Hypotension In Older Patients Research Articles

Predictive Value of Ultrasound-Measured Quadriceps Depth and Frailty Status for Hypotension in Older Patients Undergoing Reverse Total Shoulder Arthroplasty in the Beach Chair Position under General Anesthesia.

The beach chair position (BCP) is widely used in shoulder surgery; however, it frequently leads to hypotension. Hypotension in BCP is prevalent among older patients who are at risk of secondary complications such as ischemic injuries. Therefore, this prospective study aimed to investigate the association and predictive value of frailty, as assessed by ultrasound-measured quadriceps depth and questionnaire, in patients aged ≥65 years undergoing elective shoulder surgery under general anesthesia. A multivariable logistic regression analysis was performed to identify independent risk factors for hypotension in BCP under general anesthesia. Receiver operating characteristic curves were constructed to assess the predictive values of various parameters. The results indicated that a quadriceps depth < 2.3 cm and BCP for an extended period significantly increased the risk of hypotension. The combined consideration of quadriceps depth < 2.3 cm and frailty demonstrated markedly superior predictive power compared with each factor individually. In conclusion, the study findings facilitate the screening and identification of risk factors for older patients undergoing surgery in BCP, thereby enhancing perioperative management.

Preoperative echocardiography as a predictor of spinal anesthesia-induced hypotension in older patients with mild left ventricular diastolic dysfunction: a retrospective observational study.

Spinal anesthesia-induced hypotension (SAH) frequently occurs in older patients, many of whom have mild left ventricular (LV) diastolic dysfunction, often asymptomatic at rest. This study investigated the association between preoperative echocardiographic measurements and SAH in older patients with mild LV diastolic dysfunction. We conducted a retrospective observational study using data from electronic medical records. The patients ≥ 65 years old who underwent spinal anesthesia for urologic surgery between January 2016 and December 2017 and whose preoperative echocardiography within 6 months before surgery revealed grade I LV diastolic dysfunction were recruited. SAH was investigated using the anesthesia records. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed. A total of 163 patients were analyzed. SAH and significant SAH developed in 55 (33.7%) patients. The mitral inflow E velocity was an independent risk factor for SAH (odds ratio [OR], 0.886; 95% confidence interval [CI], 0.845-0.929; P < 0.001). The area under the ROC curve for mitral inflow E velocity to predict SAH was 0.819 (95% CI, 0.752-0.875; P < 0.001). If mitral inflow E velocity was ≤ 60 cm/s, SAH was predicted with a sensitivity of 83.6% and specificity of 70.4%. The preoperative mitral inflow E velocity demonstrated the greatest predictability of SAH in older patients with mild LV diastolic dysfunction. This may assist in identifying patients at high risk of SAH and guiding preventive strategies in the future.

Norepinephrine prevents hypotension in older patients under spinal anesthesia with intravenous propofol sedation: a randomized controlled trial

Reducing hypotension is crucial as hypotension is the most common side effect of spinal anesthesia, and in older patients with various comorbidities, it can lead to fatality. We hypothesized that continuous infusion of norepinephrine could effectively prevent hypotension in older patients undergoing hip surgery under spinal anesthesia with propofol sedation. The study randomly assigned patients aged ≥ 70 years to either a control (Group C, n = 35) or a norepinephrine group (Group N, n = 35). After spinal anesthesia, continuous infusion of propofol and normal saline or norepinephrine was initiated. The number of hypotensive episodes, the primary outcome, as well as other intraoperative hemodynamic events and postoperative complications were compared. In total, 67 patients were included in the final analysis. The number of hypotensive episodes was significantly higher in Group C than in Group N (p < 0.001). Furthermore, Group C required a greater amount of fluid to maintain normovolemia (p = 0.008) and showed less urine output (p = 0.019). However, there was no difference in postoperative complications between the two groups. Continuous intravenous infusion of prophylactic norepinephrine prevented hypotensive episodes, reduced the requirement of fluid, and increased the urine output in older patients undergoing unilateral hip surgery under spinal anesthesia with propofol sedation.Clinical trial registration number: KCT0005046 (https://cris.nih.go.kr). IRB number: 2020-0533 (Institutional Review Board of Asan Medical Center, approval date: 13/APR/2020).

