Incidence Of Hypotension Research Articles

Effect of Dexmedetomidine on Intraoperative Hemodynamics and Blood Loss in Patients Undergoing Spine Surgery: A Systematic Review and Meta-Analysis

Objective Dexmedetomidine (Dex) is a highly selective α2 adrenoceptor agonist that reduces blood pressure and heart rate. However, its ability to provide stable hemodynamics and a clinically significant reduction in blood loss in spine surgery is still a matter of debate. This study aimed to investigate the effects of Dex on intraoperative hemodynamics and blood loss in patients undergoing spine surgery.Methods The Web of Science, MEDLINE, EMBASE, and the Cochrane Library were searched up to February 2023 for randomized controlled trials (RCTs) including patients undergoing spine surgeries under general anaesthesia and comparing Dex and saline. A fixed- or random-effect model was used depending on heterogeneity.Results Twenty-one RCTs, including 1388 patients, were identified. Dex added the overall risk of intraoperative hypotension (odds ratio [OR]: 2.11; 95% confidence interval [CI]: 1.24 - 3.58; P=0.006) and bradycardia (OR: 2.48; 95%CI: 1.57 - 3.93; P=0.0001). The use of a loading dose of Dex led to significantly increased risks of intraoperative hypotension (OR: 2.00; 95%CI: 1.06 - 3.79; P=0.03) and bradycardia (OR: 2.28; 95%CI: 1.42 - 3.66; P=0.0007). For patients receiving total intravenous anesthesia, there was an increased risk of hypotension (OR: 2.90; 95%CI: 1.24 - 6.82; P=0.01) and bradycardia (OR: 2.66; 95%CI: 1.53 - 4.61; P=0. 0005). For patients in the inhalation anesthesia group, only an increased risk of bradycardia (OR: 4.95; 95%CI: 1.41 - 17.37; P=0.01) was observed. No significant increase in the risk of hypotension and bradycardia was found in the combined intravenous-inhalation anesthesia group. The incidence of severe hypotension (OR: 2.57; 95%CI: 1.05 - 6.32; P=0.04), but not mild hypotension, was increased. Both mild (OR: 2.55; 95%CI: 1.06 - 6.15; P=0.04) and severe (OR: 2.45; 95%CI: 1.43 - 4.20; P=0.001) bradycardia were associated with a higher risk. The overall analyses did not reveal significant reduction in intraoperative blood loss. However, a significant decrease in blood loss was observed in total inhalation anesthesia subgroup (mean difference [MD]: -82.97; 95%CI: -109.04 - -56.90; P<0.001).Conclusions Dex increases the risks of intraoperative hypotension and bradycardia in major spine surgery. The administration of a loading dose of Dex and the utilization of various anesthesia maintenance methods may potentially impact hemodynamic stability and intraoperative blood loss.

Utility of Supine Stress Test to Anticipate Spinal Anaesthesia Induced Hypotension in Patients Undergoing Elective Cesarean Section

INTRODUCTION Reduction in venous return caused by compression of the inferior vena cava by the gravid uterus, known as the supine hypotensive syndrome of pregnancy, is one of the reasons for particular susceptibility to hypotension at cesarean delivery. The hypotensive effect of spinal anaesthesia further exacerbates maternal hypotension in the supine position in term parturients. This study was conducted with the objective to evaluate the ability of supine stress test to predict spinal anaesthesia induced hypotension in patients undergoing elective cesarean section. MATERIAL AND METHODS A prospective observational study was done among 232 singleton parturients scheduled for elective cesarean delivery under spinal anaesthesia in Universal College of Medical Sciences Teaching Hospital. Patients were subjected preoperatively to supine stress test and divided into two group of 116 patients each. SBP, DBP, MAP, HR were compared between two groups. Descriptive as well as inferential statistics were used to analyze the data. RESULTS Supine stress test was positive by heart rate criteria in 50% of positive patient. The incidence of hypotension in positive test group was 73.3%, while it was 11.2% in negative test group, which was statistically significant (p&lt;0.001). CONCLUSION This study demonstrates supine stress test preferably can easily identify parturients in risk of developing hypotension during cesarean section under spinal anaesthesia.

