Cause Of Hypotension Research Articles

0099. Nitrite reductase activity during sepsis

Nitric oxide (NO) excess is considered to be the main cause of hypotension in sepsis. Research has mainly focussed upon NO production by isoforms of NO synthase (NOS). However, alternative pathways may make an important contribution, including nitrite (NO2-) reduction by the reductase activity possessed by numerous heme- and pterin-based enzymes. The temporal contribution of these pathways to NO production in sepsis is currently unclear.

Bilateral adrenal gland haemorrhage: an unusual cause.

SummaryOur patient had drainage of a large amoebic liver abscess. This got complicated by a severe degree of hypotension, which required aggressive fluid resuscitation and hydrocortisone support. Computerised tomography (CT) of the abdomen revealed bilateral adrenal gland haemorrhage (BAH) resulting in primary adrenal gland failure, which was the cause for hypotension. Patient was on long-term warfarin for provoked deep vein thrombosis of lower limb, which was discontinued before the procedure. Thrombophilia profile indicated the presence of lupus anticoagulant factor with prolonged activated partial thromboplastin time (aPTT). Patient was discharged on lifelong warfarin. This case emphasises the need for strong clinical suspicion for diagnosing BAH, rare but life-threatening condition, and its association with amoebic liver abscess and anti-phospholipid antibody syndrome (APLS).Learning points Recognition of BAH as a rare complication of sepsis.APLS can rarely cause BAH.

OPTIMIZED PROCEDURE TO EVALUATE THE THERMAL ENERGY TRANSFER IN HEMODIALYSIS TREATMENT

Hemodialysis treatment is biased by complications during its operative phases. One of these potential accidents consists in intradialytic hypotension, that causes discomfort to the patient and may even increase the risk of death. Therefore, it is very important to predict these events in routine clinical procedures. A cause of hypotension may be thermal energy/heat exchanges between extracorporeal system and the surrounding environment. A model to evaluate these heat losses is proposed and improved in order to maintain constant patient blood temperature. A convenient procedure is defined to improve and optimize clinical treatment. Although most hemodialysis machines automatically control the dialysate solution temperature starting from peripheral body temperature measurements, the proposed method is based on the control of the pre-dialysis core temperature of the patient, and the temperature of the blood entering the artery from the extracorporeal circuit after the treatment in the dialyzer. Measurements of arterial and venous blood temperatures are obtained in a non invasive way by a suitable estimate of the thermal energy exchanges between the blood and the environment during the extracorporeal recirculation. The suggested model guarantees a constant core temperature of the patient, improving prevention from intradialytic hypotension.

Ruptured splenic artery aneurysms and the use of an adapted fast protocol in reproductive age women with hemodynamic collapse: case series.

Nontraumatic symptomatic hypotension in all patients requires prompt diagnosis and appropriate treatment for optimum outcome. The female population specifically has an expanded differential diagnosis that should be considered when these patients present with hemodynamic collapse. While the most common causes of hypotension in pregnant patients are dehydration, ruptured ectopic pregnancy, and placental and uterine abnormalities, less common nonobstetrical etiologies such as hepatic rupture and ruptured abdominal and visceral artery aneurysms should also be considered. Splenic artery aneurysms are associated with high rates of mortality and in cases of pregnancy, maternal and fetal mortality. These high rates can be attributed to the asymptomatic nature of the aneurysm, rapid deterioration after rupture, and frequent misdiagnosis. In patients with hemodynamic collapse, the role of traditional imaging is limited mainly due to the critical condition of the patient. Bedside ultrasound has emerged as a diagnostic imaging resource in patients with undifferentiated hypotension and in patients with traumatic injuries. However, its use has not been studied specifically in the female population. We present two patients with ruptured splenic artery aneurysms, discuss the role of bedside ultrasound in their management, and introduce a new ultrasound protocol for use in reproductive age female patients with hemodynamic collapse.

