Episodes Of Arterial Hypotension Research Articles

Severe course of leptospirosis: A case report

This study describes a clinical case of severe leptospirosis. Patient K., was admitted to the neurosurgical department on November 26, 2023, with a diagnosis of “Closed craniocerebral injury dated 22.11.2023. Severe brain injury. Linear fracture of the occipital bone. Eyelid hematoma. An abrasion of the upper eyelid on the right.” On November 29, 2023, an objective examination drew attention to an increase in body temperature to 39.5°C, subictericity of the sclera and skin, and conjunctival injections. Hemorrhagic rash appeared on the skin of the trunk and limbs. The hemodynamics was unstable, with episodes of arterial hypotension. Laboratory examination revealed mild anemia, signs of hepatic–renal insufficiency, hyperbilirubinemia, and increased concentrations of creatine phosphokinase, C-reactive protein, and procalcitonin. Fluctuations in hepatic–renal insufficiency and levels of creatine phosphokinase and procalcitonin increased. In addition, the differential diagnostic search aimed at identifying the following infectious diseases: hemorrhagic fever with renal syndrome, leptospirosis, malaria, and viral hepatitis. IgM to Leptospira interrogans were detected (December 11, 2023). The patient received antibacterial therapy, extracorporeal detoxification, artificial ventilation, infusion therapy, and correction of the hemostasis system. With the complex treatment, the patient’s condition stabilized, and the patient was discharged from the hospital on the 61st day with restoration of health.

Mixed infection with COVID-19 and tropical malaria (case report)

This article describes a clinical case of mixed infection with COVID-19 and tropical malaria. Patient Z., 37 years old, arrived from the Central African Republic with a diagnosis of New coronavirus infection COVID-19, confirmed (PCR RNA SARS-CoV-2+ from January 27, 2022) mild form. During an objective examination, the subictericity of the sclera and skin integument attracted attention. During thermometry, an increase in body temperature to 39.0C was found. Consciousness at the level of somnolence was observed. Hemodynamics was unstable, with episodes of arterial hypotension; heart rate was 96 beats per minute. Respiratory rate was 24 breaths in 1 minute, SpO2 95%, and with inspiratory dyspnea. According to the patients laboratory study results, severe thrombocytopenia, apparent signs of hepatic and renal insufficiency, hyperbilirubinemia, increased concentrations of C-reactive protein, and procalcitonin were revealed. A differential diagnostic search was performed between acute viral hepatitis and malaria. Blood microscopy revealed young trophozoites of Plasmodium falciparum (++++) using the thick drop method. Antimalarial therapy with Malacur was prescribed, which was then replaced with parenteral Quinine followed by mefloquine. In parallel, extracorporeal detoxification operations were performed. The patients condition was stabilized against adequate etiotropic therapy and complex intensive care measures. On the 40th day, the patient was discharged restored health.
 The purpose of demonstrating a clinical case is to attract increased attention to the problem of imported cases of malaria, which, when combined with COVID-19 infection, may remain unrecognized for a long time, especially in cases where the diagnosis of COVID-19 receives rapid laboratory confirmation.
 Adequate and timely antimalarial therapy, including a complex of intensive care measures supplemented with extracorporeal detoxification methods, is the basis for a successful outcome in patients with severe malaria with the development of severe complications.

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.

Intermittent hemodiafiltration as a down-step transition therapy in patients with acute kidney injury admitted to intensive care unit who initially underwent continuous venovenous hemodiafiltration.

Continuous renal replacement therapies (CRRT) are initially employed in patients with acute kidney injury (AKI) in ICU setting. After the period of serious illness, hemodialysis is usually used as a mode of transition from CRRT. Intermittent hemodiafiltration (HDF) is not commonly applied in this scenario. To evaluate the feasibility of using HDF as transition therapy after CVVHDF in critically patients with AKI. An observational and prospective pilot study was conducted in ICU patients with dialysis-requiring AKI. Patients were initially treated with CVVHDF and, after medical improvement, those who still needed renal replacement therapy were switched to HDF treatment. Ten Patients underwent 53 HDF sessions (mean of 5.3 sessions/patient). The main cause of renal dysfunction was sepsis (N = 7; 70%). The APACHE II mean score was 27.6 ± 6.9. During HDF treatment, the urea reduction ratio was 64.5 ± 7.5%, for β-2 microglobulin serum levels the percentage of decrease was 42.0 ± 7.8%, and for Cystatin C was 36.2 ± 6.9%. Five episodes of arterial hypotension occurred (9.4% of sessions). There were 20 episodes of electrolytic disturbance (37.7% of sessions), mainly hypophosphatemia. No pyrogenic or suggestive episode of bacteremia was observed. Hemodiafiltration was safe and efficient to treat critically ill patients with acute kidney injury during the transition phase from continuous to intermittent dialysis modality. Special attention should be paid regarding the occurrence of electrolytic disturbance, mainly hypophosphatemia.

