Incidence Rate Of Hypotension Research Articles

Relationship between carotid atherosclerotic plaque characteristics in magnetic resonance imaging and perioperative hemodynamic instability

Objective: To analyze the relationship between carotid atherosclerotic plaque characteristics in magnetic resonance imaging (MRI) and perioperative hemodynamic instability in patients with severe carotid artery stenosis undergoing carotid artery stenting (CAS). Methods: A total of 89 patients with carotid artery stenosis who underwent CAS treatment at Beijing Tsinghua Changgung Hospital affiliated to Tsinghua University from January 1, 2017, to December 31, 2021, were prospectively included. Among them, 74 were male and 15 were female, with an age range of 43 to 87 years (mean age: 67.8±8.2 years). Preoperative examinations included carotid artery MRI vessel wall imaging to analyze the existence of large lipid-rich necrotic core (LRNC), intraplaque hemorrhage (IPH), and fibrous cap rupture in carotid artery plaques. Plaques without the above-mentioned risk factors were defined as stable plaque group (34 cases), while those with such risk factors were defined as vulnerable plaque group (55 cases). The number of risk factors present in each plaque was also calculated. Intraoperative changes in blood pressure and heart rate were recorded, and the use of dopamine postoperatively was noted. Using the risk factors that the plaque has as independent variables and the clinical outcomes as dependent variables, the RR values were calculated, and the differences in clinical outcomes of patients with different risk factors were compared. Results: The incidence rates of hypotension and bradycardia were higher in patients with vulnerable plaques than those with stable plaques (60.0% (33/55) vs 14.7%(5/34) and 38.2%(21/55) vs 14.7%(5/34), respectively; both P<0.05). Based on MRI imaging features, the large LRNC was present in 45 cases, with RR values for hypotension and bradycardia of 3.15 (1.69-5.87) and 2.20 (1.07-4.53), respectively; IPH was present in 37 cases, with RR values for hypotension and bradycardia of 2.70 (1.61-4.55) and 2.25 (1.15-4.39), respectively; and fibrous cap rupture was present in 29 cases, with RR values for hypotension and bradycardia of 1.50 (0.94-2.40) and 1.29 (0.67-2.49), respectively. The higher the number of risk factors in vulnerable plaques, the higher the incidence of intraoperative blood pressure and heart rate decrease: when the number of risk factors ranged from 0 to 3, the incidence of blood pressure decrease was 14.7% (5/34), 9/18, 11/18, and 13/19, respectively (P<0.001), and the incidence of heart rate decrease was 14.7% (5/34), 6/18, 7/18, and 8/19, respectively (P=0.022). There was no significant difference in the number of cases of dopamine use between the two groups (P>0.05). Conclusion: Patients with a higher number of risk factors for vulnerable carotid plaques, as indicated by carotid artery MRI vessel wall imaging, are at a higher risk of experiencing blood pressure and heart rate decrease during CAS surgery.

#4345 NOVEL REAL-TIME PREDICTION SYSTEM FOR HYPOTENSION IN DIALYSIS COMBINING RISK INCIDENCE AND NUMERICAL PREDICTION MODEL

Abstract Background and Aims Although there have been many studies on the machine learning prediction model of intradialytic hypotension, the high prediction accuracy in the academic field needs to be transferred to the clinical environment to aid in medical professionals' decision-making process. Before this clinical trial, our team built a data storage, edge computing, and decision support system. However, to achieve real-time decision support, real-time data transmission is also needed along with the system to achieve clinical decision needs. Therefore, this study aims to integrate the AI predictive model with edge computing to build an overall decision support system for intradialytic hypotension in the real-world clinical environment; we have developed a system architecture to deploy the system. Method Development of the IDH decision support system: We developed a complete IDH prediction system to be implemented in dialysis centers and hospitals, which incorporates patient data retrieval to AI prediction models to the web application and monitoring dashboard for medical professionals. The system architecture includes a bridge service used to retrieve the HIS database (patient history), DIS database (dialysis information), and NIS database (nursing care). The data is stored in a data warehouse and then converted into a structured format for AI model training and prediction. Furthermore, an API Server, a communication service for the database and front-end web, is used to present the warning signals in real-time. Lastly, there is a multi-bed monitoring dashboard presenting personalized patient information, the incidence rate of hypotension and numerical prediction of the actual blood pressure value. Design and validation of the online AI prediction model The real-time AI prediction model is built through automatic machine-learning training, which retrains the model every week, utilizing the data of the past 180 days. The features of the input data include biochemistry lab data, nursing records, demographical characteristics, hemodialysis machine parameters and vital signs; it then uses the SMOTE method to fill in missing values and via RFECV to do feature extraction and selection. Lastly, the model is trained through improved RNN models of LSTM (Long short-term memory) and GRU (Gated Recurrent Unit) integrated with machine learning models of XGboost and LightGBM algorithms to generate a combination of binary classification and numerical prediction. Hypotension's output label is defined when systolic blood pressure drops below 90 mmHg. Finally, the validation of the AI machine learning models for binary classification used accuracy score, specificity and sensitivity, whereas the numerical prediction model used RMSE and MAE. Results With the implementation of the edge computing and decision support system, clinical and dialysis data of the patients upload directly to the data warehouse in real-time, and it presents the hypotension prediction information to the medical professional's computer. As a result, the online real-time AI prediction system for the binary classification model yielded an accuracy score, specificity and sensitivity of 0.95, 0.99 and 0.86, respectively, and the RMSE and MAE yielded 17.5 and 11.6, respectively. Furthermore, the model predicted within 15 seconds to ensure a real-time and automatic parameters update. Conclusion Introducing and implementing this integrated intelligence AI prediction system reduces the occurrence of hypotension in dialysis, improves patient safety and satisfaction of patients, and enhances the work environment of medical professionals. Furthermore, this framework and validation can also be provided to home dialysis patients to improve their quality of care. In addition, this system architecture can also be extended to other medical conditions in developing intelligent decision support systems for practical clinical applications.

