Hypotension In Group Research Articles

Varying Presentations and Outcomes of Septic Shock: Should Septic Shock be Stratified?

Recent studies have revealed there are three presentations of septic shock in patients: refractory hypotension without hyperlactatemia, hyperlactatemia without refractory hypotension, and both refractory hypotension and hyperlactatemia. In this study, we sought to identify differences in the outcomes of septic shock patients with these three presentations. We performed a secondary analysis of a large-scale, multicenter, controlled trial. The septic shock patients were categorized into the following three groups according to the presence or absence of refractory hypotension and hyperlactatemia: a hypotension group (refractory hypotension without hyperlactatemia), a hyperlactatemia group (hyperlactatemia without refractory hypotension), and a typical group (both refractory hypotension and hyperlactatemia). The 90-day all-cause mortality was compared among these three groups. A total of 1588 septic shock patients were enrolled in the present study, including 854 (53.8%) in the hypotension group, 477 (30.0%) in the hyperlactatemia group, and 257 (16.2%) in the typical group. The 90-day all-cause mortality were 12.3 per cent for the patients in the hypotension group, 23.1 per cent for those in the hyperlactatemia group, and 31.9 per cent for those in the typical group, these differences among the three groups were significant (Pearson's χ2 = 58.49, P < 0.001). And also, there was a significant difference between hyperlactatemia group and typical group (Pearson's χ2 = 6.77, P < 0.05). In this study, we demonstrated that the three different presentations of septic shock resulted in significantly different outcomes, suggesting that septic shock should be stratified.

Mortality after emergent trauma laparotomy: A multicenter, retrospective study.

Two decades ago, hypotensive trauma patients requiring emergent laparotomy had a 40% mortality. In the interim, multiple interventions to decrease hemorrhage-related mortality have been implemented but few have any documented evidence of change in outcomes for patients requiring emergent laparotomy. The purpose of this study was to determine current mortality rates for patients undergoing emergent trauma laparotomy. A retrospective cohort of all adult, emergent trauma laparotomies performed in 2012 to 2013 at 12 Level I trauma centers was reviewed. Emergent trauma laparotomy was defined as emergency department (ED) admission to surgical start time in 90 minutes or less. Hypotension was defined as arrival ED systolic blood pressure (SBP) ≤90 mm Hg. Cause and time to death was also determined. Continuous data are presented as median (interquartile range [IQR]). One thousand seven hundred six patients underwent emergent trauma laparotomy. The cohort was predominately young (31 years; IQR, 24-45), male (84%), sustained blunt trauma (67%), and with moderate injuries (Injury Severity Score, 19; IQR, 10-33). The time in ED was 24 minutes (IQR, 14-39) and time from ED admission to surgical start was 42 minutes (IQR, 30-61). The most common procedures were enterectomy (23%), hepatorrhaphy (20%), enterorrhaphy (16%), and splenectomy (16%). Damage control laparotomy was used in 38% of all patients and 62% of hypotensive patients. The Injury Severity Score for the entire cohort was 19 (IQR, 10-33) and 29 (IQR, 18-41) for the hypotensive group. Mortality for the entire cohort was 21% with 60% of deaths due to hemorrhage. Mortality in the hypotensive group was 46%, with 65% of deaths due to hemorrhage. Overall mortality rate of a trauma laparotomy is substantial (21%) with hemorrhage accounting for 60% of the deaths. The mortality rate for hypotensive patients (46%) appears unchanged over the last two decades and is even more concerning, with almost half of patients presenting with an SBP of 90 mm Hg or less dying.

