Fall In Systolic Blood Pressure Research Articles

#2990 Prevalence and risk factors of altered control of BP during the night in a large hemodialysis population investigated by 48 hours ABPM

Abstract Background and Aims Altered BP control during the night (non-dipping, reverse dipping and nocturnal hypertension) is recognized as a powerful risk factor for death and CV events in the hemodialysis (HD) population. However, these alterations have been described in relatively small studies and the epidemiology and risk factors for subtypes non-dipping and nocturnal hypertension are still poorly characterized in the current literature. We investigated the problem in a large Registry (The EURECAm Registry) that is the sole that adopted state of the art 48 h ABPM recording in the HD population. Method We included in this analysis 534 HD patients, enrolled in 7 centers, led by members of the EURECA-m working group, in 3 European countries. 48 h ABPM was measured by using well validated instruments (AAMI/ESH/ISO). As recommended by the European Society of Hypertension guidelines, recordings were made at 15-minute intervals during the day and 30 minutes during the night. Hypertension was defined as 48 h blood pressure (BP) >130/80, nocturnal hypertension as a nighttime BP >120/70 mmHg, non-dipping as a night/day systolic BP fall <10% and reverse dipping as a night/day ratio >1. Results Among 534 HD patients, 317 were hypertensive and. 217 normotensive. As many as 274 patients were non-dippers (51%), 32% were reverse dippers, and 381 (71%) had nocturnal hypertension. Of note, forty-one per cent of non-dippers, 37% of reverse dippers and 19% of patients with nocturnal hypertension were normotensives. As expected, the majority of reverse dippers (87%) had frank nocturnal hypertension. In a combined analysis of non-dippers and reverse dippers, as compared to dippers, these patients more frequently exhibited atrial fibrillation and had lower Heart Rate both pre-dialysis (72± 11 vs 77±13 bpm, P = 0.004) and post-dialysis (74± 13 vs 78±14 bpm, P = 0.03) and lower serum albumin (3.9±0.4 vs 4.0±0.3 g/dL, P = 0.02) but did not differ for age and gender. Conclusion In a large cohort of HD patients investigated by the state-of-the-art technique, 48 h ABPM alterations in the nocturnal BP profile were almost universal, and nocturnal hypertension was the more prevalent alteration, followed by non-dipping and reverse dipping. These alterations were independent of age and gender. Long-term, granular follow-up analyses are warranted to identify the prognostic value of these alterations.

The contribution of sodium reduction and potassium increase to the blood pressure lowering observed in the Salt Substitute and Stroke Study.

The Salt Substitute and Stroke Study (SSaSS) demonstrated significant reductions in systolic blood pressure (SBP), and the risk of stroke, major cardiovascular events and total mortality with the use of potassium-enriched salt. The contribution of sodium reduction versus potassium increase to these effects is unknown. We identified four different data sources describing the association between sodium reduction, potassium supplementation and change in SBP. We then fitted a series of models to estimate the SBP reductions expected for the differences in sodium and potassium intake in SSaSS, derived from 24-h urine collections. The proportions of the SBP reduction separately attributable to sodium reduction and potassium supplementation were calculated. The observed SBP reduction in SSaSS was -3.3 mmHg with a corresponding mean 15.2 mmol reduction in 24-h sodium excretion and a mean 20.6 mmol increase in 24-h potassium excretion. Assuming 90% of dietary sodium intake and 70% of dietary potassium intake were excreted through urine, the models projected falls in SBP of between -1.67 (95% confidence interval: -4.06 to +0.73) mmHg and -5.33 (95% confidence interval: -8.58 to -2.08) mmHg. The estimated proportional contribution of sodium reduction to the SBP fall ranged between 12 and 39% for the different models fitted. Sensitivity analyses assuming different proportional urinary excretion of dietary sodium and potassium intake showed similar results. In every model, the majority of the SBP lowering effect in SSaSS was estimated to be attributable to the increase in dietary potassium rather than the fall in dietary sodium.

Carotid blood flow changes following a simulated end-inspiratory occlusion maneuver measured by ultrasound can predict hypotension after the induction of general anesthesia: an observational study

