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#8. Is Blood Pressure Target Personalization the Way to Go? | Euroanaesthesia 2022

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  • Picture of the speaker Prof. Bernd Saugel

Listen to Bernd Saugel at Euroanesthesia 2022 as he reviews several topics, including blood pressure, what an appropriate target is for a perioperative practitioner and the post-op period and transition of care.

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Listen to Bernd Saugel at Euroanesthesia 2022 as he reviews several topics, including blood pressure, what an appropriate target is for a perioperative practitioner and the post-op period and transition of care.

This podcast was recorded by TopMedTalk in Milano, Italy at Euroanesthesia 2022. Click here if you would like to listen to it from the TopMedTalk platform.

TopMedTalk.

Desiree Chappell: Well, hello and welcome to Euroanaesthesia 2022, day 3, in Milano, Italy. I'm Desiree Chappell, your host and I'm joined by Monty Mythen from TopMedTalk. Hello, Monty.

Monty Mythen: Hi, Desiree, great to still be here on day 3.

Desiree Chappell: It is day 3. TopMedTalk on the GE Healthcare booth here in the trade exhibition.

Monty Mythen: Uh, very grateful for their sponsorship, which allows us to provide free open access medical education.

Desiree Chappell: Yes. Absolutely, it's been wonderful to be back and, uh, see some friends, for sure.

Monty Mythen: We've caught up with a lot of people.

Desiree Chappell: (laughs).

Monty Mythen: It's been quite [inaudible 00:00:32]. It's good.

Desiree Chappell: Yeah, it's great. Well, also join us is our friend Sol Aronson [inaudible 00:00:37]. Hello, Sol. (laughs).

Sol Aronson: How are you, Desiree?

Desiree Chappell: (laughs).

Sol Aronson: And Monty how much is the open access education?

Monty Mythen: Free.

Sol Aronson: It's free.

Desiree Chappell: (laughs).

Sol Aronson: It is free.

Desiree Chappell: At TopMedTalk.

Monty Mythen: [inaudible 00:00:46] that's free, free. That's European free.

Sol Aronson: Free, free.

Desiree Chappell: (laughs).

Monty Mythen: Do you know? Do you understand that?

Sol Aronson: I believe that's free.

Desiree Chappell: (laughs).

Monty Mythen: Completely free.

Sol Aronson: Yeah. Excellent.

Desiree Chappell: Yeah. Everything that we do here on TopMedTalk is completely free, generous support from all of our sponsors.

Monty Mythen: Thank you very much, indeed.

Desiree Chappell: Absolutely. Um, well, great conversation, since we've been here at the meeting covered several different topics, a lot around monitoring, uh, inter op morbidity, post-op morbidity, all those different things. Some of the highlights so far.

Monty Mythen: So, we've been, uh, visiting once again, blood pressure

Desiree Chappell: Yeah.

Monty Mythen: ... cause it's one of the hot topics.

Desiree Chappell: Yeah.

Monty Mythen: Uh, um, you know, for those of you who are new to TopMedTalk, if you go into our search engine, we've covered off pretty much everything in the perioperative space

Desiree Chappell: Yeah.

Monty Mythen: ... quite extensively. So don't think we're just obsessed with blood pressure and post-op morbidity.

Desiree Chappell: (laughs), we talk about everything, [inaudible 00:01:32].

Monty Mythen: But that's where we are right at the moment.

Desiree Chappell: Yeah.

Monty Mythen: So, we've heard the results of some very large, impressive trials, for example

Desiree Chappell: Yeah.

Monty Mythen: ... about patient warming, about breath sizes and PEEP during anesthesia

Desiree Chappell: Mm-hmm.

Monty Mythen: ... and about blood pressure management. And for example, the use of tranexamic acid. So, if you look at the interviews from

Desiree Chappell: Yeah.

Monty Mythen: ... yesterday, and the day before, quite a lot of things, which people tend to badge as negative trials.

Desiree Chappell: Yes.

Monty Mythen: In other words, very large trials, let's say, in these pragmatic situations, intraoperatively. It's not clear that many of those things make that much difference to outcomes.

Desiree Chappell: Yeah, and so everybody wants to say that's negative.

Monty Mythen: Negative. No, it's not, it's important thing to say, "Don't be too obsessed about the temperature you're trying to manage the patient at within these boundaries."

Desiree Chappell: Right.

Monty Mythen: Tem- temperature management is important. And if we take the tranexamic acid one, for example, where there's a long history of smaller and increasingly larger trials showing that bleeding is decreased.

Desiree Chappell: Yeah.

Monty Mythen: Bleeding was decreased.

Desiree Chappell: Yeah.

Monty Mythen: But it also reassured us about safety.

Desiree Chappell: Right.

Monty Mythen: So, they're really important trials. Now one of the caveats with that is the blood pressure one, for example-

Desiree Chappell: Yeah.

Monty Mythen: ... the second component of POISE-3, one simple takeaway message could be that blood pressure management does not matter.

Desiree Chappell: Yeah.

Monty Mythen: But that's not what the trial showed us.

Desiree Chappell: Yeah.

Monty Mythen: Almost no patient in a seven and a half thousand plus patient study looking intraoperatively, where they were randomized to either avoid hypotension or hypertension, almost no patient went below a threshold of 60.

Desiree Chappell: Yeah.

Monty Mythen: And these were hypertensive patients on at least one medication. Now, we know that's very unusual.

Desiree Chappell: Yeah.

Monty Mythen: So, they're already unusual

Desiree Chappell: Yeah.

