Persistent severe postoperative hypotension after pancreaticoduodenectomy is related to increased inflammatory response

BACKGROUND: Hypotension during major surgery is frequent, resulting in increased need for observation in the post-anesthesia care unit and treatment including vasopressors and fluids. However, although severe hypotension in the immediate postoperative recovery phase after major surgery is suggested to be related to increased morbidity and mortality, the underlying risk factors are not well described, hindering advancements in prevention and treatment.

METHODS: We performed a retrospective study assessing factors (age, gender, body-mass index, cardiac co-morbidity, haemoglobin, absolute and increase in c-reactive protein on the first postoperative day, bleeding, fluid balance at the end of surgery and the first postoperative day) related to severe persistent hypotension (SPH) (SPH: need for noradrenaline to maintain a mean arterial blood pressure (MAP) >65.0 mmHg on the morning after surgery) and occurrence of other early (24 hours) complications. One-hundred patients undergoing pancreaticoduodenectomy (PD) with preoperative high dose glucocorticoid and goal-directed fluid therapy were enrolled and perioperative data collected from anaesthetic and medical records.

RESULTS: Forty-five patients had SPH, who had a significantly higher increase in CRP levels the morning after surgery (median 50 mg∙L-1 vs. 41 mg∙L-1 , SPH vs non-SPH respectively, p=0.028), and a significantly more positive fluid balance at discharge (median 1457 ml vs. 1031 ml, respectively, p=0.027) vs. patients without SPH.

CONCLUSIONS: SPH after PD was associated with significantly increased inflammatory response and increased need for fluids. Future studies should investigate the effect of further inflammatory control in PD to improve haemodynamics and morbidity.