Hypotensive State Research Articles

Intraoperative vasoplegia: methylene blue to the rescue!

To evaluate the efficacy, dosing, and safety of methylene blue (MTB) in perioperative vasoplegic syndrome (VS). Vasoplegic syndrome is a state of persistent hypotension with elevated cardiac output, low filling pressures, and low systemic vascular resistance (SVR). It occurs in up to 25% of patients undergoing cardiac surgery with cardiopulmonary bypass, can last up to 72 h, and is associated with a high mortality rate. MTB has been found to increase SVR and decrease vasopressor requirements in vasoplegic syndrome by inhibiting nitric oxide synthase, thus limiting the generation of nitric oxide, while inhibiting activation of soluble guanylyl cyclase and preventing vasodilation. MTB has been used in postgraft reperfusion during liver transplantation and anaphylaxis in a limited number of cases. Additionally, this medication has been used in septic shock with promising results, but similar to the cardiac surgical population, the effects of MTB administration on clinical outcomes has yet to be elucidated. MTB should be considered during vasoplegic syndrome in cardiac surgery with cardiopulmonary bypass and usage may be more effective in an early critical window, prior to end-organ hypoperfusion. Other perioperative scenarios of MTB use show promise, but additional studies are required to develop formative conclusions.

An Under-Appreciated Manifestation of Sepsis and Diabetic Ketoacidosis, the Black Esophagus: A Case Series

Incidence of diabetic ketoacidosis (DKA) has been rising within the United States and we are observing increasing rates of complications. We identified three patients in the intensive care unit who presented in DKA with shock and were found to have upper gastroenterologic bleeding (UGIB) from acute esophageal necrosis (AEN). Case 1: A 47-year-old male with a medical history of diabetes and alcoholic cirrhosis presented with delirium and abdominal pain. The patient had hypotension and tachycardia without fever. Serum glucose was 1062 mg/dL and beta-hydoxybutyrate > 9. Exam revealed blood in the oral cavity and rectum, an irregularly irregular heart rate, and encephalopathy. Esophagogastroduodenoscopy (EGD) revealed uniform black mucosa extending from the incisors to the squamocolumnar junction with clear demarcation distal to the squamocolumnar line and circumferential esophagitis in the proximal esophagus. Case 2: A 54-year-old male with a medical history of insulin-dependent diabetes and ischemic cardiomyopathy presented with encephalopathy. The patient had hypotension and tachycardia without fever. Serum glucose was 359 mg/dL and beta-hydroxybutryate > 9. Exam revealed encephalopathy, a regular heart rate, and dried blood in his oral cavity. During DKA treatment he developed melena with a peripheral blood hemoglobin of 9.3 g/dL. EGD revealed black mucosa extending from the mid esophagus to the distal esophagus while sparing the GE junction. Biopsies obtained revealed acute fibrinopurulent exudate with fragments of gray gastric epithelium. Case 3: A 34-year-old male with a medical history of diabetes complicated by neuropathy, gastroparesis, & recurrent esophageal candidiasis presented with encephalopathy and melena. He had hypothermia, hypotension, and tachycardia. Serum glucose was 428 mg/dL and beta-hydroxybutyrate 0.7. EGD revealed sloughing black distal esophagus extending proximally from the GE junction. Biopsy revealed acute inflammatory exudates with necrotic cells and numerous fungal hyphae. The etiology of AEN in DKA is multifactorial. DKA causes transient non-obstructive gastropathy leading to increased reflux into the esophagus and mucosal damage. DKA patients typically have poor nutritional status, which impairs mucosal repair. Diabetics have compromised vasculature and DKA precipitates a prolonged hypotensive state allowing for increased end-organ ischemia. All three cases improved with resuscitation and proton pump inhibitor therapy.FigureFigure

Mitochondrial targeting by dichloroacetate improves outcome following hemorrhagic shock

Hemorrhagic shock is a leading cause of death in people under the age of 45 and accounts for almost half of trauma-related deaths. In order to develop a treatment strategy based on potentiating mitochondrial function, we investigated the effect of the orphan drug dichloroacetate (DCA) on survival in an animal model of hemorrhagic shock in the absence of fluid resuscitation. Hemorrhagic shock was induced in rats by withdrawing 60% of the blood volume and maintaining a hypotensive state. The studies demonstrated prolonged survival of rats subjected to hemorrhagic injury (HI) when treated with DCA. In separate experiments, using a fluid resuscitation model we studied mitochondrial functional alterations and changes in metabolic networks connected to mitochondria following HI and treatment with DCA. DCA treatment restored cardiac mitochondrial membrane potential and tissue ATP in the rats following HI. Treatment with DCA resulted in normalization of several metabolic and molecular parameters including plasma lactate and p-AMPK/AMPK, as well as Ach-mediated vascular relaxation. In conclusion we demonstrate that DCA can be successfully used in the treatment of hemorrhagic shock in the absence of fluid resuscitation; therefore DCA may be a good candidate in prolonged field care following severe blood loss.