Incidence of intradialytic hypotension in heart transplant recipients with acute kidney injury treated by acetate-free hemodiafiltration

Introduction. Intradialytic hypotension (IDH) is a common complication of renal replacement therapy (RRT) sessions and may be a particularly detrimental factor in heart recipients. Objective: to investigate the incidence of IDH in heart recipients with acute kidney injury (AKI). Patients and Methods: Two groups of recipients were compared – the study group (SG), n = 313, in which 49 patients required intermittent RRT (IRRT) and in which online hemodiafiltration (OL-HDF) sessions were performed using acetate-free hydrochloric acid-based dialysate fluid; and control group (CG) n = 387, in which 88 patients required IRRT, where standard dialysate with an acetate ion content of 3 mmol/L was used for OL-HDF. Results. There was a significantly lower incidence of IDH in the SG compared to the CG: 10.46% vs 20.47% (p &lt; 0.05). Conclusions. In heart recipients for whom IDH can be considered as a significant adverse factor, the use of acetate-free dialysis fluid can significantly reduce the incidence of this complication.

Comparing preoperative fasting and ultrasound-measured intravascular volume status in elective surgery, enhanced recovery patients versus inpatient, urgent surgery patients and the ability of IVC collapsibility to predict post-induction hypotension.

Hypotension following induction of general anaesthesia has been shown to result in increased complications and mortality postoperatively. Patients admitted to the hospital undergoing urgent surgery are often fasted from fluids for significant periods compared to elective patients subject to Enhanced Recovery After Surgery protocols despite guidelines stating that a two-hour fast is sufficient. The aim of this prospective, observational study was to compare fasting times and intravascular volume status between elective surgery patients subject to enhanced recovery protocols and inpatient, urgent surgery patients and to assess differences in the incidence of post-induction hypotension. Fasting data was obtained by questionnaire in the preoperative area in addition to inferior vena cava collapsibility index, a non-invasive measure of intravascular volume. Blood pressure readings and drug administration for the ten minutes following induction were obtained from patients' charts. Inpatients undergoing urgent surgery were fasted significantly longer than enhanced recovery patients and had lower intravascular volume. However, no difference was found in the incidence of post-induction hypotension.

Effects of remifentanil combined with propofol on hemodynamics and oxidative stress in patients undergoing resection of rectal carcinoma.

Rectal carcinoma (RC) treatment primarily involves laparoscopic surgery, which may induce significant hemodynamic changes and weaken immune function. Certain anesthetic approaches using opioid drugs (including remifentanil and sufentanil) pose risks, such as hypotension. To determine the effects of remifentanil combined with propofol on hemodynamics and oxidative stress in patients undergoing RC resection. A total of 211 patients one hundred and four patients with RC treated at the First Affiliated Hospital of Dalian Medical University between November 2018 and November 2022 were retrospectively analyzed. Among them, the remifentanil group included 45 patients receiving remifentanil with propofol anesthesia and the sufentanil group included 59 patients receiving sufentanil with propofol anesthesia. Changes in the hemodynamic index, oxidative stress index, general data, consumption of remifentanil, and use of vasoactive drugs were compared. The incidences of adverse reactions were calculated. The two groups did not significantly differ in terms of operation, anesthesia, and extubation times (P > 0.05). At 1 min after intubation, the sufentanil group showed a notably higher heart rate, systolic blood pressure (SBP), diastolic blood pressure, and mean arterial pressure (MAP) compared with the remifentanil group (P < 0.05), whereas the sufentanil group showed a notably higher SBP and MAP compared with the remifentanil group at 5 min after pneumoperitoneum (P < 0.05). Thirty minutes after surgery, the remifentanil group showed significantly lower plasma cortisol, noradrenaline, and glucose levels than the sufentanil group (P < 0.001). The remifentanil group consumed significantly less remifentanil than the sufentanil group (P < 0.05), and the adoption frequency of ephedrine was lower in the remifentanil group than that in the sufentanil group (P < 0.05). The incidence of hypotension was notably higher in the sufentanil group than that in the remifentanil group (P < 0.05). Remifentanil combined with propofol can improve hemodynamics and relieve oxidative stress in patients undergoing RC resection.

A Five-Year Retrospective Closed Cohort Study to Find a Superior Anaesthetic Technique for Caesarean Section From a Haemodynamic Perspective.

