Fewer Episodes Of Hypotension Research Articles

Intravenous versus Epidural Routes of Patient-Controlled Analgesia in Abdominal Surgery: Systematic Review with Meta-Analysis.

Objective: To compare the intravenous and epidural routes of patient-controlled anesthesia in abdominal surgery. Methods: We searched for randomized clinical trials that compared the intravenous and epidural modes of patient-controlled anesthesia in intra-abdominal surgery in adults. Data analysis was performed in RevMan 5.4. Heterogeneity was measured using I2 statistic. Risk of bias was assessed using the Jadad/Oxford quality scoring system. Results: Seven studies reporting 529 patients were included into the meta-analysis. For pain at rest, the mean difference with 95% confidence interval (CI) was −0.00 [−0.79, 0.78], p-value 0.99, while for pain on coughing, it was 0.43 [−0.02, 0.88], p-value 0.06, indicating that patient-controlled epidural analgesia (PCEA) was superior. For the sedation score, the mean difference with 95% CI was 0.26 [−0.37, 0.89], p-value 0.42, slightly favoring PCEA. For the length of hospital stay, the mean difference with 95% CI was 1.13 [0.29, 1.98], p-value 0.009, favoring PCEA. For postoperative complications, the risk ratio with 95% CI was 0.8 [0.62, 1.03], p-value 0.08, slightly favoring patient-controlled intravenous analgesia (PCIVA). A significant effect was observed for hypotension, favoring PCIVA. Conclusions: Patient-controlled intravenous analgesia compared with patient-controlled epidural analgesia was associated with fewer episodes of hypotension. PCEA, on other hand, was associated with a shorter length of hospital stay. Pain control and other side effects did not differ significantly. Only three studies out of seven had an acceptable methodological quality. Thus, these conclusions should be taken with caution.

Extraluminal Placement of a Bronchial Blocker Compared with Carbon Dioxide Artificial Pneumothorax in Infants Undergoing Video-Assisted Thoracoscopic Surgery.

Objective: To investigate the safety and effectiveness of extraluminal placement of a bronchial blocker compared with carbon dioxide (CO2) artificial pneumothorax in infants undergoing video-assisted thoracoscopic surgery (VATS).Methods: The study involved 33 infants (group A) who underwent one-lung ventilation (OLV) with extraluminal placement of a bronchial blocker and 35 other infants (group B) who underwent CO2 artificial pneumothorax. Clinical characteristics, the degree of lung collapse, and complications were compared.Results: The degree of lung collapse in group A was significantly higher than that in group B at T2 and T3. The mean arterial pressure (MAP) of group B was significantly lower than that of group A at 10 min and 30 min after OLV. The partial pressure of carbon dioxide (PaCO2) of group B was significantly higher than that of group A at 30 min after OLV. The incidence of hypotension in group B was higher than that in group A.Conclusion: Compared with CO2 artificial pneumothorax, extraluminal placement of a bronchial blocker is associated with a better degree of lung collapse, fewer episodes of hypotension, and lower PaCO2 accumulation during OLV in infants undergoing VATS.

A randomized trial of albumin infusion to prevent intradialytic hypotension in hospitalized hypoalbuminemic patients

BackgroundIntradialytic hypotension (IDH) is a frequent complication of intermittent hemodialysis (IHD), occurring from 15 to 50% of ambulatory sessions, and is more frequent among hospitalized patients with hypoalbuminemia. IDH limits adequate fluid removal and increases the risk for vascular access thrombosis, early hemodialysis (HD) termination, and mortality. Albumin infusion before and during therapy has been used for treating IDH with the varying results. We evaluated the efficacy of albumin infusion in preventing IDH during IHD in hypoalbuminemic inpatients.MethodsA randomized, crossover trial was performed in 65 AKI or ESKD patients with hypoalbuminemia (albumin < 3 g/dl) who required HD during hospitalization. Patients were randomized to receive 100 ml of either 0.9%sodium chloride or 25% albumin intravenously at the initiation of each dialysis. These two solutions were alternated for up to six sessions. Patients' vital signs and ultrafiltration removal rate were recorded every 15 to 30 min during dialysis. IDH was assessed by different definitions reported in the literature. All symptoms associated with a noted hypotensive event as well as interventions during the dialysis were recorded.ResultsSixty-five patients were submitted to 249 sessions; the mean age was 58 (pm 12), and 46 (70%) were male with a mean weight of 76 (pm 18) kg. The presence of IDH was lower during albumin sessions based on all definitions. The hypotension risk was significantly decreased based on the Kidney Disease Outcomes Quality Initiative definition; (15% with NS vs. 7% with albumin, p = 0.002). The lowest intradialytic SBP was significantly worse in patients who received 0.9% sodium chloride than albumin (NS 83 vs. albumin 90 mmHg, p = 0.035). Overall ultrafiltration rate was significantly higher in the albumin therapies [NS − 8.25 ml/kg/h (− 11.18 5.80) vs. 8.27 ml/kg/h (− 12.22 to 5.53) with albumin, p = 0.011].ConclusionIn hypoalbuminemic patients who need HD, albumin administration before the dialysis results in fewer episodes of hypotension and improves fluid removal. Albumin infusion may be of benefit to improve the safety of HD and achievement of fluid balance in these high-risk patients.ClinicalTrials.gov Identifier: NCT04522635

