Development and validation of a predictive model for PACU hypotension in elderly patients undergoing sedated gastrointestinal endoscopy.
Aged
Endoscopy
Gastrointestinal
Recovery room
Risk factors
Journal
Aging clinical and experimental research
ISSN: 1720-8319
Titre abrégé: Aging Clin Exp Res
Pays: Germany
ID NLM: 101132995
Informations de publication
Date de publication:
18 Jul 2024
18 Jul 2024
Historique:
received:
21
03
2024
accepted:
05
07
2024
medline:
18
7
2024
pubmed:
18
7
2024
entrez:
18
7
2024
Statut:
epublish
Résumé
Hypotension, characterized by abnormally low blood pressure, is a frequently observed adverse event in sedated gastrointestinal endoscopy procedures. Although the examination time is typically short, hypotension during and after gastroscopy procedures is frequently overlooked or remains undetected. This study aimed to construct a risk nomogram for post-anesthesia care unit (PACU) hypotension in elderly patients undergoing sedated gastrointestinal endoscopy. This study involved 2919 elderly patients who underwent sedated gastrointestinal endoscopy. A preoperative questionnaire was used to collect data on patient characteristics; intraoperative medication use and adverse events were also recorded. The primary objective of the study was to evaluate the risk of PACU hypotension in these patients. To achieve this, the least absolute shrinkage and selection operator (LASSO) regression analysis method was used to optimize variable selection, involving cyclic coordinate descent with tenfold cross-validation. Subsequently, multivariable logistic regression analysis was applied to build a predictive model using the selected predictors from the LASSO regression. A nomogram was visually developed based on these variables. To validate the model, a calibration plot, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) were used. Additionally, external validation was conducted to further assess the model's performance. The LASSO regression analysis identified predictors associated with an increased risk of adverse events during surgery: age, duration of preoperative water abstinence, intraoperative mean arterial pressure (MAP) <65 mmHg, decreased systolic blood pressure (SBP), and use of norepinephrine (NE). The constructed model based on these predictors demonstrated moderate predictive ability, with an area under the ROC curve of 0.710 in the training set and 0.778 in the validation set. The DCA indicated that the nomogram had clinical applicability when the risk threshold ranged between 20 and 82%, which was subsequently confirmed in the external validation with a range of 18-92%. Incorporating factors such as age, duration of preoperative water abstinence, intraoperative MAP <65 mmHg, decreased SBP, and use of NE in the risk nomogram increased its usefulness for predicting PACU hypotension risk in elderly patient undergoing sedated gastrointestinal endoscopy.
Sections du résumé
BACKGROUND
BACKGROUND
Hypotension, characterized by abnormally low blood pressure, is a frequently observed adverse event in sedated gastrointestinal endoscopy procedures. Although the examination time is typically short, hypotension during and after gastroscopy procedures is frequently overlooked or remains undetected. This study aimed to construct a risk nomogram for post-anesthesia care unit (PACU) hypotension in elderly patients undergoing sedated gastrointestinal endoscopy.
METHODS
METHODS
This study involved 2919 elderly patients who underwent sedated gastrointestinal endoscopy. A preoperative questionnaire was used to collect data on patient characteristics; intraoperative medication use and adverse events were also recorded. The primary objective of the study was to evaluate the risk of PACU hypotension in these patients. To achieve this, the least absolute shrinkage and selection operator (LASSO) regression analysis method was used to optimize variable selection, involving cyclic coordinate descent with tenfold cross-validation. Subsequently, multivariable logistic regression analysis was applied to build a predictive model using the selected predictors from the LASSO regression. A nomogram was visually developed based on these variables. To validate the model, a calibration plot, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) were used. Additionally, external validation was conducted to further assess the model's performance.
RESULTS
RESULTS
The LASSO regression analysis identified predictors associated with an increased risk of adverse events during surgery: age, duration of preoperative water abstinence, intraoperative mean arterial pressure (MAP) <65 mmHg, decreased systolic blood pressure (SBP), and use of norepinephrine (NE). The constructed model based on these predictors demonstrated moderate predictive ability, with an area under the ROC curve of 0.710 in the training set and 0.778 in the validation set. The DCA indicated that the nomogram had clinical applicability when the risk threshold ranged between 20 and 82%, which was subsequently confirmed in the external validation with a range of 18-92%.
