The Incidence of Intraoperative Hypotension and the Importance of Timely Detection

Robert H Sirait *

Department of Anesthesiology, Faculty of Medicine, Universitas Kristen Indonesia, Jakarta, Indonesia.

*Author to whom correspondence should be addressed.


Abstract

Aims: Intraoperative hypotension (IOH) is a common condition faced by anesthesiologists intraoperatively which poignanting patients undergoing surgery under general and neuraxial anesthesia. Its occurrence is associated with dangerous morbid situations found perioperatively that can lead into fatal complications, such as acute kidney failure, direct myocardial injury, and even can end in mortality. Despite advanced closed hemodynamic monitoring and protocols utilizing goal directed therapy, recent trend of management is remaining reactive. Anesthesiologists tend to intervene when the episode of hypotension has already occurred. This literature review aimed to discuss the incidence of intraoperative hypotension and its urgency to overcome intraoperatively.

Conclusion: The incidence of IOH varies based on the type of surgery, type of anesthesia and fragility of the patient, for example having comorbidities. Due to the rapid development of IOH which is unwanted, the effort reducing the hypotensive burden intraoperatively, as soon as possible is mandatory. By carefully predicting and preventing IOH through closed monitoring of patient’s blood pressure will surely improve patient outcome and prevent adverse unwanted post-operative event.

Keywords: Blood pressure, high risk patient, hemodynamic monitoring, adverse outcome, post-operative complication


How to Cite

Sirait , Robert H. 2024. “The Incidence of Intraoperative Hypotension and the Importance of Timely Detection”. International Blood Research & Reviews 15 (1):10-17. https://doi.org/10.9734/ibrr/2024/v15i1330.

Downloads

Download data is not yet available.

References

Connor S. Surgical procedures market volume worldwide 2021-2030; 2023 Aug, 10. Available:https://www.statista.com/statistics/1404242/worldwide-surgical-procedures-market volume/#:~:text=Surgical%20procedures%20market%20volume%20worldwide%202021%2D2030&text=In%202022%2C%20there%20were%20approximately,company%20Next%20Move%20Strategy%20Consulting

Szrama J, Gradys A, Bartkowiak T, Woźniak A, Kusza K, Molnar Z. Intraoperative hypotension prediction—a proactive perioperative hemodynamic management—a literature review. Medicina. 2023;59(3):491. DOI:https://doi.org/10.3390/medicina59030491

Ding JZ, Kong C, Sun XY, Lu SB. Perioperative complications and risk factors in degenerative lumbar scoliosis surgery for patients older than 70 Years of Age. Clin Interv Aging. 2019 Dec 16;14:2195-2203. DOI: https://doi.org/10.2147/CIA.S218204.

Aseni P, Orsenigo S, Storti E, Pulici M, Arlati S. Current concepts of perioperative monitoring in high-risk surgical patients: A review. Patient Saf Surg. 2019 Oct 23;13:32. DOI: https://doi.org/10.1186/s13037-019-0213-5.

Yetneberk T, Firde M, Tiruneh A, Fentie Y, Tariku M, Mihret G, Moore J. Incidence of unplanned intensive care unit admission following surgery and associated factors in Amhara regional state hospitals. Sci Rep. 2022 Nov 22;12(1):20121. DOI: https://doi.org/10.1038/s41598-022-24571-1.

Bowyer AJ, Royse CF. Postoperative recovery and outcomes--what are we measuring and for whom? Anaesthesia. 2016 Jan;71 Suppl 1:72-7. DOI: https://doi.org/10.1111/anae.13312.

Fowler AJ, Wan YI, Prowle JR, Chew M, Campbell D, Cuthbertson B, Wijeysundera DN, Pearse R, Abbott T. Long-term mortality following complications after elective surgery: A secondary analysis of pooled data from two prospective cohort studies. Br J Anaesth. 2022 Oct;129(4):588-597. DOI:https://doi.org/10.1016/j.bja.2022.06.019.

Schmidt AP, Stefani LC. How to identify a high-risk surgical patient? Braz J Anesthesiol. 2022 May-Jun;72(3):313-315. DOI:https://doi.org/10.1016/j.bjane.2022.04.002.

