Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study

Ana-Marija Hristovska; Bodil Uldall-Hansen; Jesper Mehlsen; Louise B Andersen; Henrik Kehlet; Nicolai B Foss

doi:10.1007/s12630-023-02556-6

Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study

Ana-Marija Hristovska^*, Bodil Uldall-Hansen, Jesper Mehlsen, Louise B Andersen, Henrik Kehlet, Nicolai B Foss

^*Corresponding author for this work

9 Citations (Scopus)

Abstract

PURPOSE: Early postoperative mobilization can be hindered by orthostatic intolerance (OI). Postoperative OI has multifactorial pathogenesis, possibly involving both postoperative hypovolemia and autonomic dysfunction. We aimed to investigate the effect of mild acute blood loss from blood donation simulating postoperative hypovolemia, on both autonomic function and OI, thus eliminating confounding perioperative factors such as inflammation, residual anesthesia, pain, and opioids.

METHODS: This prospective observational cohort study included 26 blood donors. Continuous electrocardiogram data were collected during mobilization and night sleep, both before and after blood donation. A Valsalva maneuver and a standardized mobilization procedure were performed immediately before and after blood donation, during which cardiovascular and tissue oxygenation variables were continuously measured by LiDCOrapid™ and Massimo Root™, respectively. The incidence of OI, hemodynamic responses during mobilization and Valsalva maneuver, as well as heart rate variability (HRV) responses during mobilization and sleep were compared before and 15 min after blood donation.

RESULTS: Prior to blood donation, no donors experienced OI during mobilization. After blood donation, 6/26 (23%; 95% CI, 9 to 44) donors experienced at least one OI symptom. Three out of 26 donors (12%; 95% CI, 2 to 30) terminated the mobilization procedure prematurely because of severe OI symptoms. Cardiovascular and cerebral tissue oxygenation responses were reduced in patients with severe OI. After blood loss, HRV indices of total autonomic power remained unchanged but increased sympathetic and decreased parasympathetic outflow was observed during mobilization, but also during sleep, indicating a prolonged autonomic effect of hypovolemia.

CONCLUSION: We describe a specific hypovolemic component of postoperative OI, independent of postoperative autonomic dysfunction, inflammation, opioids, and pain.

STUDY REGISTRATION: ClinicalTrials.gov (NCT04499664); registered 5 August 2020.

Original language	English
Journal	Canadian journal of anaesthesia = Journal canadien d'anesthesie
Volume	70
Issue number	10
Pages (from-to)	1587-1599
Number of pages	13
ISSN	0832-610X
DOIs	https://doi.org/10.1007/s12630-023-02556-6
Publication status	Published - Oct 2023

Keywords

Blood Pressure/physiology
Heart Rate/physiology
Hemodynamics
Hemorrhage
Humans
Hypovolemia/epidemiology
Incidence
Inflammation
Orthostatic Intolerance/epidemiology
Pain
Prospective Studies

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10.1007/s12630-023-02556-6

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Hristovska, A.-M., Uldall-Hansen, B., Mehlsen, J., Andersen, L. B., Kehlet, H., & Foss, N. B. (2023). Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study. Canadian journal of anaesthesia = Journal canadien d'anesthesie, 70(10), 1587-1599. https://doi.org/10.1007/s12630-023-02556-6

Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study. / Hristovska, Ana-Marija; Uldall-Hansen, Bodil; Mehlsen, Jesper et al.
In: Canadian journal of anaesthesia = Journal canadien d'anesthesie, Vol. 70, No. 10, 10.2023, p. 1587-1599.