Subthalamic nucleus stimulation and levodopa modulate cardiovascular autonomic function in Parkinson\u2019s disease

We aimed to explore the effects of bilateral subthalamic nucleus stimulation and levodopa on cardiovascular autonomic function in Parkinson’s disease. Twenty-six Parkinson’s disease patients with bilateral subthalamic nucleus stimulation in a stable state were tested under stimulation off and dopaminergic medication off (OFF-OFF), stimulation on and dopaminergic medication off (ON-OFF), and stimulation on and medication (levodopa) on (ON-ON) conditions by recording continuously blood pressure, ECG, and respiration at rest, during metronomic deep breathing, and head-up tilt test. Thirteen patients were diagnosed as orthostatic hypotension by head-up tilt test. Baroreflex sensitivity and spectral analyses were performed by trigonometric regressive spectral analysis. Subthalamic nucleus stimulation and levodopa had multiple influences. (1) Systolic blood pressure during tilt-up was reduced by subthalamic nucleus stimulation, and then further by levodopa. (2) Subthalamic nucleus stimulation and levodopa had different effects on sympathetic and parasympathetic regulations in Parkinson’s disease. (3) Levodopa decreased baroreflex sensitivity and RR interval only in the orthostatic hypotension group, and had opposite effects on the non-orthostatic hypotension group. These findings indicate that subthalamic nucleus stimulation and levodopa have different effects on cardiovascular autonomic function in Parkinson’s disease, which are modulated by the presence of orthostatic hypotension as well.

Hypotension and Brain Injury in Asphyxiated Newborns Treated with Hypothermia.

This study aimed to assess the incidence of hypotension in asphyxiated newborns treated with hypothermia, the variability in treatments for hypotension, and the impact of hypotension on the pattern of brain injury. We conducted a retrospective cohort study of asphyxiated newborns treated with hypothermia. Mean blood pressures, lactate levels, and inotropic support medications were recorded during the hospitalization. Presence and severity of brain injury were scored using the brain magnetic resonance imaging (MRI) obtained after the hypothermia treatment was completed. One hundred and ninety term asphyxiated newborns were treated with hypothermia. Eighty-one percent developed hypotension. Fifty-five percent of the newborns in the hypotensive group developed brain injury compared with 35% of the newborns in the normotensive group (p = 0.04). Twenty-nine percent of the newborns in the hypotensive group developed severe brain injury, compared with only 15% in the normotensive group. Nineteen percent of the newborns presenting with volume- and/or catecholamine-resistant hypotension had near-total injury, compared with 6% in the normotensive group and 8% in the group responding to volume and/or catecholamines. Hypotension was common in asphyxiated newborns treated with hypothermia and was associated with an increased risk of (severe) brain injury in these newborns.

The relationship between orthostatic hypotension and the risk of myocardial infarction in the elderly

Objective To investigate the relationship between the systolic/diastolic orthostatic hypotension(OH-S/OH-D)and myocardial infarction(MI)in the elderly. Methods 200 subjects without myocardial infarction(MI)aged 60 years and over in our urban district were selected.The orthostatic and supine blood pressure and heart rate were measured in supine position after resting for more than 5 minutes and at 0 and 2 minutes after standing.All cases were divided into systolic orthostatic hypotension(OH-S)or diastolic orthostatic hypotension(OH-D)groups based on the results of orthostatic hypotension, and followed up by telephone with mean period of 325 days.The primary endpoint was MI occurrence for analyzing the correlation between OH-S/OH-D and MI incidence. Results The prevalence rate of OH in this cohort was 38%, with OH-S 20% and OH-D 18%.In the very elderly group(≥80 years)versus the elderly group, the occurrences of 0H and OH-S were(27%vs.21%, P=0.036; 22%vs.15%, P=0.020), respectively, while no significant difference was found in OH-D between the two groups.After 325 day follow-up, the prevalence of MI was significantly(P<0.05)higher in the OH-positive subjects than in the 0H-negative subjects, which result was the same as the prevalence of MI in OH-S or and OH-D group.After adjusting for age, supine blood pressure, creatinine and cerebrovascular history, logistic regression analysis showed that MI was correlated with OH(HR 15.72, 95%CI 3.29~74.23, P=0.002), OH-S(HR 8.552, 95%CI 2.51~30.21, P=0.004)and OH-D(HR 3.80, 95%CI 1.14~13.80, P=0.042). Compared with OH-D, OH-S had more significant correlation with MI. Conclusions Orthostatic hypotension, particularly systolic orthostatic hypotension, is common in elderly patients.The OH-S and OH-D have a significant correlation with MI. Key words: Hypotension, orthostatic; Myocardial infarction