456 PARAVERTEBRAL AND RECTUS SHEATH CATHETERS AS AN ALTERNATIVE TO THORACIC EPIDURAL FOR ANALGESIA POST-ESOPHAGECTOMY

Abstract Thoracic epidural (TE) analgesia has been the gold standard for pain management post-esophagectomy and is still being widely used. While it offers excellent analgesia, it can negatively impact on recovery due to hypotension. An alternative is multimodal analgesia using intrathecal-diamorphine, paravertebral and rectus sheaths local anaesthetic infusion-catheters (LAC) and intravenous opioids (PCA). The aim of this study was to compare the effectiveness of TE analgesia and multimodal LAC analgesia and the associated incidence of hypotension. Methods Data were collected over a three-year period for patients who underwent trans-thoracic (Ivor Lewis) esophagectomy from a single high volume unit. Multimodal analgesia was integrated into the patient pathway in early 2016 and adopted by all team members. All patients were treated post operatively with a standardised enhanced recovery pathway. Pain scores using a visual analogue scale (VAS) at rest and movement, episodes of hypotension (systolic BP &amp;lt; 90 mmHg) and vasopressor requirements for post-operative days 0 to 4 (POD 0–4) were recorded for both groups. Results Overall 239 patients were included in this study, 104 patients received TE analgesia and 135 patients received multimodal analgesia. There was no statistically significant difference in the mean VAS pain scores between both cohorts on all post-operative days. (p = 0.06–0.89). In comparison to TE analgesia, the multimodal patient group had significantly fewer episodes of hypotension (multimodal: 21% vs TE: 38%, p = 0.01) and significantly less vasopressor infusion requirements to maintain their blood pressure (multimodal: 30% vs TE: 55%, p = 0.01). Conclusion Multimodal analgesia using intrathecal diamorphine with combined paravertebral and rectus sheath catheters is not inferior to TE in providing pain control post esophagectomy. In addition there are significantly fewer episodes of hypotension and significantly less need for vasopressor use. This may confer a postoperative advantage permitting better patient mobilisation and recovery in the immediate post operative period.

Advancing American Kidney Health: Perspective from DaVita, Inc.

Advancing American Kidney Health (AAKH) ([1][1]) has the potential to transform kidney care in America and outlines what the kidney care community has been striving to achieve for decades, as described in the recently released Kidney Care Partners Kidney Care First initiative ([2][2]). This includes

The analgesic efficacy of transverse abdominis plane block versus epidural analgesia: A systematic review with meta-analysis.

Background:The aim of the study was to compare the analgesic efficacy of epidural analgesia and transverse abdominis plane (TAP) block. TAP block has gained popularity to provide postoperative analgesia after abdominal surgery but its advantage over epidural analgesia is disputed.Methods:We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. Only trials comparing TAP block with epidural analgesia were included. The primary outcome was pain score at rest (analog scale, 0–10) on postoperative day 1 analyzed in subgroups according to the population (children and adults). Secondary outcomes included rate of hypotension, length of stay, and functional outcomes (time to first bowel sound, time to first flatus).Results:Ten controlled trials, including 505 patients (195 children and 310 adults), were identified. Pain scores at rest on postoperative day 1 were equivalent for TAP block and epidural analgesia groups in children (mean difference: 0.3; 95% confidence interval [CI]: −0.1 to 0.6; I2 = 0%; P = .15) and in adults (mean difference: 0.5; 95% CI: −0.1 to 1.0; I2 = 81%; P = .10). The quality of evidence for our primary outcome was moderate according to the GRADE system. The epidural analgesia group experienced a higher rate of hypotension (relative risk: 0.13; 95% CI: 0.04–0.38; I2 = 0%; P = .0002), while hospital length of stay was shorter in the TAP block group (mean difference: −0.6 days; 95% CI: −0.9 to −0.3 days; I2 = 0%; P < .0001), without impact on functional outcomes.Conclusion:There is moderate evidence that TAP block and epidural analgesia are equally effective in treating postoperative pain in both pediatric and adult patients, while TAP block is associated with fewer episodes of hypotension and reduced length of stay.

