Intraoperative hypotension: Pathophysiology, clinical relevance, and therapeutic approaches

Kouz, Karim; Hoppe, Phillip; Briesenick, Luisa; Saugel, Bernd

doi:10.4103/ija.ija_939_19

Cited by 47 publications

(12 citation statements)

References 38 publications

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“…The clinical predictors associated with post-induction hypotension are mostly non-modifiable. [ 12 ] The most common modifiable risk factor associated with hypotension after induction is hypovolaemia and fluid therapy to optimise volume status is considered the cornerstone for its management. A method that can accurately detect hypovolaemia may provide the clinician a chance to optimise the volume status before induction and avoid the occurrence of post-induction hypotension.…”

Section: Discussionmentioning

confidence: 99%

Prediction of post-induction hypotension in young adults using ultrasound-derived inferior vena cava parameters: An observational study

Mohammed¹,

Syal²,

Bhatia³

et al. 2021

Indian J Anaesth

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Background and Aims: Inferior vena cava (IVC) diameter and its respiratory variability have been shown to predict post-induction hypotension with high specificity in a mixed population of patients. We assessed whether these parameters could be as reliable in healthy adult patients as in a mixed patient population. Methods: In the present prospective observational study, 110 patients of either sex, aged between 18 and 50 years, belonging to American Society of Anesthesiologists class I and II, fasted as per the institutional protocol and scheduled for elective surgery under general anaesthesia were enroled. Prior to induction, ultrasound examination of IVC was done and variation in IVC diameter with respiration was assessed. Maximum and minimum IVC diameters [(dIVC max ) and (dIVC min ), respectively] over a single respiratory cycle were measured and collapsibility index (CI) was calculated. Vitals were recorded just before induction and at every minute after induction for 10 min. Episodes of hypotension (mean arterial pressure [MAP] <65 mmHg or fall in MAP >30% from baseline) during the observation period were recorded. The receiver operating characteristic (ROC) curve was constructed for determining optimum cut-off with sensitivity and specificity of IVC diameters and CI for development of hypotension. Results: IVC was not visualised in 22 patients. Out of the remaining 88 patients, 17 (19.3%) patients developed hypotension after induction. The dIVC max , dIVC min and CI were comparable between patients who developed and who did not develop hypotension. The area under curve of ROC for CI, dIVC max and dIVC min was 0.51, 0.55 and 0.52, respectively, with optimum cut-off value of 0.46, 1.42 and 0.73, respectively. Conclusion: Ultrasound-derived IVC parameters demonstrate poor diagnostic accuracy for prediction of hypotension after induction in healthy adult patients.

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Section: Discussionmentioning

confidence: 99%

Prediction of post-induction hypotension in young adults using ultrasound-derived inferior vena cava parameters: An observational study

Mohammed¹,

Syal²,

Bhatia³

et al. 2021

Indian J Anaesth

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“…The optimization of patients volemia before anaesthesia induction and the use of a stepwise recruitment manoeuvre should be considered in the attempt to reduce the hypotensive events during RM. [ 29 ] In fact, the occurrence of intraoperative hypotension, even of short (1–3 min) duration, may be associated with impaired outcomes [ 30 ].…”

Section: Discussionmentioning

confidence: 99%

Intraoperative protective ventilation in patients undergoing major neurosurgical interventions: a randomized clinical trial