Hypotension induced coronary spasm: A vascular access complication

Hypotension after successful angioplasty with stenting can be a fatal complication. The fact that it can ruin the final outcome despite the lesion and the procedure being uncomplicated is a cause for concern. We were able to document hypotension as the cause for coronary spasm and were successful in treating hypotension & coronary vasospasm with vasospastics. Bleeding, both obvious and occult is a prime cause of hypotension as was found in this case.

Diagnosis of Megaureter by Point-of-Care Ultrasound

BackgroundPresentation of congenital megaureter in adult life is rare; patients usually become symptomatic in childhood. Case ReportA 32-year-old man presented to the Emergency Department (ED) with dyspnea, tongue swelling, and a rash, which he attributed to amoxicillin he had taken shortly prior to onset of symptoms. He was hypotensive on arrival to the ED. To further evaluate the hypotension, point-of-care ultrasound of the heart, lungs, and abdomen were performed while treatment for anaphylaxis was initiated. Ultrasound examination did not identify a cause for hypotension, but the treating physician noted an anechoic structural abnormality posterior to the bladder, suggestive of megaureter. The patient responded well to treatment of anaphylaxis; further history and diagnostic imaging subsequently confirmed a diagnosis of congenital megaureter. ConclusionWe report an unusual case of congenital megaureter, identified by point-of-care ultrasound performed to evaluate hypotension. Clinicians performing limited ultrasound examinations must be attentive to incidental findings that will require follow-up.

Sustained Hypotension Following Intravenous Metoclopramide

To report a case of sustained hypotension associated with the use of intravenous metoclopramide. A 50-year-old woman developed a hypotensive episode lasting approximately 90 minutes after the administration intravenous metoclopramide for the treatment of a migraine. The patient presented to the emergency department after she woke up with a severe headache that was much worse than her normal migraine headaches. Her past medical history included migraines, diabetes type 2, hypertension, and hyperlipidemia. Fifteen minutes after the administration of intravenous metoclopramide 10 mg, the patient's systolic blood pressure decreased from 138 to 84 mmHg (a mean arterial pressure decrease of 40.7 mmHg). The patient was given 1 L of intravenous NaCl 0.9% that had minimal effect on blood pressure. The patient did not reapproach her baseline systolic blood pressure until 90 minutes after the metoclopramide administration when it was measured at 138 mmHg. Subsequent contrast tomography of the head was negative and the patient's headache was successfully treated with butalbital/acetaminophen/caffeine. The patient was discharged home the same day. There are few published case reports of metoclopramide-induced hypotension in the current literature. Of those published, all showed transient hypotension with metoclopramide, lasting seconds to minutes. An objective causality assessment for drug-associated adverse drug reaction showed metoclopramide as a probable cause of the patient's hypotension (Naranjo score of 5). In this case, several indicators of metoclopramide induced hypotension were evident, including the timing of the hypotension after drug administration and the lack of any other possible causes of hypotension. This is the first published case report of sustained hypotension due to intravenous metoclopramide. Intravenous metoclopramide may cause sustained episodes of hypotension.

Simplified detection of myocardial ischemia by seismocardiography

Seismocardiography (SCG) is a noninvasive technique for recording cardiac vibrations. Changes in these waves have been correlated with chronic and acute alterations in myocardial function. This analysis is complex and clinical integration limited. The current study aimed to simplify the utilization of SCG by fast Fourier transformation for a reliable discrimination between different intra- and postoperative causes of hypotension (i.e., myocardial ischemia or hypovolemia). We operated on nine pigs and recorded SCG at baseline, at hypovolemia (occlusion of the inferior vena cava), and at ischemia (occlusion of the right coronary artery). In conclusion, SCG enables detection and differentiation of ischemia and hypovolemia as important causes of altered myocardial function during and after surgery. Thus, this simple and noninvasive diagnostic tool may be used intra- and postoperatively to identify patients at risk.

