Ashish K Khanna1,2, Kamal Maheshwari3, Guangmei Mao3,4, Liu Liu3,4, Silvia E Perez-Protto3, Praneeta Chodavarapu3, Yehoshua N Schacham3, Daniel I Sessler3. 1. Center for Critical Care, Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH. 2. Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC. 3. Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH. 4. Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.
Abstract
OBJECTIVES: Hypotension thresholds that provoke renal injury, myocardial injury, and mortality in critical care patients remain unknown. We primarily sought to determine the relationship between hypotension and a composite of myocardial injury (troponin T ≥ 0.03 ng/mL without nonischemic cause) and death up to 7 postoperative days. Secondarily, we considered acute kidney injury (creatinine concentration ≥ 0.3 mg/dL or 1.5 times baseline). DESIGN: Retrospective cohort. SETTING: Surgical ICU at an academic medical center. PATIENTS: Two-thousand eight-hundred thirty-three postoperative patients admitted to the surgical ICU. INTERVENTIONS: A Cox proportional hazard survival model was used to assess the association between lowest mean arterial pressure on each intensive care day, considered as a time-varying covariate, and outcomes. In sensitivity analyses hypotension defined as pressures less than 80 mm Hg and 70 mm Hg were also considered. MEASUREMENTS AND MAIN RESULTS: There was a strong nonlinear (quadratic) association between the lowest mean arterial pressure and the primary outcome of myocardial injury after noncardiac surgery or mortality, with estimated risk increasing at lower pressures. The risk of myocardial injury after noncardiac surgery or mortality was an estimated 23% higher at the 25th percentile (78 mm Hg) of lowest mean arterial pressure compared with at the median of 87 mm Hg, with adjusted hazard ratio (95% CI) of 1.23 (1.12-1.355; p < 0.001). Overall results were generally similar in sensitivity analyses based on every hour of mean arterial pressure less than 80 mm Hg and any mean arterial pressure less than 70 mm Hg. Post hoc analyses showed that the relationship between ICU hypotension and outcomes depended on the amount of intraoperative hypotension. The risk of acute kidney injury increased over a range of minimum daily pressures from 110 mm Hg to 50 mm Hg, with an adjusted hazard ratio of 1.27 (95% CI, 1.18-1.37; p < 0.001). CONCLUSIONS: Increasing amounts of hypotension (defined by lowest mean arterial pressures per day) were strongly associated with myocardial injury, mortality, and renal injury in postoperative critical care patients.
OBJECTIVES:Hypotension thresholds that provoke renal injury, myocardial injury, and mortality in critical care patients remain unknown. We primarily sought to determine the relationship between hypotension and a composite of myocardial injury (troponin T ≥ 0.03 ng/mL without nonischemic cause) and death up to 7 postoperative days. Secondarily, we considered acute kidney injury (creatinine concentration ≥ 0.3 mg/dL or 1.5 times baseline). DESIGN: Retrospective cohort. SETTING: Surgical ICU at an academic medical center. PATIENTS: Two-thousand eight-hundred thirty-three postoperative patients admitted to the surgical ICU. INTERVENTIONS: A Cox proportional hazard survival model was used to assess the association between lowest mean arterial pressure on each intensive care day, considered as a time-varying covariate, and outcomes. In sensitivity analyses hypotension defined as pressures less than 80 mm Hg and 70 mm Hg were also considered. MEASUREMENTS AND MAIN RESULTS: There was a strong nonlinear (quadratic) association between the lowest mean arterial pressure and the primary outcome of myocardial injury after noncardiac surgery or mortality, with estimated risk increasing at lower pressures. The risk of myocardial injury after noncardiac surgery or mortality was an estimated 23% higher at the 25th percentile (78 mm Hg) of lowest mean arterial pressure compared with at the median of 87 mm Hg, with adjusted hazard ratio (95% CI) of 1.23 (1.12-1.355; p < 0.001). Overall results were generally similar in sensitivity analyses based on every hour of mean arterial pressure less than 80 mm Hg and any mean arterial pressure less than 70 mm Hg. Post hoc analyses showed that the relationship between ICU hypotension and outcomes depended on the amount of intraoperative hypotension. The risk of acute kidney injury increased over a range of minimum daily pressures from 110 mm Hg to 50 mm Hg, with an adjusted hazard ratio of 1.27 (95% CI, 1.18-1.37; p < 0.001). CONCLUSIONS: Increasing amounts of hypotension (defined by lowest mean arterial pressures per day) were strongly associated with myocardial injury, mortality, and renal injury in postoperative critical care patients.
Authors: Christian Koch; Emmanuel Schneck; Christoph Arens; Melanie Markmann; Michael Sander; Michael Henrich; Markus A Weigand; Christoph Lichtenstern Journal: Int J Clin Pharm Date: 2019-11-21
Authors: Juan Victor Lorente; Ignacio Jimenez; Javier Ripollés-Melchor; Alejandra Becerra; Wilbert Wesselink; Francesca Reguant; Irene Mojarro; Maria de Los Angeles Fuentes; Ane Abad-Motos; Elizabeth Agudelo; Francisco Herrero-Machancoses; Paula Callejo; Joan Bosch; Manuel Ignacio Monge Journal: BMJ Open Date: 2022-06-02 Impact factor: 3.006
Authors: Nathan J Smischney; Andrew D Shaw; Wolf H Stapelfeldt; Isabel J Boero; Qinyu Chen; Mitali Stevens; Ashish K Khanna Journal: Crit Care Date: 2020-12-07 Impact factor: 9.097
Authors: Ward H van der Ven; Lotte E Terwindt; Nurseda Risvanoglu; Evy L K Ie; Marije Wijnberge; Denise P Veelo; Bart F Geerts; Alexander P J Vlaar; Björn J P van der Ster Journal: J Clin Monit Comput Date: 2021-11-13 Impact factor: 1.977
Authors: Frederik C Loft; Søren M Rasmussen; Mikkel Elvekjaer; Camilla Haahr-Raunkjaer; Helge B D Sørensen; Eske K Aasvang; Christian S Meyhoff Journal: Acta Anaesthesiol Scand Date: 2022-03-14 Impact factor: 2.274
Authors: Kaveh Hajifathalian; Reem Z Sharaiha; Sonal Kumar; Tibor Krisko; Daniel Skaf; Bryan Ang; Walker D Redd; Joyce C Zhou; Kelly E Hathorn; Thomas R McCarty; Ahmad Najdat Bazarbashi; Cheikh Njie; Danny Wong; Lin Shen; Evan Sholle; David E Cohen; Robert S Brown; Walter W Chan; Brett E Fortune Journal: PLoS One Date: 2020-09-30 Impact factor: 3.240
Authors: Anne Gregory; Wolf H Stapelfeldt; Ashish K Khanna; Nathan J Smischney; Isabel J Boero; Qinyu Chen; Mitali Stevens; Andrew D Shaw Journal: Anesth Analg Date: 2021-06-01 Impact factor: 6.627