Background A cesarean section (CS) is common and requires a safe and effective anesthetic technique for the safety of both the mother and the fetus. This study aims to compare the intraoperative hemodynamic safety profile with general anesthesia (GA) and regional anesthesia (RA) and propose a superior technique for cesarean from the hemodynamic perspective. Methods After obtaining ethical committee approval, a retrospective closed cohort study was conducted on patients who underwent cesarean with GA and RA. This study was conducted at a tertiary-level university hospital in Oman from January 2015 to December 2019. The investigators collected maternal and fetal data (hypotension, bradycardia, blood loss, APGAR score, fetal mortality, complications, and length of stay) from January 2015 to December 2019. The primaryoutcome was the incidence of intraoperative hypotension, and the secondaryoutcomes studied were significant blood loss and APGAR score in both anesthesia techniques. Results A total of 2500 cesarean patients were studied, of whom 1379 received RA and 1121 received GA. The overall hypotension (systolic BP<90 mm Hg) rate observed was 40.1%; it was significantly lower with GA as compared to RA (32.1% versus 46.5%, respectively, P<0.001, OR 0.545, 95% CI 0.462 to 0.643). Consequently, the requirement for vasopressors was low with GA compared to RA (1.6% versus 23.1%, P<0.001, OR 0.054, 95% CI 0.034 to 0.088). Blood loss (>1 L) was remarkably higher in GA as compared to the RA (15.5% versus 8.9%, respectively, P<0.001, OR 1.916, 95% CI 1.499 to 2.448). APGAR scores were lower with GA than RA (2.8% versus 0.9%, P<0.001). Bradycardia and fetal mortality were almost equal in both groups. Conclusion GA is associated with significantly better hemodynamic stability during the cesarean section.

Dobutamine use in horses during romifidine and isoflurane anaesthesia

This retrospective study aimed to assess the incidence of hypotension and the subsequent administration of dobutamine in horses anesthetized with isoflurane and romifidine during elective surgery. Time from induction of anaesthesia to administration of dobutamine was registered, as well as the time and dose needed to restore mean arterial pressure (MAP) ≥ 70 mmHg. Additionally, the influence of patient and anaesthesia related parameters on the need for dobutamine supplementation was evaluated.In total, 118 horses were included in this retrospective study. Dobutamine was administered to effect when MAP<70 mmHg. Data registered: patient weight, acepromazine premedication, body position, administration of intraoperative ketamine bolus, locoregional anaesthesia, mechanical ventilation, duration of anaesthesia, dose and duration of dobutamine administration, heart rate, MAP before dobutamine administration, MAP and time required to increase MAP≥70 mmHg.Dobutamine infusion was needed in 54.2% of the horses 30 ± 17 min after isoflurane-romifidine anaesthesia started. Dobutamine 0.55 ± 0.18 μg kg−1 min−1 achieved a MAP≥70 mmHg in 12 ± 8 min. Duration of dobutamine infusion was 56 ± 37 min.An univariable logistic regression showed a significant association between dobutamine and acepromazine administration (p = 0.01; OR = 3.43), anaesthesia time (p = 0.02; OR = 2.41) and dorsal recumbency (p < 0.001; OR = 8.40). In a multivariable logistic regression, only dorsal recumbency significantly increased the need for dobutamine supplementation (p < 0.001; OR = 7.70). There was no significant association between patient weight (p = 0.11; OR = 1), locoregional anaesthesia (p = 0.07; OR = 0.47), administration of a ketamine bolus (p = 0.95; OR = 0.98) or volume controlled ventilation (p = 0.94; OR = 1.04) and dobutamine administration.Low doses of dobutamine were suitable to restore MAP above 70 mmHg within a limited time period. Only dorsal recumbency increased the need of dobutamine administration.

Apnea Testing Practice to Increase Baseline PaCO2 and Frequency of Blood Gas Analyses

ObjectiveTo study the influence of the initial partial pressure of carbon dioxide (PaCO2) and frequency of blood gas analyses on the positivity rate and safety of apnea testing (AT). Designprospective multicenter cohort study. SettingSeven teaching hospitals. Participants55 patients who underwent AT. InterventionsPatients were divided into two groups according to their initial PaCO2: the experimental group (≥40 mmHg, 27 patients) and control group (<40 mmHg, 28 patients). Blood gas analysis was performed at 3 min, 5 min and 8 min, and vital signs were taken. AT results and complications were compared between groups. ResultsThe initial PaCO2 of the experimental group was 42.8±2.2 mmHg vs. 36.4±2.9 mmHg in the controls. The AT positivity rate was 100%. The experimental group needed less time to reach the target PaCO2 than the control group (4.07±1.27 min vs. 5.68±2.06 min; P=0.001). Twenty-six patients (96.3%) in the experimental group reached the target PaCO2 in 5 minutes vs. 17 in the control group (60.7%) (P=0.001). Seven patients (12.7%) were unable to complete 8 min disconnection due to hypotension. The experimental group had a slightly lower incidence of hypotension than the control group, but there was no statistical difference (7.4% vs. 17.9%, P=0.245). ConclusionIncreasing the baseline PaCO2 and doing more blood gas analyses can significantly shorten the time needed for AT and improve the AT positivity rate.

