Relationship between Intraoperative Mean Arterial Pressure and Clinical Outcomes after Noncardiac Surgery

TLDR

Intraoperative hypotension may lead to postoperative acute kidney injury and myocardial injury, yet the unsafe blood pressure range remains undefined. The study aimed to determine the MAP threshold below which the risk of AKI and myocardial injury rises and to assess whether shorter MAP < 55 mmHg episodes increase that risk, with a view to informing future trials. Using perioperative data from 33,330 noncardiac surgeries at the Cleveland Clinic, the authors examined MAP values between 55 and 75 mmHg and the duration of MAP < 55 mmHg, adjusting for confounders. They found that MAP < 55 mmHg was associated with higher rates of AKI (7.4%) and myocardial injury (2.3%), and that even brief periods below this threshold (1–5 min) increased risk, with risk escalating with longer durations.

Abstract

Abstract Background: Intraoperative hypotension may contribute to postoperative acute kidney injury (AKI) and myocardial injury, but what blood pressures are unsafe is unclear. The authors evaluated the association between the intraoperative mean arterial pressure (MAP) and the risk of AKI and myocardial injury. Methods: The authors obtained perioperative data for 33,330 noncardiac surgeries at the Cleveland Clinic, Ohio. The authors evaluated the association between intraoperative MAP from less than 55 to 75 mmHg and postoperative AKI and myocardial injury to determine the threshold of MAP where risk is increased. The authors then evaluated the association between the duration below this threshold and their outcomes adjusting for potential confounding variables. Results: AKI and myocardial injury developed in 2,478 (7.4%) and 770 (2.3%) surgeries, respectively. The MAP threshold where the risk for both outcomes increased was less than 55 mmHg. Compared with never developing a MAP less than 55 mmHg, those with a MAP less than 55 mmHg for 1–5, 6–10, 11–20, and more than 20 min had graded increases in their risk of the two outcomes (AKI: 1.18 [95% CI, 1.06–1.31], 1.19 [1.03–1.39], 1.32 [1.11–1.56], and 1.51 [1.24–1.84], respectively; myocardial injury 1.30 [1.06–1.5], 1.47 [1.13–1.93], 1.79 [1.33–2.39], and 1.82 [1.31–2.55], respectively]. Conclusions: Even short durations of an intraoperative MAP less than 55 mmHg are associated with AKI and myocardial injury. Randomized trials are required to determine whether outcomes improve with interventions that maintain an intraoperative MAP of at least 55 mmHg.