Guarracino and Bertini Journal of Anesthesia, Analgesia and Critical Care (2022) 2:17

[Link]
Journal of Anesthesia,
Analgesia and Critical Care

REVIEW Open Access

Perioperative hypotension: causes and

remedies
Fabio Guarracino* and Pietro Bertini

Abstract
Background: Arterial hypotension is common in patients during surgery and those admitted to the intensive care
unit (ICU) postoperatively. Perioperative arterial hypotension reportedly significantly affects surgical patients’
outcomes. Blood pressure level is the most crucial factor that influences organ perfusion. Hypoperfusion and organ
dysfunction are correlated based on their severity associated with hypotension. As several factors can cause
intraoperative hypotension, anesthetists must promptly identify the etiology for appropriate treatment and revert
the patient’s hemodynamic profile.
Objectives: This review discusses the concept of perioperative hypotension, identifies its effects in clinical
situations, and provides remedies and techniques to predict and avoid its significant consequences.
Conclusions: The primary determinant of organ perfusion is blood pressure. On the other hand, profound
hypotension is common in surgical patients and is connected to hypoperfusion and organ failure. Currently,
hypotension is addressed once low blood pressure levels are recorded. Early detection of oncoming hypotension or
its clinical prediction is of paramount importance in allowing the clinician to treat hypotension and reduce the
incidence and length of hypotensive episodes promptly and aggressively.
Keywords: Anesthesia, Surgery, Perioperative, Arterial pressure, Hypotension, Treatment

Background hypotension-induced hypoperfusion, blood pressure is al-

When examining organ-specific outflow pressure, mean most entirely responsible for perfusion of other organ sys-
arterial pressure (MAP) is the fundamental predictor of tems, particularly splanchnic organs, such as the stomach,
end-organ perfusion. Healthy people’s blood pressure liver, and pancreas, which have a low blood flow autoregu-
changes greatly during the day, although it may be kept lation capacity [15]. Intermittent or continuous blood pres-
steady within certain parameters. Patients who are sure monitoring using invasive or non-invasive
undergoing surgery, who are critically ill, and who have measurement methods is the standard of care in periopera-
tissue hypoperfusion and organ damage are more likely tive and critical care medicine to preserve patient safety
to experience profound hypotension [1, 2]. and improve perfusion pressure. To reduce the overall de-
Intraoperative hypotension has been linked to a higher gree of severe hypotension, imminent hypotension is in-
risk of postoperative mortality [3, 4], myocardial injury after creasingly being recognized and treated early.
non-cardiac surgery (MINS) [5], myocardial infarction [6], In the present review, we discuss the concept of
cardiogenic shock [7], acute renal failure [8], delirium [2], hypotension, identify its effects in most clinical situa-
and stroke [9] in patients undergoing non-cardiac surgery tions, and provide remedies and techniques to predict
under general anesthesia [10–14]. Although blood flow and avoid its significant consequences.
autoregulation protects the brain, heart, and kidneys from
The physiology of blood pressure
* Correspondence: [Link]@[Link]
Department of Anaesthesia and Critical Care Medicine, Azienda Ospedaliero Systolic arterial pressure (SAP) is the maximum pressure
Universitaria Pisana, Via Paradisa 2, 56123 Pisa, Italy measured in the arterial vasculature and arises from the
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Guarracino and Bertini Journal of Anesthesia, Analgesia and Critical Care (2022) 2:17 Page 2 of 7

