The edition · Anaesthesiology
A simple MAP alarm at 72 mmHg matched the Hypotension Prediction Index in a blinded trial
Two randomised trials suggest the proprietary index adds little over an earlier blood pressure trigger; international extubation guidelines make 'at-risk' assessment explicit; and propofol versus volatile makes no difference to survival after cancer surgery.
The edition in brief
Five findings for anaesthetists and perioperative teams. A blinded single-centre trial of 143 adults having moderate- or high-risk non-cardiac surgery found a mean arterial pressure alarm at 72 mmHg non-inferior to a Hypotension Prediction Index alarm above 85 for hypotension burden, with no differences in drugs, fluids or outcomes. A separate two-centre open-label trial of 100 patients found HPI-guided care was not superior to treating at MAP 73 mmHg or below. The Project for Universal Management of Airways published international extubation guidelines built on explicit assessment of hypoxaemia, aspiration and airway-stimulation risk, deferral when it lowers risk, and conversion procedures that keep a guide in place. A meta-analysis of 11 randomised trials (7,811 patients) found no difference in overall survival (HR 1.05, 95% CI 0.94-1.17) or recurrence-free survival between propofol-based and volatile anaesthesia for cancer surgery. A post hoc iPROVE analysis of 1,963 patients found antiemetic-dose corticosteroids were not associated with fewer pulmonary complications after weighting (OR 0.86, 0.62-1.18), and a meta-analysis of over a million patients found no consistent association between intraoperative handover and morbidity or mortality.
PUMA extubation guidelines: assess risk explicitly, defer when safer, and convert rather than replace
Declare each extubation 'at risk' or not before it happens, and for at-risk airways defer or keep a guide in place.
HPI-guided care was not superior to treating at MAP 73 mmHg
Before paying for HPI, try treating earlier: a MAP trigger around 73 mmHg was not shown to be worse.
Propofol or volatile: no difference in survival or recurrence after cancer surgery
Pick propofol or volatile anaesthesia for cancer surgery on its other merits; survival is the same either way.
Antiemetic-dose steroids did not reduce pulmonary complications after major surgery
Give antiemetic dexamethasone for nausea, not for the lungs; it did not reduce pulmonary complications after adjustment.
Intraoperative handover was not consistently linked to worse outcomes
Hand over with a structured tool when relief is needed; handovers themselves were not consistently linked to harm.
Set the arterial line alarm before you need it
Set the lower MAP alarm above your treatment threshold at the start of every case with an arterial line.
A MAP alarm at 72 mmHg was non-inferior to the Hypotension Prediction Index
For proactive blood pressure management, a MAP alarm at 72 mmHg does the job of the Hypotension Prediction Index at no extra cost.
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