Vigilance of hemodynamic changes immediately after transferring patients is crucial

A decrease in blood pressure is sometimes observed when a postsurgical patient is transferred to another bed after recovering from anesthesia. However, the mechanism behind this hypotension has not been completely elucidated. The purpose of this study was to investigate and compare changes in hemodynamic properties for possible causes of hypotension before and after transfer to another bed of postsurgical patients receiving general anesthesia, combined epidural and general anesthesia, or combined spinal and general anesthesia. We studied 69 patients undergoing elective surgery who were randomized to receive anesthesia by one of the three methods. After surgery, the tracheal tube was removed, and each patient was transferred to another bed. Hemodynamic data recorded immediately before and after transfer of the patient to another bed were compared. After transfer of patients receiving general anesthesia or combined epidural and general anesthesia, systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and cardiac output (CO) decreased; heart rate (HR) and systemic vascular resistance (SVR) did not change. However, after transfer of patients receiving combined spinal and general anesthesia, SAP, DAP, HR, and CO decreased, but SVR did not change. The decrease in blood pressure observed after transfer of a postsurgical patient to another bed after general, combined epidural and general, and combined spinal and general anesthesia was associated with a decrease in CO and no change in SVR, but HR decreased after combined spinal and general anesthesia, whereas it was unchanged after general and combined epidural and general anesthesia. The decrease in blood pressure is assumed to be caused by a decrease in venous return, and several reflexes might participate in this decrease of blood pressure, especially after combined spinal and general anesthesia.

The role of computed tomography in the primary survey of polytrauma patients

British Journal of Hospital MedicineVol. 74, No. 2 EditorialThe role of computed tomography in the primary survey of polytrauma patientsPurnajyoti Banerjee, Praveen PanosePurnajyoti BanerjeeSearch for more papers by this author, Praveen PanoseSearch for more papers by this authorPurnajyoti Banerjee; Praveen PanosePublished Online:27 Sep 2013https://doi.org/10.12968/hmed.2013.74.2.66AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Becker CD, Poletti PA (2005) The trauma concept: the role of MDCT in the diagnosis and management of visceral injuries. Eur Radiol 15 (Suppl 4D): 105–9 Crossref, Google ScholarGallagher J (2012) Trauma care: CT scanner is ‘merged’ with A&E in hospital first. BBC News Health 23 November (www.bbc.co.uk/news/health-20174883 accessed 11 January 2013) Google ScholarHessmann MH, Hofmann A, Kreitner KF, Lott C, Rommens PM (2005) The benefit of multislice computed tomography in the emergency room management of polytraumatized patients. Eur J Trauma 31(3): 231–8 Crossref, Google ScholarHessmann MH, Hofmann A, Kreitner KF, Lott C, Rommens PM (2006) The benefit of multislice CT in the emergency room management of polytraumatized patients. Acta Chir Belg 106(5): 500–7 Crossref, Medline, Google ScholarHuber-Wagner S, Lefering R, Qvick LM et al.; Working Group on Polytrauma of the German Trauma Society (2009) Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 373(9673): 1455–6 Crossref, Medline, Google ScholarHui CM, MacGregor JH, Tien HC, Kortbeek JB (2009) Radiation dose from initial trauma assessment and resuscitation: review of the literature. Can J Surg 52(2): 147–52 Medline, Google ScholarLeidner B, Adiels M, Aspelin P, Gullstrand P, Wallén S (1998) Standardized CT examination of the multitraumatized patient. Eur Radiol 8(9): 1630–8 Crossref, Medline, Google ScholarLinsenmaier U, Krötz M, Häuser H et al. (2002) Whole-body computed tomography in polytrauma: techniques and management. Eur Radiol 12(7): 1728–40 Crossref, Medline, Google ScholarMahoney EJ, Biffl WL, Harrington DT, Cioffi WG (2003) Isolated brain injury as cause of hypotension in the blunt trauma patient. J Trauma 55: 1065–9 Crossref, Medline, Google ScholarRegel G, Lobenhoffer P, Lehmann U, Pape HC, Pohlemann T, Tscherne H (1993) Results of the treatment of polytraumatized patients. A comparative analysis of 3.406 cases between 1972 and 1991. Unfallchirurg 96: 350–62 Medline, Google ScholarSierink JC, Saltzherr TP, Reitsma JB, Van Delden OM, Luitse JS, Goslings JC (2012a) Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients. Br J Surg 99 (Suppl 1): 52–8 Crossref, Medline, Google ScholarSierink JC, Saltzherr TP, Beenen LF et al.; REACT-2 study group (2012b) A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2). BMC Emerg Med 12: 4 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetailsCited ByDo clinical guidelines for whole body computerised tomography in trauma improve diagnostic accuracy and reduce unnecessary investigations? A systematic review and narrative synthesis29 March 2017 | Trauma, Vol. 19, No. 3Computed tomography in hemodynamically unstable severely injured blunt and penetrating trauma patientsJournal of Trauma and Acute Care Surgery, Vol. 80, No. 4 1 February 2013Volume 74Issue 2ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 27 September 2013 Published in print 1 February 2013 Information© MA Healthcare LimitedPDF download

