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Perioperative Hemodynamic Instability: an APSF Patient Safety Imperative

Op-Med is a collection of original articles contributed by Doximity members.

Although the principle of first do no harm is the foundation of how we care for patients, preventable harm is endemic in American health care.  According to Richard Dutton, MD, “Hemodynamic instability occurs with high frequency in the perioperative period, can lead to end-organ hypoperfusion, and is associated with a range of adverse events.”  Yet, there are no specific recommendations to guide clinicians in identifying risks, best monitoring, specific patient thresholds for intervention, and administering effective and timely interventions.

Accordingly, in 2022 the Anesthesia Patient Safety Foundation held a Consensus Conference to address this patient safety issue.  Working with stakeholders to craft consensus recommendations designed to aid clinicians in identifying and addressing hemodynamic instability (HI) is an area where I felt we could make a difference in patient care. The results of the conference will be published soon and were presented at a panel at the recent annual meeting of the American Society of Anesthesiologists (ASA), which brought more than 12,000 anesthesiologists from around the globe together in San Francisco from October 13-17.

Our scientific session featuring an expert panel of contributors—Drs. Michael Scott, Louise Sun, Vilma Joseph, and Richard Dutton—was a late breaking, and popular, addition to the conference schedule. I was pleased to see the standing room only response with high engagement by the attendees. “The session’s popularity speaks to the widespread recognition that hemodynamic instability in the perioperative period is a major patient safety issue and an area that offers real hope for improvement,” according to presenter Michael Scott, MB. 

A complex syndrome involving many physiological parameters resulting in impaired circulation and oxygen delivery to vital organs, HI is commonly characterized by abnormalities of blood pressure, heart rate, cardiac output, stroke volume, and central venous pressure. Blood pressure is the most utilized indicator of HI in the perioperative period, and the current state of clinical practice is primarily focused on diagnosing and treating blood pressure as a surrogate for HI. Accordingly, the emphasis of APSF’s consensus meeting, and our ASA presentation of best practices stemming from the consensus meeting, addressed hypotension with the understanding that blood pressure is simply one component of a multifaceted system. 

Following APSF’s November consensus meeting, a modified Delphi process was employed using discussions, voting, and feedback that resulted in 17 high level recommendations to advance the perioperative care of patients at risk of, or with, HI. In her presentation summarizing the adverse effects of HI, Louise Sun, MD, said, “Sharing these multi-faceted recommendations at ASA’s annual meeting is an effective way to educate clinicians on how they can contribute at a practice and systems level.” And presenter Vilma Joseph, MD, added, “The best practice recommendations we’ve put forth are designed to support change and improve patient safety. We believe these practices can make a positive impact on decreasing the performance gap between anesthesia providers.” Dr. Joseph detailed the subject of using big data to drive quality improvement, and went over a new measure submitted by ePreop and Cleveland Clinic to the Centers for Medicare and Medicaid to incorporate HI avoidance as a quality indicator.

The 17 high-level recommendations fall within seven unique domains: current knowledge, prevention, data driven quality improvements, patient communication, the importance of technology, scientific advancement, and the communication of findings through a national campaign. Recommendations within those domains range from proposing more formalized teaching of new types of monitoring in postgraduate training programs to enable early detection of HI and precise diagnosis of the underlying cause, to triaging after surgery to the appropriate level of care to allow early identification and treatment of HI, to funding multicenter clinical efficacy studies to reduce HI and individualize hemodynamic goals to determine if harm can be mitigated, to name only a few of the recommendations experts agreed on—recommendations we were pleased to share with the anesthesia community at their annual meeting.

Addressing gaps in the literature and providing guidance on best practices, not only for individual clinicians caring for patients in the perioperative space, but also for industry, can lead to more reliable and consistent resources and clinical decision making and, ultimately, decrease patient harm.  Industry can help address the gap in the information gathered across the perioperative continuum.  Advances in wearable sensors and non-invasive monitors which provide more comprehensive data that allow for more precise decisions and treatments directed at the underlying cause of HI should impact best outcomes.

The popularity of our session confirms clinicians are open to guidance that will help them close the gap between where we are today and what we can achieve. Patients have a right to healthcare that is safe, reliable and of the highest quality. I’m excited to see where these steps will take us. Together, we can take one more step toward fulfilling our vision that “no one shall be harmed by anesthesia care.”

Dr. Cole has no conflicts of interest to report.

Image by Alphavector / Shutterstock

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