Limiting blood loss in orthognathic surgery with Esmolol as a hypotensive agent

Orthognathic surgery may be complicated by difficulty in achieving hemostasis because unlike soft tissue, the vessels traversing bone cannot be identified and isolated before osteotomy. In this study we evaluated the amount of blood loss and duration of surgery under deliberate hypotensive anesthesia in comparison to amount of blood loss and duration of surgery under normotensive anesthesia on patients undergoing orthognathic surgical procedures. A total of 16 cases undergoing orthognathic surgery were included in this clinical study.Patients were randomly grouped under normotensive (group I) or hypotensive group (group 2). Patients in hypotensive anesthesia group were given Esmolol to maintain mean arterial pressure in the range of 70-80 mm of Hg till osteotomy segments were fixed. There was more than 40% reduction in blood loss in orthognathic surgical procedures when induced hypotension was used, but there was not statistically significant (p=0.91) reduction in the operative time. Based on surgeons and anesthetist’s assessment fast acting agents like Esmolol can be used intraoperatively to induce hypotension as and when required.

Hypotension and the need for transfusion in pediatric blunt spleen and liver injury: An ATOMAC + prospective study

PurposeChildren with blunt liver or spleen injury (BLSI) requiring early transfusion may present without hypotension despite significant hypovolemia. This study sought to determine the relationship between early transfusion in pediatric BLSI and hypotension. MethodsSecondary analysis of a 10-institution prospective observational study was performed of patients 18years and younger presenting with BLSI. Patients with central nervous system (CNS) injury were excluded. Children receiving blood transfusion within 4h of injury were evaluated. Time to first transfusion, vital signs, and physical exams were analyzed. Patients with hypotension were compared to those without hypotension. ResultsOf 1008 patients with BLSI, 47 patients met inclusion criteria. 22 (47%) had documented hypotension. There was no statistical difference in median time to first transfusion for those with or without hypotension (2h vs. 2.5h, p=0.107). The hypotensive group was older (median 15.0 versus 9.5years; p=0.007). Median transfusion volume in the first 24h was 18.2mL/kg (IQR: 9.6, 25.7) for those with hypotension and 13.9mL/kg (IQR: 8.3, 21.0) for those without (p=0.220). Mortality was 14% (3/22) in children with hypotension and 0% (0/25) in children without hypotension. ConclusionHypotension occurred in less than half of patients requiring early transfusion following pediatric BLSI suggesting that hypotension does not consistently predict the need for early transfusion. Type of studySecondary analysis of a prospective observational study. Level of evidenceLevel IV cohort study.

Clinical analysis on the relationship of orthostatic hypotension in elderly hypertensive patients with left ventricular structure and function

Objectives To explore the relationship of orthostatic hypotension in elderly hypertensive patients with left ventricular structure and function. Methods 101 cases of elderly patients with hypertension were selected from July 2013 to June 2015.After blood pressure measurement in vertical and decubitus position, all patients were divided into non-orthostatic hypotension and orthostatic hypotension groups, received the echocardiography and the accurate calculation of left ventricular mass index. Results Compared with non-orthostatic hypotension, orthostatic hypotension in patients with left ventricular diastolic diameter, left ventricular posterior wall thinckness and interventricular septum thickness.Left ventricular mass index significantly increased(48.13±5.54)mm vs.(52.45±1.48)mm in left ventricular diastolic diameter, (10.08±1.87)mm vs.(11.29±1.98)mm in left ventricular posterior wall thickness, (10.18±1.88)mm vs.(11.61±1.66)mm in interventricular septum thickness, and(114.59±22.72)g/m2 vs.(131.98±23.43)g/m2 〔t=4.386、2.985、4.397、8.672, in left ventricular mass index(BMI), all P<0.05〕. Left heart ventricular ejection fraction and mitral peak early/late diastolic blood flow decreased〔(60.81±4.73)vs.(53.60±2.58)and(0.93±0.23)vs(0.76±0.26)t=4.298、3.654, all P<0.05〕. Conclusions There is relationship of orthostatic hypotension with left ventricular structure and function in elderly hypertension patients, and it is essential not only to control blood pressure effectively, but also to focus on controlling orthostatic hypotension. Key words: Elderly hypertension; Orthostatic hypotension; Left ventricular structure

