Pediatric Surgery International

https://doi.org/10.1007/s00383-018-4359-5

ORIGINAL ARTICLE

Risk factors for post-induction hypotension in children presenting

for surgery
Tariq M. Wani1 · Mohammed Hakim2 · Archana Ramesh4 · Shabina Rehman5 · Yasser Majid3 · Rebecca Miller2 ·
Dmitry Tumin2 · Joseph D. Tobias2

Accepted: 9 October 2018

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Background  Preoperative factors have been correlated with pre-incision hypotension (PIH) in children undergoing surgery,
suggesting that PIH can be predicted through preoperative screening. We studied blood pressure (BP) changes in the 12 min
following the induction of anesthesia to study the incidence of post-induction hypotension and to assess the feasibility of
predicting PIH in low-risk children without preoperative hypotension or comorbid features.
Methods  We retrospectively evaluated 200 patients ranging in age from 2 to 8 years with American Society of Anesthesiolo-
gists’ (ASA) physical status I or II, undergoing non-cardiac surgery. Patients were excluded if they had preoperative (baseline)
hypotension (systolic blood pressure (SBP) < 5th percentile for age). BP and heart rate (HR) were recorded at 3 min intervals
for 12 min after the induction of anesthesia. Pre-incision hypotension (PIH) was initially defined as SBP < 5th percentile
for age: (1) at any timepoint within 12 min of induction; (2) for the median SBP obtained during the 12 min study period;
or (3) at 2 or more timepoints including the final point at 12 min after the induction of anesthesia (sustained hypotension).
In addition, we examined PIH defined as > 20% decrease in SBP from baseline: (4) at any timepoint within 12 min of the
induction of anesthesia; (5) for the median SBP obtained during the 12 min study period; or (6) at two or more timepoints
including the final point at 12 min after the induction of anesthesia. Agreement among the six definitions was analyzed, in
addition to the effects of age, gender, type of anesthetic induction, use of premedication, preoperative BP, preoperative HR,
and body mass index on the incidence of PIH according to each definition.
Results  Five patients were excluded due to baseline hypotension and six were excluded for missing data. In the remaining
cohort, estimated PIH prevalence ranged from 4% [definition (Stewart et al., in Paediatr Anaesth 26:844–851, 2016), sustained
PIH according to SBP percentile-for-age] to 57% [definition (Task Force on Blood Pressure Control in Children, in Pediat-
rics 79:1–25, 1987), at least one timepoint where SBP was > 20% lower than baseline]. Pairwise agreement among the six
definitions ranged from 49 to 91% agreement. No sequelae of PIH were noted during subsequent anesthetic or postoperative
care. On multivariable analysis, no covariates were consistently associated with PIH risk across all six definitions of PIH.
Conclusion  The present study describes the incidence and prediction of PIH in a cohort of relatively healthy children. In
this setting, accurate prediction of PIH appears to be hampered by lack of agreement between definitions of PIH. Overall,
there was a low PIH incidence when the threshold of SBP < 5th percentile for age was used.
Level of evidence II.

Keywords  Pre-incision hypotension · Systolic blood pressure

3
* Mohammed Hakim Department of Anesthesia, King Fahad Medical City,
mohammed.hakim@nationwidechildrens.org Riyadh, Saudi Arabia
4
1 Department of Anesthesiology, University of Nebraska
Department of Anesthesia, Pediatric Division, Sidra
Medical Center, Nebraska, USA
Medicine, Doha, Qatar
5
2 Department of Biochemistry, School of Medicine, University
Department of Anesthesiology and Pain Medicine,
of West Virginia, Morgantown, USA
Nationwide Children’s Hospital, 700 Children’s Drive,
Columbus, OH 43205, USA