Hypotensive episodes on program hemodialysis during dialysis procedure: modern approach for diagnostics, prophylaxis and correction

The study objective is to evaluate the effectiveness of different approaches to correction and prevention of arterial hypotension episodes in patients undergoing long-term hemodialysis (HD). Materials and methods. The study included 35patients undergoing long-term hemodialysis in the dialysis center. In all patients, automatic non-invasive measurement of arterial pressure (AP) was performed using a built-in option of the “artificial kidney” device. Prior to the study, all patients underwent clinical test with evaluation of “dry weight” and bioelectrical impedance analysis. Crossover design was used in the study: at the beginning, hypotensive episodes were corrected in all patients using the standard method (the first 4 hemodialysis procedures); then during the following 4 procedures in addition to standard methods a computer algorithm automatically controlling ultrafiltration rate using an automatic system of pressure control (ASPC) with constant AP monitoring (AP was measured prior to hemodialysis and after it and at least 1 time in the first 5 min of the procedure; from the 4h procedure onwards, intervals were determined by the algorithm automatically) was used. Values of mean AP during hemodialysis procedures for the whole monitoring period were analyzed. The duration of the study was 3 weeks for all patients. Results . Mean pre-dialysis systolic and diastolic AP in the patients for the standard approach was 124.6 ± 27.7 and 74.5 ± 21.1 mm Hg, post-dialysis AP was 114.4 ± 24.4 and 71.3 ± 16.3 mm Hg, respectively. For ASPC, pre-dialysis and post-dialysis AP was statistically significantly higher than for the standard approach: 133.2 ± 21.3 and 79.3 ± 15.8 mm Hg (p <0.001; p = 0.009), 125.7 ± 23.9 and 75.9 ± 18.3 mm Hg (p <0.001; p <0.001). Detailed analysis of intra-dialysis AP measured during the standard approach showed that it was 110.2 ± 17.3 and 68.3 ± 13.9 mm Hg. Using ASPC, intra-dialysis AP was significantly higher: 124 ± 20.5 and 75.9 ± 14.2 mm Hg (p = 0.03; p = 0.02). Mean AP was also higher: 82.5 ± 13.9 mm Hgfor the standard approach versus 91.5 ± 15.6 mm Hg (p = 0.01) for ASPC. The ultrafiltration rates were slightly higher without ASPC (8.2 ml/kg/hour vs. 7.9 ml/kg/hour). Therefore, it was shown that the use of ASPC in addition to standard methods of hypotension correction is effective and safe. There weren»t any significant differences in «hemodialysis-dose effectiveness» (Kt/V) in both groups; however, in the ASPC group target values of inorganic phosphorus in serum (for a dialysis patient) were reached which is one of the most important parameters of hemodialysis adequacy. Concentration of inorganic phosphorus for the ultrafiltration control algorithm was 1.5 mmol/l, for the standard dialysis program — 1.8 mmol/l which shows benefits of ASPC. This data didn»t reach statistical significance (p = 0.07) which likely can be attributed to a low number of observations. Conclusion . Intra-dialysis hypotension with high ultrafiltration rates is a frequent and potentially dangerous complication of hemodialysis which negatively affects patients» long-term prognosis mainly due to an increase in cardiovascular morbidity and mortality. A new method for prevention and correction of hypotension using ASPC allows to decrease ultrafiltration rate on time preventing a hypotensive episode, decreasing its rates and improving attainment of AP target values (both pre- and post-dialysis) as well as intra-dialysis variation during dialysis procedure.