Effect of Esketamine Added to Propofol Sedation on Desaturation and Hypotension in Bidirectional Endoscopy

Propofol sedation is widely used for endoscopic procedures, but it poses risks of hemodynamic and respiratory depression. The addition of esketamine as an adjuvant may reduce propofol requirements and associated adverse events. To evaluate the effects of low-dose esketamine added to propofol-based sedation on desaturation and hypotension during same-visit bidirectional endoscopy. This multicenter, double-blind, placebo-controlled randomized clinical trial assessed patients from 3 teaching hospitals in China who were scheduled for same-visit bidirectional endoscopy between February 8 and November 30, 2022, and randomly assigned to receive esketamine or normal saline (placebo). After induction of sedation with 0.1 μg/kg of sufentanil and 0.5 mg/kg of propofol, patients in the esketamine group received 0.15 mg/kg of intravenous esketamine, whereas patients in the placebo group received an equivalent volume of saline. Sedation was achieved through propofol titration. The primary outcome was the composite of desaturation and hypotension during the procedures. Secondary outcomes included desaturation, hypotension, propofol requirements, postprocedure pain and fatigue, nausea or vomiting, dizziness or headache, hallucination or nightmare, endoscopist satisfaction, and patient satisfaction. Among the 663 initially enrolled patients, 660 completed the study (median [IQR] age, 48 [36-57] years; 355 [53.8%] female), with 331 randomized to the esketamine group and 329 to the placebo group. The administration of esketamine compared with placebo significantly reduced the incidence of the composite outcome of desaturation and hypotension (8.2% vs 21.0%; difference, -12.8 percentage points; odds ratio [OR], 0.34; 95% CI, 0.21-0.54; P < .001). Additionally, esketamine led to significantly lower incidences of desaturation (OR, 0.36; 95% CI, 0.18-0.72; false discovery rate q = .01) and hypotension (OR, 0.33; 95% CI, 0.18-0.60; q < .001) and reduced propofol requirements (difference, -58.9 mg; 95% CI, -65.7 to -52.2 mg; q < .001), without significant effects on other secondary outcomes. In this randomized clinical trial of patients undergoing same-visit bidirectional endoscopy, the administration of low-dose esketamine resulted in an approximately 61% reduction in the incidence of desaturation and hypotension, accompanied by decreased propofol requirements. These findings support the use of esketamine as an adjuvant to propofol-based sedation in endoscopic procedures. Chinese Clinical Trial Registry Identifier: ChiCTR2200055938.

Impact of clinicians’ behavior, an educational intervention with mandated blood pressure and the hypotension prediction index software on intraoperative hypotension: a mixed methods study

PurposeIntraoperative hypotension (IOH) is associated with adverse outcomes. We therefore explored beliefs regarding IOH and barriers to its treatment. Secondarily, we assessed if an educational intervention and mandated mean arterial pressure (MAP), or the implementation of the Hypotension Prediction Index-software (HPI) were associated with a reduction in IOH.MethodsStructured interviews (n = 27) and questionnaires (n = 84) were conducted to explore clinicians’ beliefs and barriers to IOH treatment, in addition to usefulness of HPI questionnaires (n = 14). 150 elective major surgical patients who required invasive blood pressure monitoring were included in three cohorts to assess incidence and time-weighted average (TWA) of hypotension (MAP < 65 mmHg). Cohort one received standard care (baseline), the clinicians of cohort two had a training on hypotension and a mandated MAP > 65 mmHg, and patients of the third cohort received protocolized care using the HPI.ResultsClinicians felt challenged to manage IOH in some patients, yet they reported sufficient knowledge and skills. HPI-software was considered useful and beneficial. No difference was found in incidence of IOH between cohorts. TWA was comparable between baseline and education cohort (0.15 mmHg [0.05–0.41] vs. 0.11 mmHg [0.02–0.37]), but was significantly lower in the HPI cohort (0.04 mmHg [0.00 to 0.11], p < 0.05 compared to both).ConclusionsClinicians believed they had sufficient knowledge and skills, which could explain why no difference was found after the educational intervention. In the HPI cohort, IOH was significantly reduced compared to baseline, therefore HPI-software may help prevent IOH.Trial registrationISRCTN 17,085,700 on May 9th, 2019.

