Hypotensive Episodes Research Articles

Description of STRIVE-ON Study Protocol: Safety and Tolerability of GTX-104 (Nimodipine Injection for IV Infusion) Compared with Oral Nimodipine in Patients Hospitalized for Aneurysmal Subarachnoid Hemorrhage (aSAH): A Prospective, Randomized, Phase III Trial (STRIVE-ON).

Oral nimodipine is the only drug approved in North America for patients with aneurysmal subarachnoid hemorrhage (aSAH). However, bioavailability is variable and frequently poor, leading to fluctuations in peak plasma concentrations that cause dose-limiting hypotension. Furthermore, administration is problematic in patients who cannot swallow. An oral liquid formulation exists but causes diarrhea. An intravenous nimodipine formulation (GTX-104) has been developed that has bioavailability approaching 100% and is not affected by feeding or gastrointestinal absorption. GTX-104 causes less hypotension and has more consistent peak plasma concentrations than oral nimodipine in human volunteers. Herein, we describe the protocol of a prospective, randomized, open-label safety, and tolerability study of GTX-104 compared with oral nimodipine in patients with aSAH (Safety and Tolerability of GTX-104 [Nimodipine Injection for Intravenous Infusion] Compared with Oral Nimodipine; ClinicalTrials.gov identifier: NCT05995405). The study is designed to seek approval of GTX-104 by the Food and Drug Administration 505(b)(2) pathway. Inclusion and exclusion criteria match the prescribing information for oral nimodipine and include adult patients with aSAH of all Hunt and Hess grades who can receive investigational product within 96h of aSAH. Study participants at imminent risk of death will be excluded. Study participants will be randomly assigned 1:1 to receive GTX-104 or oral nimodipine for up to 21days. The primary end point is the proportion of study participants with clinically significant hypotension, defined as hypotension requiring treatment that has a reasonable likelihood of being due to investigational product as determined by an independent, blinded end point adjudication committee. No statistical analysis of the end point is planned. Secondary end points include all episodes of hypotension, all adverse events, delayed cerebral ischemia, rescue therapy, and suicidal ideation. Clinical and health economic outcomes include quality of life using the EuroQol 5-dimension/3-level, modified Rankin Scale score at 30 and 90days after aSAH and hospital resource use. The planned sample size is 100 study participants across 25 sites in the United States and Canada.

Case Series of Anesthetic Management of Gene Therapy in Children With Aromatic L-Amino Acid Decarboxylase Deficiency.

Aromatic L-amino acid decarboxylase (AADC) deficiency is a rare life-threatening inborn error of neurotransmitter biosynthesis. It is characterized by deficient biosynthesis of neurotransmitters dopamine and serotonin, leading to catecholamines deficiency and sympathetic deprivation, while the parasympathetic system remains functional. Since 2012, gene therapy has led to clinical improvements in symptoms and motor function with a severe phenotype. General anesthesia of children with AADC deficiency is challenging. Describe prolonged anesthesia management of children with aromatic L-amino acid decarboxylase deficiency undergoing stereotactically guided gene therapy. Prospective reporting of epidemiologic and anesthetics data of four children consecutively undergoing magnetic resonance-guided direct delivery of an AADC vector for gene therapy under general anesthesia. General anesthesia was initiated with sevoflurane and ketamine and rocuronium was the neuromuscular blocking agent of choice throughout the procedures. Intraoperative hemodynamic monitoring included an arterial line. All children required low doses of diluted norepinephrine during the intraoperative period. No dysautomic episodes as well as no episode of severe hypotension and no severe hypoglycemia were reported throughout the procedures. Vasopressor support was discontinued for all children at the end of the procedures. Moreover, no peroperative and postoperative effects secondary to AADC vector injection were noted. Using an anesthetic plan based on atropine, ketamine, sevoflurane, and a titrated infusion of norepinephrine, prolonged anesthesia appeared to be safe and reproductible in this population.

Non-Occlusive Mesenteric Ischemia in Aortic Surgery: What You Need to Know.