Prevalence of hypotension and its association with cognitive function among older adults

ABSTRACTBackground and Objective: The negative effect of hypertension has overshadowed possible health problems associated with hypotension. The purposes of this study were to describe the prevalence of hypotension in older adults and to determine the association between hypotension and cognitive function, after adjusting for possible covariates.Methodology: The data for the study consisting of 1067 community-dwelling older adults were obtained from a national survey entitled “Identifying Psychosocial and Identifying Economic Risk Factor of Cognitive Impairment among Elderly”, conducted in Malaysia. The hypotension was considered as blood pressure <120/75 mm Hg, measuring by standard mercury manometer. Data analysis was performed using the SPSS Version 22.0.Results: The mean age of the respondents was 68.27 (SD = 5.93). Mean score of cognitive function as measured by MMSE was 22.70 (SD = 4.95). The prevalence of hypotension was 29.3%. The prevalence of cognitive impairment for hypotension group was 25.6%. Results of multiple linear regression analysis revealed that hypotension is negatively associated with cognitive function (Beta = −0.11, p<.01), after adjusting for age, gender, education, marital status, employment status, diabetes, heart disease, stroke and gastritis.Conclusion: The study showing hypotension is significantly associated with decreased cognitive function in later life, implies more attention to low blood pressure in old age.

Effect of co-administration of different doses of phenylephrine with oxytocin on the prevention of oxytocin-induced hypotension in caesarean section under spinal anaesthesia: A randomised comparative study.

Introduction:Co-administration of phenylephrine prevents oxytocin-induced hypotension during caesarean section under spinal anaesthesia (SA), but higher doses cause reflex bradycardia. This study compares the effects of co-administration of two different doses of phenylephrine on oxytocin-induced hypotension during caesarean section under SA.Methods:In this prospective, double-blind study, 90 parturients belonging to the American Society of Anesthesiologists' physical status 1 or 2, undergoing caesarean section under SA were randomised into Group A: oxytocin 3U and phenylephrine 50 μg, Group B: oxytocin 3U and phenylephrine 75 μg, Group C: oxytocin 3U and normal saline, administered intravenously over 5 min after baby extraction. The incidence of hypotension (the primary outcome), rescue vasopressor requirement and side effects were recorded. Statistical analyses were with analysis of variance, Kruskal-Wallis, chi-square and Fisher's exact tests.Results:Demographic parameters such as age, height, weight, level of sensory block at 20 min and duration of surgery were comparable in all the groups. The incidence of hypotension (Group A – 90%, Group B – 10%, Group C – 98%, P = 0.001), magnitude of fall in mean arterial pressure (Group A-15.03 ± 6.12 mm of Hg, Group B – 6.63 ± 4.49 mm of Hg and Group C-13.03 ± 3.39 mm of Hg, P < 0.001) and rescue vasopressor requirement (Group A-45 ± 15.25 mg, Group B-5 ± 15.25, Group C-91.66 ± 26.53, P < 0.001) were significantly lower in Group B compared to A and C.Conclusion:Co-administration of phenylephrine 75 μg with oxytocin 3U reduces the incidence of oxytocin-induced hypotension compared to phenylephrine 50 μg with oxytocin 3U during caesarean section under spinal anaesthesia.