Efficacy and safety of patient-controlled epidural analgesia versus patient-controlled intravenous analgesia following open hepatectomy: A single-center retrospective study

BackgroundPostoperative analgesia is an essential component of enhanced recovery after surgery following abdominal surgery. Studies comparing the effectiveness of epidural analgesia with that of other analgesic modalities after liver surgery have reported inconsistent results. Consequently, the use of epidural analgesia for open hepatectomy is controversial. ObjectiveThe present single-center retrospective study aimed to compare the efficacy and safety of patient-controlled epidural analgesia (PCEA) and patient-controlled intravenous analgesia (PCIA) in adults undergoing open hepatectomy. MethodsPatients who underwent open hepatectomy between January 2018 to December 2019 at Zhongshan Hospital, Fudan University were retrospectively analyzed. Propensity score matching was used to adjust baseline information between the PCEA and PCIA groups. The primary outcome measure was scores of the numeric rating scales (NRSs) for resting, exercise, and nocturnal pain at postoperative 24 h (postoperative day 1 [POD1]) and 48 h (POD2). The secondary outcome indicators included postoperative nausea and vomiting (PONV), hypotension, pruritus, respiratory depression, functional activity score (FAS), effective analgesic pump compression ratio, analgesic relief rate, discontinuation of the analgesic pump, reasons for discontinuation of the analgesic pump, and patient satisfaction with postoperative analgesia. ResultsThe NRS scores of the PCEA group on POD1 were significantly lower than those of the PCIA group (P < 0.05). On POD2, the difference between the two groups was significant only for motion NRS scores (P < 0.05). The PCIA group had significantly more patients with lower FAS functional class than the PCEA group (P < 0.001). The effective analgesic pump compression ratio and the analgesic relief rate at 2 days after the surgery were lower in the PCEA group than in the PCIA group (P < 0.001). The incidence of pump discontinuation was higher in the PCEA group than in the PCIA group on POD2 (P = 0.044). Moreover, on POD1 and POD2, the PCEA group showed a higher incidence of pruritus and hypotension than the PCIA group (P < 0.001). Both groups showed no significant difference in PONV incidence. ConclusionIn patients undergoing open hepatectomy, PCEA was more effective than PCIA in relieving moderate to severe pain on POD1. However, improving the safety and effectiveness of PCEA remains a challenge.

Comparison of sedation efficacy of intravenous infusion of dexmedetomidine versus propofol in terms of opioid consumption in patients requiring postoperative mechanical ventilation after head and neck onco-surgeries – A randomized prospective study

Abstract Background: The conventional drug regimen of sedation for patients requiring mechanical ventilation in an intensive care unit (ICU) is propofol or midazolam. Dexmedetomidine is a newer drug for sedation with a better clinical profile. We conducted this study to compare the sedative efficacy of dexmedetomidine versus propofol in patients after head and neck cancer surgeries requiring mechanical ventilation. Methods: After ethics committee approval and written informed consent, 80 patients undergoing head and neck onco-surgery were recruited. The patients were randomly allocated to group I [1 mg/kg of bolus propofol over 15 minutes followed by infusion of 1 mg/kg/hour titrated by increasing or decreasing the infusion dose to Ramsay Sedation Score (RSS) 2–4] or group II (a loading dose of dexmedetomidine 1 mcg/kg over 15 minutes followed by a maintenance dose of 0.4 µg/kg/hour titrated to desired sedation level). The RSS, behavioral pain scale (BPS), heart rate, blood pressure, fentanyl consumption, additional sedative agent, extubation time, length of ICU stays, mechanical ventilation duration, side effects, and patient’s satisfaction were noted. Results: Total fentanyl required was 0.56 ± 0.13 µg/kg/hour in group II and 0.58 ± 0.18 µg/kg/hour in group I (P = 0.75). Extubation time, RSS, BPS, patient satisfaction, and ICU duration were similar in both the groups. The incidence of hemodynamic-related adverse effects were 41.67% in group II and 11.11% in group I (P = 0.006). Conclusion: The fentanyl requirement was comparable in both the groups in the postoperative period. Dexmedetomidine was associated with an increased incidence of bradycardia and hypotension as compared to the propofol group. Propofol should be the preferred sedative for postoperative mechanical ventilation after head and neck onco-surgeries.

