Intra-operative Hypotension


Associated with post-operative mortality and morbidity, intra-operative hypotension (IOH) is a topic of increasing interest amongst both clinical researchers and clinicians responsible for the hemodynamic management of patients in the operating room.


During non-cardiac surgery, variations in intraoperative blood pressure beyond normal physiological ranges are a common occurrence.

Hemodynamic instability

During the peri-operative period, surgical patients are often hemodynamically unstable, and this may result in a supply-demand mismatch1.

A primary goal of anesthetic management is hemodynamic control, but little is known about the optimal targets for such management.

What is IOH?

IOH is a common and frequent occurrence in patients undergoing general anesthesia for non-cardiac surgery. A 2014 study of almost 17,000 anesthetic records revealed that 26% of the surgical patients involved had a peri-operative systolic blood pressure of <80 mmHg for >5minutes2

Definition of IOH

At present, there is no widely accepted definition of IOH and this absence confounds the association between blood pressure deviations during surgery and adverse sequelae3,4,5.

Measurement of IOH

Blood pressure signals are complex and demonstrate considerable variation over time. Multi-component, they include diastolic, systolic, mean and pulse pressures. The optimum method for characterizing these complex signals has yet to be defined. Several different approaches have been advocated and examined clinically. These include mean, time-weighted average, minimum, time under various thresholds, area under thresholds, time-weighted average under thresholds and minimum pressure maintained for various pre-defined periods.

Any identified association between blood pressure and outcome will have a primary dependency on the method chosen to characterize the pressure. More complex methodologies, e.g. those quantifying the duration and magnitude of pressure changes are likely to be more useful than simpler approaches such as mean and time-weighted average6.

IOH and unfavorable outcomes

It has long been recognized that IOH is associated with post-operative mortality3. The link between IOH and adverse outcomes such as acute kidney injury (AKI) and myocardial injury (MI) has been conclusively demonstrated by several landmark clinical studies5,7,8Furthermore, accumulating evidence from other studies indicates that even brief periods of IOH may be harmful to patients9. Of concern is the fact that the threshold for harm may reside below blood pressure levels that are currently accepted as standard of care10.

Several clinical studies that have defined hypotension in terms of minutes or integrated pressures below various absolute limits have demonstrated associations between low mean arterial pressure (MAP) and organ injury11.

IOH, defined in various ways, is weakly associated with AKI and strongly associated with MI and death11.

In a study of 104,000 non-cardiac surgery patients, 30-day mortality was strongly related to time-weighted average intra-operative MAP12.

The threshold for myocardial injury is a MAP ≤65mmHg. Recent clinical evidence suggests that the threshold for renal injury may be higher, possibly nearer 75mmHg. A few minutes of a MAP <55mmHg is associated with AKI and MI risk—both of which have been demonstrated to increase markedly with prolonged IOH8.

Adverse outcomes associated with IOH such as AKI and MI require additional treatment and length of stay. These incur substantial extra hospital expenditures14.

Benefits of preventing IOH

The prevention of IOH, by tailoring management of peri-operative blood pressure to individual patient physiology, may improve post-operative outcomes. In a randomized clinical trial of patients undergoing major abdominal surgery, those in the individualized blood pressure management arm demonstrated significantly lower rates of post-operative organ dysfunction than those managed with standard practice (38.1% vs. 51.7% respectively) 13.

A recent Monte Carlo modelling study based on current US epidemiological and cost outcomes literature has suggested that “improved intra-operative hypotension control in a hospital with an annual volume of 10,000 non-cardiac surgical patients is associated with mean cost reductions ranging from $1.2–$4.6 million per year” 14.

How can the problem be addressed?

Directed Systems Ltd (Cambridge, UK and Austin, USA) has developed and received FDA 510(k) clearance, for a new software medical device, Hypotension Decision Assist (HDA), which provides guidance to anesthesiologists in relation to the real-time management of patient cardiovascular physiology.

HDA is designed to help anesthesiologists respond to the problem of hypotension in patients undergoing anesthesia during surgical procedures.

The information provided by HDA is intended to complement, not replace, the information provided by the standard multi-parameter monitoring systems that are routinely used in the operating room. 

HDA continually processes and displays, in graphical charts and numeric format, hemodynamic data and derived variables in comparison with user defined targets. It detects and indicates to the user when blood pressure shown as MAP is above or below a defined target range.

HDA includes algorithms that provide insight into the determinants of cardiovascular function, including trends in cardiac output and systemic vascular resistance15-20.

HDA allows the user to add labels to the graphic display chart to show the administration of vasopressors, as bolus or infused, and volume challenges.


What we know

Traditionally, the management of blood pressure is frequently based on empirically chosen targets and the expertise of individual clinicians.

Blood pressure signals are complex and demonstrate considerable variation over time.

The optimum method for characterizing these complex signals has yet to be defined, although several different approaches have been advocated and examined clinically.

IOH is a common and frequent occurrence in patients undergoing general anesthesia for non-cardiac surgery.

IOH is an important contributor to post-operative mortality.

IOH is an important contributor to post-operative kidney and myocardial injury.