Nonocclusive mesenteric ischemia (NOMI), a subtype of acute mesenteric ischemia, is primarily caused by mesenteric arterial vasoconstriction and decreased vascular resistance, leading to impaired intestinal perfusion.Commonly observed after cardiac surgery, NOMI affects older patients with cardiovascular or systemic diseases, accounting for 20-30% of acute mesenteric ischemia cases with a mortality rate of ∼50%. This review explores NOMI's pathophysiology, clinical implications in aortic dissection, and the unmet needs in diagnosis and management, emphasizing its prognostic significance. A comprehensive literature review was conducted using multiple electronic databases to extract relevant data and information. NOMI is a life-threatening condition characterized by mesenteric vasoconstriction and reduced splanchnic blood flow, often triggered by cardiac surgery, haemodialysis, or hypotensive episodes. Epidemiological studies highlight its prevalence in ICU settings, with a high mortality rate linked to delayed diagnosis and systemic hypoperfusion. Risk factors include advanced age, vasopressor use, and inflammatory markers. Biomarkers such as I-FABP, citrulline, and D-lactate show potential for early detection but lack robust clinical validation. Management includes fluid resuscitation, vasodilators, and surgical intervention for bowel necrosis. Emerging endovascular approaches show promise but are limited to select cases without bowel infarction. This review underscores the critical need for timely diagnosis, risk factor identification, and tailored interventions to improve outcomes. NOMI remains poorly understood despite advances in surgical and perioperative care. Its pathophysiology, linked to cardiopulmonary bypass and intraoperative factors, requires heightened clinical vigilance. Limited evidence underscores the need for a multidisciplinary approach involving surgeons, radiologists, and anaesthetists to improve diagnosis, management, and outcomes in aortic surgery patients. Figure 1. Schematic illustration of morphological and haemodynamic patterns of mesenteric ischaemia. The aortic type (A) and branch type (B) cause significant malperfusion, while mild compression of the true lumen (TL) or double tract perfusion do not cause malperfusion. AB-AO abdominal aorta, FL false lumen, SMA superior mesenteric artery. Reproduced from Orihashi et al. [REF] with copyright permission obtained.

Hypotensive Episodes Identified on 24-Hour Ambulatory Blood Pressure and Impaired Cognitive Function: Insights From the SPRINT Study.

Hypotensive episodes detected by 24-hour ambulatory blood pressure (BP) monitoring capture daily cumulative hypotensive stress and could be clinically relevant to cognitive impairment, but this relationship remains unclear. We included participants from the Systolic Blood Pressure Intervention Trial (receiving intensive or standard BP treatment) who had 24-hour ambulatory BP monitoring measured near the 27-month visit and subsequent biannual cognitive assessments. We evaluated the associations of hypotensive episodes (defined as systolic BP drops of ≥20 mm Hg between 2 consecutive measurements that reached <100 mm Hg) and hypotensive duration (cumulative time of systolic BP <100 mm Hg) with subsequent cognitive function using adjusted linear mixed models. We further assessed 24-hour average BP and variability. Among 842 participants with treated hypertension (mean age, 71±9 years; 29% women), the presence (versus absence) of recurrent hypotensive episodes (11%) was associated with lower digit symbol coding scores (difference in Z scores, -0.249 [95% CI, -0.380 to -0.119]) and faster declines (difference in Z score changes, -0.128 [95% CI, -0.231 to -0.026]). A consistent dose-response association was also observed for longer hypotensive duration with worse Montreal Cognitive Assessment and digit symbol coding scores. The association with digit symbol coding scores remained significant after further adjusting for 24-hour average BP and variability and was not observed for hypotension defined by clinic, orthostatic, or 24-hour average BP. Intensive BP treatment increased 24-hour hypotensive episodes and modified its association with the decline in digit symbol coding score. Twenty-four-hour hypotensive episodes were associated with worse cognitive function, especially in processing speed, and could be a novel marker for optimal BP control and dementia prevention.

COMPARISON OF HYPERBARIC BUPIVACAINE AND FENTANYL MIXTURE AND HYPERBARIC BUPIVACAINE ALONE ON BLOOD PRESSURE AND HEART RATE AMONG PATIENTS UNDERGOING UNILATERAL SPINAL BLOCK FOR LOWER LIMB SURGERIES

Background: Unilateral spinal anesthesia is widely utilized in lower limb surgeries due to its ability to provide effective anesthesia with reduced hemodynamic instability. Combining hyperbaric bupivacaine with fentanyl has been proposed to enhance anesthetic efficacy while reducing adverse effects such as hypotension and bradycardia. Despite its documented benefits, limited research has explored the impact of this combination in the Pakistani population, where unique demographic and physiological characteristics may influence clinical outcomes. Objective: To compare the effects of hyperbaric bupivacaine combined with fentanyl versus hyperbaric bupivacaine alone on blood pressure and heart rate in patients undergoing unilateral spinal block for lower limb surgeries. Methods: This randomized controlled trial was conducted over six months at Northwest General Hospital, Peshawar, and included 60 patients aged 20–60 years undergoing unilateral lower limb surgery. Patients were randomly divided into two groups: Group A received 7.25 mg of hyperbaric bupivacaine combined with 25 µg fentanyl, while Group B received 10 mg of hyperbaric bupivacaine alone. Blood pressure and heart rate were closely monitored pre- and post-anesthesia. Hypotension, defined as a systolic blood pressure drop of more than 20% from baseline, was treated with ephedrine or phenylephrine, while bradycardia, defined as a heart rate below 50 beats per minute, was managed with atropine. Results: Group A demonstrated significantly fewer episodes of hypotension (12%) compared to Group B (28%) and a lower incidence of bradycardia (4% vs. 10%). Group A also exhibited improved hemodynamic stability and faster recovery. No significant adverse events were reported in either group. Conclusion: The combination of fentanyl and hyperbaric bupivacaine improves hemodynamic stability and reduces the risk of hypotension and bradycardia in unilateral spinal anesthesia for lower limb surgeries, offering a safer and more effective anesthetic option.

Deep learning model to identify and validate hypotension endotypes in surgical and critically ill patients.

