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| Name | Class |
|---|---|
| Kehlet, Henrik, M.D., Ph.D. | INDIV |
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Incidence and pathophysiologic hemodynamics of orthostatic intolerance and orthostatic hypotension in patients undergoing unilateral THA
Early postoperative mobilization is a cornerstone in the so-called fast track multimodal perioperative approach and is essential in preventing postoperative morbidity and reducing hospital length-of-stay. Intact orthostatic blood pressure regulation is essential for early postoperative mobilization. However, early postoperative mobilization can be delayed due to postoperative orthostatic hypotension (POH) defined as a fall in systolic pressure > 20 mmHg and/or diastolic pressure > 10 mmHg or due to postoperative orthostatic intolerance (POI), characterized by dizziness, nausea, vomiting, blurred vision or syncope during mobilization. Although these conditions are well-known clinical problems that can delay early mobilization, relatively few data are available on pathophysiological mechanisms and possible treatments.
Several prospective studies with standardized mobilization procedures have already established that the incidence of POI and POH after THA is 38-42% at 6 hours after surgery.
Previous studies on patients undergoing prostatectomy and THA have also demonstrated that attenuated vasopressor response and a concomitant reduction in cardiac output (CO) and cerebral perfusion during postural changes after surgery contributes to POI and POH. Strategies aiming to reduce the incidence of POI and POH by pain management, vasoconstrictive treatment with alpha-1 receptor agonist, optimized fluid management with goal-directed fluid therapy and reduction of surgical stress-response with pre-operative high-dose glucocorticoid did not solve the problem.
The precise pathophysiological mechanisms of POI and POH remain to be elucidated and this is therefore the aim of the current prospective observational study.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Orthostatic intolerant (OI) | Patients that experience symptoms of orthostatic intolerance (dizziness, nausea, vomiting, blurry vision or syncope) or orthostatic hypotension (fall in systolic pressure > 20 mmHg and/or diastolic pressure > 10 mmHg) during mobilisation | ||
| Orthostatic tolerant (OT) | Patients that do not experience symptoms of orthostatic intolerance (dizziness, nausea, vomiting, blurry vision or syncope) or orthostatic hypotension (fall in systolic pressure > 20 mmHg and/or diastolic pressure > 10 mmHg) during mobilisation |
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| Measure | Description | Time Frame |
|---|---|---|
| Incidence of orthostatic intolerance | Symptoms of orthostatic intolerance: dizziness, nausea, vomiting, blurry vision or syncope during mobilization | 6 hours postoperatively |
| Incidence of orthostatic hypotension | Orthostatic hypotension is defined as a fall in systolic pressure > 20 mmHg and/or diastolic pressure > 10 mmHg during mobilization | 6 hours postoperatively |
| Measure | Description | Time Frame |
|---|---|---|
| Changes in systolic arterial pressure (SAP) during mobilization | Measured in mmHg | Preoperatively, 6 and 24 hours postoperatively |
| Changes in diastolic arterial pressure (DAP) during mobilization |
| Measure | Description | Time Frame |
|---|---|---|
| Pain score | Measured by verbal rating scale (VRS) from 0 to 10 (0 = no pain, 10 = worse pain imaginable) | Preoperatively, 6 and 24 hours postoperatively |
| Estimated bleeding | Measured in mL |
Inclusion Criteria:
Exclusion Criteria:
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Patients undergoing primary unilateral total hip arthroplasty in spinal anesthesia in standardized fast-track setting
| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Ana-Marija Hristovska, MD | Contact | +4538621508 | ana-marija.hristovska.02@regionh.dk | |
| Nicolai Foss, MD | Contact | nicolai.bang.foss@regionh.dk |