Perioperative transoesophageal echocardiography: past, present & future

Perioperative transoesophageal echocardiography: past, present & future

My patient has no blood pressure: is their heart working?

How can point-of-care (PoC) ultrasound be used to help the clinician identify cardiogenic and certain non-cardiogenic causes of undifferentiated, non-traumatic hypotension? Hypotension is a common emergency presentation in the emergency department and medical admissions unit. Due to the physiological complexities of this state, the aetiology is often unclear to clinicians at initial presentation. This has clear implications for treatment and outcomes of the patient. Clinical indicators such as vital signs and physical examination are often unreliable in distinguishing causes of hypotension, identifying the correct aetiology in only 25–50% of cases. PoC ultrasound (PoCUS) of the heart can help differentiate between cardiogenic causes such as left ventricular dysfunction, and obstructive causes such as cardiac tamponade, and can point towards other causes such as sepsis and hypovolaemia. Limited cardiac echocardiography or ‘echo in life support’ can be performed as a part of goal-directed protocols for undifferentiated, non-traumatic hypotension. Use of such protocols early can significantly improve the diagnostic accuracy to 80%, thereby reducing the time to diagnosis and the time to initiating appropriate therapies. In this article, we review our approach to PoCUS of the heart in the setting of hypotension.

Suspected unexpected adverse effect of sugammadex: hypotension

Dear Editor Cyclic oligosaccharides, cyclodextrins, are increasingly used in clinical practice [1]. A chemically modified γ-cyclodextrin consisting of eight glucopyranose units, sugammadex, is used to reverse neuromuscular blockade induced with rocuronium and other aminosteroid neuromuscular agents. The mode of action of sugammadex is unique: chelation of aminosteroid agents [2]. Human studies in healthy volunteers and patients indicate that sugammadex is well tolerated, but some adverse effects may occur. Themost commonly reported adverse effect of sugammadex is dysgeusia [2]. Other commonly reported adverse events are anesthetic complications, as well as uncommonly reported hypersensitivity reactions, unwanted awareness during anesthesia, and a rare case of anaphylaxis. In October 2010, a 33-years old Caucasian woman with normal body weight (54 kg; height 164 cm) was admitted to our day-case surgical unit for laparoscopic sterilization. In her medical history, she had arterial hypertension. Blood pressures were in good control with the angiotensin-converting enzyme inhibitor (ACEI) enalapril 20 mg once daily. She used an orally administered contraceptive of 3 mg drospirenone and 0.03 mg ethinylestradiol but had no other concomitant medication. She had taken the latest dose of enalapril at 6:00 a.m. and fasted since. For premedication, she received paracetamol 1.5 g by mouth at 8:30 a.m. Normal saline infusion was started, and anesthesia was induced at 10:00 a.m. with midazolam 1 mg, propofol 150mg, and fentanyl 100μg. Rocuronium 30mgwas given to facilitate orotracheal intubation, and she was given dexamethasone 5 mg for postoperative nausea prevention. Anesthesia was maintained with sevoflurane, end-tidal concentration 1.5–2.0%, in oxygen in air, with positive-pressure ventilation. During surgery, she was given fentanyl 100 μg. She had a stable hemodynamic, arterial blood pressure was approximately 130/90 mmHg during intra-abdominal carbon dioxide insufflation and after decompression of the abdominal cavity 105/45 mmHg, and at the end of anaesthesia 124/87 mmHg. At the end of surgery, 30 min after anesthesia induction, she received sugammadex 50 mg (Bridion 100 mg ml, Batch no. 463393, Schering Plough, Oss, Netherlands), and train-offour ratio recovered to 0.9 within 2 min. At 10 min after sugammadex injection, she developed severe hypotension, the lowest arterial blood pressure being 50/30 mmHg. The patient was given etilephrine (total dose 7 mg) and phenylephrine (total dose 0.3 mg) and infused with 1,000 ml normal saline and gelatin 500 ml. Blood pressure returned to