Efficacy and Safety of Remimazolam Tosilate Combined with Propofol in Digestive Endoscopy: A Randomised Trial

Current Knowledge and Objective. Remimazolam tosilate is a novel intravenous sedative of benzodiazepines with no tissue accumulation, which offers a faster onset of action and recovery time than midazolam. The aim of this trial was to compare the efficacy and safety of remimazolam (RM) combined with propofol and traditional propofol in painless digestive endoscopy with painless gastroscopy and colonoscopy. Methods. Patients were randomised into three groups: RM combined with propofol (RMP group, n = 35), RM (RM group, n = 40), and propofol (P group, n = 38). Each group received 0.1 μg/kg sufentanyl analgesia. An induction dose of 0.1 mg/kg RM and 1 mg/kg propofol was administered to the RMP group, 0.3 mg/kg RM to the RM group, and 2 mg/kg propofol to the P group. Per 5 min, the RMP and RM groups received an additional dose of 0.05 mg/kg RM, while the P group received an extra 0.5 mg/kg propofol. The comparisons involved induction regimen success rate, incidence of hypotension, low pulse rate, injection pain, grade of low oxygen saturation (SpO2), and postoperative adverse reactions. Results and Discussion. The RMP and P groups’ composition powers were 100%, and the RM group’s composition power was 95% ( P = 0.113 ). The incidence rates of hypotension were 40.0%, 18.4%, and 44.7% in the RMP, RM, and P groups, respectively ( P = 0.037 ). The low pulse incidence rates were 5.7%, 2.6%, and 5.3% in the RMP, RM, and P groups, respectively ( P = 0.771 ). The incidence rates of injection pain were 11.4%, 2.6%, and 26.3% in the RMP, RM, and P groups, respectively ( P = 0.007 ). There was no significant difference in low SpO2 severity scores ( P = 0.148 ). New Findings and Conclusion. Remimazolam tosilate combined with propofol can be used for painless endoscopy, with almost the same safety as propofol. Remimazolam tosilate produces a low incidence of adverse reactions and is a safe anaesthetic option for painless endoscopies.

Spinal induced hypotension in pre-eclamptic and healthy parturients

Background: Preeclampsia/eclampsia is the third leading cause of maternal morbidity and mortality. This study aimed to evaluate the incidence and severity of spinal-induced hypotension in preeclamptic and healthy parturients. Material &amp; Methods: A total of 60 pregnant patients undergoing a C-Section with spinal anesthesia were randomly allocated into two groups. Group I: Preeclamptic 0.5%, 2.5cc (12.5mg) Hyperbaric Bupivacaine group: 30 patients. Group II: Normotensive 0.5%, 2.5cc (12.5mg) Hyperbaric Bupivacaine group: 30 patients. The blood pressure values were recorded before spinal anesthesia and 2.5 minutes after a spinal puncture. Results: The mean age of the study group was 25.17+3.61 years (Mean +S.D.) and range is 18-30Years. The BP falls from baseline were significantly greater in the healthy parturients compared to those with preeclampsia (25.8% ± 10.1 vs 18.8% ± 17.0 for SBP, 28.5% ± 8.8 vs 22.5% ± 10.4 for DBP, and 31.2% ± 14.2 vs 18.2% ± 12.6% for MAP, p &lt; 0.05). The incidence rate of hypotension in preeclamptic was 53% compared to 25% in healthy parturients (p &lt; 0.001). Conclusion: The incidence of spinal-induced hypotension associated with patients undergoing C-Section is more in preeclamptic than in healthy parturients.

