Arterial Hypotension In Patients Research Articles

Arterial hypotension in patients with essential hypertension II–III: unresolved issues and ambulatory blood pressure monitoring diagnostic criteria

The aim was to study the prevalence of sustained arterial hypotension in high cardiovascular risk patients with II–III stage essential hypertension and associated factors. Materials and methods. Patients with II–II stage essential hypertension and sinus rhythm (n = 179, mean age 61 (95 % CI: 59.6‒62.5) years, 57.0 % were males) underwent ambulatory blood pressure monitoring (ABPM). Arterial hypotension episodes were evaluated according to the blood pressure (BP) office measurement (<110/70 mm Hg) and ABPM over 24 hours (<100/60 mm Hg), daytime (<105/65 mm Hg) and nighttime (<90/50 mm Hg). To determine the covariates associated with the probability of arterial hypotension, models were constructed using binary logistic regression analysis. Results. There was an almost threefold increase in the prevalence of arterial hypotension according to ABPM (6.2 %, 11/179), compared with the results of office measurement (2.2 %, 4/179). The prevalence of masked arterial hypotension was 63.6 %. Hypotension episodes (n = 22) were detected in 11 patients mainly during the daytime (13/22). Hypotension was represented by a significant percentage of people with isolated diastolic (81.8 %) and lower – with systo-diastolic fall in BP (18.2 %). Hypotension associated risk factors were reaching the target level of intensive BP control, lower mean arterial pressure (24-hour time, daytime, nighttime analysis), its extreme dipping pattern, and female sex. Conclusions. The method of ABPM has advantages over office BP measurement in detecting episodes of sustained arterial hypotension. The risk of developing hypotension is increased in intensive BP control. The sustained hypotension is associated with lower mean arterial pressure values, its extreme dipping pattern and female sex.

Inferior vena cava ultrasonography before general anesthesia cannot predict arterial hypotension in patients undergoing vascular surgery.

Intraoperative hypotension (IH) is an independent predictor of mortality. Some experts have suggested that ultrasound measurement of the inferior vena cava (IVC) in spontaneous ventilation can predict IH. To evaluate the capacity of ultrasound measures of IVC in spontaneous ventilation to predict episodes of IH after anaesthesia induction. We studied 55 high-risk cardiac patients undergoing vascular surgery. The maximum (dIVCmax) and minimum (dIVCmin) diameter of the IVC were measured and the collapsibility index CI = (dIVCmax-dIVCmin)/dIVCmax was calculated prior to anaesthesia induction. Three definitions of IH were used: systolic blood pressure (SBP) less than 100 mmHg, mean arterial pressure (MAP) less than 60 mmHg, and a decrease in MAP greater than or equal to 30% compared to baseline. There were no significant differences in dIVCmax or in CI between patients presenting IH after anaesthesia induction and those who did not. ROC curves for dIVCmax showed an area under the curve of 0.55 (0.39-0.70), 0.69 (0.48-0.90), and 0.57 (0.42-0.73) and ROC curves for the CI were 0.62 (0.47-0.78), 0.60 (0.41-0.78) and 0.62 (0.47-0.78) for the 3 definitions of IH (<100 mmHg, MAP < 60 mmHg, and MAP ≥30% baseline), respectively. Ultrasound measurements of IVC in spontaneous ventilation are not good predictors of IH after anaesthesia induction in these patients. The optimal cut-off points show low specificity and moderate sensitivity for predicting IH.