Spontaneous Intracranial Hypotension (SIH) and Idiopathic Intracranial Hypertension (IIH): Imaging Presentations

Background: Any change in Intracranial pressure (ICP), either elevation or reduction, could be with clinical and Neuroimaging presentations which depend to the severity of the pressure changes. The principal symptom in both of these syndromes, that is, Intracranial Hyper and Hypotension, is headache which in SIH , is mainly orthostatic or postural (positional) type which occurs when the patient is in upright position, and gradually disappears when the patient is lying down. In most cases, the headaches gradually increase from the moment the patient wakes up in the morning. However, in other cases the headaches are quick and severe. The acuteness of the headaches varies in each case, which affects how quickly the condition is diagnosed. Some of the other related symptoms in in intracranial hypotension state are loss of hearing, dizziness, tinnitus, vertigo, stiffness of the neck, nausea, Loss of consciousness, Coma and even vomiting. In Intracranial Hypertension situation transient visual obscuration or blurring ,double vision, visual loss and less likely joint pain ,low back pain and even intermittent ataxia. In neurological examinations cranial nerve palsies (mainly VI) may be found. In neuroimaging studies especially on MR imaging several nonspecific and heterogeneous presentations such as dural enhancement, vertical displacement of the brain (an appearance like Arnold-Chiari type I malformation ), subdural effusion or subdural hematomas mainly in chronic cases in Idiopathic intracranial hypotension and flattening of the posterior sclera, distension of perioptic subarachnoid space, tortuosity of optic nerve and an empty sella in Idiopathic intracranial Hypertension might be seen which the presence of 3 or more of the MRI features is 95% specific in predicting idiopathic intracranial hypertension. CSF leak is a recognized cause of intracranial hypotension. This condition may be spontaneous or secondary to spinal puncture; neurosurgical procedures (iatrogenically); dehydration; uremia and spinal trauma. In intracranial hypertension situation the etiology is unknown. However, two hypothesis are reduced CSF absorption at the level of the arachnoid villi and increased brain intraparenchymal water (Vasogenic brain edema). Objectives: Upon completion of this presentation, participants will be able to: 1) Recognize MRI appearance of the spontaneous intracranial hypotension and idiopathic intracranial hypertension (Pseudotumor cerebri). 2) Review their various clinical and imaging presentations. Conclusions: In this presentation we will review Imaging presentations of our several proved cases. As mentioned, there are heterogeneous groups of signs and symptoms and MRI presentation in these disorders which may cause misdiagnosis with other neurologic disorders and awareness, understanding, and recognition of these presentations may permit the radiologist to play a significant role in the prevention of misdiagnosis, unwanted surgical interventions or extensive diagnostic evaluation procedures.

Distributive Shock in the Emergency Department: Sepsis, Anaphylaxis, or Capillary Leak Syndrome?

BackgroundDistributive shock is a hyperdynamic process resulting from excessive vasodilatation. Impaired blood flow causes inadequate tissue perfusion, which can lead to end-organ damage. Although the most common etiology is septic shock, anaphylactic and other etiologies should be considered. Case ReportWe report the case of a 30-year-old female who presented to the emergency department with nonspecific symptoms and hypotension after a viral upper respiratory infection. Her physical examination revealed mild edema and rebound tenderness in the right upper and bilateral lower quadrants. She also presented with hypotension concomitant with hypoperfusion symptoms, which were manifested by the loss of consciousness in the hour after her presentation. Neither etiologic agent nor drug use history was provided at the presentation; these may have caused anaphylaxis; however, she later reported that she took a propolis extract 1 day earlier. The hypotensive state was refractory to large amount of crystalloid infusion and a series of examinations were performed to determine the shock etiology. Computed tomography images showed pneumonic infiltrates in the lower zone of the right lung, an enlarged liver, a thickened gallbladder wall, and an extensive amount of free fluid in the perihepatic and retroperitoneal areas. All radiologic changes were thought to be due to a secondary condition that triggers them, none were considered as septic focus. Capillary leak syndrome was considered in differential diagnosis and 3 days after her presentation, her hypotension improved and she was discharged in a healthy state. Why Should an Emergency Physician Be Aware of This?Capillary leak syndrome is a variant of distributive shock. After assessing other etiologies for this condition, emergency physicians should focus on a triggering event that may have caused hypoalbuminemia and a fluid shift.

