Journal of Clinical Anesthesia

Volume 89, October 2023, 111159

Original Contribution

Incidence, severity and detection of blood pressure

and heart rate perturbations in postoperative ward
patients after noncardiac surgery
Ashish K. Khanna (MD,MS,FCCP,FCCM,FASA) a b c , Nathaniel S. O'Connell (PhD) d , Sanchit Ahuja (MD) c e ,
Amit K. Saha (PhD) a b , Lynnette Harris (BSN) a b , Bruce D. Cusson (RN) a , Ann Faris (MSN) b f ,
Carolyn S. Huffman (PhD) b f , Saraschandra Vallabhajosyula (MD,MSc) b g , Clancy J. Clark (MD) h ,
Scott Segal (MD) a b , Brian J. Wells (MD, PhD) i j , Eric S. Kirkendall (MD) k l , Daniel I. Sessler (MD) m

Show more

Share Cite

https://doi.org/10.1016/j.jclinane.2023.111159
Get rights and content

Abstract

Study objective
We sought to determine changes in continuous mean and systolic blood pressure and heart rate in a cohort
of non-cardiac surgical patients recovering on the postoperative ward. Furthermore, we estimated the
proportion of vital signs changes that would remain undetected with intermittent vital signs checks.

Design
Retrospective cohort.

Setting
Post-operative general ward.
:
 Patients
14,623 adults recovering from non-cardiac surgical procedures.

Interventions & measurements

Using a wireless, noninvasive monitor, we recorded postoperative blood pressure and heart rate at 15-s
intervals and encouraged nursing intervention as clinically indicated.

Main results
7% of our cohort of 14,623 patients spent >15 sustained minutes with a MAP <65 mmHg, and 23% had MAP
<75 mmHg for 15 sustained minutes. Hypertension was more common, with 67% of patients spending at
least 60 sustained minutes with MAP >110 mmHg. Systolic pressures <90 mmHg were present for 15
sustained minutes in about a fifth of all patients, and 40% of patients had pressures >160 mmHg sustained
for 30 min. 40% of patients were tachycardic with heart rates >100 beats/min for at least continuous 15 min
and 15% of patients were bradycardic at a threshold of <50 beats/min for 5 sustained minutes. Conventional
vital sign assessments at 4-h intervals would have missed 54% of mean pressure episodes <65 mmHg
sustained >15 min, 20% of episodes of mean pressures >130 mmHg sustained >30 min, 36% of episodes of
heart rate > 120 beats/min sustained <10 min, and 68% of episodes of heart rate sustained <40 beats per
minute for >3 min.

Conclusions
Substantial hemodynamic disturbances persisted despite implementing continuous portable ward
monitoring coupled with nursing alarms and interventions. A significant proportion of these changes would
have gone undetected using traditional intermittent monitoring. Better understanding of effective responses
to alarms and appropriate interventions on hospital wards remains necessary.

Introduction

Intraoperative mortality is now so rare that it is now hard to quantify [1,2]. In contrast, 30-day mortality
after noncardiac surgery for inpatients over 45 years ranges between 0.5 and 4% [[3], [4], [5], [6], [7]]. About
70% of postoperative deaths occur during the initial hospitalization, that is under direct medical care in our
highest-level healthcare facilities. About half of all adverse events in hospitalized patients occur in hospital
wards rather than in higher-acuity units [[8], [9], [10]]. Major bleeding, myocardial injury, and sepsis,
together account for about half of all in-hospital deaths [11]. Intraoperative and postoperative hypotension
are associated with myocardial and renal injury, and with death [12,[13], [14], [15], [16]]. Postoperative
hypertension and tachycardia are also associated with myocardial injury, stroke, and bleeding risk [8,17,18].

Most acute cardiorespiratory events do not occur suddenly, instead are preceded by hours of progressively
worsening vital signs [19]. The difficulty is that many disturbances are missed when vital signs are only
assessed at standard 4–6-h intervals as is typical. Consequently, postoperative blood pressure and heart rate
:
 perturbations are often sustained for long periods without recognition [20]. However, the extent to which
postoperative patients experience vital sign abnormalities, and the extent to which they are missed with
conventional monitoring remains unclear because previous studies have been small, restricted to selected
populations, and sometimes blinded clinicians to supplemental monitoring [20,[21], [22], [23]].

The current study evaluated continuous ward vital signs to determine the incidence and severity of
abnormalities in a broad general surgical population. Specifically, we describe the incidence and severity of
blood pressure (defined as changes in mean arterial pressure and systolic pressure) and heart rate
abnormalities based on pre-defined thresholds in patients recovering from noncardiac surgery in routine
hospital wards. We also estimated the proportion of patients who experienced potentially meaningful
hemodynamic disturbances that would not have been detected by intermittent vital signs assessments at 4-
hour intervals.