Monty Mythen: ... to be in that category. And then the si- signal separation between those trying to achieve a level of 80 and 60, there wasn't that much difference between the two groups.

Desiree Chappell: Yeah.

Monty Mythen: So, the big takeaway from it was that somewhere in that 60 to 70 -ish range

Desiree Chappell: Yeah.

Monty Mythen: ... is still the reference point, uh, against which we should judge subsequent trials. I'll be quiet in a second, cause the other discussion to point we want to go into in a moment is, are we just looking in the wrong place?

Desiree Chappell: Mm-hmm.

Monty Mythen: Because we... it's easy to look into operatively.

Desiree Chappell: Yes.

Monty Mythen: But we're told that all the real badness happens postoperatively. So, are we looking as I said yesterday, under the lamp, even though we dropped our keys somewhere else?

Desiree Chappell: Yeah. Yeah.

Monty Mythen: So, we're, we're gonna go with, I think with our guest into those two points.

Desiree Chappell: Um, so well, let's go ahead and introduce our guest today. We have Bernd Saugel, from Hamburg, Germany. Bernd, thank you so much for joining us today on TopMedTalk. I know you've been very busy here at Euroanaesthesia (laughs) 2022. I think I was looking at like seven different lectures and participation and events throughout the, throughout the meeting.

Bernd Saugel: I stopped counting. Yeah.

Desiree Chappell: (laughs), well, I know you came just fr- just from a session. So, thank you for taking the time out to join us. For, um, those who may not know you tell us a little bit more about yourself.

Bernd Saugel: Absolutely. My name is Bernd Saugel, I'm from Hamburg in Germany. So, I'm a professor of anesthesiology and the Vice Chair of the Department of Anesthesiology at the University Medical Center in Hamburg, in Germany. And well, my research interests are the optimization of cardiovascular dynamics in high-risk patients having surgery and in critically ill patients and I especially focus on concepts of personalizing hemodynamics with regards to blood pressure and even cardiac output.

Desiree Chappell: [inaudible 00:04:46] Interesting, well, I'd l- we wanna deep dive into, into all those things, but we've had a lot of conversation here over the meeting about several different topics. Monty some of the things we've been talking to Bert about.

Monty Mythen: So, the first section of this discussion, but I want to pick off two things. One is whether... And this is a loaded question.

Desiree Chappell: (laughs).

Monty Mythen: One is whether choosing that blood pressure as a treatment target is too simplistic?

Desiree Chappell: Hmm.

Monty Mythen: Because, you know, we know that we can hit that target by starting a vasopressor infusion and do what might be the wrong thing to achieve the right number. And the second one, which I know you're very interested in, is about, if we aren't going to personalize that blood pressure number, what should that blood pressure number be? So, number one, the simple target of blood pressure, too simple.

Bernd Saugel: In my opinion, it's too simple. Yeah, what we know now, uh, what we know now, of course, is that there is an association between hypotension and low blood pressure during surgery and post-operative organ injury. And if we look at the population level, the population harm threshold, usually is around, uh, 60 to 65 for a mean arterial pressure. So, when you look at the whole population, this is the point where the risk kind of goes up for postoperative organ injury.

Bernd Saugel: And now we have a couple of trials, um, three or four, actually, that, uh, tried to compare different blood pressure targets. The biggest trial so far, of course, is what you already mentioned, the POISE-3 trial. Um, that is not published yet, but from what we know they compare two different, uh, fixed blood pressure targets and didn't find the difference in outcome. The same, by the way is true for a study that was published last year by Banna et all, it's substantially smaller trial than POISE-3, but, uh, still more than 450 patients. And they also compare, uh, to fixed blood pressure targets, like more than keeping, maintaining, uh, tem- I mean, a temperature above 65 versus a higher threshold. But again, fixed thresholds. And they didn't find a difference in patient centered outcomes too.

Bernd Saugel: And then we have a third trial that I find very interesting, and that is the IMPRESS trial that was published a couple of years ago in the JAMA. And what were [inaudible 00:06:50] there, they tried to individualize blood pressure, based on the preoperative systolic blood pressure. So specifically, they measured systolic blood pressure during, uh, the... Well, when, when they checked the patient before surgery, and if that value was not available, they did it the day before surgery on the normal ward. But there was a single blood pressure reading I- in the resting patient. And they then took this, uh, systolic blood pressure and then try to maintain it within a 10%, um, range during surgery.

Bernd Saugel: And there are a couple of limitations with this trial, including that there were two different ways of [inaudible 00:07:27] in both, uh... the two groups. And that the endpoint is a little bit unusual, because it was a composite of systemic inflammatory response syndrome and, uh, at least one, uh, organ failing, at least one major organ system. But this trial was successful in the terms that individualizing treatment improved outcomes, the other trials were neutral. I don't like to speak about them as a negative trial, but they were neutral. So, there's some... At least the hint that individualizing blood pressure targets may, may, may be the way to go.

Desiree Chappell: Yeah.

Monty Mythen: So how do we individualize it?

Desiree Chappell: That's what I was just gonna ask, (laughs). How do

Bernd Saugel: That is-

Desiree Chappell: ... we get there, (laughs)?

Bernd Saugel: That is a big question, of course. And at least I can say what we shouldn't do.

Desiree Chappell: Yeah.

Bernd Saugel: So first of all, I think that what [inaudible 00:08:08] and colleagues did was a single measurement. Um, this is a little bit too simple, because we know from cardiology, uh, that a single measurement hardly reflects, um, personal blood pressure physiology. So this is something that we know for years, because there is, uh, white coat hypertension, this is hypo... people being, uh, hypertensive only when they are at the doctor, but not when they are home. But there's also the opposite like mass hypotension. So they feel safe when they see a doctor and they are not hypertensive there, but they are hypertensive at home.