BackgroundThe primary purpose of this study was to investigate the predictive value of alterations in cervical artery hemodynamic parameters induced by a simulated end-inspiratory occlusion test (sEIOT) measured by ultrasound for predicting postinduction hypotension (PIH) during general anesthesia.MethodsPatients undergoing gastrointestinal tumor resection under general anesthesia were selected for this study. Ultrasound has been utilized to assess hemodynamic parameters in carotid artery blood flow before induction, specifically focusing on variations in corrected flow time (ΔFTc) and peak blood flow velocity (ΔCDPV), both before and after sEIOT. Anesthesia was induced by midazolam, sufentanil, propofol, and rocuronium, and blood pressure (BP) and heart rate (HR) were recorded within the first 10 min following endotracheal intubation. PIH was defined as fall in systolic blood pressure (SBP) or mean arterial pressure (MAP) by > 30% of baseline or MAP to < 60 mm Hg.ResultsThe area under the receiver operating characteristic curves (AUC) for carotid artery ΔFTc was 0.88 (95%CI, 0.81 to 0.96; P < 0.001), and the optimal cutoff value was -16.57%, with a sensitivity of 91.4% and specificity of 77.60%. The gray zone for carotid artery ΔFTc was -16.34% to -15.36% and included 14% of the patients. The AUC for ΔCDPV was 0.54, with an optimal cutoff value of -1.47%. The sensitivity and specificity were calculated as 55.20% and 57.10%, respectively.ConclusionThe corrected blood flow time changes in the carotid artery induced by sEIOT can predict hypotension following general anesthesia-induced hypotension, wherein ΔFTc less than 16.57% is the threshold.Trial registrationChinese Clinical Trial Registry (www.chictr.org.cn; 20/06/2023; ChiCTR2300072632).

Comparison of Equivalent Doses of Intrathecal Hyperbaric Levo-bupivacaine and Hyperbaric Bupivacaine for Caesarean Section: A Prospective Randomised Double-Blind Study

Introduction: Subarachnoid Block (SAB) with Hyperbaric Bupivacaine (HB) is the most common anaesthetic technique for Lower Segment Caesarean Section (LSCS). Levo-bupivacaine, an enantiomer of racemic bupivacaine, has been developed to provide anaesthesia with the same effectiveness but with better haemodynamic stability. Aim: To compare the effectiveness of hyperbaric levobupivacaine to HB in achieving sensory and motor blocks in Caesarean Section(CS) using equivalent doses. Materials and Methods: Eighty parturients aged 18-38 years with no co-morbidities were randomly divided into two groups receiving equivalent doses of HB and hyperbaric levobupivacaine for SAB. The effectiveness of the two drugs was compared in terms of the time taken to achieve sensory and motor blocks, as well as the time for block regression for two segments for sensory block and the return of motor block assessed by the ability to flex the ankle joint. Adverse events such as a fall in Systolic Blood Pressure (SBP) and the dose of vasopressor were noted for the two groups. Results: The time taken to attain a T6 dermatomal block level was 2.43±1.00 and 2.80±1.51 (p-value 0.08) for the bupivacaine and levo-bupivacaine groups, respectively. Complete motor block of the lower limb was achieved in 4.85±1.67 and 5.15±1.82 (p-value 0.53). However, the time to 2-segment regression for sensory block was significantly faster in the levo-bupivacaine group than in the bupivacaine group (125.9±28.56 minutes and 109.13±28.84 minutes, respectively, p-value 0.009). Regression from motor block was also found to be highly statistically significant (158.38±34.92 minutes for bupivacaine and 138.75±25.71 minutes for the levobupivacaine group, p-value 0.006). Spinal-induced hypotension was comparable in both groups, but the bupivacaine group needed a much higher repetition of dose of vasopressor than the levo-bupivacaine group. Conclusion: Levo-bupivacaine is comparable to its racemic isomer bupivacaine in achieving anaesthesia when administered Intrathecally (IT) for CS. However, with equivalent doses, the duration of action is significantly shorter with hyperbaric levobupivacaine. Dose adjustment might be required with hyperbaric levo-bupivacaine based on the duration of the surgery. Haemodynamic stability is also similar with both drugs.

Comparison between Bispectral Index-guided Propofol Induction and Clinically-guided Induction in Adult Hypertensive Patients Undergoing Elective Laparoscopic Surgery: A Randomised Controlled Study