13
Vol.:(0123456789)

Introduction
Hypotension after the induction of anesthesia and prior to
incision is frequently observed in children. However, the
exact incidence, clinical consequences, and risk factors
for pre-incision hypotension (PIH), as well as the need
for specific interventions, are often unclear. The previ-
ous studies have identified demographic and preoperative
predictors of PIH in children undergoing various surger-
ies, suggesting that the prediction of PIH can be improved
through preoperative screening [1–3]. These studies have
investigated heterogeneous cohorts of children, many
of whom had significant comorbid diseases and/or pre-
existing hypotension that may have strongly contributed
to intraoperative occurrence of PIH. By contrast, the lower
incidence of PIH among preoperatively normotensive chil-
dren suggests that, in relatively low-risk children, preop-
erative characteristics may be less useful for predicting
PIH [1].
Hypotension in children has been commonly defined as
a systolic blood pressure (SBP) below the fifth percentile
for age [4, 5]. Although there is currently no consensus
on what constitutes intraoperative hypotension (IOH) in
the pediatric anesthesia literature, hypotension may be
a crucial sign of impending compromise and, therefore,
may require prompt investigation and treatment [6]. The
present study was designed to highlight the issues related
to defining the post-induction hypotension. We conducted
a retrospective review assessing the incidence of and the
feasibility of predicting PIH in low-risk children (ASA
physical status I and II) with no preoperative hypotension
or significant comorbid conditions presenting for surgery.
We hypothesized that, in children with no preoperative
hypotension, the accuracy of predicting PIH according to
preoperative characteristics would be limited.
Methods
This observational retrospective data analysis was
approved by the Hospital’s Institutional Review Board
and registered at ClinicalTrials.gov (NCT01934062). The
study included children (2–8 years of age) undergoing
general anesthesia for non-cardiac surgery performed at
Nationwide Children’s Hospital (Columbus, Ohio) over a
6-month period. Patients with comorbid cardiac diseases
including corrected congenital cardiac defects, previ-
ously diagnosed hypertension, primary pulmonary disease
(including reactive airway disease), and kidney disease
were excluded from the study. Based on the incidence of
hypotension reported in the literature and the feasibility
13
Pediatric Surgery International
of completing manual retrospective review, a random con-
venience sample of 200 patients ranging in age from 2 to
8 years and ASA status I and II were selected for review
of blood pressure (BP) and heart rate (HR) information
recorded at 3-min intervals after the induction of anesthe-
sia (0, 3, 6, 9, and 12 min). Patients were included only
if there was no intervention addressing the low BP values
during the study timeframe. Patients with preoperative
hypotension, defined below, and missing data on covari-
ates were excluded from further analysis.
The exclusion criterion of preoperative hypotension was
preoperative SBP < 5th percentile for age with SBP per-
centiles calculated using NIH guidelines and taking into
account age, gender, and height-for-age Z-score [7, 8]. PIH
was initially defined as SBP < 5th percentile for age: (1) at
any timepoint within 12 min of the induction of anesthesia;
(2) for the median SBP obtained during the 12-min study
period; or (3) at two or more timepoints including the final
point at 12 min after the induction of anesthesia (sustained
hypotension). In addition, we examined the incidence of
PIH defined as > 20% decrease in SBP from baseline: (4) at
any timepoint within 12 min of the induction of anesthesia;
(5) for the median SBP obtained during the 12-min study
period; or (6) at two or more timepoints including the final
point at 12 min after the induction of anesthesia. Defini-
tions (4–6) were based on a previous survey of pediatric
anesthesiologists, where most respondents considered IOH
as a 20–30% decrease from baseline SBP [6].
Other data obtained for analysis included the type of
anesthetic induction, use of premedication, preoperative
BP, preoperative HR, body mass index (BMI; categorized
as underweight, normal weight, or overweight according to
gender-age-specific World Health Organization guidelines)
[9], and demographic characteristics (age, gender). Data
were summarized using means with standard deviations
for continuous variables, and counts with percentages for
categorical variables. Patient characteristics were compared
according to the presence of PIH at any timepoint in the
study using unpaired t tests for continuous data and Chi-
square tests or Fisher’s exact for categorical data. Paired
t tests were used to compare post-induction hemodynamic
parameters to preoperative values. Agreement among the
six definitions of PIH was summarized using percent agree-
ment and the kappa statistic (κ), where κ < 0.4 was consid-
ered to represent poor agreement [10]. Multivariable logistic
regression models of PIH used forward selection to include
covariates listed above if they were associated with each
definition of PIH at P < 0.2. As patients with preoperative
hypotension (preoperative SBP < 5th percentile for age) were
excluded from the analysis, preoperative SBP was consid-
ered as a continuous variable. Data analysis was performed
using Stata/IC 14.2 (College Station, TX; StataCorp, LP),
and P < 0.05 was considered statistically significant.
Pediatric Surgery International

