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. 2025 Jul;135(1):40-47.
doi: 10.1016/j.bja.2024.10.050. Epub 2025 Jan 24.

Influence of frailty status on the incidence of intraoperative hypotensive events in elective surgery: Hypo-Frail, a single-centre retrospective cohort study

Nils Daum  1 , Laerson Hoff  2 , Claudia Spies  2 , Anne Pohrt  3 , Annika Bald  2 , Nadine Langer  2 , Jörn Kiselev  4 , Nils Drewniok  2 , Maximilian Markus  2 , Oliver Hunsicker  2 , Rudolf Mörgeli  2 , Björn Weiss  2 , Dario von Wedel  5 , Felix Balzer  5 , Stefan J Schaller  6
Affiliations

Influence of frailty status on the incidence of intraoperative hypotensive events in elective surgery: Hypo-Frail, a single-centre retrospective cohort study

Nils Daum et al. Br J Anaesth. 2025 Jul.

Abstract

Background: Frailty is a predictor of morbidity and mortality in older patients. This study aimed to investigate the influence of frailty status on likelihood, rate, duration, and severity of intraoperative hypotension (IOH), which can lead to severe organ dysfunction.

Methods: Surgical patients (≥70 yr old) with preoperative frailty assessment were analysed retrospectively. Frailty status was defined as robust, prefrail, or frail based on modified Fried criteria. IOH was defined as mean arterial pressure <65 mm Hg. For likelihood, rate, duration, and severity of IOH, logistic and Poisson regression were used.

Results: We included 2495 patients. There was no significant difference in likelihood of IOH. An increase of 9% in rate of IOH during surgery for prefrail (incidence rate ratio [IRR] 1.09 [95% CI 1.03-1.16], P=0.002), and 16% increase for frail patients (IRR 1.16 [1.04-1.29], P=0.007) was observed. During anaesthesia induction, prefrail patients exhibited a 28% increase in IOH (IRR 1.28 [1.12-1.47], P<0.001). Although there were no differences in the severity of IOH if surgery or anaesthesia induction duration was taken into account, frailty status was associated with a 15% longer time-weighted duration of IOH during anaesthesia induction (IRR 1.15 [1.06-1.24], P=0.001). Mediator analysis revealed that frailty status accounted for >90% after considering number of measured blood pressures and surgical duration and >70% after accounting for total propofol dose.

Conclusions: Prefrail and frail patients aged ≥70 yr experienced up to 16% more IOH during surgery and 28% more during anaesthesia induction compared with robust patients. Preoperative optimisation (prehabilitation) and modification of intraoperative management (e.g. invasive blood pressure management) have the potential to reduce IOH in prefrail and frail patients.

Keywords: frailty; geriatric anaesthesia; haemodynamics; hypotension; risk assessment.

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Conflict of interest statement

Declaration of interest The authors declare that they have no conflicts of interest.

Figures

Fig 1
Fig 1
Flowchart of included patients. MET, metabolic equivalent of task.
Fig 2
Fig 2
Rate of hypotensive events for the total surgery (a) and anaesthesia induction time (b) over time (min) in relation to frailty status. Shaded brown median and interquartile range of anaesthesia induction time of the overall cohort; blue robust; yellow prefrail; red frail; coloured lines Kernel Density Estimation.
Figure S1
Figure S1
Total surgery (a) and anaesthesia induction time (b). green robust; yellow prefrail; red frail; coloured lines Kernel Density Estimation.
Figure S2
Figure S2
Surgery departments of the total cohort.
See this image and copyright information in PMC

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