SPECIAL ARTICLES DOI: https://doi.org/10.5114/ait.2023.

126309

Heart rate variability in anaesthesiology – narrative review

Magdalena Wujtewicz, Radoslaw Owczuk

Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland

Abstract Anaesthesiol Intensive Ther 2023; 55, 1: 1–8

Heart rate variability (HRV) is a measure that shows the variation in time between
consecutive heartbeats – a physiological phenomenon controlled by the autonomic
nervous system. Over the years the analysis of this parameter has been used in many
fields of medicine, including anaesthesiology, for scientific and research purposes. We
carried out a review of the available literature on the applicability of HRV assessment in
anaesthesiology. Several potential applications of HRV in clinical anaesthesia have been
identified and proven feasible. As a non-invasive and relatively easy method to gauge
the autonomic nervous system, HRV analysis can provide the anaesthesiologist with ad-
ditional datapoints, potentially useful in assessing efficacy of a blockade and adequacy
of analgesia, and in predicting adverse events. However, interpretation of HRV and
generalizability of research findings can be problematic due to the multiplicity of fac-
tors that influence this parameter and bias in methods introduced by the researchers.
CORRESPONDING AUTHOR:
Key word: HRV, bradycardia, heart rate variability, hypotension, autonomic
Magdalena Wujtewicz, Department of Anaesthesiology
nervous system activity, general anesthesia, regional anaesthesia, intraoperative and Intensive Therapy, Faculty of Medicine,
hypotension. Medical University of Gdansk, Gdansk, Poland,
e-mail: magdalena.wujtewicz@gumed.edu.pl

In a healthy person, the sinoatrial node generates important in assessing the risk of death after myo-
rhythmic, regular signals that lead to a contraction cardial infarction [4].
of the heart muscle. As early as the 18th century, it was In 1996, the working group of the European So-
noted that in animals the pulse rate changes with ciety of Cardiology and the North American Society
respiration, and in the mid-19th century, respiratory of Pacing and Electrophysiology described the stan-
variability of heart rate was confirmed in humans [1]. dards and use of HRV in clinical practice [5].
Differences in the distance between successive RR
waveforms, as recorded on electrocardiography,
are a sign of cardiovascular well-being and are re-
ferred to as heart rate variability (HRV) (Figure 1).
The primary regulator of heart rate variability is
the autonomic nervous system. Thanks to autonomic
regulation the heart rate increases or decreases (Fig-
ure 2).
Analysis of HRV thus provides information about FIGURE 1. Differences between consecutive RR intervals
the interplay between the sympathetic and para-
sympathetic parts of the autonomic nervous system
(ANS) and the potential disruption of this delicate
balance, influenced by various factors [2].
Historical milestones in the study of the cardio-
vascular system and its variation under the influence
of respiration were presented by Billman [1]. The first
researchers to highlight the clinical aspects of HRV
(in the foetus) were Hon and Lee [3]. In the follow-
ing years, numerous researchers explored this is-
sue and developed tools to assess the ANS, as de-
scribed in detail by the aforementioned Billman [1].
HRV analysis became clinically important in the late FIGURE 2. The influence of the sympathetic and parasympathetic
1980s when heart rate variability was found to be parts of the autonomic nervous system on heart rate

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Magdalena Wujtewicz, Radoslaw Owczuk

