DrPH,
Department of Anesthesiology, Mount Sinai School of Medicine, New York, New York
Relatively little is known about the influence of intraoperative hemodynamic variables on surgical outcomes. We
drew subjects (n 797) from a study of patients undergoing major noncardiac surgery. The physiological component of the POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality) operative
risk stratification index was determined, and intraoperative measurements of heart rate (HR), mean arterial blood
pressure, and systolic arterial blood pressure (SAP) were
retrieved from computerized anesthesia records. For every 5-min epoch during the surgery, HR, mean arterial
blood pressure, and SAP were each classified as low, normal, or high. Negative surgical outcome (NSO) was defined as a hospital stay of 10 days with a morbid condition or death during the hospital stay. Statistical analyses
included Mantel-Haenszel tests and multiple logistic regression. There was no significant association between hemodynamic variables and NSO with short operations. In
388 patients with operations longer than the median time
of 220 min, NSO occurred in 15.6%. Controlling for
POSSUM score and operation time beyond 220 min, both
high HR (odds ratio, 2.704; P 0.01) and high SAP (odds
ratio, 2.095; P 0.009) were associated with NSO in longer
operations. Thus, intraoperative tachycardia and hypertension were associated independently with adverse outcomes after major noncardiac surgery of long duration,
over and above the risk imparted by underlying medical
conditions.
(Anesth Analg 2002;95:2737)
statistical analyses to univariate tests. Statistical methods that assess the independent effects of the intraoperative hemodynamic aberrations on the risk of morbidity and mortality after adjusting for the effects of
underlying medical conditions are required. For example, intraoperative hypertension may be a marker
for essential hypertension, such that intraoperative
blood pressure deviations may or may not add additional risk beyond that of the underlying condition of
essential hypertension.
The advent of computerized anesthesia information systems provides the opportunity to record and
store intraoperative hemodynamic data with great
accuracy (5 8). By use of such systems, the independent associations between intraoperative hemodynamic abnormalities and death, stroke, and perioperative myocardial infarction in cardiac surgical
patients have been published (9,10). The purpose of
this investigation was to determine whether intraoperative aberrations of blood pressure or HR were
associated with perioperative mortality or major
morbidity in patients undergoing complex noncardiac surgery while controlling for the influence of
major coexisting medical illness.
Anesth Analg 2002;95:2737
273
274
Methods
The study was institutionally approved as a retrospective investigation. Subjects (n 797) were drawn from
a group of 1056 patients who had participated in an
IRB-approved anesthesia outcome study of patients
undergoing major elective noncardiac surgery at one
institution (11). The IRB waived the requirement for
informed consent.
Patients undergoing the following elective surgical
procedures were enrolled: major orthopedic (e.g., revision hip arthroplasty, fusion/instrumentation of
multiple lumbar or thoracic vertebrae); major general
(e.g., any laparotomy expected to exceed 2 h, including partial hepatectomy, pancreatic surgery, and colon
surgery); major urological (e.g., radical cystectomy,
radical nephrectomy); major vascular (e.g., abdominal
aortic aneurysm repair); and major gynecological (e.g.,
cancer debulking procedure, abdominal hysterectomy
with oophorectomy). These procedures were selected
for several reasons: 1) they are routinely performed
surgeries, 2) they represent a diverse group of procedure types, and 3) a previous study performed at
Duke University Medical Center found these procedures to be associated with prolonged hospitalization
and postoperative complications (12). Study patients
received routine anesthetic care and surgical management. Each patient was treated after surgery according
to standard institutional surgical care maps; only
patients undergoing surgical procedures enabling
them to be targeted for discharge from the hospital
before the 10th postoperative day were enrolled.
To quantify perioperative risk of morbidity and
mortality due to underlying medical conditions, the
physiological component of the POSSUM (Physiological and Operative Severity Score for the enUmeration
of Mortality) operative risk stratification index (13)
was determined for each patient. The POSSUM criteria have been cited as the most appropriate scoring
system available for assessing risk in noncardiac surgical patients (14). The POSSUM physiological score
includes 12 preoperative factors (including age, preoperative blood pressure, cardiac disease, and renal
function). A point value of 1, 2, 4, or 8 was assigned for
10 of the 12 factors, depending on the severity of the
abnormality (e.g., 1 point for no dyspnea and 8 points
for dyspnea at rest). The POSSUM score was obtained
by prospective evaluation in the operating room before surgery by a trained anesthesia research nurse.