Introduction: Traditional clinical endpoints for propofol induction often led to unintentional overdose, leading to haemodynamic instability, delayed recovery, and other complications. Bispectral Index monitoring could potentially prevent undesired haemodynamic changes like hypotension. Aim: To compare BIS-guided propofol induction with clinically guided propofol induction. Materials and Methods: A randomised controlled study was conducted in the Department of Anaesthesiology at Apollo Hospitals, Guwahati, Assam, India, between December 7, 2020 and December 6, 2021, on adult hypertensive patients undergoing elective laparoscopic surgeries. The Clinical Group (n=30) received propofol induction based on clinical guidance, and the Bispectral index group (n=30) underwent Bispectral Index (BIS) guided induction. Demographic variables, the dose of drug required for BIS 50, and the total amount of drug consumed were recorded. After the administration of each dose, Systolic BP (SBP), Diastolic BP (DBP), Mean Arterial BP (MAP), Heart Rate (HR), and SpO2 were recorded. Frequencies and percentages were used to describe qualitative data, whereas the mean and standard deviation were used to express quantitative data. Parametric tests included unpaired t-tests for comparison between groups. A p-value of &lt;0.05 was considered statistically significant. Results: Total 60 patients with 30 in each group, were studied. There was a steady fall in SBP, DBP, and MAP with successive incremental doses of 0.5 mg in both groups. Mean SBP was comparable between the two groups at dosages of 1 mg/ kg, 1.5 mg/kg, and 2 mg/kg. At 2.5 mg/kg, the clinical group had a significantly lower SBP (p=0.0001). Mean DBP was comparable in both groups at doses of 2 mg/kg and 2.5 mg/ kg but significantly lower in the BIS group at 1 mg/kg and at 1.5 mg/kg (p=0.003, p=0.01). Mean MAP was comparable at doses of 2 and 2.5 mg/kg but significantly lower in the BIS group at doses of 1 mg/kg and 1.5 mg/kg (p=0.007, p=0.02). Mean HR was comparable between the two groups at doses of 1 and 1.5 mg/kg. HR showed an increase in group CL and a gradual drop in group BIS with incremental doses. Mean HR was significantly lower in the group BIS at doses of 2 mg/kg and 2.5 mg/kg (p=0.001, p=0.001). The BIS group required a substantially lower total dose of propofol compared to the CL group (158.63±30.57 mg vs. 118.23±28.53 mg, p=0.0001). Conclusion: BIS-guided propofol induction leads to more stable haemodynamics during induction. It helps to titrate propofol administration, which, in turn, reduces the frequency of propofol overdose and its subsequent adverse effects on haemodynamic stability. The total dose of propofol consumed is also reduced.

Orthostatic hypotension in the elderly: Prevalence and its management by simple isometric limb tensing exercises.

Orthostatic hypotension (OH), an important cause of falls in the elderly, is grossly underdiagnosed. Our study aimed to determine the prevalence and associated factors of OH among the elderly attending a secondary care hospital. Furthermore, we assessed and compared the effectiveness of simple arm and leg tensing exercises, performed just prior to standing, to mitigate the orthostatic fall in blood pressure (BP) in elderly OH patients. A cross-sectional study screened elderly patients (≥65 years) for OH and recruited them into a randomized controlled trial (CTRI/2020/08/027182) of two parallel groups performing either arm tensing or leg tensing exercises just before standing up. We performed an interim analysis of the ongoing trial using paired t-test for within-group comparisons. Patients identified to have OH based on systolic or diastolic fall in BP were analyzed separately. Chi-square analysis compared the improvement in OH status between the two groups. Nineteen out of 186 screened elderly patients were diagnosed with OH (10.21%, 95% CI: 7.99-12.43). Arm exercise significantly reduced the orthostatic-induced fall in systolic and diastolic BP, while leg exercise effectively reduced only the systolic fall in BP among patients with OH. The proportion of patients with OH after arm exercise (20%) was significantly lower than after leg exercise (77.8%) (P = 0.023, Fischer's exact test). We found a 10.21% prevalence of OH in our elderly population. Furthermore, we found that simple isometric arm tensing exercise ameliorates the fall in BP on standing up in OH patients.

Effect of renal denervation on diastolic function in patients with resistant hypertension and type 2 diabetes mellitus

Aim: To assess the change in the left ventricular (LV) diastolic function (DF) in patients with resistant hypertension (RHTN) and type 2 diabetes mellitus (T2DM) during 6-month follow-up after renal denervation (RDN) according to echocardiography in conjunction with changes in hemodynamic parameters.Material and Methods. A single center prospective interventional study with renal denervation included 30 patients with RHTN and T2DM. All patients underwent measurement of office and 24-hour blood pressure (BP), echocardiography according to the standard method with an assessment of LV DF.Results. At 6 months after RDN, a significant antihypertensive effect was noted (p &lt; 0.05), as well as an improvement in LV DF in the form of a decrease in E/e` by 1 c.u. was observed in 50% (15) patients. A significant decrease in the average E/e` was documented (–1.3 [95% CI –2.55; –0.08], р = 0.038). There were no changes in the indexed volumes of the left atrium (р = 0.940). The baseline values of E/e` had correlation with the level of mean pulse BP 24h (r = 0.51, р = 0.001) in the absence of significant relationships with other ABPM parameters. A decrease in systolic BP 24h by 3 mm Hg and an increase in nocturnal systolic BP fall by 1.6% were accompanied by a decrease in the average E/e` by 1 unit. According to the ROC-analysis, baseline level of nocturnal systolic BP fall 5.5% or less associated with a decrease in the E/e` ratio by more than 1 unit.Conclusion. Renal denervation in patients with RHTN and T2DM is accompanied by a favorable effect on LV diastolic function during 6-month follow-up, closely related to the hemodynamic effects of the procedure such as a decrease in systolic and pulse BP 24h, as well as improvement in the circadian rhythm of BP.