Results percentile-for-age and definitions of PIH based on SBP

Of the 200 patients selected for review, 5 were excluded
due to preoperative hypotension at study baseline, and
additional 6 were excluded due to missing data on study
variables, thereby leaving a study cohort of 189 patients.
The characteristics of the remaining 189 patients are
summarized according to the occurrence of PIH at any
study timepoint (using either SBP percentile-for-age or
change in SBP from baseline) in Table  1. At all time-
points after the induction of anesthesia, there were sig-
nificant decreases in average SBP, diastolic blood pres-
sure (DBP), and mean arterial pressure (MAP), relative to
baseline values (Table 2). Despite these BP changes, no
treatment was administered by the anesthesia team. Fur-
thermore, no significant perioperative events including
cardiac arrest occurred due to these BP changes. Table 3
summarizes the prevalence of PIH and agreement among
various definitions of PIH in the study cohort. The pres-
ence of PIH varied significantly according to how PIH was
defined, with the lowest prevalence of PIH estimated as
7% (defined as sustained SBP < 5th percentile-for-age) and
the highest prevalence of PIH estimated as 57% (defined
as any decline in SBP > 20% from the baseline value).
Agreement between the definitions of PIH based on SBP
percent decline from baseline was poor (percent agree-
ment ranging from 48 to 72% and kappa statistic ranging
from 0.1 to 0.2).
In stepwise multivariable analysis predicting PIH, no
covariates were statistically significantly associated with
PIH when it was defined as SBP < 5th percentile-for-age at
the median observation, or sustained SBP < 5th percentile-
for-age (definitions 2 and 3). Multivariable logistic regres-
sion models for the remaining four definitions of PIH are
shown in Table 4. Most importantly, no covariate was con-
sistently associated with the various definitions of PIH. In
the case of preoperative SBP, this covariate had opposite
estimated effects on PIH risk depending on how PIH was
defined. For example, higher preoperative SBP was associ-
ated with lower risk of any SBP < 5th percentile-for-age (OR
0.97; 95% CI 0.94, 1.00; P = 0.036), but higher risk of any
SBP > 20% decline from baseline (OR 1.10; 95% CI 1.06,
1.14; P < 0.001).
Discussion
PIH is frequently encountered in children under general
anesthesia, although causative factors and the necessity for
intervention are not always evident. Adverse events related

Table 1  Characteristics of study cohort according to the presence of hypotension at any timepoint, 0–12  min after the induction of induction
(N = 189)
Variable PIH defined as SBP < 5th percentile for age at any timepoint PIH defined as > 20% decrease of SBP from baseline at
any timepoint
PIH absent (n = 137) PIH present (n = 52) P value PIH absent (n = 82) PIH present (n = 107) P value
Mean (SD) or N (%) Mean (SD) or N (%) Mean (SD) or N (%) Mean (SD) or N (%)

