Hypertensive Episodes Research Articles

Is segmental epidural anaesthesia an optimal technique for patients undergoing percutaneous nephrolithotomy?

Background and Aims:Neuraxial anaesthesia has recently become popular for percutaneous nephrolithotomy (PCNL). We conducted a study comparing general anaesthesia (GA) with segmental (T6–T12) epidural anaesthesia (SEA) for PCNL with respect to anaesthesia and surgical characteristics.Methods:Ninety American Society of Anesthesiologists Physical Status-I and II patients undergoing PCNL randomly received either GA or SEA. Overall patient satisfaction was the primary end point. Intraoperative haemodynamics, epidural block characteristics, post-operative pain, time to rescue analgesic, total analgesic consumption, discharge times from post-anaesthesia care unit, surgeon satisfaction scores and stone clearance were secondary end points. Parametric data were analysed by Student's t-test while non-parametric data were compared with Mann–Whitney U-test.Results:Group SEA reported better patient satisfaction (P = 0.005). Patients in group GA had significantly higher heart rates (P = 0.0001) and comparable mean arterial pressures (P = 0.24). Postoperatively, time to first rescue analgesic and total tramadol consumption was higher in Group GA (P = 0.001). Group SEA had lower pain scores (P = 0.001). Time to reach Aldrete's score of 9 was shorter in group SEA (P = 0.0001). The incidence of nausea was higher in group GA (P = 0.001); vomiting rates were comparable (P = 0.15). One patient in group SEA developed bradycardia which was successfully treated. Eight patients (18%) had hypertensive episodes in group GA versus none in group SEA (P = 0.0001). One patient in GA group had pleural injury and was managed with intercostal drain. Stone clearance and post-operative haemoglobin levels were comparable in both groups.Conclusion:PCNL under SEA has a role in selected patients, for short duration surgery and in expert hands.

Paroxysmal Sympathetic Hyperactivity

It is not uncommon for physicians who treat patients with traumatic brain injuries to see wide fluctuations in the heart rate, respiratory rate and blood pressure. For decades, these fluctuations were thought to be seizures, caused by pressure on the thalamus. They were originally termed Diencephalic Autonomic Seizures by Dr. Wilder Penfield in 1929. He described episodes of lacrimation, hypertension, diaphoresis and agitation. Dr. Penfield’s “seizures” were later shown to have no electrographic correlate. Since that time, many names have been used to describe similar episodes: Dysautonomia, Sympathetic Storming, Brainstem Attacks, Autonomic Dysregulation, Paroxsymal Autonomic Instability with Dystonia and Paroxysmal Sympathetic Hyperactivity to name only a few.

Pheochromocytomatosis Treated By Radio-Guided Surgery

ABSTRACT Objective: Pheochromocytomatosis is a rare cause of recurrent pheochromocytoma due to seeding of tumor cells at the time of adrenalectomy. The diagnosis can be difficult and a high degree of suspicion is required pre-operatively. We present the case of a 57-year-old woman with a long history of symptoms suggestive of recurrent pheochromocytoma that evaded diagnosis for many years. Methods: We describe the clinical course, diagnosis, and management. We also present a comprehensive review of the current literature. Results: Pheochromocytomatosis in our patient presented as multiple recurrent episodes of tachycardia and hypertension 15 years after left adrenalectomy for pheochromocytoma. Diagnosis was evaded until complete hormonal evaluation confirmed biochemical evidence of catecholamine overproduction. Imaging revealed two sites of recurrence. Management included alpha-blockade followed by radio-guided surgery using 123I-labeled metaiodobenzylguanidine scintigraphy and a gamma probe. At surgery, ...

Glaucomatocyclitic Crises May Occur in Patients with Narrow or Closed Angles.

