Effect of new technology on the behaviour of clinicians regarding the treatment of hypotension during surgery

Intraoperative hypotension has a high incidence in the perioperative population and is associated with an increase in postoperative complications and mortality. A MAP below 65 mmHg or a decrease of ƒ®20% from baseline increases the incidence of myocardial injury after non-cardiac surgery (MINS) and acute kidney injury (AKI). Recently, the FloTrac IQ algorithm (Edwards Lifesciences, Irvine, CA, USA) incorporating a hypotension predictability index (HPI), dynamic arterial elastance variable (Eadyn) and index assessment of left ventricular contractility (dP/dT) was developed which provides clinicians an early warning of an impending hypotensive episode as well as insight into its pathophysiology and thus buys time to take measures to prevent this hypotension from occurring. In addition, this algorithm also incorporates variables used in standard care such as pulse pressure variation (PPV), stroke volume variation and index (SVV and SVI) and cardiac index (CI). Whether clinicians find the new information acceptable to use, or that it confers clinical utility remains unknown and for this technology to become accepted, and in turn lead to a reduced incidence of hypotension, this would require a change in current behaviours including attitudes and skills. The underlying rationale is that by using the HPI and secondary information, intraoperative hypotension can be reduced and appropriately treated or even prevented. Alternatively, hypotension can also be avoided simply by requiring the treating clinician to keep the MAP >65 mmHg, although the treatments may be inappropriate in view of the underlying pathophysiology. Therefore, we aim to use education intervention on treatment of hypotension and incorporating HPI in this clinical treatment to alter clinician¡¦s behaviour.

Does education intervention about adding HPI to standard practice alter clinician behaviour to the treatment of hypotension?

As a secondary objective we assess whether incorporating HPI in a Goal-directed fluid therapy (GDFT) algorithm lowers the incidence of intraoperative hypotension.

- after cohort 1, before education: structured inteview about beliefs of clinicians (15-20) about costs and benefits of controlling hypertension.

- During cohort 2 and 3: questionnaires for clinicians attending cohort 2 and 3 about the perceived barriers for effective control of hypotension.

- 2 motnhs after training FlowTracIQ: questionnaires about usefulness en usibility of the FlowTracIQ and observations of 6-8 surgical procedures

- After phase 3; workshop with other clinicians focusing on likelihood of wider adoption.

Patients:

Cohort 1 (first 50 patients): management of hypotension as usual.

Cohort 2 (second 50 patients): management of hypotension keeping the MAP >65.

Cohort 3 (third 50 patients): management of hypotonsion by using the FlowTrac IQ

Clinicians:

Between cohort 1 and 2, treating physicians receive education intervention regarding current evidence of intraoperative hypotension and adverse outcomes. Between cohort 2 and 3, treating physicians receive education intervention regarding how to use FlowTrac IQ and its parameters in the clinical management of hypotension.

On various time points, interviews and questionnaires measuring a range of social-cognitive determinants of behavior change will be performed.