HRV analysis is based on electrocardiographic re- low frequency (ULF). More and more is known about
cordings and uses 2 methods: time domain and fre- their significance – it is suggested that the VLF
quency domain (spectral). The time-domain meth- component depends on thermoregulatory mecha-
od evaluates rhythm variability in general and does nisms, changes induced by the renin–angiotensin–
not distinguish between changes specific to differ- aldosterone system, and peripheral chemoreceptor
ent frequencies. The frequency-domain method, activity, and the ULFs – are a consequence of diur-
in which random, nonrhythmic noise is ignored, nal oscillations [7]. Reduced variability of the VLF
allows easy distinction between major rhythmic os- component is associated with arrhythmias, post-
cillations present in HRV. For cardiovascular control traumatic stress disorder, severe inflammation, and
in humans, the 2 main rhythmic oscillations, result- increased mortality [8–11].
ing from the parasympathetic and sympathetic ac- HF changes are thought to reflect parasympa-
tivity, occurring at the frequency equal to the respi- thetic impulses associated with vagus nerve activity,
ratory rate and the frequency of approx. 0.10 Hz, are whereas LF changes are more difficult to interpret
of greatest importance [6]. clinically because they reflect both sympathetic
In the time-domain method 2 types of indices and parasympathetic activity. However, in practice,
are evaluated: indices calculated from the duration LF changes can regarded as reflecting sympathetic
of consecutive R-R intervals (referred to as NN inter- changes. The LF/HF ratio is considered to reflect
val), which represent both components of the au- the relative and absolute changes between the sym-
tonomic system (SDNN, SDANN, SDNN index), and pathetic and parasympathetic components. This
those calculated from the differences between con- approach to the LF/HF ratio is simplistic, however,
secutive R-R intervals of the sinus rhythm – mainly because it assumes that there is a sympathetic-para-
representing the vagal tone (NN 50, pNN50, RMSSD). sympathetic balance that modulates sinus node ac-
The indices are defined as follows [5]: tivity in a simple way that is typical of mathematical
• SDNN – standard deviation of all NN intervals; reasoning [6].
• SDANN – standard deviation of the averages of One cannot help but mention that there are ar-
NN intervals in all 5-minute segments of the entire guments against such an easy interpretation of this
recording; indicator [12].
• SDANN index – mean of the standard deviation of The utility of HRV analysis in the context of chro­
all NN intervals for all 5-minute segments of the nic disease is well established. HRV analysis demon-
entire recording; strates abnormalities in the ANS activity and is corre-
• RMSSD – the square root of the mean of the sum lated with increased risk of death in individuals with
of the squares of differences between adjacent cardiovascular disease, diabetes, chronic kidney dis-
NN intervals; ease, and many other conditions [13–18].
• NN50 – number of pairs of adjacent NN intervals HRV assessment has been widely used in the pre-
differing by more than 50 ms; diction of sudden cardiac death [19]. It is well known
• pNN50 – the number of NN50 divided by the total that chronic conditions, especially cardiovascular
number of NN intervals. disease, typically characterized by reduced HRV, pose
Frequency analysis is defined as the evaluation a significant burden to the anaesthetized patient and
of cyclic fluctuations in the R-R interval that occur a challenge to the anaesthesiologist [20].
at a specific frequency in a healthy individual. A fast Therefore, it is worth trying to answer the ques-
Fourier transform (FFT) algorithm is used to sort out tion: is there a place for HRV analysis in anaesthesio­
the chaotic total variance of heart rate variability logy?
and fit the variance to the appropriate frequency
bands. The operation of the FFT can be compared METHODS
to the prismatic effect of scattering light into waves A review of the Pubmed and Google Scholar
of different lengths and colours. With the FFT, databases was conducted while searching for ar-
the variance of the R-R intervals is organized and ticles focused on heart rate variability in relation to
shown as a spectrum. Specific components, charac­ anaesthesiology. The research was performed by
teristic of the cyclic variance of the R-R intervals, using the key terms “heart rate variability”, “heart
can be distinguished in the spectrum. Among rate variability anesthesiology”, “heart rate vari-
them, the most important are the high-frequency ability regional anaesthesia”, “heart rate variability
(HF) and low-frequency (LF) power. The total power subarachnoid blockade”, and “ heart rate variability
spectrum (TP) is the total variance of the signal, epidural”.
which represents the sum of all power frequencies. While describing the utility of heart rate variabil-
Most of the spectrum (95%) is occupied by the other ity analysis in anaesthesia therapy, articles on adult
2 components: very low frequency (VLF) and ultra- populations were mainly used.

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 Heart rate variability in anaesthesiology – narrative review