Purpose To report cases of glaucomatocyclitic crises and discuss the possibility of occurrence in patients with narrow or closed angles. Background The prevalence of angle closure is much higher among Asians than among the Western population. Currently, there is no evidence for a direct relationship between the etiology and angle structure. Design A retrospective and observational case series. Methods We retrospectively collected data from nine adult patients (three males and six females) who were diagnosed with a glaucomatocyclitic crisis and a shallow anterior chamber over a 21-year period, from 1995 to 2016, at the Kaohsiung Medical University Hospital. A narrow angle was defined as a grade less than the Shaffer system grade II. Ophthalmic examinations, including anterior segment biomicroscopy, direct ophthalmoscopy, intraocular pressure measurements, anterior chamber reaction, visual field tests, and the grade of the anterior chamber angle according to the Shaffer system, were reviewed. Results These patients experienced at least one typical unilateral ocular hypertensive episode that fulfilled the criteria of a glaucomatocyclitic crisis without the angle feature. All patients had gonioscopically narrow or closed angles with or without peripheral anterior synechiae. Conclusions The coexistence of narrow or closed angles and a glaucomatocyclitic crisis is possible, especially in patients of Asian descent. In patients with shallow anterior chambers, a glaucomatocyclitic crisis may be a cause of acute glaucoma episodes.

A Case of Accelerated Hypertension Complicated by Acute Coronary Syndrome and Bezold Jarisch Reflex

A 73-year-old woman presented with acute coronary syndrome on a background of worsening symptoms of left heart failure and accelerated hypertension. Patient was severely hypertensive with clinical findings suggestive of acute pulmonary congestion on presentation. Whilst being stabilised with medical therapy, patient developed multiple episodes of prolonged asystole (Fig. 1) with ongoing severe uncontrolled hypertension requiring haemodynamic support with temporary wire. Improved hypertension control over the next 24 hours stabilised the patient without recurrence of bradyarrhythmia. Secondary causes of severe hypertension were excluded and culprit ramus artery was stented. Bezold Jarisch reflex is a triad of bradycardia, asystole and hypotension which has been implicated in various cardiac conditions [[1]Mark A.L. The Bezold Jarisch reflex revisited: clinical implications of inhibitory reflexes originating in the heart.J Am Coll Cardiol. 1983; 1: 90-102Crossref PubMed Scopus (568) Google Scholar]. This case demonstrates accelerated hypertension complicated by acute coronary syndrome and acute pulmonary odema with multiple episodes of Bezold Jarisch Reflex mediated bradycardia and asystole. Asystolic episodes resulted from increased vagal stimulation due to stretching of mechanoreceptors in ventricular myocytes during accelerated hypertensive episode [[2]Julius S. Esler M. Increased central blood volume: a possible pathophysiological factor in mild low-renin esse ntial hypertension.Clin Sci Mol Med Suppl. 1976; 3: 207s-210sPubMed Google Scholar]. Decongestive therapy and optimisation of hypertension control resulted in complete resolution of bradyarrhythmia. Recognition of association of BJR with accelerated hypertension is important because treatment of hypertension restores the baroreceptor function without requiring permanent pacing.

Autonomic dysreflexia: a cardiovascular disorder following spinal cord injury.

Autonomic dysreflexia (AD) is a serious cardiovascular disorder in patients with spinal cord injury (SCI). The primary underlying cause of AD is loss of supraspinal control over sympathetic preganglionic neurons (SPNs) caudal to the injury, which renders the SPNs hyper-responsive to stimulation. Central maladaptive plasticity, including C-fiber sprouting and propriospinal fiber proliferation exaggerates noxious afferent transmission to the SPNs, causing them to release massive sympathetic discharges that result in severe hypertensive episodes. In parallel, upregulated peripheral vascular sensitivity following SCI exacerbates the hypertensive response by augmenting gastric and pelvic vasoconstriction. Currently, the majority of clinically employed treatments for AD involve anti-hypertensive medications and Botox injections to the bladder. Although these approaches mitigate the severity of AD, they only yield transient effects and target the effector organs, rather than addressing the primary issue of central sympathetic dysregulation. As such, strategies that aim to restore supraspinal reinnervation of SPNs to improve cardiovascular sympathetic regulation are likely more effective for AD. Recent pre-clinical investigations show that cell transplantation therapy is efficacious in reestablishing spinal sympathetic connections and improving hemodynamic performance, which holds promise as a potential therapeutic approach.

