Differences in incidence of post-induction hypotension depending on the time of day: a post-hoc propensity score...

Many physiological processes show a diurnal rhythm, including sympathetic and parasympathetic tone, adrenal hormone secretion and blood pressure. Since these physiological rhythms may affect the sensitivity to anaesthesia, we hypothesised that the time of day when anaesthesia induction occurs may affect the incidence of post-induction hypotension.

This was a post-hoc propensity score matched analysis of prospectively collected blood pressure data of 760 elective non-cardiac surgery patients receiving general anaesthesia. The primary endpoint was the incidence of post-induction hypotension, defined as mean arterial pressure < 65 mmHg for at least one minute. Secondary endpoints were a > 30 % decrease in mean arterial pressure, and baroreflex sensitivity.

In the analysis of 237 propensity score matched pairs, post-induction hypotension was more frequent if anaesthesia induction occurred in the morning (08:00 AM - 12:00 PM) (odds ratio (OR) 1.48, 95 % confidence interval (CI): 1.00-2.20, p = 0.049). Secondary analyses of the matched cohort showed that a > 30 % decrease in mean arterial pressure was likewise more frequent in the morning than the afternoon (12:00 PM - 17:00 PM) (OR 1.45, 95 % CI: 1.00-2.11, p = 0.0499), but no differences in instantaneous baroreflex sensitivity were observed.

Post-induction hypotension was more frequent in the morning compared to the afternoon. While this finding is in line with the presumed physiological mechanisms, it may be affected by unmeasured confounding. These findings should be replicated in larger, preferably randomised, studies to confirm whether a causal relationship between the time of day of anaesthesia induction and post-induction hypotension exists. Clinical registration number This study was registered in the Dutch Medical Research in Humans (OMON) register on 18 June 2019 (ID: NL7810). The study was approved by the Medical Ethics Committee of the Amsterdam UMC, location AMC, Netherlands in December 2018 (NL 6748.018.18; 2018).