Complications and Predictors of Hypotension Requiring Vasopressor after Carotid Artery Stenting

A significant controversy exists regarding the clinical impact of hemodynamic depression on major adverse events after carotid artery stenting (CAS). The purpose of this study was to evaluate the incidence, predictors, and clinical significance of hypotension after CAS. A total of 118 cases of carotid artery stenosis were treated with CAS. Hypotension was defined as sustained systolic blood pressure <80 mmHg and requiring intravenous administration of vasopressor to maintain adequate systolic blood pressure after the procedure. Baseline characteristics, procedural characteristics, and periprocedural major adverse events were retrospectively compared between postprocedural hypotension group and non-hypotension group. Morphological and procedural characteristics were not significantly different between the two groups. Periprocedural major adverse events, presence of new ischemic lesions, and number of new ischemic lesions were not significantly different between the two groups (P = 1, P = 0.36, P = 0.68). Hypertension was an independent protective factor (P = 0.037), and use of proximal protection and the distance from carotid bifurcation to maximum stenotic lesion ≤ 10 mm were independent risk factors for developing hypotension after CAS (P = 0.034, P = 0.027). There was no significant relationship between hypotension after CAS and major adverse events in this study. Maintenance of periprocedural adequate cerebral perfusion is thought to be important to prevent ischemic complications due to hypotension after CAS, especially in these cases.

Autonomic Cardiovascular Control and Executive Function in Chronic Hypotension.

Chronic low blood pressure (hypotension) is characterized by complaints such as fatigue, reduced drive, dizziness, and cold limbs. Additionally, deficits in attention and memory have been observed. Autonomic dysregulation is considered to be involved in the origin of this condition. The study explored autonomic cardiovascular control in the context of higher cognitive processing (executive function) in hypotension. Hemodynamic recordings were performed in 40 hypotensive and 40 normotensive participants during execution of four classical executive function tasks (number-letter task, n-back task, continuous performance test, and flanker task). Parameters of cardiac sympathetic control, i.e., stroke volume, cardiac output, pre-ejection period, total peripheral resistance, and parasympathetic control, i.e., respiratory sinus arrhythmia and baroreflex sensitivity, were obtained. The hypotensive group exhibited lower stroke volume and cardiac output, as well as higher pre-ejection period and baroreflex sensitivity during task execution. Increased error rates in hypotensive individuals were observed in the n-back and flanker tasks. In the total sample, there were positive correlations of error rates with pre-ejection period, baroreflex sensitivity and respiratory sinus arrhythmia, and negative correlations with cardiac output. Group differences in stroke volume, cardiac output, and pre-ejection period suggest diminished beta-adrenergic myocardial drive during executive function processing in hypotension, in addition to increased baroreflex function. Although further research is warranted to quantify the extent of executive function impairment in hypotension, the results from correlation analysis add evidence to the notion that higher sympathetic inotropic influences and reduced parasympathetic cardiac influences are accompanied by better cognitive performance.

Novel orbital findings of intracranial hypotension

PurposeTo determine whether orbital findings on routine brain MRI can be used to differentiate patients with intracranial hypotension from controls. MethodsThe authors evaluated axial T2-weighted images for the amount of optic nerve sheath CSF and 3D-T1-weighted images for optic nerve angle of sixteen patients with intracranial hypotension and 60 controls. ResultsPatients with intracranial hypotension demonstrated significantly decreased CSF in the optic nerve sheath. Optic nerve angle was higher in the intracranial hypotension group compared to controls. ConclusionsDecreased optic nerve sheath CSF and straightened optic nerve angle are significantly more common in the setting of intracranial hypotension.

Retinal Arterioles in Hypo-, Normo-, and Hypertensive Subjects Measured Using Adaptive Optics.

PurposeSmall artery and arteriolar walls thicken due to elevated blood pressure. Vascular wall thickness show a correlation with hypertensive subject history and risk for stroke and cardiovascular events.MethodsThe inner and outer diameter of retinal arterioles from less than 10 to over 150 μm were measured using a multiply scattered light adaptive optics scanning laser ophthalmoscope (AOSLO). These measurements were made on three populations, one with habitual blood pressures less than 100/70 mm Hg, one with normal blood pressures without medication, and one with managed essential hypertension.ResultsThe wall to lumen ratio was largest for the smallest arterioles for all three populations. Data from the hypotensive group had a linear relationship between outer and inner diameters (r2 = 0.99) suggesting a similar wall structure in individuals prior to elevated blood pressures. Hypertensive subjects fell below the 95% confidence limits for the hypotensive relationship and had larger wall to lumen ratios and the normotensive group results fell between the other two groups.ConclusionHigh-resolution retinal imaging of subjects with essential hypertension showed a significant decrease in vessel inner diameter for a given outer diameter, and increases in wall to lumen ratio and wall cross-sectional areas over the entire range of vessel diameters and suggests that correcting for vessel size may improve the ability to identify significant vascular changes.Translational RelevanceHigh-resolution imaging allows precise measurement of vasculature and by comparing results across risk populations may allow improved identification of individuals undergoing hypertensive arterial wall remodeling.

