Incidence, Severity, and Detection of Blood Pressure Perturbations after Abdominal Surgery

Abstract

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Intraoperative and postoperative hypotension are associated with myocardial and kidney injury and 30-day mortality. Intraoperative blood pressure is measured frequently, but blood pressure on surgical wards is usually measured only every 4 to 6 h, leaving long intervals during which hypotension and hypertension may be undetected. This study evaluated the incidence and severity of postoperative hypotension and hypertension in adults recovering from abdominal surgery and the extent to which serious perturbations were missed by routine vital-sign assessments. Methods Blood pressure was recorded at 1-min intervals during the initial 48 h in adults recovering from abdominal surgery using a continuous noninvasive monitor. Caregivers were blinded to these measurements and depended on routine vital-sign assessments. Hypotension and hypertension were characterized as time under and above various mean arterial pressure thresholds. Results Of 502 available patients, 312 patients with high-quality records were analyzed, with a median measurement time of 48 [interquartile range: 41, 48] postoperative hours. Nearly a quarter experienced an episode of mean arterial pressure of less than 70 mm Hg lasting at least 30 min (24%; 95% CI, 20%, 29%), and 18% had an episode of mean arterial pressure of less than 65 mm Hg lasting at least 15 min. Nearly half the patients who had mean arterial pressure of less than 65 mm Hg for at least 15 min (47%; 95% CI, 34%, 61%) were undetected by routine vital-sign assessments. Episodes of mean arterial pressure greater than 110 mm Hg lasting at least 30 min were observed in 42% (95% CI, 37%, 48%) of patients; 7% had mean arterial pressure greater than 130 mm Hg for at least 30 min, 96% of which were missed by routine assessments. Episodes of mean arterial pressure less than 65 mm Hg and mean arterial pressure greater than 110 mm Hg captured by routine vital-sign assessments but not by continuous monitoring occurred in 34 and 8 patients, respectively. Conclusions Postoperative hypotension and hypertension were common, prolonged, profound, and largely undetected by routine vital-sign assessments in a cohort of adults recovering from abdominal surgery. Frequent or continuous blood pressure monitoring may detect hemodynamic perturbations more effectively and potentially facilitate treatment.

Association between complications and death within 30 days after noncardiac surgery

“…Studies that obtained continuous pulse oximetry and blood pressure readings from patients on surgical floors have shown that many patients have prolonged hypoxia and hypotension that is not identified by health care providers. 22,23 Given that some studies have shown that hypoxia and hypotension are precursors to postoperative complications, 24,25 remote automated monitoring technology with a health care provider who is available to respond to early signs of an impending complication may improve outcomes after surgery, similar to how anesthesiologists and enhanced monitoring improved intraoperative outcomes. These interventions require evaluation in prospective studies.…”

Effect of intraoperative goal-directed balanced crystalloid versus colloid administration on postoperative maximum NT-proBNP concentration in patients undergoing noncardiac surgery

“…(25) Moreover, it seems likely, that postoperative NT-proBNP concentration might be affected by several perioperative factors such as surgical stress, hemodynamic perturbations, or in ammation rather than by uid management alone. (26)(27)(28) We further evaluated the effect of colloids versus crystalloids on the incidence of MINS. We hypothesized that patients receiving colloids had a better hemodynamic stability, which might result in an improved myocardial perfusion and consequently in lower postoperative troponin T concentrations.…”

“…It is now well known that postoperative hypotension is common and that it is as an important risk factor for MINS (28,29). Thus, it is likely that postoperative hypotension was associated with MINS.…”

Rapid declines in systolic blood pressure are associated with an increase in pulse transit time

“…In practice, this means that for most hospitalized patients, BP is monitored using intermittent cuff-based measurements. The interval between measurements may be several hours, and a recent publication found that a substantial proportion of significant BP-perturbations may go undetected with standard monitoring [2]. This implies that continuous non-invasive BP-monitoring (cNIBP) could benefit patients who are not candidates for arterial line placement.…”