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Intraoperative Hypotension Is Associated With Adverse Clinical Outcomes After Noncardiac Surgery.

ABSTRACT:

Background

Intraoperative hypotension (IOH) occurs frequently during surgery and may be associated with organ ischemia; however, few multicenter studies report data regarding its associations with adverse postoperative outcomes across varying hemodynamic thresholds. Additionally, no study has evaluated the association between IOH exposure and adverse outcomes among patients by various age groups.

Methods

A multicenter retrospective cohort study was conducted between 2008 and 2017 using intraoperative blood pressure data from the US electronic health records database to examine postoperative outcomes. IOH was assessed in 368,222 noncardiac surgical procedures using 5 methods: (a) absolute maximum decrease in mean arterial pressure (MAP) during surgery, (b) time under each absolute threshold, (c) total area under each threshold, (d) time-weighted average MAP under each threshold, and (e) cumulative time under the prespecified relative MAP thresholds. MAP thresholds were defined by absolute limits (≤75, ≤65, ≤55 mm Hg) and by relative limits (20% and 40% lower than baseline). The primary outcome was major adverse cardiac or cerebrovascular events; secondary outcomes were all-cause 30- and 90-day mortality, 30-day acute myocardial injury, and 30-day acute ischemic stroke. Residual confounding was minimized by controlling for observable patient and surgical factors. In addition, we stratified patients into age subgroups (18-40, 41-50, 51-60, 61-70, 71-80, >80) to investigate how the association between hypotension and the likelihood of major adverse cardiac or cerebrovascular events and acute kidney injury differs in these age subgroups.

Results

IOH was common with at least 1 reading of MAP ≤75 mm Hg occurring in 39.5% (145,743) of cases; ≤65 mm Hg in 19.3% (70,938) of cases, and ≤55 mm Hg in 7.5% (27,473) of cases. IOH was significantly associated with the primary outcome for all age groups. For an absolute maximum decrease, the estimated odds of a major adverse cardiac or cerebrovascular events in the 30-day postsurgery was increased by 12% (95% confidence interval [CI], 11-14) for ≤75 mm Hg; 17.0% (95% CI, 15-19) for ≤65 mm Hg; and by 26.0% (95% CI, 22-29) for ≤55 mm Hg.

Conclusions

IOH during noncardiac surgery is common and associated with increased 30-day major adverse cardiac or cerebrovascular events. This observation is magnified with increasing hypotension severity. The potentially avoidable nature of the hazard, and the extent of the exposed population, makes hypotension in the operating room a serious public health issue that should not be ignored for any age group.

SUBMITTER: Gregory A

PROVIDER: S-EPMC8115733 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:PurposeTo evaluate the clinical applicability of intraoperative predictors for surgical outcomes after gonioscopy-assisted transluminal trabeculotomy (GATT) and microincisional trabeculectomy (MIT).MethodsConsecutive patients with primary, or secondary glaucoma (trauma, aphakic, or status post-retinal surgeries) with uncontrolled IOP>21mm Hg, who were scheduled to undergo GATT or MIT with or without significant cataract surgery, at a tertiary eye centre in East India between September 2021 to March 2023, were included. All surgeries were done by a single surgeon. Blanching and Trypan blue (0.4%) staining after intracameral injection using a 25 canula, were analysed in each video. The extent/pattern of blanching and blue staining in each eye was analysed objectively using an overlay of a circle with 12 sectors and a protractor tool to quantify the degrees or quadrants of blanching/staining. Multivariate regression was used to identify predictors for surgical success or the need for medications after surgery.ResultOf 167 eyes that were included (male: female- 134: 33), 49 eyes and 118 eyes underwent GATT and MIT, respectively, with 81 of 167 eyes undergoing concurrent cataract surgery. All eyes had a significant reduction in the number of medications after surgery. Blanching was seen in 154 of 167 eyes in a mean of 2±1.8 quadrants with 41% of eyes showing a blanching effect in >3 quadrants. Of 99 of 167 eyes where Trypan blue staining was assessed, staining in a venular, diffuse haze, or reticular pattern of staining was seen in 73 eyes, 26 eyes showed blue staining in >2 quadrants, with 16% staining in >3 quadrants. Surgical success was not predicted by the quadrants of blanching, blue staining, or other clinical variables (age, visual field, baseline intraocular pressure, type of surgery). The variables significantly predicting the need for medications included blanch (r = -0.1, p = 0.03), and blue staining (r = -0.1, p = 0.04) in <2 quadrants.ConclusionsBlanching and Trypan blue staining in >2 quadrants after GATT or MIT can serve as surrogate predictors for the need for medications. However more studies are mandated to find predictors for surgical success after GATT or MIT.

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