A subset of patients from the original study had
undergone surgery in operating rooms with computerized anesthesia information systems (CompuRecord;
Philips, Andover, MA). Every patient with a valid computerized anesthesia record (n 797) from the original
study (n 1056) was included in this study. Intraoperative hemodynamic data were derived from these computerized anesthesia records that automatically stored
ANESTH ANALG
2002;95:2737
Results
The median operation length in this cohort was
220 min. Patient characteristics and surgical outcomes
ANESTH ANALG
2002;95:2737
CARDIOVASCULAR ANESTHESIA
REICH ET AL.
TACHYCARDIA, HYPERTENSION, AND OUTCOME
Low
High
55
80
45
100
160
110
Data
No. Patients
797
Age (yr)
60 (4373)
Sex (% male)
54
Race (% Caucasian)
71
Weight (kg)
70 (6080)
Preoperative serum creatinine (mg/dL)
1.0 (0.801.2)
Operative duration (min)
220 (160285)
Intraoperative IV fluid administration (L)
3.5 (2.55.0)
Temperature at the end of surgery (C)
36 (35.536.5)
Negative surgical outcome (%)a
15.6
In-hospital death (%)
1.6
Postoperative hospitalization (days)
7 (610)
Continuous data are presented as median (interquartile range).
a
In-hospital death or hospitalization for 10 days with a morbid condition after surgery.
275
Operations
220 min*
Operations
220 min
15
1618
1923
23
Total
5/128 (3.9%)
7/94 (7.5%)
9/92 (9.8%)
21/95 (22.1%)
42/409 (10.3%)
17/142 (12.0%)
13/76 (17.1%)
18/81 (22.2%)
34/89 (38.2%)
82/388 (21.1%)
* P 0.001; P 0.001.
No high HR
High HR
15
1618
1923
23
15/125 (12%)
10/66 (15.2%)
16/74 (21.6%)
26/77 (33.8%)
2/17 (11.8%)
3/10 (30.0%)
2/7 (28.6%)
8/12 (66.7%)
No high SAP
High SAP
15
1618
1923
23
9/95 (9.5%)
5/33 (15.2%)
7/41 (17.1%)
10/34 (29.4%)
11/47 (17.0%)
8/43 (18.6%)
11/40 (27.5%)
24/55 (43.6%)
No low MAP
Low MAP
15
1618
1923
23
12/117 (10.3%)
10/65 (15.4%)
14/70 (20%)
29/71 (40.9%)
5/25 (20%)
3/11 (27.3%)
4/11 (36.4%)
5/18 (27.8%)
The confounding effect of decreased MAP and increased HR was apparent in the multiple logistic regression analyses. Although each contributed significantly when considered without the other, increased
HR was the stronger predictor. The independent influence of increased HR and increased SAP in operations 220 min is shown in the multiple regression
276
ANESTH ANALG
2002;95:2737
Table 7. Multivariate Analysis of Negative Surgical Outcome in Long Operations (220 minutes)
Variable
Odds ratio
P value
1.003
1.096
2.704
2.095
0.02
0.0001
0.01
0.009
Discussion
This study investigated associations between hemodynamic variables measured in the course of complex
noncardiac surgery, and poor postoperative outcome.
Preoperative risk assessment with the POSSUM physiological score was included in the model to examine
the additional effects of intraoperative hemodynamic
aberrations on poor postoperative outcome, over and
above the influence of the factors that existed when
patients were brought to surgery. The POSSUM physiological score reflects the presence of preoperative
hypotension, hypertension, tachycardia, and bradycardia. Thus, our findings suggest that intraoperative
tachycardia and hypertension during long, complex
noncardiac surgery may partially explain the variability in outcome seen among patients with similar degrees of preoperative risk.
There are very few reports of independent associations of intraoperative hemodynamic aberrations
with complications. Jain et al. (9) reported that SAP
90 mm Hg after cardiopulmonary bypass was an
independent predictor of perioperative myocardial infarction. In a previous study at two institutions (including the authors), we identified independent associations between various hemodynamic aberrations,
including increased pulmonary artery diastolic pressure, with death, stroke, and myocardial infarction
after coronary artery bypass surgery (9).
A potential limitation of our study relates to the
selection of the primary end point as a composite of
mortality and prolonged postoperative hospitalization
with morbidity. Mortality is the most important end
point, but it is relatively infrequent compared with
morbidity in this group of surgical patients. We chose
prolonged postoperative hospitalization with morbidity because the presence of both strongly suggests that
the prolonged hospitalization was due to the morbid
condition (12). Furthermore, if the morbidity resulted
in a prolonged hospitalization, it also has a greater
economic effect.
A major question not addressed by this study is the
reason for the association of brief periods of hemodynamic abnormalities with complications that are overwhelmingly noncardiac. The majority of the morbidity
ANESTH ANALG
2002;95:2737
CARDIOVASCULAR ANESTHESIA
REICH ET AL.
TACHYCARDIA, HYPERTENSION, AND OUTCOME
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