Bernd Saugel: So what the gold standard is when we look at cardiology is that you need to have an ambulatory 24-hour blood pressure measurement. That means you have an automated oscillometric system that allows to measure blood pressure, like every 15, and 30 or 60 minutes. And then you do that for one day and for one, for one night, during the usual activity. So patients during the daytime do whatever they do, and at night, they usually sleep. And then you can see the blood pressure profile over those 24 hours. And what pa- patients d- people usually do is they dip at night. So blood pressure goes down at night and this is an important and physiologic, uh... physiologically, uh, reasonable thing.

Desiree Chappell: Yeah.

Bernd Saugel: So at night your blood pressure drops and this... By the way, this non... if, if you are non-dipper. If your blood pressure does not

Desiree Chappell: (laughs).

Bernd Saugel: ... go down at night, this is, uh, uh, a risk factor for cardiovascular disease, even, even more than hypertension, per se. And this is how I got interested in, in kind of looking at those ambulatory measurements in patients who are scheduled for major surgery.

Desiree Chappell: Yeah.

Bernd Saugel: And, um, yeah, there are... then we, we do... we, we, we, we did one more study that perhaps I should, uh, should talk about when we talk about this. So we, we did an observational pilot study in, in more than 350 patients, and we did those, uh, ambulatory 24-hour measurements. And this gave us, um, the opportunity to answer a couple of interesting questions. And the first was, we looked at the pre-induction value, so a value that a patient has when he just arrives

Monty Mythen: Hmm.

Bernd Saugel: ... at the induction area

Desiree Chappell: Yes. Yeah.

Bernd Saugel: ... because, I, I... many anesthetists say, "Okay, I individualize blood pressure." And I asked, "How do you do that?" And they say, "Okay, just take the pre-induction value, and this is what the patient has." And we... Well, we're a- we were able to answer that question with this s- with this, uh, study, because we had mean daytime and nighttime values, and we had the pre-induction value. So we compared the pre-induction value to the mean daytime value, just asking the question, is the pre-induction value a good surrogate on

Desiree Chappell: Yeah.

Bernd Saugel: ... on the daytime value? And well, it's not.

Desiree Chappell: I was gonna ask you so, (laughs).

Bernd Saugel: So, yeah, but pre-induction is a very, very poor surrogate, it has nothing to do with the normal

Desiree Chappell: Wow.

Bernd Saugel: ... daytime blood pressure value, so it doesn't reflect it. So this is... I wouldn't use a p- uh, the value that you just take, uh... just before induction as a, as a baseline. And I wouldn't take a single value anyway. So what we then did was we looked at how do those blood pressures during nighttime relate to 65? So why did we do that? Because the nighttime blood pressure is for me something like an individual safe threshold. You usually don't wake up with a heart attack or myocardial injury or kidney injury or stroke in the morning. So the lowest blood pressure during night is something like the individual safe threshold. And we compared it to 65, because that is a population harm threshold. And if you do this... And this was very interesting for me, you'll see first, there's a huge variability in nighttime pressure. This is not so surprising. But when you look

Desiree Chappell: Per individual.

Bernd Saugel: Per-

Desiree Chappell: Yeah.

Bernd Saugel: Yeah, between indu- and between individuals. And it's, um... And when you then compare it to 65, you will see that about one-third of the patients, uh, have lower blood pressures than 65 at night, so they have blood pressures of 50, 55, or whatever at night. And I would say that it's quite reasonable to assume that those patients may also tolerate lower pressures during surgery. But honestly, that is not the direction where my research is, is

Desiree Chappell: (laughs).

Bernd Saugel: ... heading to, because I do not want to advocate for low pressures during surgery. But on the other hand, and that is more important, two-thirds of the patients during nighttime physiologic sleep, never have blood pressures as low as 65, they are substantially higher.

Desiree Chappell: Mm-hmm.

Bernd Saugel: And those are the patients we wanna focus on. And, uh, I would hypothesize, uh, those patients who have... are never as low as 65, that those patients need higher pressures, and that you should individualize target for them.

Monty Mythen: From a practical, uh, point of view. And I, I want to get further into the discussion about, um, how we might be able to envelop and incorporate the, the evening circa- circadian rhythm as, as a way to, to find that baseline. We can talk about baseline in a second. Th- those patients, that two-thirds of the patients who never got as low as 65. Were there any characteristics of their preoperative sort of, uh, walking and talking and chewing gum daytime blood pressure? Were they pre-hypertensive, were they hypertensives, um, or were they normal, and they just had an interesting biology?

Bernd Saugel: Well, th- th- that is a very complicated question, because it's a very inhomo- inhomogeneous group of patients, because you have patients in there who have high blood pressure th- th- during daytime, and who have no antihypertensive treatment, and most of those do not dip at night, and, uh, this is the worst combination. So you have chronic arterial hypertension, and you are a non-dipper, then you have patients with chronic arterial hypertension who still dip at night. And this is something that we should talk to cardiologist too, probably, but this, uh, may be not as bad as being hypertensive and a non-dipper.

Monty Mythen: Okay.

Bernd Saugel: And, um, then there are patients who have, uh, normal, normal blood pressure during the daytime, but don't dip at night or have normal, uh... so, and dip at night. So there's any combination that you can think of. But I still think that looking at the nighttime pressure is a good way to go when we think about intraoperative targets.