SPINAL BLOCK are described: one intentional (at the time used in
The effects of subarachnoid anaesthesia on Japan as a treatment for postherpetic neuralgia),
HRV were among the first to be described in clini- and one being a complication of epidural anaes-
cal anaesthesiology. In 1995 Introna et al. [21] de- thesia. In both cases, complete subarachnoid an-
scribed the sequelae of subarachnoid anaesthesia aesthesia was associated with a decrease in HRV;
on the ANS as “acute” isolated “withdrawal of sym- the increase in HF, as modulated by the parasym-
pathetic activity”. The blockade was achieved by pathetic system, occurred gradually and was most
administering 70–85 mg of 5% lidocaine mixed pronounced at the end of the block. HF decreased
with 5% glucose. After the injection, patients were and heart rate and LF increased just before the re-
placed in the supine position. Power spectrum re- turn of consciousness. Although this method of an-
cordings from pre-blockade and post-blockade aesthesia is not used, the investigators’ description
ECGs, comprising 150 heartbeat segments from reflects the changes in autonomic system tone that
consecutive RR wave intervals, were compared. occur as a result of an extensive sympathetic block-
Using an autoregressive algorithm, they found that ade. Based on this and similar observations, HRV
the cephalic spread of the blockade was associated analysis has found application in predicting adverse
with decreased heart rate variability. clinical consequences of a central blockade.
In patients in whom blockade sufficient to allow The older literature contains many papers argu-
the procedure to be performed was achieved, a sig­ ing for the use of HRV to predict hypotension af-
nificant reduction in HRV occurred when sensory ter subarachnoid blockade. These mainly concern
blockade reached the thoracic (T) level of T3–T4. the obstetric population. Thus, in their publications
For the T1–T2 level, HRV virtually disappeared – Hanss et al. [24–26] found the utility in predicting
the variability in the LF component disappeared severe hypotension and used the results to imple-
(P < 0.016). The parasympathetic activity also weak- ment effective preventive therapy in patients whose
ened – the HF component decreased, which the au- baseline LF/HF ratio values indicated a high risk
thors associate with impaired reflex responses rath- of hypotension after the blockade.
er than direct vagus nerve block. The LF/HF ratio, HRV analysis in healthy pregnant women un-
as an expression of sympathetic-parasympathetic dergoing caesarean section under subarachnoid
balance, increased when the block reached T3–T4 anaesthesia showed that high sympathetic tension
to return to a value equal to 1 after reaching the and lack of sympathetic modulation, defined as
T1–T2 level blockade. It follows that the LF/HF ratio LF/HF ratio > 2.3, found before the blockade, were
did not permit conclusions regarding the quantita- independent risk factors (7.7; 95% CI: 1.04–56.6,
tive assessment, which was obtained by using pow- P = 0.023) for hypotension during the subarachnoid
er spectrum analysis and finding a decrease in this blockade [27].
power as an expression of suppression of rhythm In an observational study, in women undergo-
variability. ing caesarean section, Bishop et al. [28] found that
Some patients required an additional dose the LF/HF ratio, calculated from ≥ 5 minutes of ECG
of local anaesthetic before the procedure began recording, could predict hypotension after block
because the extent of sensory blockade did not (P = 0.046; OR 1.478, 95% CI: 1.008–1.014), and they
achieve surgical anaesthesia. The researchers found considered a value of 2 as the optimal cut-off point.
that in this group of patients, spectrum power was According to the conclusion of the systematic
unchanged as compared to before the blockade. In review by Frandsen et al. [29], the use of preopera-
the group in which the first dose was already suf- tive HRV is a promising tool for predicting hypoten-
ficient, a decrease in spectrum power was observed. sion after spinal anaesthesia in caesarean section.
In conclusion, the authors gathered that block- The usefulness of HRV assessment as part of
ade of cardiac sympathetic impulsion, while leaving the prediction of hypotension after subarachnoid
the parasympathetic pathway intact, leads to a reduc- anaesthesia in diabetic patients was evaluated by
tion in both components of HRV – LF and HF. Based Vinayagam et al. [30].
on their results, they stated that HRV analysis during In the course of diabetes, HRV is reduced by both
sympathetic blockade may be an alternative way to sympathetic and parasympathetic activity [31]. It is
assess the extent and effectiveness of the blockade. not surprising to find decreased HRV parameters in
One year earlier, HRV changes occurring during the studied patients. Hypotension after blockade oc-
total spinal anaesthesia were described by Kimura curred in 69%, and the indicators that differentiated
et al. [22]. It must be emphasized that total spinal the group with and without hypotension were base-
block is not used in a daily practice, occurring rath- line differences in SDNN and RMSSD. At the same
er as a complication of neuraxial blockade [23]. In time, these indices showed low accuracy in predict-
the paper 2 case reports of total spinal anaesthesia ing hypotension.

