Is the “Triple Low” Association with Death Statistically Valid or Reflective of Clinical Practice?

We are intrigued to read Willingham et al.’s1 strongly worded retrospective, observational conclusion from three previously reported trials that the concurrence of intraoperative hypotension, low minimum alveolar concentration, and low bispectral index (BIS), the so-called “triple low,” was independently associated with postoperative death. We have several observations noting that several of the current authors were original contributors to the referenced studies.For all of these reasons, the alarming title and inferences need to be followed with clear caveats, including use of research-based protocols in the previous studies, which may not accurately reflect immediate corrections in current clinical practice, incorporation of only a quarter of the original cohort for matching, and the retrospective propensity analysis. These suggest that conclusions be tempered with caution until these statistical and clinical concerns can be addressed in future prospective investigations.The authors declare no competing interests.