Effects of pre-injection of pressors on pressor response and bispectral index of patients receiving lower abdominal surgery under total intravenous anesthesia

Surgery in the lower abdomen can cause many adverse reactions in nervous system, metabolic and endocrine systems. Conventional intravenous anesthesia applied for lower abdominal surgery can cause the drop in blood pressure leading to hypoperfusion of vital organs. Hence, an ideal anesthesia state is required to make patients unconscious, unaware and have no postoperative memory during anesthesia. In this study, we investigated the effects of pre-injection of different pressors on the pressor response and bispectral index (BIS) of patients receiving lower abdominal surgery under total intravenous anesthesia. For this, 300 patients undergoing lower abdominal surgery under total intravenous anesthesia were divided into normal saline (Gr. A), ephedrine (Gr. B) and phenylephrine groups (Gr. C) (n=100). Hemodynamics indices were recorded before anesthesia induction (T0) and 1, 3, 5, 7 and 9 min after drug injection (T1-T5, respectively). We observed the following reactions and recorded. BIS values at T0-T5 as well as the time points when the values rose to 65, 75, 85 and 95 and those for respiratory recovery, consciousness recovery and extubation after stopping target-controlled infusion were recorded. Compared with Gr. A, Gr. B had significantly higher systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR) and cardiac output (CO) at T1-T5 (P <0.05), and Gr. C had higher SBP, DBP, MAP and lower HR (P <0.05). Adverse reactions viz., intraoperative hypotension, hypertension, postoperative bradycardia, tachycardia, nausea and vomiting were also observed. The incidence rates of hypotension and total adverse reactions in groups B and C were significantly lower than those of Gr. A (P <0.05). Group B had significantly higher BIS values at T1-T5 than those of Gr. A (P <0.05). The time when BIS values recovered to 65 and 75 in group B was significantly shorter than that of Gr. A (P <0.05). Pre-injection of ephedrine and phenylephrine to patients undergoing lower abdominal surgery under total intravenous anesthesia elevated the blood pressure and reduced the incidence rate of adverse reactions without affecting the recovery time.

Timing of surgical ligation of patent ductus arteriosus in very low birth weight infants

To study the effect of timing of surgical ligation of patent ductus arteriosus (PDA) on the prognosis of very low birth weight infants (VLBWI). The medical data of VLBWI who underwent transthoracic ligation for PDA from June 2018 to May 2021 were reviewed retrospectively. The infants were divided into early ligation group (≤21 days of age) and late ligation group (>21 days of age) based on the age of ligation. The two groups were compared in terms of perioperative clinical features, complications, and mortality. The risk factors for early surgical ligation were analyzed. A total of 72 VLBWI were enrolled, with 19 infants (26%) in the early ligation group and 53 infants (74%) in the late ligation group. There were significant differences in birth weight, gestational age, weight at operation, days of age at operation, rates of preoperative invasive and noninvasive mechanical ventilation, incidence rate of pulmonary hemorrhage, incidence rate of hypotension, preoperative PDA internal diameter (mm/kg), intraoperative PDA external diameter (mm/kg), incidence rate of post-ligation cardiac syndrome, and duration of postoperative invasive mechanical ventilation between the two groups (P<0.05). A binary logistic regression analysis showed that pulmonary hemorrhage was an indication of early surgical ligation of PDA (P<0.05). There were no significant differences in the incidence rates of post-operative complications and the mortality rate between the early ligation and late ligation groups. Early surgical ligation may be performed for VLBWI who are experiencing pulmonary hemorrhage and hemodynamically significant PDA confirmed by cardiac ultrasound after birth. However, post-ligation cardiac syndrome should attract enough attention. In addition, early surgical ligation of PDA does not increase the risk of surgery-related and long-term complications or death, indicating that it is a safe and feasible treatment option.

Comparison of the Hemodynamic Changes in Normotensive and Severe Preeclamptic Pregnant Woman Posted For Cesarean Section under Spinal Anaesthesia

Background: Spinal anesthesia is widely considered a technique of choice for cesarean delivery. But due to fear of sudden and extensive sympathetic blockade, spinal anesthesia may not be considered safe in severe preeclampsia. Objectives: The aim of the present study was to compare the heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), incidence of hypotension, phenyl ephrine requirement and neonatal outcome between normotensive and severe pre-eclamptic women undergoing cesarean section under spinal anesthesia. Material and Methods: A total of 35 severe pre-eclamptic (BP &gt; 160/110 mmHg) 3(Group A) and 35 healthy parturients (group B), meeting the inclusion criteria were included in the study. After preloading with 10 ml/kg of ringer lactate (RL) solution spinal anesthesia was administered with 12.5 mg of hyper baric bupivacaine. Heart rate and blood pressure were recorded before spinal anesthesia and thereafter at 3 minute intervals upto 60 minutes. Hypotension was defined as MAP LESS,THAN 30% of the baseline or a decrease in SBP to LESS THAN 100 mm Hg over the same time interval and was treated with 50 mcg phenylephrine intravenously (i.v). Apgar score was noted 1 and 5 min after birth. Results: The incidence rate of hypotension among the preeclamptic patients was lower than that of the healthy parturients (55.6% vs. 34.1%). The minimum SBP, DBP, and MAP recorded were lower in normotensive, and the difference between two groups was statistically significant. The mean phenylephrine requirement in the normotensive group (151.1 ± 70) was significantly greater (P LESS THAN 0.0001) than that of pre-eclamptic group (48.3 ± 35). The total doses of IV Phenylephrine for treating hypotension were significantly lower among the preeclamptic patients (72 mcg in preeclamptic patients versus 188 mcg in normotensive patients) (P LESS THAN 0.05). There was no statistical difference in the neonatal outcome and Apgar score in the study groups. Conclusion: Pre-eclamptics experienced less hypotension following subarachnoid block (SAB) than normotensives and required less phenylephrine with comparable fetal Apgar scores.