Age (years) 4 (2) 4 (2) 0.990 5 (2) 4 (2) 0.047

Female 60 (44%) 16 (31%) 0.103 37 (45%) 39 (36%) 0.228
BMI-for-age category
 Underweight 10 (7%) 4 (8%) > 0.999 6 (7%) 8 (7%) 0.998
 Normal weight 90 (66%) 34 (65%) 54 (66%) 70 (65%)
 Overweight 37 (27%) 14 (27%) 22 (27%) 29 (27%)
ASA physical status
 1 42 (31%) 8 (15%) 0.034 25 (30%) 25 (23%) 0.271
 2 95 (69%) 44 (85%) 57 (70%) 82 (77%)
Type of induction
 Inhalational 114 (83%) 44 (85%) 0.878 68 (83%) 90 (84%) 0.624
 Intravenous 6 (4%) 1 (2%) 2 (2%) 5 (5%)
 Combined 17 (12%) 7 (13%) 12 (15%) 12 (11%)
Premedication 52 (38%) 19 (37%) 0.857 26 (32%) 45 (42%) 0.145
Preoperative SBP 110 (11) 106 (11) 0.017 104 (9) 112 (11) < 0.001
Preoperative HR 106 (19) 100 (17) 0.041 105 (21) 104 (17) 0.906

ASA American Society of Anesthesiologists, BMI body mass index, HR heart rate, IV intravenous, PIH preincision hypotension, SBP systolic
blood pressure (mm Hg), SD standard deviation

13
 Pediatric Surgery International

Table 2  Hemodynamic changes during post-induction and pre-inci- to extreme IOH may include postoperative mortality, car-
sion period, compared to preoperative baseline values (n = 189) diac arrest, central nervous system or end-organ injury, and
Measure and timepoint Change from preoperative value prolonged postoperative recovery. In the current cohort of
after induction healthy, ASA I and II patients, the incidence varied based
Mean (SD) 95% CI P value
on the definition used, being 27.5% (52 of 189 patients) if
SBP (mmHg) the 5th percentile of the SBP for age was used versus 57.2%
 0 min − 10 (18) (8, 13) < 0.001 (107 of 189 patients) when a 20% decrease of the SBP from
 3 min − 14 (18) (12, 17) < 0.001 baseline was used. The definition required that only one low
 6 min − 18 (16) (15, 20) < 0.001 SBP meet the criteria during the various study assessment
 9 min − 17 (15) (15, 19) < 0.001 points. A more stringent definition (repeated low values)
 12 min − 16 (16) (14, 18) < 0.001 would have definitely lowered the incidence.
DBP (mmHg) The previous predictive models of PIH in children have
 0 min − 12 (15) (10, 14) < 0.001 been derived from heterogeneous cohorts including cohorts
 3 min − 18 (15) (16, 20) < 0.001 with a significant percentage of patients having preopera-
 6 min − 23 (13) (21, 24) < 0.001 tive hypotension or those with comorbid conditions [1, 2].
 9 min − 24 (12) (22, 26) < 0.001 By comparison, our study excluded children with preopera-
 12 min − 23 (12) (22, 25) < 0.001 tive hypotension, included only ASA I and II physical status
MAP (mmHg) patients, and found that prediction of factors that correlated
 0 min − 11 (16) (9, 13) < 0.001 with PIH, defined as sustained SBP < 5th percentile for age
 3 min − 16 (16) (14, 19) < 0.001 within 12 min after the induction of anesthesia, was not fea-
 6 min − 20 (13) (19, 22) < 0.001 sible due to low incidence of this outcome [1, 3]. When
 9 min − 21 (13) (19, 23) < 0.001 PIH was defined according to a decline in SBP > 20% from
 12 min − 20 (13) (19, 22) < 0.001 baseline, the estimated incidence of PIH was higher, but
HR (bpm) measures of PIH based on SBP percent decline from base-
 0 min + 12 (26) (8, 15) < 0.001 line demonstrated poor agreement with measures of PIH
 3 min + 16 (28) (12, 19) < 0.001 based on SBP percentile-for-age.
 6 min + 11 (23) (8, 14) < 0.001 Different degrees of hypotension are common during
 9 min + 10 (21) (7, 13) < 0.001 the perioperative period, and the extent of oxygen demand
 12 min + 12 (23) (9, 15) < 0.001 mismatch influences the pathophysiology behind ischemia
of various organs. Specific complications of intraopera-
CI confidence interval, DBP diastolic blood pressure, HR heart rate,
MAP mean arterial pressure, SBP systolic blood pressure, SD stand- tive hypotension (IOH) may include myocardial infarction
ard deviation due to decrease in diastolic blood pressure with possible
ischemic renal injury [11–13]; and infantile postoperative
encephalopathy, due to decrease in the cerebral perfusion
pressure [14]. In adults, low blood pressure intraopera-
tively has been associated with adverse patient outcomes