Cafedrine/Theodrenaline (20:1) Is an Established Alternative for the Management of Arterial Hypotension in Germany-a Review Based on a Systematic Literature Search.

A 20:1 combination of cafedrine:theodrenaline (Akrinor®) is widely used in Germany for the treatment of hypotensive states during anesthesia and in emergency medicine. Although this drug formulation has been available since 1963, there are few studies relating to its use and many of the data are only available in German. In this article, we summarize the available data and propose mechanisms for the effects of cafedrine/theodrenaline on cardiac muscle cells and vascular smooth muscle cells. Cafedrine/theodrenaline leads to a rapid increase in mean arterial pressure that is characterized by increased cardiac preload, stroke volume, and cardiac output. Systemic vascular resistance and heart rate remain mostly unchanged. Factors which impact the effects of cafedrine/theodrenaline are gender, high arterial pressure at baseline, use of β-blockers, and heart failure. Importantly, the drug is frequently used in obstetric anesthesia without detrimental effects on umbilical cord pH or APGAR score.

Vertebral Artery Transection in Non-Penetrating Cervical Spine Injury: A Case Report

Introduction: Vertebral artery injury associated with blunt cervical trauma has been infrequently reported. The prevalence of traumatic vertebral artery injury is approximately 0.5-2.0% to overall trauma patients, usually occurs in the setting of high-energy trauma. The most common mechanism of injury was high-speed motor vehicle collisions and pedestrian-versus-automobile collision. Here, we would like to report a case of cervical spine fracture with cord injury and left vertebral artery transection after a slipping down event that was successfully managed by endovascular intervention with favourable outcome. Case report: A 42-year-old man having medical history of alcoholic liver disease and hepatitis C was sent to our ER in December 2016 in a conscious disturbance and hypotension state after suffering a slipping down event at a slope in a market after drinking. After resuscitation, a series of trauma imaging survey was arranged. Results: His CT scan of brain showed essentially negative finding; his CT scan of C-spine demonstrated fracture of right transverse process and transverse foramen of C3, avulsion fracture of left transverse process of C4; his MRI of C-spine disclosed a large hematoma at pre-vertebral space, cord contusion and hemorrhage at C3/C4 without significant compressive lesion and loss of flow void at left upper vertebral artery at the level of C3-C4. Angiography was arranged to identify his vascular injury and it showed the interruption of left vertebral artery at C4 with formation of arteriovenous fistula draining into adjacent venous plexus. After evaluating his vital signs, liver function, and family discussion, endovascular intervention was preferred to manage his left vertebral artery injury. After the detachable coils were approved, successful trapping of the left vertebral artery was done by endovascular embolization. The angiography performed just before coiling showed the newly development of pseudoaneurysm closed to the injured site. 27 days after admission, he was discharged with stable vital signs, clear consciousness, but the muscle power of his right upper limb was grade 2/5 while the muscle power of his other extremities was grade 4/5 and he had no sphincter problem. Conclusion: There is a particularly high risk for vertebral artery injury in the setting of cervical spine fractures with subluxation, and/or extension to the foramen transversarium. Under such circumstances, the vascular injury most likely occurs when tensile or shear strain exceeds the mechanical limits of arterial tissue during hyperflexion, hyperextension, anteroposterior translation, and/or forcible rotation. Displaced bone fragments can injure the artery directly especially when the foramen transversarium is disrupted. The clinician must be aware of the presence of vertebral artery injury in cases of cervical spine trauma.

Hypotensive anesthesia for the correction of scoliosis under total intravenous anesthesia: comparison between dexmedetomidine and magnesium sulfate