Research output: Contribution to journal › Journal article › Research › peer-review

Hristovska, A-M, Uldall-Hansen, B, Mehlsen, J , Andersen, LB , Kehlet, H & Foss, NB 2023, 'Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study', Canadian journal of anaesthesia = Journal canadien d'anesthesie, vol. 70, no. 10, pp. 1587-1599. https://doi.org/10.1007/s12630-023-02556-6

Hristovska AM, Uldall-Hansen B, Mehlsen J , Andersen LB , Kehlet H , Foss NB. Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study. Canadian journal of anaesthesia = Journal canadien d'anesthesie. 2023 Oct;70(10):1587-1599. doi: 10.1007/s12630-023-02556-6

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title = "Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study",

abstract = "PURPOSE: Early postoperative mobilization can be hindered by orthostatic intolerance (OI). Postoperative OI has multifactorial pathogenesis, possibly involving both postoperative hypovolemia and autonomic dysfunction. We aimed to investigate the effect of mild acute blood loss from blood donation simulating postoperative hypovolemia, on both autonomic function and OI, thus eliminating confounding perioperative factors such as inflammation, residual anesthesia, pain, and opioids.METHODS: This prospective observational cohort study included 26 blood donors. Continuous electrocardiogram data were collected during mobilization and night sleep, both before and after blood donation. A Valsalva maneuver and a standardized mobilization procedure were performed immediately before and after blood donation, during which cardiovascular and tissue oxygenation variables were continuously measured by LiDCOrapid{\texttrademark} and Massimo Root{\texttrademark}, respectively. The incidence of OI, hemodynamic responses during mobilization and Valsalva maneuver, as well as heart rate variability (HRV) responses during mobilization and sleep were compared before and 15 min after blood donation.RESULTS: Prior to blood donation, no donors experienced OI during mobilization. After blood donation, 6/26 (23\%; 95\% CI, 9 to 44) donors experienced at least one OI symptom. Three out of 26 donors (12\%; 95\% CI, 2 to 30) terminated the mobilization procedure prematurely because of severe OI symptoms. Cardiovascular and cerebral tissue oxygenation responses were reduced in patients with severe OI. After blood loss, HRV indices of total autonomic power remained unchanged but increased sympathetic and decreased parasympathetic outflow was observed during mobilization, but also during sleep, indicating a prolonged autonomic effect of hypovolemia.CONCLUSION: We describe a specific hypovolemic component of postoperative OI, independent of postoperative autonomic dysfunction, inflammation, opioids, and pain.STUDY REGISTRATION: ClinicalTrials.gov (NCT04499664); registered 5 August 2020.",

keywords = "Blood Pressure/physiology, Heart Rate/physiology, Hemodynamics, Hemorrhage, Humans, Hypovolemia/epidemiology, Incidence, Inflammation, Orthostatic Intolerance/epidemiology, Pain, Prospective Studies, heart rate variability, hemodynamics, hypovolemia, orthostatic intolerance, perioperative care",

author = "Ana-Marija Hristovska and Bodil Uldall-Hansen and Jesper Mehlsen and Andersen, \{Louise B\} and Henrik Kehlet and Foss, \{Nicolai B\}",

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doi = "10.1007/s12630-023-02556-6",