normal level within 15min, and she recovered without sequela (Fig. 1). The case was reported to the marketing authorization holder and to the Finnish Medicines Agency. The first case of hypotension after sugammadex was reported in 2006 [3]. In a dose-finding study, a patient who received sugammadex 3mg kg developed deep hypotension consistent with our case within 10min after dosing. Sorgenfrei and colleagues [3] speculated that hypotension was caused by propofol and fentanyl given 2–5 min before the event. In our case, the patient was given propofol and fentanyl earlier during the course of anesthesia, her blood pressure was stable, she was pain free after surgery, and hypotension developed only at 10 min after sugammadex injection. Thus, we believe that sugammadex is the most probable cause of hypotension in this patient. As a concomitant medication the patient used enalapril, and it is known that ACEI may induce hypotension as an interaction with anesthetics [4]. However, with ACEI, it M. Kokki :M. Ali :M. Turunen :H. Kokki Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, School of Medicine, University of Eastern Finland, PO Box 1777, FI-70211 Kuopio, Finland

Simulation Scenario- Myocardial Ischemia in a Patient With a Cardiac Transplant After Subarachnoid Block

OPEN ACCESSNovember 21, 2011Simulation Scenario- Myocardial Ischemia in a Patient With a Cardiac Transplant After Subarachnoid Block Daniel Chun, MD, Pablo Gavazza, MD, Christine Hollister, MD, Cecilia Canales, MPH, Sharon Lin, MD Daniel Chun, MD University of California, Irvine, School of Medicine Google Scholar More articles by this author , Pablo Gavazza, MD University of California - Irvine Google Scholar More articles by this author , Christine Hollister, MD University of California - Irvine Google Scholar More articles by this author , Cecilia Canales, MPH University of California - Irvine Google Scholar More articles by this author , Sharon Lin, MD University of California - Irvine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.9029 SectionsAboutAbstract ToolsDownload Citations ShareFacebookTwitterEmail AbstractAbstractThis resource is a simulation scenario originating from a case experienced in the operating room. In this scenario, an 80-year-old male, who had a cardiac transplant 13 years prior, undergoes a spinal anesthetic for a wide local excision of Merkel cell carcinoma in his right thigh and thereafter develops refractory hypotension and subsequent myocardial ischemia. Sympathectomy and hypotension are well-known complications of a subarachnoid block. Identification and treatment of these common occurrences are considered basic principles in the use of neuraxial blocks. In a patient with a transplanted heart, the physiology involved can be further complicated as patients are preload dependent. This scenario exposes participants to the extreme complications of a subarachnoid block (hypotension and myocardial ischemia) in a patient with a cardiac transplant, as well as to the complicated responses to different treatments.Educational Objectives By the end of this resource, learners will be able to: Identify sympathectomy as the cause of hypotension immediately following subarachnoid block.Discuss the diagnosis and treatment of myocardial ischemia.Describe the appropriate selection of medications in a cardiac transplant patient experiencing severe refractory intraoperative hypotension.Demonstrate effective communication with operating room staff during a crisis and delegate tasks effectively.List the differential diagnosis of intraoperative hypotension.Describe the physiology of a patient with a transplanted heart and the effect of a subarachnoid block.Describe the preoperative evaluation of a patient with a transplanted heart. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Myocardial Ischemia Simulation Case.doc To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. Copyright & Permissions© 2011 Chun et al. This is an open-access article publication under the terms of the Creative Commons Attribution-No Derivatives license.KeywordsSubarachnoid BlockHypotensionMyocardial Ischemia Disclosures None to report. Funding/Support None to report. Loading ...

