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Are We Getting What We Ask For: Few Patients Meet Mean Arterial Pressure (MAP) Goals After Intraoperative
Michaela J O'Connor1, Michael W Brown, Mehdi M Elfilali
1Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY.
Insights
Postoperative hypotension is common in pediatric spine surgery patients with intraoperative neurophysiological monitoring (IONM) changes, despite established mean arterial pressure (MAP) goals. Adherence to these critical MAP targets remains a significant challenge, impacting patient outcomes.
Area of Science:
- Neurosurgery
- Pediatric Orthopedics
- Critical Care Medicine
Background:
- Hypotension is a critical risk factor for neurological deficits in spine surgery.
- Patients with intraoperative neurophysiological monitoring (IONM) changes are particularly vulnerable to hypotension.
- These patients require intensive postoperative monitoring in the ICU.
Purpose of the Study:
- To evaluate adherence to patient-specific mean arterial pressure (MAP) goals in the first 24 hours post-spinal surgery following IONM changes.
- To identify the gap between established hemodynamic management goals and actual postoperative blood pressure control.
Main Methods:
- Retrospective review of pediatric patients undergoing spinal surgery with IONM changes (2023-2025).
- Documentation of demographic and radiographic data.
- Establishment of individual 24-hour postoperative Target MAP goals and collection of arterial line MAP values.
- Definition of hypotension as MAP <5th percentile for age-based norms.
Main Results:
- Twenty-one pediatric patients with IONM changes during deformity surgery were analyzed.
- Ninety-five percent of patients did not continuously meet their MAP goal; 33% had below-target 24-hour average MAPs.
- Patients spent an average of 27% of the time below their target MAP, with 19% experiencing documented hypotension.
Conclusions:
- Postoperative blood pressure management frequently failed to meet MAP goals in high-risk pediatric spine surgery patients.
- This highlights a critical gap in hemodynamic management adherence despite ICU care and established goals.
- Improved strategies are needed to ensure adherence to MAP goals for better patient outcomes.
Background:
Hypotension is a critical, modifiable risk factor for neurological deficit in spine surgery. Patients with intraoperative neurophysiological monitoring (IONM) changes are particularly vulnerable, as their spinal cord has already demonstrated sensitivity to correction, and hypotension may exacerbate areas of inadequate perfusion. These patients are admitted postoperatively to the ICU for close neurological and hemodynamic monitoring. This study evaluated adherence to patient-specific mean arterial pressure (MAP) goals in the first 24 hours following IONM changes.
Methods:
A retrospective review of patients undergoing spinal surgery with IONM changes between 2023 and 2025 at a single institution was conducted. Demographic and radiographic data were documented. Individual 24-hour postoperative "Target MAP" goals were established. Arterial line MAP values were collected. Hypotension was defined as MAP <5th percentile for age-based norms.
Results:
Twenty-one patients [12 female, 9 male; mean age 14.3±2.6 y (range: 7.7 to 19.0)] with IONM changes during pediatric deformity surgery were included. Etiologies included 8 idiopathic, 6 neuromuscular, 5 congenital, and 2 syndromic patients. Of those with major coronal deformities (n=19), mean preoperative and postoperative major curves were 79±22 degrees (range: 40 to 120 degrees) and 38±16 degrees (range: 18 to 75 degrees), respectively, with an average correction of 56%±11% (range: 41% to 71%) in completed cases. Four surgeries were aborted. Six patients (29%) had persistent neurological deficits beyond the first postoperative day. The median MAP goal was >80 mm Hg (range: >60 to >100). Twenty patients (95%) did not continuously meet their MAP goal, defined as ≥1 instance of MAP beneath target. Seven patients' (33%) 24-hour average MAPs were below target. On average, patients spent 27% of the time (6.4 h) beneath their target MAP. Four patients (19%) had a documented period of hypotension.
Conclusions:
Despite ICU-level care and established MAP goals in critical patients with prior IONM loss or within warning criteria, postoperative blood pressure management often failed to meet MAP goals. This is the first study to highlight this crucial gap between management goals and postoperative hemodynamic adherence.
Levels Of Evidence:
Level IV.
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Monitoring Both Arms:
Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.