Gareth L Ackland1, Charles S Brudney2, Maurizio Cecconi3, Can Ince4, Michael G Irwin5, Jonathan Lacey6, Michael R Pinsky7, Michael Pw Grocott8, Monty G Mythen9, Mark R Edwards8, Timothy E Miller10. 1. Translational Medicine & Therapeutics, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK. Electronic address: g.ackland@qmul.ac.uk. 2. Department of Anesthesiology, University of Manitoba, Winnipeg, MB, Canada. 3. Department of Intensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, London, UK. 4. Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands. 5. Department of Anaesthesiology, University of Hong Kong, Hong Kong Special Administrative Region. 6. University College London Hospitals NHS Trust, London, UK. 7. Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA. 8. Respiratory and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton, NHS Foundation Trust, Southampton, UK; Integrative Physiology and Critical Illness Group, Faculty of Medicine, University of Southampton, Southampton, UK. 9. UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK. 10. Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
Abstract
BACKGROUND: Perioperative arterial blood pressure management is a physiologically complex challenge influenced by multiple factors. METHODS: A multidisciplinary, international working subgroup of the Third Perioperative Quality Initiative (POQI) consensus meeting reviewed the (patho)physiology and measurement of arterial pressure as applied to perioperative medicine. We addressed predefined questions by undertaking a modified Delphi analysis, in which primary clinical research and review articles were identified using MEDLINE. Strength of recommendations, where applicable, were graded by National Institute for Health and Care Excellence (NICE) guidelines. RESULTS: Multiple physiological factors contribute to the perioperative physiological importance of arterial pressure: (i) arterial pressure is the input pressure to organ blood flow, but is not the sole determinant of perfusion pressure; (ii) blood flow is often independent of changes in perfusion pressure because of autoregulatory changes in vascular resistance; (iii) microvascular dysfunction uncouples microvascular blood flow from arterial pressure (haemodynamic incoherence). From a practical clinical perspective, we identified that: (i) ambulatory measurement is the optimal method to establish baseline arterial pressure; (ii) automated and invasive arterial pressure measurements have inherent physiological and technical limitations; (iii) individualised arterial pressure targets may change over time, especially in the perioperative period. There remains a need for research in non-invasive, continuous arterial pressure measurements, macro- and micro-circulatory control, regional perfusion pressure measurement, and the development of sensitive, specific, and continuous measures of cellular function to evaluate blood pressure management in a physiologically coherent manner. CONCLUSION: The multivariable, complex physiology contributing to dynamic changes in perioperative arterial pressure may be underappreciated clinically. The frequently unrecognised dissociation between arterial pressure, organ blood flow, and microvascular and cellular function requires further research to develop a more refined, contextualised clinical approach to this routine perioperative measurement.
BACKGROUND: Perioperative arterial blood pressure management is a physiologically complex challenge influenced by multiple factors. METHODS: A multidisciplinary, international working subgroup of the Third Perioperative Quality Initiative (POQI) consensus meeting reviewed the (patho)physiology and measurement of arterial pressure as applied to perioperative medicine. We addressed predefined questions by undertaking a modified Delphi analysis, in which primary clinical research and review articles were identified using MEDLINE. Strength of recommendations, where applicable, were graded by National Institute for Health and Care Excellence (NICE) guidelines. RESULTS: Multiple physiological factors contribute to the perioperative physiological importance of arterial pressure: (i) arterial pressure is the input pressure to organ blood flow, but is not the sole determinant of perfusion pressure; (ii) blood flow is often independent of changes in perfusion pressure because of autoregulatory changes in vascular resistance; (iii) microvascular dysfunction uncouples microvascular blood flow from arterial pressure (haemodynamic incoherence). From a practical clinical perspective, we identified that: (i) ambulatory measurement is the optimal method to establish baseline arterial pressure; (ii) automated and invasive arterial pressure measurements have inherent physiological and technical limitations; (iii) individualised arterial pressure targets may change over time, especially in the perioperative period. There remains a need for research in non-invasive, continuous arterial pressure measurements, macro- and micro-circulatory control, regional perfusion pressure measurement, and the development of sensitive, specific, and continuous measures of cellular function to evaluate blood pressure management in a physiologically coherent manner. CONCLUSION: The multivariable, complex physiology contributing to dynamic changes in perioperative arterial pressure may be underappreciated clinically. The frequently unrecognised dissociation between arterial pressure, organ blood flow, and microvascular and cellular function requires further research to develop a more refined, contextualised clinical approach to this routine perioperative measurement.
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