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Differential diagnosis and treatment of hypotension in perioperative care. The baseline measurements of blood pressure (BP), cardiac output (CO), stroke volume (SV), heart rate (HR), and systemic vascular resistance (SVR) are used as a reference during decision-making. ↓ indicates decreased or insufficient; ↑, increased; and (−), no change or stable. It should be noted that most vasoactive drugs for hypotension treatment yield multiple cardiovascular effects, including arterial vasocontraction, venoconstriction, and positive/negative inotropic and chronotropic effects.
Source publication
A s one of the vital signs, blood pressure (BP) is measured at least once every 5 minutes using a noninvasive cuff method in patients having anesthesia and surgery, and in many instances, BP is actually monitored beat to beat using an inva-sive transducing method. The rationale for routine and regular BP monitoring in perioperative care is based on...
Contexts in source publication
Context 1
... treatment of perioperative hypotension should be based on a reference to the patient's baseline measurements of BP, cardiac output, stroke volume, heart rate, and systemic vascular resistance ( Figure 5). BP is determined by the product of cardiac output and systemic vascular resistance. ...
Context 2
... treatment of perioperative hypotension should be based on a reference to the patient's baseline measurements of BP, cardiac output, stroke volume, heart rate, and systemic vascular resistance ( Figure 5). BP is determined by the product of cardiac output and systemic vascular resistance. ...
Context 3
... treatment of perioperative hypotension should be based on a reference to the patient's baseline measurements of BP, cardiac output, stroke volume, heart rate, and systemic vascular resistance ( Figure 5). BP is determined by the product of cardiac output and systemic vascular resistance. ...
Citations
... This underscores the importance of closely monitoring blood pressure in pregnant individuals. For maintaining proper organ perfusion, most individuals require a minimum MAP of 60 mmHg (DeMers and Wachs 2022), whereas the normal range for adult MAP is 70-100 mmHg (Meng et al. 2018). Elevated MAP can result in heightened cardiac oxygen demand, ventricular remodeling, vascular damage, and an increased risk of stroke (Wehrwein and Joyner 2013). ...
The relationship between exposure to air pollutants and fetal growth outcomes has shown inconsistency, and only a limited number of studies have explored the impact of air pollution on gestational hypertension and birth outcomes. This study aimed to evaluate how maternal exposure to air pollutants and blood pressure could influence fetal birth outcomes. A total of 55 women with gestational hypertension and 131 healthy pregnant women were enrolled in this study. Data pertaining to personal characteristics, prenatal examinations, outdoor air pollutant exposure, and fetal birth outcomes were collected. The study revealed that fetal birth weight and abdominal circumference exhibited a significant reduction among women with gestational hypertension compared to healthy pregnant women, even after adjustments for body mass index, gestational age, and exposure to air pollutants had been made. Moreover, maternal exposure to outdoor air pollutants displayed a notable correlation with decreased birth length of fetuses. Consequently, the study concluded that maternal blood pressure and exposure to outdoor air pollutants during pregnancy potentially stand as pivotal factors influencing fetal birth outcomes.
Graphical abstract
... Accuracy of disposable transducers must be less than +/-3% or +/-3mm Hg in accordance with the published ISO/ANSI standards. 36,37 Transducers are prone to drift and must be re-zeroed at regular intervals. 33 To accurately measure BP using an A-line, the clinician must level and zero the transducer and check the quality of the resulting BP waveform. ...
Background Blood pressure (BP) is one of the most frequently measured and monitored physiologic vital signs by all stroke clinicians, yet data suggest that only 1 out of 5 clinicians applies evidence-based methods for BP monitoring. Methods An exhaustive review of the literature was conducted and assembled to provide a historical clinical account of BP monitoring modalities and related evidence-based clinical methods. Results Evidence-based clinical methods are described for use of manual sphygmomanometry, noninvasive oscillometric automatic BP (NIBP) monitors, and arterial lines. Implications for practice are discussed in relation to provision of acute and critical care of ischemic and hemorrhagic stroke patients. Conclusion Use of evidence-based BP monitoring methods ensures accurate management of highly vulnerable stroke patients. Knowledge of the history of BP monitoring, along with the benefits and limitations of different measurement methods enables accuracy in BP treatment, benefitting stroke patient outcomes.
... Long-term use of antihypertensive drugs in patients with hypertension can be combined with autonomic nervous dysfunction of regulation of blood pressure, which leads to the decrease of perioperative tolerance to hypovolemia and postural change, and sharp fluctuation of circulation, especially during the induction period of anesthesia. A retrospective study (3) found that one-third of patients undergoing non-cardiac surgery had hypotension before the skin incision, and the frequency was four times higher than that after skin incision, and postinduction hypotension was significantly associated with the prognosis of patients (4). So there are significant challenges to maintain hemodynamic stability for elderly hypertensive patients who are undergoing general anesthesia (5). ...
Introduction
The hemodynamic effects of withholding vs. continuing angiotensin II receptor blockers (ARBs) before surgery in elderly patients undergoing spinal surgery in a prone position during anesthesia induction to skin incision are still unknown.
Methods
In this prospective study, 80 patients undergoing spinal surgery in a prone position with general anesthesia, aged 60–79 years, American Society of Anesthesiologists (ASA) II or III, were enrolled. Patients who had ARBs only in their preoperative medication list were randomly divided into two groups at a 1:1 ratio: In Group A, ARBs were continued on the morning of surgery, while in Group B, they were withhold. Norepinephrine was infused to maintain the blood pressure at the baseline level of ±20% during anesthesia induction in all patients. The primary outcome was the consumption of norepinephrine in each group from anesthesia induction to skin incision. The secondary outcomes include changes in invasive arterial blood pressure and heart rate, the fluid infusion volumes, the amounts of anesthetic drugs, and the total time from induction to skin incision.
Results
There were no significant differences in the demographics, the fluid infusion volumes, the amounts of anesthetic drugs, the total time from induction to skin incision, and hemodynamics at different time points (p > 0.05), while significant differences were found in norepinephrine consumption between the two groups (p < 0.001). Compared with Group B, the consumption of norepinephrine increased significantly in Group A (93.3 ± 29.8 vs. 124.1 ± 38.7 μg, p = 0.000). In addition, the same trend was illustrated in the pumping rate of norepinephrine between Group B (0.04 ± 0.01 μg·kg⁻¹·min⁻¹) and Group A (0.06 ± 0.02 μg·kg⁻¹·min⁻¹) (p = 0.004).
Conclusion
Our study conducted in elderly patients with hypotension undergoing prone spinal surgery demonstrated a greater pumping rate of norepinephrine during anesthesia induction in patients with ARBs continuing before surgery than those withholding, indicating that it was more difficult to maintain hemodynamic stability.
Clinical Trial Registration: https://www.chictr.org.cn/showproj.html?proj=141081, ChiCTR2100053583.
... Informed consent was obtained from each participant or immediate surrogate (not cooperative due to traumatic injury), and data were collected using a semistructured questionnaire based on the literature review of previous studies. It has been modified and used in the present study [15,17,[24][25][26]. ...
Introduction
Traumatic head injury (THI) poses a significant global public health burden, often contributing to mortality and disability. Intraoperative hypotension (IH) during emergency neurosurgery for THI can adversely affect perioperative outcomes, and understanding associated risk factors is essential for prevention.
Method
A multi-center observational study was conducted from February 10 to June 30, 2022. A simple random sampling technique was used to select the study participants. Patient data were analyzed using bivariate and multivariate logistic regression to identify significant factors associated with intraoperative hypotension (IH). Odds ratios with 95% confidence intervals were used to show the strength of association, and P value < 0.05 was considered as statistically significant.
Result
The incidence of intra-operative hypotension was 46.41% with 95%CI (39.2,53.6). The factors were duration of anesthesia ≥ 135 min with AOR: 4.25, 95% CI (1.004,17.98), severe GCS score with AOR: 7.23, 95% CI (1.098,47.67), intracranial hematoma size ≥ 15 mm with AOR: 7.69, 95% CI (1.18,50.05), and no pupillary abnormality with AOR: 0.061, 95% CI (0.005,0.732).
Conclusion and recommendation
The incidence of intraoperative hypotension was considerably high. The duration of anesthesia, GCS score, hematoma size, and pupillary abnormalities were associated. The high incidence of IH underscores the need for careful preoperative neurological assessment, utilizing CT findings, vigilance for IH in patients at risk, and proactive management of IH during surgery. Further research should investigate specific mitigation strategies.
... Anesthesiologists are pivotal in adjusting intraoperative blood pressure goals based on individual patient risk factors and medical history, contributing to more precise and tailored interventions. This personalized approach recognizes the unique characteristics of each patient and optimizes blood pressure management in the perioperative period [39]. ...
... Guidelines, such as those from the UK National Institute for Health and Care Excellence (NICE) and the American College of Cardiology/American Heart Association (AoA/BHS), provide recommendations for managing preoperative hypertension and its implications for intraoperative blood pressure management. Machine learning algorithms and individualized blood pressure targets based on baseline characteristics represent recent advances in predicting and managing intraoperative blood pressure changes [37][38][39]40]. Post-procedural care for blood pressure management is crucial, involving monitoring the patient's blood pressure to prevent complications. ...
... This is particularly evident in endovascular treatments for acute ischemic stroke, where adherence to specific guidelines for blood pressure management before, during, and after the procedure is crucial. Integrating age-related factors into perioperative protocols ensures a more targeted and safer approach, aligning with older individuals' unique needs and responses [39]. ...
This comprehensive review delves into the intricate dynamics of cerebral perfusion and blood pressure management within the context of neurosurgical and endovascular aneurysm interventions. The review highlights the critical role of maintaining a delicate hemodynamic balance, given the brain's susceptibility to fluctuations in blood pressure. Emphasizing the regulatory mechanisms of cerebral perfusion, particularly autoregulation, the study advocates for a nuanced and personalized approach to blood pressure control. Key findings underscore the significance of adhering to tailored blood pressure targets to mitigate the risks of ischemic and hemorrhagic complications in both neurosurgical and endovascular procedures. The implications for clinical practice are profound, calling for heightened awareness and precision in hemodynamic management. The review concludes with recommendations for future research, urging exploration into optimal blood pressure targets, advancements in monitoring technologies, investigations into long-term outcomes, and the development of personalized approaches. By consolidating current knowledge and charting a path for future investigations, this review aims to contribute to the continual enhancement of patient outcomes in the dynamic field of neurovascular interventions.
... 2,3 It is imperative to effectively control blood pressure (BP) during the perioperative period, as uncontrolled BP can lead to severe postoperative complications, including intracranial hemorrhage, myocardial ischemia, myocardial infarction, and renal failure. [4][5][6] However, the management of perioperative HT poses a challenge because of the delicate balance required between the risk of organ ischemia and the risk of bleeding. In addition, specific guidelines for HT management tailored to neurosurgical patients are lacking. ...
Objectives
Current evidence supporting the use of continuous intravenous labetalol for blood pressure (BP) control in neurosurgical patients is limited. This study aims to assess the efficacy and safety of labetalol in neurosurgical patients and identify potential contributing factors to these outcomes.
Methods
We retrospectively reviewed the medical records of neurosurgical patients who received continuous labetalol infusion for BP control. Efficacy was assessed based on the time needed to achieve the target BP (systolic BP ≤ 140 mmHg or diastolic BP ≤ 90 mmHg). Safety was assessed according to adverse events that occurred during labetalol administration. Factors associated with efficacy and safety were analyzed using a logistic regression model.
Results
Among 79 patients enrolled in this study, 47 (59.49%) achieved the target BP within 1 hour (early response). No factors were significantly associated with an early response. Hypotension was observed in 11 patients (13.9%), and bradycardia was observed in 8 patients (10.1%). Hypotension was significantly associated with patient age and motor impairment, while bradycardia was significantly associated with diabetes mellitus.
Conclusion
The efficacy and safety profiles of labetalol infusion suggest this treatment as a promising option for BP control in neurosurgical patients.
... One parameter that is often used to monitor a patient's blood pressure during and after surgery or anesthesia is Mean Arterial Pressure (MAP), Mean Arterial Pressure (MAP) is the average arterial pressure that delivers blood into the tissue throughout the cardiac cycle [6]. A low MAP value (<70 mmHg) can be considered hypotension while a high MAP value (>100 mmHg) can be considered hypertension. ...
Purpose: to determine the description of changes in Mean Arterial Pressure (MAP) of patients after general anesthesia at Juanda Kuningan Hospital, West Java. Methods: This research is descriptive quantitative with a cross sectional approach. The sample in this study were all surgery patients with general anesthesia who met the criteria, while the sampling technique used was total sampling resulting in 100 respondents. Data analysis using univariate test. Findings: The results of the analysis showed that the most dominant age of respondents was early elderly (34%), with female gender (58%) and the most dominant Body Mass Index (BMI) was normal (91%). Normal MAP (70-100 mmHg) was obtained before induction of anesthesia as much as (77%), normal MAP (70-100 mmHg) after general anesthesia in the recovery room as much as (93%%). Conclusions: These results describe that changes in MAP values after general anesthesia can occur and the majority of pre-induction anesthesia MAP values of respondents will experience a decrease in MAP values during post-general anesthesia in the recovery room. So it is very important to maintain normal MAP values (70-100 mmHg) so as to reduce the risk of postoperative complications that can occur in patients.
... It seems a complex diagram, but it summarizes the daily practice of anesthesiologists. [17] We can better understand hemodynamic monitoring if we think about its aim. The real goal is the optimization of the delivery of oxygen to the tissues. ...