Dharap SB, Barbaniya P, Navgale S. Incidence and risk factors of postoperative complications in general surgery patients. Cureus. 2022 Nov 1;14(11):e30975. DOI: https://doi.org/10.7759/cureus.30975.

Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: A systematic review. BMC Geriatr. 2016 Aug 31;16(1):157. DOI: https://doi.org/10.1186/s12877-016-0329-8.

Jiang Y, Luo Y, Lyu H, Li Y, Gao Y, Fu X, Wu H, Wu R, Yin P, Zhang L, Tang P. Trends in comorbidities and postoperative complications of geriatric hip fracture patients from 2000 to 2019: Results from a hip fracture cohort in a tertiary hospital. Orthop Surg. 2021 Aug;13(6):1890-1898. DOI: https://doi.org/10.1111/os.13142.

Cheng H, Clymer JW, Po-Han Chen B, Sadeghirad B, Ferko NC, Cameron CG, Hinoul P. Prolonged operative duration is associated with complications: A systematic review and meta-analysis. J Surg Res. 2018 Sep;229:134-144. DOI:https://doi.org/10.1016/j.jss.2018.03.022.

Fellahi JL, Futier E, Vaisse C, Collange O, Huet O, Loriau J, Gayat E, Tavernier B, Biais M, Asehnoune K, Cholley B, Longrois D. Perioperative hemodynamic optimization: from guidelines to implementation-an experts' opinion paper. Ann Intensive Care. 2021 Apr 14;11(1):58. DOI: https://doi.org/10.1186/s13613-021-00845-1.

Song Q, Li J, Jiang Z. Provisional Decision-making for perioperative blood pressure management: A narrative review. Oxid Med Cell Longev. 2022 Jul 11;2022:5916040. https://doi.org/10.1155/2022/5916040.

Brock-Utne JG. Sudden Intraoperative Hypotension. In: Clinical Anesthesia; 2008. Springer, New York, NY. DOI: https://doi.org/10.1007/978-0-387-72525-3_29

Meng L. Heterogeneous impact of hypotension on organ perfusion and outcomes: A narrative review. Br J Anaesth. 2021 Dec;127(6):845-861. DOI:https://doi.org/10.1016/j.bja.2021.06.048.

Wijnberge M, Schenk J, Bulle E, Vlaar AP, Maheshwari K, Hollmann MW, Binnekade JM, Geerts BF, Veelo DP. Association of intraoperative hypotension with postoperative morbidity and mortality: Systematic review and meta-analysis. BJS Open. 2021 Jan 8;5(1):zraa018. DOI:https://doi.org/10.1093/bjsopen/zraa018.

Huang WW, Zhu WZ, Mu DL, Ji XQ, Li XY, Ma D, Wang DX. Intraoperative hypotension is associated with shortened overall survival after lung cancer surgery. BMC Anesthesiol. 2020 Jun 29;20(1):160. DOI: https://doi.org/10.1186/s12871-020-01062-2.

de la Hoz MA, Rangasamy V, Bastos AB, Xu X, Novack V, Saugel B, Subramaniam B. Intraoperative hypotension and acute kidney injury, stroke, and mortality during and outside cardiopulmonary bypass: A retrospective observational cohort study. Anesthesiology. 2022 Jun 1;136(6):927-939. DOI:https://doi.org/10.1097/ALN.0000000000004175.

Wang L, Bui CM, Hofer I, Gabel E, Wray C, Xia VW. Intraoperative hypotension and 30-D mortality After liver transplantation. Transplant Direct. 2022 Sep 15;8(10):e1380. DOI:https://doi.org/10.1097/TXD.0000000000001380.

Hallqvist L, Granath F, Fored M, Bell M. Intraoperative hypotension and myocardial infarction development among high-risk patients undergoing noncardiac surgery: A nested case-control study. Anesth Analg. 2021 Jul 1;133(1):6-15. DOI:https://doi.org/10.1213/ANE.0000000000005391.

