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Journal of Clinical Monitoring and Computing

https://doi.org/10.1007/s10877-018-0125-4

ORIGINAL RESEARCH

https://doi.org/10.1007/s10877-018-0125-4 ORIGINAL RESEARCH Impact of continuous non-invasive blood pressure monitoring

Impact of continuous non-invasive blood pressure monitoring on hemodynamic fluctuation during general anesthesia: a randomized controlled study

Takashi Juri 1 · Koichi Suehiro 1 Kiyonobu Nishikawa 1

Juri 1 · Koichi Suehiro 1 Kiyonobu Nishikawa 1 · Aya Kimura 1 · Akira Mukai

· Aya Kimura 1 · Akira Mukai 1 · Katsuaki Tanaka 1 · Tokuhiro Yamada 1 · Takashi Mori 1 ·

Received: 25 September 2017 / Accepted: 2 March 2018 © Springer Science+Business Media B.V., part of Springer Nature 2018

Abstract This study assessed the ability of a continuous non-invasive blood pressure (BP) monitoring system to reduce intra-anesthetic hemodynamic fluctuation compared with intermittent BP cuff measurement. Forty patients undergoing total knee arthroplasty under general anesthesia were enrolled and randomly divided into two groups (Control and CS group). BP management was performed using the same protocol with BP measured by intermittent BP cuff in the Control and that by continuous non-invasive BP monitoring in the CS group. We assessed the accuracy and precision of the continuous non-invasive BP monitoring compared with BP cuff measurement using Bland–Altman, four-quadrant plot, and polar-plot analyses. Addition- ally, the occurrence of hypotension and hypertention during general anesthesia was compared between the two groups. The continuous non-invasive BP monitoring showed excellent accuracy of − 1.1 ± 8.1 mmHg during surgery and an acceptable trending ability with a concordance rate of 95.1% according to the four-quadrant plot analysis and an angular concordance rate of 86.7% by polar-plot analysis. Hypotension was less common in the CS group during induction of anesthesia (p = 0.002) and surgery (p = 0.008). Hypertension occurred more frequently in the Control group during emergence from anesthesia (p = 0.037). The duration of hemodynamic stability (systolic BP 80–110% of baseline) intraoperatively was longer in the CS group than in the Control group (87.7 vs. 61.9%; p < 0.001). Accuracy and trending ability of the continuous non-invasive BP monitoring was clinically acceptable, and lead to hemodynamic stability and reduction of intra-anesthetic hypotension and hypertension intraoperatively.

Keywords Continuous blood pressure monitoring · Cuff measurement · General anesthesia · Hemodynamic fluctuation · Non-invasive

1 Introduction

With advances in surgical techniques and perioperative care, the number of patients undergoing major non-cardiac sur- gery is increasing and intraoperative management of anes- thesia can impact short and long-term outcomes [13]. For example, postoperative outcome is improved by intraopera- tive goal-directed fluid therapy [4], restrictive blood trans- fusion [5], and avoiding intraoperative hypothermia [6] and

* Koichi Suehiro suehirokoichi@yahoo.co.jp

1 Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abenoku, Osaka City, Osaka 545-8586, Japan

1-5-7 Asahimachi, Abenoku, Osaka City, Osaka 545-8586, Japan a deep anesthetic level [ 2 ]. Also,

a deep anesthetic level [2]. Also, cardiovascular complica- tions frequently occur in the perioperative period, and can lead to mortality [7]. Therefore, reducing the incidence of perioperative cardiovascular complications remains a con- cern [8]. One anesthetic approach to decrease intraoperative and postoperative cardiac morbidity is to maintain a stable hemodynamic status during surgery [9, 10]. Hemodynamic fluctuation are common during general anesthesia because of the vasodilation and myocardial suppression caused by anesthetic drugs, surgical stress, and blood loss [1116]. Both hypotension and hyperten- sion may increase organ oxygen demand and reported to be correlated to postoperative morbidity and mortality [17]. Intraoperative blood pressure (BP) measurement is typically performed using an automated digital sphygmomanometer and is usually taken every 5 min as recommended by the

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Journal of Clinical Monitoring and Computing