contraction of the left ventricle. It depends on stroke Myocardial blood flow is autoregulated within certain
volume (SV), heart rate (HR), systemic vascular resist- limits of coronary perfusion pressure (CoPP), although
ance (SVR), the distensibility of the aorta, and the large myocardial perfusion is not maintained at a constant
arteries near the heart. The lowest pressure recorded in value; instead, it is adjusted to the current myocardial
the arterial tree is called diastolic arterial pressure O2 demand [20].
(DAP). DAP is influenced by SVR, compliance of the In daily routine, blood pressure is often used as a sur-
vasculature (“windkessel model” of the vasculature), the rogate for blood flow. Nevertheless, perioperative
duration of diastole, and the duration of the cardiac changes in blood pressure are unreliable substitutes for
cycle [16]. simultaneous changes in cardiac output (CO), as demon-
Mean arterial pressure (MAP) is the average arterial strated in 402 anesthetized patients undergoing different
pressure throughout one cardiac cycle. surgical procedures [21]. In each case, the blood pres-
Cardiac output (CO) and SVR are the determinants of sure parameters SAP, DAP, MAP, PP, and CO were
MAP. The MAP value is under the control of the renin- measured before and after the administration of a fluid
angiotensin-aldosterone system and the autonomic ner- bolus of 500 ml colloidal solution for 10–20 min. As the
vous system, whose complex physiology is well beyond CO increased by > 15%, a positive response to the vol-
the scope of this review. However, it is important to ume expansion was evaluated. Although blood pressure
emphasize that anesthesiologists should be aware of the parameters increased more in responders than in non-
implications of changes in both peripheral resistance responders, relative changes in pressure values showed
and circulating volume on MAP via regulation of the ca- low sensitivity and specificity. Thus, the relative pressure
rotid sinus and aortic arch baroceptors and the renin- changes failed to predict changes in CO in more than
angiotensin-aldosterone cascade. In fact, most of the half of the patients. Similar results were found in pa-
anesthesia drugs and techniques routinely used and tients with septic shock [19].
many factors related to the surgical procedure occurring
perioperatively, of which blood loss is a caricatural ex- Defining arterial hypotension
ample, can alter either the vascular tone or the plasma Whereas blood pressure management is a pillar of
volume. anesthetic care perioperatively, the definition of
The goal of physiological regulation of blood pressure hypotension remains challenging. Although there are
and flow with the oxygen content of arterial blood is to numerous references that support the need for peri-
facilitate adequate tissue oxygenation. operative blood pressure regulation [22–25], at present,
Systemic perfusion pressure (PP) regulates the blood there are no universally accepted perioperative blood
flow of the whole organism [17]. PP is calculated as pressure thresholds to define hypotension [26].
MAP–central venous pressure (CVP). When analyzing Weinber and colleagues published a comprehensive
the single end-organ perfusion instead, it is less correct study of intraoperative hypotension criteria in adults
to refer to CVP as downstream pressure; hence, the clos- who underwent non-cardiac surgery [27]. Hypotension
ing pressure (CP) of the respective area or tissue should was mostly defined by changes in SAP, MAP, or a com-
be taken into account. bination of the two. The investigators tried to determine
The best example of such a concept is the perfusion of whether studies reported an absolute threshold value for
the brain, which, under physiological conditions, de- hypotension, hypotension as a change from a pressure
pends on the cerebral perfusion pressure (CPP), which is baseline value, a baseline blood pressure for reporting
calculated as MAP–intracranial pressure (ICP), where relative threshold values, and a methodology for deter-
ICP is assimilated CP or downstream pressure. An ana- mining the severity of hypotension.
log case occurs under pathological conditions in other The majority of studies reported a MAP < 60 mmHg
body areas, such as in the muscle compartment or the and/or a SAP < 90 mmHg as absolute numerical thresh-
abdomen, when compartment syndrome occurs. olds for hypotension. A total of 126 studies used a rela-
In some organs, such as the brain, spinal cord, kidneys, tive threshold to represent hypotension, most of which
and heart, blood flow is kept constant within MAP limits showed a percentage decrease (10 to 60%) from baseline
of autoregulation blood flow [18]. On the other hand, for either MAP or SAP (Fig. 1). Other hypotension defi-
autoregulation occurs within a defined range of blood nitions refer to a blood pressure requiring therapeutic
pressure. For example, for cerebral perfusion, MAP interventions, such as volume expansion or vasoactive
values in healthy individuals are 60–160 mmHg, within medications.
which blood flow is kept constant.
Kidneys blood flow is maximal within 70–130 mmHg Causes of perioperative hypotension
of MAP values [19]; therefore, glomerular filtration is The causes of perioperative hypotension can be related
optimal in this pressure range. to the patient, anesthesia, or surgery.
Guarracino and Bertini Journal of Anesthesia, Analgesia and Critical Care (2022) 2:17 Page 3 of 7