Prophylactic Ephedrine Versus Phenylephrine for Maternal Hypotension in Women Undergoing Spinal Anesthesia for Caesarean Section-A Randomized Double Blind Clinical Trial

Introduction: The incidence of hypotension after administration of anesthesia in the spinal canal in women undergoing abdominal surgical delivery may be about to eighty percent if preventive amplifications, for instance precedent the introduction of additional fluid into the body, propelling the uterus to the left, and vasopressors, have not been considered. Aims: are to analyze the effect of ephedrine and phenylephrine in prophylaxis and treatment of low blood pressure in patients undergoing spinal anesthesia, to figure out the side effects of these drugs and to determine fetal Apgar scores. Method: Fifty five women were randomly designated into two groups to get preventative ephedrine (n=27) or phenylephrine (n=28). Blood pressure, heart rate, frequency of low blood pressure, reactive high blood pressure, heart rate less than 60 BPM, heart rate more than 100 BPM, nausea, vomiting, and Apgar scores were checked out. Results: There were no significant differences in the characteristic data between the groups. The mean (± SD) dose of ephedrine used was 19.81 mg (± 5.46) and phenylephrine was 125.71 μg (± 35.64). Differences in systolic and diastolic pressure were compatible in the two groups. There were significant alterations in the frequency of reactive hypertension episodes (Ephedrine group: 48 (14.5%) vs. Phenylephrine group: 26 (7.7%) P 0.301). There were significant differences in the incidence of nausea and vomiting (Ephedrine group: 10 (37%) vs. Phenylephrine group: 3(10.7%); P>0.018). There were no significant diversity in the incidence of hypotension, with an incidence of 18(66.7%) in the Ephedrine group and 17(60.7%) (P<0.646) in the Phenylephrine group. Maternal arrhythmias were more common in the Ephedrine group at 10(37%) than in the Phenylephrine group at 7(25%), but the difference is not significant (P=0.334). Additionally, maternal restlessness was more common in the Ephedrine group: 8(30.8%) than the Phenylephrine group: 3(10.7%), but with an insignificant difference (P=0.068). Diversity in the Apgar score in the 1st and 5th minute was not observed. Number of patients who required rescue dose in the Ephedrine group was 24(88.9%), which was significantly higher than the Phenylephrine group at 20(71.4%), P<0.005). There are significant differences in the number of rescue doses of the two drugs. In the Phenylephrine group there was only one patient (3.6%) that had the rescue dose 3 times, and for the Ephedrine group there were 9 patients (33.3%) that had the rescue dose 3 times each, (P=0.033). Conclusion: This study reinforces the usefulness of phenylephrine for the retainment of blood pressure during administration of anesthesia in the spine for optional surgical delivery.

Night-time blood pressure variability negatively correlated with reactive hyperemia index

Hypertension is a definitive risk for cardiovascular events, and represents the leading risk factor for the overall global burden of disease [ [1] Lim S.S. Vos T. Flaxman A.D. et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the global burden of disease study 2010. Lancet. 2012; 380: 2224-2260 Abstract Full Text Full Text PDF PubMed Scopus (8597) Google Scholar ]. Recently, several types of blood pressure (BP) variability such as day-to-day, visit-to-visit, or seasonal have been evaluated [ [2] Rothwell P.M. Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension. Lancet. 2010; 375: 938-948 Abstract Full Text Full Text PDF PubMed Scopus (560) Google Scholar ]. BP variability within 24 h assessed by ambulatory BP monitoring (ABPM) is also reported to have independent prognostic value for cardiovascular events, especially with night-time BP variability [ [3] Palatini P. Reboldi G. Beilin L.J. et al. Added predictive value of night-time blood pressure variability for cardiovascular events and mortality: the ambulatory blood pressure-international study. Hypertension. 2014; 64: 487-493 Crossref PubMed Scopus (133) Google Scholar ]. However, the pathogenesis is poorly understood.

A Single-institution Experience with Open Irreversible Electroporation for Locally Advanced Pancreatic Carcinoma.