Comparison of the Hemodynamic Changes in Normotensive and Severe Preeclamptic Pregnant Woman Posted For Cesarean Section under Spinal Anaesthesia

Background: Spinal anesthesia is widely considered a technique of choice for cesarean delivery. But due to fear of sudden and extensive sympathetic blockade, spinal anesthesia may not be considered safe in severe preeclampsia. Objectives: The aim of the present study was to compare the heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), incidence of hypotension, phenyl ephrine requirement and neonatal outcome between normotensive and severe pre-eclamptic women undergoing cesarean section under spinal anesthesia. Material and Methods: A total of 35 severe pre-eclamptic (BP &gt; 160/110 mmHg) 3(Group A) and 35 healthy parturients (group B), meeting the inclusion criteria were included in the study. After preloading with 10 ml/kg of ringer lactate (RL) solution spinal anesthesia was administered with 12.5 mg of hyper baric bupivacaine. Heart rate and blood pressure were recorded before spinal anesthesia and thereafter at 3 minute intervals upto 60 minutes. Hypotension was defined as MAP LESS,THAN 30% of the baseline or a decrease in SBP to LESS THAN 100 mm Hg over the same time interval and was treated with 50 mcg phenylephrine intravenously (i.v). Apgar score was noted 1 and 5 min after birth. Results: The incidence rate of hypotension among the preeclamptic patients was lower than that of the healthy parturients (55.6% vs. 34.1%). The minimum SBP, DBP, and MAP recorded were lower in normotensive, and the difference between two groups was statistically significant. The mean phenylephrine requirement in the normotensive group (151.1 ± 70) was significantly greater (P LESS THAN 0.0001) than that of pre-eclamptic group (48.3 ± 35). The total doses of IV Phenylephrine for treating hypotension were significantly lower among the preeclamptic patients (72 mcg in preeclamptic patients versus 188 mcg in normotensive patients) (P LESS THAN 0.05). There was no statistical difference in the neonatal outcome and Apgar score in the study groups. Conclusion: Pre-eclamptics experienced less hypotension following subarachnoid block (SAB) than normotensives and required less phenylephrine with comparable fetal Apgar scores.

Value of bedside echocardiography in predicting persistent patency of the ductus arteriosus during the early postnatal period in very low birth weight infants.

To study the value of bedside echocardiography in predicting persistent patency of the ductus arteriosus during the early postnatal period in very low birth weight (VLBW) infants. A retrospective analysis was performed for 51 VLBW infants who were admitted from March 2020 to June 2021, with an age of ≤3 days and a length of hospital stay of ≥14 days. According to the diameter of patent ductus arteriosus (PDA) on days 14 and 28 after birth, the infants were divided into three groups: large PDA group (PDA diameter ≥2 mm), small PDA group (PDA diameter <2 mm), and PDA closure group (PDA diameter =0 mm). The echocardiographic parameters measured at 72 hours after birth were compared among the three groups. The receiver operating characteristic (ROC) curve was used to evaluate the value of the echocardiographic parameters in predicting persistent patency of the ductus arteriosus (PDA≥2 mm) at the ages of 14 and 28 days. On day 14 after birth, there were 17 infants in the large PDA group, 11 in the small PDA group, and 23 in the PDA closure group. On day 28 after birth, there were 14 infants in the large PDA group, 9 in the small PDA group, and 26 in the PDA closure group. There were significant differences in gestational age, birth weight, rate of pulmonary surfactant use, and incidence rate of hypotension among the three groups (P<0.05). PDA diameter, end-diastolic velocity of the left pulmonary artery, left ventricular output, and left ventricular output/superior vena cava flow ratio measured at 72 hours after birth were associated with persistent patency of the ductus arteriosus at the ages of 14 and 28 days (P<0.05), and the ratio of the left atrium to aorta diameter was associated with persistent patency of the ductus arteriosus at the age of 28 days (P<0.05). The ROC curve analysis showed that the area under the curve that the PDA diameter measured at 72 hours after birth predicting the persistent patency of the ductus arteriosus at the ages of 14 and 28 days was the largest (0.841 and 0.927 respectively), followed by end-diastolic velocity of the left pulmonary artery, with the area under the curve of 0.793 and 0.833 respectively. The indicators obtained by beside echocardiography at 72 hours after birth, especially PDA diameter and end-diastolic velocity of the left pulmonary artery, can predict persistent patency of the ductus arteriosus at the ages of 14 and 28 days in VLBW infants, which provides a basis for the implementation of early targeted treatment strategy for PDA.