Hypotension is associated with organ injury and death in surgical and critically ill patients. In clinical practice, treating hypotension remains challenging because it can be caused by various underlying haemodynamic alterations. We aimed to identify and independently validate endotypes of hypotension in big datasets of surgical and critically ill patients using unsupervised deep learning. We developed an unsupervised deep learning algorithm, specifically a deep learning autoencoder model combined with a Gaussian mixture model, to identify endotypes of hypotension based on stroke volume index, heart rate, systemic vascular resistance index, and stroke volume variation observed during episodes of hypotension. The algorithm was developed with data from 871 surgical patients who had 6962 hypotensive events and validated in two independent datasets, one including 1000 surgical patients who had 7904 hypotensive events and another including 1000 critically ill patients who had 53 821 hypotensive events. We defined hypotension as a mean arterial pressure <65 mm Hg for at least 1 min. In the development dataset, we identified four hypotension endotypes. Based on their physiological and clinical characteristics, we labelled them as: vasodilation, hypovolaemia, myocardial depression, and bradycardia. The same four hypotension endotypes were identified in the two independent validation datasets of surgical and critically ill patients. Unsupervised deep learning identified four endotypes of hypotension in surgical and critically ill patients: vasodilation, hypovolaemia, myocardial depression, and bradycardia. The algorithm provides the probability of each endotype for each hypotensive data point. Identifying hypotensive endotypes could guide clinicians to causal treatments for hypotension.

Improving Diagnosis of Acute Cholecystitis with US: New Paradigms.

Acute cholecystitis is an inflammatory condition of the gallbladder typically incited by mechanical obstruction. Accurate diagnosis of this common clinical condition is challenging due to variable imaging appearances as well as overlapping clinical manifestations with biliary colic, acute hepatitis, pancreatitis, and cholangiopathies. In acute cholecystitis, increased dilatation and high intraluminal pressures lead to gallbladder inflammation and may progress to gangrenous changes, focal wall necrosis, and subsequent perforation. In acute calculous cholecystitis, gallstones are the cause of obstruction and are often impacted in the gallbladder neck or cystic duct, leading to gallbladder inflammation. In acalculous cholecystitis, patients are typically critically ill, often with hypotensive episodes and prolonged gallbladder stasis, which lead to obstruction, gallbladder ischemia, and inflammation. Helpful sonographic findings of acute cholecystitis include a dilated gallbladder; increased intraluminal pressures in the gallbladder, resulting in a bulging fundus (tensile fundus sign); intraluminal sludge in the setting of right upper quadrant pain; wall hyperemia, which may be quantified by elevated cystic artery velocities or hepatic artery velocities; mucosal ischemic changes, characterized by loss of mucosal echogenicity; pericholecystic inflammation, characterized by hyperechoic pericholecystic fat; and mucosal discontinuity. Extruded complex fluid next to a wall defect is definitive for gallbladder wall perforation, and further evaluation with CT or MRI allows evaluation of the full extent of perforation and other potential complications. The sonographic Murphy sign, while helpful if positive, is relatively insensitive for accurate diagnosis of acute cholecystitis. Thus, overreliance on the sonographic Murphy sign results in surprisingly low diagnostic accuracy in practice.

Hypotension with and Without Hypertensive Episodes During Endoscopic Adrenalectomy for Pheochromocytoma or Paraganglioma-Should Perioperative Treatment Be Individualized?

Background: Hemodynamic instability is common during adrenalectomy for pheochromocytoma and paraganglioma (PPGL). Most analyses focus on the risk factors for intraoperative hypertension, but hypotension is a frequent and undesirable phenomenon during PPGL surgery. This study aimed to analyze the risk factors for hypotensive episodes during the removal of PPGL, and whether these episodes are always associated with concomitant intraoperative hypertensive events. Methods: A consecutive series of 121 patients (91.7% receiving preoperative alpha-blockade) treated with transperitoneal endoscopic adrenalectomy at a university hospital were analyzed, and pre- and intraoperative risk factors for intraoperative hypotension with or without intraoperative hypertension were analyzed using univariable and multivariable logistic regression analyses. Results: In total, 58 (56.2%) patients presented with intraoperative hypotension. Of these, 25 (20.7%) patients showed only hypotensive episodes but no hypertensive episodes (group 1), and 43 (35.5%) patients had both intraoperative hypotension and hypertension (group 2). The remaining 53 patients did not present with hypotension at all (group 3). When comparing group 1 (hypotension only) to all other patients with incidental diagnosis, higher age and lower preoperative diastolic arterial blood pressure (ABP) were significant risk factors for intraoperative hypotension; only the latter two were still significant in multivariate analysis. The significant risk factors for hypotension independent of hypertension (group 1 + 2 vs. group 3) were age and incidental diagnosis, pre-existing diabetes mellitus, and intraoperative use of remifentanil. Incidental diagnosis and use of remifentanil reached the level of significance in multivariate analysis. Conclusions: Since older age, incidental diagnosis of PPGL, lower preoperative ABP, and diabetes mellitus are risk factors for intraoperative hypotension, preoperative alpha-blocker treatment should be individualized for those at risk for hypotension. In addition, remifentanil should be used cautiously in the risk group.