Section snippets

Methods

With institutional board review approval (IRB 00065685) and waived consent, we obtained data from adults
who had noncardiac surgery with general anesthesia and were subsequently admitted to conventional
surgical wards between January 1, 2016, to October 31, 2019 at the Atrium Health Wake Forest Baptist
Medical Center. (Fig. 1) Patients in our surgical wards are continuously monitored with untethered ViSi
units (Sotera Wireless, Inc. San Diego, California) that continuously record saturation,…

Results

Among 28,108 continuously monitored noncardiac surgical patients, 13,485 were excluded because they
had total monitoring time < 12 h and had gaps in monitoring >4 h, and/or had >30% of missing monitoring
time. 14,623 patients did have qualifying records based on monitoring time of at least 12 h and with gaps in
monitoring <4 h, and/or <30% of monitoring time. (Fig. 1) Patient characteristics and types of surgeries for
the included and excluded sample are shown in Table 1. Excluded patients had…

Discussion

We evaluated nearly 15,000 largely unselected adults recovering from noncardiac surgery on general
surgical wards. Our large population, about 30 times the size of previous continuous ward monitoring
studies, presumably resulted in precise estimates of ward hemodynamic disturbances. Blood pressure and
heart rate abnormalities were common and often persistent. For example, about 23% of patients had MAP
<75 mmHg for at least 15 sustained minutes, 67% of patients spent at least 60 min with a MAP…
:
 Author contributions

Ashish K. Khanna: This author helped conceptualize the idea, acquire, and interpret data, and draft and
revise the manuscript.

Nathaniel Sean O'Connell: This author helped with the statistical analysis, and draft and revise the
manuscript.

Sanchit Ahuja: This author helped draft and revise the manuscript.

Amit K. Saha: This author helped acquire and interpret data and revise the manuscript.

Lynnette Harris: This author helped acquire the data and revise the manuscript.

Bruce D. Cusson: This author…

Disclosures

Supported by departmental funds.…

Funding

This work was supported by departmental resources. Dr. Segal is supported by grants from the Anesthesia
Patient Safety Foundation, the Wake Forest Clinical and Translational Science Institute (UL1TR001420), and
the National Institutes of Health (NIBIB; 1 R21 EB029493-01A1). Dr.Khanna, is supported by a grant from
the Wake Forest Clinical and Translational Science Institute.…

Declaration of Competing Interest

Dr. Khanna is a consultant for Edwards Lifesciences, Caretaker Medical, Retia Medical, Philips Research
North America, GE Healthcare, Baxter, and Medtronic, and is supported by an NIH/NCATS KL2 award for a
pilot trial of continuous hemodynamic and oxygenation monitoring on hospital wards. The Department of
Anesthesiology at Wake Forest School of Medicine is funded by Edwards Lifesciences, Masimo, and
Medtronic. Dr. Sessler is a consultant for Edwards Lifesciences, Sensifree and Perceptive…

Recommended articles

References (32)

L.W. Andersen et al.

:
 Acute respiratory compromise on inpatient wards in the United States: incidence, outcomes,
and factors associated with in-hospital mortality
Resuscitation. (2016)

R.M. Pearse et al.

Mortality after surgery in Europe: a 7 day cohort study
Lancet. (2012)

P.E. Marik et al.

Perioperative hypertension: a review of current and emerging therapeutic agents
J Clin Anesth (2009)

A.E. Sigmund et al.

Postoperative tachycardia: clinically meaningful or benign consequence of orthopedic surgery?
Mayo Clin Proc (2017)

L.W. Andersen et al.

The prevalence and significance of abnormal vital signs prior to in-hospital cardiac arrest
Resuscitation. (2016)

M. Weenk et al.
Wireless and continuous monitoring of vital signs in patients at the general ward
Resuscitation. (2019)

A.K. Khanna et al.

Postoperative ward monitoring - why and what now?
Best Pract Res Clin Anaesthesiol (2019)

Y. Eddahchouri et al.
Effect of continuous wireless vital sign monitoring on unplanned ICU admissions and rapid
response team calls: a before-and-after study
Br J Anaesth (2022)

A. Lienhart et al.
Survey of anesthesia-related mortality in France
Anesthesiology. (2006)

G. Li et al.
Epidemiology of anesthesia-related mortality in the United States, 1999-2005
Anesthesiology. (2009)

View more references

:
 Cited by (0)

View full text

© 2023 Elsevier Inc. All rights reserved.

All content on this site: Copyright © 2023 Elsevier B.V., its licensors, and contributors. All rights are reserved, including those for text and data mining, AI training, and similar
technologies. For all open access content, the Creative Commons licensing terms apply.
: