title: Hospital stay and mortality are increased in patients having a "triple low" of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia.
abstract: BACKGROUND
  Low mean arterial pressure (MAP) and deep hypnosis have been associated with complications and mortality. The normal response to high minimum alveolar concentration (MAC) fraction of anesthetics is hypotension and low Bispectral Index (BIS) scores. Low MAP and/or BIS at lower MAC fractions may represent anesthetic sensitivity. The authors sought to characterize the effect of the triple low state (low MAP and low BIS during a low MAC fraction) on duration of hospitalization and 30-day all-cause mortality.
  
  
  METHODS
  Mean intraoperative MAP, BIS, and MAC were determined for 24,120 noncardiac surgery patients at the Cleveland Clinic, Cleveland, Ohio. The hazard ratios associated with combinations of MAP, BIS, and MAC values greater or less than a reference value were determined. The authors also evaluated the association between cumulative triple low minutes, and excess length-of-stay and 30-day mortality.
  
  
  RESULTS
  Means (±SD) defining the reference, low, and high states were 87 ± 5 mmHg (MAP), 46 ± 4 (BIS), and 0.56 ± 0.11 (MAC). Triple lows were associated with prolonged length of stay (hazard ratio 1.5, 95% CI 1.3-1.7). Thirty-day mortality was doubled in double low combinations and quadrupled in the triple low group. Triple low duration ≥60 min quadrupled 30-day mortality compared with ≤15 min. Excess length of stay increased progressively from ≤15 min to ≥60 min of triple low.
  
  
  CONCLUSIONS
  The occurrence of low MAP during low MAC fraction was a strong and highly significant predictor for mortality. When these occurrences were combined with low BIS, mortality risk was even greater. The values defining the triple low state were well within the range that many anesthesiologists tolerate routinely.
authors.affiliation: Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH 44195, USA. ds@or.org
authors.forename: Daniel I
authors.initials: DI
authors.lastname: Sessler
authors.forename: Jeffrey C
authors.initials: JC
authors.lastname: Sigl
authors.forename: Scott D
authors.initials: SD
authors.lastname: Kelley
authors.forename: Nassib G
authors.initials: NG
authors.lastname: Chamoun
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Manberg
authors.forename: Leif
authors.initials: L
authors.lastname: Saager
authors.forename: Andrea
authors.initials: A
authors.lastname: Kurz
authors.forename: Scott
authors.initials: S
authors.lastname: Greenwald
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000768:Anesthesia, General; D000769:Anesthesia, Inhalation; D018685:Anesthetics, Inhalation / Q000378:metabolism* / Q000493:pharmacokinetics; D015992:Body Mass Index; D056805:Consciousness Monitors; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007022:Hypotension / Q000150:complications / Q000401:mortality*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011650:Pulmonary Alveoli / Q000502:physiology*; D055815:Young Adult
chemical_list: D018685:Anesthetics, Inhalation