Pre‐operative autonomic nervous system function – a missing link for post‐induction hypotension?

Frandsen, Mikkel Nicklas; Mehlsen, Jesper; Foss, Nicolai Bang; Kehlet, Henrik

doi:10.1111/anae.15546

Cited by 12 publications

(15 citation statements)

References 26 publications

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“…The cardiac autonomic system plays an important role in the occurrence of hemodynamic changes during anesthesia. 17 The incidence of hypotension and vasopressor use after anesthetic induction for ophthalmic surgery was higher in diabetic patients with CAD compared with nondiabetics without CAD. 18 The incidence of postinduction hypotension was 67 to 83% versus 9 to 17% in patients with and without CAD aged ≥40 years undergoing day-care surgery.…”

Section: Discussionmentioning

confidence: 93%

Effect of Preanesthetic Fluid Loading on Postinduction Hypotension and Advanced Cardiac Parameters in Patients with Chronic Compressive Cervical Myelopathy: A Randomized Controlled Trial

Paul

Sriganesh

Chakrabarti

et al. 2022

JNRP

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Purpose Hypotension during the early intraoperative phase is common and can lead to adverse perioperative outcomes. Fluid preloading is one of the methods to limit its occurrence. Patients with chronic compressive cervical myelopathy may have autonomic dysfunction, which can aggravate hemodynamic alterations during anesthesia. This study compared the occurrence of postinduction hypotension and changes in cardiac dynamic indices in patients with and without crystalloid preloading undergoing decompressive cervical spine surgery. Methods This randomized controlled trial was conducted over 15 months after obtaining patient consent, approval of the institute ethics committee, and trial registration. We compared preanesthetic fluid loading with Ringer's lactate (20 mL/kg over 30 minutes) with no preloading (2 mL/kg/h maintenance) in 60 consecutive patients undergoing cervical spine surgery. The ANSiscope was used to determine baseline cardiac autonomic function. Noninvasive cardiac output monitor was used to assess changes in heart rate, mean arterial pressure, cardiac index (CI), stroke volume variation (SVV), and total peripheral resistance index during study intervention, anesthetic induction, tracheal intubation, and change in position from supine to prone. Results The incidences of postinduction hypotension were 26.7% (8/30) and 86.7% (26/30) and the median doses of mephentermine used were 0 and 6 mg, respectively, in patients with and without fluid preloading (both p < 0.001). Preloading resulted in improvement in CI, reduction in SVV, and lesser vasopressor use. Conclusion Preloading reduced the occurrence of postinduction hypotension and vasopressor use, improved CI, and reduced SVV during the early intraoperative period. Registration number of Clinical Trial The trial was registered with Clinical Trial Registry of India (CTRI/2018/07/014970 on 19/07/2018).

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Section: Discussionmentioning

confidence: 93%

Effect of Preanesthetic Fluid Loading on Postinduction Hypotension and Advanced Cardiac Parameters in Patients with Chronic Compressive Cervical Myelopathy: A Randomized Controlled Trial

Paul

Sriganesh

Chakrabarti

et al. 2022

JNRP

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“…Chronic arterial hypertension has been recently reported to predict post-induction hypotension or intraoperative hypotension ( 7 , 8 ). Dysfunction of the autonomic nervous system has been assumed to be one of the mechanisms underlying impaired blood pressure regulation and cardiovascular events ( 9 ), including the risk of hemodynamic instability after anesthetic induction ( 10 ). A preoperative high sympathetic tone may mask preload insufficiency, leading to hypotension due to vasoplegia by the suppressed sympathetic tone after induction ( 10 ).…”

Section: Introductionmentioning

confidence: 99%

“…Dysfunction of the autonomic nervous system has been assumed to be one of the mechanisms underlying impaired blood pressure regulation and cardiovascular events ( 9 ), including the risk of hemodynamic instability after anesthetic induction ( 10 ). A preoperative high sympathetic tone may mask preload insufficiency, leading to hypotension due to vasoplegia by the suppressed sympathetic tone after induction ( 10 ). Furthermore, autonomic dysfunction also leads to inadequate response to tissue perfusion, resulting in the persistent hypotension ( 10 ).…”