Table 3  Prevalence and agreement among definitions of pre-incision hypotension (n = 189)

PIH definition Prevalence in Agreement with competing definitions, % agreement (κ)
cohort, N (%)
(2) (3) (4) (5) (6)

SBP < 5th percentile-for-age
(1) Any timepoint 0–12 min after induction 52 (28%) 79% (κ = 0.3) 77% (κ = 0.2) 68% (κ = 0.4) 67% (κ = 0.2) 64% (κ = 0.1)
(2) Median SBP obtained within 12 min after induc- 13 (7%) 97% (κ = 0.7) 49% (κ = 0.1) 71% (κ = 0.2) 71% (κ = 0.1)
tion
(3) Two or more timepoints and sustained at 12 min 8 (4%) 48% (κ = 0.1) 70% (κ = 0.1) 72% (κ = 0.1)
SBP > 20% decline from baseline
(4) Any timepoint 0–12 min after induction 107 (57%) 76% (κ = 0.5) 74% (κ = 0.5)
(5) Median SBP obtained within 12 min after induc- 62 (33%) 91% (κ = 0.8)
tion
(6) Two or more timepoints and sustained at 12 min 58 (31%)

SBP systolic blood pressure

13
Pediatric Surgery International

Table 4  Multivariable logistic regression models of pre-incision hypotension (n = 189)

Variablea PIH ­definitionb
(1) (4) (5) (6)
OR (95% CI) P OR (95% CI) P OR (95% CI) P OR (95% CI) P

Age (years) 0.7 (0.6, 0.9) 0.001 0.5 (0.4, 0.7) < 0.001 0.5 (0.4, 0.7) < 0.001
Female 0.5 (0.3, 1.1) 0.096
BMI-for-age category
 Underweight 1.3 (0.3, 6.2) 0.768 0.9 (0.1, 6.2) 0.900
 Normal weight Ref. Ref.
 Overweight 0.3 (0.1, 0.9) 0.024 0.4 (0.1, 1.0) 0.057
ASA
 I Ref. Ref.
 II 2.6 (1.1, 6.3) 0.030 1.7 (0.8, 3.5)
Premedication 0.5 (0.2, 1.1) 0.094
Preoperative SBP (mmHg) 0.97 (0.94, 1.00) 0.036 1.1 (1.06, 1.14) < 0.001 1.16 (1.10, 1.21) < 0.001 1.21 (1.14, 1.28) < 0.001
Preoperative HR (bpm) 0.98 (0.96, 1.00) 0.030 0.97 (0.95, 0.99) 0.014 0.98 (0.96, 1.01) 0.189 0.97 (0.95, 1.00) 0.050

ASA American Society of Anesthesiologists, BMI body mass index, CI confidence interval, HR heart rate, IV intravenous, OR odds ratio, PIH
preincision hypotension, SBP systolic blood pressure
a
 Variables included in each multivariable model according to stepwise forward selection at inclusion threshold of P < 0.2
b
 PIH definitions with one or more statistically significant covariates: (1) SBP < 5th percentile-for-age at any timepoint within 12 min of induc-
tion; (4) SBP > 20% decline from baseline at any timepoint within 12 min of induction; (5) SBP > 20% decline from baseline at the median SBP
obtained during the 12-min period; or (6) SBP > 20% decline from baseline at two or more timepoints including the final point at 12 min after
induction