Haase-Fielitz A, Haase M, Bellomo R, Calzavacca P, Spura A, Baraki H, Kutschka I, Albert C. Perioperative hemodynamic instability and fluid overload are associated with increasing acute kidney injury severity and worse outcome after cardiac surgery. Blood Purif. 2017;43(4):298-308. DOI: https://doi.org/10.1159/000455061.

Bergholz A, Greiwe G, Kouz K, Saugel B. Continuous blood pressure monitoring in patients having surgery: A narrative review. medicina. 2023;59(7):1299. DOI:https://doi.org/10.3390/medicina59071299

Jessen MK, Vallentin MF, Holmberg MJ, Bolther M, Hansen FB, Holst JM et al. Goal-directed haemodynamic therapy during general anesthesia for noncardiac surgery: A systematic review and meta-analysis. Br J Anaesth. 2022 Mar;128(3): 416-33. DOI:https://doi.org/10.1016/j.bja.2021.10.046.

Andrzejewska A, Miegoń J, Zacha S, Skonieczna-Żydecka K, Jarosz K, Zacha W, Biernawska J. The impact of intraoperative haemodynamic monitoring, prediction of hypotension and goal-directed therapy on the outcomes of patients treated with posterior fusion due to adolescent idiopathic scoliosis. Journal of Clinical Medicine. 2023;12(14):4571. DOI: https://doi.org/10.3390/jcm12144571

Wesselink EM, Kappen TH, Torn HM, Slooter AJC, van Klei WA. Intraoperative hypotension and the risk of postoperative adverse outcomes: A systematic review. Br J Anaesth. 2018 Oct;121(4):706-721. DOI:https://doi.org/10.1016/j.bja.2018.04.036.

Sessler DI, Turan A, Stapelfeldt WH, Mascha EJ, Yang D, Farag E et al. Triple-low alerts do not reduce mortality: A real-time randomized trial. Anesthesiology. 2019 Jan;130(1):72-82. DOI:https://doi.org/10.1097/ALN.0000000000002480.

Bijker JB, van Klei WA, Kappen TH, van Wolfswinkel L, Moons KG, Kalkman CJ. Incidence of intraoperative hypotension as a function of the chosen definition: Literature definitions applied to a retrospective cohort using automated data collection. Anesthesiology. 2007 Aug;107(2):213-20. DOI:https://doi.org/10.1097/01.anes.0000270724.40897.

DeMers D, Wachs D. Physiology, Mean Arterial Pressure. [Updated 2023 Apr 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: DOI:https://www.ncbi.nlm.nih.gov/books/NBK538226/

Asfar P, Radermacher P, Ostermann M. MAP of 65: target of the past? Intensive Care Med 44. 2018;1551–1552. DOI: https://doi.org/10.1007/s00134-018-5292-8

Saasouh W, Christensen AL, Xing F, Chappell D, Lumbley J, Woods B, Mythen M, Dutton RP. Incidence of intraoperative hypotension during non-cardiac surgery in community anesthesia practice: A retrospective observational analysis. Perioper Med (Lond). 2023 Jun 24; 12(1):29. DOI: https://doi.org/10.1186/s13741-023-00318-y.

Shah NJ, Mentz G, Kheterpal S. The incidence of intraoperative hypotension in moderate to high risk patients undergoing non-cardiac surgery: A retrospective multicenter observational analysis. J Clin Anesth. 2020 Nov;66:109961. DOI:https://doi.org/10.1016/j.jclinane.2020.109961.

Katori N, Yamakawa K, Kida K, Kimura Y, Fujioka S, Tsubokawa T. The incidence of hypotension during general anesthesia: A single-center study at a university hospital. JA Clin Rep. 2023 May 13;9(1):23. DOI: 10.1186/s40981-023-00617-9. Erratum in: JA Clin Rep. 2023 Jun 1; 9(1):32.

Luther DGP, Scholes S, Wharton N, Kinsella SM. Selection of baseline blood pressure to guide management of hypotension during spinal anesthesia for caesarean section. Int J Obstet Anesth. 2021 Feb;45:130-132. DOI:https://doi.org/10.1016/j.ijoa.2020.11.010.