Fig. 1 Definitions of perioperative hypotension

Preoperative risk factors associated with hypotension According to the 2014 American College of Cardi-
are advanced age, low blood pressure before anesthesia ology/American Heart Association guidelines [31],
induction, hypovolemia [28–30], higher American Soci- continuing therapy before surgery is appropriate.
ety of Anesthesiologists (ASA) status, chronic treatment Additionally, if therapy is stopped, it should be re-
with antihypertensive drugs, and planned high-risk sur- sumed as soon as clinically possible, whereas the
gery [31–34](Fig. 2). Canadian Cardiovascular Society’s most recent guide-
Whereas beta blockers and calcium antagonists have dir- lines [32] recommend skipping therapy 24 h before
ect recommendations relating to the perioperative regime, surgery (strong recommendation, low quality of
because they have been associated with both injury and evidence).
benefit, there is controversy about whether angiotensin- The European Society of Cardiology/European Society
converting enzyme inhibitors/angiotensin II receptor of Anaesthesiology approach [33], on the other hand,
blockers (ACE-Is/ARBs) should be maintained in the peri- bases its recommendations on the indication for ACE-I/
operative period. Intraoperative hypotension caused by ARB treatment, including 24-h termination if the medi-
ACE-I and ARB medication that persists throughout the cation is indicated for hypertension and continuation if
perioperative period [35] has been linked to severe peri- it is prescribed for heart failure or left ventricular sys-
operative morbidity [36] and has prompted some clinicians tolic dysfunction [33].
to discontinue treatment. The current perioperative guide- In addition, if these latter patients are not on ACE-I/
lines are divided in their recommendations for continuing ARB medication prior to surgery, recommendations ad-
or stopping ACEIs/ARBs during surgery. vise starting it one week before surgery [34].

Fig. 2 Predicting factors of perioperative hypotension

Guarracino and Bertini Journal of Anesthesia, Analgesia and Critical Care (2022) 2:17 Page 4 of 7

Intraoperative hypotension has a complex origin, and Wijnberge et al. [54] presented the Hypotension Pre-
it is most prevalent in patients undergoing surgery under diction (HYPE) trial, in which 68 patients undergoing
general and neuraxial anesthesia [9, 37–39]. The main elective non-cardiac surgery were randomly assigned to
factors contributing to hypotension intraoperatively are either an AI early warning system for intraoperative
excessive depth of anesthesia [40, 41], blood loss [42], treatment (intervention group) or conventional care
and vasodilation. (control group). The goal of their study was to investi-
Hypotension is also common in postoperative care in gate whether the intervention decreased the depth and
the ICU. Several causes can be listed, including myocardial duration of intraoperative hypotension. As evidenced by
ischemia [43], hypovolemia, arrhythmias [44, 45], vasople- the primary result of a decreased time-weighted average
gia, dynamic left ventricle outflow tract (LVOT) obstruc- of intraoperative hypotension, the trial showed that the
tion [46, 47], pneumothorax [48], tamponade [49], intervention successfully reduced patients' exposure to
pulmonary embolism [50], sepsis [51], and bleeding [52]. hypotension.
Although physicians may use arterial pulse pressure
Remedies to treat hypotension waveforms to make reasonable judgments about the risk
Although patient-related causes of hypotension are not of forthcoming episodes of hypotension, there is a good
modifiable, there is room for the anesthetic team to inter- chance that an AI system might make more accurate
vene on anesthesia- and surgery-related causes to prevent predictions [55].
or promptly reverse hypotension (Fig. 3, Table 1).
Treatment of any specific cause of hypotension should
be pursued in a timely and appropriate manner. To do so, Conclusions
identifying and correcting the underlying pathophysiologic Blood pressure is a critical factor in determining organ
mechanisms, such as decreased cardiac preload, altered perfusion. Perioperative hypotension is common and is
cardiac afterload, or reduced myocardial contractility, is linked to hypoperfusion and organ failure. Therefore,
pivotal for causal treatment of hypotension [12]. optimal management of arterial blood pressure is re-
Predicting hypotensive episodes may lead to preventive quired in the perioperative setting to avoid
treatment and assist in avoiding hypotension. Recently, a complications.
new technology based on AI has shown promise in pre- Currently, hypotension is addressed once low blood
dicting hypotension. Hatib et al. developed a pressure levels are recorded. Preoperative risk stratifica-
“hypotension prediction index” (HPI) to predict real- tion for perioperative hypotension, intraoperative, and
time hypotension [53]. They used machine learning to postoperative early detection of oncoming hypotension
analyze many hemodynamic variables collected from the or its clinical prediction allow the clinician to treat
arterial blood pressure waveform in real time. After the hypotension and reduce the incidence and length of
verified the method, the model predicted arterial hypotensive episodes. Machine learning-based algo-
hypotension 15 min ahead of time, with a sensitivity of rithms have recently been applied to predict
88% and a specificity of 87%. hypotension. However, clinical trials are needed to