Monty Mythen: Per- per- perfect. And I love the way that we're parsing, um, the definition of blood pressure and it's fascinating. But, but point of clarification, when we say hypertension, are we talking about systolic, mean, diastolic? What, what is the definition of hypertension in our discussion that we're having right now?

Bernd Saugel: Well, I always look at mean arterial pressure. But, uh, if you look at guidelines for cardiologists’ societies, in Europe, in the United States, they often define it based on systolic and diastolic, of course. Um, so in that w- w- perspective, uh, the European guidelines for, uh, for hypertension, uh, for example, they define... and, and in the same in the United States, they define an optimal blood pressure and blood pressure of 120 systolic over 80 diastolic, and if you kind of do the math here, this was... would result in a mean arterial pressure of 93. So, uh, this is something that we need to keep in mind that when we talk about intraoperative hypotension, we are still talking about very low pressures when we s- that we speak about 65. So a- an optimal pre- pressure is 93 in an awake patient, of course, not having [inaudible 00:15:06]-

Monty Mythen: We, we spent some time years ago, um, demonstrating in the cardiac surgical population, that isolated systolic blood pressure is unto itself a predictor of risk and badness as is isolated pulse pressure, hypertension. And, and it, I- it's a fascinating conversation. It's complex. And I just want to lay the foundation that, that we're talking about mean arterial pressure?

Bernd Saugel: Yeah, well, that is, uh... we are used to talking about mean in, in the OR, there are data that it's... that the associations between, uh, hypotension, whether you define it on systolic or mean are equally strong. Uh, there are same with outcomes are equally strong. Whether you look at systolic or mean. I, I... I- it's just... well, in, in [inaudible 00:15:50] (laughs) anesthesiology, we're just used... so much used to look at, look at mean by it. I, I, I agree that we should look at all three blood pressure components [inaudible 00:15:58] uh, all three blood pressure components have an important physiologic meaning.

Monty Mythen: So Bernd, before we move on to the second part of our conversation, which is are we looking in the wrong place. I believe you've recently received a substantial grant to address the issue from this perspective, which sounded to many people implausible by getting ambulatory blood pressures measured preoperatively. But you've demonstrated it's achievable, it is feasible, it's plausible. Can you tell us about that grant? And what the study design looks like?

Bernd Saugel: Oh, absolutely, I would love to do that. This will be the improved study. So this is something that we worked on during the last couple of years. We did a couple of pilot studies and trials, and well, we were even able to show that, uh, arterial... chronic arterial hypertension and non-dipping on ambulatory monitoring is an independent risk factor of intraoperative hypertension. So we really established a physiologic basis for all of, all of that. And we, uh, are now happy that the German Research Foundation funded that trial with more than 2.5 million euros. And we hope that we will have the first patient in within this year. And the, uh, uh, basic concept of the trial is to test the hypothesis that individualized blood pressure management, based on the ambulatory nighttime mean arterial pressure, improves the composite of post-operative perfusion related complications compared to routine care that will be maintaining blood pressure above 65.

Monty Mythen: A- and in your treatment al- algorithm or approach, how do you mitigate the risk of people running vasopressors without addressing volume and flow?

Bernd Saugel: Well, first of all, we have an upper intervention threshold that we de- we defined as a mean arterial pressure, um, of 110, because you will be surprised how high a nighttime blood pressures are in, in some patients.

Monty Mythen: Okay.

Bernd Saugel: And of- uh, this is what we saw on the pilot trials. And, um, we don't have a specific treatment protocol, because we, um, we assume that [inaudible 00:17:55], it's a multicenter trial in 16 center, university centers in Germany, but we trust physicians that they are able to combine fluids vasopressors, and inotropes to avoid hypotension. But at that point, we wanna be somehow pragmatic. We know that, um, the preoperative assessment of the baseline [inaudible 00:18:13] is considered quite complex, but I think physiology is complex too, and we need to make an effort to get that baseline value right. Um, on the other hand, the intraoperative period is quite, uh, pragmatic. So we will have the individualized target or the 65, and, uh, there's no specific treatment protocol.

 Monty Mythen: In, in, in that study, though, you don't have a specific protocol for managing blood pressure vis-a-vis vaso, active medicines or volume or whatever. Are you m- m- are you asking your sites to measure it so that you may wanna do a post-hoc analysis in that sense?

Bernd Saugel: Of course, we will record and mela... measure all of the thera- therapeutic interventions. And, um, what you mentioned is an important point, you know. Uh, we m- uh, we kind of, uh, need to balance a couple of a couple of dangerous things here. One dangerous thing may be hypotension. The other dangerous thing may be excessive fluid therapy and the next dangerous thing maybe very, very high doses of vasopressors. Um, nevertheless, I think that is, um... it's, it's a good approach to not, to not use a specific protocol that, uh, would trigger therapy that would rarely be used in clinical practice. You know, we know from our Goal-directed therapy study, for example, of course, we give a lot of inotropes, uh, in, in those patients, but we hardly see any inotropes in patients who are not in a randomized trial.

So we try to keep it pragmatic with, uh, resp- uh, respect to the, to the treatment algorithm.

Desiree Chappell: Yeah, lots of, lots of variability.

Monty Mythen: So congratulations on getting the grant. Thank you for your

Desiree Chappell: Yeah.

Monty Mythen: ... great work in-

Desiree Chappell: That is wonderful.

Monty Mythen: ... that space. And now we're going to shift gears to postdoc.