CONCLUSION
CONCLUSIONS
Incorporating factors such as age, duration of preoperative water abstinence, intraoperative MAP <65 mmHg, decreased SBP, and use of NE in the risk nomogram increased its usefulness for predicting PACU hypotension risk in elderly patient undergoing sedated gastrointestinal endoscopy.
Identifiants
pubmed: 39023685
doi: 10.1007/s40520-024-02807-6
pii: 10.1007/s40520-024-02807-6
doi:
Types de publication
Journal Article
Validation Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
149Subventions
Organisme : National Natural Science Foundation of China
ID : 82172190
Organisme : General Project of Medical Scientific Research Project of Jiangsu Provincial Health Commission
ID : M2021105
Organisme : Special Fund for Yangzhou Key Laboratory Cultivation
ID : YZ20211148
Informations de copyright
© 2024. The Author(s).
Références
Huang Y, Gui Q, Li H et al (2021) Age is the only predictor for upper gastrointestinal malignancy in Chinese patients with uncomplicated dyspepsia: a prospective investigation of endoscopic findings. BMC Gastroenterol 21:441. https://doi.org/10.1186/s12876-021-01951-x
doi: 10.1186/s12876-021-01951-x
pubmed: 34814828
pmcid: 8609854
Schreuders E, Ruco A, Rabeneck L et al (2015) Colorectal cancer screening: a global overview of existing programmes. Gut 64:1637–1649. https://doi.org/10.1136/gutjnl-2014-309086
doi: 10.1136/gutjnl-2014-309086
pubmed: 26041752
Zhou S, Zhu Z, Dai W et al (2021) National survey on sedation for gastrointestinal endoscopy in 2758 Chinese hospitals. Br J Anaesth 127:56–64. https://doi.org/10.1016/j.bja.2021.01.028
doi: 10.1016/j.bja.2021.01.028
pubmed: 33685636
Eberl S, Preckel B, Bergman J et al (2016) Satisfaction and safety using dexmedetomidine or propofol sedation during endoscopic oesophageal procedures: a randomised controlled trial. Eur J Anaesthesiol 33:631–637. https://doi.org/10.1097/eja.0000000000000438
doi: 10.1097/eja.0000000000000438
pubmed: 26950082
Berzin T, Sanaka S, Barnett S et al (2011) A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administered sedation. Gastrointest Endosc 73:710–717. https://doi.org/10.1016/j.gie.2010.12.011
doi: 10.1016/j.gie.2010.12.011
pubmed: 21316669
Coté G, Hovis R, Ansstas M et al (2010) Incidence of sedation-related complications with propofol use during advanced endoscopic procedures. Clin Gastroenterol Hepatol 8:137–142. https://doi.org/10.1016/j.cgh.2009.07.008
doi: 10.1016/j.cgh.2009.07.008
pubmed: 19607937
Wadhwa V, Issa D, Garg S et al (2017) Similar risk of cardiopulmonary adverse events between propofol and traditional anesthesia for gastrointestinal endoscopy: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 15:194–206. https://doi.org/10.1016/j.cgh.2016.07.013
doi: 10.1016/j.cgh.2016.07.013
pubmed: 27451091
Geng W, Jia D, Wang Y et al (2018) A prediction model for hypoxemia during routine sedation for gastrointestinal endoscopy. Clinics 73:e513. https://doi.org/10.6061/clinics/2018/e513
doi: 10.6061/clinics/2018/e513
pubmed: 30462756
pmcid: 6218956
Leslie K, Allen M, Hessian E et al (2017) Safety of sedation for gastrointestinal endoscopy in a group of university-affiliated hospitals: a prospective cohort study. Br J Anaesth 118:90–99. https://doi.org/10.1093/bja/aew393
doi: 10.1093/bja/aew393
pubmed: 28039246
Mehta P, Kochhar G, Kalra S et al (2014) Can a validated sleep apnea scoring system predict cardiopulmonary events using propofol sedation for routine EGD or colonoscopy? A prospective cohort study. Gastrointest Endosc 79:436–444. https://doi.org/10.1016/j.gie.2013.09.022
doi: 10.1016/j.gie.2013.09.022
pubmed: 24219821
