Matthew D McEvoy1, Ruchir Gupta2, Elena J Koepke3, Aarne Feldheiser4, Frederic Michard5, Denny Levett6, Julie K M Thacker7, Mark Hamilton8, Michael P W Grocott9, Monty G Mythen10, Timothy E Miller3, Mark R Edwards11, Timothy E Miller3, Monty G Mythen10, Michael Pw Grocott11, Mark R Edwards11. 1. Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address: matthew.d.mcevoy@vumc.org. 2. Department of Anesthesiology, Stony Brook School of Medicine, Stony Brook, NY, USA. 3. Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA. 4. Department of Anesthesiology and Operative Intensive Care Medicine, Charite Universitatsmedizin, Berlin, Germany. 5. MiCo Sarl, Lausanne, Switzerland. 6. Department of Perioperative Medicine and Critical Care, Southampton University Hospital NHS Foundation Trust, Southampton, UK. 7. Department of Surgery, Duke University Medical Center, Durham, NC, USA. 8. Department of Intensive Care Medicine and Anaesthesia, St. George's Hospital and Medical School NHS Foundation Trust, London, UK. 9. Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK; Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK. 10. UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK. 11. Respiratory and Critical Care Research Area, NIHR Biomedical Research Centre, University Hospital Southampton, NHS Foundation Trust, Southampton, UK.
Abstract
BACKGROUND: Postoperative hypotension and hypertension are frequent events associated with increased risk of adverse outcomes. However, proper assessment and management is often poorly understood. As a part of the PeriOperative Quality Improvement (POQI) 3 workgroup meeting, we developed a consensus document addressing this topic. The target population includes adult, non-cardiac surgical patients in the postoperative phase outside of the ICU. METHODS: A modified Delphi technique was used, evaluating papers published in MEDLINE examining postoperative blood pressure monitoring, management, and outcomes. Practice recommendations were developed in line with National Institute for Health and Care Excellence guidelines. RESULTS: Consensus recommendations were that (i) there is evidence of harm associated with postoperative systolic arterial pressure <90 mm Hg; (ii) for patients with preoperative hypertension, the threshold at which harm occurs may be higher than a systolic arterial pressure of 90 mm Hg; (iii) there is insufficient evidence to precisely define the level of postoperative hypertension above which harm will occur; (iv) a greater frequency of postoperative blood pressure measurement is likely to identify risk of harm and clinical deterioration earlier; and (v) there is evidence of harm from withholding beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors in the postoperative period. CONCLUSIONS: Despite evidence of associations with postoperative hypotension or hypertension with worse postoperative outcome, further research is needed to define the optimal levels at which intervention is beneficial, to identify the best methods and timing of postoperative blood pressure measurement, and to refine the management of long-term antihypertensive treatment in the postoperative phase.
BACKGROUND:Postoperative hypotension and hypertension are frequent events associated with increased risk of adverse outcomes. However, proper assessment and management is often poorly understood. As a part of the PeriOperative Quality Improvement (POQI) 3 workgroup meeting, we developed a consensus document addressing this topic. The target population includes adult, non-cardiac surgical patients in the postoperative phase outside of the ICU. METHODS: A modified Delphi technique was used, evaluating papers published in MEDLINE examining postoperative blood pressure monitoring, management, and outcomes. Practice recommendations were developed in line with National Institute for Health and Care Excellence guidelines. RESULTS: Consensus recommendations were that (i) there is evidence of harm associated with postoperative systolic arterial pressure <90 mm Hg; (ii) for patients with preoperative hypertension, the threshold at which harm occurs may be higher than a systolic arterial pressure of 90 mm Hg; (iii) there is insufficient evidence to precisely define the level of postoperative hypertension above which harm will occur; (iv) a greater frequency of postoperative blood pressure measurement is likely to identify risk of harm and clinical deterioration earlier; and (v) there is evidence of harm from withholding beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors in the postoperative period. CONCLUSIONS: Despite evidence of associations with postoperative hypotension or hypertension with worse postoperative outcome, further research is needed to define the optimal levels at which intervention is beneficial, to identify the best methods and timing of postoperative blood pressure measurement, and to refine the management of long-term antihypertensive treatment in the postoperative phase.
Authors: Greg S Martin; David A Kaufman; Paul E Marik; Nathan I Shapiro; Denny Z H Levett; John Whittle; David B MacLeod; Desiree Chappell; Jonathan Lacey; Tom Woodcock; Kay Mitchell; Manu L N G Malbrain; Tom M Woodcock; Daniel Martin; Chris H E Imray; Michael W Manning; Henry Howe; Michael P W Grocott; Monty G Mythen; Tong J Gan; Timothy E Miller Journal: Perioper Med (Lond) Date: 2020-04-21