Severe IOH is poorly tolerated and there is increasing evidence that less severe IOH may also adversely influence outcomes.

Multiple definitions of IOH have been used by researchers, but several analyses have associated a MAP <65mmHg with worse clinical outcome.

A few minutes of a MAP <55mmHg is associated with AKI and MI.

The risk of organ damage and death increases markedly with prolonged IOH.


1     Sessler DI, Meyhoff CS, Zimmerman NM, Mao G, Leslie K, Vásquez SM, Balaji P, Alvarez-Garcia J, Cavalcanti AB, Parlow JL, Rahate PV, Seeberger MD, Gossetti B, Walker SA, Premchand RK, Dahl RM, Duceppe E, Rodseth R, Botto F, Devereaux PJ.Period-dependent Associations between Hypotension during and for Four Days after Noncardiac Surgery and a Composite of Myocardial Infarction and Death: A Substudy of the POISE-2 Trial. Anesthesiol 2018; 128:317-327

2     Nair BG, Horibe M, Newman SF, Wu WY, Peterson GN, Schwid HA. Anesthesia information management system-based near real-time decision support to manage intraoperative hypotension and hypertension. Anesth Analg 2014; 118: 206–214

3     Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg 2005; 100: 4-10

4     Monk TG, Bronsert MR, Henderson WG, Mangione MP, Sum-Ping ST, Bentt DR, Nguyen JD, Richman JS, Meguid RA, Hammermeister KE. Association between Intraoperative Hypotension and Hypertension and 30-day Postoperative Mortality in Noncardiac Surgery. Anesthesiol 2015; 123:307-319

5     Wesselink EM, Kappen TH, Torn HM, Slooter AJC, van Klei WA. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. BJA 2018; 121: 706-721

6     Sessler DI, Khanna AK. Perioperative myocardial injury and the contribution of hypotension. Intensive Care Med. 2018; 44: 811-822

7     Sun LY, Wijeysundera DN, Tait GA, Beattie WS. Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery.Anesthesiol 2015; 123: 515–515

8     Walsh M, Devereaux PJ, Garg AX, Kurz A, Turan A, Rodseth RN, Cywinski J, Thabane L, Sessler DI. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension. Anesthesiol 2013; 119: 507-515

9     Godet T, Grobost R, Futier E. Personalization of arterial pressure in the perioperative period. Curr Opin Crit Care 2018; 24: 554-559

10   Stapelfeldt WH, Yuan H, Dryden JK, Strehl KE, Cywinski JB, Ehrenfeld JM, Bromley P. The SLUScore: A Novel Method for Detecting Hazardous Hypotension in Adult Patients Undergoing Noncardiac Surgical Procedures. Anesth Analg 2017; 124:1135–152

11   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. Anesthesiol 2017; 126: 47-65

12   Mascha EJ, Yang D, Weiss S, Sessler DI. Intraoperative Mean Arterial Pressure Variability and 30-day Mortality in Patients Having Noncardiac Surgery. Anesthesiol 2015; 123:79–91

13   Futier E, Lefrant JY, Guinot PG, Godet T, Lorne E, Cuvillon P, Bertran S, Leone M, Pastene B, Piriou V, Molliex S, Albanese J, Julia JM, Tavernier B, Imhoff E, Bazin JE, Constantin JM, Pereira B, Jaber S; INPRESS Study Group. Effect of Individualized vs Standard Blood Pressure Management Strategies on Postoperative Organ Dysfunction Among High-Risk Patients Undergoing Major Surgery: A Randomized Clinical Trial. JAMA 2017; 318: 1346–1357

14   Keuffel EL, Rizzo J, Stevens M, Gunnarsson C, Maheshwari K. (2019) Hospital costs associated with intraoperative hypotension among non-cardiac surgical patients in the US: a simulation model. J Med Econ 2019; 22: 645-651

15   Liljestrand G, Zander E. Vergleichen die Bestimmungen des Minutenvolumens des Herzens beim Menschen mittels der Stichoxydulmethode und durch Blutdruckmessung. Ztschr ges exper med 1928; 59:105–122

16   Caillard A, Gayat E, Tantot A, Dubreuil G, M’Bakulu E, Madadaki C, Bart F, Bresson D, Froelich S, Mebazaa A, Vallée F. Comparison of cardiac output measured by oesophageal Doppler ultrasonography or pulse pressure contour wave analysis. Br J Anaesth 2015; 114: 893-900

17   Zhang J, Critchley LA, Huang L. Five algorithms that calculate cardiac output from the arterial waveform: a comparison with Doppler ultrasound.  Br J Anaesth 2015;115: 392-402

18   Monge García MI, Romero MG, Cano AG, Rhodes A, Grounds RM, Cecconi M. Impact of arterial load on the agreement between pulse pressure analysis and esophageal Doppler. Crit Care 2013; 17(3): R113

19   Sun JX, Reisner AT, Saeed M, Heldt T, Mark RG. The cardiac output from blood pressure algorithms trial. Crit Care Med 2009; 37: 72-80

20   Atlas G, Berger J, Dhar S. Afterload assessment with or without central venous pressure: A preliminary clinical comparison. Cardiovasc Eng 2010; 10(4): 246–252