Calculation of effective dose of phenylephrine bolus for treatment of post-spinal hypotension in pre-eclamptic patients undergoing caesarean section – a non-randomised controlled trial

BackgroundPatients with pre-eclampsia require smaller vasopressor doses compared with those with normotension for management of post-spinal hypotension during caesarean section. However, the literature has little evidence as to the phenylephrine dose required for patients with pre-eclampsia. MethodsFifty patients, with either pre-eclampsia or normotension, and developing post-spinal hypotension during caesarean section under spinal anaesthesia, were studied. Women in both groups did not receive prophylactic vasopressors. The first patient in each group received phenylephrine 50 µg to treat the first episode of hypotension, defined as fall of systolic blood pressure ≥20% from baseline or an absolute value <100 mmHg. If hypotension was corrected within one minute it was considered a ‘success’. The doses for the subsequent patients were determined by responses to all previous patients, according to a variation of Narayana’s rule for the up-down sequential allocation method. ResultsThe 95% effective dose (ED95) and 50% effective dose (ED50) of phenylephrine was 41.7 µg (95% CI 33.8 to 49.6 µg) and 29.1 µg (95% CI 26.0 to 32.2 µg) respectively in the pre-eclampsia group, and 64.9 µg (95% CI 54.1 to 75.7 µg) and 47.3 µg (95% CI 39.7 to 54.9 µg) respectively in the normotensive group. The proportionate reduction in phenylephrine dose ranged from 33% (95% CI 18 to 44%) to 40% (95% CI 19 to 52%). ConclusionPatients with pre-eclampsia may need a 33% to 40% reduction in the first phenylephrine bolus dose, compared with patients with normotension, for the treatment of the first episode of post-spinal hypotension.

Postural fall in systolic blood pressure is a useful warning sign in dengue fever

Background: Capillary leak is the hallmark of development of severe dengue. A rise in haematocrit has been a major warning sign in WHO guidelines. Postural hypotension, which could reflect the intravascular volume reduction in capillary leak has been noted as warning sign in CDC and Pan American Health Organisation guidelines. We evaluated the diagnostic accuracy of postural hypotension as a marker of development of severe dengue. Methods: 150 patients admitted with dengue fever were recruited in this prospective observational study. Diagnostic accuracy of conventional warning signs (abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, liver enlargement, increasing hematocrit with decreasing platelets) and postural hypotension was evaluated. Results: 23 (15.3%) subjects developed severe dengue. Multiple logistic regression analysis showed that ascites/pleural effusion and postural fall in systolic blood pressure of &gt;10.33% had odds ratio of 5.024(95%CI:1.11 – 22.75) and 11.369 (95% CI:2.27 – 56.87), respectively. Other parameters did not reach statistical significance. Sensitivity and specificity of ascites/pleural effusion were 82.6% and 88.2% for development of severe dengue whereas postural fall in systolic blood pressure had sensitivity and specificity of 87% and 82.7%. Conclusions: These findings present a strong case for including postural hypotension as a warning sign in patients with dengue fever, especially in resource limited settings.

#5537 GENETIC VARIABILITY IN THE PROSTAGLANDIN E2 PATHWAY IS RELATED TO SALT SENTIVITY IN TREATMENT-NAïVE HYPERTENSIVE PATIENTS

Abstract Background and Aims Hypertensive nephropathy is a common aging-related disorder. One of the main factors that contributes to the development of hypertension is salt intake. Based on blood pressure (BP) variation after sodium intake in an acute salt load test, individuals can be grouped in: sodium sensitive (SS), sodium resistant (SR) or inverse sodium sensitivity (ISS). Prostaglandin E2 (PGE2) is the main renal metabolite of the cyclooxygenase pathway, a major actor mediating renal injury and it has also been related to renal blood flow and hemodynamic changes. Our aim was to determine common, functional variants in genes involved in the PGE2 pathway to identify associations with the sodium sensitivity phenotype of hypertensive patients, as well as with parameters of renal function and BP traits. Method We studied 511 treatment-naïve hypertensive patients, who were subjected to an acute salt load test and consequently stratified into 173 SR patients, 172 SS patients and 166 ISS, after they showed an increase in BP values (SS), no substantial variation (SR) or a paradoxical decrease (ISS). Renal function was established by estimated glomerular filtration rate (eGFR) using the MDRD-4 formula. All participants were screened for 216 tag-SNPs that define the variability of 12 genes of the PGE2 pathway, namely PLA2G4A, PLA2G7, SCARB1, PTGS1, PTGS2, PGTES, PTGES2, PTGES3, PTGER1, PTGER2, PTGER3 and PTGER4. Regression models were utilized to evaluate associations with clinical parameters. Results Using the SS group as a reference, eleven variants in genes coding for two phospholipases (PLA2G4A, PLA2G7), cyclooxygenase-1 (PGTS1) and PGE2 receptors (PTGER1 and PTGER4) were linked to the susceptibility of becoming SR or ISS patients. Seven of these variants produced protective odds ratios, whilst four of them were associated with increased risk (Table 1). Next, we analyzed BP traits in each cohort. In SR, PTGES3 rs12824563 was associated with variability in nighttime BP values (p&amp;lt;0.001, p&amp;lt;0.01, p&amp;lt;0.001 and p&amp;lt;0.05 for systolic BP, diastolic BP, mean BP and nighttime BP fall, respectively). For the SS group, two variants in PTGER3, rs61777123 and rs12410289, were also associated with the same parameters (p&amp;lt;0.01). Finally, in the ISS group, the most significant finding was that PTGES2 rs13283456 was strongly linked to daytime and nighttime measurements (p&amp;lt;0.001 for each parameter). Regarding renal function, we examined the 511 patients as a whole and observed that several variants affected eGFR. Most significantly, carriers of PTGER3 rs6424406 and rs1409986 were found to be associated with higher values [Mean difference vs. non carriers: 6.34 (2.42-10.26), p&amp;lt;0.01 and 6.20 (1.76-10.64) ml/min/1,73 m2, p&amp;lt;0.01]. Conclusion Variability in genes that participate in the PGE2 pathway, is associated with the response of treatment-naïve hypertensive patients to salt intake. In addition, these genetic variants may also modify BP traits and eGFR values in these patients.