Context This study was designed to compare dexmedetomidine with magnesium sulfate as an adjunctive to total intravenous anesthesia (TIVA) as regards the efficacy and safety as hypotensive agents in scoliosis correction surgery. Patients and methods This prospective randomized double-blinded study included 40 patients of American Society of Anesthesiology II who were scheduled for the correction of scoliosis under TIVA and divided into two groups of 20 patients each. The first group was the Dex group, which was administered dexmedetomidine infusion at a rate of 0.5 μg/kg/h, and the second group was the Mg group, which was administered magnesium sulfate infusion at a rate of 15 mg/kg/h. The target mean arterial pressure (MAP) was 60–70 mmHg. The two groups were compared as regards MAP, heart rate (HR), intraoperative blood loss, blood transfusion, quality of surgical field, need for vasodilators and analgesics, time to extubation, time to recover the hypotension, time to recover the full conscious level, and perioperative serum levels of calcium and magnesium. Results Both groups could achieve the target MAP before skin incision. The Dex group showed more HR stability, less intraoperative blood loss, and less intraoperative blood transfusion with better surgical field quality. Moreover, the need for vasodilators was lesser in this group. However, the Mg group showed faster extubation time, faster reversibility of hypotension, and faster recovery of full conscious level. Need for intraoperative analgesia was comparable between the two groups. Intraoperative and postoperative serum magnesium were higher in the Mg group and intraoperative and postoperative serum calcium levels showed gradual drop in the Mg group compared with the Dex group and the preoperative level in the Mg group. Both electrolytes showed recovery to normal preoperative level 24 h postoperatively without interference. Conclusion TIVA with both dexmedetomidine and magnesium sulfate could achieve the target MAP for hypotensive anesthesia. Dexmedetomidine can control MAP with lesser need for vasodilators and with better control of HR. It provided lesser blood loss and better quality of surgical field. Magnesium sulfate showed faster extubation and recovery of conscious level with faster reversibility of hypotensive state but with the risk for perioperative hypocalcemia.

The association between orthostatic hypotension and cognitive state among adults 65 years and older who underwent a comprehensive geriatric assessment.

The prevalence of cognitive impairment and orthostatic hypotension (OH) increases with age, but the results of studies that assessed possible associations between them are inconsistent.The aim of this study is to assess possible associations between cognitive impairment and OH in patients ≥65 years of age who underwent a comprehensive geriatric assessment.A retrospective analysis was conducted of the computerized medical records of the study population from 2005 to 2013. Data collected included blood pressure measurements that enabled the calculation of OH, results of the mini-mental state examination (MMSE), results of the Montreal cognitive assessment (MoCA) test, and cognitive diagnoses that were determined over the course of the assessment.The rate of OH in the study population of 571 adults was 32.1%. The mean MMSE score was 22.5 ± 5.2 among participants with OH and 21.6 ± 5.8 among those without OH (P = 0.09). The absence of a significant association between OH and MMSE remained after adjusting the MMSE score for age and education level. The mean MoCA score was 16.4 ± 5.0 among participants with OH and 16.4 ± 4.8 among those without (P = 0.33). The prevalence of OH was 39% among participants without cognitive impairment, 28.9% among those with mild cognitive impairment (MCI), and 30.6% among those with dementia (P = 0.13).There was no association between OH and cognitive impairment in adults who underwent a comprehensive geriatric assessment.

PWE-035 The Endoscopy and Endoscopic Therapy in Bleeding and Hypotension State of Upper Gastrointestinal Haemorrhage

Introduction The mortality of the cirrhotic patients with shock induced by esophageal varices (EV) rupture haemorrhage remains high despite all medical advances. The clinical study aims to exhibit the efficacy of endoscopic therapy using esophageal varicose ligation (EVL) in treating hypotension caused by upper gastrointestinal haemorrhage, as well as compare the long-term difference in effectiveness of single-band and multi-bands techniques for the patients. Methods sixty-seven patients with clinical diagnosis of cirrhosis were hospitalised in an emergency for massive hematemesis. The blood pressure (Bp) of the patients was between 60–82/30-55 mmHg, and the haemoglobin (Hb) was in the range of 50–87 g/L. As well as preparing blood protects, we take fluid resuscitation and apply somatostatin or terlipressin to reduce portal vein pressure of the patients, whose Hb was lower than 60 g/L were taken blood transfusion. When their Bp could stabilise between 78–86/50-55 mmHg and the Hb between 55–60 g/L, the emergency endoscopy examination and treatment were performed without narcosis. The patients with EV bleeding were randomly divided into single-band and multi-band ring ligation groups, while accompanying GV treated by injecting in the bleeding gastric varicose vein with sequential sclerosing agent, tissue adhesive, sclerosing agent, which is named sandwich method of GV injection therapy. The sixty-seven patients were found EV by gastroscoy, in whom there were fifty-three accompanying GV. In multi-bands treatment group with thirty-five patients, two, three, or four bands were applied on the varices according to the severity of EV. The single-band treatment group was consisting in thirty-two patients. Results Sixty-six cases were rescued successfully by emergency endoscopic treatment within 24 h of bleeding. Unfortunately, one person was still bleeding although EVL and sclerotherapy both being applied the bleeding oesophagus because it had been more than 24 hours since the bleeding and he had been treated with Sengtaken-Blakemore tube for three days, causing the erosion and ulcer of oesophagus. Two days after the endoscopic therapy, the patient died for the poor control of haemorrhage as he continually accepted comprehensive treatment. In the multi-bands ligation group, the number of patients with EV completely eradicated and mostly eradicated was eight and twenty-one respectively. The disappearance percents of varicose veins were 82.8%. In the single-band ligation group, the number of people with EV completely eradicated and mostly eradicated were five and fourteen, respectively, which the disappearance percent of the varicose veins was 59.4%. There were great significant differences between the two groups ( p p Conclusion The patients with EV and (or) GV rupture haemorrhage in bleeding and hypotension state can be rescued successfully by endoscopy and endoscopic therapy. The long-term efficacy of the multi-band ligation is superior to single-band EV ligation (EVL). Disclosure of Interest None Declared

