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Perioperative Quality Initiative consensus statement on the physiology of arterial blood pressure control in perioperative medicine

Perioperative Quality Initiative consensus statement on the physiology of arterial blood pressure control in perioperative medicine
Perioperative Quality Initiative consensus statement on the physiology of arterial blood pressure control in perioperative medicine

Background: Perioperative arterial blood pressure management is a physiologically complex challenge influenced by multiple factors. Methods: A multidisciplinary, international working subgroup of the Third Perioperative Quality Initiative (POQI) consensus meeting reviewed the (patho)physiology and measurement of arterial pressure as applied to perioperative medicine. We addressed predefined questions by undertaking a modified Delphi analysis, in which primary clinical research and review articles were identified using MEDLINE. Strength of recommendations, where applicable, were graded by National Institute for Health and Care Excellence (NICE) guidelines. Results: Multiple physiological factors contribute to the perioperative physiological importance of arterial pressure: (i) arterial pressure is the input pressure to organ blood flow, but is not the sole determinant of perfusion pressure; (ii) blood flow is often independent of changes in perfusion pressure because of autoregulatory changes in vascular resistance; (iii) microvascular dysfunction uncouples microvascular blood flow from arterial pressure (haemodynamic incoherence). From a practical clinical perspective, we identified that: (i) ambulatory measurement is the optimal method to establish baseline arterial pressure; (ii) automated and invasive arterial pressure measurements have inherent physiological and technical limitations; (iii) individualised arterial pressure targets may change over time, especially in the perioperative period. There remains a need for research in non-invasive, continuous arterial pressure measurements, macro- and micro-circulatory control, regional perfusion pressure measurement, and the development of sensitive, specific, and continuous measures of cellular function to evaluate blood pressure management in a physiologically coherent manner. Conclusion: The multivariable, complex physiology contributing to dynamic changes in perioperative arterial pressure may be underappreciated clinically. The frequently unrecognised dissociation between arterial pressure, organ blood flow, and microvascular and cellular function requires further research to develop a more refined, contextualised clinical approach to this routine perioperative measurement.

arterial pressure, blood pressure monitoring, haemodynamics, micro-circulation, perioperative care, perioperative medicine
0007-0912
542-551
Ackland, Gareth L.
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Brudney, Charles S.
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Cecconi, Maurizio
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Ince, Can
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Irwin, Michael G.
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Lacey, Jonathan
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Pinsky, Michael R.
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Grocott, Michael P.W.
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Mythen, Monty G.
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Edwards, Mark R.
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Miller, Timothy E.
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Sanders, Robert
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Hughes, Finton
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Bader, Angela
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Thompson, Annemarie
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Hoeft, Andreas
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Williams, David
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Shaw, Andrew D.
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Sessler, Daniel I.
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Aronson, Sol
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Berry, Colin
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Gan, Tong J.
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Kellum, John
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Plumb, James
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Bloomstone, Joshua
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McEvoy, Matthew D.
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Thacker, Julie K.M.
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Gupta, Ruchir
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Koepke, Elena
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Feldheiser, Aarne
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Levett, Denny
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Michard, Frederic
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Hamilton, Mark
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POQI-3 workgroup
POQI chairs
Physiology group
Preoperative blood pressure group
Intraoperative blood pressure group
Postoperative blood pressure group
Ackland, Gareth L.
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Brudney, Charles S.
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Cecconi, Maurizio
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Ince, Can
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Irwin, Michael G.
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Lacey, Jonathan
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Pinsky, Michael R.
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Grocott, Michael P.W.
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Mythen, Monty G.
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Edwards, Mark R.
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Miller, Timothy E.
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Sanders, Robert
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Hughes, Finton
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Bader, Angela
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Thompson, Annemarie
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Hoeft, Andreas
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Williams, David
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Shaw, Andrew D.
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Sessler, Daniel I.
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Aronson, Sol
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Berry, Colin
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Gan, Tong J.
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Kellum, John
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Plumb, James
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Bloomstone, Joshua
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McEvoy, Matthew D.
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Thacker, Julie K.M.
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Gupta, Ruchir
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Koepke, Elena
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Feldheiser, Aarne
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Levett, Denny
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Michard, Frederic
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Hamilton, Mark
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Ackland, Gareth L., Brudney, Charles S., Cecconi, Maurizio, Ince, Can, Irwin, Michael G., Lacey, Jonathan, Pinsky, Michael R., Grocott, Michael P.W., Mythen, Monty G., Edwards, Mark R. and Miller, Timothy E. , POQI-3 workgroup, POQI chairs, Physiology group, Preoperative blood pressure group, Intraoperative blood pressure group and Postoperative blood pressure group (2019) Perioperative Quality Initiative consensus statement on the physiology of arterial blood pressure control in perioperative medicine. British Journal of Anaesthesia, 122 (5), 542-551. (doi:10.1016/j.bja.2019.01.011).