Prospective randomized multicenter study to demonstrate the benefits of haemodialysis without acetate (with citrate): ABC-treat Study. Acute effect of citrate

IntroductionDialysis fluid (DF), an essential element in hemodialysis (HD), is manufactured in situ by mixing three components: treated water, bicarbonate concentrate and acid concentrate. To avoid the precipitation of calcium and magnesium carbonate that is produced in DF by the addition of bicarbonate, it is necessary to add an acid. There are 2 acid concentrates that contain acetate (ADF) or citrate (CDF) as a stabilizer. ObjectiveTo compare the acute effect of HD with CDF vs. ADF on the metabolism of calcium, phosphorus and magnesium, acid base balance, coagulation, inflammation and hemodynamic stability. MethodsProspective, multicenter, randomized and crossed study, of 32 weeks duration, in patients in three-week HD, AK-200-Ultra-S or Artis monitor, 16 weeks with ADF SoftPac®, prepared with 3mmol/L of acetate, and 16 weeks with CDF SelectBag Citrate®, with 1mmol/L of citrate. Patients older than 18 years were included in HD for a minimum of 3 months by arteriovenous fistula. Epidemiological, dialysis, pre and postdialysis biochemistry, episodes of arterial hypotension, and coagulation scores were collected monthly during the 8 months of the study. Pre and post-dialysis analysis were extracted: venous blood gas, calcium (Ca), ionic calcium (Cai), phosphorus (P), magnesium (Mg) and parathyroid hormone (PTH) among others.ClinicalTrials.gov NCT03319680. ResultsWe included 56 patients, 47 (84%) men and 9 (16%) women, mean age: 65.3 (16.4) years, technique HD/HDF: 20 (35.7%)/36 (64.3%).We found differences (p<0.05) when using the DF with citrate (C) versus acetate (A) in the postdialysis values of bicarbonate [C: 26.9 (1.9) vs. A: 28.5 (3)mmol/L], Cai [C: 1.1 (0.05) vs. A: 1.2 (0.08)mmol/L], Mg [C: 1.8 (0.1) vs A: 1, 9 (0.2)mg/dL] and PTH [C: 255 (172) vs. 148 (149)pg/mL]. We did not find any differences in any of the parameters measured before dialysis. Of the 4416 sessions performed, 2208 in each group, 311 sessions (14.1%) with ADF and 238 (10.8%) with CDF (p<0.01), were complicated by arterial hypotension. The decrease in maximum blood volume measured by Hemoscan® biosensor was also lower [−3.4 (7.7) vs −5.1 (8.2)] although without statistical significance. ConclusionDialysis with citrate acutely produces less postdialysis alkalemia and significantly modifies Ca, Mg and PTH. CDF has a positive impact on hemodynamic tolerance.

Nurse understaffing is associated with adverse events in postanaesthesia care unit patients.

To investigate the associations between nurse staffing and the incidence and severity of hypoxaemia, arterial hypotension and bradycardia of postoperative patients during their postanaesthesia care unit stay. Nurse understaffing has been associated with adverse patient outcomes in a variety of hospital settings. In the postanaesthesia care unit, nursing shortage is common and can be related to compromised prevention, detection and treatment of adverse events. Observational, single-centre, prospective study that adhered to Strengthening the Reporting of Observational studies in Epidemiology checklist (see Supporting information Appendix S1); 2,207 patients admitted to the postanaesthesia care unit of a tertiary care hospital over a 5-month period were enrolled. Incidence of hypoxaemia (arterial oxygen saturation <95%), arterial hypotension (systolic blood pressure <90mmHg) and bradycardia (heart rate <50 beats per minute), along with episode severity, was recorded. Patients were classified into three groups as follows: sufficient staffing, low and high understaffing. Risk for hypoxaemia, arterial hypotension and bradycardia was adjusted according to patient, anaesthesia and operation characteristics. The incidence of hypoxaemia was significantly higher in the high understaffing group patients, while the incidence of arterial hypotension was significantly higher in both low and high understaffing group patients, compared to sufficient staffing group ones. In the high understaffing group patients, hypoxaemia and arterial hypotension episodes were of significantly higher severity. These associations between hypoxaemia and arterial hypotension and postanaesthesia care unit understaffing indicate that care quality and patient safety can be compromised in case patient acuity is not matched with sufficient nursing resources. Higher incidence of hypoxaemia and arterial hypotension advocates for the prevention of imbalances between patient number and care demands and the number of available nurses.

