IOH is a risk for all surgical patients
Despite overwhelming evidence associating intraoperative hypotension with poor outcomes, its prevalence remains high across surgical patient populations.
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Intraoperative Hypotension
Evidence suggests that intraoperative hypotension (IOH) is associated with an increased risk of adverse postoperative outcomes.¹⁻⁶
- The Burden of IOH
- Risks of IOH
- IOH Can Be Prevented
IOH is a common perioperative complication associated with adverse patient outcomes.¹⁻⁶
Lower intraoperative blood pressure has been associated with increased risk of adverse outcomes.¹⁻⁶
Intraoperative hypotension (IOH) is a frequent side effect of general anaesthesia and is associated with increased risk of unfavourable outcomes for the patient.2-3 IOH may occur in patients experiencing haemodynamic instability and has been associated with an increased risk of postoperative complications.²⁻⁶
Though IOH is common in non-cardiac surgical patients, published studies have reported an association between IOH and myocardial injury after non-cardiac surgery (MINS), acute kidney injury (AKI), and mortality.²⁻⁶
IOH is common and the consequences may be severe.
In a retrospective observational study, 88% of non-cardiac surgery patients experienced intraoperative hypotension (defined as MAP <65 mmHg) for at least one minute.⁷
In a retrospective observational study conducted in community anaesthesia practices, 29% of patients experienced IOH (defined as MAP <65 mmHg) for at least 15 minutes.⁸
*Hypotension defined as MAP <65 mmHg for at least 1 min.
**In an observational study of 127,095 patients undergoing non-emergency, non-cardiac surgery in community anesthesia practices where hypotension is defined as MAP <65mmHg.
Even low-risk surgical patients may face serious consequences.
- Gregory A, Stapelfeldt WH, Khanna AK, et al. Intraoperative hypotension is associated with adverse clinical outcomes after noncardiac surgery. Anesth Analg. 2021;132(6):1654-1665.
- Wijnberge M, et al. Association of intraoperative hypotension with postoperative morbidity and mortality: systematic review and meta-analysis. BJS Open. 2021;5(1):zraa018.
- Wesselink EM, Kappen TH, Torn HM, et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth. 2018;121(4):706-721.
- Scott MJ; APSF HIWG. Perioperative patients with hemodynamic instability: Consensus recommendations of the Anesthesia Patient Safety Foundation. Anesth Analg. 2024;138(4):713-724.
- Mascha EJ, Yang D, Weiss S, et al. Intraoperative mean arterial pressure variability and 30-day mortality in patients having noncardiac surgery. Anesthesiology. 2015;123(1):79-91.
- Salmasi V, Maheshwari K, Yang D, et al. Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney injury and myocardial injury. Anesthesiology. 2017;126(1):47-65.
- Shah NJ, Mentz G, Kheterpal S. The incidence of intraoperative hypotension in moderate to high risk patients undergoing non-cardiac surgery: a retrospective multicenter observational analysis. J Clin Anesth. 2020;66:109961.
- Saasouh W, Christensen AL, Xing F, et al. Incidence of intraoperative hypotension during non-cardiac surgery in community anesthesia practice: a retrospective observational analysis. Periop Med (Lond). 2023;12:29.
Published evidence suggests that the severity and duration of intraoperative hypotension are associated with adverse postoperative outcomes.¹
Published studies have reported associations between intraoperative hypotension and adverse postoperative outcomes, including myocardial injury after non-cardiac surgery (MINS), acute kidney injury (AKI), delirium and mortality.²⁻⁵
Exposure to lower MAPs is associated with increased risk of myocardial injury after non-cardiac surgery (MINS) and 30-day mortality.3,5
In a published US study, AKI was associated with increased hospitalisation costs ranging from US$9,146 to US$49,320.⁶
Patients typically considered lower risk are still susceptible to the adverse complications associated with IOH, including younger patients (18-39), patients with lower ASA physical status (ASA II), and patients undergoing shorter procedures.4,8,9,12
In a multicentre retrospective study of over 300,000 non-cardiac surgeries, the study found increased risk across a range of intraoperative hypotension exposures.⁴
Depth and duration matter
Hypotension is not only common—non-cardiac surgical patients are also experiencing significant amounts. Evidence indicates that longer duration and greater severity of hypotension are associated with an increased risk of adverse postoperative outcomes.⁵
*In an observational study where hypotension was defined as MAP <65 mmHg for ≥15 cumulative minutes.
Explore the research
For a review of the associations between IOH and risk of adverse clinical outcomes, see the list of published studies below.
- Gregory A, Stapelfeldt WH, Khanna AK, et al. Intraoperative hypotension is associated with adverse clinical outcomes after noncardiac surgery. Anesth Analg. 2021;132(6):1654-1665.
- Wesselink EM, Kappen TH, Torn HM, et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: A systematic review. Br J Anaesth. 2018;121(4):706-721.
- Shah NJ, Mentz G, Kheterpal S, et al. The incidence of intraoperative hypotension in moderate to high risk patients undergoing non-cardiac surgery: A retrospective multicenter observational analysis. J Clin Anesth. 2020;66:109961.