language = "English",

volume = "70",

pages = "1587--1599",

journal = "Canadian journal of anaesthesia = Journal canadien d'anesthesie",

issn = "0832-610X",

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TY - JOUR

T1 - Orthostatic intolerance after acute mild hypovolemia

T2 - incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study

AU - Hristovska, Ana-Marija

AU - Uldall-Hansen, Bodil

AU - Mehlsen, Jesper

AU - Andersen, Louise B

AU - Kehlet, Henrik

AU - Foss, Nicolai B

PY - 2023/10

Y1 - 2023/10

N2 - PURPOSE: Early postoperative mobilization can be hindered by orthostatic intolerance (OI). Postoperative OI has multifactorial pathogenesis, possibly involving both postoperative hypovolemia and autonomic dysfunction. We aimed to investigate the effect of mild acute blood loss from blood donation simulating postoperative hypovolemia, on both autonomic function and OI, thus eliminating confounding perioperative factors such as inflammation, residual anesthesia, pain, and opioids.METHODS: This prospective observational cohort study included 26 blood donors. Continuous electrocardiogram data were collected during mobilization and night sleep, both before and after blood donation. A Valsalva maneuver and a standardized mobilization procedure were performed immediately before and after blood donation, during which cardiovascular and tissue oxygenation variables were continuously measured by LiDCOrapid™ and Massimo Root™, respectively. The incidence of OI, hemodynamic responses during mobilization and Valsalva maneuver, as well as heart rate variability (HRV) responses during mobilization and sleep were compared before and 15 min after blood donation.RESULTS: Prior to blood donation, no donors experienced OI during mobilization. After blood donation, 6/26 (23%; 95% CI, 9 to 44) donors experienced at least one OI symptom. Three out of 26 donors (12%; 95% CI, 2 to 30) terminated the mobilization procedure prematurely because of severe OI symptoms. Cardiovascular and cerebral tissue oxygenation responses were reduced in patients with severe OI. After blood loss, HRV indices of total autonomic power remained unchanged but increased sympathetic and decreased parasympathetic outflow was observed during mobilization, but also during sleep, indicating a prolonged autonomic effect of hypovolemia.CONCLUSION: We describe a specific hypovolemic component of postoperative OI, independent of postoperative autonomic dysfunction, inflammation, opioids, and pain.STUDY REGISTRATION: ClinicalTrials.gov (NCT04499664); registered 5 August 2020.

AB - PURPOSE: Early postoperative mobilization can be hindered by orthostatic intolerance (OI). Postoperative OI has multifactorial pathogenesis, possibly involving both postoperative hypovolemia and autonomic dysfunction. We aimed to investigate the effect of mild acute blood loss from blood donation simulating postoperative hypovolemia, on both autonomic function and OI, thus eliminating confounding perioperative factors such as inflammation, residual anesthesia, pain, and opioids.METHODS: This prospective observational cohort study included 26 blood donors. Continuous electrocardiogram data were collected during mobilization and night sleep, both before and after blood donation. A Valsalva maneuver and a standardized mobilization procedure were performed immediately before and after blood donation, during which cardiovascular and tissue oxygenation variables were continuously measured by LiDCOrapid™ and Massimo Root™, respectively. The incidence of OI, hemodynamic responses during mobilization and Valsalva maneuver, as well as heart rate variability (HRV) responses during mobilization and sleep were compared before and 15 min after blood donation.RESULTS: Prior to blood donation, no donors experienced OI during mobilization. After blood donation, 6/26 (23%; 95% CI, 9 to 44) donors experienced at least one OI symptom. Three out of 26 donors (12%; 95% CI, 2 to 30) terminated the mobilization procedure prematurely because of severe OI symptoms. Cardiovascular and cerebral tissue oxygenation responses were reduced in patients with severe OI. After blood loss, HRV indices of total autonomic power remained unchanged but increased sympathetic and decreased parasympathetic outflow was observed during mobilization, but also during sleep, indicating a prolonged autonomic effect of hypovolemia.CONCLUSION: We describe a specific hypovolemic component of postoperative OI, independent of postoperative autonomic dysfunction, inflammation, opioids, and pain.STUDY REGISTRATION: ClinicalTrials.gov (NCT04499664); registered 5 August 2020.

KW - Blood Pressure/physiology

KW - Heart Rate/physiology

KW - Hemodynamics

KW - Hemorrhage

KW - Humans

KW - Hypovolemia/epidemiology

KW - Incidence

KW - Inflammation

KW - Orthostatic Intolerance/epidemiology

KW - Pain

KW - Prospective Studies

KW - heart rate variability

KW - hemodynamics

KW - hypovolemia

KW - orthostatic intolerance

KW - perioperative care

UR - https://www.scopus.com/pages/publications/85172678504

U2 - 10.1007/s12630-023-02556-6

DO - 10.1007/s12630-023-02556-6

M3 - Journal article

C2 - 37752379

SN - 0832-610X

VL - 70

SP - 1587

EP - 1599

JO - Canadian journal of anaesthesia = Journal canadien d'anesthesie

JF - Canadian journal of anaesthesia = Journal canadien d'anesthesie

IS - 10

ER -

Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study

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