• Mark D Willingham, Elliott Karren, Amy M Shanks, Michael F O'Connor, Eric Jacobsohn, Sachin Kheterpal, and Michael S Avidan.
• From the Department of Anesthesiology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri (M.D.W., M.S.A.); Department of Anesthesiology, University of Utah Medical School, Salt Lake City, Utah (E.K.); Center for Perioperative Outcomes Research, and Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan (A.M.S., S.K.); Department of Anesthesiology, University of Chicago, Chicago, Illinois (M.F.O.); and Department of Anesthesiology, University of Manitoba, Winnipeg, Manitoba, Canada (E.J.).
• Anesthesiology. 2015 Oct 1; 123 (4): 775785775-85.

BackgroundAn intraoperative concurrence of mean arterial pressure less than 75 mmHg, minimum alveolar concentration less than 0.8, and bispectral index less than 45 has been termed a "triple low" state. An association between triple low and postoperative mortality has been reported but was not replicated in a subsequent study. The authors pooled existing data from clinical trials to further evaluate the purported association in an observational study.MethodsThis retrospective observational study included 13,198 patients from three clinical trials: B-Unaware, BAG-RECALL, and Michigan Awareness Control Study. Patients with greater than 15 not necessarily consecutive minutes of triple low were propensity matched to controls with similar characteristics and comorbidities. A multivariable Cox proportional hazards model was used to evaluate the association between triple low duration and postoperative mortality.ResultsThirty-day mortality was 0.8% overall, 1.9% in the triple low cohort, and 0.4% in the nontriple low cohort (odds ratio, 5.16; 95% CI, 4.21 to 6.34). After matching and adjusting for comorbidities, cumulative duration of triple low was significantly associated with an increased risk of mortality at 30 days (hazard ratio, 1.09; 95% CI, 1.07 to 1.11, per 15 min) and 90 days (hazard ratio, 1.09; 95% CI, 1.08 to 1.11, per 15 min).ConclusionThere is a weak independent association between the triple low state and postoperative mortality, and the propensity-matched analysis does not suggest that this is an epiphenomenon.

This article appears in the collection: Postoperative mortality and intraoperative anesthetic depth.

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