- Futier E, Lefrant JY, Guinot PG, et al. Effect of individualized vs standard blood pressure management strategies on postoperative organ dysfunction among high-risk patients undergoing major surgery: A randomized clinical trial. JAMA. 2017;318(14):1346-1357.
- Smeltz AM, Cooter M, Rao S, et al. Elevated pulse pressure, intraoperative hemodynamic perturbations, and acute kidney injury after coronary artery bypass grafting surgery. J Cardiothorac Vasc Anesth. 2018;32(3):1214-1224.
- Hallqvist L, Granath F, Fored M, et al. Intraoperative hypotension is associated with acute kidney injury in noncardiac surgery: An observational study. Eur J Anaesthesiol. 2018;35(4):273-279.
- Vernooij LM, van Klei WA, van Wolfswinkel L, et al. Different methods of modelling intraoperative hypotension and their association with postoperative complications in patients undergoing non-cardiac surgery. Br J Anaesth. 2018;120(5):1080-1089.
- Abbott TEF, Pearse RM, Archbold RA, et al. A prospective international multicentre cohort study of intraoperative heart rate and systolic blood pressure and myocardial injury after noncardiac surgery: Results of the VISION study. Anesth Analg. 2018;126(6):1936-1945.
- Maheshwari K, Turan A, Mao G, et al. The association of hypotension during non-cardiac surgery, before and after skin incision, with postoperative acute kidney injury: A retrospective cohort analysis. Anaesthesia. 2018;73(10):1223-1228.
- Sun LY, Wijeysundera DN, Tait GA, et al. Defining an intraoperative hypotension threshold in association with stroke in cardiac surgery. Anesthesiology. 2018;129(3):440-447.
- Saugel B, Kouz K, Meidert AS, et al. Automated ambulatory blood pressure measurements and intraoperative hypotension in patients having noncardiac surgery with general anesthesia: A prospective observational study. Anesthesiology. 2019;131(1):74-83.
- Mathis MR, Khanna AK, Freundlich RE, et al. Preoperative risk and the association between hypotension and postoperative acute kidney injury. Anesthesiology. 2020;132(3):461-475.
- Naylor AJ, Gelb AW, Baxter MG, et al. Arterial catheters for early detection and treatment of hypotension during major noncardiac surgery: A randomized trial. Anesth Analg. 2020;131(5):1540-1550.
- Ahuja S, Mascha EJ, Yang D, et al. Associations of intraoperative radial arterial systolic, diastolic, mean, and pulse pressures with myocardial and acute kidney injury after noncardiac surgery: A retrospective cohort analysis. Anesthesiology. 2020;132(2):291-306.
- Sessler DI, Meyhoff CS, Zimmerman NM, et al. Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth. 2019;122(5):563-574.
- Ono M, Brady K, Easley RB, et al. Blood pressure excursions below the cerebral autoregulation threshold during cardiac surgery are associated with acute kidney injury. Crit Care Med. 2013;41(2):464-471.
- Ono M, Arnaoutakis GJ, Fine DM, et al. Duration and magnitude of blood pressure below cerebral autoregulation threshold during cardiopulmonary bypass is associated with major morbidity and operative mortality. J Thorac Cardiovasc Surg. 2014;147(1):483-489.
- Hori D, Brown C, Ono M, et al. Arterial pressure above the upper cerebral autoregulation limit during cardiopulmonary bypass is associated with postoperative delirium. Br J Anaesth. 2014;113(6):1009-1017.
- Hori D, Ono M, Rappold T, et al. Hypotension after cardiac surgery based on autoregulation monitoring leads to brain cellular injury. Ann Thorac Surg. 2015;100(2):487-493.
- Chuan A, Flick S, Moran C, et al. Is cerebrovascular autoregulation associated with outcomes after major noncardiac surgery? A prospective observational pilot study. Acta Anaesthesiol Scand. 2019;63(1):8-17.
- Brady KM, Lee JK, Kibler KK, et al. Personalizing the definition of hypotension to protect the brain. Anesthesiology. 2020;132(1):170-179.
- Chan B, Aneman A. A prospective, observational study of cerebrovascular autoregulation and its association with delirium following cardiac surgery. Anaesthesia. 2019;74(1):33-44.
- Brown CH 4th, Azman AS, Gottschalk A, et al. Effect of targeting mean arterial pressure during cardiopulmonary bypass by monitoring cerebral autoregulation on postsurgical delirium among older patients: A nested randomized clinical trial. JAMA Surg. 2019;154(9):819-826.
Intraoperative hypotension is considered a potentially modifiable risk factor and may represent an important focus for perioperative management.4,7,10
Haemodynamic instability is complex, and relying solely on blood pressure measurements can lead to missed warning signs or inappropriate treatments.
The Anesthesia Patient Safety Foundation has identified haemodynamic instability as a critical patient safety issue, highlighting the importance of monitoring and management of haemodynamic instability during the perioperative period.¹¹
- Perfusion
- Interventions
- Variability
Blood pressure is the most widely used surrogate for haemodynamic instability in the perioperative period, but blood pressure alone does not reflect perfusion. Hypotension may be associated with impaired tissue perfusion; however, blood pressure alone does not provide a complete assessment of haemodynamic status.