Ефективність застосування мультимодального знеболювання у пацієнтів офтальмохірургічного профілю при антиглаукомних операціях

Актуальність. У роботі висвітлюються результати проведення багатокомпонентного загального знеболювання при офтальмологічних оперативних втручаннях з метою поліпшення якості інтраопераційного і післяопераційного знеболювання, зниження кількості ускладнень, пов’язаних з анестезіологічною допомогою у післяопераційному періоді. Матеріали та методи. Дослідження було проведено у пацієнтів віком від 19 до 42 років, яким виконувалися антиглаукомні оперативні втручання. Для проведення порівняльного аналізу хворі були розподілені на групи з урахуванням виду обраного знеболювання: 1-ша група (n = 20) — пацієнти, у яких була застосована тактика профілактичного введення мелоксикаму під час премедикації, проводилася анестезія шляхом ретробульбарної блокади і седації пропофолом, знеболювання мелоксикамом продовжували в післяопераційному періоді за схемою запобіжної аналгезії; 2-га група (n = 24) — пацієнти, знеболювання яких здійснювалося за раніше прийнятою в нашій клініці схемою (премедикація сибазон + фентаніл), внутрішньовенний наркоз пропофолом зі збереженим спонтанним диханням і болюсним введенням фентанілу під час потенційно хворобливих етапів втручання. Післяопераційне знеболювання на вимогу пацієнтів внутрішньом’язовим введенням кетопрофену. Результати. Вираженість больового синдрому менше 3 балів за візуально-аналоговою шкалою в 1-й групі пацієнтів становила 90 і 85 %, у 2-й групі — 45,8 і 58,3 % на 6 і 12 годинах післяопераційного періоду відповідно. Розвиток післяопераційної нудоти і блювання в 1-й групі пацієнтів з використанням схеми мультимодального використання становив 5 % порівняно з 33,3 % в контрольній групі пацієнтів. Розвиток артеріальної гіпертензії в післяопераційному періоді в 1-й групі відзначався у 15 % пацієнтів порівняно з 45,8 % пацієнтів у 2-й групі. Розвиток артеріальної гіпотензії відзначався тільки у пацієнтів контрольної групи, і частота даного ускладнення становила 37,5 %. Не було зареєстровано жодного випадку гіпотензії у пацієнтів 1-ї групи. Висновки. Використання запропонованої схеми мультимодального знеболювання дозволяє підвищити ефективність і керованість анестезіологічного знеболювання у вигляді забезпечення адекватного знеболювання в післяопераційному періоді без застосування наркотичних анальгетиків, зниження ризику розвитку післяопераційних ускладнень (післяопераційної нудоти і блювання, артеріальної гіпертензії і гіпотензії).

Вариант анестезии при операциях тотального эндопротезирования суставов нижних конечностей

In this study we sought to optimize analgesia in total joint arthroplasty of the lower extremity and reduce the risk of arterial hypotension in patients with various degrees of obesity. The optimization contributed to the development of a new technique of spinal anesthesia. The technique leads to the epidural volume extension, as well as the decrease of local anesthetic doses administered into the subarachnoid space and saving the level of sensory block. The aim of the study was to study the effect of the spinal anesthesia with the epidural volume extension technique on the level of sensory block and hemodynamics in patients with various degrees of obesity during total arthroplasty of the lower extremity joints for III stage osteoarthritis. The prospective single-center study included 103 patients (79 men (76.7%), mean age 59±11 years, range from 33 to 74 years) who were treated in the Department of Traumatology and Orthopedics from September 2019 to May 2020. Anthropometric parameters, levels of sensory and motor blocks, level of pain syndrome, sympathetic block, duration of surgery and anesthesia were analyzed. To assess the impact of all factors on the outcome, methods of one-dimensional analysis with the calculation of relative risk (RR) were used. All patients were divided into two groups: the control group (combined spinal-epidural anesthesia was used) and the main group (spinal anesthesia with epidural volume extension was used). The average upper level of the sensor block (Th-segment) at 15 minutes after spinal anesthesia did not significantly differ in the groups (p=0.95). Differences in the frequency of hypotension in the groups were not statistically significant (p˃0.05). RR: 1.17 [95% CI: 0.794; 1.726]. Reducing the dose of a local anesthetic by 25% to provide adequate spinal anesthesia with the epidural volume extension in patients with a high body mass index achieves the same result when assessing sensory, motor and sympathetic blockages when compared with the traditional method of anesthesia.