Background:Locally advanced pancreatic carcinoma (LAPC) is characterized by poor prognosis despite recommended concurrent chemoradiotherapy. Irreversible electroporation (IRE) has emerged as a potential option for the management of unresectable pancreatic cancer. This study was conducted to evaluate the safety and short-term efficacy of open IRE for the treatment of LAPC.Methods:Retrospective data of 25 consecutive patients receiving IRE for T3 lesions from July 2015 to June 2016 at a single center were analyzed. The perioperative and long-term IRE-related complications were reviewed to evaluate the safety of the procedure. The tumor reduction and biological response were analyzed through computed tomography/magnetic resonance imaging; the serum level of CA19-9 was measured as a secondary endpoint to evaluate the short-term efficacy of IRE.Results:All patients were successfully treated; the median tumor size was 4.2 cm and the median IRE time was 36 min. Four intraoperative procedure-related complications were observed (16%): two transient hypertensive episodes, one hypotension case, and one transient supraventricular tachycardia case. Nine postoperative complications were described, including three Grade A pancreatic fistulas, three delayed gastric emptying, one acute pancreatitis, one upper gastrointestinal hemorrhage, and one portal vein thrombosis. The overall rate of stable disease was 28%, 36% achieved partial response, and lower serum CA19-9 levels were recorded in all patients at discharge.Conclusions:IRE is feasible for the treatment of LAPC and is a reasonable intervention strategy owing to its combined attributes of safety and efficacy.

Deliberate employment of postoperative hypotension for brain arteriovenous malformation surgery and the incidence of delayed postoperative hemorrhage: a prospective cohort study.

OBJECTIVE The aim of this study was to examine the impact of deliberate employment of postoperative hypotension on delayed postoperative hemorrhage (DPH) for all Spetzler-Ponce Class (SPC) C brain arteriovenous malformations (bAVMs) and SPC B bAVMs ≥ 3.5 cm in diameter (SPC B 3.5+). METHODS A protocol of deliberate employment of postoperative hypotension was introduced in June 1997 for all SPC C and SPC B 3.5+ bAVMs. The aim was to achieve a maximum mean arterial blood pressure (BP) ≤ 70 mm Hg (with cerebral perfusion pressure > 50 mm Hg) for a minimum of 7 days after resection of bAVMs (BP protocol). The authors compared patients who experienced DPH (defined as brain hemorrhage into the resection bed that resulted in a new neurological deficit or that resulted in reoperation during the hospitalization for microsurgical bAVM resection) between 2 periods (prior to adopting the BP protocol and after introduction of the BP protocol) and 4 bAVM categories (SPC A, SPC B 3.5- [that is, SPC B < 3.5 cm maximum diameter], SPC B 3.5+, and SPC C). Patients excluded from treatment by the BP protocol were managed in the intensive care unit to avoid moderate hypertensive episodes. The pooled cases of all bAVM treated by surgery were analyzed to identify characteristics associated with the risk of DPH. These identified characteristics were then examined by multiple logistic regression analysis in both SPC B 3.5+ and SPC C cases. RESULTS From a cohort of 641 bAVMs treated by microsurgery, 32 patients with DPH were identified. Of those, 66% (95% CI 48-80) had a permanent new neurological deficit with a modified Rankin Scale score of 2-6. This included a mortality rate of 13% (95% CI 4.4-29). The BP protocol was used to treat 162 patients with either SPC B 3.5+ or SPC C. For SPC B 3.5+, there was no significant reduction in DPH with the introduction of the BP protocol (p = 0.77). For SPC C, there was a significant (p = 0.035) reduction of DPH from 29% (95% CI 13%-53%) to 8.2% (95% CI 3.2%-18%) associated with the introduction of the BP protocol. Multiple logistic regression analysis found that the absence of the BP protocol (p = 0.011, odds ratio 7.5, 95% CI 1.6-36) remained significant for the development of DPH in patients with SPC C bAVMs. CONCLUSIONS Treating patients with SPC C bAVMs with a protocol that lowers BP immediately after resection seems to reduce the risk of DPH. For SPC A and SPC B 3.5- bAVMs, there is unlikely to be a need to do more than avoid postoperative hypertension. For SPC B 3.5+ bAVMs, a larger number of patients would be required to test the absence of benefit of the BP protocol.

Cardiac Consequences of Autonomic Dysreflexia in Spinal Cord Injury.