Exercise training attenuates the pressor response evoked by peripheral chemoreflex in rats with heart failure.

The effects of exercise training (ExT) on the pressor response elicited by potassium cyanide (KCN) in the rat model of ischemia-induced heart failure (HF) are unknown. We evaluated the effects of ExT on chemoreflex sensitivity and its interaction with baroreflex in rats with HF. Wistar rats were divided into four groups: trained HF (Tr-HF), sedentary HF (Sed-HF), trained sham (Tr-Sham), and sedentary sham (Sed-Sham). Trained animals underwent to a treadmill running protocol for 8 weeks (60 m/day, 5 days/week, 16 m/min). After ExT, arterial pressure (AP), baroreflex sensitivity (BRS), peripheral chemoreflex (KCN: 100 μg/kg body mass), and cardiac function were evaluated. The results demonstrate that ExT induces an improvement in BRS and attenuates the pressor response to KCN relative to the Sed-HF group (P < 0.05). The improvement in BRS was associated with a reduction in the pressor response following ExT in HF rats (P < 0.05). Moreover, ExT induced a reduction in left ventricular end-diastolic pressure and pulmonary congestion compared with the Sed-HF group (P < 0.05). The pressor response to KCN in the hypotensive state is decreased in sedentary HF rats. These results suggest that ExT improves cardiac function and BRS and attenuates the pressor response evoked by KCN in HF rats.

Bowel Ischemia from Heat Stroke: A Rare Presentation of an Uncommon Complication.

A healthy 27-year-old female presented to the hospital after she collapsed an hour into her first marathon run on a hot humid day. On presentation, she was hyperthermic, encephalopathic, tachycardic, and hypotensive. On admission, she was found to have lactic acidosis, rhabdomyolysis, and acute kidney injury and was treated with cold normal saline and cooling blankets. She subsequently started having abdominal pain and bloody bowel movements. Computed tomography of the abdomen revealed ascending colon thickening. Furthermore, her lab findings showed transaminitis and elevated coagulation parameters. Due to the acute hypotensive state from the heat stroke, patient had developed bowel ischemia, ischemic hepatitis, and disseminated intravascular coagulation, all of which are uncommon complications of heat stroke. She was managed aggressively with intravenous fluid hydration with resolution of her symptoms over the course of 4 days. In addition to the uncommon complications, early presentation of this bowel ischemia despite adequate hydration in such a healthy individual is another unique aspect of the case.

Non-Adrenergic Vasopressors in Patients with or at Risk for Vasodilatory Shock. A Systematic Review and Meta-Analysis of Randomized Trials.

IntroductionHypotensive state is frequently observed in several critical conditions. If an adequate mean arterial pressure is not promptly restored, insufficient tissue perfusion and organ dysfunction may develop. Fluids and catecholamines are the cornerstone of critical hypotensive states management. Catecholamines side effects such as increased myocardial oxygen consumption and development of arrhythmias are well known. Thus, in recent years, interest in catecholamine-sparing agents such as vasopressin, terlipressin and methylene blue has increased; however, few randomized trials, mostly with small sample sizes, have been performed. We therefore conducted a meta-analysis of randomized trials to investigate the effect of non-catecholaminergic vasopressors on mortality.MethodsPubMed, BioMed Central and Embase were searched (update December 31st, 2014) by two independent investigators. Inclusion criteria were: random allocation to treatment, at least one group receiving a non-catecholaminergic vasopressor, patients with or at risk for vasodilatory shock. Exclusion criteria were: crossover studies, pediatric population, non-human studies, studies published as abstract only, lack of data on mortality. Studied drugs were vasopressin, terlipressin and methylene blue. Primary endpoint was mortality at the longest follow-up available.ResultsA total of 1,608 patients from 20 studies were included in our analysis. The studied settings were sepsis (10/20 studies [50%]), cardiac surgery (7/20 [35%]), vasodilatory shock due to any cause (2/20 [19%]), and acute traumatic injury (1/20 [5%]). Overall, pooled estimates showed that treatment with non-catecholaminergic agents improves survival (278/810 [34.3%] versus 309/798 [38.7%], risk ratio = 0.88, 95% confidence interval = 0.79 to 0.98, p = 0.02). None of the drugs was associated with significant reduction in mortality when analyzed independently. Results were not confirmed when analyzing studies with a low risk of bias.ConclusionsCatecholamine-sparing agents in patients with or at risk for vasodilatory shock may improve survival. Further researches on this topic are needed to confirm the finding.

