Incidence, Severity and Clinical Factors Associated with Hypotension in Patients Admitted to an Intensive Care Unit: A Prospective Observational Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Participants
2.3. Measurements
2.4. Analyses
2.5. Signal Quality and Arterial Waveform Analyses
2.6. Data Acquisition
2.7. Statistical Analyses
3. Results
3.1. Patient Characteristics
3.2. Incidence and Severity of Hypotension
3.3. Severity Expressed in TWA
3.4. Clinical Factors Associated with Hypotension
4. Discussion
4.1. Incidence
4.2. Severity
4.3. Clinical Factors Associated with Hypotension
4.4. Limitations
4.5. Strengths
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Study Acronym
Editor’s Key Points
Abbreviations
AKI | Acute kidney injury |
AUT | Area under the threshold |
BP | Blood pressure |
BMI | Body mass index |
CO | Cardiac output |
CI | Cardiac index |
HR | Heart rate |
ICU | Intensive care unit |
MAP | Mean arterial pressure |
MI | Myocardial injury |
PPV | Pulse pressure variation |
SOFA | Sequential organ failure assessment |
SV | Stroke volume |
SVI | Stroke volume index |
SVV | Stroke volume variation |
TWA | Time weighted average |
WMO | Dutch Medical Research Involving Human Subjects Act |
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Baseline Parameters | All Patients n = 499 |
---|---|
Sex, male, n (%) | 327 (66) |
Age, years, mean (sd) | 61 (14) |
Number of patients older than 65 years, n (%) | 221 (44) |
Weight (kg), mean (sd) | 82.97 (19.5) |
Height (cm), mean (sd) | 174 (9.9) |
BMI, mean (sd) | 27 (6) |
SOFA score, mean (sd) | 10 (3) |
Vasoactive medication during measurements, n (%) | 302 (61) |
Mechanical ventilation, n (%) | 358 (72) |
Measurement details | |
Blood pressure monitoring time per patient (minutes), median [Q1–Q3] | 441 [411–962] |
Signal quality percentage per patient, median [Q1–Q3] | 98.0 [94.6–99.0] |
Number of daytime measurements, n (%) | 305 (61) |
Number of night-time measurements, n (%) | 194 (39) |
Reason of ICU admission | |
Respiratory failure, n (%) | 57 (11) |
Neurological disease, n (%) | 82 (16) |
Sepsis, n (%) | 38 (8) |
Cardiac shock/other cardiac, n (%) | 19 (4) |
Postoperative after surgery, n (%) | 216 (43) |
Assigned shock groups | |
Cardiogenic shock, n (%) | 66 (13) |
Distributive shock, n (%) | 94 (19) |
Hypovolemic shock, n (%) | 12 (2) |
Obstructive shock, n (%) | 2 (0.4) |
Combination type of shock, n (%) | 32 (6) |
Non-shock classification, n (%) | 293 (59) |
Hypotension Classification | |||
---|---|---|---|
Baseline Parameters | Absent MAP ≥ 65 mmHg n = 123 (25%) | Present MAP < 65 mmHg n = 376 (75%) | p-Value |
Sex, male, n (%) | 71 (58) | 256 (68) | 0.062 |
Age, years, mean (sd) | 58 (14) | 62 (14) | 0.003 |
BMI, mean (sd) | 28 (6) | 27 (6) | 0.049 |
Day-time measurements, n (%) | 87 (71) | 218 (58) | 0.008 |
Medical history | |||
Myocardial infarction, n (%) | 11 (9) | 59 (16) | 0.251 |
Hypertension, n (%) | 37 (30) | 109 (29) | 0.819 |
Pulmonary disease, n (%) | 1 (1) | 12 (3) | 0.314 |
Diabetes mellitus type II, n (%) | 15 (12) | 66 (18) | 0.204 |
Cerebral vascular accident, n (%) | 6 (5) | 18 (5) | 1.000 |
Gastrointestinal disease, n (%) | 19 (16) | 57 (15) | 0.427 |
Renal insufficiencies, n (%) | 6 (5) | 29 (8) | 0.664 |
Oncological disease, n (%) | 7 (6) | 16 (4) | 0.293 |
Reason of ICU admission | |||
OHCA, n (%) | 4 (3) | 27 (7) | 0.136 |
Post cardiac surgery, n (%) | 32 (26) | 167 (44) | <0.001 |
Intracranial bleeding (SAB), n (%) | 27 (22) | 24 (6) | <0.001 |
Sepsis, n (%) | 12 (10) | 26 (7) | 0.326 |