Effect of remimazolam besylate versus propofol on haemodynamic profiles in patients undergoing thyroid surgery with recurrent laryngeal nerve monitoring: a protocol for a randomised controlled trial

IntroductionThyroid surgery with intraoperative nerve monitoring under total intravenous anaesthesia often requires deeper sedation due to limitations or lack of neuromuscular blocking agents, usually resulting in haemodynamic instability. Remimazolam, a...

Abstract 4125636: Impaired blood pressure regulation in post-COVID-19 postural orthostatic tachycardia syndrome: novel disease mechanisms beyond sinus tachycardia

Background: Postural orthostatic tachycardia syndrome (POTS) is a prevalent cardiovascular disorder after COVID-19 infection. Although POTS is characterized by the presence of sinus tachycardia, other hemodynamic disturbances including blood pressure (BP) regulation, remain largely unexplored. Aims: We investigated BP changes using 24-hour ambulatory-BP-monitoring in patients with new-onset POTS after COVID-19 compared with pre-pandemic healthy controls. Methods: We performed a case-control study in 100 verified COVID-19 patients with new-onset POTS (mean age 40.0±12.9 years, 85% women) diagnosed by positive head-up tilt-testing versus 100 healthy controls (mean age 45.0±14.6 years, 70% women) from a population-based cohort with negative active standing test, no history of syncope, orthostatic intolerance, or endocrine disease. We analyzed 24-hour Systolic BP (SBP) and hypotensive SBP episodes (&lt;80, &lt;90, and &lt;100mmHg). Results: Study characteristics are illustrated in the Table . Post-COVID-19 POTS patients had significantly higher nighttime-SBP, but not daytime-SBP, and more daytime SBP hypotensive episodes (&lt;80, &lt;90, and &lt;100 mmHg, Figure ) compared with controls. Non-dipper (34% vs 19%, p&lt;0.001) and reverse dipper patterns (9% vs 0 %, &lt;0.001) were more frequent in post-COVID-19 POTS. In the logistic regression, post-COVID-19 POTS was associated with significantly higher mean 24h SBP (odds ratio (OR) 1.08, 95%CI 1.04-1.11, p&lt;0.001) and nighttime SBP (OR 1.07, 95%CI 1.04-1.10, p&lt;0.001), independently of age and sex. Conclusions: Post-COVID-19 POTS patients demonstrate higher mean 24h and nighttime systolic BP, and show signs of disrupted BP regulation compared with healthy controls. They also have more daytime hypotensive episodes. Future studies are needed to assess if post-COVID-19 POTS patients may benefit from tailored BP therapy.

Blood Pressure Regulation in Post-COVID POTS: Beyond Sinus Tachycardia.

Postural orthostatic tachycardia syndrome (POTS) is a frequently diagnosed cardiovascular disorder after COVID-19 infection. POTS is characterized by the presence of excessive sinus tachycardia on standing without a fall in blood pressure (BP). We investigated the BP profile using 24-hour ambulatory BP monitoring in patients with new-onset POTS after COVID-19 compared with prepandemic population-based controls. We performed a case-control study in 100 patients (mean age, 40.0±12.9 years; 85% women) with verified post-COVID-19 new-onset POTS diagnosed by a positive head-up tilt testing versus 100 controls from a population-based cohort with a negative active standing test, no history of syncope, POTS, or endocrine disease (mean age, 42.3±14.0 years; 78% women). Twenty-four-hour BP profile was assessed for circadian BP variation including hypotensive systolic BP (SBP) episodes (<80, <90, and <100 mm Hg). Patients with post-COVID-19 POTS had significantly higher nighttime SBP, but not daytime SBP, and more daytime SBP hypotensive episodes compared with controls. Nondipping (34% versus 19%; P<0.001) and reverse dipping patterns (9% versus 0%; P<0.001) were more frequent in post-COVID-19 POTS. In the logistic regression, patients with post-COVID-19 POTS had significantly higher mean 24-hour SBP (odds ratio, 1.08 [95% CI, 1.04-1.11]; P<0.001) and nighttime SBP (odds ratio, 1.07 [95% CI, 1.04-1.10]; P<0.001), independent of age and sex. Patients with post-COVID-19 POTS demonstrate higher mean 24-hour and nighttime SBP and show disruptions of circadian BP rhythm regulation compared with population-based controls, as well as more daytime hypotensive episodes. Future studies are needed to test whether patients with post-COVID-19 POTS may benefit from tailored BP therapy.

The prevalence and associated factors of intraoperative hypotension following thoracic surgery in resources limited area, 2023: multicentre approach.

