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LETTER TO THE EDITOR

Recommendations for Postinduction Hypotension: Are They Supported by the Evidence?

Departments of Anesthesiology, Mount Sinai School of Medicine, New York, NY, david.reich{at}mssm.edu

In Response:

We appreciate the comments of Drs. Lim and Ellahee (1). As a retrospective investigation, our study was not designed to examine all potential causes of hypotension after anesthetic induction, and it is plausible that preoperative hypovolemia was a contributing factor in our patient cohort. We did, however, examine our data in detail to elucidate associations between anesthetic induction drug doses and incidence of hypotension, and these associations were not present in our dataset. Regarding the suggestion that inadequate stratification of propofol doses accounts for the lack of a dose-dependent relationship in our study, we feel that this is unlikely because there was no evidence at all of a difference between the large-dose and small-dose groups. Rather, the dose-response effect was most likely obscured by the anesthesiologists' clinical judgment in selecting induction drugs and doses based on their assessments of the patients' medical conditions. Consequently, we observed that the oldest and sickest patients received propofol less frequently in our cohort.

Our data demonstrating the strong association of postinduction hypotension with adverse outcomes will elicit criticism from many. We did not study the influence of postinduction hypotension on end-organ perfusion but rather on its association with the ultimate outcomes (morbidity and/or mortality), controlling for other factors. The corresponding association with mortality alone was not reported in the manuscript but was nearly statistically significant (P = 0.066). The majority of our colleagues apparently believe that transient hypotension is inconsequential to outcomes. Although limited by the problems associated with retrospective studies, the results of our study provide preliminary evidence that runs counter to the prevailing wisdom regarding transient severe hypotension during general anesthesia.

Although it may be that the postinduction hypotension was a positive response to an anesthetic "stress test" that is a marker for higher perioperative risk rather than a primary cause of adverse outcomes, this remains to be proven. Whatever the underlying causes, there is growing evidence that hypotension during anesthesia is not a benign condition (2,3). In the absence of data supporting the safety of transient severe hypotension during anesthesia, we assert that our data are sufficiently robust to justify considering alternatives to propofol in elderly sick patients and avoiding it in hypotensive patients.

References

1. Lim M, Ellahee P. Recommendations for postinduction hypotension: are they supported by the evidence? Anesth Analg 2006;102:xxx.
2. Monk TG, Saini V, Weldon C, Sigl JC. Anesthetic management and 1-year mortality after noncardiac surgery. Anesth Analg 2005;100:4–10.[Abstract/Free Full Text]
3. Reich DL, Bodian CA, Krol M, et al. Intraoperative hemodynamic predictors of mortality, stroke and myocardial infarction following coronary artery bypass surgery. Anesth Analg 1999;88:814–22.

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