Longhini

Pasin

Montagnini³

et al. 2021

BMC Anesthesiol

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Background Post-operative pulmonary complications (PPC) can develop in up to 13% of patients undergoing neurosurgical procedures and may adversely affect clinical outcome. The use of intraoperative lung protective ventilation (LPV) strategies, usually including the use of a low Vt, low PEEP and low plateau pressure, seem to reduce the risk of PPC and are strongly recommended in almost all surgical procedures. Nonetheless, feasibility of LPV strategies in neurosurgical patients are still debated because the use of low Vt during LPV might result in hypercapnia with detrimental effects on cerebrovascular physiology. Aim of our study was to determine whether LPV strategies would be feasible compared with a control group in adult patients undergoing cranial or spinal surgery. Methods This single-centre, pilot randomized clinical trial was conducted at the University Hospital “Maggiore della Carità” (Novara, Italy). Adult patients undergoing major cerebral or spinal neurosurgical interventions with risk index for pulmonary post-operative complications > 2 and not expected to need post-operative intensive care unit (ICU) admission were considered eligible. Patients were randomly assigned to either LPV (Vt = 6 ml/kg of ideal body weight (IBW), respiratory rate initially set at 16 breaths/min, PEEP at 5 cmH2O and application of a recruitment manoeuvre (RM) immediately after intubation and at every disconnection from the ventilator) or control treatment (Vt = 10 ml/kg of IBW, respiratory rate initially set at 6–8 breaths/min, no PEEP and no RM). Primary outcomes of the study were intraoperative adverse events, the level of cerebral tension at dura opening and the intraoperative control of PaCO2. Secondary outcomes were the rate of pulmonary and extrapulmonary complications, the number of unplanned ICU admissions, ICU and hospital lengths of stay and mortality. Results A total of 60 patients, 30 for each group, were randomized. During brain surgery, the number of episodes of intraoperative hypercapnia and grade of cerebral tension were similar between patients randomized to receive control or LPV strategies. No difference in the rate of intraoperative adverse events was found between groups. The rate of postoperative pulmonary and extrapulmonary complications and major clinical outcomes were similar between groups. Conclusions LPV strategies in patients undergoing major neurosurgical intervention are feasible. Larger clinical trials are needed to assess their role in postoperative clinical outcome improvements. Trial registration registered on the Australian New Zealand Clinical Trial Registry (www.anzctr.org.au), registration number ACTRN12615000707561.

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“…Norepinephrine actively expel blood from the splanchnic capacitance vessels, causing a rapid increase in the venous return. Pathophysiologic mechanisms of anesthesia-related hypotension include vasodilation, impairment of sympathetic nervous system, and compromised baroreflex regulation 15 . Norepinephrine can attenuate vasodilation and decrease the requirement of fluid supplement.…”

Section: Discussionmentioning

confidence: 99%

Comparing effects of intraoperative fluid and vasopressor infusion on intestinal microcirculation

Fan

Yang

Shih

et al. 2020

Sci Rep

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Several studies have revealed that vasopressor may be more appropriate for treating intraoperative hypotension and preventing hypervolemia. This study compared the effects of vasopressor infusion and fluid supplementation on intestinal microcirculation during treating intraoperative hypotension. Thirty-two rats were randomly divided into the following four groups: Light Anesthesia group (LA, 0.8–1% isoflurane); Deep Anesthesia group (DA, 1.5–1.8% isoflurane); Fluid DA group (1.5–1.8% isoflurane and fluid supplementation); and Norepinephrine DA group (1.5–1.8% isoflurane and norepinephrine infusion). At 240 min, perfused small vessel density (PSVD) of the mucosa did not differ significantly between the Fluid DA and Norepinephrine DA groups [26.2 (3.2) vs 28.9 (2.5) mm/mm2, P = 0.077], and tissue oxygen saturation of the mucosa was lower in the Fluid DA groups than in the Norepinephrine DA groups [ 48 (7) vs 57 (6) %, P = 0.02]. At 240 min, TSVD and PSVD of the seromuscular layer were higher in the Norepinephrine DA group than in the Fluid DA group. Fluid administration was higher in the Fluid DA group than in the Norepinephrine DA group [66 (25) vs. 9 (5) μL/g, P = 0.001]. Our results showed that norepinephrine can resuscitate intraoperative hypotension related microcirculatory alteration and avoid fluid overload.

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Intraoperative hypotension: Pathophysiology, clinical relevance, and therapeutic approaches

Cited by 47 publications

References 38 publications

Prediction of post-induction hypotension in young adults using ultrasound-derived inferior vena cava parameters: An observational study

Prediction of post-induction hypotension in young adults using ultrasound-derived inferior vena cava parameters: An observational study

Intraoperative protective ventilation in patients undergoing major neurosurgical interventions: a randomized clinical trial

Comparing effects of intraoperative fluid and vasopressor infusion on intestinal microcirculation

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