Low Bispectral Index Values and Death

Low Bispectral Index Values and Death

A Case of Postprandial Hypotension in the Intensive Care Unit Treated With Acarbose

Postprandial hypotension (PPH) has not been described as a cause of hypotension after the return of spontaneous circulation (ROSC) in the intensive care unit (ICU). A 74 year old man underwent cardiopulmonary resuscitation (CPR) due to monomorphic ventricular tachycardia. After the ROSC, inotropic agents were not reduced but increased. PPH had occurred, according to the flow sheet, so a provocation test was performed. We noted hypotension but no serum hypoglycemia or tachycardia. The hypotension was diagnosed as PPH. We chose acarbose for treatment; thus, the inotropic agents were discontinued. This is the first case in which hypotension occurred in a patient recovering after CPR in the ICU and that the PPH was treated with acarbose. PPH should be considered and treated to manage hypotension in elderly patients in the ICU.

Serum Vasopressin Concentrations During Orthotopic Liver Transplantation

Background We report measurements of the temporal response of serum vasopressin concentrations in the period after reperfusion of the liver graft during orthotopic liver transplantation (OLT). Methods Vasopressin concentrations were determined in 11 adult patients undergoing OLT by radioimmunoassay of samples collected after induction, at 5 minutes prior to reperfusion, and at 10, 20, 30, 40, 50, 60, 90, and 120 minutes after reperfusion. Results Pre-incision vasopressin concentrations ranged from <0.5 to 2.6 pg/mL (reference serum vasopressin, <1.7 pg/mL). Overall, levels increased before reperfusion, but fell thereafter. Individual patients manifested elevated levels during the period after reperfusion. Values immediately before reperfusion exhibited most variability, ranging from 0.8 to 40 pg/mL (median, 15; interquartile range [IQR], 4–29) Median vasopressin concentrations 10 minutes postreperfusion were 7.6 pg/mL (IQR, 3–27). Only 3 of the 11 patients failed to generate vasopressin levels >20 pg/mL. In each of these patients, hemodynamics were satisfactory without the need for additional pressor infusion. Maximum vasopressin concentration measured in any patient was 85 pg/mL. There was no correlation between vasopressin concentration and mean blood pressure or systemic vascular resistance index. Conclusion Vasopressin concentrations during OLT vary widely and are elevated periodically during the anhepatic and postreperfusion stages, with no apparent relationship between vasopressin concentrations and blood pressure. Although vasopressin concentrations were not as high as those measured during some other clinical situations, these data suggest that a relative vasopressin deficiency is not a direct cause of hypotension during OLT.