Vargo J, Niklewski P, Williams J et al (2017) Patient safety during sedation by anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38 million procedures. Gastrointest Endosc 85:101–108. https://doi.org/10.1016/j.gie.2016.02.007
doi: 10.1016/j.gie.2016.02.007
pubmed: 26905938
Rex D, Deenadayalu V, Eid E et al (2009) Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology 137:1229–1237. https://doi.org/10.1053/j.gastro.2009.06.042
doi: 10.1053/j.gastro.2009.06.042
pubmed: 19549528
Lee C, Lee S, Chung I et al (2011) Balanced propofol sedation for therapeutic GI endoscopic procedures: a prospective, randomized study. Gastrointest Endosc 73:206–214. https://doi.org/10.1016/j.gie.2010.09.035
doi: 10.1016/j.gie.2010.09.035
pubmed: 21168838
Sieg A, Beck S, Scholl S et al (2014) Safety analysis of endoscopist-directed propofol sedation: a prospective, national multicenter study of 24 441 patients in German outpatient practices. J Gastroenterol Hepatol 29:517–523. https://doi.org/10.1111/jgh.12458
doi: 10.1111/jgh.12458
pubmed: 24716213
Poincloux L, Laquière A, Bazin J et al (2011) A randomized controlled trial of endoscopist vs. anaesthetist-administered sedation for colonoscopy. Dig Liver Dis 43:553–558. https://doi.org/10.1016/j.dld.2011.02.007
doi: 10.1016/j.dld.2011.02.007
pubmed: 21450542
Allen M, Leslie K, Hebbard G et al (2015) A randomized controlled trial of light versus deep propofol sedation for elective outpatient colonoscopy: recall, procedural conditions, and recovery. Can J Anaesth 62:1169–1178. https://doi.org/10.1007/s12630-015-0463-3
doi: 10.1007/s12630-015-0463-3
pubmed: 26335904
Smischney N, Beach M, Loftus R et al (2012) Ketamine/propofol admixture (ketofol) is associated with improved hemodynamics as an induction agent: a randomized, controlled trial. J Trauma Acute Care Surg 73:94–101. https://doi.org/10.1097/TA.0b013e318250cdb8
doi: 10.1097/TA.0b013e318250cdb8
pubmed: 22743378
An R, Pang Q, Liu H (2019) Association of intra-operative hypotension with acute kidney injury, myocardial injury and mortality in non-cardiac surgery: a meta-analysis. Int J Clin Pract 73:e13394. https://doi.org/10.1111/ijcp.13394
doi: 10.1111/ijcp.13394
pubmed: 31332896
Sessler D, Bloomstone J, Aronson S et al (2019) Perioperative quality initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth 122:563–574. https://doi.org/10.1016/j.bja.2019.01.013
doi: 10.1016/j.bja.2019.01.013
pubmed: 30916004
Jor O, Maca J, Koutna J et al (2018) Hypotension after induction of general anesthesia: occurrence, risk factors, and therapy. A prospective multicentre observational study. J Anesth 32:673–680. https://doi.org/10.1007/s00540-018-2532-6
doi: 10.1007/s00540-018-2532-6
pubmed: 30027443
Davies S, Vistisen S, Jian Z et al (2020) Ability of an arterial waveform analysis-derived hypotension prediction index to predict future hypotensive events in surgical patients. Anesth Analg 130:352–359. https://doi.org/10.1213/ane.0000000000004121
doi: 10.1213/ane.0000000000004121
pubmed: 30896602
Schneck E, Schulte D, Habig L et al (2020) Hypotension prediction index based protocolized haemodynamic management reduces the incidence and duration of intraoperative hypotension in primary total hip arthroplasty: a single centre feasibility randomised blinded prospective interventional trial. J Clin Monit Comput 6:1149–1158. https://doi.org/10.1007/s10877-019-00433-6
doi: 10.1007/s10877-019-00433-6
Kendale S, Kulkarni P, Rosenberg A et al (2018) Supervised machine-learning predictive analytics for prediction of postinduction hypotension. Anesthesiology 129:675–688. https://doi.org/10.1097/aln.0000000000002374
doi: 10.1097/aln.0000000000002374
pubmed: 30074930
Wijnberge M, Geerts B, Hol L et al (2020) 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 323:1052–1060. https://doi.org/10.1001/jama.2020.0592