Assigned shock groups | |||
Cardiogenic shock, n (%) | 4 (3) | 62 (16) | <0.001 |
Distributive shock, n (%) | 20 (16) | 74 (20) | 0.506 |
Hypovolemic shock, n (%) | 1 (1) | 11 (3) | 0.309 |
Obstructive shock, n (%) | 1 (1) | 1 (0.3) | 0.430 |
Non-shock classification, n (%) | 89 (72) | 204 (54) | <0.001 |
Clinical data | |||
Length of stay ICU (days), median [Q1–Q3] * | 3 [1–10] | 2 [1–7] | 0.407 |
Length of stay in hospital (days), median [Q1–Q3] * | 10 [5–23] | 10 [6–20] | 0.877 |
Lactate (mmol/L), median [Q1–Q3] | 1.5 [1.2–2.0] | 1.4 [1.1–2.0] | 0.985 |
Diuresis (ml/kg/h), median [Q1–Q3] | 0.93 [0.61–1.48] | 0.87 [0.58–1.32] | 0.377 |
Haemoglobin (mmol/L), median [Q1–Q3] | 6.8 [5.9–7.8] | 6.5 [5.7–7.4] | 0.118 |
Saturation (%), median [Q1–Q3] | 94 [91–96] | 93 [71–96] | 0.002 |
No treatment with Norepinephrine, n (%) | 55 (45) | 221 (59) | 0.012 |
Propofol sedation, n (%) | 39 (32) | 142 (38) | 0.280 |
Mechanical ventilation, n (%) | 83 (68) | 274 (73) | 0.356 |
Days of mechanical ventilation during admission ICU, median [Q1–Q3] * | 12 [2–74] | 8 [2–47] | 0.299 |
Apache score, median [Q1–Q3] * | 34 [32–60] | 49 [36–63] | 0.031 |
Died during ICU admission, n (%) * | 12 (9.8) | 54 (14.4) | 0.220 |
Died during hospital admission, n (%) * | 18 (14.6) | 70 (18.6) | 0.340 |
Haemodynamic data | |||
Systolic BP (mmHg), median [Q1–Q3] | 133 [114–163] | 121 [108–143] | 0.005 |
Diastolic BP (mmHg), median [Q1–Q3] | 60 [52–69] | 55 [50–62] | <0.001 |
Number of events per patients, median [Q1–Q3] | - | 6 [2–13] | |
Total duration of events per patient (min), median [Q1–Q3] | - | 52 [5–170] | |
Total percentage duration of measurement in hypotension (%), median [Q1–Q3] | - | 9.3 [0.7–29.1] | |
TWA per patient (mmHg), 10 s median [Q1–Q3] | - | 0.3 [0.03–1.0] |
Mild TWA Group (≤0.0233 mmHg) n = 166 (33%) | Moderate TWA Group (0.0234–0.5719 mmHg) n = 166 (33%) | Severe TWA Group (≥0.5720 mmHg) n = 167 (34%) | p-Value | |
---|---|---|---|---|
Baseline parameters | ||||
Sex, male, n (%) | 96 (58) | 117 (71) | 114 (68) | 0.035a |
Age, years, mean (sd) | 57 (14) ¥® | 63 (12) ¥ | 62 (15) ® | <0.001 |
BMI, mean (sd) | 28 (7) | 27 (6) | 27 (6) | 0.422 |
SOFA score, median [Q1–Q3] | 9 [6–11] ¥® | 11 [9–12] ¥ | 10 [9–12] ® | <0.001 |
Temperature °C, mean (sd) | 37.0 (0.8) ¥® | 36.7 (0.8) ¥ | 36.7 (0.8) ® | 0.006 |
Medical history | ||||
Myocardial infarction, n (%) | 17 (10) | 25 (15) | 28 (17) | 0.731 |
Hypertension, n (%) | 52 (31) | 43 (26) | 51 (31) | 0.502 |
Diabetes mellitus type 2, n (%) | 27 (16) | 23 (14) | 31 (19) | 0.507 |
Cerebral vascular accident, n (%) | 8 (5) | 7 (4) | 9 (5) | 0.883 |
Renal disease and insufficiencies, n (%) | 14 (8) | 7 (4) | 14 (8) | 0.097 |
Reason of ICU admission | ||||
OHCA, n (%) | 8 (5) | 9 (5) | 14 (8) | 0.353 |
IHCA, n (%) | 2 (1) | - | 7 (4) | 0.013 |
Post cardiac surgery, n (%) | 38 (23) | 77 (46) | 84 (50) | <0.001 |
Pneumonia, n (%) | 2 (1) | 11 (7) | 5 (3) | 0.026 |
Intracranial bleeding (SAB), n (%) | 42 (25) | 5 (3) | 4 (2) | <0.001 |
Neurological other, n (%) | 19 (11) | 6 (4) | 3 (2) | <0.001 |
Sepsis, n (%) | 9 (5) | 13 (8) | 16 (10) | 0.356 |
Assigned shock groups | ||||
Cardiogenic shock, n (%) | 7 (4) | 23 (14) | 36 (22) | <0.001 |
Distributive shock, n (%) | 13 (8) | 39 (24) | 42 (25) | <0.001 |
Hypovolemic shock, n (%) | 2 (1) | 5 (3) | 5 (3) | 0.466 |
Obstructive shock, n (%) | - | 1 (1) | 1 (1) | 0.603 |
Combination type of shock, n (%) | 2 (1) | 13 (8) | 17 (10) | 0.002 |
Non-shock classification, n (%) | 141 (85) | 85 (51) | 67 (40) | <0.001 |