Fig. 3 Causes and remedies of perioperative hypotension

Guarracino and Bertini Journal of Anesthesia, Analgesia and Critical Care (2022) 2:17 Page 5 of 7

Table 1 Specific causes and remedies for perioperative hypotension

Causes Remedy
Preoperative
Hypovolemia Replace volume depletion with fluids according to the current guidelines or local protocol, minimize
starvation if possible [28–30].
ACE-Is/ARBs Suspend medications in the perioperative period [31–34].
Intraoperative
Excessive depth of anesthesia Minimize excessive anesthesia intensity by monitoring the depth of the anesthetic plane [40, 41].
Neuraxial blockade Administer intravenous fluids, ephedrine, phenylephrine, ondansetron, leg compression [39].
Blood loss Replace volume depletion with fluids and blood products according to the current guidelines or local
protocol [42].
Myocardial ischemia Hemodynamic and biohumoral markers assessment [31], intraoperative TEE to detect and confirm
alteration in myocardial contractility [43].
Postoperative
Myocardial ischemia Appropriate hemodynamic and biohumoral markers assessment [31].
Hypovolemia Replace volume depletion with fluids and blood products according to the current guidelines or
local protocol
Arrhythmias Monitor ECG and correct arrythmia using ACLS, ALS or analogue protocols [31, 44, 45].
Dynamic LVOT Obstruction Administer fluids, give medications to lower heart rate (e.g beta blockers), stop beta agonists [46, 47].
Pneumothorax Treatment as needed (ranges from tight follow-up to chest tube insertion to thoracic surgery) [48].
Tamponade Drainage of the pericardial space [49].
Pulmonary embolism Treatment according to the guidelines or local protocols [50].
Sepsis Treatment according to the Surviving Sepsis Guidelines [51].
Bleeding Replace volume depletion, monitor coagulation and correct shortage of coagulation determinants if
possible, according to the current protocols [42, 52]
ACE-Is/ARBs angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, ECG electrocardiogram, ACLS advanced cardiac life support, ALS advanced
life support

confirm the ability of new technologies to effectively pre- Availability of data and materials
dict hypotension cases. Not applicable

Based on current knowledge, anesthesiologists should Declarations

carefully screen patients at risk for hypotension at the
time of the preoperative evaluation, pay a high level of Ethics approval and consent to participate
Not applicable
attention to the perioperative clinical management to
avoid hypotensive episodes, and treat the disease aggres- Consent for publication
sively in a timely fashion. Not applicable

Abbreviations Competing interests

ICU: Intensive care unit; MAP: Mean arterial pressure; SAP: Systolic arterial FG received honorarium from Edwards in 2019. PB has no competing
pressure; DAP: Diastolic arterial pressure; SVR: Systemic vascular resistances; interests.
CVP: Central venous pressure; CPP: Cerebral perfusion pressure;
ICP: Intracranial pressure; CO: Cardiac output; PP: Perfusion pressure; Received: 17 January 2022 Accepted: 4 April 2022
ASA: American Society of Anesthesiologists status; AI: Artificial intelligence;
HPI: Hypotension prediction index
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