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Hvidovre Hospital | Recruiting | Copenhagen | Denmark |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 22174345 | Background | Jans O, Bundgaard-Nielsen M, Solgaard S, Johansson PI, Kehlet H. Orthostatic intolerance during early mobilization after fast-track hip arthroplasty. Br J Anaesth. 2012 Mar;108(3):436-43. doi: 10.1093/bja/aer403. Epub 2011 Dec 15. | |
| 29573263 | Background | Lindberg-Larsen V, Petersen PB, Jans O, Beck T, Kehlet H. Effect of pre-operative methylprednisolone on orthostatic hypotension during early mobilization after total hip arthroplasty. Acta Anaesthesiol Scand. 2018 Aug;62(7):882-892. doi: 10.1111/aas.13108. Epub 2018 Mar 24. |
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| ID | Term |
|---|---|
| D054971 | Orthostatic Intolerance |
| D007024 | Hypotension, Orthostatic |
| D011183 | Postoperative Complications |
| ID | Term |
|---|---|
| D054969 | Primary Dysautonomias |
| D001342 | Autonomic Nervous System Diseases |
| D009422 | Nervous System Diseases |
| D009461 | Neurologic Manifestations |
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Measured in mmHg
| Preoperatively, 6 and 24 hours postoperatively |
| Changes in mean arterial pressure (MAP) during mobilization | Measured in mmHg | Preoperatively, 6 and 24 hours postoperatively |
| Changes in systemic vascular resistance (SVR) during mobilization | Measured in mmHg⋅min⋅mL-1 | Preoperatively, 6 and 24 hours postoperatively |
| Changes in cardiac output (CO) during mobilization | Measured in mL/min | Preoperatively, 6 and 24 hours postoperatively |
| Changes in stroke volume (SV) during mobilization | Measured in mL | Preoperatively, 6 and 24 hours postoperatively |
| Changes in heart rate variability (HRV) during mobilization | Measured in ms | Preoperatively, 6 and 24 hours postoperatively |
| Changes in baroreflex sensitivity (BRS) during mobilization | Measured in ms/mmHg | Preoperatively, 6 and 24 hours postoperatively |
| Changes in peripheral perfusion index (PPI) during mobilization | Measured in arbitrary units (AU) | Preoperatively, 6 and 24 hours postoperatively |
| Changes in cerebral perfusion (ScO2) during mobilization | Measured in % | Preoperatively, 6 and 24 hours postoperatively |
| Changes in muscular perfusion (SmO2) during mobilization | Measured in % | Preoperatively, 6 and 24 hours postoperatively |
| Changes in total blood volume (TBV) | Measured in mL | Preoperatively, 6 and 24 hours postoperatively |
| Changes in erythrocyte volume (ECV) | Measured in mL | Preoperatively, 6 and 24 hours postoperatively |
| Changes in plasma volume (PV) | Measured in mL | Preoperatively, 6 and 24 hours postoperatively |
| Changes in hematocrit | Measured in % | Preoperatively, 6 and 24 hours postoperatively |
| Changes in haemoglobin (Hgb) concentration | Measured in millimoles/L | Preoperatively, 6 and 24 hours postoperatively |
| Changes in C-Reactive Protein | Measured in mg/L | Preoperatively, 6 and 24 hours postoperatively |
| Intraoperatively, 6 and 24 hours postoperatively |
| Opioid use | Measured in mg | 6 and 24 hours postoperatively |
| Cumulative fluid administration and losses | Measured in mg | Intraoperatively, 6 and 24 hours postoperatively |
| 26492477 | Background | Jans O, Mehlsen J, Kjaersgaard-Andersen P, Husted H, Solgaard S, Josiassen J, Lunn TH, Kehlet H. Oral Midodrine Hydrochloride for Prevention of Orthostatic Hypotension during Early Mobilization after Hip Arthroplasty: A Randomized, Double-blind, Placebo-controlled Trial. Anesthesiology. 2015 Dec;123(6):1292-300. doi: 10.1097/ALN.0000000000000890. |
| 23756453 | Background | Bundgaard-Nielsen M, Jans O, Muller RG, Korshin A, Ruhnau B, Bie P, Secher NH, Kehlet H. Does goal-directed fluid therapy affect postoperative orthostatic intolerance?: A randomized trial. Anesthesiology. 2013 Oct;119(4):813-23. doi: 10.1097/ALN.0b013e31829ce4ea. |
| 27638295 | Background | Jans O, Kehlet H. Postoperative orthostatic intolerance: a common perioperative problem with few available solutions. Can J Anaesth. 2017 Jan;64(1):10-15. doi: 10.1007/s12630-016-0734-7. Epub 2016 Sep 14. No abstract available. |
| D012816 | Signs and Symptoms |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D007022 | Hypotension |
| D014652 | Vascular Diseases |
| D002318 | Cardiovascular Diseases |
| D010335 | Pathologic Processes |