Comparison of the innovative endoscopic oropharyngeal airway and the conventional mouthpiece in elderly outpatients undergoing esophagogastroduodenoscopy under sedation: a prospective and randomized study

BackgroundUndesirable outcomes may appear for elderly patients undergoing esophagogastroduodenoscopy (EGD) under sedation, such as hypoxia and hypotension. The aim of our study was to investigate the ability of the innovative endoscopic oropharyngeal airway to reduce the frequency of hypoxia during EGD under sedation in elderly patients.MethodsIn this trial, aged patients undergoing EGD were randomized into airway group and mouthpiece group. The primary outcome was the incidence of the minimum pulse oxygen saturation < 90% and minimum pulse oxygen saturation. In addition, sedation dose, recovery time, emergency management and adverse reactions were recorded.Results360 patients completed the study (180 in each groups). The minimum pulse oxygen saturation during EGD was significantly higher in airway group (97.66 ± 2.96%) than in mouthpiece group (95.52 ± 3.84%, P < 0.001). The incidence of pulse oxygen saturation of 85–89% of airway group (5.0%, 9/180) was lower than mouthpiece group (10.6%, 19/180, P = 0.049). The endoscopy entry time in airway group was 3 (2, 4) seconds and in mouthpiece group was 5 (4, 6) (P < 0.001). Propofol total dose and awakening time were significantly lower in the airway group than in the mouthpiece group (P = 0.020 and P = 0.012, respectively). Furthermore, the incidence rate of hypotension was significantly higher in mouthpiece group (12.2%) than in airway group (5.0%) (P = 0.015). By comparison with the mouthpiece group, the satisfaction of endoscopists was higher in airway group (P = 0.012).ConclusionElderly patients undergoing EGD, Endoscopy Protector was associated with a significantly lower incidence of hypoxia, shortened endoscopy entry time and more stable hemodynamics.Trial registration: ChiCTR, ChiCTR2000031998, 17/04/2020. http://www.chictr.org.cn/index.aspx

Effect of Different Anesthesia Methods on Emergence Agitation and Related Complications in Postoperative Patients with Osteosarcoma.

Purpose To explore the effect of different anesthesia methods on emergence agitation (EA) and related complications in postoperative patients with osteosarcoma. Methods According to the order of admission, 115 patients requiring osteosarcoma surgery treated in our hospital from January 2018 to December 2020 were selected as the research object and randomly divided into the control group (n = 57, accepted the general anesthesia with tracheal intubation) and the experimental group (n = 58, accepted the combined spinal-epidural anesthesia) to compare their anesthesia effect, incidence rates of agitation and complications, and other indexes. Results In terms of the hemodynamic indexes (MAP, HR, and CVP values), both groups had lower ones at T1 than at T0, but the decline of the experimental group was generally lesser than that of the control group; at T2, no statistical difference was shown within the experimental group's indexes when comparing with those at T1, but the control group obtained a significant increase; at T3 and T4, both groups had their hemodynamic indexes increased, but such increase within the experimental group showed no statistical difference when comparing with those at T0, while the control group achieved obviously higher values at T4 than at T0 (before the anesthesia); and the between-group difference in the hemodynamic indexes at T1 and T4 was significant. Compared with the control group, the experimental group achieved better VAS scores and anesthesia indexes and lower incidence rates of EA and complications such as the hypoxemia, cardiovascular response, delayed recovery, and headache. In addition, the differences in the incidence rates of hypotension and cognitive dysfunction between the two groups were not statistically significant. Conclusion When comparing with tracheal intubation general anesthesia, the combined spinal-epidural anesthesia has a better effect in osteosarcoma surgery, with less hemodynamics influence on patients, reduced postoperative pain and stress reaction, and lowered incidence rates of postoperative EA and complications, which is worthy of wide application in clinical treatment.

The Use of Ketamine for Air Medical Rapid Sequence Intubation Was Not Associated With a Decrease in Hypotension or Cardiopulmonary Arrest

ObjectiveRapid sequence intubation (RSI) is associated with a number of complications that can increase morbidity and mortality. Among RSI agents used to blunt awareness of the procedure and produce amnesia, ketamine is unique in its classification as a dissociative agent rather than a central nervous system depressant. Thus, ketamine should have a lower risk of peri-RSI hypotension because of the minimal sympatholysis compared with other agents. Recent recommendations include the use of ketamine for RSI in hemodynamically unstable patients. The main goal of this analysis was to explore the incidence of hypotension and/or cardiopulmonary arrest in patients receiving ketamine, etomidate, midazolam, and fentanyl during air medical RSI. We hypothesized that ketamine would be associated with a lower risk of hemodynamic complications, particularly after adjusting for covariables reflecting patient acuity. In addition, we anticipated that an increased prevalence of ketamine use would be associated with a decreased incidence of peri-RSI hypotension and/or arrest. MethodsThis was a retrospective, observational study using a large air medical airway database. A waiver of informed consent was granted by our institutional review board. Descriptive statistics were used to present demographic and clinical data. The incidence rates of hypotension and cardiopulmonary arrest were calculated for each sedative/dissociative agent. Multivariable logistic regression was used to calculate the odds ratios of both hypotension and arrest for each of the sedative/dissociative agents. The prevalence of use for each agent and the incidence of hemodynamic complications (hypotension and arrest) were determined over time. ResultsA total of 7,466 RSI patients were included in this analysis. The use of ketamine increased over the duration of the study. Ketamine was associated with a higher incidence of both hypotension and arrest compared with other agents, even after adjustment for multiple covariables. The overall incidence of hypotension, desaturation, and cardiopulmonary arrest did not change over the study period. ConclusionsAlthough the incidence of hemodynamic complications was higher in patients receiving ketamine, this may reflect a selection bias toward more hemodynamically unstable patients in the ketamine cohort. The incidence of hypotension and arrest did not change over time despite an increase in the prevalence of ketamine use for air medical RSI. These data do not support a safer hemodynamic profile for ketamine.