Cafedrine/theodrenaline in anaesthesia: influencing factors in restoring arterial blood pressure.

BackgroundHypotensive states that require fast stabilisation of blood pressure can occur during anaesthesia. In 1963, the 20:1 mixture of cafedrine/theodrenaline (Akrinor®) was introduced in Germany for use in anaesthesia and emergency medicine in the first-line management of hypotensive states. Though on the market for many years, few pharmacodynamic data are available on this combination net beta-mimetic agent.AimThis study aimed to examine the drug combination in real-life clinical practice and recorded time to 10 % mean arterial blood pressure (MAP) increase and heart rate. Furthermore, potential factors that influence drug effectiveness under anaesthesia were assessed.MethodsData were collected within a standardised anaesthesia protocol. A total of 353 consecutive patients (female/male = 149/204) who received cafedrine/theodrenaline after a drop in MAP ≥ 5 % were included in the study. The time to 10 % increase in MAP, dosage of cafedrine/theodrenaline, volume loading, blood pressure and heart rate were monitored over time.ResultsPatients were a mean (standard deviation) of 64.4 ± 15.1 years old with a baseline MAP of 82 ± 14 mmHg, which dropped to a mean of 63 ± 10 mmHg during anaesthesia without gender differences. Cafedrine/theodrenaline (1.27 ± 1.0 mg/kg; 64 ± 50 µg/kg) significantly increased MAP (p < 0.001) by 11 ± 16 mmHg within 5 min, reaching peak values within 17.4 ± 9.0 min. Heart rate was not affected in a clinically significant manner. Cafedrine/theodrenaline induced a 10 % MAP increase after 7.2 ± 4.6 min (women) and after 8.6 ± 6.3 min (men) (p = 0.018). Independent of gender, the dose of cafedrine/theodrenaline required to achieve the observed MAP increase of 14 ± 16 mmHg at 15 min was significantly different in patients with heart failure [1.78 ± 1.67 mg/kg (cafedrine)/89.0 ± 83.5 µg/kg (theodrenaline)] compared with healthy patients [1.16 ± 0.77 mg/kg (cafedrine)/58.0 ± 38.5 µg/kg (theodrenaline)] (p = 0.005). Concomitant medication with beta-blocking agents significantly prolonged the time to 10 % MAP increase [9.0 ± 7.0 vs. 7.3 ± 4.3 min (p = 0.008)].ConclusionCafedrine/theodrenaline quickly restores MAP during anaesthesia. Female gender is associated with higher effectiveness, while heart failure and beta-blocker administration lower the anti-hypotonic effect. Prospective studies in defined patient populations are warranted to further characterise the effect of cafedrine/theodrenaline.

Adenosine, lidocaine and Mg2+improves cardiac and pulmonary function, induces reversible hypotension and exerts anti-inflammatory effects in an endotoxemic porcine model