Section: Introductionmentioning

confidence: 99%

Intraoperative hypotension in non-emergency decompression surgery for cervical spondylosis: The role of chronic arterial hypertension

et al. 2022

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BackgroundCervical spondylotic myelopathy and chronic hypertension show a cause-effect relationship. Hypertension increases cardiovascular risk and is associated with intraoperative hypotension. We aimed to evaluate intraoperative hypotension in patients undergoing non-emergency decompression surgery for cervical spondylosis and its association with clinical myelopathy and chronic arterial hypertension.MethodsThis retrospective cohort study used healthcare data of adult patients undergoing cervical spine surgeries at Taipei Veterans General Hospital from 2015 to 2019. The primary outcomes were the incidence of intraoperative hypotension and predictive factors, and the secondary outcomes were the association of intraoperative hypotension and postoperative adverse outcomes in the surgical population.ResultsAmong the 1833 patients analyzed, 795 (43.4%) required vasopressor treatment and 342 (18.7%) showed persistent hypotension. Factors independent associated with hypotension after anesthetic induction were age [odds ratio (OR), 1.15; 95% confidence interval (CI), 1.07-1.23 per 5 years, P < 0.001], male sex (OR, 1.63; 95% CI, 1.21-2.19, P < 0.001), chronic hypertension (OR, 1.77; 95% CI, 1.32-2.38, P < 0.001), upper cervical spine level C0-2 treated (OR, 3.04; 95% CI, 1.92-4.84, P < 0.001 vs. C3-T1), and increased number of spine segments treated (OR, 1.43; 95% CI 1.26-1.63, P < 0.001). Patients who developed intraoperative hypotension experienced more acute postoperative kidney injury (OR, 7.90; 95% CI, 2.34–26.63, P < 0.001), greater need for intensive care (OR, 1.80; 95% CI, 1.24–2.60, P = 0.002), and longer admission after surgery (1.09 days longer, 95% CI 0.06-2.12, P = 0.038).ConclusionIntraoperative hypotension is common even in non-emergency cervical spine surgery. A history of hypertension independently predicted intraoperative hypotension. Prompt assessments for identifiable features can help ameliorate intraoperative hypotension.

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“…Post-induction hypotension is a common problem in surgery and is associated with worse postoperative outcome [18], even in a modern fast track surgery setup. We have previously argued that HRV measurement might predict a subset of patients at risk of intraoperative hypotension, and provide information about patients' autonomic status necessary for understanding the pathophysiology behind intraoperative hypotension and prevention hereof [19]. Similar considerations may apply to preoperative HRV analysis regarding postoperative orthostatic intolerance, but our study did not have the statistical power for this analysis.…”

Section: Discussionmentioning

confidence: 88%

Time-course of heart rate variability after total hip arthroplasty

Frandsen

Varnum

Foss

et al. 2022

Preprint

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Purpose Heart rate variability (HRV) is a measure of the autonomic nervous system function and possibly related to postoperative outcome. Despite several HRV studies in different surgical settings, optimal indices and timepoints for measuring have not been adequately determined. Consequently, there is a need for detailed descriptive procedure-specific studies on the time-course of perioperative HRV within a modern fast-track surgical setting. Method We measured HRV continuously in 24 patients from 4 days before until 9 days after total hip arthroplasty (THA). Patients completed the Orthostatic Discriminant and Severity Scale five times during the study, to describe the patient burden potentially related to autonomic nervous system dysfunction. Results Standard deviation between normal-to-normal beats and the total power of HRV were reduced for at least nine days following THA, with a trend towards increased HRV leading up to the day of surgery. The balance between low- and high-frequency power of HRV was reduced in the postoperative evenings. There was increased orthostatic intolerance symptom burden on the first day after surgery, with symptoms of pain, fatigue, and weakness reduced in the postsurgical period. Median hospital stay was 1 day. Conclusion We provide the first detailed description of perioperative time-course of HRV and orthostatic symptoms in fast-track THA, showing reduced HRV after surgery for at least a week, and that HRV changes are sensitive to time of day and timing before and after surgery. These results are helpful in designing future HRV studies in perioperative risk assessment and outcome.

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Pre‐operative autonomic nervous system function – a missing link for post‐induction hypotension?

Cited by 12 publications

References 26 publications

Effect of Preanesthetic Fluid Loading on Postinduction Hypotension and Advanced Cardiac Parameters in Patients with Chronic Compressive Cervical Myelopathy: A Randomized Controlled Trial

Effect of Preanesthetic Fluid Loading on Postinduction Hypotension and Advanced Cardiac Parameters in Patients with Chronic Compressive Cervical Myelopathy: A Randomized Controlled Trial

Intraoperative hypotension in non-emergency decompression surgery for cervical spondylosis: The role of chronic arterial hypertension

Time-course of heart rate variability after total hip arthroplasty

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