What are the implications of hypotension (blood pressure 88/60 mmHg) during hernia surgery?

From the Guidelines

A blood pressure of 88/60 during hernia surgery is considered hypotension and requires immediate attention to prevent organ hypoperfusion and potential complications. The anesthesiologist should first assess if this is causing decreased organ perfusion by checking other vital signs, urine output, and patient's clinical status 1. Initial management includes ensuring adequate intravenous access, increasing the rate of fluid administration (crystalloids like normal saline or Ringer's lactate), and temporarily reducing anesthetic depth if appropriate.

Key Considerations

• The goal is to maintain a mean arterial pressure of at least 60 mm Hg in at-risk patients, as recommended by the perioperative quality initiative international consensus statement on perioperative arterial pressure management 1.
• If hypotension persists despite fluid resuscitation, vasopressors such as ephedrine (5-10 mg IV bolus) or phenylephrine (50-100 mcg IV bolus) should be administered.
• For ongoing hypotension, a continuous infusion of norepinephrine (0.01-0.1 mcg/kg/min) may be necessary.
• The surgical team should be informed, and the cause of hypotension should be investigated, including checking for surgical bleeding, pneumoperitoneum effects, or anesthetic-related causes.

Management Strategies

• Continuous intraoperative arterial pressure monitoring can help reduce the severity and duration of hypotension compared to intermittent arterial pressure monitoring 1.
• Postoperative hypotension is often unrecognized and might be more important than intraoperative hypotension because it is often prolonged and untreated, thus requiring careful monitoring and management.
• Future research should focus on identifying patient-specific and organ-specific hypotension harm thresholds and optimal treatment strategies for intraoperative hypotension, including the choice of vasopressors 1.

From the Research

Blood Pressure Management During Surgery

• The blood pressure reading of 88/60 during hernia surgery indicates hypotension, which can be a concern in the perioperative period 2, 3, 4.
• Hypotension is associated with postoperative complications, such as acute kidney injury, myocardial injury, and increased mortality 2, 4.
• The use of vasopressors, such as norepinephrine or phenylephrine, may be required to correct hypotension during surgery 2, 5.
• The choice of vasopressor and the management of blood pressure during surgery should be individualized and based on the patient's underlying pathophysiology 3, 5.

Perioperative Blood Pressure Management

• The management of blood pressure during surgery is crucial to prevent complications and ensure optimal outcomes 6, 3, 4.
• The perioperative period is characterized by hemodynamic instability, which can be exacerbated by factors such as age, comorbidities, and the type of surgery 4.
• Elderly patients may be particularly vulnerable to adverse events associated with perioperative hemodynamic instability 4.
• Precise and intentional management of hemodynamic parameters, medication regimens, and blood pressure monitoring may reduce adverse events in patients undergoing surgery 4.

Treatment of Hypotension During Surgery

• Norepinephrine and phenylephrine are commonly used vasopressors to treat hypotension during surgery 2, 5.
• The choice between norepinephrine and phenylephrine may depend on the patient's individual characteristics and the underlying cause of hypotension 5.
• Bolus doses of norepinephrine may be effective in treating hypotension during cesarean delivery under spinal anesthesia in patients with preeclampsia 5.
• The use of vasopressors should be guided by careful monitoring of blood pressure and other hemodynamic parameters to avoid excessive vasoconstriction or hypotension 2, 5.