Elderly patients have a high risk of perioperative morbidity and mortality. Pluri-morbidities, polypharmacy, and functional dependence may have a great impact on intraoperative management and request specific cautions. In addition to surgical stress, several perioperative noxious stimuli such as fasting, blood loss, postoperative pain, nausea and vomiting, drug adverse reactions, and immobility may trigger a derangement leading to perioperative complications. Older patients have a high risk of major hemodynamic derangement due to aging of the cardiovascular system and associated comorbidities. The hemodynamic monitoring as well as fluid therapy should be the most accurate as possible. Aging is accompanied by decreased renal function, which is related to a reduction in renal blood flow, renal mass, and the number and size of functioning nephrons. Drugs eliminated predominantly by the renal route need dosage adjustments based on residual renal function. Liver mass, hepatic blood flow, and intrinsic metabolic activity are decreased in the elderly, and all drugs metabolized by the liver have a variable half-life, thus requiring dose reduction. Decreased neural plasticity contributes to a high risk for postoperative delirium. Monitoring of anesthesia depth should be mandatory to avoid overdosage of hypnotic drugs. Prevention of postoperative pulmonary complications requires both protective ventilation strategies and adequate recovery of neuromuscular function at the end of surgery. Avoidance of hypothermia cannot be missed. The aim of this review is to describe comprehensive strategies for intraoperative management plans tailored to meet the unique needs of elderly surgical patients, thus improving outcomes in this vulnerable population.
... A frequently referenced threshold for these patients is a minimum MAP no less than 20% from their baseline blood pressure, usually averaged over several previous measurements. 20 Mechanistically, a worsened microcirculation in the chronically hypertensive and the need for a higher perfusion pressure to maintain end-organ perfusion contribute to the underlying pathophysiology. 21 After post-acute myocardial infarction, higher MAP goals are associated with smaller infarct sizes, and thus use of vasopressor and inotropic support to obtain higher mean pressures is recommended in this population. ...
Blood pressure goals in the intensive care unit (ICU) have been extensively investigated in large datasets and have been associated with various harm thresholds at or greater than a mean pressure of 65 mm Hg. While it is difficult to perform interventional randomized trials of blood pressure in the ICU, important evidence does not support defense of a higher pressure, except in retrospective database analyses. Perfusion pressure may be a more important target than mean pressure, even more so in the vulnerable patient population. In the cardiac ICU, blood pressure targets are tailored to specific cardiac pathophysiology and patient characteristics. Generally, the goal is to maintain adequate blood pressure within a certain range to support cardiac function and to ensure end organ perfusion. Individualized targets demand the use of both invasive and noninvasive monitoring modalities and frequent titration of medications and/or mechanical circulatory support where necessary. In this review, we aim to identify appropriate blood pressure targets in the ICU, recognizing special patient populations and outlining the risk factors and predictors of end organ failure.
... Intra-operative hypotension was defined as an absolute mean arterial pressure <65 mm Hg or a relative, a reduction of mean arterial pressure or systolic blood pressure of ≥20% from baseline. [23,24] Intra-operative desaturation was defined as an oxygen saturation of <90%, as reported previously. [1,25] Post-operative data relating to the incidence of planned and unplanned intensive care unit (ICU) admissions, length of ICU stay, total hospital stay, ventilator use, duration of ventilator use, and discharge status were collected. ...
Most post-operative stroke cases occur within 24 hours. This retrospective case-control study aimed to investigate the incidence, risk factors, and outcomes of early post-operative stroke that occurred within 24 hours after surgery in a university-based tertiary care hospital. Medical records were collected and reviewed between 2015 and 2021. Early post-operative stroke cases were compared with age-matched controls in a 1:3 ratio, and data regarding patient characteristics, intra-operative events, and post-operative outcomes were analyzed. Multiple logistic regression was performed to identify the risk factors for post-operative stroke. The incidence of early (≤24 hours) post-operative stroke was 0.015% (43 out of 284,105 cases). The multivariable analysis revealed that American Society of Anesthesiologists (ASA) physical status ≥3 (adjusted odds ratio [OR]: 3.12; 95% confidence interval [CI]: 1.22-7.99, P = .017), operation time >120 minutes (adjusted OR: 10.69; 95% CI: 3.95-28.94, P < .001), and intra-operative hypotension and inotrope/vasopressor use (adjusted OR: 2.80; 95% CI: 1.08-7.24, P = .034) were risk factors for early post-operative stroke. Compared to the controls, stroke patients had higher rates of planned and unplanned intensive care unit (ICU) admission, length of stay, ventilator use, and death. Despite its low incidence (0.015%), stroke is associated with poor clinical outcomes and increased mortality. Stratification of potential risks and establishment of risk optimization may help reduce stroke incidence.
