The triple variable index combines information generated over time from common monitoring variables to identify patients expressing distinct patterns of intraoperative physiology

• Published in: BMC medical research methodology 2019-01, Vol.19 (1), p.17-17, Article 17
• Main Authors: Schnetz, Michael P, Hochheiser, Harry S, Danks, David J, Landsittel, Douglas P, Vogt, Keith M, Ibinson, James W, Whitehurst, Steven L, McDermott, Sean P, Duque, Melissa Giraldo, Kaynar, Ata M
• Format: Article
• Language: English
• Subjects: Adult; Analysis; Anesthesia; Anesthesiology; Arterial Pressure - physiology; Bispectral index; Blood pressure; Cardiopulmonary Bypass - mortality; Consciousness Monitors; Humans; Hypoxia; K-means clustering; Ketamine; Machine Learning; Mean arterial pressure; Methods; Middle Aged; Minimum alveolar concentration; Monitoring, Intraoperative - methods; Mortality; Patient outcomes; Patients; Perioperative Medicine; Physiologic monitoring; Physiology; Postoperative period; Pulmonary Alveoli - physiology; Surgery; Systematic review; Thoracic Surgical Procedures; Triple low state; Triple variable index; Variables; Variables (Mathematics)
• ISSN: 1471-2288; 1471-2288
• DOI: 10.1186/s12874-019-0660-9

Mean arterial pressure (MAP), bispectral index (BIS), and minimum alveolar concentration (MAC) represent valuable, yet dynamic intraoperative monitoring variables. They provide information related to poor outcomes when considered together, however their collective behavior across time has not been characterized. We have developed the Triple Variable Index (TVI), a composite variable representing the sum of z-scores from MAP, BIS, and MAC values that occur together during surgery. We generated a TVI expression profile, defined as the sequential TVI values expressed across time, for each surgery where concurrent MAP, BIS, and MAC monitoring occurred in an adult patient (≥18 years) at the University of Pittsburgh Medical Center between January and July 2014 (n = 5296). Patterns of TVI expression were identified using k-means clustering and compared across numerous patient, procedure, and outcome characteristics. TVI and the triple low state were compared as prediction models for 30-day postoperative mortality. The median frequency MAP, BIS, and MAC were recorded was one measurement every 3, 5, and 5 min. Three expression patterns were identified: elevated, mixed, and depressed. The elevated pattern displayed the highest average MAP, BIS, and MAC values (86.5 mmHg, 45.3, and 0.98, respectively), while the depressed pattern displayed the lowest values (76.6 mmHg, 38.0, 0.66). Patterns (elevated, mixed, depressed) were distinct across the following characteristics: average patient age (52, 53, 54 years), American Society of Anesthesiologists Physical Status 4 (6.7, 16.1, 27.3%) and 5 (0.1, 0.6, 1.6%) categories, cardiac (2.2, 6.5, 16.1%) and emergent (5.8, 10.5, 12.8%) surgery, cardiopulmonary bypass use (0.3, 2.6, 9.8%), intraoperative medication administration including etomidate (3.0, 7.3, 12.6%), hydromorphone (47.6, 26.3, 25.2%), ketamine (11.2, 4.6, 3.0%), dexmedetomidine (18.4, 16.6, 13.6%), phenylephrine (74.0, 74.8, 83.0), epinephrine (2.0, 6.0, 18.0%), norepinephrine (2.4, 7.5, 21.2%), vasopressin (3.4, 7.6, 21.0%), succinylcholine (74.0, 69.0, 61.9%), intraoperative hypotension (28.8, 33.0, 52.3%) and the triple low state (9.4, 30.3, 80.0%) exposure, and 30-day postoperative mortality (0.8, 2.7, 5.6%). TVI was a better predictor of patients that died or survived in the 30 days following surgery compared to cumulative triple low state exposure (AUC 0.68 versus 0.62, p