Performance of the Hypotension Prediction Index with non-invasive arterial pressure waveforms in non-cardiac surgical patients

Kamal Maheshwari, Sai Buddi, Zhongping Jian, Jos Settels, Tetsuya Shimada, Barak Cohen, Daniel I Sessler, Feras Hatib, Kamal Maheshwari, Sai Buddi, Zhongping Jian, Jos Settels, Tetsuya Shimada, Barak Cohen, Daniel I Sessler, Feras Hatib

Abstract

An algorithm derived from machine learning uses the arterial waveform to predict intraoperative hypotension some minutes before episodes, possibly giving clinician's time to intervene and prevent hypotension. Whether the Hypotension Prediction Index works well with noninvasive arterial pressure waveforms remains unknown. We therefore evaluated sensitivity, specificity, and positive predictive value of the Index based on non-invasive arterial waveform estimates. We used continuous hemodynamic data measured from ClearSight (formerly Nexfin) noninvasive finger blood pressure monitors in surgical patients. We re-evaluated data from a trial that included 320 adults ≥ 45 years old designated ASA physical status 3 or 4 who had moderate-to-high-risk non-cardiac surgery with general anesthesia. We calculated sensitivity and specificity for predicting hypotension, defined as mean arterial pressure ≤ 65 mmHg for at least 1 min, and characterized the relationship with receiver operating characteristics curves. We also evaluated the number of hypotensive events at various ranges of the Hypotension Prediction Index. And finally, we calculated the positive predictive value for hypotension episodes when the Prediction Index threshold was 85. The algorithm predicted hypotension 5 min in advance, with a sensitivity of 0.86 [95% confidence interval 0.82, 0.89] and specificity 0.86 [0.82, 0.89]. At 10 min, the sensitivity was 0.83 [0.79, 0.86] and the specificity was 0.83 [0.79, 0.86]. And at 15 min, the sensitivity was 0.75 [0.71, 0.80] and the specificity was 0.75 [0.71, 0.80]. The positive predictive value of the algorithm prediction at an Index threshold of 85 was 0.83 [0.79, 0.87]. A Hypotension Prediction Index of 80-89 provided a median of 6.0 [95% confidence interval 5.3, 6.7] minutes warning before mean arterial pressure decreased to < 65 mmHg. The Hypotension Prediction Index, which was developed and validated with invasive arterial waveforms, predicts intraoperative hypotension reasonably well from non-invasive estimates of the arterial waveform. Hypotension prediction, along with appropriate management, can potentially reduce intraoperative hypotension. Being able to use the non-invasive pressure waveform will widen the range of patients who might benefit.Clinical Trial Number: ClinicalTrials.gov NCT02872896.

Keywords: Hypotension Prediction Index; Hypotension prediction; Intraoperative hypotension; Machine learning; Non-invasive blood pressure.

Conflict of interest statement

KM, DS are consultant for Edwards Lifesciences. SB, ZJ, JS, and FH are employees of Edwards Lifesciences.

Figures

Fig. 1
Fig. 1
Effect of clinical intervention on HPI and MAP. HPI Hypotension Prediction Index, MAP mean arterial pressure
Fig. 2
Fig. 2
ROC plot at 5, 10, and 15-min for the entire cohort of 305 patients
Fig. 3
Fig. 3
Hypotensive, MAP MAP mean arterial pressure

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