Kruger GH, Shanks A, Kheterpal S, Tremper T, Chiang CJ, Freundlich RE, Blum JM, Shih AJ, Tremper KK. Influence of non-invasive blood pressure measurement intervals on the occurrence of intra-operative hypotension. J Clin Monit Comput. 2018 Aug;32(4):699-705. DOI: https://doi.org/10.1007/s10877-017-0065-4.

Reich, David L, Hossain Sabera Bodian, Carol A. What Good are Large Databases of Intraoperative Data? Anesthesia & Analgesia. 2006;103(1):252. DOI:https://doi.org/10.1213/01.ANE.0000215158.24299.16

Guarracino F, Bertini P. Perioperative hypotension: Causes and remedies. J Anesth Analg Crit Care. 2022 Apr 14;2(1):17. DOI: https://doi.org/10.1186/s44158-022-00045-8.

de Boniface J, Szulkin R, Johansson ALV. Major surgical postoperative complications and survival in breast cancer: Swedish population-based register study in 57 152 women. Br J Surg. 2022 Sep 9;109(10):977-983. DOI: https://doi.org/10.1093/bjs/znac275.

Petsiti A, Tassoudis V, Vretzakis G, Zacharoulis D, Tepetes K, Ganeli G, Karanikolas M. Depth of Anesthesia as a Risk Factor for Perioperative Morbidity. Anesthesiol Res Pract. 2015;2015:829151. DOI: https://doi.org/10.1155/2015/829151.

Ida M, Sumida M, Naito Y, Tachiiri Y, Kawaguchi M. Impacto da hipotensão e perda sanguínea intraoperatórias na lesão renal aguda após cirurgia de pâncreas [Impact of intraoperative hypotension and blood loss on acute kidney injury after pancreas surgery]. Braz J Anesthesiol. 2020 Jul-Aug;70(4):343-348. DOI:https://doi.org/10.1016/j.bjan.2020.04.011.

Connelly NR, Hall S. Intraoperative hypotension due to unrecognized bleeding from a continuous spinal catheter site. J Clin Anesth. 1993 Nov-Dec;5(6):497-9. DOI: https://doi.org/10.1016/0952-8180(93)90069-q.

Neelakanta G, Mahajan A, Antin C. Systemic vasodilation is a predominant cause of hypotension in a patient with familial amyloid polyneuropathy during liver transplantation. J Clin Anesth. 2005 May;17(3):202-4. DOI:https://doi.org/10.1016/j.jclinane.2004.03.014.

van Waes JA, van Klei WA, Wijeysundera DN, van Wolfswinkel L, Lindsay TF, Beattie WS. Association between intraoperative hypotension and myocardial injury after vascular surgery. Anesthesiology. 2016 Jan;124(1):35-44. DOI:https://doi.org/10.1097/ALN.0000000000000922.

Wongtangman K, Wachtendorf LJ, Blank MY, Grabitz SD, Linhardt FC, Azimaraghi O et al. Effect of intraoperative arterial hypotension on the risk of perioperative stroke after noncardiac surgery: A retrospective multicenter cohort study. Anesthesia & Analgesia. 2021;133:1000-8. DOI:https://doi.org/10.1213/ANE.0000000000005604

Gu WJ, Hou BL, Kwong JSW, Tian X, Qian Y, Cui Y, Hao J, Li JC, Ma ZL, Gu XP. Association between intraoperative hypotension and 30-day mortality, major adverse cardiac events, and acute kidney injury after non-cardiac surgery: A meta-analysis of cohort studies. Int J Cardiol. 2018 May 1;258:68-73. DOI:https://doi.org/10.1016/j.ijcard.2018.01.137.

Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messé SR, Mijalski C, Nelson MT, Power M, Welch BG. American heart association stroke council; Council on arteriosclerosis, thrombosis and vascular biology; Council on cardiovascular and stroke nursing; Council on clinical cardiology and council on epidemiology and prevention. Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement from the American Heart Association/American Stroke Association. Circulation. 2021 May 11;143(19):e923-e946. DOI:https://doi.org/10.1161/CIR.0000000000000968.