Record type: Article

Abstract

Background: Perioperative arterial blood pressure management is a physiologically complex challenge influenced by multiple factors. Methods: A multidisciplinary, international working subgroup of the Third Perioperative Quality Initiative (POQI) consensus meeting reviewed the (patho)physiology and measurement of arterial pressure as applied to perioperative medicine. We addressed predefined questions by undertaking a modified Delphi analysis, in which primary clinical research and review articles were identified using MEDLINE. Strength of recommendations, where applicable, were graded by National Institute for Health and Care Excellence (NICE) guidelines. Results: Multiple physiological factors contribute to the perioperative physiological importance of arterial pressure: (i) arterial pressure is the input pressure to organ blood flow, but is not the sole determinant of perfusion pressure; (ii) blood flow is often independent of changes in perfusion pressure because of autoregulatory changes in vascular resistance; (iii) microvascular dysfunction uncouples microvascular blood flow from arterial pressure (haemodynamic incoherence). From a practical clinical perspective, we identified that: (i) ambulatory measurement is the optimal method to establish baseline arterial pressure; (ii) automated and invasive arterial pressure measurements have inherent physiological and technical limitations; (iii) individualised arterial pressure targets may change over time, especially in the perioperative period. There remains a need for research in non-invasive, continuous arterial pressure measurements, macro- and micro-circulatory control, regional perfusion pressure measurement, and the development of sensitive, specific, and continuous measures of cellular function to evaluate blood pressure management in a physiologically coherent manner. Conclusion: The multivariable, complex physiology contributing to dynamic changes in perioperative arterial pressure may be underappreciated clinically. The frequently unrecognised dissociation between arterial pressure, organ blood flow, and microvascular and cellular function requires further research to develop a more refined, contextualised clinical approach to this routine perioperative measurement.

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More information

Accepted/In Press date: 2 January 2019
e-pub ahead of print date: 14 February 2019
Published date: May 2019
Keywords: arterial pressure, blood pressure monitoring, haemodynamics, micro-circulation, perioperative care, perioperative medicine

Identifiers

Local EPrints ID: 430953
URI: http://eprints.soton.ac.uk/id/eprint/430953
ISSN: 0007-0912
PURE UUID: f991ab0b-ed73-45b9-a877-769d2a26f785
ORCID for Michael P.W. Grocott: ORCID iD orcid.org/0000-0002-9484-7581

Catalogue record

Date deposited: 17 May 2019 16:30
Last modified: 18 Feb 2021 17:12

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Contributors

Author: Gareth L. Ackland
Author: Charles S. Brudney
Author: Maurizio Cecconi
Author: Can Ince
Author: Michael G. Irwin
Author: Jonathan Lacey
Author: Michael R. Pinsky
Author: Monty G. Mythen
Author: Mark R. Edwards
Author: Timothy E. Miller
Author: Robert Sanders
Author: Finton Hughes
Author: Angela Bader
Author: Annemarie Thompson
Author: Andreas Hoeft
Author: David Williams
Author: Andrew D. Shaw
Author: Daniel I. Sessler
Author: Sol Aronson
Author: Colin Berry
Author: Tong J. Gan
Author: John Kellum
Author: James Plumb
Author: Joshua Bloomstone
Author: Matthew D. McEvoy
Author: Julie K.M. Thacker
Author: Ruchir Gupta
Author: Elena Koepke
Author: Aarne Feldheiser
Author: Denny Levett
Author: Frederic Michard
Author: Mark Hamilton
Corporate Author: POQI-3 workgroup
Corporate Author: POQI chairs
Corporate Author: Physiology group
Corporate Author: Preoperative blood pressure group
Corporate Author: Intraoperative blood pressure group
Corporate Author: Postoperative blood pressure group

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