Desiree Chappell: We are... I mean, during the conversations that we've had over the course... well, forever, (laughs) [inaudible 00:20:00] talked about a lot this week and weekend, um, is talking about, you know, we know what happens intraoperatively and as anesthesia, we're so focused on that. But what happens whenever we drop our patients off, and everyone is tucked in nicely and looks perfect, that, you know, everything happens after that, that time. So, um, I wanted to talk to you a little bit about, you know, that transition of care and where we are in the space. We know we're lacking in monitoring capabilities and the consistency of, of monitoring frequency of monitoring. Where do you stand on a lot of that, um, that, that topic?

Bernd Saugel: Well, I think this will be one of the, of the game-changers of the, of the next decade, probably in perioperative medicine. So if you think about it in a way like, well, if you're, if you're having surgery, at no time in life, you will be as closely monitored as during those two to six or whatever hours.

Desiree Chappell: Mm-hmm.

Bernd Saugel: So you have a lot of monitoring in place. You have an anesthesiologist at the bedside, you have an anesthetic nurse, uh, with you all the time. And then you may have close monitoring in the post anesthesia care unit, and then you're kind of pushed into a

Desiree Chappell: I know, (laughs).

Bernd Saugel: ... black hole. [inaudible 00:21:07].

Desiree Chappell: Yeah.

Bernd Saugel: And we always say that we're there to spot monitoring like every four to eight hours.

Desiree Chappell: Yeah.

Bernd Saugel: But not even that is true in many institutions. And sometimes, uh, nurses are even shy to disturb the patient or sta- things like that.

Desiree Chappell: Yeah.

Bernd Saugel: And, um, we simply [inaudible 00:21:24] in, in clinical routine practice, we simply do not know how much hyper- how much hypertension there is. And there are a few observational-

Desiree Chappell: Mm-hmm.

Bernd Saugel: ... studies now using m- monitoring methods that more or less accurately and precisely measure blood pressure that, um, are, um... that looked at the incidence of postoperative hypotension, and postoperative hypotension is absolutely common.

Desiree Chappell: Yeah.

Bernd Saugel: And, uh, we know from, from at least one se- secondary analysis of a big study, that the association or the odds ratio, uh, for, uh, for postoperative, uh, major complications is a lot higher when you have, uh, hypertension on postoperative days one to four. So postoperative hypertension surely is an issue.

Desiree Chappell: Yeah.

Bernd Saugel: And, um, yeah, at the moment, we are simply ignoring it because we are just not measuring it.

Desiree Chappell: Yeah.

Monty Mythen: One of the things that just struck me from that topic is, I... First of all, congratulations on your proactive approach to define baseline, which has haunted us for decades. And, and I think it's elegant, and in frankly, just cool. Um, postoperative hypertension, same baseline. Um

Desiree Chappell: Hmm. Good question.

Bernd Saugel: That is a difficult one, (laughs).

Desiree Chappell: (laughs).

Bernd Saugel: Um, I, I, I, I do... Personally, I think that, um, what... we, we know very, very little about postoperative harm thresholds and postoperative, uh, uh, lower intervention thresholds. I would say that they are presumably, presumably a little bit higher than during surgery. But this is more or less speculation and not based on, based on data. The main problem at the moment still is that we simply miss it. Um, I, I think we... And the problem is, well, blood pressure is a, is a complex bio signal. It's very hard to measure. And it's, it's even hard to measure when you have an interior catheter. And now imagine how you can, uh... how you need to measure it in a patient who is treated on a normal ward after surgery, because, well, we want those patients moving around.

Desiree Chappell: Yeah.

Bernd Saugel: So you need monitoring that is attached to the patient, but without any cables. So he needs to be able to do for the therapy, walk around, stuff like this. But at the same time, we should have continuous monitoring of various, uh, vital signs, of course, but I very much interested into blood pre- um, blood pressure, of course, but it's, uh... Blood pressure is, is, is a, is a... is perhaps the most, um... the bio signal that is, uh... It's very hard to measure. You know, except that we have good, good sensors for supersaturation, heart rate, respiratory

Desiree Chappell: Yeah.

Bernd Saugel: ... rate, even position or, or movement, you know. Our, our, uh, cell phones

Desiree Chappell: (laughs).

Bernd Saugel: ... in the pockets, uh, they monitor movement all the time.

Desiree Chappell: Yeah.

Bernd Saugel: But the problem with, uh, with blood pressure is it's a complicated bio signal. And, uh, uh, I'm not aware of a system that reliably measures blood pressure on the ward without any, uh, any cables attached to the patient at the moment.

Monty Mythen: And to be practical at the moment. Do we, do we need the... I know we'd love to have it.

Desiree Chappell: Yeah.

Monty Mythen: But to make progress, could we work with heart rates and respiratory rates? Cause there's a prodromal period-

Desiree Chappell: Yeah.

Bernd Saugel: Yeah.

Monty Mythen: ... where there's usually variations in respiratory rate and pulse rate prior to a sagging blood pressure cause of sympathetic compensation. And we then need to be... at least be able to react with continuous non-invasive blood pressure, et cetera, which is... That's feasible at the moment.

Desiree Chappell: Yeah.

Bernd Saugel: Absolutely. I couldn't agree more. And, and I think we especially need to look at the combination of different vital signs.

Desiree Chappell: Mm-hmm.

Bernd Saugel: You know, it's, uh, we know that respiratory, for example, is the most, uh, sensitive variable when it comes to predicting complications. It's, uh... But we need to integrate the different, the different, the different signals, you know, it's... And we need to have smart alarms because it makes a difference whether a patient is lying in bed or whether he's exercising. So a heart rate of 120, maybe, maybe normal when he's exercising in a physical therapy, but it's not normal when he's, uh, when he's in bed and s- and, and things like that. So it's a combination... combining different, uh, bio signals, vital signs, uh, having smart alarms, integrating the, the... or taking, taking into account the, uh... what the patient is doing at the moment. So it's contextualized monitoring.