Isolated prehospital hypotension correlates with injury severity and outcomes in patients with trauma

ObjectivePatients normotensive in the trauma bay despite documented prehospital hypotension may not be recognized as significantly injured. The purpose of this study was to determine whether isolated prehospital hypotension portends poor outcomes and correlates with injury severity.MethodsProspective cohort study conducted at a level 1 university trauma center. The lowest recorded prehospital systolic blood pressure (SBP) and the first recorded SBP on hospital arrival were used to divide patients into either the normotensive (NP) or hypotensive (HP) group. Patients who failed to achieve normotension on hospital arrival were excluded. Hypotension was defined as SBP≤110 mmHg.ResultsCompared to NP (n=206), HP (n=81) had lower Glasgow Coma Scores both prehospital (12.81±0.44 vs 14.38±0.13) and at hospital admission (12.78±0.47 vs 14.37±0.14). Injury Severity Score positively correlated with prehospital hypotension (HP 12.27±1.12 vs NP 9.22±0.49). Prehospital hypotension positively correlated with intensive care unit (ICU) admission (HP 56.79% vs NP 22.82%), ICU length of stay (LOS) (HP 3.23±0.71 vs NP 0.71±0.17), hospital LOS (HP 8.58±1.39 vs NP 4.86±0.33), ventilator days (HP 3.38±1.20 vs NP 0.27±0.08 days), and repeat hypotensive episodes during their hospital stay (HP 81.71% vs NP 38.16%). HP also required more packed red blood cells in the first 24 hours after admission (22% vs 6%). Significance was set at p<0.05.ConclusionsIsolated prehospital hypotension in patients in the trauma and emergency department correlates with increased injury severity and portends worse outcomes despite a normal blood pressure reading at admission. Prehospital hypotension must be given heavy consideration in triage, as these patients may be transiently hypotensive and appear less critical than their true status.Level of EvidenceLevel II, Prognostic study.

Prevalence of orthostatic hypotension in patients aged 80 or over and associated risk factors

Objective To investigate the prevalence of orthostatic hypotension in hypertensive patients aged 80 or over and associated risk factors at level A tertiary hospitals. Methods A multi-center cross-sectional study was conducted among very old hypertensive patients(≥80 years) at 28 level A tertiary hospitals by using questionnaire-based surveys. A total of 1298 hypertensive subjects aged between 80 and 101 years were enrolled in this study. Blood pressures was measured in the supine position and the upright position within three minutes of standing, and 316 patients were assigned to the orthostatic hypotension(OH) group and the other 982 patients to the non-orthostatic hypotension(NOH) group. Additional information was acquired through patients' medical records and the questionnaire. Results The prevalence of OH was 24.3%(316 cases) There were no significan different betueen OH patienl with NOHones in gender and age.OH patients had higher supine systolic and diastolic blood pressure(P=0.003 and 0.000, respectively), lower standing systolic and diastolic blood pressure(P=0.000 and 0.000, respectively), and higher rates of past coronary heart disease, stroke and renal abnormalities(P=0.037, 0.001 and 0.014, respectively) than NOH patients. Logistic regression analysis showed that the prevalence of OH in the patients was positively correlated with supine systolic blood pressure(OR=1.196, CI: 1.153-1.242, P=0.000) and supine diastolic blood pressure(OR=1.740, CI: 1.602-1.885, P=0.000) and was negatively correlated with standing systolic blood pressure(OR=0.824, CI: 0.795-0.855, P=0.000) and standing diastolic blood pressure(OR=0.584, CI: 0.539-0.634, P=0.000). Conclusions The prevalence of orthostatic hypotension is high in hypertensive patients aged 80 years or over at level A tertiary hospitals. Poor blood pressure control may increase the risk of orthostatic hypotension. Key words: Elderly, aged over 80 years; Hypertension; Hypotension