Incidence of Arterial Hypotension in Patients Receiving Peroral or Continuous Intra-arterial Nimodipine After Aneurysmal or Perimesencephalic Subarachnoid Hemorrhage.

Oral nimodipine is used for prophylaxis and treatment of delayed cerebral ischemia in patients with aneurysmal or perimesencephalic subarachnoid hemorrhage (SAH). In cases of serious refractory cerebral vasospasm, a continuous intra-arterial (IA) infusion of nimodipine (CIAN) may be required to avoid cerebral ischemia. Nimodipine can cause arterial hypotension requiring either a dosage reduction or its discontinuation. Aim of the present study was to examine the effect of different nimodipine formulations on arterial blood pressure in aneurysmal or perimesencephalic SAH patients and to measure the plasma levels after both, peroral administration as tablet or solution and IA infusion. In a prospective setting, over a 1-year observation period, data on the course of arterial blood pressure and nimodipine dosage were collected for 38 patients undergoing treatment for aneurysmal or perimesencephalic SAH in an intensive care unit. In addition, plasma concentrations of nimodipine were measured by liquid chromatography-tandem mass spectrometry. The intended full dose of 60mg of nimodipine given orally every 4h could only be administered on 57.2% of the examined days. Ninety-seven episodes of relevant arterial hypotension probably caused by the administration of nimodipine were observed within the first 14days of treatment. Drops in blood pressure occurred about three times as often after administration of nimodipine as oral solution than as tablet. However, there were no differences in nimodipine plasma levels between the two formulations. In patients suffering from higher-grade SAH, arterial hypotension and consequent dosage reduction or discontinuation of nimodipine were more frequent than in patients with lower-grade SAH. Plasma concentrations of nimodipine during CIAN did not exceed those achieved by oral administration. Dosage reduction or discontinuation of oral nimodipine is often necessary in patients with higher-grade SAH. Oral nimodipine solutions cause drops in blood pressure more frequently than tablets. Intra-arterial infusion rates of less than 1mg/h result in venous plasma concentrations of nimodipine similar to those observed after oral application of 60mg every 4 h.

Role of vasopressin in current anesthetic practice.

Arginine vasopressin (AVP), also known as antidiuretic hormone, is a peptide endogenously secreted by the posterior pituitary in response to hyperosmolar plasma or systemic hypoperfusion states. When administered intravenously, it causes an intense peripheral vasoconstriction through stimulation of V1 receptors on the vascular smooth muscle. Patients in refractory shock associated with severe sepsis, cardiogenic or vasodilatory shock, or cardiopulmonary bypass have inappropriately low plasma levels of AVP (‘relative vasopressin deficiency’) and supersensitivity to exogenously-administered AVP. Low doses of AVP and its synthetic analog terlipressin can restore vasomotor tone in conditions that are resistant to catecholamines, with preservation of renal blood flow and urine output. They are also useful in the treatment of refractory arterial hypotension in patients chronically treated with renin-angiotensin system inhibitors, cardiac arrest, or bleeding esophageal varices. In the perioperative setting, they represent attractive adjunct vasopressors in advanced shock states that are unresponsive to conventional therapeutic strategies.

CIRCADIAN BLOODE PRESSURE PROFILE IN PATIENTS WITH COMMUNITY PNEUMONIA WITH VARYING SEVERITY ENDOGENOUS INTOXICATION

Background. Purpose. Evaluate the effect of endogenous intoxication (EI) on circadian blood pressure profile with community-acquired pneumonia (CAP). Methods. In 140 patients with CAP investigated hemodynamic systemic circulation at EI varying severity. Result. It was found that the II and III degree of EI was characterized by an increase in hypotonic stress on target organs and decrease variability of blood pressure (BP) during both day and night, against excessive daily index of BP (p <0.05). In this therapy eliminates the EP violation of hemodynamic parameters in most patients, with the exception of III degree EI, where preserved signs of hypotension during convalescence. Conclusion. Endogenous intoxication initiates the development of a stable systolic and diastolic arterial hypotension in patients with CAP, reaching maximum changes at the III degree of EI at night.