Preoperative Frailty Is an Independent Risk Factor for Postinduction Hypotension in Older Patients Undergoing Noncardiac Surgery: A Retrospective Cohort Study.

Intraoperative hypotension is a risk factor for perioperative adverse outcomes and is highly prevalent in older patients. Frailty has been associated with hemodynamic instability but its impact on postinduction hypotension is unclear. Therefore, we assessed the association between frailty and postinduction hypotension in older patients. We retrospectively evaluated electronic medical records of patients aged ≥65 years who were assessed for preoperative frailty and underwent noncardiac surgery under general anesthesia. Reported Edmonton Frail Scale (REFS) scores were used to stratify patients into a nonfrail (REFS scores 0-5), prefrail (6-7), and frail (8-18) groups. Postinduction hypotension was defined as a mean blood pressure below 65 mmHg or 20% from baseline occurring within the first 20 minutes after anesthesia induction and evaluated using multivariate logistic regression analysis. Independent factors related to postinduction hypotension in our sample (421 patients) were status of frail (REFS score ≥8) compared to nonfrail (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.44-5.18; p = .002), lower baseline mean blood pressure in the operating room (OR, 0.98; 95% CI, 0.96-0.999; p = .034) and at the presurgical center (OR, 0.96; 95% CI, 0.94-0.99; p = .003), and orthopedic (compared to urologic) surgery (OR, 2.22; 95% CI, 1.14-4.30; p = .019). Preoperative frail status based on REFS scores is associated with postinduction hypotension. Frailty screening tool for older patients may enhance traditional risk calculators and improve patient selection for noncardiac surgery under general anesthesia.

Comparison of the hemodynamic effects of opioid-based versus lidocaine-based induction of anesthesia with propofol in older adults: a randomized controlled trial

BackgroundThe present study aims to compare the hemodynamic profile of lidocaine and fentanyl during propofol induction of general anesthesia. MethodsThis randomized controlled trial included patients aged above 60 years undergoing elective non-cardiac surgery. The included patients received either 1 mg/kg lidocaine (n = 50) or 1 mcg/kg fentanyl (n = 50) based on total body weight with propofol induction of anesthesia. Patient’s hemodynamics were recorded every minute for the first 5 min then every 2 min until 15 min after induction of anesthesia. Hypotension (mean arterial pressure [MAP] <65 mmHg or >30% reduction from baseline) was treated by intravenous 4 mcg bolus of norepinephrine. Outcomes included norepinephrine requirements (primary), the incidence of postinduction hypotension, MAP, heart rate, intubation condition, and postoperative delirium via the cognitive assessment method. ResultsForty-seven patients in the lidocaine group and 46 patients in the fentanyl group were analyzed. None in the lidocaine group experienced hypotension, while 28/46 (61%) of patients in the fentanyl group developed at least one episode of hypotension requiring a median (25th and 75th quartiles) norepinephrine dose of 4 (0,5) mcg, p-value <0.001 for both outcomes. The average MAP was lower in the fentanyl group than in the lidocaine group at all time points after anesthesia induction. The average heart rate was comparable between the two groups nearly at all time points after anesthesia induction. The overall intubation condition was comparable between the two groups. None of the included patients developed postoperative delirium. ConclusionLidocaine-based regimen for induction of anesthesia reduced the risk of postinduction hypotension in older patients compared to the fentanyl-based regimen.

Quality improvement project to improve diagnosis and management of postural hypotension in older patients over 65 years during acute admission

Quality improvement project to improve diagnosis and management of postural hypotension in older patients over 65 years during acute admission

The value of ambulatory blood pressure measurement to detect masked diastolic hypotension in older patients treated for hypertension.

