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The Impact of Hypotension

For decades, intraoperative hypotension has been seen as an expected part of anesthesia. The literature is starting to suggest that it needs to be taken far more seriously.

  Key Takeaway

The evidence says intraoperative hypotension is harmful. The pharmacology of current anesthetic drugs makes it unavoidable. Expanesthetics is being built to change that.

The Growing Evidence on Intraoperative Hypotension

Though it has long been regarded as a manageable side effect of anesthesia, intraoperative hypotension (IOH) is one of the most common hemodynamic events in surgery. But a growing body of peer-reviewed evidence is prompting the field to reconsider the full impact of IOH on adverse outcomes.

Recent Evidence
  • A Significant Issue: A 2025 study spanning more than 28 million surgical patients, found that perioperative organ injury is a significant and underrecognized contributor to postoperative morbidity and mortality. [1]
  • Adverse Outcomes: Research has associated IOH with adverse outcomes after noncardiac surgery, including acute kidney injury, myocardial injury, and increased mortality. [2]
  • Even Short Durations Matter: The relationship between hypotension and harm may not be limited to extreme or prolonged episodes. Even modest reductions in blood pressure over relatively short periods may be clinically significant. [3]

Institutional and Regulatory Response

These findings have not gone unnoticed, as patient safety and government regulatory agencies have started issuing guidance around the dangers of IOH.

APSF
Anesthesia Patient Safety Foundation (APSF)
The APSF published consensus recommendations on perioperative hemodynamic instability,[4] and issued a "public safety announcement" directed at anesthesia professionals on the risks of intraoperative hypotension.[5]
APSF
Centers for Medicare & Medicaid Services (CMS)
According to a U.S. government report, hypotension is the most common adverse event associated with surgeries and procedures,[6] and CMS has incorporated intraoperative hypotension into the MIPS quality reporting program as a marker of care quality.[7]

Taken together, the mounting evidence and the institutional response suggest that the field's understanding of IOH is shifting, as the impact on patient outcomes appears more significant than previously recognized.

Why Nothing Has Changed

The last new inhaled anesthetic was discovered almost 60 years ago, before we landed on the moon.

The last new inhaled anesthetic was discovered almost 60 years ago, before we landed on the moon. In the decades since, innovation in inhaled anesthesia has effectively stopped. Large pharmaceutical companies moved on. The agents in use today are effective and familiar, and their risks have been manageable in the hands of trained specialists, which for a long time reduced pressure to find something better.

The last new inhaled anesthetic was discovered almost 60 years ago, before we landed on the moon.

But the clinical landscape has changed. Patients are older, sicker, and more hemodynamically vulnerable. The literature on the impact of hypotension on adverse outcomes continues to grow. The expectations around quality measurement are tightening. And the pharmacology of the available agents has not changed at all.

The field has been managing the same limitation with better monitoring and faster interventions, never daring to dream that the drugs themselves could be better.

A Different Starting Point

Expanesthetics grew out of research led by Dr. Robert Brosnan at UC Davis exploring how the physical properties of anesthetic compounds predict their receptor-level behavior [8]. That work led to a discovery platform capable of identifying novel inhaled anesthetics with more targeted receptor profiles [9].

Over more than a decade, that platform has produced a series of preclinical compounds that suggest a different hemodynamic profile is achievable. The work has been supported from the beginning by a growing community of accredited anesthesiologists and anesthesia clinicians — now over 100 — who believe the problem is worth solving, and who have put their own capital behind it.

The last new inhaled anesthetic
was discovered before we landed on the moon.

It's Time.

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What We've Found

We've identified three inhaled anesthetic candidates that are normotensive at MAC. Curious to learn more?

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References

  1. Kork F, Liang Y, Ginde AA, Yuan X, Rossaint R, Liu H, Evers AS, Eltzschig HK. Impact of perioperative organ injury on morbidity and mortality in 28 million surgical patients. Nat Commun. 2025 Apr 9;16(1):3366. (View Reference)
  2. Gregory A, Stapelfeldt WH, Khanna AK, Smischney NJ, Boero IJ, Chen Q, Stevens M, Shaw AD. Intraoperative Hypotension Is Associated With Adverse Clinical Outcomes After Noncardiac Surgery. Anesth Analg. 2021 Jun 1;132(6):1654-1665. (View Reference)
  3. Salmasi V, Maheshwari K, Yang D, Mascha EJ, Singh A, Sessler DI, Kurz A. Relationship between Intraoperative Hypotension, Defined by Either Reduction from Baseline or Absolute Thresholds, and Acute Kidney and Myocardial Injury after Noncardiac Surgery: A Retrospective Cohort Analysis. Anesthesiology. 2017 Jan;126(1):47-65. (View Reference)
  4. Scott MJ; APSF Hemodynamic Instability Writing Group. Perioperative Patients With Hemodynamic Instability: Consensus Recommendations of the Anesthesia Patient Safety Foundation. Anesth Analg. 2024 Apr 1;138(4):713-724. (View Reference)
  5. Yerdon A, Sherrer DM, Chappell D. Intraoperative Hypotension: A Public Safety Announcement for Anesthesia Professionals. APSF Newsletter. 2024;42-45 (View Reference)
  6. Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018. Grimm CA. Washington DC: Office of the Inspector General; May 2022. Report no. OEI-06-18-00400. (View Reference)
  7. Popovich, Matthew T. PhD; Moore, James MD. Tracking Intraoperative Hypotension: A Measure for Payment and Improvement Purposes. ASA Monitor. 88(1):p 28-29, January 2024. (View Reference)
  8. Brosnan RJ, Pham TL. Anesthetic-sensitive ion channel modulation is associated with a molar water solubility cut-off. BMC Pharmacol Toxicol. 2018 Sep 14;19(1):57. (View Reference)
  9. Brosnan RJ, Austin S, Antognini JF. A New General Anesthetic BTTE: Physical Properties, Hypnotic and Hemodynamic Effects in Rats, and Effects on GABA and NMDA Receptors Expressed in Frog Oocytes. Anesth Analg. 2026 Feb 3. Epub ahead of print. (View Reference)