ASSOCIATION BETWEEN NOCTURNAL VARIATION IN BLOOD PRESSURE AND RISK OF ACUTE ISCHEMIC STROKE: A SYSTEMATIC REVIEW

Objective: Blood pressure (BP) is a dynamic parameter characterized by fluctuations during the 24-hour period. Variability of BP has been associated with cardiovascular risk and the occurrence of acute ischemic stroke (AIS). Circadian variation in BP during the night shows some basic patterns. The purpose of this study is to to correlate deviations from baseline patterns of circadian BP variation with the risk of AIS to select the optimal therapeutic intervention. Design and method: To complete our study, we systematically reviewed the literature from 1990-2022 through electronic medical databases (MEDLINE, Scopus and Cochrane). Results: During the nighttime hours, BP drops 10 - 20% in normotensive and untreated hypertensive patients - a dipping phenomenon, followed by a rapid and gradual increase during waking hours. In the studies being reviewed, patients were classified according to the rate of fall in systolic BP during 24-hour recording into four categories: the extreme-dippers drop &gt;20%, dippers drop &gt;10% and &lt;20%, non-dippers drop &lt;10% and &gt;0%, and reverse-dippers or risers drop &lt;0%. Deviating from standard dipping patterns is associated with an increased risk of AIS and highlights the value of chronotherapy, whereas no significant difference is observed in stroke prognosis. The extreme-dipping phenomenon is associated with the occurrence of ischemic stroke (IS), either due to under-treatment or due to subsequent morning hypertensive spike, whereas aggressive antihypertensive treatment seems to be significantly responsible. Interestingly, the occurrence of microbleeds in IS territory has been strongly associated with the reverse-dipping pattern. Conclusions: Overnight BP variation is an independent and robust predictor of cardiovascular risk, including AIS. Nocturnal BP may constitute a therapeutic target for the prevention of AIS. However, the available data on the effect of antihypertensive drugs and the implementation of chronotherapy with pre-sleep medication are conflicting in terms of improving cardiovascular risk. Therefore, at present, current guidelines for the treatment of BP do not recommend the aforementioned therapeutic approach as the best treatment in day-to-day clinical practice. More extensive and targeted studies are needed in the future to confirm the potential benefits of the application of chronotherapy in the prevention of AIS.

Composite autonomic severity scoring in spinocerebellar ataxia type 1 and 2

ObjectivesThe aim of the present study was to evaluate the integrity of autonomic nervous system in spinocerebellar ataxia (SCA) type 1 and 2 patients using battery of autonomic function tests and their comprehensive scoring using composite autonomic severity score (CASS). Material and methodsBattery of autonomic function test comprising of cardiovascular (baroreflex dependent and non-baroreflex dependent) and sudomotor functions were assessed in age and gender-matched SCA1 (n = 31), SCA2 (n = 40) patients along with healthy controls (n = 40). To assess the grade of autonomic abnormalities, the composite autonomic severity score (CASS) was computed using the results of the standard autonomic function tests. ResultsWe found reduction in baroreflex dependent autonomic reactivity parameters predominantly a significant fall of systolic blood pressure (<0.001) and lower 30:15 ratio (<0.001) during head up tilt in both the SCA1 and SCA2 as compared to controls. On sudomotor assessment, distal leg latency of sweat response was prolonged in SCA1 than SCA2 patients. Moderate generalized autonomic failure was commonly found amongst SCA1 (80.65%) and SCA2 (85%) patients. Severe autonomic failure was found to be more in SCA1 (6.45%) than SCA2 (2.50%) patients. ConclusionsCardiovascular autonomic function assessment in SCA1 and SCA2 patients revealed a significant impairment in the baroreflex loop integrity. Severity scoring using CASS suggests the existence of moderate autonomic failure in majority of both SCA1 and SCA2 patients.