Hypotension is an independent predictor of long-term patient morbidity and duration of hospital stay. Multiple factors contribute to the development of intraoperative hypotension. Prevention and treatment of these factors may reduce patients' hypotension and its associated morbidity and mortality. This study aimed to assess the prevalence and associated factors of intraoperative hypotension in patients undergoing elective thoracic surgery. This institution-based cross-sectional study was conducted among 174 adult patients who underwent elective thoracic surgery. A systematic random sampling technique was used, and quantitative data were collected through interviews and data retrieval from charts via a pretested questionnaire. Both bivariable and multivariable logistic regression analyses were performed to evaluate the associations between independent and dependent variables. The level of statistical significance was defined as a P-value less than 0.05. The data were entered into Info 7.2.1 and analyzed via SPSS version 26 software, which was used to calculate descriptive statistics, and bivariate and multivariate logistic regression were performed. In general, information was collected from 174 patients during the study period. The results of the present study revealed that 65 (41%) patients developed intraoperative hypotension (95% CI: 36.43-48%). Intraoperative blood loss was significantly associated with intraoperative hypotension [AOR=9.58, 95% CI (2.57-35.8)] (P=0.001). The findings of this study revealed high rates of intraoperative hypotension episodes, which were 41%, in patients who underwent elective thoracic surgery. Age, ASA class, type of intraoperative blood loss, type of procedure pre-existence comorbidity, and duration of surgery were predictors of intraoperative hypotension in patients who underwent elective thoracic surgery. The anaesthetist's, surgeon, and PACU staff's understanding of these factors is very crucial for close follow-up of this group of patients.

Comparison Of Bolus Ephedrine, Mephentermine And Phenylephrine For The Management Of Hypotension During Spinal Anaesthesia For Caesarean Section – A Clinical Study

Background: Anaesthesia to a parturient is not only unique but also requires highest degree of care because the anaesthesiologist has to look after two individuals, the mother and fœtus. Hypotension during spinal anaesthesia for caesarean delivery can have detrimental effects on both mother and neonate. These effects include decreased utero-placental blood flow, impaired foetal oxygenation with asphyxial stress and foetal acidosis and maternal symptoms of low cardiacoutput such as nausea, vomiting, dizziness and decreased consciousness. Vasopressor like Ephedrine, Mephentermine, Phenylephrine, are used for treating the hypotension. In this study we compared the efficacy of Ephedrine, Mephentermine and Phenylephrine in treating the hypotension for caesarean section and their desirable side effects. Materials and Methods: In this prospective randomised controlled study, 90 patients of ASA physical status I and II belonging to age group of 18-35 years undergoing elective or emergency LSCS under sub-arachnoid block were randomly allocated into 3 groups of 30patients each, Group E (Ephedrine) and Group M (Mephentermine) and Group P (Phenyephrine). Group E received Inj Ephedrine 6 mg IV bolus, Group M received Inj Mephentermine 6 mg IV bolus and Group P received Inj Phenylephrine 100 microgram IV bolus for spinal anaesthesia. The changes in hemodynamic parameters, neonatal outcome, side-effects and usage of rescue vasopressor were compared between the groups. Results: The mean age in group P was 24.2 years, in group E 25.7 years and in group M was 25.7 years, which was similar across the groups. The time between induction and delivery was 87.8 sec in group P, 89.4 sec in group E and 89.6 sec in group M. The time at which 1st vasopressor dose given was 5.2 min in group P, 4.8 min in group E and 4.87 min in group M. The mean heart rate was lower in group P at all the points of study after episode of hypotension. The bolus drug requirement was highest in group P with mean of 3.52 followed by group M with mean of 2.86 and group E with mean of 2.55. The group E required rescue analgesia 73% of time, group M 70% of time and group P also 70% of time in study. The mean APGAR score at 1 minute was 8.2 in group P, 8.4 in group E and 8.6 in group M. Conclusion: During subarachnoid block for cesarean delivery, all three of the study's vasopressors— phenylephrine, ephedrine, and mephentermine—effectively maintained arterial blood pressure and were safe to use in the treatment of hypotension. Compared to ephedrine and mephentermine, phenylephrine significantly lowered heart rate, which may be helpful for cardiac patients or those in whom tachycardia is not desired

Low-dose oral minoxidil does not significantly affect blood pressure: A systematic review and meta-analysis

IntroductionMinoxidil, traditionally used as an anti-hypertensive, is now widely used for treating various forms of alopecia due to its vasodilatory effects. While topical minoxidil has been the standard treatment, low-dose oral minoxidil (LDOM) is emerging as an effective alternative. This study investigates LDOM’s potential hypotensive effects. MethodsStudies were selected based on criteria such as the use of LDOM (≤5 mg/day) and reporting on blood pressure changes. Mean differences (MD) were calculated for mean arterial pressure (MAP), systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR). ResultsLDOM did not significantly alter SBP (MD: -0.13, 95% CI: -2.67-2.41) or DBP (MD: -1.25, 95% CI: -3.21-0.71). Though MAP was not significantly altered, there was a strong tendency towards decreased MAP (MD: -1.92, 95% CI: -4.00-0.17). There was a significant increase in HR (MD: 2.67, 95% CI: 0.34-5.01). Hypotensive symptoms were reported in 119 patients (5.0%), but no hypotensive episodes were observed. Hypertrichosis was the most frequent side effect, leading to 34.6% of discontinuations. LimitationsStudies lacked control groups and showed variability in dosing regimens and blood pressure monitoring. ConclusionLDOM appears to be a safe treatment for alopecia with no significant impact on blood pressure.