IntroductionThe combination of Adenosine (A), lidocaine (L) and Mg2+ (M) (ALM) has demonstrated cardioprotective and resuscitative properties in models of cardiac arrest and hemorrhagic shock. This study evaluates whether ALM also demonstrates organ protective properties in an endotoxemic porcine model.MethodsPigs (37 to 42 kg) were randomized into: 1) Control (n = 8) or 2) ALM (n = 8) followed by lipopolysaccharide infusion (1 μg∙kg-1∙h-1) for five hours. ALM treatment consisted of 1) a high dose bolus (A (0.82 mg/kg), L (1.76 mg/kg), M (0.92 mg/kg)), 2) one hour continuous infusion (A (300 μg∙kg-1 ∙min-1), L (600 μg∙kg-1 ∙min-1), M (336 μg∙kg-1 ∙min-1)) and three hours at a lower dose (A (240∙kg-1∙min-1), L (480 μg∙kg-1∙min-1), M (268 μg∙kg-1 ∙min-1)); controls received normal saline. Hemodynamic, cardiac, pulmonary, metabolic and renal functions were evaluated.ResultsALM lowered mean arterial pressure (Mean value during infusion period: ALM: 47 (95% confidence interval (CI): 44 to 50) mmHg versus control: 79 (95% CI: 75 to 85) mmHg, P <0.0001). After cessation of ALM, mean arterial pressure immediately increased (end of study: ALM: 88 (95% CI: 81 to 96) mmHg versus control: 86 (95% CI: 79 to 94) mmHg, P = 0.72). Whole body oxygen consumption was significantly reduced during ALM infusion (ALM: 205 (95% CI: 192 to 217) ml oxygen/min versus control: 231 (95% CI: 219 to 243) ml oxygen/min, P = 0.016). ALM treatment reduced pulmonary injury evaluated by PaO2/FiO2 ratio (ALM: 388 (95% CI: 349 to 427) versus control: 260 (95% CI: 221 to 299), P = 0.0005). ALM infusion led to an increase in heart rate while preserving preload recruitable stroke work. Creatinine clearance was significantly lower during ALM infusion but reversed after cessation of infusion. ALM reduced tumor necrosis factor-α peak levels (ALM 7121 (95% CI: 5069 to 10004) pg/ml versus control 11596 (95% CI: 9083 to 14805) pg/ml, P = 0.02).ConclusionALM infusion induces a reversible hypotensive and hypometabolic state, attenuates tumor necrosis factor-α levels and improves cardiac and pulmonary function, and led to a transient drop in renal function that was reversed after the treatment was stopped.

Isolated perioperative hypertension: clinical implications & contemporary treatment strategies.

Perioperative hypertension has been shown to be a risk factor for the development of perioperative morbidity and mortality. The time spent outside acceptable blood pressure ranges, in a state of hypertension or hypotension, is correlated with the incidence of stroke, acute coronary syndrome, renal dysfunction, and death. The ideal perioperative treatment of hypertension would include an easily titratable agent, with fast onset and offset and minimal side effects. Several medication classes are routinely used in the operating room, including, but not limited to, beta-blockers, calcium channel blockers, nitrates, and angiotensin-converting enzyme (ACE) inhibitors.Proper treatment of chronic hypertension and continuation of chronic anti-hypertensive medications in the perioperative period has been demonstrated to improve patient outcomes. This review article will outline the importance of perioperative blood pressure management, the treatment pitfalls, and the novel medications being used in the perioperative setting.

Analysis of operating room related factors and nursing countermeasures for pressure ulcers in patients with laparoscopic surgery

Objective To study operating room related factors and nursing countermeasures for pressure ulcers in patients with lap -aroscopic surgery.Methods Totaled of 180 patients with laparoscopic surgery data were retrospectively analysized , the operating room relat-ed causes of pressure ulcers were discussed , and put forward nursing countermeasures.Results Among the 186 patients with laparoscopic surgery a total of stage Ⅰ-Ⅱpressure sores 17cases, the incidence of pressure ulcers was 9.14%;operating rooms related reasons includ-ed operation position , operation time too long , skin moisture, intraoperative hypotension state duration , hypoxemia etc ..Conclusions Laparoscopic surgery in patients with postoperative pressure sores are the result of a variety of factors , according to the related reasons for pressure sores , intraoperative strengthen preventive measures can help to reduce the incidence of pressure ulcers after surgery . Key words: Laparoscopic surgery Pressure ulcers Operating room Related reasons Nursing countermeasures

Adenosine, lidocaine and Mg2+ (ALM) induces a reversible hypotensive state, reduces lung edema and prevents coagulopathy in the rat model of polymicrobial sepsis.