Comparison of hemodynamic stability of propofol ketamine versus etomidate ketamine during induction in peritonitis cases posted for emergency surgery

The aim: The aim of the present study is to evaluate the hemodynamic stability of propofol ketamine versus etomidate ketamine during induction of anaesthesia in peritonitis cases posted for emergency surgery.&#x0D; Methods: Sixty patients with peritonitis, posted for emergency surgery under general anaesthesia, were randomly allocated to two groups. Group propofol ketamine (P + K) comprised of 30 patients (n=30) were induced with propofol 1 mg/kg and ketamine 0.75 mg/kg IV. Group etomidate ketamine (E + K) comprised 30 patients induced with etomidate 0.3 mg/kg and ketamine 0.75 mg/kg. The hemodynamic effects of the combination of the drugs in both groups were compared before and after induction.&#x0D; Results: The change in saturation (SPO2) and Heartrate between the groups P+K &amp; group E+K before induction and after intubation was similar in both groups. There was a statistically insignificant fall in systolic blood pressure (SBP) and diastolic blood pressure (DBP), and mean arterial pressure (MAP) in group P+K before and after induction when compared to group E+K.&#x0D; Conclusions: The propofol ketamine and etomidate ketamine combinations have a similar haemodynamic profile and are equally effective in maintaining haemodynamic stability during induction and intubation.

Study on Perioperative Management of Blood Pressure and Effects of Anaesthesia in Hypertensive Patients Undergoing General &amp; Orthopaedic Surgery

Background and Aim: During anesthesia, hypertension is the most common additional risk factor that contributes to higher mortality rate. Antihypertension medicine’s withdrawal might leads to symptoms such as anxiety, rebound hypertension, myocardial infarction, tachyarrhythmia, angina exaggeration, and sudden death. The present study aimed to assess the perioperative management of blood pressure and effects of anesthesia in hypertensive patients undergoing general and orthopedic surgery. Patients and Methods: This cross-sectional study was carried out on 162 hypertensive patients in the General Surgery and Orthopedics Units of Khyber Teaching Hospital, Peshawar for the duration from April 2022 to September 2022. Study protocol was approved by institute ethical committee. Patients aged 16 to 70 years of either gender underwent general surgery and orthopaedic surgery were enrolled. The data was acquired during the anesthetist’s initial visit to the operated hypertensive patients' 24 hour postoperative period. Antihypertensive medications, hemodynamics, anesthesia drugs, fluid use, and blood loss were main variables noted. Heart rate, systolic blood pressure, and diastolic blood pressure were Intraoperative hemodynamics. SPSS version 27 was used for data analysis. Results: Of the total 162 hypertensive patients, there were 68 (42%) male and 94 (58%) females. The overall mean age was 58.62±8.4 years. Before surgery, about 119 (73.5%) patients took antihypertensive medication whereas 124 (76.5%) had antihypertensive medication within 24 hours. The most prevalent antihypertensive medication used and most common class during postoperative management was Calcium channel Blockers and Amlodipine. The most prevalent used anesthetic drug use was Bupivacaine. The incidence of Systolic Blood Pressure (SBP) fall and rise was found in 28 and 6 patients respectively. The incidence of Diastolic Blood Pressure (DBP) fall and rise during intraoperative management was 11 and 8 patient respectively. Conclusion: The present study found that a decreased heart rate in patients who were taking beta blockers consistently. Those who took diuretics had greater DBP and HR at the completion of the procedure. There was no significant change in hemodynamic parameters with any other antihypertensive treatment. Keywords: Hypertension, General Surgery, Orthopaedic, Hemodynamics

Effectiveness Of Saddle Block Vs Spinal Anaesthesia In Turp: An Open Label Randomized Control Trial.

One of the most frequent diseases among male gender is benign prostatic hyperplasia. Transurethral resection of the prostate (TURP) is a minimally invasive procedure for resection of prostate through endoscopic technique. Recently there was a debate on role of saddle block in TURP. There we aimed to determine the effectiveness of spinal anaesthesia versus saddle block in terms of hemodynamic stability and vasoprbessor requirement in TURP. This open label randomized control trial was performed at Hamdard University Hospital, Karachi, Pakistan, during 1st October, 2021 to 31st March, 2022. Male patients of age 45-65 years requiring TURP, with well controlled diabetes and hypertension of ASA grade I-II were included into the study and randomly assigned into two study groups. Patients' parameters including blood pressure, heart rate, mean arterial pressure and oxygen saturation (SPO2) were measured at baseline and intraoperative at every fifth minute interval till surgery completion. Patients' other parameters including age, surgery duration and comorbidity were also recorded. Total 60 patients with 30 patients in each group were enrolled into the study. Maximum fall in systolic blood pressure, diastolic blood pressure, pulse rate and mean arterial pressure from baseline was significantly lower in patients receiving saddle block anaesthesia than spinal anaesthesia. Maximum fall in SPO2 was not significantly different among two study groups. Maximum fall in all parameters excluding SPO2 was significant between two groups for initial 20 minutes of the procedure. No statistically significant maximum fall was seen for all of the parameters beyond 20 minutes of the procedure. Vasopressor consumption was significantly lower in saddle block group than spinal anaesthesia. Application of saddle block anaesthesia is effective for TURP procedure with controlled hemodynamic status than spinal anaesthesia. Moreover, saddle block requires less vasopressor consumption than spinal anaesthesia technique.