Hypothalamic Injury as a Cause of Refractory Hypotension after Sellar Region Tumor Surgery

Fluid-resistant arterial hypotension can result in hypoperfusion of the brain and other organs. Well-known causes of arterial hypotension in neurosurgical practice include cardiac failure, septic shock, adrenal insufficiency, brainstem, and cervical spinal cord damage. Fluid-resistant arterial hypotension can occur in patients with brain edema without damage to brainstem when hypothalamic nuclei suffer. This phenomenon is not a well-documented cause of hypotension. We prospectively investigated 15 cases with clinical syndrome of arterial hypotension in patients following surgery for sellar region tumors. These cases were taken from 1005 patients operated between May 2003 and December 2005. Pulmonary artery catheter was used to investigate hemodynamic profile. The mechanism of arterial hypotension consisted of decrease of vascular tone (SVRI was 1503 +/- 624 dyn x s x cm(5) x m(2)) and relative hypovolemia (CVP: 4.5 +/- 2.6 torr, PAWP: 7.4 +/- 3.5 torr). In all cases arterial hypotension was corrected with phenylephrine after failure to respond to fluid resuscitation alone. Fluid balance was positive over the next 72 h. Twenty-seven percent of patients had transitory thyroid insufficiency. In these situations dopamine was administrated as symptomatic therapy and dose of thyroid hormone was increased. Mortality was 53%. Hypothalamic damage can result in life-threatening vasodilatory arterial hypotension after sellar region tumor surgery. beta-Sympatomimetics are indicated in cases with thyroid insufficiency.

Arterial hypotension in patients undergoing coronary revascularization with high thoracic epidural anaesthesia

Casalino, S.; Mangia, F.; Sozio, C.; Stelian, E.; Novelli, E.; Lanzillo, G.; Diena, M.; Tesler, U. F. Author Information

Continuous blood pressure monitoring in cirrhosis: Relations to splanchnic and systemic haemodynamics

Background/Aims: Low arterial blood pressure is recognised as a distinctive factor in the hyperdynamic circulation in cirrhosis. 24-hour monitoring of the blood pressure and heart rate has recently revealed a reduced circadian variation with relation to liver function. However, associations with other clinical and haemodynamic characteristics have not been investigated and the aim of the present study was to identify splanchnic and systemic determinants of the 24-h blood pressure and heart rate in cirrhosis. Methods: The variables were measured by an automatic ambulant device for monitoring blood pressure and related to the results of an invasive haemodynamic investigation, including measurements of intra-arterial blood pressure (9.00–11.00 h) in 37 patients with cirrhosis. Results: The 24-h blood pressures were significantly lower and the heart rate was significantly higher in patients with cirrhosis than in matched controls ( p<0.05–0.001). To identify determinants of 24-h or intra-arterial blood pressures and heart rate, pertinent variables were included in a multivariate regression model. This model revealed that independent determinants of a low 24-h arterial blood pressure were a high post-sinusoidal resistance, a low plasma volume, a short central circulation time, and the presence of ascites. In contrast, a low intra-arterial blood pressure was determined by a low serum sodium, a low haemoglobin, and a high cardiac output. Diuretic treatment did not influence this model. Conclusions: Although the 24-h blood pressure and the intra-arterial blood pressure were determined by different variables, the overall results indicate that abnormalities in both splanchnic and central haemodynamics and sodium-water retention are important in the pathophysiology of arterial hypotension in patients with portal hypertension.

Drug interactions with intravenous and local anaesthetics.