after cardiac and non-cardiac surgery, including 30-day and
1-year mortality [15]. These consequences have motivated
varying approaches to predicting IOH based on retrospective
data, but this effort has been limited by a lack of consensus
on the definition of IOH [6, 16–18]. The effective therapy
for these BP issues mandates that we develop stricter criteria
for hypotension during the perioperative period.
In our study, definitions of PIH according to SBP per-
centile-for-age and SBP decline from baseline demonstrated
poor agreement. Furthermore, no covariates in our analy-
sis were consistently associated with the risk of PIH when
comparing the available definitions of this outcome. When
defining PIH as the percent decline in SBP from baseline, a
high preoperative SBP was associated with greater odds of
this outcome, consistent with the findings of Stewart et al.,
who identified preoperative hypertension as predicting PIH
in a heterogeneous cohort of children with a higher ASA
status [3]. Surprisingly, however, the preoperative high SBP
had the opposite (negative) association with the risk of PIH
when defined according to SBP percentile-for-age. Without
consensus on which definition of PIH is appropriate in this
setting, it is unclear how preoperative SBP and other char-
acteristics should be used to predict PIH.
This study has certain limitations that merit discussion.
We had a smaller sample size as compared to previous
studies; however, based on the incidence of incidence of
hypotension reported in the literature, the sample size was
large enough to provide the needed data. Although the initial
intent was to include a study cohort of 200 patients, 11 were
excluded. Given that the final cohort of 189 provided the
needed data, additional 11 patients were not added to the
study cohort. We could not include all the variables from
the past studies, although it is unclear whether inclusion of
additional variables would have improved prediction of PIH
according to SBP percentile-for-age, given the low incidence
of this outcome. Furthermore, we constructed our data on
PIH from the median of 5 observations collected for the first
12 min after the induction of anesthesia, and did not aim
to characterize the incidence of IOH throughout the subse-
quent procedure. We wanted to present data that were com-
parable to the other related studies and as such chose sys-
tolic BP rather than mean arterial pressure. Whether mean
arterial pressure is more representative and has a greater
physiologic impact has not been determined. Comparing
homogenous surgical procedures will be more consistent;
our study population was diverse with regard to surgical
procedures. The present study was not meant to detect the
adverse events. The low kappa statistics and poor percent
agreement (Table 3) are not based on statistical null hypoth-
esis testing. Despite these limitations, our study provides
additional clinical information regarding potential discrep-
ancies among the definitions of PIH, and the challenges of
predicting and studying PIH in relatively healthy children
who are not hypotensive before surgery.