doi: 10.1001/jama.2020.0592
pubmed: 32065827
pmcid: 7078808
Lee S, Lee H, Chu Y et al (2021) Deep learning models for the prediction of intraoperative hypotension. Br J Anaesth 126:808–817. https://doi.org/10.1016/j.bja.2020.12.035
doi: 10.1016/j.bja.2020.12.035
pubmed: 33558051
Sessler D, Khanna A (2018) Perioperative myocardial injury and the contribution of hypotension. Intensive Care Med 44:811–822. https://doi.org/10.1007/s00134-018-5224-7
doi: 10.1007/s00134-018-5224-7
pubmed: 29868971
Sessler D, Meyhoff C, Zimmerman N et al (2018) Period-dependent associations between hypotension during and for four days after noncardiac surgery and a composite of myocardial infarction and death: a substudy of the POISE-2 trial. Anesthesiology 128:317–327. https://doi.org/10.1097/aln.0000000000001985
doi: 10.1097/aln.0000000000001985
pubmed: 29189290
McEvoy M, Gupta R, Koepke E et al (2019) Perioperative quality initiative consensus statement on postoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth 122:575–586. https://doi.org/10.1016/j.bja.2019.01.019
doi: 10.1016/j.bja.2019.01.019
pubmed: 30916008
Turan A, Chang C, Cohen B et al (2019) Incidence, severity, and detection of blood pressure perturbations after abdominal surgery: a prospective blinded observational study. Anesthesiology 130:550–559. https://doi.org/10.1097/aln.0000000000002626
doi: 10.1097/aln.0000000000002626
pubmed: 30875354
Cheng K, Chu C, Lin T et al (2015) Lipid paradox in acute myocardial infarction-the association with 30-day in-hospital mortality. Crit Care Med 43:1255–1264. https://doi.org/10.1097/ccm.0000000000000946
doi: 10.1097/ccm.0000000000000946
pubmed: 25738856
Sneyd J, Absalom A, Barends C et al (2022) Hypotension during propofol sedation for colonoscopy: a retrospective exploratory analysis and meta-analysis. Br J Anaesth 128:610–622. https://doi.org/10.1016/j.bja.2021.10.044
doi: 10.1016/j.bja.2021.10.044
pubmed: 34916051
Ahuja S, Mascha E, Yang D et al (2020) 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 132:291–306. https://doi.org/10.1097/aln.0000000000003048
doi: 10.1097/aln.0000000000003048
pubmed: 31939844
Futier E, Lefrant J, Guinot P et al (2017) 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 318:1346–1357. https://doi.org/10.1001/jama.2017.14172
doi: 10.1001/jama.2017.14172
pubmed: 28973220
pmcid: 5710560
van Waes J, van Klei W, Wijeysundera D et al (2016) Association between intraoperative hypotension and myocardial injury after vascular surgery. Anesthesiology 124:35–44. https://doi.org/10.1097/aln.0000000000000922
doi: 10.1097/aln.0000000000000922
pubmed: 26540148
Vernooij L, van Klei W, Machina M et al (2018) Different methods of modelling intraoperative hypotension and their association with postoperative complications in patients undergoing non-cardiac surgery. Br J Anaesth 120:1080–1089. https://doi.org/10.1016/j.bja.2018.01.033
doi: 10.1016/j.bja.2018.01.033
pubmed: 29661385
Wesselink E, Kappen T, Torn H et al (2018) Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth 121:706–721. https://doi.org/10.1016/j.bja.2018.04.036
doi: 10.1016/j.bja.2018.04.036
pubmed: 30236233
Walsh M, Devereaux P, Garg A et al (2013) Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension. Anesthesiology 119:507–515. https://doi.org/10.1097/ALN.0b013e3182a10e26
doi: 10.1097/ALN.0b013e3182a10e26
pubmed: 23835589
De Backer D, Orbegozo Cortes D, Donadello K et al (2014) Pathophysiology of microcirculatory dysfunction and the pathogenesis of septic shock. Virulence 5:73–79. https://doi.org/10.4161/viru.26482
doi: 10.4161/viru.26482
pubmed: 24067428