Monty Mythen: Uh-

Desiree Chappell: Yeah.

Monty Mythen: And that's what we're doing with our early warning scores everywhere

Desiree Chappell: Yeah.

Monty Mythen: ... at the moment, but it's, uh, it's a nurse-led, chart-based

Bernd Saugel: Absolutely.

Desiree Chappell: Yeah.

Monty Mythen: ... very, very slow cadence of measurement, we're just trying to make that continuous is, is

Bernd Saugel: That exactly the point.

Monty Mythen: ... all we're trying to do.

Bernd Saugel: And those are the point when we discussed this with our hospital management. So, uh, rapid response teams and stuff like this-

Desiree Chappell: Yeah.

Bernd Saugel: ... those can only be as good as the information they have. And while monitoring all of the patients continuously, that will create dense data streams. You know, there will be a lot of data, and we need to...

whether, uh, uh, there... we need to develop concepts, uh

Desiree Chappell: Yeah.

Bernd Saugel: ... that are very, that are... that require a cultural change. You know, there may be a new specialty, like somebody who's analyzing all those, all those incoming data, and perhaps we need some, uh, support there, like, uh, uh-

Desiree Chappell: Yeah.

Bernd Saugel: ... a machine learning. Uh, this isn't report systems, whatever, but

Desiree Chappell: Clinicians to be able to look at that.

Bernd Saugel: Yeah, and then the cli- At some point, the clinician needs to kind of get those information’s and simply call his colleague on the floor and tell him, "You need to go to room three now-"

Desiree Chappell: Yeah.

Bernd Saugel: "... because we have a combination of a low saturation and a high heart rate, and this is new, and the patient is lying in bed."

Desiree Chappell: Yeah.

Bernd Saugel: And this would be the dream for the future that we really start monitoring our patients, uh, in the hospital because it's, uh, kind of, uh, um, strange that we now... that those patients develop those complications are under direct supervision, and we simply do not recognize it.

Monty Mythen: We're talking to Dan Sessler and Frederick Michard yesterday, and one of the things that Frederick pointed out is the... "For many, many patients who come in, we ask them to take off their smartwatch."

Bernd Saugel: True, (laughs).

Desiree Chappell: (laughs).

Monty Mythen: (laughs).

Bernd Saugel: That is a good point. Yeah.

Monty Mythen: "And put them into a void of information."

Desiree Chappell: (laughs), [inaudible 00:27:14].

Monty Mythen: "Whereas if we let them keep it on-"

Bernd Saugel: Absolutely.

Monty Mythen: "... [inaudible 00:27:17] already be in a better place."

Bernd Saugel: Yeah.

Desiree Chappell: Well, what about the ambulatory blood pressures that you're doing preoperatively? I mean, bringing that in, I mean, that people make that... make things like that work. So surely we could figure out how to do it in the hospital.

Bernd Saugel: I think that would be better than, uh

Desiree Chappell: (laughs).

Bernd Saugel: ... checking blood pressure, only other... only every four to eight hours.

Desiree Chappell: Yes.

Bernd Saugel: But again, it's... this is... would be only every 15 or 30 minutes. So it's

Desiree Chappell: It's still missing.

Bernd Saugel: ... it's, it's, it's more-

Desiree Chappell: Yeah.

Bernd Saugel: ... high frequency, but it's far away from continuous monitoring.

Desiree Chappell: Yeah.

Bernd Saugel: I think it would... But it would, it, uh, uh... We are kidding about it now, but it would, it

Desiree Chappell: I, I, (laughs)-

Bernd Saugel: ... would increase patient safety compared to checking blood pressure, like, like e- every four to eight hours. Yeah.

Monty Mythen: Just from a practical standpoint, uh, walk us through how you are measuring

Desiree Chappell: Mm-hmm.

Monty Mythen: ... um, preoperative blood pressures to establish what that personalized blood pressure, um, albeit systolic, diastolic, or mean, would be that would help guide if you will your baseline, I, I... I- I- is it prime time? Are we doing that, and should we be doing that, and how can we be doing that routinely?

Bernd Saugel: Well, first of all, it's, it's a routine procedure. It's, it's something that, um, that cardiologists do all the time because it's in the guidelines as the gold standard metho- method to diagnose hypertension. So you're on... basically you're, uh, m- y- you only can diagnose hypertension when you have an ambulatory 24-hour measurement. So this is something that is... that we didn't invent. It's not new, it's simply we kind of transferred it to perioperative medicine. Maybe because I'm, uh, uh, I'm specialized in... I'm an internist too, though, I'm not only an

Desiree Chappell: Oh.

Bernd Saugel: ... anesthesiologist and intensivist, but I worked in, uh, internal medicine, um, for many years. So this is something that was not new for me. And this is also why I was so surprised that

Monty Mythen: I-

Bernd Saugel: ... everybody thinks it's, it's something that is, that is new, offensive, whatever. It's, it's absolutely standard-

Monty Mythen: I, I, I... Looking around this wonderful-

Desiree Chappell: Yeah.

Monty Mythen: ... um, you know, exhibit hall and I do not see anyone introducing that concept. So I say that in a tongue-in-cheek way.

Bernd Saugel: Absolutely.

Monty Mythen: Um, it's novel to this audience.

Bernd Saugel: Yeah.