Relatively few clinically significant drug interactions with anaesthetics have been documented in the literature. The following should be stressed since these interactions are not readily predictable or are potentially fatal. Pethidine should never be administered to patients who have received monamine oxidase inhibiting drugs within the last fortnight, since a fatal hyperpyrexia and/or hypertension may result. Thiopentone induction seems to make the heart more susceptible to arrhythmias caused by adrenergic drugs, and may cause severe arterial hypotension in patients treated with diazoxide. Midazolam orally should possibly be avoided as premedication in patients treated with erythromycin since anaesthetic concentrations of midazolam may result. Patients for whom bupivacaine analgesia is planned could preferentially be premedicated with other drugs than diazepam, which causes the serum level of bupivacaine to increase. Bradycardia and hypotension not attributable to sympathetic blockade have been reported following bupivacaine extradurally in verapamil-treated patients. Sulfonamides and the ester group of local anaesthetics, such as prilocaine in combination, may result in severe methaemoglobinaemia in infants. Epinephrine added to local anaesthetics may cause local vasodilation if administered to patients concurrently being treated with cyclic antidepressants, and the combination imposes the risk of severe hypertension and arrhythmias.

透析低血圧の病態に関する研究 (第2報)

透析患者の低血圧例は動脈直接穿刺法によるValsalva検査で, 心拍数変化R-R比が1.22±0.12と正常血圧例1.40±0.11 (p<0.01), 高血圧例1.35±0.06 (p<0.001) に比べ有意に低下していた. 動脈圧の反応としてovershoot陽性率は低血圧10例中1例で, 正常血圧7例中5例, 高血圧8例全例に比べ低率であった. この結果, 低血圧例は, 非低血圧例に比べ, 圧受容体反射弓に異常があることが示唆された. これら低血圧例の圧受容体反射弓の障害部位の判定に, 寒冷昇圧試験 (遠心性交感神経路), clonidine負荷試験 (中枢交感神経活性), 末梢運動神経伝導速度 (末梢神経) を測定し評価した. 寒冷昇圧試験の平均動脈圧の変化 (ΔMAP: mmHg) は低血圧10.86±4.41で, 正常血圧12.60±7.27, 高血圧21.20±15.25, 健常人14.92±5.71に比べ有意の差は認められなかった. clonidine負荷試験は透析低血圧で降圧反応を示し, clonidineは中枢性にα2 adrenoreceptor agonistとして作用したものと考えられる. 末梢運動神経伝導速度は低血圧例で軽度の遅延を示した. これらの成績から, 透析患者の低血圧例はValsalva検査による圧受容体反射弓の障害を示すが, その反射弓の遠心性交感神経路, 中枢交感神経活性は維持されていることが示唆された. 末梢神経障害は末梢運動神経伝導速度の遅延から軽度認められた. これらの結果から, 透析患者の低血圧の成因の詳細な点は未だ明らかでなく, 今後, 求心路, 血管壁の反応性等について検討を加えねばならない.

A comparison of the acute hemodynamic effects of prostacyclin and hydralazine in primary pulmonary hypertension

In patients with primary pulmonary hypertension the administration of a vasodilating drug is often used to test pulmonary vasoreactivity. Hydralazine has been employed as a test drug, but because of its long duration of action there is a risk of sustained systemic arterial hypotension in patients with a fixed pulmonary vascular resistance. In this study we compared the acute hemodynamic effects of intravenous prostacyclin, a potent, short-acting vasodilator, with the effects of oral or intravenous hydralazine. Both prostacyclin and hydralazine increased cardiac output and decreased systemic pressure without changing pulmonary arterial pressure in seven patients with primary pulmonary hypertension. The average decrease in total pulmonary resistance with prostacyclin (−46% ± 5%) was more than that with hydralazine (−32% ± 6%). The respective decreases in total systemic resistance were −50% ± 4% vs −43% ± 6%. The percent changes in individual responses to the two agents were correlated (p < 0.05) for pulmonary arterial pressure, systemic arterial pressure, total pulmonary resistance, and total systemic resistance. We concluded that the pulmonary hemodynamic effects of prostacyclin resembled those of hydralazine. Prostacyclin may predict the acute pulmonary hemodynamic effects of hydralazine in primary pulmonary hypertension and because of its prompt, brief action may provide greater patient safety.