Spinal-Induced Hypotension in Preeclamptic and Healthy Parturients Undergoing Cesarean Section.

BACKGROUND:There is a widespread belief that spinal anaesthesia in patients with preeclampsia might cause severe hypotension and decreased uteroplacental perfusion. This study aimed to evaluate the incidence and severity of spinal induced-hypotension in preeclamptics and healthy parturients.METHODS:Total of 78 patients (40 healthy and 38 preeclamptic) undergoing a C-Section with spinal anaesthesia were included. Spinal anaesthesia was performed with a mixture of 8-9 mg isobaric 0.5% bupivacaine, 20 mcg fentanyl and 100 mcg morphine (total volume 2.2-2.4 ml). Blood pressures (BP)-SBP, DBP, MAP were recorded non-invasively before performing spinal anaesthesia and at 2.5 minutes after a spinal puncture.RESULTS:The BP falls (%) from baseline were significantly greater in the healthy parturients compared to those with preeclampsia (25.8% ± 10.1 vs 18.8% ± 17.0 for SBP, 28.5% ± 8.8 vs 22.5% ± 10.4 for DBP, and 31.2% ± 14.2 vs 18.2% ± 12.6% for MAP, p < 0.05). The incidence rate of hypotension in the preeclamptics was 25% compared to 53% in healthy parturients (p < 0.001). Higher doses of vasopressors both ephedrine (16.5 ± 8.6 vs 6.0 ± 2.0 mg) and phenylephrine (105 ± 25 mg) in the healthy women were required. There was no need for phenylephrine treatment in the preeclamptic group.CONCLUSION:This study showed that the incidence and severity of spinal-induced hypotension in preeclamptic patients are less than in healthy women. The use of low dose spinal anaesthesia also contributed to this statement.

Clinical indicators of adrenal insufficiency following discontinuation of oral glucocorticoid therapy: A Danish population-based self-controlled case series analysis.

BackgroundBiochemical adrenal insufficiency induced by glucocorticoid treatment is prevalent, but data on the clinical implications are sparse. We investigated clinical consequences of glucocorticoid-induced adrenal insufficiency after oral glucocorticoid cessation.MethodsWe conducted a Danish population-based self-controlled case series utilizing medical registries. In this design each individual serves as their own control allowing event rates to be compared as a function of time and treatment. Clinical indicators of adrenal insufficiency were defined as diagnoses of gastrointestinal symptoms, hypotension, cardiovascular collapse, syncope, hyponatremia, and hypoglycaemia. We included 286,680 persons who discontinued long-term (≥ 3 months) oral glucocorticoid treatment. We defined five risk periods and a reference period (before treatment): period 0 (on treatment), withdrawal period (1 month before and after cessation), followed by three consecutive 2 month-risk periods after withdrawal (periods 2–4).ResultsMedian age at cessation was 69 years and 57% were female. Median treatment duration was 297 days and median cumulative dose was 3000 mg prednisolone equivalents. The incidence rates of hypotension, gastrointestinal symptoms, hypoglycemia and hyponatremia were increased in the withdrawal period compared to before treatment started (reference period). Incidence rate ratios comparing the withdrawal period with the reference period were 2.5 [95% confidence interval (CI): 1.4–4.3] for hypotension, 1.7 (95% CI: 1.6–1.9) for gastrointestinal symptoms, 2.2 (95% CI: 0.7–7.3) for hypoglycemia, and 1.5 (95% CI: 1.1–2.0) for hyponatremia. During 7 months of follow up, the rates of hypotension and gastrointestinal symptoms remained elevated compared to the reference period. Risk factors included use of antibiotics, increasing average daily dose of glucocorticoids, cumulative dose, and age.ConclusionOral glucocorticoid withdrawal was associated with adverse outcomes attributable to adrenal insufficiency. Our study underscores the need for future research to establish evidence-based clinical guidance on management of patients who discontinue oral glucocorticoids.