Clinical data | ||||
Lactate (mmol/L), mean (sd) | 1.6 (1.2) | 1.7 (1.5) | 2.07 (1.9) | 0.088 |
Diuresis (ml/kg/h), mean (sd) | 1.2 (1.0) ® | 1.0(0.79) | 0.9 (0.8) ® | 0.002 |
Saturation (%), median [Q1–Q3] | 93 [89–95] ¥® | 92 [70–94] ¥ | 92 [68–94] ® | <0.001 |
Haemoglobin (mmol/L), mean (sd) | 6.8 (1.4) ¥® | 6.5 (1.2) ¥ | 6.3 (1.2) ® | <0.001 |
Maximum need for norepinephrine dose (mcg/kg/min) during measurement), mean (sd) | 0.12 (0.11) ® | 0.16 (0.13) ‡ | 0.22 (0.20) ®‡ | <0.001 |
Minimum need for norepinephrine dose (mcg/kg/min) during measurement, mean (sd) | 0.07 (0.13) | 0.05 (0.08) ‡ | 0.11 (0.15) ‡ | 0.002 |
Mechanical ventilation, n (%) | 108 (65) | 124 (75) | 125 (75) | 0.077 |
Haemodynamic data * | ||||
Cardiac output (L/min), median [Q1–Q3] | 6.0 [4.9–7.5] ¥ | 5.6 [4.5–6.9] ¥ | 5.6 [4.7–6.7] | 0.027 |
Systolic BP (mmHg), median [Q1–Q3] | 140 [124–158] ¥® | 117 [107–128] ¥ | 109 [99–120] ® | <0.001 |
Diastolic BP (mmHg), median [Q1–Q3] | 67 [61–72] ¥® | 57 [54–62] ¥‡ | 51 [48–55] ‡® | <0.001 |
MAP (mmHg), median [Q1–Q3] | 89 [82–101] ® | 75 [73–80] ‡ | 69 [66–71] ®‡ | <0.001 |
Hypotension MAP < 65 mmHg | Severe TWA Group TWA > 0.5720 mmHg | ||||||||
---|---|---|---|---|---|---|---|---|---|
Covariate | Odds ratio | 95% C.I. | p-Value | Covariate | Odds ratio | 95% C.I. | p-Value | ||
Lower | Upper | Lower | Upper | ||||||
Age | 1.03 | 1.01 | 1.06 | 0.005 | Reason of ICU admission: post cardiac surgery | 2.33 | 1.30 | 4.19 | 0.005 |
Sex (Male) | 2.59 | 1.38 | 4.85 | 0.003 | Reason of ICU admission: IHCA | 5.99 | 0.63 | 56.74 | 0.119 |
BMI | 0.95 | 0.90 | 1.00 | 0.046 | Reason of ICU admission: Intracranial bleeding (SAB) | 0.14 | 0.01 | 1.45 | 0.100 |
Cardiogenic shock classification | 3.70 | 1.17 | 11.66 | 0.026 | Non-shock classification | 0.59 | 0.31 | 1.12 | 0.104 |
Non-shock classification | 0.55 | 0.27 | 1.14 | 0.106 | Haemoglobin (mmol/L) during measurement | 0.84 | 0.68 | 1.04 | 0.108 |
Minimum need for norepinephrine dose (mcg/kg/min) during measurement | 0.12 | 0.01 | 1.23 | 0.074 | Maximum need for norepinephrine dose (mcg/kg/min) during measurement | 7.14 | 0.83 | 61.42 | 0.073 |
Minimum need for norepinephrine dose (mcg/kg/min) during measurement | 31.80 | 0.95 | 1061.59 | 0.053 |
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Terwindt, L.E.; Schuurmans, J.; van der Ster, B.J.P.; Wensing, C.A.G.C.L.; Mulder, M.P.; Wijnberge, M.; Cherpanath, T.G.V.; Lagrand, W.K.; Karlas, A.A.; Verlinde, M.H.; et al. Incidence, Severity and Clinical Factors Associated with Hypotension in Patients Admitted to an Intensive Care Unit: A Prospective Observational Study. J. Clin. Med. 2022, 11, 6832. https://doi.org/10.3390/jcm11226832
Terwindt LE, Schuurmans J, van der Ster BJP, Wensing CAGCL, Mulder MP, Wijnberge M, Cherpanath TGV, Lagrand WK, Karlas AA, Verlinde MH, et al. Incidence, Severity and Clinical Factors Associated with Hypotension in Patients Admitted to an Intensive Care Unit: A Prospective Observational Study. Journal of Clinical Medicine. 2022; 11(22):6832. https://doi.org/10.3390/jcm11226832
Chicago/Turabian StyleTerwindt, Lotte E., Jaap Schuurmans, Björn J. P. van der Ster, Carin A. G. C. L. Wensing, Marijn P. Mulder, Marije Wijnberge, Thomas G. V. Cherpanath, Wim K. Lagrand, Alain A. Karlas, Mark H. Verlinde, and et al. 2022. "Incidence, Severity and Clinical Factors Associated with Hypotension in Patients Admitted to an Intensive Care Unit: A Prospective Observational Study" Journal of Clinical Medicine 11, no. 22: 6832. https://doi.org/10.3390/jcm11226832