COMPARATIVE STUDY OF ETOMIDATE AND PROPOFOL FOR INDUCTION OF GENERAL ANESTHESIA IN ELDERLY PATIENTS

Introduction: An ideal induction agent for general anesthesia should have hemodynamic stability, minimal respiratory side effect and rapid recovery. Presently etomidate and propofol are popular rapid acting inducing agents. Material and methods: After obtaining informed written consent from patients this prospective, randomized, double blind study was conducted in 100 patients of ASA grade 3 and 4 posted for elective surgeries under general anaesthesia. They were divided into two groups of 50 in each group based on random number as group A and group B. The patients in Group A given Inj. Propofol and the patients in Group B received Inj. Etomidate. Parameters such as heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure and spo2 were monitored continuously and recorded. Incidence and degree of pain of myoclonic movements were recorded. Demographic variables such as age Result: , gender, weight and ASA grade were comparable no significant difference existed between both the groups.Baseline mean heart rate, mean systolic blood pressure and mean diastolic blood pressure were comparable in both the Groups. (P&gt;0.05)Significant (P&lt;0.05) fall in mean systolic blood pressure, mean diastolic pressure and mean arterial pressure was observed immediately after induction, at 2, 5, 10 minutes up to 30 minutes in group A (propofol) compare to group B (etomidate). After then no significant difference seen in mean systolic pressure, mean diastolic pressure and mean arterial pressure. Etomidate was found ideal for its hemodynamic stability when compared to Propofol Conclusion: along with less incidence of pain on injection, the only drawback being high incidence of myoclonus elderly patient

Phenylephrine and Ephedrine for Prevention of Hypotension in Women during Lower Segment Caesarean Section under Spinal Anaesthesia: A Randomised Clinical Study

Introduction: Hypotension is the most common serious adverse event associated with Spinal Anaesthesia (SA) and is associated with nausea and vomiting leading to pulmonary aspiration, respiratory depression and cardiac arrest. Phenylephrine (PE) and Ephedrine (EP) are vasopressors commonly used for prevention of hypotension associated with SA. Aim: To compare the efficacy and safety of PE and EP in prevention of hypotension induced by SA in women during Lower Segment Caesarean Section (LSCS) surgery. Materials and Methods: The present randomised clinical study was conducted on 60 women, between 18-36 years of age and a Heart Rate (HR) of 60-100 per minute randomised to receive either 100 mcg Intravenous (i.v.) bolus of PE, or 12 mg i.v. of EP during intrathecal block. Women having intraoperative hypotension were injected additional doses of vasopressor. Cardiovascular parameters were recorded at baseline (before block) and then at 1, 5, 10, 15, 30, 40 and 60 minutes. Further, safety was also assessed based on hypotension events and adverse events reported during immediate postoperative period. Data analysis was done using IBM SPSS 17 and a p-value &lt;0.05 was considered statistically significant. Results: The mean age of the study participants in PE and EP group was 26.67±5.40 and 26.23±4.59 years, respectively. Significant differences were observed between PE and EP groups for change in Systolic Blood Pressure (SBP) after 1, 10, 30, 40 and 60 minutes. Overall, there was a slight fall in SBP with PE, whereas, with EP there was a slight rise in SBP. Also, the Diastolic Blood Pressure (DBP) was maintained with EP throughout the 60 minute period, whereas with PE there was an initial rise in DBP followed by a slight fall in DBP. The Mean Arterial Pressure (MAP) was well maintained with PE throughout, whereas with EP there was a fall in MAP after 15 minutes. However, these changes were not clinically significant. The Pulse Rate (PR) was lower with PE compared to EP group at time points of 1, 5, 15 and 20 minutes. The mean respiratory rates and blood oxygen saturation were similar with PE and EP administration (p&gt;0.05). A total of 13 (43.3%) patients in the PE group and 14 (46%) in the EP group had adverse events excluding hypotensive patients. Conclusion: According to the findings of the present study, the i.v. bolus of 100 mcg PE and 12 mg EP administered immediately after SA are equally effective in prevention of maternal hypotension and do not cause any significant cardiovascular and respiratory effects.