assess how many patients with low ambulatory diastolic blood pressure (DBP) are not identified when relying on office DBP alone, and thus have 'masked diastolic hypotension'. cross-sectional, retrospective cohort study. academic hospital. 848 patients treated for hypertension who received ambulatory blood pressure monitoring (ABPM). cut-off value between on- and off-target systolic blood pressure (SBP): 140mmHg. Cut-off for low office and/or ambulatory DBP: DBP ≤ 70mmHg. 'Masked diastolic hypotension' was defined as office DBP > 70mmHg and mean ambulatory DBP ≤ 70mmHg. mean age of the sample was 60 ± 13years, 50% was female, 37% had diabetes, 42% preexisting cardiovascular disease (CVD), mean office blood pressure (BP) was 134/79mmHg. In all patients (n = 848), low office DBP was present in n = 84(10%), while n = 183(22%) had low ambulatory DBP. In all patients with normal-to-high office DBP (n = 764), n = 122(16%) had 'masked diastolic hypotension'. In this group, ambulatory DBP was 14-19mmHg lower than office DBP. Patients with low ambulatory DBP were older, had more (cardiovascular) comorbidities, and used more (antihypertensive) drugs. Antihypertensive drugs were lowered or discontinued in 30% of all patients with 'masked diastolic hypotension' due to side effects. 'masked diastolic hypotension' is common among patients treated for hypertension, particularly in older patients with CVD (e.g. coronary artery disease, diabetes), patient groups in which the European Society of Cardiology/Hypertension guideline advises to prevent low DBP. Although it remains to be examined at which BP levels the harms of low DBP outweigh the benefits of lowering SBP, our observations are aimed to increase awareness among physicians.

Is Arterial Stiffness a Determinant of Hypotension?

Previous observation identified both hypotension and arterial aging, indexed as Pulse Wave Velocity (PWV), as significant determinants of cognitive decline in older subjects. To investigate the role of PWV as a determinant of hypotension in older patients. A cohort of 344 subjects came to our Outpatient Clinic, free of cancer, acute myocardial infarction or stroke, atrial fibrillation, renal, hepatic or cardiac failure, secondary hypertension, or thyroid disease. Hypotension occurred in 49% of participants. SBP levels (OR 0.79, 95% CI 0.67-0.84, p < 0.01), PWV (OR 0.86, 95% CI 0.77-0.94, p < 0.01), and use of beta-blockers (OR 2.42, 95% CI 1.09-5.36, p < 0.05), were independent determinants of the risk of hypotension. Hypotension is a quite common phenomenon in older subjects. Its prevention requires a more accurate management of hypertension aimed at better identifying which older subjects in whom intensive BP control may be harmful and those who may benefit from it.

Different patterns of orthostatic hypotension in older patients with unexplained falls or syncope: orthostatic hypotension patterns in older people.

To evaluate different patterns of orthostatic hypotension (OH) and its relation to mortality in older patients with unexplained falls or syncope. This is an observational cohort study in consecutive patients aged ≥ 65years with unexplained falls or syncope at a Fall Syncope day clinic November 2011 until May 2016. OH is defined as a decrease in systolic blood pressure (BP) ≥ 20mmHg and/or in diastolic BP ≥ 10mmHg during standing test. Main outcomes are the baseline characteristics and prevalence of patients with classical OH (decrease BP until 3min), delayed OH (decrease of BP from 5 to 10min) and continuous OH (decrease of BP for 10min). Secondary outcome is the relation between different OH patterns and mortality. Of 374 patients with a mean age of 80year (SD 6.6), 56% of the patients had OH: 16% had classical OH, 8% delayed OH, 32% had continuous OH and 44% had no OH. Patients with continuous OH and patients with delayed OH tended to have a higher mortality compared to patients with classical OH, 14 vs. 5% (P = 0.07) and 17 vs. 5% (P = 0.06). This possible relation between OH patterns and mortality could not be confirmed in multivariate analysis. In these very old patients, there are various patterns of decline in standing BP. Delayed and continuous OH will be missed if BP is measured only for 3min during standing. This is important because patients with continuous OH and delayed OH might have a relation with mortality. Our results encourage additional studies investigating the relation between different OH patterns and mortality.

A Retrospective Observational Study of Anesthetic Induction Dosing Practices in Female Elderly Surgical Patients: Are We Overdosing Older Patients?