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Magdalena Wujtewicz, Radoslaw Owczuk

A completely different method of assessing HRV T8 in the other – sympathetic simulation preserved
was used by the group of Chamchad [32]. The au- in blockades reaching T8 may limit HRV changes.
thors applied a nonlinear HRV analysis – better at The results may also have been influenced by
describing the chaos of heart rate variability – using the fact that some patients needed vasoactive
the point correlation dimension parameter pPD2. drugs to correct hypotension.
Based on this parameter the authors were able to Finally, the aforementioned Kweon et al. [35]
distinguish 2 groups of patients: the low-value (LO) evaluated the utility of HRV in predicting hypoten-
group and the high-value (HI) group. The blockade sion after subarachnoid blockade in hypertensive
resulted in a decrease in pPD2 in all subjects, but hy- patients. They found no change in LF/HF or total
potension after blockade developed only in the LO power spectrum in patients who exhibited hypo­
group, and more ephedrine was administered in this tension of varying severity due to subarachnoid
group. Interestingly, the traditional evaluation by blockade. According to the authors, this conclusion
frequency analysis, done before the blockade was may have been influenced by the fact that the pa-
performed, showed no differences between the LO tients studied already had impaired regulation
and HI groups. of the autonomic system at baseline – they were
In the contemporary literature, however, it is dif- hypertensive patients taking various antihyperten-
ficult to find work based on nonlinear HRV analysis sive drugs. Diabetes mellitus and coronary artery
in relation to anaesthesiology. disease were also reported among the patients with
Although many papers support the clinical ben- comorbidities.
efit of using HRV analysis in patients undergoing Based on the literature cited above, it appears
subarachnoid anaesthesia, it should be noted that that the use of HRV analysis in predicting hypoten-
some authors take a different position. sion after subarachnoid blockade has found greater
Shehata et al. [33] in a study of preeclamptic significance in relatively healthy subjects, without
pregnant women found that temporal HRV analy- chronic disease and not taking medications that af-
sis, recorded by electrical impedance, did not allow fect the sympathetic nervous system.
the prediction of hypotension after the blockade.
However, they observed an increase in heart rate EPIDURAL BLOCK
variability at 5 minutes and 15 minutes after injec- Epidural blockade, as a part of enhanced re-
tion compared to pre-blockade values. covery after surgery protocols, is a very useful
A similar conclusion was reached several years technique for pain treatment [36]. Thoracic block
earlier by Toptas et al. [34] and Kweon et al. [35]. influences cardiac repolarization and results in its
Toptas studied the differences in effects on hae- anti-arrhythmic action [37]. Analysis of the heart
modynamics and HRV between isobaric and hy- rate variability has been evaluated for years to as-
perbaric bupivacaine in a non-obstetric population. sess changes occurring during this blockade.
Hypotension was observed in 25% of all subjects. Unfortunately, the interpretation of the results
The subarachnoid blockade resulted in changes of heart rate variability during epidural blockade is
in HRV – a decrease in the LF/HF ratio was noted, inconclusive, as researchers have come to differing
with statistical significance found only in the heavy conclusions, as summarized by Veering et al. [38] as
bupivacaine group. Similarly, the HF component in- early as in the year 2000. It should be kept in mind
creased in both groups, with a statistical difference that the researchers evaluated the effect of blockade
for hyperbaric bupivacaine. LF value decreased non- performed at different levels – mainly thoracic and
statistically in both groups. The authors relate the lack lumbar.
of prognostic utility of HRV concerning post-block In a study by Fleisher et al. [39], lumbar block-
hypotension to the relatively small baseline LF/HF ade led to an increase in the LF/HF ratio, suggesting
values in the analysed population and the small num- a shift in balance toward sympathetic dominance.
ber of subjects with an LF/HF ratio > 2.5 in their study. At the same time, in the study by Hopf et al. [40]
It is worth mentioning here that the cut-off value sympathetic blockade in the thoracic segment did
of 2.5 stems from previous literature reports. In the not affect changes in LF.
paper by Hanss et al. [26] in the group of obstet- In a study by Owczuk et al. [37] in a group
ric patients with baseline LF/HF ratio > 2.5, higher of American Society of Anaesthesiologist (ASA)
doses of vasopressor had to be administered to class I and II males in whom thoracic block was
correct hypotension compared to the group with performed, the only independent risk factor for sig-
baseline ratio < 2.5. The phenomenon limiting the nificant mean arterial pressure decrease was LF/HF
changes in HRV in the study by Toptas et al. [34] may ratio ≥ 2.5. According to the researchers, those in-
also have been, in their opinion, the block height, consistencies in the results may be due to the un-
the median of which reached T7 in one group and even blockade of sympathetic fibres and the lack

