• Sanchit Ahuja, Edward J Mascha, Dongsheng Yang, Kamal Maheshwari, Barak Cohen, Ashish K Khanna, Kurt Ruetzler, Alparslan Turan, and Daniel I Sessler.
• From the Departments of OUTCOMES RESEARCH, (S.A., E.J.M., D.Y., K.M., B.C., A.K.K., K.R., A.T., D.I.S.) Quantitative Health Sciences (E.J.M., D.Y.) General Anesthesiology (K.M., K.R., A.T.), Cleveland Clinic, Cleveland, Ohio the Department of Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Health System, Detroit, Michigan (S.A.) the Division of Anesthesia, Critical Care, and Pain Management, Tel-Aviv Medical Center, Tel Aviv University, Tel-Aviv, Israel (B.C.) the Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Center for Biomedical Informatics, and the Critical Injury, Illness and Recovery Research Center, Winston-Salem, North Carolina (A.K.K.).
• Anesthesiology. 2020 Feb 1; 132 (2): 291306291-306.

BackgroundArterial pressure is a complex signal that can be characterized by systolic, mean, and diastolic components, along with pulse pressure (difference between systolic and diastolic pressures). The authors separately evaluated the strength of associations among intraoperative pressure components with myocardial and kidney injury after noncardiac surgery.MethodsThe authors included 23,140 noncardiac surgery patients at Cleveland Clinic who had blood pressure recorded at 1-min intervals from radial arterial catheters. The authors used univariable smoothing and multivariable logistic regression to estimate probabilities of each outcome as function of patients' lowest pressure for a cumulative 5 min for each component, comparing discriminative ability using C-statistics. The authors further assessed the association between outcomes and both area and minutes under derived thresholds corresponding to the beginning of increased risk for the average patient.ResultsOut of 23,140 patients analyzed, myocardial injury occurred in 6.1% and acute kidney injury in 8.2%. Based on the lowest patient blood pressure experienced for greater than or equal to 5 min, estimated thresholds below which the odds of myocardial or kidney injury progressively increased (slope P < 0.001) were 90 mmHg for systolic, 65 mmHg for mean, 50 mmHg for diastolic, and 35 mmHg for pulse pressure. Weak discriminative ability was noted between the pressure components, with univariable C-statistics ranging from 0.55 to 0.59. Area under the curve in the highest (deepest) quartile of exposure below the respective thresholds had significantly higher odds of myocardial injury after noncardiac surgery and acute kidney injury compared to no exposure for systolic, mean, and pulse pressure (all P < 0.001), but not diastolic, after adjusting for confounding.ConclusionsSystolic, mean, and pulse pressure hypotension were comparable in their strength of association with myocardial and renal injury. In contrast, the relationship with diastolic pressure was poor. Baseline factors were much more strongly associated with myocardial and renal injury than intraoperative blood pressure, but pressure differs in being modifiable.

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