A Case of a Maintenance Hemodialysis Patient in Whom a Change of Sensitivity to Acetate Was Suspected

Sodium acetate, which is a buffering agent in dialysates, has a vasodilatation effect as well as effects for depression of myocardial contractility even in low dosages. Also, it is presumed to be one of the causes of hypotension during hemodialysis (HD). In recent years, acetate-free dialysates [A(-)D] have been developed. In this case, although it was possible to maintain a relatively stable hemodynamic condition during HD using 10 mEq/L of acetate-containing dialysate [A(+)D], after HD using A(-)D for 4 months and then switched back to A(+)D, the patient complained of several symptoms such as nausea, vomiting, and headache, and severe hypotension episodes increased during HD. Furthermore, stabilization of the hemodynamic condition was obtained after switching back to A(-)D. Moreover, the nutritional state and anemia were improved. Conventionally, it has been considered that cases referred to as acetate intolerance have various symptoms with increasing blood acetate levels; however, this case suggests the possibility that tolerance to acetate was acquired by using the A(+)D over time, and the tolerance dissipated after using the A(-)D for 4 months. The number of cases involving broadly defined acetate intolerance as in this case was higher than expected. These findings suggest that using A(-)D for such cases, it may therefore be possible to maintain stable hemodynamic conditions during HD and improve the nutritional state and anemia.

Probable valproate sodium-associated hypotension

Background: Valproate sodium, a commonly used antiepileptic drug (AED), is effective for the treatment of status epilepticus and is often used as a second-line agent when other AEDs are contraindicated. Some studies have reported that infusion of valproate sodium is generally well tolerated, whereas other studies have reported various degrees of hypotension during infusion. The objective of this case report was to call attention to the potential risk of hypotension after intravenous infusion of valproate sodium. Case summary: This was the case of a 75-year-old Hispanic man (height, 145 cm; weight, 68 kg) who developed hypotension after receiving an intravenous loading dose of valproate sodium. The patient received the loading dose 12 hours after administration of his last dose of phenytoin (300 mg daily), which had been discontinued secondary to a cutaneous drug reaction. The patient's medical history was significant for seizure disorder, a cerebrovascular accident, and controlled type 2 diabetes mellitus. He was taking glyburide 5 mg daily and aspirin 81 mg daily. At baseline, the patient's blood pressure (measured while seated, at rest, using an upper-extremity cuff) was 135/70 mm Hg. The intravenous loading dose of valproate sodium (20 mg/kg) was administered at a rate of 14 mg/min (total dose, 1280 mg over 90 min). Approximately 2.5 hours after completion of the loading dose, the patient's blood pressure decreased to 107/48 mm Hg. Because our standard operating procedure is to measure blood pressure every 4 hours after the baseline measurement, the patient's hypotension was not detected during the infusion. The next morning (22 hours after completion of the valproate sodium infusion), divalproex sodium 1000 mg orally once daily was initiated as maintenance therapy. The patient's blood pressure reached a nadir of 82/44 mm Hg. The hypotension was treated initially with intravenous fluid hydration with normal saline, but the blood pressure correction was transient using this approach. The patient remained hypotensive for 3 days. The hypotension was ultimately found to be self-limited, and the patient was asymptomatic throughout his hospital stay. The patient's Naranjo adverse drug reaction probability scale score was 6, indicating that the relationship between valproate sodium infusion and hypotension was probable. Conclusion: In this case report, infusion of valproate sodium at a rate of 14 mg/min was a probable cause of hypotension in a 75-year-old man.

An unusual cause of hypotension and abnormal electrocardiogram (ECG) — scombroid poisoning

Abstract Scombroid fish or histamine food poisoning is an illness typically associated with fish consumption, rarely encountered and reported in Europe. Symptoms develop quickly and resemble an allergic reaction. This paper reports three cases of severe scombroid poisoning in previously healthy patients, which presented diffuse macular erythema, hypotension, palpitations, and abnormal electrocardiogram (ECG). All patients required intensive care, with a complete resolution of symptoms and ECG changes within 24 hours. This is the first Romanian report of scombroid poisoning, emphasizing that medical personnel should be aware of this condition, because symptoms and ECG changes often lead to confusion with other diseases.