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. 2023 Oct:89:111159.
doi: 10.1016/j.jclinane.2023.111159. Epub 2023 Jun 8.

Incidence, severity and detection of blood pressure and heart rate perturbations in postoperative ward patients after noncardiac surgery

Ashish K Khanna  1 , Nathaniel S O'Connell  2 , Sanchit Ahuja  3 , Amit K Saha  4 , Lynnette Harris  5 , Bruce D Cusson  6 , Ann Faris  7 , Carolyn S Huffman  8 , Saraschandra Vallabhajosyula  9 , Clancy J Clark  10 , Scott Segal  11 , Brian J Wells  12 , Eric S Kirkendall  13 , Daniel I Sessler  14
Affiliations

Incidence, severity and detection of blood pressure and heart rate perturbations in postoperative ward patients after noncardiac surgery

Ashish K Khanna et al. J Clin Anesth. 2023 Oct.

Abstract

Study objective: We sought to determine changes in continuous mean and systolic blood pressure and heart rate in a cohort of non-cardiac surgical patients recovering on the postoperative ward. Furthermore, we estimated the proportion of vital signs changes that would remain undetected with intermittent vital signs checks.

Design: Retrospective cohort.

Setting: Post-operative general ward.

Patients: 14,623 adults recovering from non-cardiac surgical procedures.

Interventions & measurements: Using a wireless, noninvasive monitor, we recorded postoperative blood pressure and heart rate at 15-s intervals and encouraged nursing intervention as clinically indicated.

Main results: 7% of our cohort of 14,623 patients spent >15 sustained minutes with a MAP <65 mmHg, and 23% had MAP <75 mmHg for 15 sustained minutes. Hypertension was more common, with 67% of patients spending at least 60 sustained minutes with MAP >110 mmHg. Systolic pressures <90 mmHg were present for 15 sustained minutes in about a fifth of all patients, and 40% of patients had pressures >160 mmHg sustained for 30 min. 40% of patients were tachycardic with heart rates >100 beats/min for at least continuous 15 min and 15% of patients were bradycardic at a threshold of <50 beats/min for 5 sustained minutes. Conventional vital sign assessments at 4-h intervals would have missed 54% of mean pressure episodes <65 mmHg sustained >15 min, 20% of episodes of mean pressures >130 mmHg sustained >30 min, 36% of episodes of heart rate > 120 beats/min sustained <10 min, and 68% of episodes of heart rate sustained <40 beats per minute for >3 min.

Conclusions: Substantial hemodynamic disturbances persisted despite implementing continuous portable ward monitoring coupled with nursing alarms and interventions. A significant proportion of these changes would have gone undetected using traditional intermittent monitoring. Better understanding of effective responses to alarms and appropriate interventions on hospital wards remains necessary.

Keywords: Blood pressure; Continuous; Heart rate; Monitoring; Vital signs.

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Conflict of interest statement

Declaration of Competing Interest Dr. Khanna is a consultant for Edwards Lifesciences, Caretaker Medical, Retia Medical, Philips Research North America, GE Healthcare, Baxter, and Medtronic, and is supported by an NIH/NCATS KL2 award for a pilot trial of continuous hemodynamic and oxygenation monitoring on hospital wards. The Department of Anesthesiology at Wake Forest School of Medicine is funded by Edwards Lifesciences, Masimo, and Medtronic. Dr. Sessler is a consultant for Edwards Lifesciences, Sensifree and Perceptive Medical. The Department of Outcomes Research is funded by Edwards Lifesciences, GE Healthcare, and Masimo. None of the other authors have any potential competing interests to report.

Figures

Fig. 1.
Fig. 1.
Consort chart.
Fig. 2.
Fig. 2.
(A): Percent of time spent under various MAP thresholds. Each line represents Y% of patients (Y-axis) that spent X% of time (X-axis) under the specified line threshold given by the MAP color. (B): Percent of patients below a range of MAP thresholds by maximum continuous or sustained time spent under each threshold. Each line represents Y% of patients (Y-axis) that spent X threshold of MAP (X-axis) under the specified levels given by sustained time in various colors.
Fig. 3.
Fig. 3.
(A): Percent of time spent above various MAP thresholds. Each line represents Y% of patients (Y-axis) that spent X% of time (X-axis) above the specified line threshold given by the MAP color. (B): Percent of patients above a range of MAP thresholds by maximum continuous or sustained time spent above each threshold. Each line represents Y% of patients (Y-axis) that spent X threshold of MAP (X-axis) above the specified levels given by sustained time in various colors.
Fig. 4.
Fig. 4.
(A): Percent of time spent above various heart rate (HR) thresholds. Each line represents Y% of patients (Y-axis) that spent X% of time (X-axis) above the specified line threshold given by the HR color. (B): Percent of patients above a range of heart rate (HR) thresholds by maximum continuous or sustained time spent above each threshold. Each line represents Y% of patients (Y-axis) that spent X threshold of HR (X-axis) above the specified levels given by sustained time in various colors.
Fig. 5.
Fig. 5.
(A): Percent of time spent under various heart rate (HR) thresholds. Each line represents Y% of patients (Y-axis) that spent X% of time (X-axis) under the specified line threshold given by the HR color. (B): Percent of patients below a range of heart rate (HR) thresholds by maximum continuous or sustained time spent under each threshold. Each line represents Y% of patients (Y-axis) that spent X threshold of HR (X-axis) under the specified levels given by sustained time in various colors.
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