Saugel B, Sessler DI. Perioperative blood pressure management. Anesthesiology 2021;134:250–61 DOI:https://doi.org/10.1097/ALN.0000000000003610

Czajka S, Putowski Z, Krzych ŁJ. Post-induction hypotension and intraoperative hypotension as potential separate risk factors for the adverse outcome: A cohort study. J Anesth 2023;37:442–50. DOI: https://doi.org/10.1007/s00540-023-03191-7

Temesgen N, Fenta E, Eshetie C, Gelaw M. Early intraoperative hypotension and its associated factors among surgical patients undergoing surgery under general anesthesia: An observational study. Ann Med Surg (Lond). 2021 Sep 11;71:102835. DOI:https://doi.org/10.1016/j.amsu.2021.102835.

Convertino VA, Hinojosa-Laborde C, Muniz GW, Carter R 3rd. Integrated Compensatory Responses in a Human Model of Hemorrhage. J Vis Exp. 2016 Nov 20;(117):54737. DOI: https://doi.org/10.3791/54737.

Bilehjani E, Nader N, Farzin H, Haghighate Azari M, Fakhari S. The Evaluation of Factors Affecting Hemodynamic Variability in Mechanically-Ventilated Patients After Cardiac Surgery. Anesth Pain Med. 2020 Aug 12;10(4):e101832. DOI: https://doi.org/10.5812/aapm.101832.

Lee S, Lee HC, Chu YS, Song SW, Ahn GJ, Lee H et al. Deep learning models for the prediction of intraoperative hypotension. Br J Anaesth. 2021 Apr;126(4):808-17. DOI:https://doi.org/10.1016/j.bja.2020.12.035.

Kouz K, Hoppe P, Briesenick L, Saugel B. Intraoperative hypotension: Pathophysiology, clinical relevance, and therapeutic approaches. Indian J Anaesth. 2020 Feb;64(2):90-6. DOI:https://doi.org/10.4103/ija.IJA_939_19

Saugel B, Sakka SG. Editorial: Less and non-invasive hemodynamic monitoring techniques. Front Med (Lausanne). 2018 Sep 19;5:258. DOI:https://doi.org/10.3389/fmed.2018.00258.

Meidert AS, Dolch ME, Mühlbauer K, Zwissler B, Klein M, Briegel J, Czerner S. Oscillometric versus invasive blood pressure measurement in patients with shock: a prospective observational study in the emergency department. J Clin Monit Comput. 2021 Apr;35(2):387-93. DOI: https://doi.org/10.1007/s10877-020-00482-2.

Romagnoli S, Ricci Z, Quattrone D, Tofani L, Tujjar O, Villa G, Romano SM, De Gaudio AR. Accuracy of invasive arterial pressure monitoring in cardiovascular patients: An observational study. Crit Care. 2014 Nov 30;18(6):644. DOI: https://doi.org/10.1186/s13054-014-0644-4.

Fortin J, Rogge DE, Fellner C, Flotzinger D, Grond J, Lerche K, Saugel B. A novel art of continuous noninvasive blood pressure measurement. Nat Commun. 2021 Mar 2;12(1):1387. DOI: https://doi.org/10.1038/s41467-021-21271-8.

Gratz I, Deal E, Spitz F, Baruch M, Allen IE, Seaman JE, Pukenas E, Jean S. Continuous non-invasive finger cuff caretaker® comparable to invasive intra-arterial pressure in patients undergoing major intra-abdominal surgery. BMC Anesthesiol. 2017 Mar 21;17(1):48. DOI: https://doi.org/10.1186/s12871-017-0337-z.

Schuurmans J, van Nieuw Amerongen AR, Terwindt LE, Schenk J, Veelo DP, Vlaar APJ, van der Ster BJP. Feasibility of continuous non-invasive finger blood pressure monitoring in adult patients admitted to an intensive care unit: A retrospective cohort study. Heart Lung. 2023 Sep-Oct;61:51-58. DOI:https://doi.org/10.1016/j.hrtlng.2023.04.012.

Hatib F, Jian Z, Buddi S, Lee C, Settels J, Sibert K, Rinehart J, Cannesson M. Machine-learning algorithm to predict hypotension based on high-fidelity arterial pressure waveform analysis. Anesthesiology. 2018 Oct;129(4):663-674. DOI:https://doi.org/10.1097/ALN.0000000000002300