Estudio prospectivo aleatorizado multicéntrico para demostrar los beneficios de la hemodiálisis sin acetato (con citrato): Estudio ABC-treat. Efecto agudo del citrato

IntroductionDialysis fluid (DF), an essential element in hemodialysis (HD), is manufactured in situ by mixing three components: treated water, bicarbonate concentrate and acid concentrate. To avoid the precipitation of calcium and magnesium carbonate that is produced in DF by the addition of bicarbonate, it is necessary to add an acid. There are 2 acid concentrates that contain acetate (ADF) or citrate (CDF) as a stabilizer. ObjectiveTo compare the acute effect of HD with CDF vs. ADF on the metabolism of calcium, phosphorus and magnesium, acid base balance, coagulation, inflammation and hemodynamic stability. MethodsProspective, multicenter, randomized and crossed study, of 32 weeks duration, in patients in three-week HD, AK-200-Ultra-S or Artis monitor, 16 weeks with ADF SoftPac®, prepared with 3mmol/L of acetate, and 16 weeks with CDF SelectBag Citrate®, with 1mmol/L of citrate. Patients older than 18 years were included in HD for a minimum of 3 months by arteriovenous fistula. Epidemiological, dialysis, pre and postdialysis biochemistry, episodes of arterial hypotension, and coagulation scores were collected monthly during the 8 months of the study. Pre and post-dialysis analysis were extracted: venous blood gas, calcium (Ca), ionic calcium (Cai), phosphorus (P), magnesium (Mg) and parathyroid hormone (PTH) among others.ClinicalTrials.gov NCT03319680. ResultsWe included 56 patients, 47 (84%) men and 9 (16%) women, mean age: 65.3 (16.4) years, technique HD/HDF: 20 (35.7%)/36 (64.3%).We found differences (p<0.05) when using the DF with citrate (C) versus acetate (A) in the postdialysis values of bicarbonate [C: 26.9 (1.9) vs. A: 28.5 (3) mmol/L], Cai [C: 1.1 (0.05) vs. A: 1.2 (0.08) mmol/L], Mg [C: 1.8 (0.1) vs A: 1, 9 (0.2) mg/dL] and PTH [C: 255 (172) vs. 148 (149) pg/mL]. We did not find any differences in any of the parameters measured before dialysis. Of the 4,416 sessions performed, 2,208 in each group, 311 sessions (14.1%) with ADF and 238 (10.8%) with CDF (p<0.01), were complicated by arterial hypotension. The decrease in maximum blood volume measured by Hemoscan® biosensor was also lower [−3.4 (7.7) vs −5.1 (8.2)] although without statistical significance. ConclusionDialysis with citrate acutely produces less postdialysis alkalemia and significantly modifies Ca, Mg and PTH. CDF has a positive impact on hemodynamic tolerance.

Clevidipine for hypertension treatment in pheochromocytoma surgery

Pheochromocytoma is a catecholamine-producing tumour and laparoscopic adrenalectomy is its treatment of choice. During pneumoperitoneum insufflation and tumour handling there is a high risk of massive catecholamine release and hypertensive crisis. After tumour excision, severe arterial hypotension is a common effect, due to relative vasodilation and the residual effect of antihypertensive drugs. We report the case of a patient with pheochromocytoma who was treated with laparoscopic adrenalectomy. During surgical manipulation there was a sudden hypertensive peak that could be controlled quickly with clevidipine infusion. After tumour resection, clevidipine perfusion was stopped and there were no arterial hypotension episodes. Clevidipine is a new intravenous calcium antagonist with rapid onset of action and short half-life that has no residual effect and does not produce arterial hypotension after tumour resection. For these reasons, it can be a first-choice drug for this kind of surgery.