Outcomes following acute kidney injury requiring dialysis: A cohort study

ObjectiveRetrospective study to examine the outcomes of acute kidney injury requiring dialysis (AKI-D) patients that received outpatient hemodialysis as part of continued AKI-D care and explore factors associated with recovery of kidney function and discontinuation of dialysis. MethodsRecords of all admissions to Emory Dialysis centers between January 2010 to December 2021 were reviewed to include patients with confirmed diagnosis of AKI-D. Basic demographics, comorbidities, duration of hospitalization and cause of AKI were extracted from hospital records and cross-referenced with the dialysis center electronic health record. Patients were followed starting from the day of the first outpatient hemodialysis up to 180 days. All hemodialysis sessions and laboratory data were analyzed. Logistic regression models were used to examine factors associated with recovery of kidney function, defined as survival free of dialysis. Results132 patients were analyzed, corresponding to 12,662 patient-day of outpatient AKI-D care. Among those, 19 (14 %) patients died during the observation period. 54 % of patients were male and 70 % were Black race. Median Age was 64 years (IQR 49–79). 42 patients (32 %) recovered enough kidney function to discontinue dialysis. Median time to kidney recovery was 31 days (IQR: 19–75), and the cumulative probability of kidney recovery at 6 months was 39 %. Patients who discontinued dialysis were younger (58 vs 66 years), had higher estimated glomerular filtration rate (eGFR) at time of admission (69 vs 46 ml/min/1.73m2) to the hospital, and were less likely to have a history of hypertension (61 % vs 82 %). Intra-dialytic hypotension was more common in patients who did not recover kidney function. Conclusions39 % of patients with AKI-D recovered kidney function within 180 days of outpatient HD start. The median time to recovery was 31 days. Younger age, higher e-GFR at time of hospital admission, and absence of hypertension were predictors of kidney recovery. Patients who recover kidney function experienced episodes of intradialytic hypotension less frequently.

Outcomes of burn patients presenting with hypotension within 48 hrs of admission to a level 1 Burn Centre

IntroductionBurns is one of the important presentations in trauma surgery in both first and third-world countries. Hypotension is often seen in the clinical presentation of a burn injury. Hypotension is the strongest independent predictor of an adverse outcome, according to a study done on emergency departments’ hospital outcomes; the lower the systolic, the worse the outcome. No direct study shows that presenting with or developing hypotension within 48hrs of admission and burn injury will have a worse outcome in our low-middle income setting. ObjectivesTo determine the outcomes of burn patients who developed hypotension within 48hrs of arrival at a Burn Centre in Johannesburg. In a singled time event. MethodsA retrospective descriptive study was conducted at a Level 1 Trauma Centre Burn unit in Johannesburg from 01 Jan 2019 to 31 Dec 2020. Patients who had a hypotensive episode at any point during the 48 h period were recruited. Hypotension was defined as a systolic blood pressure of less than 90mmhg. The patients were then divided into two groups: those who presented with or developed hypotension within 48hrs and those who did not. After that, the in-hospital mortality of both groups was to be determined. The study included all the patients who presented to the Burn Centre. Those younger than 18, or requiring readmission in the same study or delayed admissions of more than 24 h were excluded. Demographics, burn information, resuscitation data, outcomes and disposition status were evaluated. The STATA Statistics/Data Analysis version 16.0 was used to analyse the data. The level of significance was set at a p-value < 0.05. Ethical approval was obtained from the Human Research Ethics Committee (HREC) (medical) of the University of the Witwatersrand with the clearance number: M220132. ResultsOf the 132 patients seen, only 105 met the study inclusion criteria. Most patients were male: 91/105 (86.6 %). Flame burns accounted for the majority of the burns, 64/105 (60.95 %), followed by electrical burns, 26/105 (24.76 %). Hot water and chemical burns only accounted for 11/105 (10.48 %) and 4 (3.81 %) cases. Hypotension within 48hrs was noted in 37/105(35 %) of the cases. Hypotensive patients had an increased burn depth (p = 0.03), higher inhalation rate component (p = <0.001), greater lactate levels(p = 0.00001), higher baux score(p = 0.00001) and more likelihood of being placed on the ventilator (p = <0.00001) or dialysis (p = 0.008). Mortality was noted in 16 (43 %) of the patients who developed hypotension compared to 5 (7.4 %) patients of non-hypotensive patients (p < 0.001). The mortality of patients who presented with or developed hypotension was 9.59 times (95 % CI 3.1–29.4; p = 0.00001) higher than those who did not develop hypotension. Age and TBSA affected by burn, were found to have significant predictive value for mortality (p < 0.0001), respectively. Propensity matching was limited due to sample size. TBSA and the development of hypotension were matched, and the odds ratio of developing mortality was still increased. ConclusionHypotension was seen among burn injury patients admitted to a specialized intensive care unit. Hypotension was associated with higher TBSA % and increased age. In terms of characteristics, increased used of organ support was more likely with hypotensive patients with ventilation, inotropes, and dialysis. Length of stay was decreased in hypotensive patients. The odds of mortality were much higher in hypotensive patients, with age and TBSA being significant variables.