Despite guidelines suggesting a 25-50% reduction in induction doses of intravenous anesthetic agents in the elderly (≥65years), we hypothesized that practitioners were not sufficiently correcting drug administration for age, contributing to an increased incidence of hypotension in older patients undergoing general anesthesia. We conducted a retrospective, observational study in a tertiary-care academic hospital. The study included 768 female patients undergoing gynecologic surgeries who received propofol-based induction of general anesthesia. Weight-adjusted anesthetic induction dosing, age-associated differences in dosing by ASA-PS (American Society of Anesthesiology-Physical Status), and hemodynamic outcomes between younger (18-64years, n=537) and older (≥65years, n=231) female patients were analyzed. Older patients received lower doses of propofol and midazolam than younger patients (propofol: 2.037±0.783 vs 2.322±0.834mg/kg, p<0.001; midazolam: 0.013±0.014 vs 0.023±0.042mg/kg, p<0.001). However, practitioners still consistently exceeded the FDA recommended dose (1-1.5mg/kg) of propofol for elderly patients. There was no significant difference in the doses of fentanyl administered between the two age groups (1.343±0.744 vs 1.363±0.763μg/kg, p=0.744), and doses of fentanyl in older patients exceeded the recommended dose (0.5-1.0μg/kg). Corresponding to observed overdosing of induction agents, older patients experienced larger decreases in post-induction blood pressure and were more likely to receive vasopressor therapy. Anesthetic induction doses of fentanyl and propofol were not sufficiently corrected in older patients in accordance with recommendations. Significantly greater frequency of post-induction hypotension occurred amongst older patients. Quality improvement efforts may lead to improved outcomes in this vulnerable population.

Effect of vitamin D supplementation on orthostatic hypotension: data from the vitamin D in isolated systolic hypertension randomized controlled trial.

Orthostatic hypotension commonly accompanies supine hypertension, and is associated with low 25-hydroxyvitamin D levels. We tested whether high-dose intermittent oral vitamin D therapy could ameliorate orthostatic hypotension in older patients with isolated systolic hypertension. We conducted a subgroup analysis of data from a parallel-group, double-blind, randomized, placebo-controlled trial. Patients aged over 70 years with supine office SBP above 140 mmHg and DBP below 90 mmHg received 100 000 units oral vitamin D3 or matching placebo every 3 months for 1 year. Office supine and standing blood pressure were measured at baseline, and 3, 6, 9 and 12 months, along with arterial stiffness and flow-mediated dilatation of the brachial artery. Of 159 patients randomized to the main trial, 75 patients with orthostatic hypotension at baseline were included in this analysis. The mean age was 78 (SD 5) years, baseline blood pressure was 162/76 mmHg and the mean baseline orthostatic fall in blood pressure on standing was 32/5 mmHg. After adjustment for baseline age, 25-hydroxyvitamin D, SBP and orthostatic fall, the fall in SBP was less in the vitamin D group at 3 months [treatment effect 6 mmHg, 95% confidence interval (CI) 0 to 12], but repeated-measures analysis showed no significant treatment effect (3 mmHg for systolic fall, 95% CI -1 to 8; 1 mmHg for diastolic fall, 95% CI -1 to 3). Twelve months of intermittent, high-dose oral vitamin D3 did not significantly improve orthostatic hypotension in older patients with isolated systolic hypertension.

Hypertension and orthostatic hypotension in older patients

Hypertension and orthostatic hypotension in older patients

Orthostatic hypotension in older patients

Orthostatic hypotension (OH) is a clinical condition which frequently results in troublesome symptoms such as dizziness, giddiness, blurred vision and light-headedness. It is a common disorder associated with an increased risk of falling, especially in older individuals. OH is the presenting haemodynamic manifestation of several different and diverse underlying pathological conditions, including disorders of blood pressure (BP) regulation and disorders leading to reduced intravascular volume. In younger and middle-aged adults, the presence of OH should not be considered a primary diagnosis in itself but rather a starting point in the diagnostic pathway before the primary underlying abnormality has been identified. In older patients however, asymptomatic blood pressure drops are very frequently encountered so that, in certain cases, an exhaustive diagnostic search for an underlying cause is not warranted. However, reversible causes of OH do frequently exist in older patients. Prominent among these are the use of several commonly prescribed cardiovascular drugs and vitamin B12 deficiency.

