Cambios dinámicos en la vena yugular interna durante la posición supina y la elevación pasiva de las piernas como predictores de hipotensión inducida por la anestesia espinal en los mayores: un estudio de precisión diagnóstica prospectivo

Abstract

Background

Spinal anesthesia-induced hypotension is common in elderly patients and is associated with serious complications, including myocardial ischemia, arrhythmias, acute heart failure, stroke, renal injury, and, in rare cases, perioperative blindness. Reliable predictors are needed to identify vulnerable patients before anesthesia induction. This study evaluated whether dynamic changes in internal jugular vein diameter and between supine and passive leg raising could predict spinal anesthesia-induced hypotension in elderly patients.

Methods

This prospective study was conducted at Cairo University hospitals after ethics approval and trial registration. Patients older than 65 years, classified as American Society of Anesthesiologists physical status I-II, scheduled for elective infraumbilical surgery under spinal anesthesia, were enrolled. Exclusion criteria included obesity, uncontrolled hypertension, reduced cardiac function, emergency surgery, and contraindications to spinal anesthesia. Baseline hemodynamics were recorded supine. Internal jugular vein diameter and cross-sectional area were measured by ultrasound in supine and passive leg raising positions. Spinal anesthesia was performed with hyperbaric bupivacaine and fentanyl. Hypotension was defined as mean arterial pressure less than 65 mmHg or a reduction greater than 20% from baseline. Receiver operating characteristic analysis was used to evaluate predictive accuracy.

Results

Of 92 patients screened, 70 were analyzed. Spinal anesthesia-induced hypotension occurred in 42 patients (60%), with severe hypotension in 7 patients (10%). Patients who developed hypotension showed significantly greater reductions in mean arterial pressure compared with stable patients. Percentage changes in internal jugular vein diameter and cross-sectional area between supine and passive leg raising were significantly higher in hypotensive patients (P < 0.001). Receiver operating characteristic analysis demonstrated excellent predictive accuracy: a change in diameter greater than 11 percent yielded an area under the curve of 1.00 with 100% sensitivity and specificity, while a change in cross-sectional area greater than 21.5% achieved an area under the curve of 0.99 with 100% sensitivity and 93% specificity. Static measurements alone had poor predictive value.

Conclusion

Dynamic changes in internal jugular vein diameter and cross-sectional area during passive leg raising are reliable, noninvasive predictors of spinal anesthesia-induced hypotension in elderly patients. Incorporating internal jugular vein ultrasonography into routine preoperative assessment may enhance risk stratification and guide preventive strategies. Larger multicenter studies are warranted to confirm these findings and evaluate their impact on clinical outcomes.