Influence of orthostatic blood pressure changes on the effects of intensive blood pressure control in patients with type 2 diabetes

Abstract Background Intensive blood pressure (BP) control has been proven to reduce the risks of major cardiovascular diseases (CVD) in patients with type 2 diabetes mellitus (T2DM) (1). Excessive orthostatic BP changes should be fully addressed, given its high prevalence and associations with adverse events among T2DM patients (2-5). However, the benefits of intensive BP control among T2DM patients with significant orthostatic BP changes have been equivocal. Purpose To examine whether orthostatic BP changes modify the efficacy of intensive BP control on CVD outcomes in patients with T2DM. Methods The Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial (ACCORD BP) is a 2×2 factorial designed trial that aimed to evaluate the effects of intensive glycemia and BP control on major CVD events among T2DM patients (6). We enrolled participants with at least one record of orthostatic BP values for analysis. The composite CVD outcome in this study comprised cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and hospitalized congestive heart failure. Associations between orthostatic BP changes and the composite CVD outcome and all-cause death, respectively, were presented by restricted cubic spline curves based on multivariable Cox models. We examined if the effects of intensive BP control varied across the orthostatic BP change for the composite CVD outcome and all-cause death. Results Among 4330 participants, 877 (20.3%) experienced episodes of orthostatic hypotension (OH) at baseline or during follow-up. There was no significant difference in the proportions of OH participants between the intensive and standard BP arms. U-shaped associations were observed between orthostatic systolic BP changes and the composite CVD outcome, as well as all-cause mortality (Figure 1). In the standard glycemia arm, intensive BP control was significantly associated with a lower risk of composite CVD outcome (HR 0.76, 95%CI 0.59-0.97). There was a beneficial association of intensive BP control with all-cause mortality without statistical significance (HR 0.85, 95%CI 0.56-1.30). The favorable effect of intensive BP control was not influenced by orthostatic BP changes (P for interaction 0.51 for the composite CVD outcome and 0.97 for all-cause mortality) (Figure 2). Beneficial effects of intensive BP control were not observed for participants in the intensive glycemia arm on the composite CVD outcome (HR 0.99, 95%CI 0.76-1.28) and all-cause mortality (HR 1.19, 0.79-1.80). Conclusion Orthostatic BP changes should not be a barrier to intensive BP control for T2DM patients treated with guideline-recommended standard glycemia control.

Comparing the cardiorespiratory safety of parenteral olanzapine and benzodiazepines to parenteral haloperidol/droperidol and benzodiazepines in emergency department patients

IntroductionThis study sought to assess the cardiorespiratory safety of parenteral olanzapine and benzodiazepine combination treatment compared to parenteral droperidol or haloperidol and benzodiazepine combination treatment. Materials and methodsThis was a retrospective chart review conducted in adult emergency department patients who received intramuscular (IM) or intravenous (IV) droperidol, haloperidol, or olanzapine within one hour of IM or IV benzodiazepine. Patients were stratified into groups based on whether they received either olanzapine in combination with a benzodiazepine (n = 48) or droperidol or haloperidol in combination with a benzodiazepine (n = 48). ResultsPatients in each group had a decrease in their systolic blood pressure (SBP) after IM/IV olanzapine and IM/IV droperidol or haloperidol when used in combination with an IM/IV benzodiazepine ((Olanzapine + benzodiazepine (mmHg), median (IQR): Pre-SBP: 132 (117–151) vs. Post-SBP: 117 (99–131), p < 0.01) (Droperidol or haloperidol + benzodiazepine (mmHg), median (IQR): Pre-SBP: 138 (122–149) vs. Post-SBP: 106 (98–127), p < 0.01)). Both groups had similar percent SBP decreases post-combination treatment (Olanzapine + benzodiazepine (15.6 %) vs. Droperidol or haloperidol + benzodiazepine (15.2 %); p = 0.55). We did not observe any statistically significant between group differences for hypotension (Olanzapine + benzodiazepine: 1/48, 2.1 % vs. Droperidol or haloperidol + benzodiazepine: 3/48, 6.3 %; p = 0.62)), escalation in oxygen requirements (Olanzapine + benzodiazepine: 7/48, 14.6 %) vs. Droperidol or haloperidol + benzodiazepine: 5/48, 10.4 %; p = 0.76)), or intubation due to cardiorespiratory depression (Olanzapine + benzodiazepine: 0/0, 0 % vs. Droperidol or haloperidol + benzodiazepine: 0/0, 0 %; p = 1.00)). ConclusionThis study found decreases in SBP after administering parenteral olanzapine and parenteral droperidol or haloperidol in combination with a parenteral benzodiazepine. The percent change in SBP and the frequency of hypotensive episodes post-combination treatment were not different between groups. There were also no differences between groups in need of increased oxygen requirements post-combination treatment or need for intubation due to cardiorespiratory depression. This study suggests parenteral olanzapine in combination with a parenteral benzodiazepine may have comparable cardiorespiratory safety versus parenteral droperidol or haloperidol in combination with a parenteral benzodiazepine when treating agitation in the adult ED.