Morley AP, Nalla BP, Vamadevan S et al (2010) The influence of duration of fluid abstinence on hypotension during propofol induction. Anesth Analg 111:1373–1377
doi: 10.1213/ANE.0b013e3181f62a2b
pubmed: 20861421
Bonnet J, Buggy E, Cusack B et al (2020) Can routine perioperative haemodynamic parameters predict postoperative morbidity after major surgery? Perioper Med 9:9. https://doi.org/10.1186/s13741-020-0139-6
doi: 10.1186/s13741-020-0139-6
Lu W, Kumar S, Zheng S (2014) A single-centre based analysis of hospitalized elderly surgical patients and the related perioperative mortality. J Am Geriatr Soc 62:S383–S384
Kozarek K, Sanders RD, Head D (2020) Perioperative blood pressure in the elderly. Curr Opin Anaesthesiol 1:122. https://doi.org/10.1097/ACO.0000000000000820
doi: 10.1097/ACO.0000000000000820
Griffiths R, Beech F, Brown A et al (2014) Peri-operative care of the elderly 2014: association of anaesthetists of Great Britain and Ireland. Anaesthesia 69:81–98. https://doi.org/10.1111/anae.12524
doi: 10.1111/anae.12524
pubmed: 24303864
Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American society of anesthesiologists task force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology 2017, 126(3):376–393. https://doi.org/10.1097/aln.0000000000001452
Osland E, Yunus R, Khan S et al (2011) Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis. JPEN J Parenter Enteral Nutr 35:473–487. https://doi.org/10.1177/0148607110385698
doi: 10.1177/0148607110385698
pubmed: 21628607
Denkyi L (2020) An exploration of pre-operative fasting practices in adult patients having elective surgery. Br J Nurs 29:436–441. https://doi.org/10.12968/bjon.2020.29.7.436
doi: 10.12968/bjon.2020.29.7.436
pubmed: 32279558
van Noort H, Eskes A, Vermeulen H et al (2021) Fasting habits over a 10-year period: an observational study on adherence to preoperative fasting and postoperative restoration of oral intake in 2 Dutch hospitals. Surgery 170:532–540. https://doi.org/10.1016/j.surg.2021.01.037
doi: 10.1016/j.surg.2021.01.037
pubmed: 33712307
Simpao A, Wu L, Nelson O et al (2020) Preoperative fluid fasting times and postinduction low blood pressure in children: a retrospective analysis. Anesthesiology 133:523–533. https://doi.org/10.1097/aln.0000000000003343
doi: 10.1097/aln.0000000000003343
pubmed: 32433278
Dennhardt N, Beck C, Huber D et al (2016) Optimized preoperative fasting times decrease ketone body concentration and stabilize mean arterial blood pressure during induction of anesthesia in children younger than 36 months: a prospective observational cohort study. Paediatr Anaesth 26:838–843. https://doi.org/10.1111/pan.12943
doi: 10.1111/pan.12943
pubmed: 27291355
Lambert E, Carey S (2016) Practice guideline recommendations on perioperative fasting: a systematic review. JPEN J Parenter Enteral Nutr 40:1158–1165. https://doi.org/10.1177/0148607114567713
doi: 10.1177/0148607114567713
pubmed: 25575497
McDonagh S, Cross R, Masoli J et al (2023) Understanding measurement of postural hypotension: a nationwide survey of primary care practice in England. J Hypertens 41:e7
doi: 10.1097/01.hjh.0000938944.01772.b8
Cheema S, Anderson J, Duncan C et al (2022) Survey of healthcare professionals’ knowledge, attitudes and practices regarding spontaneous intracranial hypotension. BMJ Neurol Open 4:e000347. https://doi.org/10.1136/bmjno-2022-000347
doi: 10.1136/bmjno-2022-000347
pubmed: 36110926
pmcid: 9445790
Biswas D, Karabin B, Turner D (2019) Role of nurses and nurse practitioners in the recognition, diagnosis, and management of neurogenic orthostatic hypotension: a narrative review. Int J General Med 12:173–184. https://doi.org/10.2147/ijgm.S170655
doi: 10.2147/ijgm.S170655