The prognostic value of transient arterial hypertension in patients with chronic heart insufficiency and preserved left ventricular ejection function

The study included 169patients (74 men and 95 women) with CHI (mean age 56,3±10,9 yr). All of them had PEF higher than 50%. 105 patients had FCII CHI, 64 ones FCIII CHI. Stage IIA was documented in 136 and stage IIB in 33 patients. Duration of the study 24 months. The combined end point included non-fatal myocardial infarction and cardiovascular death. Arterial hypotension at office AP was diagnosed in 16 (9,5%) patients, transient arterial hypotension based at 24 hr AP monitoring in 104 (61,6%) patients. A total of 8 combined end points were documented during the study period. All these patients had transient systole-diastolic and/or systolic arterial hypotension . No myocardial infarction or lethal outcome developed in CHI patients without episodes of arterial hypotension (x=4,28, р=0,04). 24 hr AP monitoring in CHI-PEF patients permits to significantly increase the frequency of detection ofpotentially dangerous changes of AP. Transient arterial pressure occurs in 61.6% of the FCII-III CHI-PEF patients. Transient systole-diastolic arterial hypotension significantly increases the risk of non-fatal myocardial infarction and cardiovascular death in CHI-PEF patients

Transient arterial hypotension in hypertensive patients: interrelations with risk factors and target organ damage

To investigate the prevalence, clinical manifestation and hemodynamic parameters of short-time arterial hypotension episodes in relation to risk factors and target organ damage in elderly hypertensive patients. Design and methods. 260 hypertensive patients aged 75,0 (68-79) years were investigated. The ambulatory blood pressure monitoring (ABPM) was performed. In the ABPM curves the extreme systolic BP falls were identified, and the hemodynamic parameters and circadian structure of these episodes were analyzed. Antihypertensive treatment regimens, prevalence of risk factors, target organ damage and established cardiovascular diseases were compared in patients with and without BP extreme falls. Results and conclusions. We detected 63 short-time BP falls in 48 (18,5 %) hypertensive patients. Most of them (68,8 %) were asymptomatic. Two time intervals of most frequent BP falls incidence were found, including early morning and postprandial hours. BP falls were associated with the total cholesterol level and left ventricular mass increase, reduced glomerular filtration rate, previous myocardial infarction and angiotensin converting enzyme inhibitors administration. These facts should be taken into account when antihypertensive therapy is administered to elderly subjects.

Clonidine as an Adjuvant to Intrathecal Local Anesthetics for Surgery: Systematic Review of Randomized Trials

Clonidine is added to intrathecal local anesthetics to improve intraoperative analgesia and to increase the duration of sensory and motor block. The aim of this systematic review is to quantify beneficial and harmful effects of clonidine when used as an adjuvant to intrathecal local anesthetics for surgery. We included data from 22 randomized trials (1,445 patients) testing a large variety of doses of clonidine, added to intrathecal bupivacaine, mepivacaine, prilocaine, or tetracaine. Clonidine 15 to 150 microg prolonged in a linear, dose-dependent manner, the time to 2 segment regression (range of means, 14 to 75 minutes) and the time to regression to L2 (range of means, 11 to 128 minutes). The time to first analgesic request (median 101 minutes, range 35 to 310) and of motor block (median 47 minutes, range 6 to 131) was prolonged without evidence of dose-responsiveness. Time to achieve complete sensory or motor block, and extent of cephalic spread remained unchanged. There were fewer episodes of intraoperative pain with clonidine (relative risk, 0.24; 95% confidence interval [CI], 0.09-0.64; number needed to treat, 13) but more episodes of arterial hypotension (relative risk, 1.81; 95% CI 1.44-2.28; number needed to harm, 8) without evidence of dose-responsiveness. The risk of bradycardia was unchanged. This study may serve as a rational basis to help clinicians decide whether or not to combine clonidine with an intrathecal local anesthetic for surgery. The optimal dose of clonidine, however, remains unknown.