Continuous spinal anesthesia versus single small dose bupivacaine–fentanyl spinal anesthesia in high risk elderly patients: A randomized controlled trial

BackgroundGreater numbers of patients are presenting for surgery with aging-related, pre-existing conditions that place them at greater risk of an adverse outcome. Hemodynamic instability due to high sympathetic block largely limits the use of conventional dose spinal anesthesia in high risk elderly patients. In this study we aim to compare the hemodynamic stability and the incidence of hypotension in continuous spinal anesthesia (CSA) versus single low dose spinal anesthesia (SD) in elderly high risk patients.MethodsThis prospective randomized blinded study was carried on 34 ASA III & IV elderly patients aged >75 years undergoing orthopedic lower limb surgery. The patients were randomly assigned to one of the study groups. Group CSA received intermittent dosing of local anesthetic solution via an intrathecal catheter using 0.5 ml of 0.5% isobaric bupivacaine increments and 0.5 ml of fentanyl (25 μg) while group SD single dose of 1.5 ml of 0.5% isobaric bupivacaine and 0.5 ml of fentanyl (25 μg). The study groups were compared regarding hemodynamic stability, incidence of hypotension and total ephedrine consumption.ResultsIncidence of severe hypotension was significant. 52.9% of patients in SD group experienced an episode of severe hypotension versus none of them in CSA group (p 0.033∗). Total dose of fluids infused was significantly more in the SD group. The use of ephedrine was significantly more in SD group.ConclusionCSA provided fewer episodes of hypotension and no severe hypotension versus SD 7.5 mg bupivacaine. CSA offers the added advantage of the ability to titrate dose of local anesthetic as needed while maintaining hemodynamic stability.

Comparison of intradialytic blood pressure variability between conventional thrice‐weekly hemodialysis and short daily hemodialysis

Intradialytic blood pressure (BP) variability may be associated with increased mortality. We examined the effect of short daily hemodialysis (SDHD) on intradialytic BP variability relative to conventional thrice-weekly HD (CHD). This is a retrospective cohort study. Subjects were those converted from CHD to SDHD (n=12). All intradialytic BPs were collected on the last month of CHD, and on month 6 of SDHD. Absolute predialysis BP level and intradialytic BP variability were defined as the intercept and average residual terms, respectively, from a mixed-effects linear regression model of time on BP. Dialysis modality was a predictor variable (CHD vs. SDHD). Outcome variables were intradialytic BP variability and hypotension (BP<90/55 mmHg at any time during HD). In addition to a predictor and outcomes, the demographics, estimated dry weight, and ultrafiltration ratio were examined. The median (range) age of the patients was 48 (34-77); all had hypertension, and 4 (33%) had diabetes. By a mixed effects linear regression model, the intradialytic systolic BP variability was 13.2 (quartile range 9.5-14.0) mmHg and 10.0 (8.3-10.9) mmHg for CHD and SDHD, respectively (P<0.006). Intradialytic diastolic BP variability was also significantly reduced (7.7 [6.4-9.2] vs. 6.1 [5.5-6.6] mmHg, P=0.005). Relative to CHD, less hypotension was observed during treatment on SDHD: the odds ratio (95% confidence interval) was 0.36 (0.16-0.81; P=0.008). In this retrospective study, SDHD was associated with less intradialytic BP variability and with fewer episodes of hypotension during treatments. Further studies are necessary to generalize these findings.

A new dosing protocol reduces dexmedetomidine-associated hypotension in critically ill surgical patients

Background Although no ideal sedative exists, dexmedetomidine is unique because it produces sedation and analgesia without decreasing the respiratory drive. Hemodynamic responses to dexmedetomidine are variable and dependent on the patient population. Our initial experience was associated with an unacceptable incidence of hypotension and bradycardia. We evaluated occurrence of hypotension and bradycardia in critically ill surgical patients receiving dexmedetomidine before and after implementation of a dosing protocol. Methods This is a retrospective chart review of all admissions to a university medical center–based, 44-bed surgical intensive care unit pre and post protocol implementation. Results Forty-four patients received dexmedetomidine including 19 historic controls and 25 dosed via protocol. Both groups had comparable demographics and initial and maximum dosages of dexmedetomidine. Use of the dosing protocol resulted in fewer dosage changes (mean ± standard deviation, 4.8 ± 3.8 compared to 7.8 ± 3.9; P = .014) and fewer episodes of hypotension (16% vs 68.4%; P = .0006) but did not influence bradycardic episodes (20% vs 15.5%; P > .99). Conclusion We found that use of a protocol that increases the time interval between dosage adjustments may reduce dexmedetomidine-associated hypotension.