Hypotensive Epidural Anesthesia Reduces Blood Loss in Pelvic and Sacral Bone Tumor Resections

Resection of pelvic and sacral tumors can cause severe blood loss, complications, and even postoperative death. Hypotensive epidural anesthesia has been used to mitigate blood loss after elective arthroplasty, but to our knowledge, it has not been studied as an approach that might make resection of pelvic and sacral tumors safer. The purposes of this study were (1) to compare the blood loss and blood product use for patients undergoing pelvic and sacral tumor surgery under standard anesthesia or hypotensive epidural anesthesia; (2) to assess the frequency of end-organ damage with the two techniques; and (3) to compare 90-day mortality between the two techniques. Between 2000 and 2014, 285 major pelvic and sacral resections were performed at one center. A total of 174 (61%) had complete data sets for analysis of blood loss, transfusion use, complications, and mortality at 90 days. Of those, 102 (59%) underwent hypotensive epidural anesthesia, whereas the remainder received standard anesthetic care. The anesthetic approach was determined by the anesthetists in charge of the case with hypotensive epidural anesthesia exclusively performed by one of two subspecialty trained anesthetists as their routine for major pelvic or sacral surgery. The groups were comparable in terms of potential confounding variables such as age, gender, tumor volume, and operation performed. Hypotensive epidural anesthesia was defined as a technique using an extensive epidural block up to T2-3 dermatome, peripherally administered low-concentration intravenous adrenaline infusion, and using unimpeded spontaneous respiration to achieve controlled hypotension, precise rate control of the heart, and enhanced velocity of venous return, all aggregated thus to minimize blood loss during pelvic surgery while preserving vital perfusion. The groups were assessed for perioperative blood loss calculated from pre- and postsurgery hemoglobin and transfusion use as well as postoperative complications, morbidity, and mortality at 90 days. There was less mean blood loss in the hypotensive epidural anesthesia group (1457 mL, SD 1721, 95% confidence interval [CI], 1114-1801 versus 2421 mL, SD 2297, 95% CI, 1877-2965; p = 0.003). Patients in the hypotensive epidural anesthesia group on average received fewer packed red cell transfusions (2.7 units, SD 2.9, 95% CI, 2.1-3.2 versus 3.9 units, SD 4.4, 95% CI, 2.9-5.0; p = 0.03). There were no differences in the proportions of patients experiencing end-organ injury (7%, n = seven of 102 versus 6%, n = four of 72; p = 0.72). With the numbers available, there was no difference in 90-day mortality rate between groups (1.9%, n = two of 102 versus 1.3%, n = one of 72; p = 0.77). We found that hypotensive epidural anesthesia resulted in less blood loss, fewer transfusions, and no apparent increase in serious complications in pelvic and sacral tumor surgery performed in the setting of a high-volume tertiary sarcoma referral hospital. We recommend that further collaborative studies be undertaken to confirm our results with hypotensive epidural anesthesia in surgery for pelvic tumors. Level III, therapeutic study.

Prominent Inferior Intercavernous Sinus on Sagittal T1-Weighted Images: A Sign of Intracranial Hypotension.

The purpose of this study is to describe the diagnostic accuracy of the dilatation of the inferior intercavernous sinus as a sign of intracranial hypotension and to raise awareness of this anatomic structure, which can be mistaken for a focal pituitary lesion. Sagittal T1-weighted images of 26 patients with intracranial hypotension and 28 control subjects were evaluated to determine the presence of a distended inferior intercavernous sinus. Information about the shape, size, and signal of the inferior intercavernous sinus was also collected. The chi-square test was used to compare both groups. Sensitivity and specificity of the dilatation of the inferior intercavernous sinus as a sign of intracranial hypotension were calculated. A visible inferior intercavernous sinus was found in 13 of 26 patients with intracranial hypotension (50%) and in four of 28 control subjects (14.3%). These percentages were significantly different (p = 0.005). There was no significant difference in size of the inferior intercavernous sinus in the intracranial hypotension group (median, 5.86 mm(2); interquartile range, 6.28 mm(2)) compared with the control group (median, 8.25 mm(2); interquartile range, 16.69 mm(2)). Changes in the size of the inferior intercavernous sinus were detected in congruence with the appearance or resolution of intracranial hypotension. Dilatation of the inferior intercavernous sinus is frequently associated with intracranial hypotension, although it can also be found in the healthy adult as a normal anatomic variant. Recognition of this anatomic structure is important to avoid mistaking it for a focal pituitary lesion.

