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The Triple Low: Causative or Predictive?

A review of the literature on the anesthetic phenomenon the Triple Low. Keywords: Anesthesia, DNAP, CRNA

Tony Amato

on 14 March 2014

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Transcript of The Triple Low: Causative or Predictive?

Causative or Predictive? The Triple Low: Triple Low Low MAC < 0.7 Low BIS < 45 When combined with MAC = anesthetic "sensitivity" Low MAP < 75 mmHg When combined with BIS = anesthetic "sensitivity" The “triple low” is an aggregate of indices purported to influence long term negative outcomes related to anesthesia care involving the triad of low anesthetic (mean alveolar concentration (MAC) < 0.7), low bispectral index (BIS) values (<45) and low mean arterial pressure (MAP < 75mmHg). Sessler D. "Triple Low" - An Ominous Predictor. In: APSF Workshop; 2010; New Orleans, LA: Anesthesia Patient Safety Foundation; 2010 relative risk = 1.036 for every minute SBP<80mmHg Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg 2005;100:4-10 We searched PubMed MeSH terms including blood pressure, consciousness monitors, humans, anesthesia/mortality, and anesthetics inhalation and included articles involving the triple low Methods Prospective, observational study.(n=1064) demonstrating a relative risk of 1.036 for every minute SBP<80mmHg, as well as a relative risk of 1.24 per cumulative hour of BIS <45.
Possibly due to an altered inflammatory response
Greatest predictors of 1 year postop mortality was Comorbidity, followed by ASA status.
Cause of death in 30% was cancer Monk, 2005. Anesthetic Management
and One-Year Mortality After
Noncardiac Surgery Retrospective, observational (n = 18,961)
Patients with low MAC had higher risk of mortality at 1 year
Risk increased further with the Triple low
Odds Ratio = 2.5 Gan et. al. (2011). Mortality at One Year
is Increased by a "Triple Low"
Combination of BIS, Blood Pressure
and Anesthetic Concentration Observational study of 17,067
Classified into 1 of 5 groups who either had a TL state (> 5 min), and whether a vasopressor (phenylephrine or ephedrine) was administered at all, < 5 minutes or > 5 minutes after entering TL
Only a 7% increase in mortality (vs. reference) if treated within 5 min
20% increase if > 5 min
31% increase if untreated Saager et. al. (2009). Vasopressors
May Reduce Mortality Associated with
a "Triple Low" of Low Blood Pressure,
BIS, and MAC Sessler, Daniel (2010). "Triple Low"-
An Ominous Predictor Retrospective, observational (n = 23,999)
HOTN and prolonged periods of low BIS are independent risk factors for 1 year postop mortality
Low MAC lower in non-survivors
46% of pt's had at least 1 TL episode
Mortality associated with DURATION of TL
Improved outcomes following administration of a vasopressor Anesthetic “sensitivity,” indicated by low MAC requirement, varies from person to person, and may be influenced by a variety of comorbidities. While pre-operative morbidity plays a substantial role in patient outcomes, these findings suggest that anesthetic management may be significant factor in patient mortality. The literature suggests the need for further research in this area, using stronger levels of evidence to strengthen the association between the triple low and postoperative mortality. Currently it cannot be determined whether this phenomenon is simply correlative, or whether it represents a bona fide surrogate metric of poor outcome. If it proves to be of predictive value it may empower us to provide goal-directed interventions. Conclusions Sessler, 2012. 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 Prospective, observational (n = 24,120)
TL present in 6% of study sample
TL associated with prolonged LOS
DL doubled 30-day mortality
TL quadrupled 30-day mortality
Cumulative (not necessarily consecutive) duration of TL increased mortality
The values defining the TL are well within the range that many providers tolerate routinely
Did NOT find that low MAP or BIS alone were independent risk factors Incidence of 6-46% of noncardiac cases
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