Autonomic dysreflexia (AD), which describes episodic hypertension, is highly prevalent in people with spinal cord injury (SCI). In non-SCI, primary hypertension depresses cardiac contractile reserve via β-adrenergic mechanisms. In this study, we investigated whether AD contributes to the impairment in cardiac contractile function that accompanies SCI. We induced SCI in rodents and stratified them into sham, SCI, or SCI plus repetitive induction of AD. At 6-week post-SCI, we assessed cardiac function using in vivo (speckle-tracking echocardiography), ex vivo (working heart), and molecular approaches (Western blot). We also provide unique translational insight by comparing the relationship between the number of daily AD events and cardiac function in 14 individuals with cervical SCI. We found SCI and SCI plus repetitive induction of AD exhibited a reduction in left ventricular dimensions at 6-week post-SCI versus preinjury (P<0.049). Compared with sham, SCI exhibited a reduction in peak radial strain along with a down and rightward shift in the Starling curve (P<0.037), both of which were further depressed in SCI plus repetitive induction of AD (P<0.042). In response to β-adrenergic stimulation, SCI plus repetitive induction of AD exhibited an attenuated increase in contractile indices (P<0.001), despite no differences in β-receptor expression within the left ventricle. Our clinical data confirm our experimental findings by demonstrating significant associations between the number of daily AD events and markers of systolic and diastolic function along with left ventricular mechanics. Here, we provide the first evidence from a translational perspective that AD exerts insidious effects on cardiac function in rodents and humans with SCI.

Epidural Analgesia Complicated by Dural Ectasia in the Marfan Syndrome

Patients with the Marfan syndrome are considered to be high risk during pregnancy and warrant a complete multidisciplinary evaluation. One goal is to minimize hemodynamic fluctuations during labor since hypertensive episodes may result in aortic dissection or rupture. Although they may prevent these complications, neuraxial techniques may be complicated by dural ectasia. The case of a parturient with the Marfan syndrome and mild dural ectasia is presented. During attempted labor epidural placement, unintentional dural puncture occurred. A spinal catheter was used for adequate labor analgesia, and a resultant postdural puncture headache was alleviated by an epidural blood patch under fluoroscopic guidance.

Dexmedetomidine versus labetalol infusions for controlling emergence hypertension in cranial surgeries for supratentorial tumors

BackgroundAcute hypertension is a common accompaniment during emergence from anesthesia especially in intracranial neurosurgical procedures and may be associated with the development of intracranial hematoma. Although various drugs have been evaluated, management of emergence hypertension in this subset of patients continues to be a challenge for anesthesiologists.MethodologySeventy-five patients ASA (I-II) scheduled for supratentorial craniotomy under general anesthesia were randomly allocated to one of three groups at the time of dural closure: Group “dex” received dexmedetomidine infusion in a rate of 1 μg/kg/hr, Group “labetalol” received labetalol infusion in a rate of 0.5 mg/kg/hr, and Group “control” a control group where patients received saline infusion at the same rate of dexmedetomidine and labetalol. Hypertensive episodes were managed with nitroglycerin at a dose starting from 1 μg/kg/min if systolic blood pressure exceeded 25% of its preinduction value. Hemodynamic parameters as well as the number of patients, the total dose of nitroglycerin required in each group and the time to extubation were recorded.ResultsDexmedetomidine and labetalol had a significant effect in reducing SBP, MAP, DBP, HR during emergence from anesthesia, with more reduction of the SBP, MAP and DBP in the dexmedetomidine group and of the HR in the labetalol group in comparison with the other two groups. The number of patients needing nitroglycerin was 8 representing 32% of patients in dexmedetomidine group, 5 representing 20% of patients in labetalol group and 22 representing 88% of patients in control group (P value = 0.032). Time to emergence from anesthesia was comparable in the three groups.ConclusionBoth dexmedetomidine and labetalol had favorable effects on hemodynamics at time of emergence from anesthesia in comparison with control group without prolongation of the time of extubation.