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 Heart rate variability in anaesthesiology – narrative review

of blockade of sympathetic fibres innervating tion during surgery was associated with exclusion
the adrenal medulla. from further analysis. Changes occurring under
There are not many reports in the literature on the influence of the blockade were compared, and
the prognostic use of HRV analysis in relation to the significance of the side on which the blockade
haemodynamic disturbances caused by the epi- was performed was assessed.
dural blockade. It was concluded that only right-sided block-
Deschamp et al. [41] studied HRV during epidural ade was associated with a decrease in the LF com-
blockade in obstetric women. They showed decreas- ponent, suggesting attenuation of sympathetic
es in sympathetic tone and increases in parasym- tone. Moreover, parasympathetic activity assessed
pathetic activity, whereas no static changes were by the time-domain method increased statistically
found with respect to heart rate or blood pressure. significantly, and when assessed by the frequency-
Therefore, the authors could not draw any conclu- domain method – not significantly.
sions regarding the prognostic use of HRV analysis Left-sided blockade had virtually no effect on
in predicting the onset of haemodynamic instability. HRV parameters, except for a trend toward para-
Another application of HRV monitoring was de- sympathetic dominance, expressed as a decrease
scribed by Song et al. [42]. When performing epi- in the LF/HF ratio. The authors thus supported
dural blockade from sacral access in an unconscious the hypo­thesis reported in the literature that chang-
patient, which is often the case in paediatric anaes- es in the autonomic system result from the spread
thesia, it is not easy to confirm the effectiveness of anaesthesia to the stellate ganglion on the same
of the procedure. The use of HRV analysis as a tool to side, and this effect depends on the side in which
assess autonomic system tone may be helpful here, the blockade was performed.
and this is what the Korean researchers focused on. Because of the small size of the study group,
They found that decreases in time-domain HRV they were unable to indicate whether differences
analysis were statistically significant (SDNN was between subjects with Horner syndrome or brady-
most strongly reduced 3 minutes after the block­ cardia/hypotension could be demonstrated from
ade) whereas changes observed based on frequen­ HRV analysis. Additionally, a decrease in the LF/HF
cy analysis were characterized by the trend towards ratio in the course of a brachial plexus blockade was
suppression of sympathetic activity, also maximally also demonstrated by Frassanito et al. [46].
expressed 3 minutes after performing the blockade. Several authors evaluated HRV variability in rela-
In their opinion, based on HRV analysis, it is tion to stellate ganglion blockade and, among others,
possible to confirm the efficacy of sacral epidural based on HRV changes, confirmed the dominance
anaesthesia in children under general anaesthesia, of the right stellate ganglion concerning the sinus
although the authors emphasize the lack of objec- node [47–49]. Only in the study by Kim et al. [49] did
tive confirmation of efficacy regarding the analgesic the left-sided blockade result in increased parasym-
effect, which is the primary goal of the blockade. pathetic activity, whereas no changes in autonomic
activity were found after the right-sided blockade.
PERIPHERAL BLOCKS These findings are of clinical importance because
Peripheral blocks are essential method of pain the blockade of stellate ganglion can be a useful tool
treatment in different types of surgery [43, 44]. With in the treatment of electrical storm [50, 51].
regard to peripheral blockades, the literature describ- Because changes in ANS activity toward sup-
ing the use of HRV analysis is sparse and mainly from pression of cardiac sympathetic tone did not affect
many years ago, being mostly of historical interest. blood pressure values in the study by Koyama et al.
Because of the haemodynamic abnormalities [48], the authors concluded that right stellate gan-
associated with brachial plexus blockade, this par- glion blockade can be considered safe for the treat-
ticular blockade has been a source of interest to ment of chronic pain.
investigators.
In 2013, the influence of brachial plexus blockade GENERAL ANAESTHESIA
from axillary access and effects of the side on which In numerous studies, it was found that general
the block was performed on indices of heart rate anaesthesia leads to decreased heart rate variabil-
variability were described. Simeoforidou et al. [45] ity [52–54]. The specific changes occurring within
hypothesized that this blockade is associated with the LF, HF, or LF/HF ratio components vary depend-
the occurrence of haemodynamic instability in ing on the anaesthetics or opioids studied as well as
approximately one-third of patients. In patients combinations of different drugs [55, 56].
without any comorbidities, the blockade was per- The practical use of HRV assessment as a prog-
formed with ropivacaine, without the addition nostic tool for haemodynamic abnormalities is
of epinephrine; the need for clonidine administra- of clinical importance.

