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BJA Advance Access originally published online on April 27, 2009
British Journal of Anaesthesia 2009 102(6):756-762; doi:10.1093/bja/aep083
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© The Author [2009]. Published by Oxford University Press on behalf of The Board of Directors of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournal.org

Orthostatic intolerance and the cardiovascular response to early postoperative mobilization

M. Bundgaard-Nielsen1,2,*, C. C. Jørgensen1,2, T. B. Jørgensen2, B. Ruhnau2, N. H. Secher2 and H. Kehlet1

1 Section of Surgical Pathophysiology
2 Department of Anaesthesia, Rigshospitalet, University of Copenhagen, DK-2100 Copenhagen, Denmark

* Corresponding author. E-mail: morten.bundgaard-nielsen{at}rh.regionh.dk

Background: A key element in enhanced postoperative recovery is early mobilization which, however, may be hindered by orthostatic intolerance, that is, an inability to sit or stand because of symptoms of cerebral hypoperfusion as intolerable dizziness, nausea and vomiting, feeling of heat, or blurred vision. We assessed orthostatic tolerance in relation to the postural cardiovascular responses before and shortly after open radical prostatectomy.

Methods: Orthostatic tolerance and the cardiovascular response to sitting and standing were evaluated on the day before surgery and 6 and 22 h after operation in 16 patients. Non-invasive systolic (SAP) and diastolic arterial pressure (DAP) (Finometer®), heart rate, cardiac output (CO, Modelflow®), total peripheral resistance (TPR), and central venous oxygen saturation (ScvO2) were monitored.

Results: Before surgery, no patients had symptoms of orthostatic intolerance. In contrast, 8 (50%) and 2 (12%) patients were orthostatic intolerant at 6 and ~22 h after surgery, respectively. Before surgery, SAP, DAP, and TPR increased (P<0.05), whereas CO did not change (P>0.05) and ScvO2 decreased (P<0.05) upon mobilization. At 6 h after operation, SAP and DAP declined with mobilization (P<0.05) and the arterial pressure response differed from the preoperative response both upon sitting (P<0.05) and standing (P<0.05) due to both impaired TPR and CO. At ~22 h, the SAP and DAP responses to mobilization did not differ from the preoperative evaluation (P>0.05).

Conclusions: The early postoperative postural cardiovascular response is impaired after radical prostatectomy with a risk of orthostatic intolerance, limiting early postoperative mobilization. The pathogenic mechanisms include both impaired TPR and CO responses.

Keywords: anaesthesia, general; recovery, postoperative; surgery, postoperative period


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