Long-term follow-up for anicteric survival with native liver after redo Kasai: a first report

PurposeWe present a first report of the long-term follow-up of biliary atresia (BA) patients who became anicteric with the native liver (ANL; total bilirubin <1.5mg/dL) after redo-Kasai. MethodsForty-six redo-Kasai cases (1984–2015) were the subjects for this study. ANL ratios were determined using the Kaplan–Meier estimate. ResultsBA type was I (n=3), II (n=1), and III (n=42). Mean ages (initial/redo) at Kasai were 60.3/231.9days, respectively. Jaundice persisted after the initial Kasai in 24/46 cases while 22 had recurrence of jaundice after initially becoming anicteric. After redo, 5/24 of the persistent jaundice cases and 14/22 of the initially anicteric cases became anicteric (p<.05). Of these 19, 7 (one type I, six type III) are currently ANL while the remaining 12 had LTx or died. Morbidity/Complications documented in the 7 post-redo ANL cases after a mean follow-up of 16.7years (range: 10.0–31.1) included 4 episodes of cholangitis, 3 episodes of portal hypertension, 4 episodes of esophageal varices, 3 episodes of splenomegaly, one splenectomy, and 4 episodes of thrombocytopenia. ConclusionsOurs is the first long-term follow-up study of redo-Kasai cases. We found that the ANL ratio after redo-Kasai was low at 7/46 (15.2%) and that ANL were prone to multiple morbidity. Level of evidenceRetrospective comparative study, level III.

The impact of preoperative evaluation on perioperative events in patients undergoing cataract surgery: a cohort study.

PurposeAmbulatory surgery is a major area of surgical and anesthetic practice, and preoperative clinics are being increasingly used for low-risk surgical procedures. This study investigated the impact of preoperative evaluation on perioperative events in patients undergoing cataract surgery.MethodsThis was a retrospective cohort study of 968 consecutive patients undergoing cataract surgery. Details of medical conditions, surgical, anesthetic, and postoperative information were collected from medical records. A logistic regression model was developed using propensity score adjustment for baseline characteristics.ResultsOut 968 patients included, 240 (24.7%) underwent outpatient preoperative evaluation. There were no perioperative major cardiovascular events. Hypertension occurred in 319 (33%) patients, accounting for 79.7% of all adverse events. Preoperative evaluation resulted in a lower hypertension rate after adjustment for propensity score (OR=0.6; 95% CI 0.41-0.93); no effects were observed on posterior capsule rupture and emergency visits/hospitalization within 7 days of surgery. Eighty-nine patients (9.3%) had an initial systolic pressure ≥180 mm Hg, which was not associated with higher risk of posterior capsule rupture (P=0.158) or postoperative adverse events (P=0.902). Median waiting time to surgery was 6 and 2 months for evaluated and non-evaluated patients, respectively (P<0.001).ConclusionsIn the context of low-risk surgery and no major perioperative and postoperative outcomes, it appears that outpatient preoperative evaluation has no role in reducing adverse events in cataract surgery candidates. Despite fewer hypertensive episodes observed in evaluated patients, these episodes were not associated with any medical or surgical outcomes.

PS 17-07 TAKAYASU'S ARTERITIS WITH RARE ABDOMINAL AORTIC THROMBOSIS CAUSED REPEATED ATTACKS OF HEART FAILURE AND UNCONTROLLED HYPERTENSION

Objective: Takayasu's arteritis (TA) is a chronic, idiopathic, inflammatory disease affecting the aorta and its branches. Abdominal aortic thrombosis due to TA was rare. To date, only one case has been reported in literatures. Design and method: After bilateral artificial subclavian-iliac bypass, a case of abdominal aortic thrombosis due to TA was delayed diagnosis in a 44-year-old male with history of recurrent episodes of heart failure and uncontrolled hypertension with claudication of two extremities and elevated blood sugar for nearly 4 years. Results: He had smoked 30 cigarettes a day for 30 years. His upper-limb blood pressure (BP) was much higher than lower-limb BP. He had a bruit over the abdominal aorta with high serum creatinine and brain natriuretic peptide. Abdominal color Doppler sonography and CT aortography (CTA) showed occlusion of the abdominal aorta and narrowing of the bilateral renal arteries. His cardiac function was improved after vascular bypass and during 2-year follow-up, his blood pressure was controlled with reduced serum creatinine under antihypertensives, antidiabetic, antiplatelet therapy etc. Compared with prebypass, CTA showed abdominal aortic thrombosis resulted in arterial occlusion extending from the left renal artery initial segment level to bilateral common iliac artery and the bifurcation of renal artery except for vascular bypass. He was rehospitalized for heart failure and hydrothorax two years after the bypass and MR imaging revealed thickened wall of aortic branch. He was discharged after glucocorticoid treatment etc. His cardiac function and blood pressure were well-controlled for the next year. Conclusions: Abdominal aortic thrombosis due to TA is rare and potentially life threatening, probably become one atherosclerosis risk factor. Doppler sonography and CTA are important in diagnosis of TA, while MRI can identify the disease phase. Artificial vascular bypass can be used for severe TA patients with complicated aortic disease and glucocorticoid treatment is essential for those in acute phase.

