outcomes after noncardiac surgery
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
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
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 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).
- 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
- 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
- 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
- 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
- Devereaux, P.J., Sessler, D.I., (2015). Cardiac Complications in Patients Undergoing Major Noncardiac Surgery, N Engl J Med
pressure and flow
Adequate perfusion requires adequate arterial pressure and cardiac output (CO)
Cardiac Output (CO) =
Stroke Volume x Heart Rate
How you manage volume matters
When managing perfusion, stroke volume can be “optimized” using the patient’s own Frank-Starling curve — a plot of stroke volume (SV) vs. preload.
The patients location on his or her Frank-Starling curve can be determined by measuring ∆SV in response to change in preload using:
Bolus fluid challenge
Passive leg raise (PLR)
Additionally, stroke volume variation (SVV) has been proven to be a highly sensitive and specific indicator for preload responsiveness when managing volume. As a dynamic parameter, SVV has been shown to be an accurate predictor of fluid responsiveness in loading conditions induced by mechanical ventilation.7,8,9
Goal-Directed Therapy (PGDT)
PGDT is a treatment protocol using dynamic and flow-based parameters with the objective of making the appropriate volume management decisions (e.g. fluid only when needed).7
PGDT can be implemented in a single procedure or as part of a larger initiative such as Enhanced Recovery After Surgery pathways.
Hemodynamic education for sustained clinical advancement
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- 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.
- 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.
- 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.
- 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.
- 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.
- Devereaux, P.J., Sessler, D.I., (2015). Cardiac Complications in Patients Undergoing Major Noncardiac Surgery, N Engl J Med, 373(23), 2258-2269.
- Peng, K., Li, J., Cheng, H., Ji, FH. (2014) Goal-directed fluid therapy based on stroke volume variations improves fluid management and gastrointestinal perfusion in patients undergoing major orthopedic surgery. Medical Principles and Practice, 23(5), 413-20.
- Berkenstadt, H., et al. (2001) Stroke Volume Variation as a Predictor of Fluid Responsiveness in Patients Undergoing Brain Surgery. Anesthesia & Analgesia, 92, 984-9
- Michard, F., Mountford, W., Krukas, M., Ernst, F., Fogel, S. (2015) Potential return on investment for implementation of perioperative goal-directed fluid therapy in major surgery: a nationwide database study. Perioperative Medicine, 4, 11.
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