Perioperative hypotension: clinical impact, diagnosis, and therapeutic approaches

Postoperative mortality is a major healthcare problem. In order to decrease postoperative mortality, avoiding postoperative complications is key. In turn, to avoid postoperative complications, modifiable risk factors independently associated with these complications need to be identified and avoided. One of the modifiable risk factors for postoperative complications may be perioperative hypotension—i.e., low blood pressure in the perioperative period. In this review, we discuss perioperative hypotension that includes intraoperative hypotension (IOH) and postoperative hypotension (POH), and its impact on postoperative patient outcomes, challenges related to its diagnosis, and potential therapeutic approaches. IOH is common in patients having non-cardiac surgery under general anesthesia and is associated with acute kidney injury, myocardial injury, and death. The relationship between IOH and serious postoperative complications is supported by many observational analyses and one randomized trial that suggests that individualized blood pressure management reduces the risk of postoperative organ dysfunction compared with usual care. More randomized controlled trials are needed before recommendations can be given on how to individualize intraoperative blood pressure targets in clinical routine. POH refers to hypotension occurring on the remaining day of surgery and during the first days after surgery. Available data suggest that POH after non-cardiac surgery is common, profound, and largely undetected by current vital sign monitoring on the general care ward. There is evidence that POH is associated with adverse postoperative outcomes, especially myocardial injury, acute kidney injury, and death. However, there is a need for more data on the pathophysiology, impact, and management of POH. Continuous ward monitoring might enable POH to be detected and treated in a timely manner. However, strategies to prevent or treat POH based on continuous ward monitoring need to be tested for their effectiveness to improve quality of care or patient-centered outcomes in large-scale interventional trials.