LBOS 01-02 CLUSTERING OF SILENT HYPOTENSIVE EPISODES IN THE MORNING/LATE-MORNING HOURS IN SUBJECTS TREATED FOR HYPERTENSION

Objective: We have previously noted morning/late-morning hypotension (M/LM) in some hypertensive subjects. Here we intended to establish its prevalence in relation to daytime blood pressure (BP) in general. Design and Method: Daytime hypotension was defined as systolic BP<110mmHg or ≥25% lower than the mean 3 first awake recordings provided that it was also < 85% of the mean 24 h systolic-BP. We evaluated 781 ABPM (Spacelabs 90207/902017A) recordings from 179 subjects with normal BP and 602 hypertensive subjects. Results: Daytime hypotension (mean systolic pressure [SP] during hypotension 101+/−1 mmHg) was more common in subjects receiving antihypertensive drugs than in untreated hypertensive subjects [158/336 (43%) vs. 76/266 (29%); p < 0.05]. In treated hypertensive subjects hypotensive episodes tended to cluster in the M/LM hours [08:00–12:00]: in nearly 50% (76/158) of treated patients with daytime [06:00–23:00] hypotension, hypotensive episodes were detected in the M/LM, as compared to 19/79 (24%;) in untreated hypertensive subjects (p < 0.05). Clustering analysis revealed that M/LM hypotension was more prevalent, compared to other daytime hours in treated, but not in untreated hypertensive subjects (OR- 1.69 and 0.87, respectively; p < 0.0005). Among treated hypertensive subjects, M/LM clustering was seen in the uncontrolled subjects (p < 0.0005) but not in controlled patients. However, daytime SP was higher in treated subjects free of daytime hypotension compared to those with falls in BP (136 ± 14 vs. 130 ± 14; t-test, p < 0.0001). SP during M/LM falls was lower in controlled than in uncontrolled hypertensive subjects (93+/−7 vs. 103+/−12mmHg; p < 0. 0001). Age (68 ± 1.7 vs. 64 ± 1; p < 0.0001) was higher among treated subjects with M/LM falls compared with treated subjects without M/LM falls. Conclusions: Daytime hypotensive episodes are common and tend to cluster in the M/LM hours in treated older hypertensive subjects, particularly in the setting of uncontrolled hypertension. Age, dosing time and circadian decline in hormones affecting blood pressure may play a role in this phenomenon.

Prophylactic phenylephrine infusion for the prevention of hypotension after spinal anesthesia in the elderly: a randomized controlled clinical trial

Study objectiveHypotension frequently occurs during spinal anesthesia (SA), especially in the elderly. Phenylephrine is effective to prevent SA-induced hypotension during cesarean delivery. The objective of this study was to evaluate the efficacy and safety of prophylactic infusion of phenylephrine after SA for orthopedic surgery in the elderly. DesignThis prospective, randomized, double-blind, and placebo-controlled study included 54 patients older than 60 years undergoing elective lower limb surgery under SA (injection of 10 mg of isobaric bupivacaine with 5 μg of sufentanyl). InterventionPatients were randomized to group P (100-μg/mL solution of phenylephrine solution at 1 mL/min after placement of SA) or the control group C (0.9% isotonic sodium chloride solution). The flow of the infusion was stopped if the mean arterial blood pressure (MAP) was higher than the baseline MAP and maintained or restarted at 1 mL/min if MAP was equal to or lower than the baseline MAP. Heart rate and MAP were collected throughout the case. MeasurementsHypotension was defined by a 20% decrease and hypertension as a 20% increase from baseline MAP. Bradycardia was defined as a heart rate lower than 50 beats per minute. Main resultsTwenty-eight patients were randomized to group P and 26 patients to group C. MAP was higher in group P than in group C (92 ± 2 vs 82 ± 2 mm Hg, mean ± SD, P< .001). The number of hypotensive episodes per patient was higher in group C compared with group P (9 [0-39] vs 1 [0-10], median [extremes], P< .01), but the number of hypotensive patients was similar between groups (19 [73%] vs 20 [71%], P= 1). The time to onset of the first hypotension was shorter in group C (3 [1-13] vs 15 [1-95] minutes, P= .004). The proportion of patients without hypotension (cumulative survival) was better in group P (P= .04). The number of hypertensive episodes per patient and the number of bradycardic episodes per patient were similar between groups (P= not significant). ConclusionProphylactic phenylephrine infusion is an effective method of reducing SA-induced hypotension in the elderly. Compared with a control group, it delays the time to onset of hypotension and decreases the number of hypotensive episodes per patient. More data are needed to evaluate clinical outcomes of such a strategy.

