Intraoperative Hypotension Is Associated With Adverse Clinical Outcomes After Noncardiac Surgery

Abstract

Background: Intraoperative hypotension (IOH) occurs frequently during surgery and may be associated with organ ischemia; however, few multicenter studies report data regarding its associations with adverse postoperative outcomes across varying hemodynamic thresholds. Additionally, no study has evaluated the association between IOH exposure and adverse outcomes among patients by various age groups.

Methods: A multicenter retrospective cohort study was conducted between 2008 and 2017 using intraoperative blood pressure data from the US electronic health records database to examine postoperative outcomes. IOH was assessed in 368,222 noncardiac surgical procedures using 5 methods: (a) absolute maximum decrease in mean arterial pressure (MAP) during surgery, (b) time under each absolute threshold, (c) total area under each threshold, (d) time-weighted average MAP under each threshold, and (e) cumulative time under the prespecified relative MAP thresholds. MAP thresholds were defined by absolute limits (≤75, ≤65, ≤55 mm Hg) and by relative limits (20% and 40% lower than baseline). The primary outcome was major adverse cardiac or cerebrovascular events; secondary outcomes were all-cause 30- and 90-day mortality, 30-day acute myocardial injury, and 30-day acute ischemic stroke. Residual confounding was minimized by controlling for observable patient and surgical factors. In addition, we stratified patients into age subgroups (18-40, 41-50, 51-60, 61-70, 71-80, >80) to investigate how the association between hypotension and the likelihood of major adverse cardiac or cerebrovascular events and acute kidney injury differs in these age subgroups.

Results: IOH was common with at least 1 reading of MAP ≤75 mm Hg occurring in 39.5% (145,743) of cases; ≤65 mm Hg in 19.3% (70,938) of cases, and ≤55 mm Hg in 7.5% (27,473) of cases. IOH was significantly associated with the primary outcome for all age groups. For an absolute maximum decrease, the estimated odds of a major adverse cardiac or cerebrovascular events in the 30-day postsurgery was increased by 12% (95% confidence interval [CI], 11-14) for ≤75 mm Hg; 17.0% (95% CI, 15-19) for ≤65 mm Hg; and by 26.0% (95% CI, 22-29) for ≤55 mm Hg.

Conclusions: IOH during noncardiac surgery is common and associated with increased 30-day major adverse cardiac or cerebrovascular events. This observation is magnified with increasing hypotension severity. The potentially avoidable nature of the hazard, and the extent of the exposed population, makes hypotension in the operating room a serious public health issue that should not be ignored for any age group.

Figure 1.

Attrition diagram. MAP indicates mean arterial pressure; OR, operating room.

Figure 2.

Adjusted ORs for the likelihood of adverse clinical events (A) for the primary outcome using all absolute exposure methods and (B) for the primary outcome using relative cumulative time (C) for the secondary outcomes for the AMD for each 5 mm Hg under IOH MAP thresholds. A, The adjusted ORs with 95% CIs for the regression models for MACCE for the following IOH exposures: AMD in MAP during surgery (maximum drop below specified MAP threshold), time spent under each absolute threshold value, total area under each threshold-time plot, TWA-MAP under each threshold during the study period are shown. B, The adjusted ORs with 95% CIs for the regression models for MACCE for the IOH exposure of cumulative time under the prespecified relative MAP thresholds during the study period are shown. C, The adjusted ORs with 95% CIs for the regression models for secondary outcomes with AMD in MAP during the study period are shown. Adj. indicates adjusted; AIS, acute ischemic stroke; AKI, acute kidney injury; AMD, absolute maximum decrease; AMI, acute myocardial infarction; CI, confidence interval; CRRT, continuous renal replacement therapy; IOH, intraoperative hypotension; MACCE, major adverse cardiac or cerebrovascular events; MAP, mean arterial pressure; OR, odds ratio; SIRS, systemic inflammatory response syndrome; TWA, time-weighted average.

Figure 3.

Adjusted ORs for the likelihood of MACCE for each 5 mm Hg under IOH MAP thresholds, by age group. The adjusted ORs with 95% CIs for the regression models with AMD in MAP during the study period are shown. ORs are plotted on the log-OR scale but labeled on the OR scale. Of note due to rounding some of the CIs appear to be asymmetrical or not visible. N for each age group by threshold: MAP ≤75 mm Hg: 18–40, N = 16,390; 41–50, N = 16,757; 51–60, N = 28,724; 61–70, N = 38,108; 71–80, N = 27,767; >80, N = 14,641; MAP ≤65 mm Hg: 18–40, N = 7466; 41–50, N = 7676; 51–60, N = 13,783; 61–70, N = 18,483; 71–80, N = 13,651; >80, N = 7553); MAP ≤55 mm Hg: 18–40, N = 2931; 41–50, N = 2843; 51–60, N = 5217; 61–70, N = 6866; 71–80, N = 5093; >80, N = 2994). Adj. indicates adjusted; AMD, absolute maximum decrease; CI, confidence interval; IOH, intraoperative hypotension; MACCE, major adverse cardiac or cerebrovascular events; MAP, mean arterial pressure; OR, odds ratio.