Should adrenaline be used in patients with hemodynamically stable anaphylaxis? Incident case control study nested within a retrospective cohort study.

Although adrenaline (epinephrine) is a cornerstone of initial anaphylaxis treatment, it is not often used. We sought to assess whether use of adrenaline in hemodynamically stable patients with anaphylaxis could prevent the development of hypotension. We conducted a retrospective cohort study of 761 adult patients with anaphylaxis presenting to the emergency department (ED) of a tertiary care hospital over a 10-year period. We divided the patients into two groups according to the occurrence of hypotension and compared demographic characteristics, clinical features, treatments and outcomes. Of the 340 patients with anaphylaxis who were normotensive at first presentation, 40 patients experienced hypotension during their ED stay. The ED stay of the hypotension group was significantly longer than that of patients who did not experience hypotension (496 min vs 253 min, P = 0.000). Adrenaline use in hemodynamically stable anaphylaxis patient was independently associated with a lower risk of developing in-hospital occurrence of hypotension: OR, 0.254 [95% CI, 0.091–0.706]. Adrenaline use in hemodynamically stable anaphylaxis patients was associated with a reduced risk of developing in-hospital occurrence of hypotension. Adverse events induced by adrenaline were rare when the intramuscular route was used.

Analysis of upper esophageal sphincter pressure with symptoms and prognosis in 158 patients with achalasia

Objective To investigate upper esophageal sphincter (UES) abnormalities in patients with achalasia (AC), and to analyze the correlation between UES abnormalities and clinical symptoms, treatment efficacy. Methods From February 2012 to December 2014, 158 patients with AC and received high resolution manometry (HRM) examination were retrospectivly analyzed. According to whether with UES abnormalities, patients were divided into UES normal group and UES abnormal group. Patients of UES abnormal group were sub-divided into UES hypotensive group (UES resting pressure 104 mmHg) and impaired relaxation group (residual pressure>12 mmHg). Analysis of Variance, Kruskal-Wallis H test and Chi square test were performed to compare the clinical data and dynamic characteristics of the patients in each group. Results A total of 74 (46.8%) AC patients had UES abnormalities, the majority of whom were impaired relaxation (35 cases, 47.3%). The age of patients in hypotensive group ((60.6±10.1) years) was significantly older than that of hypertensive group ((43.9±11.1) years) and impaired relaxation group ((46.8±16.3) years), and the disease course (10 years, 4 to 30 years) was obviously longer than that of hypertensive group (6 years, 1 to 10 years) and impaired relaxation group (8 years, 3 to 15 years), and the differences were statistically significant (F=7.983, H=13.816, both P 0.05). The results of AC subtyping indicated that type Ⅱ AC accounted 55.7% (88/158). Type Ⅱ AC cases number of UES normal group and abnormal group was 46 and 42 cases, both was majority (54.8% and 56.8%). Among these patients, 123 patients finally received peroral endoscopic myotomy (POEM), 47.2%(58/123) of whom had abnormal UES. More than 85% patients were satisfied at one month after the operation. And Eckardt scores significantly decreased. There was no significant difference in treatment efficacy between the two groups. Conclusions Most AC patients are with UES abnormality, and impaired relaxation is more common. There is no correlation between UES abnormalities and major symptoms. There is no predictive role of UES abnormalities in treatment efficacy of POEM in AC patients. Key words: High resolution esophageal manometry; Esophageal sphincter, upper; Achalasia; Peroral endoscopic myotomy