American Society of Anesthesiologists [18]. Anesthesi- ologists make decisions about hemodynamic management including administration of vasopressors and fluid loading based on the values obtained using a non-invasive BP cuff. Detection of hypertension and hypotension would be more difficult when BP was measured intermittently compared with an arterial line. However, intra-arterial catheterization can cause complications, including hematoma, nerve injury, and pseudo-aneurysm [18]. The ClearSight system (Edwards Lifesciences, Irvine, CA, USA) is a monitoring system that allows for continuous non-invasive BP measurement. This system was developed using Wesseling’s Finapres method. The Finapres system utilizes the “Physiocal” (physiologic calibration) algorithm for vascular unloading. The Physiocal algorithm induces stepwise and intermittent BP changes, and simultaneously repeats the analysis of the photoplethysmo- gram waveforms. When alternate pressure settings produce larger photoplethysmogram amplitudes, the feedback is used to achieve an unloaded state of the finger artery [18]. We hypothesized that this continuous non-invasive BP monitor- ing could allow for reduced hemodynamic fluctuation during general anesthesia when compared with standard intermit- tent BP cuff measurement. This study aimed to investigate: (1) the accuracy and precision of BP measured with the continuous non-invasive BP monitoring compared with intermittent BP cuff meas- urement during general anesthesia including induction and emergence and (2) the efficacy of the continuous non-inva- sive BP monitoring allowing for reduction of hypotension and hypertension during general anesthesia when compared with BP cuff measurement was evaluated.

2 Methods

2.1 Anesthetic management

The study protocol was approved by the institutional review board. Written informed consent was obtained from all patients. Patients undergoing total knee arthroplasty for knee osteoarthritis under general anesthesia were enrolled. The exclusion criteria were arrhythmia (atrial fibrillation, frequent ventricular or supraventricular premature beats); decreased cardiac function (preoperative ejection frac- tion < 50%); and valvular heart disease [significant (at least moderate) regurgitation or stenosis of the aortic, mitral, or tricuspid valve]. Patients were randomly divided into a Con- trol group and a CS group preoperatively. No premedication or intravenous infusions were adminis- tered preoperatively, and all patients were able to take clear liquids until 3 h before surgery. On arrival in the operating room, each patient was laid on the operating table and moni- toring devices, for pulse oximetry, electrocardiography, and

non-invasive BP cuff (IntelliVue MP70; Philips Electron- ics Japan Corp., Tokyo, Japan) measurement were attached. In the CS group, the ClearSight device was attached to an index finger. Patients rested in a supine position and kept calm in the operating theatre for 5 min. Non-invasive BP cuff measurement was then started in both groups. Systolic BP (SBP cuff ), diastolic BP (DBP cuff ), and mean BP (MBP cuff ) were measured on three occasions separated by 1-min inter- vals, and baseline value was calculated as the average of three values. In the CS group, BP measurement by the con- tinuous non-invasive BP monitoring was started simultane- ously, and systolic BP (SBP CS ), diastolic BP (DBP CS ), and mean BP (MBP CS ) were recorded as the baseline values. An intravenous line was inserted after the baseline BP measurements were completed. Administration of fluid was initiated at 10 ml/min using Ringer’s solution containing bicarbonate (Bicanate®, Otsuka Pharmaceutical Co. Ltd., Tokyo, Japan). Five minutes after initiation of fluid adminis- tration, induction of anesthesia was performed using propo- fol 1.5 mg/kg, remifentanil 0.3 µg/kg/min, and rocuronium 0.9 mg/kg. Bag-mask ventilation was then performed at around 8 ml/kg tidal volume with 100% oxygen and 4% des- flurane, and the patients were intubated after 5 min. Anesthe- sia was maintained using desflurane and remifentanil. The attending anesthesiologists were responsible for intraopera- tive administration of fluids. The depth of anesthesia was controlled to maintain bispectral index values (v4.0, Aspect Medical System Inc, Natick, MA, USA) between 45 and 60. Before closing the incision, the surgeon injected a steroid- containing local anesthetic periarticularly into all the soft tissues surrounding the knee. Fentanyl 2–4 µg/kg and aceta- minophen 15 mg/kg were administered at the end of surgery for analgesia. After the operation, sugammadex (2–4 mg/ kg) was administered, and then the patients were extubated.