Desiree Chappell: The feasibility, people anesthesia providers thinking in their mind the feasibility of this, so like, "There's no way we could do that."

Monty Mythen: Right.

Desiree Chappell: But cardiologist did that for years, (laughs).

Bernd Saugel: And I'll tell you something, pa- patients are absolutely thrilled about it. So again, everybody thought we were crazy and

Desiree Chappell: [inaudible 00:29:28].

Bernd Saugel: ... and then, then you will, you will never find a patient who is accepting this.

Desiree Chappell: Yeah.

Bernd Saugel: And I told them, "Well, I had it myself for a couple (laughs) of times."

Desiree Chappell: (laughs).

Bernd Saugel: "So I, I slept well, it's, it's, it's, it's something that cardiologists do. And we... now we did that in, in more than 1000 per- or clo- Yeah, more than 1000 patient in the meantime.

Desiree Chappell: Yeah.

Bernd Saugel: And we hardly had any patient who complained and just the opposite. They are asking for their values, of course.

Desiree Chappell: Uh, yeah.

Bernd Saugel: And we provide them their, their measurements and they take them to their cardiologist, and it's... it reit, it, it... And it, it helps the, the specialty, too, because it's really, it's a concept of perioperative medicine.

Desiree Chappell: I love it.

Bernd Saugel: So we, we, we do a baseline diagnosis of their blood pressure profile. We take care of blood pressure during surgery, and we can even, even give the, the, the results of the, of the measurements to the patient and he can, can use it for postoperative, uh, blood pressure control with his cardiologist.

Desiree Chappell: Do you think that there's, uh, uh, a way that we can work with our cardiology con- uh, uh, colleagues here, you know, like in the US, for example, to do

Monty Mythen: Uh-

Desiree Chappell: ... to do that?

Monty Mythen: I... You know, we can, we can have a whole another session

Desiree Chappell: I know, I know, I know, I know.

Monty Mythen: ... [inaudible 00:30:27].

Desiree Chappell: I'm just thinking about it.

Monty Mythen: I, I, I, I, I was actually-

Desiree Chappell: [inaudible 00:30:30].

Monty Mythen: ... asking in a practical way, how we, we

Desiree Chappell: Yeah.

Monty Mythen: ... in this space can envelop that

Desiree Chappell: Yeah.

Monty Mythen: as part of-

Desiree Chappell: Yeah.

Monty Mythen: ... our routine. I love the fact that you're doing it. I get it. I respect it. I wish we were doing that more

Desiree Chappell: Yeah.

Monty Mythen: ... routinely. Um, rather than being dependent on others to do it for us, [inaudible 00:30:46]

Desiree Chappell: Sure.

Monty Mythen: ... should we just routinely

Desiree Chappell: Yeah.

Monty Mythen: ... develop that into our routine?

Bernd Saugel: Well, we simply bought the devices

Monty Mythen: (laughs).

Bernd Saugel: ... and they are not too expensive.

Monty Mythen: Okay.

Bernd Saugel: We have, we have 40 of them. And we give it to the patient before surgery. Patients are happy to take it. Uh, uh, we, we tell them how to use it. They can even start it, uh, whenever they want.

Desiree Chappell: Hmm.

Bernd Saugel: So they just need the wrap around the

Monty Mythen: [inaudible 00:31:02].

Bernd Saugel: ... cuff and they start

Monty Mythen: Perfect.

Bernd Saugel: ... and they start the measurement. And then they bring it back when they are, um, are admitted to hospital for surgery or they send it in, uh, just using mail, by the way.

Monty Mythen: Yeah.

Bernd Saugel: Yeah.

Desiree Chappell: (laughs).

Monty Mythen: So we should wrap in a second [inaudible 00:31:16] out of time. But anything, any of the little gems you picked up at the meeting?

Bernd Saugel: Well, it's, uh, of course, the major news. Also, it wasn't so new for me, of course, it was a discussion about, uh, around POISE-3

Monty Mythen: Yeah.

Bernd Saugel: ... the blood pressure results.

Monty Mythen: Oh, yeah.

Bernd Saugel: It's, it's something that, of course is one of the major news. Um, I still think that there is... there are a lot of unanswered questions.

Desiree Chappell: Oh, of sure.

Bernd Saugel: So we need more data on the intraoperative, uh, blood pressure in those, in those patients. There are large ongoing randomized trials on that topic, who will focus on higher risk patients. Um, there's an interesting trial in Amsterdam that's going on, uh, focusing, uh, uh, in a little bit more on individualized targets, but not on a patient level like we will do. So I think it's what I take away from, from that, uh, congress is mainly the dis- not the results because I already knew them, but the

Desiree Chappell: (laughs).

Bernd Saugel: ... discussions around the POISE-3 results with all the colleagues.

Desiree Chappell: Yeah.

Monty Mythen: And wh- Sorry, so I'll just finish, and I'll let you go after. The, um... So what's your takeaway that you would go back... If you went back to residents and they wanted to know quickly, what did you make of POISE-3?

Bernd Saugel: Oh, well, first of all, it was a comparison between 65 and 85, though, uh, uh, uh, it's, uh, about maintaining blood pressure above 65, or 85, it doesn't make a difference, but we didn't look at what we will usually find is hypotension and that is below 65. So it's the message by no means can be that hypotension is not important

Desiree Chappell: Right.

Bernd Saugel: ... because this is not a study comparing, uh, hypotension versus no hypotension. Um, it is inp- h- h- it is inpatient surgery, but I think we need to... The association between hypotension and outcomes is especially important in high-risk patients. So I, I... And we need to focus on high-risk patients. And I think the [inaudible 00:32:56] what the optimal target value is, by no means it ends the story of, of hypertension, but it's an important signal, we need to, we ne- It is what it is. It's

Desiree Chappell: Yeah.