Remimazolam tosilate infusion has a lower incidence of hypotension than propofol infusion during painless colonoscopy

Background: Remimazolam tosilate is an ultra-short-acting sedative drug with the advantages of rapid onset and recovery, mild respiratory, and circulatory inhibition. This study primarily investigated the effect of remimazolam on incidence of intraoperative hypotension compared to the widely used propofol in patients undergoing outpatient painless colonoscopy. Methodology: This was a double-blinded, randomized, controlled trial. We randomly divided the eligible patients with outpatient appointment for painless colonoscopy in our hospital into the remimazolam group and the propofol group. The modified observer’s assessment of alert/sedative was used to evaluate the depth of the patient's sedation. The Narcotrend score was monitored throughout the whole process. In the propofol group, propofol 0.5-1.5 mg/kg was infused intravenously as a loading dose, followed by 3-5 mg/kg/h to maintain a satisfied sedation depth during operation. While, with regarding to the patients in remimazolam group, remimazolam 0.05-0.15 mg/kg was induced intravenously as a loading dose, and continuously pumped at a rate of 0.3-0.5 mg/kg/h. SPSS 23.0 software was used to analyze the data. Results: From December 2020 to March 2021, we enrolled 116 eligible patients. The incidence of hypotension during sedation (13.8%) in the remimazolam group was significantly lower than that in propofol (37.9%), and the success rate of remimazolam (98.3%) was slightly lower than propofol (100.0%), but the awakening time was significantly shorter (P &lt; 0.001); The incidence of respiratory inhibition, nausea, vomiting and other adverse events during colonoscopy, remimazolam was significantly lower than that of propofol (P &lt; 0.05). Conclusion: Remimazolam tosilate still has higher circulatory stability than propofol in painless colonoscopy under continuous administration with a loading dose. Trial registration: The trial was registered at the Chinese Clinical Trial Registry (ChiCTR2000040557), data of registration: December 2020. Abbreviations: BMI- Body Mass Index; MOAA/S- Modified Observer’s Assessment of Alert Scale; MAP- Mean Arterial Pressure; Rem- Remimazolam; Pro- Propofol Key words: Remimazolam tosilate; Propofol; Painless Colonoscopy; Hypotension Citation: Li S, Zhang Y, Wang H, Ye G, Yao N, Zhu X. Continuous remimazolam tosilate infusion has a lower incidence of hypotension than propofol infusion for sedation in painless colonoscopy. Anaesth. pain intensive care 2022;27(6):697−705; DOI: 10.35975/apic.v27i6.2341 Received: Aug 27, 2023; Revised: October 16, 2023; Accepted: October 16, 2023

Efficacy and safety of remimazolam compared with propofol in hypertensive patients undergoing breast cancer surgery: a single-center, randomized, controlled study

BackgroundRemimazolam, as a novel anesthetic, has recently been shown to improve hemodynamic stability during anesthesia induction and maintenance; however, it has not been reported in the hypertensive population. This study aimed to compare the effects of remimazolam and propofol on hemodynamic stability in hypertensive patients undergoing breast cancer surgery.MethodsWe enrolled 120 hypertensive patients undergoing breast cancer surgery in this prospective study and randomly allocated them to remimazolam (n = 60) or propofol (n = 60) groups. Anesthesia regimens were consistent between groups, except for the administration of remimazolam and propofol. Our primary outcome was the incidence of post-induction hypotension, which was either an absolute mean arterial pressure (MAP) < 60 mmHg or a > 30% relative drop in MAP compared to baseline within 20 min of induction or from induction to the start of surgery. Secondary outcomes included minimum MAP and MAP at different time points during anesthesia, the application of vasoactive drugs, adverse events, and the patient’s self-reported Quality of Recovery-40 scale for the day after surgery.ResultsThe incidence of post-induction hypotension was lower and the minimum MAP during induction was higher in the remimazolam group than those in the propofol group. There were no significant differences between the two groups in the remaining outcomes.ConclusionRemimazolam is safe and effective in hypertensive patients undergoing breast cancer surgery. Induction with remimazolam in hypertensive patients may result in more stable hemodynamics than propofol.Trial registrationThis study was registered at the Chinese Clinical Trials Registry (http://www.chictr.org.cn) on 03/12/2020, with registration number ChiCTR2000040579.