13

In conclusion, our study demonstrates disagreement
among measures of PIH and the difficulty of predicting PIH
in normotensive children. If PIH is determined according
to SBP change from baseline, as suggested in a survey of
anesthesia providers, then elevated preoperative SBP would
be a significant predictor of PIH risk. Yet, most cases of PIH
identified using this definition do not meet BTF criteria of
SBP < 5th percentile for age. Therefore, greater clarity is
needed on a clinically relevant threshold for PIH in children
with no preoperative hypotension or comorbid diseases. The
PIH prevalence ranged from a low of 4% (definition 3 = SBP
less than 5th percentile-for-age at two or more timepoints
including the final point at 12 min after the induction of
anesthesia) to 57% (definition 4 = at least one timepoint
where SBP was > 20% lower than baseline). On multivari-
able analysis, no covariates were consistently associated
with PIH risk across all six definitions of PIH. The current
study focused on post-induction hypotension not the intra-
operative hypotension; we would postulate that the etiolo-
gies of the post-induction hypotension and intraoperative
hypotension and their resultant impact on perioperative out-
come are likely to be different. However, most importantly,
stricter and specific criteria are needed to not only allow
for objective outcomes studies, but also to ensure equality
when comparing different studies. Given the poor correla-
tion of BP with cardiac output and end-organ perfusion, it
may be that other criteria (measures of tissue oxygenation)
are needed to more accurately reflect clinically significant
cardiovascular changes.
Funding  This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Compliance with ethical standards  tive encephalopathy: perioperative factors as a cause for concern.
Conflict of interest  Author Tariq M. Wani declares he has no conflict
of interest. Author Mohammed Hakim declares he has no conflict of
interest. Author Archana Ramesh declares she has no conflict of inter-
est. Author Shabina Rehman declares he has no conflict of interest.
Yaseer Majid declares he has no conflict of interest. Rebecca Miller
declares she has no conflict of interest. Dmitry Tumin declares he has
no conflict of interest. Joseph D. Tobias declares he has no conflict of
interest.
Informed consent  Informed consent was obtained from all individual
participants included in the study.
References
1. Nafiu OO, Kheterpal S, Morris M, Reynolds PI, Malviya S,
Tremper KK (2009) Incidence and risk factors for preincision
13
Pediatric Surgery International
hypotension in a noncardiac pediatric surgical population. Paedi-
atr Anaesth 19:232–239
2. Nafiu OO, Maclean S, Blum J, Kheterpal S, Cowan A, Tremper
KK (2010) High BMI in children as a risk factor for intraoperative
hypotension. Eur J Anaesthesiol 27:1065–1068
3. Stewart M, Scattoloni J, Tazhibi G, Nafiu OO (2016) Association
of elevated preoperative blood pressure with preincision hypoten-
sion in pediatric surgical patients. Paediatr Anaesth 26:844–851
4. Task Force on Blood Pressure Control in Children (1987) Report
of the second task force on blood pressure control in chil-
dren—1987. National Heart, Lung, and Blood Institute, Bethesda,
Maryland. Pediatrics 79:1–25
5. Coates BM, Vavilala MS, Mack CD, Muangman S, Suz P, Sharar
SR, Bulger E, Lam AM (2005) Influence of definition and location
of hypotension on outcome following severe pediatric traumatic
brain injury. Crit Care Med 33:2645–2650
6. Nafiu OO, Voepel-Lewis T, Morris M, Chimbra WT, Malviya
S, Reynolds PI, Tremper KK (2009) How do pediatric anesthe-
siologists define intraoperative hypotension. Paediatr Anaesth
19:1048–1053
7. Guidelines for Prehospital Management of TBI. 2nd edn. http://
braint​ rauma​ .org/upload​ s/Prehos​ pital​ _Guidel​ ines_​ 2nd_Editio​ n_2.
pdf
8. National High Blood Pressure Education Program Working Group
on High Blood Pressure in Children and Adolescents (2004) The
fourth report on the diagnosis, evaluation, and treatment of high
blood pressure in children and adolescents. Pediatrics 114(2 Suppl
4th Report):555–576
9. Child growth standards. http://www.who.int/child​growt​h/stand​
ards/weigh​t for age/en
10. Viera AJ, Garrett JM (2005) Understanding interobserver agree-
ment: the kappa statistic. Fam Med 37:360–363
11. Feigl EO, Neat GW, Huang AH (1990) Interrelations between
coronary artery pressure, myocardial metabolism and coronary
blood flow. J Mol Cell Cardiol 22:375–390
12. Bonventre JV, Weinberg JM (2003) Recent advances in the patho-
physiology of ischemic acute renal failure. J Am Soc Nephrol
14:2199–2210
13. Munshi R, Hsu C, Himmelfarb J (2011) Advances in understand-
ing ischemic acute kidney injury. BMC Med 9:11–13
14. McCann ME, Schouten ANJ, Dobija N (2014) Infantile postopera-
Pediatrics 133:751–757
15. Brady K, Hogue CW (2013) Intraoperative hypotension and
patient outcome: Does “one size fit all?” Anesthesiology
119:495–497
16. Horan MJ (1987) Task force on blood pressure control in children,
report of the second task force on blood pressure in children. Pedi-
atrics 79:1–7
17. Bijker JB, van Klei WA, Kappen TH, Wolfswinkel LV, Moons
KG, Kalkman CJ (2007) Incidence of Intraoperative hypoten-
sion as a function of the chosen definition: Literature definitions
applied to a retrospective cohort using automated data collection.
Anesthesiology 107:213–220
18. Davis PJ, Galinkin J, McGowan FX, Lynn AM, Yaster M, Rabb
MF, Krane EJ, Kurth CD, Blum RH, Maxwell L, Orr R (2001)
A randomized multicenter study of remifentanil compared with
halothane in neonates and infants undergoing pyloromyotomy:
Emergence and recovery profiles. Anesth Analg 93:1380–1386