Clinical effect of propofol combined with butorphanol on endoscopic retrograde cholangiopancreatography

Objective To investigate the effect of propofol combined with butorphanol on hemodynamics and anesthesia complications in patients with endoscopic retrograde cholangiopancreatography (ERCP), and to provide a reference for the selection of ERCP. Methods A total of 120 patients with ERCP were selected, aged 31-59 years, ASA grade Ⅰ-Ⅱ, BMI 17.9-25.4kg/m2, no general anesthesia contraindications before surgery, no opioid allergy history, no liver and kidney dysfunction.The patients were randomly divided into two groups with computer software: propofol + butorphanol group (B group) and propofol + remifentanil group (R group). The systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), oxygen saturation (SpO2) were recorded at the time of anesthesia induction (T0), immediately after injection of propofol (T1), 10 min (T2) after propofol injection, before ending (T3) and immediate after recovery (T4). At the same time, the propofol induced dose, propofol maintenance dose and awakening time were recorded.Regarding the adverse reactions, the intraoperative hypotension, PONV, lethargy, intraoperative physical movement, skin itching were recorded. Results The levels of SBP in R group were significantly lower than those in B group at T1, T2, T3 and T4 (t=3.952, 4.876, 5.190, 4.391, all P 0.05). The incidence rates of hypotension and hypoxia in B group were significantly lower than those in R group (14 cases vs.5 cases, 10 cases vs.3 cases, χ2=5.065, 4.227, all P<0.05). Conclusion Butorphanol can provide good analgesic effect to patients undergoing ERCP, while maintaining hemodynamics stability, the patients' respiratory depression is also mild and does not increase the incidence of other anesthesia-related complications risk, with good effect and safety.It is worth to promote in clinical. Key words: Butorphanol; Remifentanil; Cholangiopancreatography, endoscopic retrograde; Hemodynamics

Effect of lose doses ropivacaine and sufentanil in spinal anesthesia of women with severe preeclampsia for casarean delivey

Objective To evaluate whether low-dose ropivacaine in combination with sufentanil could produce effective spinal anaesthesia for severe preeclamptic parturients during cesarean section. Methods 40 severe preeclampsia parturients undergoing elective caesarean delivery under combined spinal-epidural anaesthesia were randomly divided into two groups based on a computer-generated grouping number sheet, each group in 20 cases.Group A received intrathecal ropivacaine 15mg (1.5mL)+ 10% dextrose 1mL with normal saline 0.5mL.Group B received intrathecal ropivacaine 10mg (1mL) + sufentanil 5μg(1mL) + 10% dextrose 1mL.Blood pressure, heart rate and oxygen saturation were documented at 2 min intervals for 10 min after local anaesthetic was administered.Sensory and motor block were assessed at 2.5 min intervals after spinal injection.The side effects such as hypotension, nausea and vomiting during surgery were recorded. Results The onset of motor block was longer[(4.8±2.1) min vs.(4.2±1.5) min, t=-2.83, P<0.01], and the duration was shorter[(75.9±25.2) min vs.(115.4±29.5)min, t=10.75, P<0.01] in group B than those in group A. The number of patients who had Bromage score 3 in group A was more than that in group B. Compared with group A, the duration of complete analgesia[(180±35) min vs.(120±27) min, t=15.48, P<0.001]and effective analgesia[(245±29)min vs.(184±34)min; t=16.21, P<0.001] increased in group B. More patients were sleepy but easily rousable in group B than in group A (9cases vs.0cases, χ2=8.53, P<0.01). The incidence rate of hypotension was significantly higher(45.0% vs.20.0%, χ2=4.29, P<0.05) in group A than that in group B. Compared with group A, the incidence rate of hypotension(45.0% vs.20.0%, χ2=4.29, P<0.05), vomiting(30.0% vs.5.0%, χ2=4.33, P<0.05) and shivering (50.0% vs.10.0%, χ2=7.62, P<0.01) were lower in group B. The incidence of pruritus was significantly higher in group B (χ2=10.16, P<0.01). Conclusion Hyperbaric ropivacaine 10 mg with sufentanil 5μg could produce effective spinal anaesthesia for severe preeclamptic parturients during cesarean section with less hypotension, vomiting and shivering, and longer lasting analgesia than hyperbaric ropivacaine 15 mg. Key words: Pre-eclampsia; Cesarean section; Ropivacaine; Sufentanil; Anaesthesia, spinal

Refractory hypotension induced by Sheehan syndrome with pituitary crisis: A case report.

The present study reported on an unusual case of refractory hypotension induced by Sheehan syndrome with pituitary crisis and explored the causes and treatment of hypotension in hypopiptuitarism. Refractory hypotension is a rare and severe complication of longstanding hypopituitarism induced by Sheehan syndrome with pituitary crisis. A 48-year-old Chinese woman with pituitary crisis due to Sheehan syndrome developed refractory hypotension and received longstanding vasopressor blood pressure support and hormone replacement therapy. Besides normalized blood pressure, echocardiography over 3 months revealed partial reversibility of her cardiac function with hormone replacement therapy. Consistent numerous studies reviewed, hormone replacement therapy may improve cardiac function in patients with cardiomyopathy linked to Sheehan syndrome. A retrospective study of 77 cases with hypopituitarism encountered at Qilu Hospital of Shandong University (Jinan, China) was also performed and the incidence rate of hypotension was analyzed, revealing that the present case was the first of refractory hypotension induced by Sheehan syndrome with pituitary crisis at this institution in 16 years.