Blood Pressure Response to Treadmill Stress TestingInterpretation and Critical Appraisal

A progressive and sustained decrease in systolic blood pressure on the continuation of exercise suggests severe left ventricular dysfunction irrespective of the cause. A transient decrease in systolic blood pressure followed by a normal increase in the continuation of exercise does not have any clinical significance. Failure of systolic blood pressure to increase commensurate to an increase in workload suggests the failure of adequate increase in left ventricular stroke volume with increasing workload. At present there is no consensus about the definition and significance of the exaggerated increase in systolic blood pressure during exercise. This is because different authors have used different criteria for defining abnormal response. An increase in diastolic blood pressure by 10 mm Hg over resting diastolic blood pressure or peak diastolic blood pressure of 110 mm Hg is significant and may be associated with a future risk of hypertension at rest. There is no consensus about the magnitude of the fall in systolic blood pressure during the initial few minutes of recovery. A paradoxical increase rather than a decrease in systolic blood pressure during recovery may be associated with coronary artery disease. Correct auscultatory measurement of blood pressure at peak exercise is difficult. Therefore, some authorities recommend the evaluation of blood pressure at a submaximal workload. This area needs further evaluation.

PS-P04-7: ALERTING REACTION OF BLOOD PRESSURE AND AGE: MAY MEASUREMENT MONTH 2019

Objective: The extent of the alerting reaction on systolic blood pressure (BP) measurements has been shown to be related to age and the magnitude of the first reading, with implications for the monitoring and diagnosis of hypertension. We investigated the effects of age on the direction and magnitude of change in both systolic and diastolic BP from the first to subsequent readings, using data from the May Measurement Month (MMM) global BP screening campaign in 2019. Design and method: We examined the relationship between the value of the first reading (BP1) and the change in BP from BP1 to the average (BPA) of the second (BP2) and third readings (BP3) taken at 1 minute intervals in participants with three BP readings. Mixed effects regression models were fit, stratified by age, and using random intercept for country of screening site to account for clustering. This approach was repeated for diastolic and systolic BP. Results: Of the 1,133,008 participants with three BP readings, 58.7% had a decrease in systolic and 54.2% a decrease in diastolic BP from BP1 to BPA. Above an age dependent threshold value in BP1, a higher BP1 was associated with a greater decrease from BP1 to BPA. Older participants on average exhibited relatively smaller changes in systolic BP from systolic BP1 to systolic BP2 for equivalent values of systolic BP1 than younger age groups (Fig.1A). The average difference between diastolic BP1 and diastolic BPA showed a “U shaped” interaction with age such that the largest difference was observed in the youngest and oldest age groups and the smallest difference in those aged 40 to 49 and 50 to 59 years (Fig.1B). These patterns of BPV across values of BP1 and age persisted when the models were adjusted for antihypertensive medication or sex, or if the difference in BP from BP1 to BP2 or BP3 were used as the outcome. Conclusions: Age had a significant and differential modifying effect on the fall in systolic and diastolic BP from first to subsequent readings taken on a single occasion. These results could reflect age related variation in homeostatic capabilities to regulate BP following an initial stress response or differential sizes of alerting response by age. This highlights the importance of taking multiple BP readings when assessing BP, particularly in younger individuals, to avoid overestimation and overdiagnosis.

A Comparison of Hemodynamic Changes Between the Use of Etomidate and Propofol as Induction Agents for Anesthesia in Daycare Surgeries.

Background and objective The development of modern anesthetic agents has made it possible to conduct pain-free surgical procedures. The role of the anesthetist in choosing a suitable anesthetic agent to provide a good anesthetic and sedative effect is very important in any surgical procedure. There is always a degree of risk involved as the hemodynamic parameters may be altered. This study aimed to compare the hemodynamic changes and respiratory effects between the use of etomidate and propofol for the induction of general anesthesia (GA) as well asto compare the side effects of both drugs in daycare surgeries. Methods The study was a parallel-design, randomized, double-blinded control trial conducted over a period of three years among patients undergoing elective daycare surgeries under GA. The patients were classified into two groups depending on the type of drug received: Group A or the propofol group and Group B or the etomidate group.Randomization was done by computer-generated random number generator software. A total of 174 patients were selected (87 in each group) at a ratio of 1:1. A baseline evaluation of the hemodynamic parameters was done followed by continuous monitoring. Results The age, weight, and gender distribution of the patients in both groups were comparable. Significant hemodynamic changes were observed following induction in Group A. The fall in systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial blood pressure (MABP) in Group A following induction was found to be statistically significant (p<0.00). The rise in heart rate was almost similar in both groups, with Group A demonstrating a slightly higher rate. There were fewer signs of respiratory depression in Group B. The major side effects observed after induction were myoclonus, which was more prevalent in Group B patients (21.84%), and pain at the injection site, which was observed more frequently in Group A (17.1%). Conclusion Based on our findings, etomidate is a drug with better hemodynamic stability and less pain at the site of injection compared to propofol. Hence, it may be a better induction agent in daycare surgeries.