No drug therapy has demonstrated improved clinical outcomes in the treatment of sepsis. A bolus of adenosine, lidocaine, and magnesium (ALM) has been shown to be cardioprotective and restore coagulopathy in different trauma states. We hypothesized that ALM therapy may improve hemodynamics, protect the lung, and prevent coagulopathy in the rat sepsis model. Nonheparinized, anesthetized Sprague-Dawley rats (350-450 g, n = 32) were randomly assigned to (1) shams (without sepsis), (2) saline controls, and (3) ALM treatment. Sepsis was induced by cecal ligation and puncture. A 0.3-mL bolus was administered intravenously, followed by a 4-hour intravenous infusion (1 mL/kg/h), and hemodynamics (mean arterial pressure [MAP], systolic arterial pressure, diastolic arterial pressure, and heart rate [HR]) and body temperature (BT) were monitored. Coagulation was assessed using prothrombin time and activated partial thromboplastin time (aPTT). Shams displayed progressive falls in MAP, HR, and BT as well as a prolonged aPTT, which were related to surgery, not infection. At 4 hours, controls showed more pronounced falls in MAP (33%), HR (17%), and BT (3.3°C), and MAP continued to fall after the infusion was stopped. In contrast, ALM treatment resulted in a rapid fall in MAP from 111 mm Hg to 73 mm Hg at 30 minutes (p < 0.05 all groups) and was 59 mm Hg at 240 minutes (p < 0.05 shams), which immediately corrected after 4 hours (p < 0.05 controls). HR paralleled MAP changes in ALM rats, and BT was significantly higher than that of the controls but not that of shams. ALM rats had no arrhythmias compared with the controls or shams and had significantly lower lung wet-dry ratios. Prothrombin time in saline controls at 1 hour and 5 hours was prolonged but not in the shams or ALM rats. aPTT at 1 hour in the sham, control, and ALM groups was 158 ± 41 seconds, 161 ± 41 seconds, and 54 ± 23 seconds and at 5 hours was 104 ± 43 seconds, 205 ± 40 seconds, and 33 ± 3 seconds (p < 0.05), respectively. An ALM bolus/infusion induces a stable, hypotensive hemodynamic state with no arrhythmias, significantly less pulmonary edema, and a higher BT and prevents coagulopathy compared with the controls.

Transvenous stimulation of the renal sympathetic nerves increases systemic blood pressure: a potential new treatment option for neurocardiogenic syncope.

Neurocardiogenic syncope (NCS) is a common and sometimes debilitating disorder, with no consistently effective treatment. NCS is due to a combination of bradycardia and vasodilation leading to syncope. Although pacemaker devices have been tried in treating the bradycardic aspect of NCS, no device-based therapy exists to treat the coexistent vasodilation that occurs. The renal sympathetic innervation has been the target of denervation to treat hypertension. We hypothesized that stimulation of the renal sympathetic nerves can increase blood pressure and counteract vasodilation in NCS. High-frequency stimulation (800-900 pps, 10 V, 30-200 seconds) was performed using a quadripolar catheter in the renal vein of 7 dogs and 1 baboon. A significant increase in blood pressure (BP; mean [SD] systolic BP 117 [±28] vs. 128 [±33], diastolic BP 75 [±19] vs. 87 [±29] mmHg) was noted during the stimulation, which returned to baseline after cessation of stimulation. The mean increase in systolic and diastolic BP was 13.0 (±3.3) (P = 0.006) and 10.2 (±4.6) (P = 0.08), respectively. We report the first ever study of feasibility and safety of high-frequency electrical stimulation of the renal sympathetic innervation to increase BP in animal models. This has potential applications in the treatment of hypotensive states such as NCS.

Bcl-2/Bax expression levels tend to influence AMPAergic trafficking mechanisms during hibernation in Mesocricetus auratus.

Hypothermia is a physiological condition assuring brain protection against hypoxic-related damages. In this context, investigations carried out on the facultative hibernator Mesocricetus auratus proved to be very useful for establishing the type of neurosignaling role exerted by cerebral α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid receptor (AMPAR) subtypes during hypoxic/reperfusion injuries of the entrance (EN), torpor (TORP), and arousal (AROU) hibernating states. From the evaluation of the major AMPARs (GluR1 and GluR2), together with their scaffold proteins synapse-associated protein 97kDa (SAP97) and PICK1, it resulted that GluR1 and SAP97 were mostly upregulated during the hypotensive (EN and TORP) states of the brainstem, amygdala, and hypothalamus, sites which are implicated with cardiovascular, motor, and sleep-wake events. In addition, elevated expression densities of the pro-apoptotic factor Bcl-2-associated X protein (Bax) resulted to be correlated to marked amino-cupric-silver stain signals during both hibernating states. Conversely, an increase of the neuroprotective factor GluR2, together with PICK1 and the anti-apoptotic B cell lymphoma 2 (Bcl-2), appeared to be linked with reduced argyrophilic signals in most of the above areas of the hypertensive AROU state. These first indications highlight distinct protective/degenerative measures of the above factors constituting key on/off switches during the various hibernating states that may provide potential therapeutic bearings on sleeping disorders.