Clinical significance of different carnitine levels for improving the prognosis of patients undergoing hemodialysis

Objective: To investigate plasma-free carnitine (Fc), acylcarnitine (Ac), and total carnitine (Tc) levels in patients undergoing hemodialysis (HD), and to explore their clinical significance.Methods: A total of 20 subjects were in the normal control group and 133 patients undergoing HD were divided into medicated (received carnitine treatment) and non-medicated groups. The medicated group was further divided into three subgroups according to Fc level: Fc = 80–199, 200–299, and ≥ 300 μmol/L. We used non-derivative tandem mass spectrometry to determine carnitine levels, and clinical symptoms such as weakness, hypotension, and muscle cramps were recorded during dialysis.Results: Fc and Tc levels were significantly lower in the non-medicated group than in the control group, whereas Fc, Ac, and Tc levels were higher in the medicated than non-medicated group (p< .05). The medicated group had fewer symptoms during dialysis than the non-medicated group such as weakness, hypotension, and muscle cramps (p< .05). An additional comparison showed that the incidence rates of hypotension and muscle cramps in the Fc < 80–199 μmol/L group were significantly lower than those in the Fc ≥ 300 μmol/L medicated and non-medicated groups.Conclusions: Patients undergoing HD have low carnitine levels. l-Carnitine can effectively increase Fc concentration and improve clinical symptoms; however, only the proper Fc range can reduce complications caused by dialysis. Thus, this range needs to be determined.

Comparing the Hemodynamic Effects of Spinal Anesthesia in Preeclamptic and Healthy Parturients During Cesarean Section

BackgroundDespite controversies about the safest anesthetic technique for cesarean delivery in severely preeclamptic women, there is evidence that supports the use of spinal anesthesia in this group of patients.ObjectivesThis prospective randomized clinical trial was designed to determine the hemodynamic effects of low-dose spinal bupivacaine and the incidence of spinal anesthesia-associated hypotension in severely preeclamptic and healthy parturients undergoing cesarean sections.Patients and MethodsSpinal anesthesia was performed with 10 mg (= 2 mL) hyperbaric 0.5% bupivacaine plus 2.5 µg sufentanil in two groups of patients after they received 500 mL of IV lactated Ringer’s solution. Heart rate and blood pressure were recorded before spinal anesthesia and at two minutes intervals for 15 minutes after the block, and then every five minutes until the end of the surgery. Hypotension was defined as more than 25% of decline in the mean arterial blood pressure compared to the baseline in both groups (or systolic blood pressure < 100 mmHg in healthy parturients) and was treated with 5 mg IV ephedrine. The total amounts of intravenous administered fluid and the total doses of ephedrine were recorded for each patient as well.ResultsThe incidence rate of hypotension among the preeclamptic patients was lower than that of the healthy parturients, despite the former group receiving smaller volumes of intravenous fluids (P < 0.05). The total doses of IV ephedrine for treating hypotension were significantly lower among the preeclamptic patients (3.2 mg in preeclamptic patients versus 7.6 mg in normotensive patients) (P = 0.02). The one-minute Apgar score was significantly lower for the preeclamptic parturients (8.4 ± 0.7 versus 7.2 ± 1.5) (P = 0.001), but there was no significant difference in the five-minute Apgar scores between the two groups.ConclusionsOur results confirm that low-dose bupivacaine spinal anesthesia is associated with a lower risk of hypotension than previously believed, and it can therefore be safely used in severe preeclamptic women undergoing cesarean delivery.

Ephedrine and dopamine's hypotension-preventative effect for CSEA in cesarean delivery-A single-blind controlled study

Objective To compare the effects of ephedrine and dopamine in the prevention of hypotension during combined spinal and epidural anesthesia(CSEA)for cesarean delivery. Methods Fifty ASAⅠorⅡpatients undergoing elective cesarean delivery were randomly divided into the two groups, Ephedrine group(n =51): intravenous injection of 10mg ephedrine before anesthesia; Dopamine group(n=52): continuous intravenous infusion at the speed of 5μg·kg-1·min-1.During the whole process, we investigated the incidence rate of adverse effects, compared the Apgar score of neonate and analyzed blood gas of umbilical artery and vein. Results Compare to the dopamine group, the incidence rate of hypotension was lower in the ephedrine group(43.1%vs 69.2%,χ2=7.06,P=0.00). The p H value of umbilical artery and 1 min Apgar score of neonate in the ephedrine group was lower compare with that in the dopamine group[(7.22±0.03)vs(7.27±0.06),t=0.62, P=0.02], there are no significant difference of 5min Apgar score in the two groups. Conclusion Compared with dopamine, ephedrine is a useful drug in the prevention of hypotension during combined spinal and epidural anesthesia(CSEA)for cesarean delivery and there are no significant differences of adverse effects of dopamine and ephedrine. Ephedrine has transient effect on the neonate, while the effect of dopamine is minor. Key words: Cesarean section; Anesthesia; Ephedrine; Dopamine