2.2 Blood pressure management

In both groups, BP measurement by non-invasive cuff was performed at 1-min intervals during anesthetic induction and emergence from anesthesia, and with 5-min intervals dur- ing surgery. The investigators treating the CS group were blinded to the BP values from the cuff. The BP in the CS group was controlled using the values measured by the sys- tem, whereas that in the Control group was managed using the non-invasive BP cuff values. In both groups, BP man- agement was performed using the same protocol (Fig. 1). During induction of and emergence from anesthesia, BP was controlled to maintain SBP cuff in the Control group, and SBP CS in the CS group within 90–110% of the baseline value. During surgery, the remifentanil infusion rate was controlled to maintain SBP within 80–110% of the baseline value. Vasopressors or vasodilators were administered in the

Journal of Clinical Monitoring and Computing

Journal of Clinical Monitoring and Computing Fig. 1 Protocol for BP management during a induction of

Fig. 1 Protocol for BP management during a induction of and emer- gence from anesthesia and b intraoperatively. BP blood pressure, SBP systolic blood pressure

event of a sudden decrease or increase in BP that could not be controlled by remifentanil.

2.3 Statistical analysis

For analysis of BP, we used the data measured by the cuff to standardize the BP outcome in both groups. We set the primary study endpoint to be hemodynamically stable time (HSTime), i.e., the ratio of the intraoperative duration of hemodynamic stability (SBP in the range of 80–110% of the baseline value) to the total operating time and the secondary study endpoints to be the incidence of hypotension (SBP < 90 mmHg or 80% of baseline SBP) and of hypertension (SBP > 160 mmHg or 110% of baseline SBP) during induction of and emergence from anesthesia. In a preliminary study of 5 cases, HSTime was 72 ± 18% without the continuous non-invasive BP moni- toring. We hypothesized that the HSTime when using the continuous non-invasive BP monitoring would be 90%, and

a power analysis demonstrated that a sample size of 20 sub-

jects in each group was sufficient to detect a difference of 18% between the Control and CS groups with a power of 0.80 and an alpha of 0.05. We also compared the accuracy and precision of the con- tinuous non-invasive BP monitoring for BP measurement with that of BP cuff measurement. In the CS group patients (n = 20), Bland–Altman analysis was performed to compare MBP cuff and MBP CS . The results of this analysis are demon- strated as the bias and the 95% limits of agreement (LOA) [19]. We adjusted the repeated measurements for each patient as described by Myles and Cui [20]. The BP measured by the continuous non-invasive BP monitoring was defined as acceptable if accuracy and precision were no greater than 5 and 8 mmHg, respectively, when compared with BP meas- ured by the cuff, based on the standards for evaluation of BP monitoring recommended by the Association for the Advance- ment of Medical Instrumentation [21]. The changes in MBP between two consecutive measurements, as measured using

a non-invasive BP cuff (MBP cuff ) and the continuous non- invasive BP monitoring (MBP CS ), were also compared to assess the trending ability of the continuous non-invasive BP monitoring. Four-quadrant plot and polar-plot analyses were used to evaluate tracking ability [22]. The concordance rate (CR) is defined as the percentage of data points lying in the lower left or upper right quadrant, and is evaluated as excellent when more than 92% [23, 24]. In the polar-plot analysis, the agreement between the two methods was assessed by the fol- lowing variables: the mean angular bias (i.e., the average angle between a data point and the polar axis); the angular CR (i.e., the percentage of data points within a ± 30° radial zone); and the radial LOA (i.e., the radial zone containing 95% of all the

data points). Using this analysis, the tracking ability is defined as “excellent” when the mean angular bias is within ± 5°, the angular CR is more than 95%, and the radial LOA are within

± 30° [22]. The data within a central zone of radial limits of

10% were excluded from the analysis, because a slight change in BP may not reflect trending ability. Patient characteristics were compared using the Mann–Whitney U test, the Student’s t-test, and the Chi square test. For all analyses, a p-value < 0.05 was consid- ered to be statistically significant. The statistical analysis was performed using StatFlex version 6.0 (Artech Co., Ltd, Osaka, Japan), MedCalc version 14 (MedCalc Software bvba, Ostend, Belgium), and SigmaPlot 13.0 (Systat Soft- ware Inc., San Jose, CA, USA).

3 Results

Figure 2 shows the CONSORT flow diagram. Forty-five patients were assessed for inclusion in the study, and five patients were excluded because of not meeting inclusion

Journal of Clinical Monitoring and Computing

criteria (Control group, n = 20; CS group, n = 20). There were no exclusions after randomization. As shown in Table 1, there were no significant preoperative differences between the two groups.