Orthostatic Hypotension in Older Patients

Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20 mmHg or of diastolic blood pressure of at least 10 mmHg within 3 min of standing. It occurs in 30–50% of elderly individuals with disease and/or medication risk factors. It is uncommon in healthy elderly people. Most patients with orthostatic blood pressure changes do not have typical symptoms and therefore symptoms are not helpful in deciding who should be screened. Epidemiological data suggest that the presence of orthostatic hypotension is associated with syncope, falls, stroke and death. The treatment approach is not standardized, but a stepped-care algorithm is presented in this article, which is likely to be successful in many patients. Future studies need to focus on the potential benefits of screening and treating patients with this disorder, especially if they are asymptomatic.

Combined hypertension and orthostatic hypotension in older patients: a treatment dilemma for clinicians

The combination of hypertension and orthostatic hypotension in older individuals is becoming increasingly recognized. Managing this combination of disorders presents a treatment dilemma – how to lower blood pressure to provide cardiovascular risk protection without predisposing to syncope. At present, there is no specific evidence base available with regard to managing such patients. Some antihypertensive drug classes (e.g., α-blockers) appear more problematic in this regard than others. In the absence of controlled-trial evidence, use of antihypertensives with a more gradual onset of effect commenced at lower doses and use of lower-limb compression hosiery appears to be a reasonable approach. Abdominal compression devices and elevating the head of the bed may also help to combat orthostatic hypotenstion in older patients with hypertension and warrant future research.

Orthostatic hypotension in older patients

Orthostatic hypotension (OH) is a clinical condition which frequently results in troublesome symptoms such as dizziness, giddiness, blurred vision and light-headedness. It is a common disorder associated with an increased risk of falling, especially in older individuals. OH is the presenting haemodynamic manifestation of several different and diverse underlying pathological conditions, including disorders of blood pressure (BP) regulation and disorders leading to reduced intravascular volume.

Carotid sinus hypersensitivity is common in older patients presenting to an accident and emergency department with unexplained falls.

To determine the prevalence of carotid sinus hypersensitivity and orthostatic hypotension in older patients with non-accidental falls attending an accident and emergency department. A prospective case-control non-randomized study. Data were collected from semi-structured interviews, physical examination and neurocardiovascular investigations. We recruited cases and controls from an inner-city accident and emergency department. 26 consecutive patients presenting to accident and emergency with non-accidental falls and 54 controls matched for age, sex and cognitive function presenting to the same department either because of an accidental fall or a reason other than falling. MAIN VARIABLES MEASURED: Detailed history and clinical evaluation, including postural phasic blood pressure measurements, heart rate and blood pressure responses to supine and upright carotid sinus stimulation. Orthostatic blood pressure responses did not differ between groups. The heart rate and blood pressure responses to carotid sinus massage were abnormal in patients with non-accidental falls compared with controls (P=0.002). Asystolic responses were present in 12 (46%) of 26 cases and seven (13%) of 54 controls. Loss of consciousness occurred during carotid sinus massage in seven (27%) of the cases, all of whom had asystole, and in none of the controls. Almost half of the cognitively normal older patients attending accident and emergency with non-accidental falls have carotid sinus hypersensitivity, emphasizing that a post-fall intervention strategy should include carotid sinus studies.

Drug-induced orthostatic hypotension in older patients.

Orthostatic hypotension occurs in 10 to 30% of the elderly. In several studies it has been linked to recurrent falls and syncope. Generally, it has multiple causes, of which autonomic dysfunction plays an important role in elderly people. Very often orthostatic hypotension is induced by the use of drugs. In other cases, it is already present subclinically, and is worsened by the use of drugs to become symptomatic. For most drugs, changing pharmacokinetics result in a delayed elimination and/or in a greater bioavailability in the elderly. This results in a more pronounced effect for drugs with a desired hypotensive action [e.g. diuretics, calcium channel blockers, beta-blockers, angiotensin converting enzyme (ACE) inhibitors]. For those drugs in which hypotension is a known but unwanted adverse effect (e.g. nitrates, anti-Parkinsonian drugs, antidepressants, antipsychotics), responses will be greater in the elderly and orthostatic hypotension will occur more frequently. For elderly people, doses have to be reduced and/or the dose intervals prolonged in order to avoid such adverse reactions.