Intraoperative Hypotension in Children Undergoing Noncardiac Surgery: An Exploratory Single-Center Analysis of Incidence, Associated Risk Factors, and Outcomes

BACKGROUND: Intraoperative hypotension (IOH) in pediatric patients is associated with multiple adverse outcomes. This study aims to delineate the incidence of IOH, the risk factors associated with its occurrence, and the association of IOH with outcomes in pediatric patients undergoing noncardiac procedures. METHODS: Data from 6748 pediatric patients undergoing noncardiac surgical procedures between January 2015 and August 2022 at a single center were extracted from the American College of Surgery National Surgical Quality Improvement Program pediatric database. Blood pressure data yielded the incidence of IOH, defined as a decrease in systolic blood pressure to below -2 standard deviations for the age- and sex-specific preparation and surgical phase reference values as established by de Graaff et al, for a minimum duration of 5 minutes. This threshold was chosen based on its clinical relevance and its ability to capture significant hypotensive events that may impact patient outcomes. Exploratory multivariable analysis was performed to identify independent risk factors for IOH and associated outcomes, including cardiac arrest, mortality, length of stay, and postoperative ventilation. RESULTS: The institution-specific incidence of IOH was 7.8% (529/6748, 95% CI, 7.2%-8.5%)). The majority of patients with IOH, 58.4% (309/529), had only one 5-minute epoch below the threshold. Preoperative factors including respiratory disease (aOR 1.5 [95% CI, 1.1-2.05]; P = .01), ASA ≥ 3 (aOR 1.9 [95% CI, 1.29-2.82]; P = .001), previous CPR (aOR 8.7 [95% CI, 1.09-69.2]; P = .041), malignancy (aOR 2.4 [95% CI, 1.24-4.62]; P = .009), age 2 to 5 years (aOR 4 [95% CI, 1.18-13.5]; P = .026), age 6 to 8 years (aOR 4.86 [95% CI, 1.36-17.3]; P = .015), age 9 to 11 years (aOR 6.46 [95% CI, 1.68-24.7]; P = .007), and age ≥ 12 years (aOR 7.49 [95% CI, 1.92-29.3]; P = .004) were found to be associated with IOH. Also, patients with IOH had higher rates of postoperative ventilation (aOR 2.25 [95% CI, 1.07-4.73]; P < .001). DISCUSSION: Although brief intervals of IOH among children undergoing noncardiac procedures can occur, recognizing risk factors for IOH can identify high-risk patients preoperatively. This enables the tailoring of perioperative care with preventive measures and management strategies such as adjusting anesthetic agents, fluid management, and intraoperative monitoring, to mitigate the occurrence and impact of IOH, thereby optimizing postoperative outcomes.