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Magdalena Wujtewicz, Radoslaw Owczuk

In the study by Fujiwara et al. [57], preopera- ANS reserves and at high risk for adverse events in
tive HRV significantly correlated with systolic blood the postoperative period [66].
pressure fluctuations during anaesthesia induction, An interesting concept of the relationship be-
whereas the relationship between HRV and heart tween preoperative HRV and intraoperative “fluid
rate changes was weak. Only the LF/HF ratio had responsiveness” is described in the editorial by Frand-
a strong association with the occurrence of tachy- sen et al. [67]. They indicated that in the preoperative
cardia after intubation. However, the authors em- period, the preload responsiveness can be masked by
phasize that they used an unvalidated method to the increased sympathetic activity, and intraoperative-
measure HRV. ly, the depressed sympathetic activity causes vasople-
Hypotension after induction of anaesthesia is an gia and a decrease in venous return. This may lead
unfavourable prognostic condition and may occur to preload responsivity even in the normovolaemic
in up to 60% of cases [58, 59]. patients. The authors state that, unfortunately, there
Padley et al. [60] demonstrated that reduced are a lack of literature data that describe the poten-
preoperative rhythm variability and reduced spec- tial pathogenic and therapeutic implications of pre-
tral power identified patients at risk for haemody- operative HRV analysis, as an assessment of autonom-
namic instability after induction of anaesthesia with ic nervous system function, for post-induction and
propofol and fentanyl. Hypotension was defined intra-operative hypotension. According to the conclu-
as a decrease in mean arterial pressure of more sion of the systematic review by the same authors [29],
than 30% or a systolic blood pressure ≤ 60 mmHg. the use of preoperative HRV is a promising tool for
Reduced heart rate variability was associated not predicting post-induction hypotension in abdominal
only with hypotension but also with bradycardia surgery during general anaesthesia.
after anaesthesia induction [61]. It should be noted that in most studies, heart
Knüttgen et al. [62] came to a similar conclusion rate variability was studied in patients unaffected by
earlier while studying patients with diabetes. In diseases causing autonomic dysfunction, and that
their study, HRV parameters, except LF, were lower patients taking medications affecting ANS activity
in those who developed hypotension. were also excluded. This approach limits the applica-
In contrast, in Huang’s study [63], decreased bility of the findings to the entire patient population.
spectral power, LF and HF, were independent pre- Another implementation of HRV analysis during
dictors of hypotension, and the HF component de- general anaesthesia is its use as a complementary
termined the severity of hypotension at 15 min after tool to monitor the depth of anaesthesia. The idea
endotracheal intubation. behind such a monitor would be to rely on cardio-
The utility of HRV in predicting the occurrence respiratory interactions and autonomic nervous sys-
of incident myocardial ischaemia in high-risk pa- tem activity [68–70].
tients undergoing general anaesthesia was also Another application of rhythm variability is to
evaluated. Reduced spectral power (< 400 ms2 Hz-1) use ECG and RR segment changes as a means of as-
appeared to predict the occurrence of these inci- sessing pain. The ANI (Analgesia Nociception Index)
dents and prolonged hospitalization [61, 64]. monitor is based on an assessment of parasympa-
HRV analysis, due to the high frequency of arrhy­ thetic tone – the higher it is, the lower the nocicep-
thmias, proved to be unsuitable for assessing tion (theoretically) [71].
changes occurring in the ANS during laryngoscopy Interestingly, HRV has also found applications
and endotracheal intubation [65]. outside of research and medicine, with phone apps
In a retrospective study in a group of patients designed to provide data on the body’s response
without comorbidities, scheduled for so-called to exertion during training and to lifestyle stresses
“major” abdominal surgery, HRV analysis was used based on HRV analysis (https://www.hrv4training.
to predict its usefulness in predicting vasoactive com/accessed; 10 April 2022). And although in this
drug requirements, ICU, and length of hospital case the accuracy of the method may be question-
stay. HRV recording was done on the day before able, if the anaesthesiologist had a tool that could
the procedure, and the patients were subjected reliably assess HRV in real time, they could theoreti-
to an orthostatic test. The patients were divided cally use it to modify management. It should be re-
into “reactive” and “non-reactive” based on their membered, however, that the authors of the cited
response to the orthostatic test. “Reactive” patients studies were often unable to explicitly demon-
were more likely to have intraoperative hypotension strate the usefulness of HRV analysis in predicting
and bowel obstruction in the postoperative period. the occurrence of symptoms, events, or reactions to
Also, they required longer total and intensive care the management used.
unit hospitalization. The authors concluded that In conclusion, HRV and its changes in various
HRV assessment helps to identify patients with low conditions as well as the possibility of its use in

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 Heart rate variability in anaesthesiology – narrative review

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