH may elevate risks

Myocardial injury after non-cardiac surgery (MINS)

More than 1 in 12 patients (8 million people globally) over 45 years old experience MINS each year.10-12 In 2018, Sessler et al reported that MI was the leading cause of attributable postoperative death, accounting for 25% of all mortality.5

In non-cardiac surgery patients, research findings have revealed strong associations between intraoperative hypotension and elevated risk of both acute kidney injury (AKI) and myocardial injury after non-cardiac surgery (MINS).2-4

IOH may elevate risks

Acute kidney injury

A 2017 study estimated 30-40% of all cases of AKI occur after surgery.13 Studies from 2015 and 2017 show associations between intraoperative hypotension and increased risk of acute kidney injury (AKI) in non-cardiac surgery.2,3

A large clinical study in 2015 found that post-surgery AKI was associated with:*

  • 65% higher mortality14
  • 5.5 days longer hospital stay14
  • 59% higher hospital costs14
*From a retrospective, single-centre study that examined the impact of postoperative AKI in 50,314 moderate- and high-risk adult patients* undergoing surgery with ≥24-hour admission. Patients had no history of CKD, but likely were higher risk with more comorbidities vs patients who undergo outpatient or same-day inpatient surgery.14

Depth and duration matter

In a systematic review of 42 papers,† elevated risk of postoperative myocardial injury, acute kidney injury, and mortality was reported when IOH dropped lower than 65 mmHg.8 Risk increased as blood pressure became progressively lower.8

†Studies evaluated the associations between IOH and at least one of 6 identified adverse outcomes among non-cardiac surgery.8

Depth and duration matter

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

Acumen HPI software has demonstrated a reduction* in the duration of IOH by 57%.

Acumen HPI is effective in detecting haemodynamic instability and substantially reducing* intraoperative hypotension. It is a first-of-its-kind intelligent decision support suite that provides clinicians with information regarding the likelihood of a patient trending toward a hypotensive event^, allowing proactive treatment.15,16

*A single arm, multi-centre, prospective-to-historical control where non-cardiac surgical patients received arterial line monitoring
^Hypotension/hypotensive event was defined as MAP <65 mmHg for at least one minute.
IOH can be reduced
IOH can be reduced

Acumen Hypotension Prediction Index software is unlocked with the Acumen IQ sensor or Acumen IQ cuff.

Stay ahead of IOH »

Understanding IOH in your practice

IOH can be reduced

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.

Learn about Acumen Analytics software »

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References
  1. Shah NJ, Mentz G, Kheterpal S. The incidence of intraoperative hypotension in moderate to high risk patients undergoing non-cardiac surgery: A retrospective multicenter observational analysis. J Clin Anesth. 2020 Nov;66:109961.
  2. 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 after non-cardiac surgery: A retrospective cohort analysis. Anesthesiology, 126(1), 47-65.
  3. Sun LY, Wijeysundera DN, Tait GA, Beattie WS. Association of intraoperative hypotension with acute kidney injury after elective non-cardiac surgery. Anesthesiology. 2015 Sep;123(3):515- 23.
  4. Walsh M, Devereaux PJ, Garg AX, Kurz A, Turan A, Rodseth RN, Cywinski J, Thabane L, Sessler DI. Relationship between intraoperative mean arterial pressure and clinical outcomes after non-cardiac surgery: toward an empirical definition of hypotension. Anesthesiology. 2013 Sep;119(3):507-15.
  5. Sessler DI, Khanna AK. Perioperative myocardial injury and the contribution of hypotension. Intensive Care Med. 2018 Jun;44(6):811-822. doi: 10.1007/s00134-018-5224-7. Epub 2018 Jun 4. PMID: 29868971.
  6. Bijker JB, van Klei WA, Kappen TH, van Wolfswinkel L, Moons KGM, Kalkman CJ. Incidence of intraoperative hypotension as a function of the chosen definition: literature definitions applied to a retrospective cohort using automated data collection. Anesthesiology 2007; 107: 213e20.
  7. Gregory A, Stapelfeldt WH, Khanna AK, et al. Intraoperative hypotension is associated with adverse clinical outcomes after non-cardiac surgery. Anesth Analg. 2021;132(6):1654-1665.
  8. Wesselink EM, Kappen TH, Torn HM, et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth. 2018;121(4):706-721.
  9. Davies SJ, Vistisen ST, Zhongping J, et al. Ability of an arterial waveform analysis-derived hypotension prediction index to predict future hypotensive events in surgical patients. Anesth Analg. 2020;130(2):352- 359.
  10. Khan, J., Alonso-Coello, P., Devereaux, P.J., Myocardial injury after non-cardiac surgery, Curr Opin Cardiol, 2014, 29: 307-311.
  11. Sellers, D., Srinivas, C., Djaiani, G. (2018). Cardiovascular complications after non-cardiac surgery. Anaesthesia, 73 (Suppl. 1), 34 - 42.
  12. van Waes, J., Nathoe, H., Graa, J., Kemperman, H., de Borst, G., Peelen, L., van Klei, W. (2013). Myocardial Injury After Non-cardiac Surgery and its Association With Short-Term Mortality. Circulation, 127, 2264 – 2271.
  13. Meersch M, Schmidt C, Zarbock A. Perioperative Acute Kidney Injury: An Under-Recognized Problem. Anesth Analg. 2017 Oct;125(4):1223-1232.
  14. Hobson C, OzrazgatBaslanti T, Kuxhausen A, et al. Cost and mortality associated with postoperative acute kidney injury. Ann Surg. 2015;261(6):1207-1214.

  15. Ward H. van der Ven, Denise P. Veelo, Marije Wijnberge, Björn J.P. van der Ster, Alexander P.J. Vlaar, Bart F. Geerts, One of the first validations of an artificial intelligence algorithm for clinical use: The impact on intraoperative hypotension prediction and clinical decision-making, Surgery, Volume 169, Issue 6, 2021, Pages 1300-1303, ISSN 0039-6060, https://doi.org/10.1016/j.surg.2020.09.041. (https://www.sciencedirect.com/science/article/ pii/S0039606020307728.

  16. Feras Hatib, Zhongping Jian, Sai Buddi, Christine Lee, Jos Settels, Karen Sibert, Joseph Rinehart, Maxime Cannesson; Machine-learning Algorithm to Predict Hypotension Based on Highfidelity Arterial Pressure Waveform Analysis. Anesthesiology 2018; 129:663–674 doi: https://doi.org/10.1097/ALN.0000000000002300.

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