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Prevention of hypotension after induction of general anesthesia using point-of-care ultrasound to guide fluid management: a randomized controlled trial

Prévention de l’hypotension après l’induction d’une anesthésie générale à l’aide d’une échographie ciblée pour guider la gestion liquidienne : une étude randomisée contrôlée

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Abstract

Purpose

Hypotension after induction of general anesthesia (GAIH) is common and is associated with postoperative complications including increased mortality. Collapsibility of the inferior vena cava (IVC) has good performance in predicting GAIH; however, there is limited evidence whether a preoperative fluid bolus in patients with a collapsible IVC can prevent this drop in blood pressure.

Methods

We conducted a single-centre randomized controlled trial with adult patients scheduled to undergo elective noncardiac surgery under general anesthesia (GA). Patients underwent a preoperative point-of-care ultrasound scan (POCUS) to identify those with a collapsible IVC (IVC collapsibility index ≥ 43%). Individuals with a collapsible IVC were randomized to receive a preoperative 500 mL fluid bolus or routine care (control group). Surgical and anesthesia teams were blinded to the results of the scan and group allocation. Hypotension after induction of GA was defined as the use of vasopressors/inotropes or a decrease in mean arterial pressure < 65 mm Hg or > 25% from baseline within 20 min of induction of GA.

Results

Forty patients (20 in each group) were included. The rate of hypotension after induction of GA was significantly reduced in those receiving preoperative fluids (9/20, 45% vs 17/20, 85%; relative risk, 0.53; 95% confidence interval, 0.32 to 0.89; P = 0.02). The mean (standard deviation) time to complete POCUS was 4 (2) min, and the duration of fluid bolus administration was 14 (5) min. Neither surgical delays nor adverse events occurred as a result of the study intervention.

Conclusion

A preoperative fluid bolus in patients with a collapsible IVC reduced the incidence of GAIH without associated adverse effects.

Study registration

ClinicalTrials.gov (NCT05424510); first submitted 15 June 2022.

Résumé

Objectif

L’hypotension après induction de l’anesthésie générale (AG) est fréquente et est associée à des complications postopératoires, notamment à une augmentation de la mortalité. La collapsibilité de la veine cave inférieure (VCI) a été utilisée avec succès pour prédire la l’hypotension post-induction de l’AG; cependant, il existe peu de données probantes qu’un bolus liquidien préopératoire chez les patient·es présentant une collapsibilité de la VCI puisse prévenir cette baisse de la tension artérielle.

Méthode

Nous avons réalisé une étude randomisée contrôlée monocentrique auprès de patient·es adultes devant bénéficier d’une chirurgie non cardiaque non urgente sous anesthésie générale. Les patient·es ont passé une échographie préopératoire ciblée (POCUS) pour identifier les personnes présentant une collapsibilité de la VCI (indice de collapsibilité de la VCI ≥ 43 %). Les personnes présentant une collapsibilité de la VCI ont été randomisées à recevoir un bolus de liquide préopératoire de 500 mL ou des soins de routine (groupe témoin). Les équipes chirurgicales et d’anesthésie ne connaissaient pas les résultats de l’examen ni l’attribution des groupes. L’hypotension après induction de l’AG a été définie comme l’utilisation de vasopresseurs/inotropes ou une diminution de la tension artérielle moyenne < 65 mm Hg ou > 25 % par rapport aux valeurs de base dans les 20 minutes suivant l’induction de l’AG.

Résultats

Quarante patient·es (20 dans chaque groupe) ont été inclus·es. Le taux d’hypotension après induction de l’AG était significativement réduit chez les personnes recevant des liquides préopératoires (9/20, 45 % vs 17/20, 85 %; risque relatif, 0,53; intervalle de confiance à 95 %, 0,32 à 0,89; P = 0,02). Le temps moyen (écart type) pour compléter l’échographie ciblée était de 4 (2) min, et la durée de l’administration du bolus liquidien était de 14 (5) min. Ni retards chirurgicaux ni effets indésirables ne sont survenus à la suite de l’intervention à l’étude.

Conclusion

Un bolus liquidien préopératoire chez les patient·es présentant une collapsibilité de la VCI a réduit l’incidence d’hypotension après l’induction de l’anesthésie générale sans effets indésirables associés.

Enregistrement de l’étude

ClinicalTrials.gov (NCT05424510); première soumission le 15 juin 2022.

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Author contributions

Elad Dana contributed to the conceptualization and design of the manuscript, methodology, acquisition, data curation and interpretation, and drafting the article. Cristian Arzola helped with the study conception and design, validation, writing, reviewing, editing, and administration. James Khan contributed to the study conceptualization and design, methodology, writing, reviewing, and editing.

Disclosures

None.

Funding statement

None.

Editorial responsibility

This submission was handled by Dr. Philip M. Jones, Deputy Editor-in-Chief, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.

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Authors and Affiliations

  1. Department of Anesthesia, Intensive Care and Pain Medicine, Meir Medical Center, Kfar Saba, Israel

    Elad Dana MD

  2. Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

    Elad Dana MD

  3. Mount Sinai Hospital, Toronto, ON, Canada

    Elad Dana MD, Cristian Arzola MD, MSc & James S. Khan MD, MSc

  4. Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada

    Cristian Arzola MD, MSc & James S. Khan MD, MSc

  5. Mount Sinai Hospital, 600 University Avenue, Room 20-400, Toronto, ON, M5G 1X5, Canada

    Elad Dana MD

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  1. Elad Dana MD
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Dana, E., Arzola, C. & Khan, J.S. Prevention of hypotension after induction of general anesthesia using point-of-care ultrasound to guide fluid management: a randomized controlled trial. Can J Anesth/J Can Anesth (2024). https://doi.org/10.1007/s12630-024-02748-8

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