Effects of Porta-Systemic Shunting and Ammonia Infusion on Cerebral Blood Flow Autoregulation in the Rat

Portacaval shunting of blood, hyperammonemia, and impaired cerebral blood flow (CBF) autoregulation are assumed to be involved in the development of high intracranial pressure (ICP) in liver failure. In this study, we determined whether CBF autoregulation is impaired by portacaval anastomosis and hyperammonemia. Four groups of pentobarbital-sedated and mechanically ventilated rats were investigated after construction of a portacaval anastomosis or following sham operation. Half of the rats received either infusion of ammonia (55 micromol/kg/minute) or saline for 180 minutes. Arterial pressure and ICP was monitored, and lower limit of CBF autoregulation was determined. Lower limit of autoregulation was preserved in all four groups of studied animals; vehicle lower limits were 40 +/- 2.3, 40 +/- 2, 54 +/- 1, and 51 +/- 3 mmHg in sham-operated rats, sham rats receiving ammonia infusion, portacaval anastomosis-vehicle animals, and portacaval anastomosis-hyperammonemia animals, respectively. The lower limit of auto regulation was higher in portacaval anastomosis rats (p = 0.01) compared to the sham- operated rats. Hyperammonemia in portacaval anastomosis rats did not aggravate this. Portacaval anastomosis and hyperammonemia does not impair the lower limit of CBF autoregulation. However, shunting of portal blood to the systemic circulation shifts the lower limit of autoregulation to higher blood pressure values, making the brain more sensitive to episodes of arterial hypotension.

Efficacy and safety of a new whole-blood low-density lipoprotein apheresis system (Liposorber D) in severe hypercholesterolemia.

Low-density lipoprotein (LDL) apheresis is an extracorporeal modality to lower LDL cholesterol. While most of the devices eliminate LDL particles from plasma, a recently introduced whole-blood perfusion column (DALI) adsorbs lipoproteins directly from whole blood. We investigated the efficacy and safety of a new whole-blood LDL apheresis system (Liposorber D) in 10 patients with severe hypercholesterolemia in a multicenter trial. In 93 LDL aphereses, the mean reduction in LDL cholesterol and lipoprotein(a) was 62.2 +/- 11.5% and 55.6 +/- 16.9%, respectively (P < 0.01). If hemodilution during apheresis was considered, the reductions were 58.0 +/- 10.9 and 55.3 +/- 10.9%, respectively (P < 0.01), while high-density lipoprotein (HDL) cholesterol did not change significantly. Three mild episodes of hypocalcemia and two mild episodes of arterial hypotension were observed; however, LDL apheresis could be continued in each case. In conclusion, the new whole-blood LDL apheresis with Liposorber D is a safe, simple, and useful modality to reduce LDL cholesterol and lipoprotein(a) in cardiovascular high-risk patients.

Hiperreflexia autonômica em gestante tetraplégica: relato de caso

Complications of pregnant patients with medullary injury include urinary infection, renal stones, anemia, decubitus ulcers, muscle spasms, sepsis, uterine hyperactivity and autonomic hyperreflexia. Autonomic hyperreflexia is the most severe anesthetic complication and should, before all, be prevented. It is often developed in patients with medullary transection at the level of the 5th to 7th thoracic vertebra or above. This report aims at presenting a case of tetraplegic pregnant patient with injury at the level of the 6th cervical vertebra, submitted to Cesarean section under continuous epidural anesthesia with 0.25% bupivacaine without vasoconstrictor associated to fentanyl.Caucasian, tetraplegic primiparous term patient, 39 weeks of gestational age, 22 years old, 63 kg, 168 cm, physical status ASA II, admitted for elective Cesarean section. Patient reported spinomedullary trauma at C6, three years ago. After previous hydration with 1500 ml saline, epidural anesthesia was induced with medial puncture at L3-L4 interspace with the patient in the lateral position, disposable 17G Tuohy needle and without previous local infiltration anesthesia. Immediately after needle insertion, there was adjacent paravertebral muscles contraction, blood pressure increase (BP = 158 x 72 mmHg) and heart rate increase (HR = 90 bpm). Patient, however, did not refer pain. Needle was removed and local anesthesia was induced. Epidural block proceeded with 20 ml of 0.25% bupivacaine without vasoconstrictor associated to 100 microg spinal fentanyl and epidural catheter insertion in the cephalad direction (3 to 4 cm). Surgery went on without intercurrences with no need for blockade complementation. There were two arterial hypotension episodes in the first 24 postoperative hours, which were treated with lactated Ringers solution. Epidural catheter was maintained for 48 hours. Patient was discharged three days after.For paraplegic or tetraplegic pregnant patients, continuous epidural anesthesia with low local anesthetic concentration without vasoconstrictor and associated to fentanyl is a good indication for instrumented or not vaginal delivery, and Cesarean sections to prevent autonomic hyperreflexia. It is also important that the epidural catheter remains for at least 24 hours after delivery to block sympathetic afference in case a crisis is triggered.