Dialysis-Induced Regional Left Ventricular Dysfunction Is Ameliorated by Cooling the Dialysate

Dialysis patients who develop cardiac failure have a poor prognosis. Recurrent subclinical myocardial ischemia is important in the genesis of heart failure in nondialysis patients. It has previously been demonstrated that subclinical ischemia occurs during hemodialysis; therefore, this study examined whether the improved stability of cool-temperature dialysis lessens this phenomenon. Ten patients who were prone to intradialytic hypotension entered a randomized, crossover study to compare the development of dialysis-induced left ventricular (LV) regional wall motion abnormalities (RWMA) at dialysate temperatures of 37 and 35 degrees C. Serial echocardiography with quantitative analysis was used to assess ejection fraction and regional systolic LV function. BP and hemodynamic variables were measured using continuous pulse wave analysis. The severity of thermal symptoms was scored using a simple questionnaire. Forty-nine new RWMA developed in nine patients during hemodialysis with dialysate at 37 degrees C (HD(37)), compared with thirteen RWMA that developed in four patients during HD(35) (odds ratio 3.8; 95% confidence interval 2.1 to 6.9). The majority of RWMA displayed improved function by 30 min after dialysis. Overall, regional systolic LV function was significantly more impaired during HD(37) (P < 0.001). BP was higher during HD(35), with fewer episodes of hypotension as a result of a higher peripheral resistance and no difference in stroke volume. The development of thermal symptoms was heterogeneous, with most patients tolerating HD(35) well. This study confirms previous findings of reversible LV RWMA that develop during hemodialysis. It also shows that this phenomenon can be ameliorated by reducing dialysate temperature, a simple intervention with no cost implications.

Spinal Anesthesia Using Single Injection Small-Dose Bupivacaine Versus Continuous Catheter Injection Techniques for Surgical Repair of Hip Fracture in Elderly Patients

Aging and disease may make elderly patients particularly susceptible to hypotension during spinal anesthesia. We compared the hemodynamic effect of continuous spinal anesthesia (CSA) and small dose single injection spinal anesthesia (SA) regarding the incidence of hypotension. Seventy-four patients aged >75 yr undergoing surgical repair of hip fracture were randomized into 2 groups of 37 patients each. Group CSA received a continuous spinal anesthetic with a titration of 2.5 mg boluses every 15 min of isobaric bupivacaine, while group SA received a single injection spinal anesthetic with 7.5 mg of isobaric bupivacaine. The overall variations in noninvasive automated arterial blood pressure were not statistically significantly different in the 2 groups at baseline and after CSA or SA (not significant). In the SA group, 68% of patients experienced at least one episode of hypotension (decrease in systolic arterial blood pressure greater than 20% of baseline value) versus 31% of patients in the CSA group (P = 0.005). In the SA group, 51% of patients experienced at least one episode of severe hypotension (decrease in systolic arterial blood pressure more than 30% of baseline value) versus 8% of patients in the CSA group (P < 0.0001). In the CSA group, 4.5 +/- 2 mg of ephedrine was injected versus 11 +/- 2 mg in the SA group (P = 0.005). In the CSA group, 5 mg (2.5-10) of anesthetic solution was required versus 7.5 mg in the SA group (P < 0.0001). We conclude that, in elderly patients undergoing hip fracture repair, CSA provides fewer episodes of hypotension and severe hypotension compared with a single intrathecal injection of 7.5 mg bupivacaine.

Optimization of desflurane administration in morbidly obese patients: a comparison with sevoflurane using an ‘inhalation bolus’ technique

The concept of an 'inhalation bolus' can be used to optimize inhaled drug administration. We investigated the depth of anaesthesia, haemodynamic stability, and recovery time in morbidly obese patients resulting from bispectral index (BIS)-guided sevoflurane or desflurane administration and BIS-triggered inhalation boluses of sevoflurane or desflurane combined with titration of remifentanil. Fifty morbidly obese patients undergoing laparoscopic gastroplasty received either BIS-guided sevoflurane or desflurane anaesthesia in combination with a remifentanil target-controlled infusion. Intraoperative haemodynamic stability and BIS control were measured. Immediate recovery was recorded. Intraoperatively, the BIS was between 40 and 60 for a greater percentage of time in the sevoflurane (78 (13)% of case time) than in the desflurane patients (64 (14)% of case time), owing to too profound anaesthesia in the desflurane patients at the start of the procedure. However, fewer episodes of hypotension were found in the desflurane group, without the occurrence of more hypertensive episodes. During immediate recovery, eye opening, extubation, airway maintenance, and orientation occurred sooner in the desflurane group. Immediate recovery was significantly faster in the desflurane group. Overall hypnotic controllability measured by BIS was less accurate with desflurane. Overall haemodynamic controllability was better when using desflurane. Fewer episodes of hypotension were found in the desflurane group. The use of the inhalation bolus was found to be appropriate in both groups without causing severe haemodynamic side effects. Minimal BIS values were significantly lower after a desflurane bolus.