We investigated the accuracy and precision of BP measured by the continuous non-invasive BP monitoring system. The results of Bland–Altman analysis are shown in Fig. 3 and Table 2. The bias was − 3.9 ± 10.3 mmHg

Fig. 2 CONSORT flow diagram for the present study

10.3 mmHg Fig. 2 CONSORT flow diagram for the present study Table 1 Preoperative data in

Table 1 Preoperative data in both groups

Variables

Control group (n = 20)

ClearSight group (n = 20)

p value

Gender (M/F) Age (year) Height (cm) Weight (kg) Operation side (L/R) NYHA classification I/II III/IV Preoperative complication Hypertension, n (%) Diabetes mellitus, n (%) Old myocardial infarction Asthma, n (%)

3/17

5/15

75.5 ± 5.2 152 ± 7.4 61.2 ± 7.6

71.5 ± 10.1 153 ± 8.3 59.8 ± 9.4

0.120

0.689

0.608

13/7

12/8

 

1.00

20

20

0

0

13 (65%)

12 (60%)

9 (45%)

6 (30%)

2 (10%)

2 (10%)

2 (10%)

2 (10%)

Chronic kidney disease, n (%) Baseline hemodynamic data Systolic BP (mmHg) Diastolic BP (mmHg)

0 (0%)

2 (10%)

149 ± 20.1 73.9 ± 15.6 94.6 ± 15.6 71.8 ± 9.8

140 ± 15.5 79.3 ± 10.2 95.2 ± 10.4 75.8 ± 11.8

0.119

0.204

Mean

BP (mmHg)

0.887

Heart

rate (bpm)

0.250

p < 0.05 statistically significant

Data are expressed as mean ± SD

NYHA New York Heart Association, BP blood pressure

Journal of Clinical Monitoring and Computing

during the procedure. The continuous non-invasive BP monitoring showed excellent accuracy and precision of − 1.1 ± 8.1 mmHg intraoperatively but poor accuracy and precision during induction of and emergence from anesthe- sia. The trending ability of the continuous non-invasive BP monitoring was also evaluated using four-quadrant and polar plot-analyses, shown in Fig. 4 and Table 2. In the four-quad- rant analysis, the continuous non-invasive BP monitoring showed excellent trending ability throughout the procedure (CR, 87.9% during induction of anesthesia, 97.7% intraoper- atively, 90.9% during emergence from anesthesia, and 95.1% for total operating time). In the polar-plot analysis, the angu- lar bias and CR was − 9.3 ± 21.4° and 79.2%, respectively, during the procedure. The continuous non-invasive BP mon- itoring demonstrated an acceptable tracking ability during surgery of − 10.7 ± 17.1° and 86.7% in angular bias and CR, respectively. However, the trending ability worsened during

respectively. However, the trending ability worsened during Fig. 3 Bland–Altman analysis of agreement of BP

Fig. 3 Bland–Altman analysis of agreement of BP measurements obtained by an BP intermittent cuff and the continuous non-invasive BP monitoring. MBP cuff , mean blood pressure measured by intermit- tent cuff, MBP CS , mean blood pressure measured by the continuous non-invasive BP monitoring. BP blood pressure

induction of and emergence from anesthesia (angular CR:

54.5 and 72.7%, respectively). Table 3 shows the intraoperative data for both groups. The patients in the CS group had a larger urine output; despite for the volumes of fluid administered were not different between the two study groups. The intraoperative dose of phenyle- phrine was greater in the CS group, whereas ephedrine was more likely to be used in the Control group (p < 0.05). The incidence of hypotension was lower in the CS group during induction of anesthesia and during surgery (p = 0.002 and p = 0.008, respectively). Hypertension during emergence from anesthesia was more common in the Control group (p = 0.037). Further, the hemodynamic stability time was longer in the CS group than in the Control group (87.7 vs. 61.9%, p < 0.001) (Fig. 5).

4 Discussion

We evaluate the ability of the continuous non-invasive BP monitoring allowing for reduction of hemodynamic fluc- tuation during general anesthesia. First, we assessed the accuracy and precision of BP measured by the continuous non-invasive BP monitoring with that of intermittent BP cuff measurement during general anesthesia. The bias shown by the Bland–Altman analysis was − 3.9 ± 10.3 mmHg dur- ing the procedure. Many validation studies have been per- formed for the continuous non-invasive BP monitoring of BP measurement [21, 2528]. Fisher et al. [25] evaluated the accuracy of this system in patients undergoing cardiac surgery. There was a correlation between BP measured by the continuous non-invasive BP monitoring and invasive arterial pressure measurement (p < 0.001), with a bias of 4.6 ± 6.5 mmHg. In critically ill patients, the correlation between MBP measured by the continuous non-invasive BP monitoring and that recorded by invasive arterial pressure measurement was acceptable (r 2 = 0.50, bias 6 ± 12 mmHg),