Role of Intracranial Pressure Monitoring in Management of Patients with Severe Traumatic Brain Injury: Results of a Large Level I Trauma Center in Southern Iran

To determine the role of intracranial pressure (ICP) monitoring in management of patients with severe traumatic brain injury (TBI) admitted to a large level I trauma center in Southern Iran. This was a cohort study performed during a 2-year period in a level I trauma center in Southern Iran including all adult patients (>16 years) with severe TBI (Glasgow Coma Scale [GCS] score, 3-8) who underwent ICP monitoring through ventriculostomy. The management was based on the recorded ICP values with threshold of 20 mm Hg. Decompressive craniectomy was performed in patients with intractable intracranial hypertension (persistent ICP ≥25 mm Hg). In unresponsive patients, barbiturate coma was induced. Patients were followed for 6 months and Glasgow Outcome Scale Extended was recorded. The determinants of favorable and unfavorable outcome were also determined. Overall, we included 248 patients with mean age of 34.6 ± 16.6 years, among whom there were 216 men (87.1%) and 32 women (12.9%). Eighty-five patients (34.2%) had favorable and 163 (65.8%) unfavorable outcomes. Those with favorable outcome had significantly lower age (P= 0.004), higher GCS score on admission (P < 0.001), lower Rotterdam score (P= 0.035), fewer episodes of intracranial hypertension (P < 0.001), and lower maximum recorded ICP (P= 0.041). These factors remained statistically significant after elimination of confounders by multivariate logistic regression model. Age, GCS score on admission, Rotterdam score, intracranial hypertension, and maximum recorded ICPare important determinants of outcome in patients with severe TBI. ICP monitoring assisted us in targeted therapy and management of patients with severe TBI.

Posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome refers to aneurological disorder characterized by headache, disorders of consciousness, visual disturbances, epileptic seizures, and subcortical vasogenic edema. About two thirds of patients develop neurological symptoms, which are associated with blood pressure fluctuations. One hypothesis is that hypertensive episodes cause autoregulatory failure, and values above the upper limit of cerebral autoregulation result in abreakthrough followed by hyperperfusion and blood-brain barrier dysfunction. In another hypothesis, endothelial dysfunction triggered by numerous factors including preeclampsia, immunosuppressive agents, chemotherapeutics, sepsis, or autoimmune disorders is thought to be the key pathomechanism. Endo- or exogenic toxic agents including pharmacological substances, cytokines, or bacterial toxins are supposed to trigger endothelial activation and dysfunction resulting in the release of vasoconstrictors, pro-inflammatory mediators, and vascular leakage. Diagnosis is usually based on clinical and neuroimaging findings that frequently show abilateral, symmetric, and parietooccipital pattern. However, the diagnosis can often only be confirmed during the course of disease after excluding important differential diagnoses. Currently, there is no specific treatment available. Lowering of arterial blood pressure and eliminating the underlying cause usually leads to an improvement of clinical and neuroradiological findings. Admission to acritical care unit is required in about 40 % of patients due to complicating conditions including status epilepticus, cerebral vasoconstriction, ischemia, or intracerebral hemorrhage. Prognosis is favorable; in the majority of patients neurological deficits and imaging findings resolve completely.