Combination of Intravenous Ondansetron and Intravenous Glycopyrrolate Versus Intravenous Ondansetron and Intramuscular Glycopyrrolate for Reduction of Post-spinal Hypotension in Cesaraen Section: A Randomized Double-Blinded Study.

In parturients, post-spinal hypotension is common due to loss of sympathetic tone. Compression of the inferior vena cava by the gravid uterus further aggravates it. Various pharmacologic and non-pharmacologic techniques are used to reduce the severity of hypotension. Ondansetron, a selective 5-hydroxytryptamine receptor antagonist, nullifies the Bezold Jarisch reflex response to spinal anaesthesia and glycopyrrolate, an anti-cholinergic, has been used to prevent post-spinal hypotension. We estimated the efficacy of intravenous (IV) glycopyrrolate plus IV ondansetronversusintramuscular (IM) glycopyrrolate plus IV ondansetron to reduce post-spinal hypotension in caesarean section. We compared hypotension episodes and the total ephedrine dose required to treat hypotension among the groups. Ninety parturients undergoing elective and emergency caesarean section under spinal anaesthesia were randomly assigned into three groups of 30 each. Group A received prophylactic IV glycopyrrolate 0.2mg plus IV ondansetron 4mg, Group B received IM glycopyrrolate 0.2mg plus IV ondansetron 4mg and Control Group C received 10ml of normal saline plus IV ondansetron 4mg. The total ephedrine dose required to treat hypotension (primary objective), incidence of hypotension and maternal heart rate variations were analysed. Group B required significantly less vasopressor as compared to Group C (6.4286mg±1.6036 vs 8.7mg±3.6288, p=0.0420). There is no statistically significant difference between Group A and Group C for vasopressor requirement (7.8750mg±2.8723 vs 8.7mg±3.6288, p=0.5425). Maternal heart rate in Group A was higher at the eighth minute compared to Group B and Group C (100.2±21.3 vs 95.3±14.4 vs 86.2±19.0, p=0.015). Incidence of hypotension was same in all the groups (46.7% vs 46.7% vs 51.1%, p=0.491) and complications among groups were comparable. Prophylactic use of IM glycopyrrolate plus IV ondansetron decreases total vasopressor required to treat hypotension but does not decrease the incidence of hypotension. Prophylactic use of IV glycopyrrolate increases maternal heart rate.

Effect of prophylactic infusion of norepinephrine on the prevention of hypotension during vertebroplasty: a randomized clinical trial

BackgroundTransient hypotension is a common occurrence during the implantation of bone cement. This placebo-controlled randomized clinical trial study investigated the effect of prophylactic infusion of norepinephrine on the incidence of hypotension in senior patients who underwent vertebroplasty.MethodsThe trial recruited patients who were greater than or equal to 65 years of age, had an American Society of Anesthesiologist physical status classification of I to III, and underwent vertebroplasty from August 2020 to August 2021 at the Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine in China. The patients were randomly grouped according to whether they received either a norepinephrine infusion of 0.05 µg/kg/min or an equivalent volume of saline 10 min before implantation of bone cement. Intraoperative hemodynamics were monitored continuously by the MostCare system at the following 7 time points: 10 min before implantation of bone cement and immediately, 30 s, 1, 3, 5, and 10 min after implantation of bone cement. We also recorded the number of hypotensive episodes and the total number of vasopressors after implantation of bone cement. Multivariable logistic regression was used to assess the risk factors associated with hypotension after implantation of bone cement.ResultsA total of 63 patients were randomized to the control group (n = 31; median [IQR] age, 74 [69–79] years) and the norepinephrine group (n = 32; median [IQR] age, 75 [71–79] years). The incidence of hypotension in the norepinephrine group was significantly lower than that in the control group after implantation of bone cement (12.5% vs. 45.2%; relative risk [RR], 3.61 [95% CI, 1.13–15.07]; P = 0.005). Moreover, the median (IQR) number of hypotensive episodes (0 [0–0] vs. 0 [0–2]; P = 0.005) and the total number of vasopressors (0 [0–0] vs. 0 [0–1]; P = 0.004) in the norepinephrine group were significantly lower than those in the control group. Furthermore, compared with the baseline, the MAP significantly decreased at 1 min (P = 0.007) and 3 min (P < 0.001) after bone cement implantation in the control group. However, the MAP at 3 min in the norepinephrine group was significantly higher than that in the control group (P < 0.001). The incidence of complications was not different between the groups. In multivariable logistic regression, the FRAIL score (OR, 2.29; 95% CI, 1.21–4.31) was identified as a risk factor associated with hypotension.ConclusionProphylactic infusion of norepinephrine before bone cement implantation can stabilize hemodynamics and reduce the incidence of hypotension after implantation of bone cement.