Characteristics and outcomes of Rapid Response Team activations for hypotension in orthopaedic patients

BACKGROUND: Hypotension following orthopaedic surgery has been associated with increased morbidity and mortality. Rapid Response Teams (RRTs) review patients on hospital wards with hypotension. AIMS: To evaluate the epidemiology of hypotensive RRT activations in adult orthopaedic patients to identify contributing factors, and areas for future quality improvement. METHODS: Retrospective observational study using data from RRT and clinical informatics databases. Evaluation of timing, presumed causes of hypotension and associated treatments. RESULTS: Amongst 963 RRT activations in 605 patients over three years, 226/605 (37.4%) of first calls were due to hypotension and 213/226 (94.2%) had sufficient data for analysis. The median age was 79 (IQR 66-87) years, 58 (27.2%) were male, and co-morbidities were common. Most (68%) surgery was emergent and 75.1% received intra-operative vasopressors for hypotension. Most activations occurred within 24 hours of surgery, and hypovolemia, infection and arrhythmias were common presumed causes. Fluid boluses occurred in 173 (81.2%), and the time between surgery and RRT activation was 10 (4.0-26.5) hr in cases where fluid boluses were given, compared with 33 (15.5-61.5) hr where they were not (p< 0.001). Blood transfusion (30, 14.1%) and withholding of medications were also common. Hospital mortality was 8.5% (18), and 13.6% (29) were admitted to critical care at some stage. In hospital death was associated with older age, functional dependence, arrhythmia and presumed infection. CONCLUSIONS: Hypotension-related RRT calls in orthopaedic patients are common. Future interventional studies might focus on peri-operative fluid therapy and vaso-active medications, as well as withholding of anti-hypertensive medications pre-operatively. This article is protected by copyright. All rights reserved.