Table 2 Statistical data from Bland–Altman analysis and polar plots

 

Anesthetic induction

During operation

Emergence

Total

 

from anesthesia

Bland–Altman analysis Mean bias (mmHg) 95% LA (mmHg) Four quadrant plot CR (%) Polar plot Mean angular bias (degree) Radial LA (degree) Angular CR (%)

− 8.7 ± 14.4

− 1.1 ± 8.1

− 9.9 ± 9.4

− 3.9 ± 10.3

28.3

16.2

18.5

20.5

87.9

97.7

90.9

95.1

6.3 ± 31.6

− 10.7 ± 17.1

− 5.9 ± 25.3

− 9.3 ± 21.4

61.9

33.5

49.6

41.9

54.5

86.7

72.7

79.2

Data are expressed as mean ± SD

LA limit of agreement, CR concordance rate

Journal of Clinical Monitoring and Computing

Fig. 4 Polar-plot analysis to assess the trending ability of changes of mean blood pressure measured by the continuous non-invasive BP monitoring compared with intermittent cuff for all measurements. The dis- tance from the center of the plot shows the mean percent changes in mean blood pressure, and the angle with the horizontal axis means disagreement. The data inside the limits of agreement (i.e. ± 30° shown by dotted lines) represents good trending ability. ΔMBP mean percentage changes in mean blood pressure

ΔMBP mean percentage changes in mean blood pressure but worsened in patients with edema and those

but worsened in patients with edema and those in whom noradrenaline was administered (r 2 = 0.40 and r 2 = 0.28, respectively). Chen et al. [27] compared SBP recorded by the continuous non-invasive BP monitoring with that measured by an intermittent BP cuff in surgical patients, and report a bias of − 1.0 ± 12.6 mmHg. They also assessed the trending ability for BP measurement and reported an angular CR of 81.3% by polar-plot analysis. In the meta- analysis by Kim et al. [21], the accuracy was good with a bias of − 2 ± 8, 5 ± 6.5, and 4 ± 7 mmHg for SBP, DBP, and MBP, respectively. Furthermore, intraoperative cardiac output (CO) measurement using the continuous non-invasive BP monitoring had a strong correlation to CO measured by esophageal Doppler even after phenylephrine administra- tion [29]. Therefore, the impact of acute changes in vascular resistance may not be so large in this system, which may lead to acceptable trending ability of this system for BP measure- ment. Except in critically ill patients, the accuracy and trend- ing ability of the continuous non-invasive BP monitoring was clinically acceptable, which can lead to intraoperative hemodynamic stability and reduction of the incidence of intra-anesthetic hypotension and hypertension. Perioperative morbidity and mortality as well as the long-term outcomes after surgery may be influenced by anesthetic management, especially management of arterial BP. Intraoperative hypotension is a risk factor for periopera- tive morbidity and mortality [17, 3033]. Monk et al. [30] reported that every minute of hypotension in the operating room increased the risk of postoperative mortality in the

first year after surgery (relative risk 1.036/min; p = 0.0125). In another study [17], intraoperative hypotension increases the risk of 30-day postoperative mortality. Even short dura- tions of an intraoperative MBP less than 55 mmHg can cause acute kidney and myocardial injury [31]. In vascular sur- gery, intraoperative hypotension defined as a 40% decrease from the preoperative MBP with a duration for > 30 min is associated with postoperative myocardial injury [32]. When using the surgical Apgar score, the lowest MBP was useful for predicting an outcome after surgery [33]. A continuous recording allows the anesthesiologist to intervene soon so that the patient is stable in regard to blood pressure, which could lead to a decrease in postoperative morbidity and mor- tality as well as improved long-term outcomes. As indicated in Fig. 5, the risk of intra-anesthetic hypotension was lower in the CS group than in the Control group, particularly dur- ing induction of anesthesia (90 vs. 45%, p = 0.002). It is important to be able to deal with hypotension quickly during induction of anesthesia by using the continuous blood pres- sure monitoring, because anesthesiologists may be distracted during mask-ventilation and subsequent tracheal intubation. Moreover, patients in the CS group were exposed to less hypertension during emergence from anesthesia. Although there were no significant differences in infusion and blood loss between the two groups, the amount of urine output was larger in the CS group due to maintenance of the renal blood flow. As shown by Meidert et al. [34], continuous intraopera- tive BP measurement by the ClearSight system decreased

