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Arterial Catheters for Early Detection and Treatment of Hypotension During Major Noncardiac Surgery

A Randomized Trial

Naylor, Amanda J. MA*; Sessler, Daniel I. MD*; Maheshwari, Kamal MD, MPH*,†; Khanna, Ashish K. MD, FCCP, FCCM*,†; Yang, Dongsheng MS*,‡; Mascha, Edward J. PhD*,‡; Suleiman, Iman MD*; Reville, Eric M. BS*; Cote, Devan MD*; Hutcherson, Matthew T. BS*; Nguyen, Bianka M. BS*; Elsharkawy, Hesham MD, MBA, MSc*,†; Kurz, Andrea MD*,†

doi: 10.1213/ANE.0000000000004370
Patient Safety: PDF Only

BACKGROUND: Continuous blood pressure monitoring may facilitate early detection and prompt treatment of hypotension. We tested the hypothesis that area under the curve (AUC) mean arterial pressure (MAP) <65 mm Hg is reduced by continuous invasive arterial pressure monitoring.

METHODS: Adults having noncardiac surgery were randomly assigned to continuous invasive arterial pressure or intermittent oscillometric blood pressure monitoring. Arterial catheter pressures were recorded at 1-minute intervals; oscillometric pressures were typically recorded at 5-minute intervals. We estimated the arterial catheter effect on AUC-MAP <65 mm Hg using a multivariable proportional odds model adjusting for imbalanced baseline variables and duration of surgery. Pressures <65 mm Hg were categorized as 0, 1–17, 18–91, and >91 mm Hg × minutes of AUC-MAP <65 mm Hg (ie, no hypotension and 3 equally sized groups of increasing hypotension).

RESULTS: One hundred fifty-two patients were randomly assigned to arterial catheter use and 154 to oscillometric monitoring. For various clinical reasons, 143 patients received an arterial catheter, while 163 were monitored oscillometrically. There were a median [Q1, Q3] of 246 [187, 308] pressure measurements in patients with arterial catheters versus 55 (46, 75) measurements in patients monitored oscillometrically. In the primary intent-to-treat analysis, catheter-based monitoring increased detection of AUC-MAP <65 mm Hg, with an estimated proportional odds ratio (ie, odds of being in a worse hypotension category) of 1.78 (95% confidence interval [CI], 1.18–2.70; P = .006). The result was robust over an as-treated analysis and for sensitivity analyses with thresholds of 60 and 70 mm Hg.

CONCLUSIONS: Intraoperative blood pressure monitoring with arterial catheters detected nearly twice as much hypotension as oscillometric measurements.

From the Departments of *Outcomes Research

General Anesthesiology

Quantitative Health Sciences, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.

A. K. Khanna is currently affiliated with the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

Accepted for publication July 5, 2019.

Funding: This study was supported by the Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.

Conflicts of Interest: See Disclosures at the end of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Clinical Trial Number: NCT02453815.

Reprints will not be available from the authors.

Address correspondence to Daniel I. Sessler, MD, Department of Outcomes Research, Anesthesiology Institute, Cleveland, Clinic, 9500 Euclid Ave, P-77, Cleveland, OH 44195. Address e-mail to

© 2019 International Anesthesia Research Society
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