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The Problem: Preventable Hypotension

Mortality during the 30 days after surgery is the third-leading cause of death in the United States [1] with the largest attributable factor being myocardial injury. [2] The only modifiable factor associated with perioperative myocardial injury is hypotension, with many studies in many populations from many institutions showing strong associations between perioperative hypotension and myocardial injury, acute kidney injury, and death. [3-5] Although hemodynamic management is a core skill for anesthesiologists, numerous studies show that even experienced anesthesiologists cannot tightly control blood pressure—and that the effort distracts from other tasks. For example, patients with manually controlled vasopressor infusions in both the operating room and intensive care unit spend 10-15% of their time with preventable perioperative hypotension. [6,7] There is thus a substantial gap between our knowledge of the importance of the avoidance of perioperative hypotension and the actual clinical management. This points to a critical need for a novel approach to management of vasopressors in these environments to bridge this gap; otherwise, evidence has shown that no amount of directed education or attention to this problem will significantly change current performance [8,9], and patients will continue to suffer preventable morbidity and mortality as a result.

Each year there are more than 300 million surgeries performed worldwide; hypotension remains a key preventable driver of morbidity and mortality in these patients. Similarly, vasoplegic conditions like septic shock are one of the main drivers of ICU admissions worldwide and a focus area that is ripe for innovation.

The goal of Perceptive Medical is to reduce preventable morbidity and mortality arising from the preventable hypotension that occurs in the ICU and during surgery while simultaneously reducing bedside provider workload. 

References

1.    Bartels K, Karhausen J, Clambey ET, Grenz A, Eltzschig HK. Perioperative organ injury. Anesthesiology. 2013;119(6):1474-89. Epub 2013/10/16. doi: 10.1097/ALN.0000000000000022. PubMed PMID: 24126264; PMCID: 3929362.

2.    Kristensen SD, Knuuti J, Saraste A, Anker S, Botker HE, Hert SD, Ford I, Gonzalez-Juanatey JR, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Luscher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Sousa-Uva M, Voudris V, Funck-Brentano C, Authors/Task Force M. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014;35(35):2383-431. Epub 2014/08/03. doi: 10.1093/eurheartj/ehu282. PubMed PMID: 25086026.

3.    Mascha EJ, Yang D, Weiss S, Sessler DI. Intraoperative mean arterial pressure variability and 30-day mortality in patients having noncardiac surgery. Anesthesiology. 2015;123:79-91. doi: 10.1097/ALN.0000000000000686. PubMed PMID: 25929547; PMCID: DOR, CCF.

4.    Salmasi V, Maheshwari K, Yang D, Mascha EJ, Singh A, Sessler DI, Kurz A. Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney and myocardial injury after noncardiac surgery: A retrospective cohort analysis. Anesthesiology. 2017;126(1):47-65. doi: 10.1097/ALN.0000000000001432. PubMed PMID: 27792044; PMCID: DOR, CCF, GenA, Residency.

5.    Liem VGB, Hoeks SE, Mol K, Potters JW, Grune F, Stolker RJ, van Lier F. Postoperative hypotension after noncardiac surgery and the association with myocardial injury. Anesthesiology. 2020;133(3):510-22. Epub 2020/06/04. doi: 10.1097/ALN.0000000000003368. PubMed PMID: 32487822.

6.    Yapps B, Shin S, Bighamian R, Thorsen J, Arsenault C, Quraishi SA, Hahn JO, Reisner AT. Hypotension in ICU Patients Receiving Vasopressor Therapy. Sci Rep. 2017;7(1):8551. doi: 10.1038/s41598-017-08137-0. PubMed PMID: 28819101; PMCID: PMC5561088.

7.    Rinehart J, Ma M, Calderon MD, Bardaji A, Hafiane R, Van der Linden P, Joosten A. Blood pressure variability in surgical and intensive care patients: Is there a potential for closed-loop vasopressor administration? Anaesth Crit Care Pain Med. 2019;38(1):69-71. doi: 10.1016/j.accpm.2018.11.009. PubMed PMID: 30513357.

8.    Shah NJ, Mentz G, Kheterpal S. The incidence of intraoperative hypotension in moderate to high risk patients undergoing non-cardiac surgery: A retrospective multicenter observational analysis. J Clin Anesth. 2020;66:109961. doi: 10.1016/j.jclinane.2020.109961. PubMed PMID: 32663738.

9.    Sessler DI, Turan A, Stapelfeldt WH, Mascha EJ, Yang D, Farag E, Cywinski J, Vlah C, Kopyeva T, Keebler AL, Perilla M, Ramachandran M, Drahuschak S, Kaple K, Kurz A. Triple-low Alerts Do Not Reduce Mortality: A Real-time Randomized Trial. Anesthesiology. 2018. doi: 10.1097/ALN.0000000000002480. PubMed PMID: 30312182.

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