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Multicenter Study
. 2022 Sep:80:110846.
doi: 10.1016/j.jclinane.2022.110846. Epub 2022 Apr 27.

Association of propofol induction dose and severe pre-incision hypotension among surgical patients over age 65

Robert B Schonberger  1 , Feng Dai  2 , George Michel  3 , Michelle T Vaughn  4 , Matthew M Burg  5 , Michael Mathis  4 , Sachin Kheterpal  4 , Shamsuddin Akhtar  3 , Nirav Shah  4 , Amit Bardia  3
Affiliations
Multicenter Study

Association of propofol induction dose and severe pre-incision hypotension among surgical patients over age 65

Robert B Schonberger et al. J Clin Anesth. 2022 Sep.

Abstract

Study objective: We aimed to study the association between propofol induction dose (mg/kg) and pre-incision severe hypotension (Mean Arterial Pressure (MAP) ≤ 55 mmHg) among patients ≥65 years of age.

Design: Retrospective Observational.

Setting: 40 centers participating in the Multicenter Perioperative Outcomes Group consortium.

Patients: Patients ≥65 years of age undergoing non-cardiac, non-vascular surgery who received propofol for general anesthetic induction prior to endotracheal intubation between January 2014 and December 2018.

Interventions: None.

Measurements: The primary exposure was total propofol induction dose in mg/kg, and the primary outcome was occurrence of severe hypotension (MAP≤55 mmHg) prior to surgical incision, stratified by non-invasive vs. invasive blood pressure monitoring type.

Main results: Among 320,585 total patients, 22.6% experienced the outcome of pre-incision severe hypotension (MAP≤55 mmHg). When stratified by blood pressure monitoring type, 20.7% with non-invasive blood pressure measurements, and 35.0% with invasive blood pressure measurements had the outcome. After controlling for a variety of patient and procedural factors, there was a significant independent association between propofol induction dose and pre-incision hypotension (Non-invasive blood pressure cohort odds ratio (OR) 1.10; 95% confidence interval (CI) 1.07 to 1.13; p < 0.001; and Invasive blood pressure cohort OR 1.15; 95%CI 1.10 to 1.21; adjusted p < 0.001). The association was robust to alternative definitions of the outcome, including less severe hypotension (MAP≤65 mmHg) and blood pressure drop from baseline as a continuous measure. Although no threshold safe induction dose was identified at which hypotension was avoided, an analysis of propofol dose greater or less than 1.5 mg/kg (i.e. the maximum FDA-defined typical induction dose) demonstrated that doses in excess of the FDAs threshold were positively associated with odds of severe hypotension (Non-invasive cohort: OR 1.05; 95% CI 1.02 to 1.08; p < 0.001; Invasive cohort: OR 1.11; 95%CI 1.05 to 1.17; adjusted p < 0.001).

Conclusions: In a multicenter cohort of geriatric surgical patients receiving propofol for general anesthetic induction and endotracheal intubation, severe pre-incision hypotension (MAP ≤55 mmHg) that has previously been associated with postoperative morbidity was common. The dose of propofol used was significantly associated with increased odds of this outcome after controlling for a number of clinically relevant factors. Future studies that are designed to test different approaches to anesthesia induction for reducing severe post induction pre-incision hypotension are warranted.

Keywords: Geriatrics; Hypotension; Induction; Propofol.

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Conflict of interest statement

Conflicts of interest

Dr. Schonberger reports owning stock in Johnson & Johnson, unrelated to the present work.

Dr. Schonberger and Dr. Bardia report that their institution receives research support from Merck, Inc. for a study with which they are associated and that is unrelated to the present work.

Dr. Mathis reports receiving support from the US National Institutes of Health – National Heart, Lung, and Blood Institute (grant number K01HL141701), for research that is unrelated to the present work.

Dr. Shah reports receiving support from Blue Cross Blue Shield Michigan, Edwards Lifesciences, Merck Inc., Apple Inc., and US National Institutes of Health R01LM013894.

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests.

Figures

Fig. 1.
Fig. 1.
Consort diagram showing derivation of final cohort.
Fig. 2.
Fig. 2.
unadjusted, univariate relationship between propofol dose and lowest MAP within both the non-invasive and invasive cohorts.
Fig. 3.
Fig. 3.
Quantile Regression Results showing the association of propofol dose as proportion of FDA maximum (y-axis) with pre-incision drop in blood pressure stratified across three quantiles of blood pressure drop (x-axis). The dotted horizontal line labeled “OLS” represents the Beta co-efficient calculated based on ordinary least squares regression across the entire cohort. The three circle and whiskers show the Beta coefficient (95%CI) plotted for each of three quantiles.
Fig. 4.
Fig. 4.
Forest plot of primary association stratified by surgery type, inclusive of surgeries with sufficient N for model convergence.
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