COMPARATIVE CLINICAL EVALUATION OF CAUDAL BUPIVACAINE VERSUS BUPIVACAINE PLUS TRAMADOL FOR PEDIATRIC INFRAUMBILICAL SURGERIES: A STUDY ON POSTOPERATIVE ANALGESIA

Objective: Effective post-operative pain management is crucial in pediatric patients undergoing infraumbilical surgeries. Various regional anesthesia techniques, including caudal block, have been used to provide post-operative analgesia in children. The addition of tramadol, a synthetic opioid analgesic, to bupivacaine in caudal anesthesia has shown potential benefits. This study aims to compare the clinical efficacy of single-shot caudal bupivacaine alone versus bupivacaine plus tramadol for post-operative analgesia in pediatric infra-umbilical surgeries. Methods: A prospective, randomized, double-blinded clinical study was conducted at our institute. The present study will be carried out in 60 pediatric patients of the American Society of Anesthesiologists Grades I and II between the age of 1 and 8 years, undergoing infraumbilical surgeries. These children were randomly divided into 2 groups. Group B (n=30) received caudal block with 0.25% bupivacaine (1 mL/kg) and Group BT (n=30) received caudal block with 0.25% bupivacaine (1 mL/kg) with tramadol (1 mg/kg). The variables studied were hemodynamic changes, duration of analgesia, and incidence of side effects. Pain assessment was done at 1, 2, 3, 4, 8, 12, and 24 h post-operatively using modified objective pain scale. Results: It was observed that the mean duration of analgesia in Group BT (9.05±2.21) h was significantly longer (p=0.0001) than Group B (3.78±0.94) h. Hemodynamic parameters remained comparable during intraoperative and post-operative periods. There was no incidence of nausea, vomiting, bradycardia, hypotension, pruritus, or decrease in respiratory rate in the two groups. Conclusion: In our study, we concluded that a single-shot caudal block with 0.25% bupivacaine (1 mL/kg) plus tramadol (1 mg/kg) resulted in longer duration of analgesia when compared to 0.25% bupivacaine (1 mL/kg) alone with no incidence of any side effects.

The Analysis of Multiple Outcomes between General and Regional Anesthesia in Hip Fracture Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Surgical interventions in hip fracture have been associated with multiple adverse events, including perioperative hypotension and mortality, making the choice of the anesthetic method for this procedure crucial. There is still no consensus on whether regional (RA) or general (GA) anesthesia should be used to maintain hemodynamic stability and more favorable outcomes. Therefore, this meta-analysis examines the differences between RA and GA groups in the incidence of mortality, intraoperative hypotension, and other intra- and postoperative complications. The comparison is essential given the rising global prevalence of hip fractures and the need to optimize anesthesia strategies for improved patient outcomes, particularly in an aging population. We followed PRISMA guidelines (PROSPERO #CRD42022320413). We conducted the search for studies published in English before March 2022 in PubMed, Google Scholar, and the Cochrane Library. We included RCTs that compared general and regional anesthesia in adult patients having hip fracture surgical interventions. The primary outcome was perioperative mortality. The secondary outcomes were peri- or postoperative complications and duration of hospital stay. We conducted a meta-analysis in RevMan (version 5.4). We examined the quality of the methodology with the Cochrane risk of bias 2 tool, while the quality of evidence was determined with GRADE. Fifteen studies with 4110 patients were included. Our findings revealed no significant difference between general and regional anesthesia in risk of perioperative mortality (RR = 1.42 [0.96, 2.10], p-value = 0.08), intraoperative complications, or duration of hospital length of stay. Our results suggest that regional anesthesia and general anesthesia have comparable safety and can be used as alternatives based on specific patient requirements.

Efficacy of Low Dose Intravenous Epinephrine Infusion in Improving Perioperative Outcomes in Patients Undergoing Transurethral Resection of Prostate: A Prospective Parallel Arm Double-Blind Randomized Control Trial