Evidence shows that only 50% of episodes of hemodynamic instability solely require a vasopressor12—making it imperative to identify and treat the root cause for each individual patient.
Given the variability of underlying causes of intraoperative hypotension across patients, targeted, personalized treatment—guided by continuous advanced hemodynamic monitoring—is essential.
- Sessler DI, et al. Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth. 2019.
- Salmasi V, et al. Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney injury and myocardial injury. Anesthesiology. 2017.
- Mascha EJ, et al. Intraoperative mean arterial pressure variability and 30-day mortality in patients having noncardiac surgery. Anesthesiology. 2015.
- Gregory A, et al. Intraoperative hypotension is associated with adverse clinical outcomes after noncardiac surgery. Anesth Analg. 2021.
- Wesselink EM, Kappen TH, Torn HM, Slooter AJC, van Klei WA. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth. 2018.
- French WB, Shah PR, Fatani YI, et al. Mortality and costs associated with acute kidney injury following major elective, non-cardiac surgery. J Clin Anes. 2022;82:1-7.
- Saasouh W, Christensen AL, Xing F, et al. Incidence of intraoperative hypotension during non-cardiac surgery in community anesthesia practice: a retrospective observational analysis. Periop Med. 2023;12(29):1-10.
- Maleczek M, Laxar D, Geroldinger A, Kimberger O. Intraoperative hypotension is associated with postoperative nausea and vomiting in the PACU: a retrospective database analysis. J Clin Med. 2023;12(2009):1-13.
- Dogan L, Yildirim SA, Sarikaya T, Ulugol H, Gucyetmez B, Toraman F. Different types of intraoperative hypotension and their association with post-anesthesia care unit recovery. J Clin Med. 2023;18(1):44.
- Glassman SD, Carreon LY, Djurasovic M, et al. Intraoperative hypotension is an important modifiable risk factor for major complications in spinal fusion surgery. Spine. 2025;50(10):720-727.
- Scott MJ, APSF HIWG. Perioperative patients with hemodynamic instability: Consensus recommendations of the Anesthesia Patient Safety Foundation. Anesth Analg. 2024;138(4):713-724.
- Ripollés-Melchor J, Valbuena-Bueno MA, Fernández-Valdés-Bango P, et al. Characterization of intraoperative hemodynamic instability in patients undergoing general anesthesia. Front Anesthesiol. 2024;3:1405405.
Earlier identification of patients at risk of hypotension.
Additional haemodynamic information may support clinical assessment and decision-making.
Acumen HPI™ Software is designed to provide additional haemodynamic information to support patient monitoring.
Acumen Hypotension Prediction Index™ Software analyses arterial waveform data to provide information that may assist clinicians in identifying patients at risk of hypotension. With advanced predictive intelligence, the software provides additional haemodynamic parameters that may support clinical decision-making.
In the EU HYPROTECT observational study, patients monitored with Acumen HPI™ Software had low reported incidence, duration and severity of hypotension.¹
Brief duration of hypotension
In the EU HYPROTECT study, the median duration of hypotension was approximately two minutes.¹
Low severity of hypotension
In the EU HYPROTECT study, TWA MAP <65 mmHg was reported as 0.03.¹
*Multicenter, prospective, observational study of patients across 5 EU countries monitored with Acumen IQ™ Arterial Line Sensor where hypotension was defined as >1 min below MAP 65 mmHg
Kouz K, Garcia MIM, Cerutti E, et al. Intraoperative hypotension when using hypotension prediction index software during major noncardiac surgery: A European multicentre prospective observational registry (EU HYPROTECT). BJA Open. 2023;6:100140.
Shah N, Mentz G, Kheterpal S. The incidence of intraoperative hypotension in moderate to high risk patients undergoing non-cardiac surgery: A retrospective multicenter observational analysis. J Clin Anesth. 2020;66:1-12.
Wijnberge M, Geerts BF, Hol L, et al. Effect of a machine learning-derived early warning system for intraoperative hypotension vs standard care on depth and duration of intraoperative hypotension during elective noncardiac surgery: the HYPE randomized clinical trial. JAMA. 2020;323(11):1052-1060.
Maheshwari K, Shimada T, Yang D, et al. Hypotension Prediction Index for prevention of hypotension during moderate- to high-risk noncardiac surgery. Anesthesiology. 2020;133(6):1214-1222.
Tsoumpa M, Kyttari A, Matiatou S, et al. The use of the Hypotension Prediction Index integrated in an algorithm of goal-directed hemodynamic treatment during moderate- and high-risk surgery. J Clin Med. 2021;10(24):5884.
Grundmann CD, Wischermann JM, Fassbender P, et al. Hemodynamic monitoring with Hypotension Prediction Index versus arterial waveform analysis alone and incidence of perioperative hypotension. Acta Anaesthesiol Scand. 2021;65(10):1404-1412.
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