Bernd Saugel: ... no different. Uh, at the moment, you cannot recommend to increase blood pressure above 65 to 85 in every patient, but I still think that we should do it in the individual patients and that is what we tried to prove.

Monty Mythen: I, I was just gonna add to that and I, um, I love that interpretation. It- it's a very narrow snapshot of a very large and complex topic. Yo- you know, what is blood pressure? Is it hypertension defined by systolic, mean, or diastolic? Is it blood pressure defined by preoperative, intraoperative, or postoperative? And now you introduced I- a- a- another if you will dimension, which is hy- hypertension dippers are non-hypertensive dippers, or hypertensive non-dippers. And it's a whole another, if you will slice of that very complex pie. So I think we are only now beginning to appreciate how much we don't know. Thank you for widening that, that [inaudible 00:34:00] for us. Um, and we shouldn't over interpret a- and, and, um, and underestimate how little we know in this space. So it's a long journey that we're looking forward to hearing more about.

Desiree Chappell: Yeah.

Bernd Saugel: Absolutely. Thank you very much.

Desiree Chappell: Bernd, thank you so much for joining us on TopMedTalk, excited to hear more from you in the, in the coming time and, and about the projects that you're working on. So good luck with everything and good luck with the new grant.

Bernd Saugel: Thank you very much.

Desiree Chappell: And, um, especially I can't wait to hear what happens at Prato.

Bernd Saugel: (laughs).

Desiree Chappell: (laughs), you guys are all headed there, uh, tomorrow. Yeah.

Monty Mythen: Hmm.

Desiree Chappell: So, uh, all good news from there, I'm sure. Well, thanks for listening to TopMedTalk, you know, you can always find us on your favorite, your favorite social media platform, Twitter, LinkedIn, Facebook, we are there. And at topmedtalk.com. Everything from your anesthesia will be there, all the, the wonderful conversations that we had. And as Monty said before, if there's a topic in perioperative medicine that you're interested in, go to our search engine on topmedtalk.com, and you can find conversations about it over the years.

Monty Mythen: And if you can't let us know.

Desiree Chappell: (laughs), that's right, please do reach out to us. I know we've had some people reaching out, uh, in the recent months about wanting to have conversations about things they're interested in. So we're gonna try and do that. Um, and be sure to check us out the next meeting we're gonna be at, Monty.

Monty Mythen: Great questions, it's Prato.

Desiree Chappell: (laughs).

Monty Mythen: (laughs).

Desiree Chappell: No, uh, at PaLM London, the World Congress.

Monty Mythen: [inaudible 00:35:20]. The World Congress.

Desiree Chappell: Yes, (laughs).

Monty Mythen: [inaudible 00:35:24]

Desiree Chappell: Oh, yeah.

Monty Mythen: Not the most... not the [inaudible 00:35:25]

Desiree Chappell: Not the, you. Yes, no.

Monty Mythen: Okay. Yes.

Desiree Chappell: Yeah. Our, our upcoming summer meeting at PaLM.

Monty Mythen: The World Congress.

Desiree Chappell: Yep, World Congress.

Monty Mythen: 25th anniversary.

Desiree Chappell: It is the 25th anniversary. So do check us out. We're gonna be selling virtual tickets and our p- in person tickets. I mean. [inaudible 00:35:36].

Monty Mythen: I believe it's the silver jubilee. It is, (laughs) [inaudible 00:35:39]

Desiree Chappell: It's somebody's jubilee. All right, everyone, have a great day. Thanks so much for listening to TopMedTalk. Cheers. Bye.

Monty Mythen: Ciao, ciao.

TopMedTalk.

Desiree Chappell: Desiree Chappell with TopMedTalk. It has been an exciting year and there's so much more to come. Now I'm joined here with Monty Mythen. Monty, what is coming up.

Monty Mythen: Well, next TopMedTalk [inaudible 00:35:57] gonna be coming to you live from the European Society of

Anesthesiology from Milan in Italy. You'll find us on the GE booth in the trade exhibition. We'll be the [inaudible 00:36:07]. And we'll probably pop up in a few other places. So I'm there with Desiree and [inaudible 00:36:12] coming in and Henry Hill. And after that Desiree, where do we go?

Desiree Chappell: It is time for the 25th Anniversary World Congress of Perioperative Medicine in London right? Live.

Monty Mythen: From the UCL Campus to celebrate our 25th anniversary. So that's really exciting. And then I think we've got the next one in August with your organization in America.

Desiree Chappell: It is. It's in Chicago with the American Association of Nurse Anesthetist. Monty and I are gotta pop up there, have some great conversations and then it's on to.

Monty Mythen: Dingle, so that takes us into the ultimate winter season. More about that to follow.

Desiree Chappell: And then of course, we're gonna be rounding out the year with the American Society of Anesthesiologist in New Orleans for their annual congress. So super excited about all the events for the year. Don't miss us. Be sure to check us out on topmedtalk.com and on your favorite podcatcher, we are there with late breaking anesthesia and perioperative news, right, Monty?

Monty Mythen: Absolutely. See you soon.

Desiree Chappell: Cheers.

Bernd Saugel

Prof. Bernd Saugel

Professor and Vice Chair of the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine at the University Medical Center Hamburg-Eppendorf, Germany.

  • Circulatory
  • ECG
  • NIBP
  • Cardiac care
  • Clinical