Journal of Clinical Monitoring and Computing

Table 3 Intraoperative data in both groups

Variables

Control group (n = 20)

ClearSight group (n = 20)

p value

Operation time (min)

131 ± 33.0 179 ± 37.2 110 ± 36.5 974 ± 294 40.8 ± 51.6

119 ± 37.3 163 ± 37.6 103 ± 29.6 830 ± 401 42.8 ± 77.2 668 ± 564

0.304

Anesthesia

time

(min)

0.170

Tourniquet

time

(min)

0.471

Infusion (mL) Blood loss (mL)

0.203

0.924

Urine output (mL) 269 ± 192 Total amount of vasoactive drugs

0.005*

Phenylephrine

(mg)

0.74 ± 0.58 22.3 ± 9.7 0.48 ± 0.93

1.51 ± 0.52 12.9 ± 8.0 0.82 ± 1.54

< 0.001*

Ephedrine (mg) Nicardipine (mg) Maximum blood pressure Systolic BP (mmHg) Diastolic BP (mmHg)

0.002

0.403

174 ± 18.0 78.3 ± 12.3

159 ± 21.8 84.0 ± 17.1 106 ± 28.8

0.023*

0.233

Mean BP (mmHg) 102 ± 10.9 Minimum blood pressure

0.526

Systolic BP (mmHg) Diastolic BP (mmHg)

91.2 ± 18.5 48.8 ± 10.5

100 ± 12.7 53.3 ± 8.4 64.2 ± 8.5

0.075

0.147

Mean BP (mmHg) 58.8 ± 12.1

0.114

Incidence of hypotension, cases (%) Anesthetic induction During operation Emergence from anesthesia Incidence of hypertension, cases (%) Anesthetic induction During operation Emergence from anesthesia

18 (90%)

9 (45%)

0.002*

19 (95%)

12 (60%)

0.008*

8 (40%)

6 (30%)

0.507

8 (40%) 8 (40%) 6 (30%) 61.9 ± 22.9

9 (45%) 9 (45%) 1 (5%) 87.7 ± 10.9

0.749

0.749

0.037*

Hemodynamic stability (%)

< 0.001*

Fig. 5 Duration of hemody- namic stability and incidence of hypotension in the control group and the CS group

Data are expressed as mean ± SD

BP blood pressure

*p < 0.05 statistically significant

group and the CS group Data are expressed as mean ± SD BP blood pressure *p

Journal of Clinical Monitoring and Computing

the hypotensive events during orthopedic surgery com- pared with intermittent BP monitoring. Other continuous non-invasive monitoring could induce hemodynamic sta- bility in various clinical situations [35, 36]. Benes et al. [35] reported that continuous BP monitoring by the CNAP monitor (CNSystems Medizintechnik AG, Graz, Austria) allowed for intraoperative BP stability in surgical patients in upright position. The CNAP system can also detect intraoperative hypotension more precisely than intermit- tent BP measurement after spinal anesthesia for cesarean delivery [36]. As with the continuous non-invasive BP monitoring, invasive arterial pressure measures BP con- tinuously, and may allow for better BP management. Our study has some limitations. Firstly, we measured BP using an intermittent BP cuff in the Control group. Secondly, we did not assess the postoperative course. Thirdly, although the ClearSight System can provide vari- able hemodynamic parameters such as CO and stroke vol- ume variation, we focused on blood pressure in the current study. Perioperative goal-directed therapy (GDT) using minimally invasive CO monitoring has been reported to decrease postoperative morbidity [37]. Therefore, optimi- zation of CO and stroke volume variation using the Clear- Sight system can lead to better postoperative outcomes.

5 Conclusions

We demonstrated that hemodynamic management using the continuous non-invasive BP monitoring can induce intra-anesthetic hemodynamic stability. The accuracy and trending ability of the continuous non-invasive BP monitoring for BP measurement was clinically accept- able, and led to intraoperative hemodynamic stability and a reduced incidence of intra-anesthetic hypotension and hypertension.

Funding Only departmental funds were used for this study.

Compliance with ethical standards

Conflict of interest None of the authors has any potential conflict of interest, including no commercial relationships such as consultation or equity interests that could have direct or potential influence or impart bias on the work.

Research involving human participants and/or animals All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amend- ments or comparable ethical standards.

Informed consent Informed consent was obtained from all individual participants included in the study.

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