Paraplegia following intracord injection during attempted epidural anesthesia under general anesthesia

Background and Objectives. A case of permanent paraplegia is reported following attempted epidural anesthesia for a total knee replacement in a 62-year-old woman with a history of lumbar laminectomy for a prolapsed intervertebral disc. Methods. Epidural puncture was attempted during general anesthesia and neuromuscular block. Results. After four unsuccessful attempts, an epidural catheter was inserted above the upper end of the laminectomy scar. Several episodes of arterial hypotension occurred intraoperative and postoperative. Operative blood loss was minimal, and no bone glue was used. The patient awoke paraparetic with a sensory level of anesthesia to T5 bilaterally. MRI revealed an air bubble in the cord at T10 and a region of increased T 2-weighted signal in the anterior aspect of the spinal cord between T4 and T5, consistent with infarction. Conclusion. Standards of management are discussed in relation to this case.

Effects of THAM and sodium bicarbonate on intracranial pressure and mean arterial pressure in an animal model of focal cerebral injury.

Episodes of arterial hypotension are associated with an increased mortality in head injury patients. Rapid infusion of sodium bicarbonate in such patients may cause hypotension and elevate intracranial pressure. Therefore, we examined the effects of tromethamine (THAM) versus bicarbonate on intracranial pressure and blood pressure in a model of focal cerebral injury. THAM is a buffer that in previous studies has been shown to lower intracranial pressure. After creation of a cryogenic lesion in 13 New Zealand white rabbits, equivalent infusions (15 s duration) of sodium bicarbonate and THAM (2 mEq/kg) were administered sequentially to each animal in random order. Rapid infusion was chosen to simulate the administration of these drugs during a resuscitation. THAM infusion was associated with a significantly lower intracranial pressure and blood pressure than bicarbonate. The fall in blood pressure was great enough that cerebral perfusion pressure after THAM infusion was significantly lower than after bicarbonate infusion. In this model of cerebral injury, rapid infusion of THAM offered no therapeutic advantage over bicarbonate.

Nylidrin HCL: A beta-sympathetic stimulant in the management of haemorrhagic shock

In the assessment of classical haemorrhagic shock in twenty-two dogs, thirteen of them treated with Nylidrin HC1, ten survived extended episodes of arterial hypotension down to a mean arterial pressure of 40 mm.Hg. Of nine control animals (untreated), five survived the re-infusion period. In the course of our study, Nylidrin HC1 displayed two important pharmacodynamic effects:

FUNCTIONAL CARDIAC DETERIORATION DURING DEVELOPMENT OF HEMORRHAGIC CIRCULATORY DEFICIENCY.

A massive infusion test has been devised to evaluate the functional capacity of the heart. In five dogs extensive surgical procedures followed by episodes of arterial hypotension at 30 mm Hg and lasting 90 minutes caused severe cardiac incapacity, which was demonstrated by failure of rate of cardiac work to increase throughout the infusion together with a large rise in left atrial pressure. This incapacity was not evident in tests made immediately after the hypotensive episode. The damage became more and more severe in tests performed 90 and 150 minutes after the end of the hypotension even though mean arterial pressure was maintained at 100 mm Hg. Operated control dogs did not show cardiac deterioration in tests timed as above. The rate of cardiac work continued to increase throughout the infusion with a relatively small rise of left atrial pressure. In a series of five dogs, flow to the coronary arteries and to those supplying the head and forelimbs was maintained by normal blood pressure while the rest of the animal was made hypotensive for 90 minutes. The arterial pressure in the whole animal was then returned to an average level of 100 mm Hg. Tests made at intervals after the hypotension showed equivocal evidence of cardiac deterioration. In another series of four dogs, prepared as above, the partial hypotension lasted 150 minutes before the arterial pressure was returned to normal. Tests at intervals after hypotension showed cardiac damage in all the animals and severe damage in three. Evidence is presented indicating that the peripheral vascular bed had deteriorated functionally as a result of 150 minutes of partial hypotension.