ObjectiveTo determine the efficacy of intraoperative low-dose intravenous epinephrine infusion in improving intraoperative bleeding and perioperative outcomes of TURP surgery. MethodsThis was a double-blinded, randomized control trial in which all patients undergoing bipolar TURP were included. Patients with uncontrolled hypertension, cardiac disease, and on anticoagulants were excluded. The study group received intravenous epinephrine, whereas the control group received normal saline at the same rate (0.05 μg/kg/min) throughout the procedure. Intraoperative blood loss was the primary outcome. The secondary outcomes were incidence of intraoperative hypotension (due to spinal anesthesia (SA)), resection time, indwelling catheter time, and length of hospitalization (LOH). ResultsThirty-six patients were included in each group. Demographic and clinical profiles were comparable with an overall median prostate size of 41 (34-52) gram in both groups. The primary objective, mean intraoperative blood loss in the study group was lower than the control group but statistically insignificant (67.91+/-18.7 ml vs 75.14+/-17.1 ml; p=0.086). Incidence of intraoperative hypotension was significantly lower in the study group (8.3% vs 33.3%; p= 0.01). Rest of the secondary outcomes, resection time (83 (64-111.5) min vs 86 (68-94.75) min; p=0.97), mean indwelling catheter time (p=0.94), postoperative complications (p=0.73), and LOH (p=0.87) were comparable. ConclusionsIn this first-of-its-kind trial, low-dose epinephrine infusion did not reduce intraoperative blood loss in patients undergoing TURP. However, it significantly reduced intraoperative hypotension, which complicates SA particularly in elderly population.

Effect of ultrasound-guided femoral nerve block with dexmedetomidine and ropivacaine on postoperative analgesia in patients undergoing total knee arthroplasty: a randomized controlled trial

Background: Dexmedetomidine, a potent and highly selective α2-adrenoreceptor agonist, has become a popular adjuvant to local anesthetics. This study was designed to investigate the effect of dexmedetomidine with ropivacaine for femoral nerve block on postoperative analgesia after total knee arthroplasty. Methods: Forty-six patients after total knee arthroplasty received ultrasound-guided femoral nerve block with either 0.3% ropivacaine alone (group R) or 0.3% ropivacaine with 0.5 μg/kg dexmedetomidine (group RD). Total 24-h sufentanil consumption, visual analogue scale (VAS) pain scores, frequency of patient-controlled analgesia (PCA) pressed, Ramsay sedation score, the incidence of bradycardia and hypotension, and incidence of postoperative nausea and vomiting (PONV) were recorded. Results: Compared to group R, the total 24-h sufentanil consumption was significantly reduced (110.76 ± 11.56 vs. 99.09 ± 13.31; P&lt;0.05), the VAS scores were lower at 10 and 12 h postoperatively [3(2–3) vs. 2(1–2) and 3(2–3) vs. 2(1–3), respectively; P&lt;0.05], the frequency of PCA pressed was lower at 8–12 and 12–16-h time intervals [(5(3–6) vs. 2(1–3) and 4(3–4) vs. 2(1–3), respectively; P&lt;0.05]. However, there were no differences in Ramsay’s sedation score and the incidence of PONV. Also, no patient experienced bradycardia and hypotension. Conclusions: 0.5 μg/kg dexmedetomidine with 0.3% ropivacaine for femoral nerve block significantly decreased the total 24-h sufentanil consumption, prolonged and enhanced the analgesic efficacy of ropivacaine, without clinically relevant cardiovascular depression or over-sedation in patients undergoing total knee arthroplasty.

Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?

To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED. A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs). Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8). Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.

Perioperative Hypotension in Patients Undergoing Orthopedic Upper Extremity Surgery with Dexmedetomidine Sedation: A Retrospective Study.

(1) Background: limited data exist regarding the occurrence of hypotension associated with dexmedetomidine use and its risk factors in the context of intraoperative sedation for patients receiving peripheral nerve blocks. (2) Method: This single-center retrospective study assessed the incidence of hypotension in patients undergoing orthopedic upper extremity surgery with brachial plexus blockade. Patients were classified into three groups: group N (non-sedated), group M (midazolam), and group D (dexmedetomidine), based on their primary intraoperative sedative use. The primary outcome was the incidence of perioperative hypotension, defined as systolic blood pressure (SBP) < 90 mmHg or mean blood pressure (MBP) < 60 mmHg, at a minimum of two recorded time points during the intraoperative period and post-anesthesia care unit stay. Multivariable logistic models for the occurrence of hypotension were constructed for the entire cohort and group D. (3) Results: A total of 2152 cases (group N = 445, group M = 678, group D = 1029) were included in the analysis. The odds ratio for the occurrence of hypotension in group D was 5.68 (95% CI, 2.86 to 11.28) compared with group N. Concurrent use of a beta blocker, longer duration of surgery, and lower preoperative SBP and higher preoperative heart rate were identified as significant risk factors. (4) Conclusions: the increased risk of hypotension and the associated factors should be taken into account before using dexmedetomidine in these cases.