Nitroglycerin Infusion Research Articles

EFFICACY OF NITROGLYCERINE INFUSION VERSUS SUBLINGUAL NIFEDIPINE IN SEVERE PRE-ECLAMPSIA

Background: Pre-eclampsia is a pregnancy-specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation. The incidence of preeclampsia is estimated to range between 2.5 and 5%. An accurate estimate, as well as its global burden, is difficult to obtain, due to lack of data from several countries and standardization of diagnostic criteria. Objective: To compare between the uses of continuous i.v. administration of nitroglycerine versus sublingual nifedipine in the management of women with severe pre-eclampsia who were being managed with controlled plasma volume expansion and MgSO4 loading and maintenance doses. Patients and Methods: Patients were taken from Sayed Galal Hospital. This study was carried out on 100 women with severe pre-eclampsia who were being managed with controlled plasma volume expansion and MgSO4 loading and maintenance doses. Those women were randomly assigned into two equal groups: Nitroglycerine or nifedipine. Both groups were compared as regard maternal adverse effects of vasodilator therapy, mean arterial pressure changes within one hour after vasodilator therapy, post therapy changes in fetal cardiotocography (CTG) and for feto-maternal complications including gestational age of termination of pregnancy, time of maternal intensive care unit (ICU) stay and the need of neonatal ICU. Results: Statistical analysis of the magnitude and time course of maternal hypotensive responses after initiation of the vasodilator therapy showed that, in nitroglycerine group, a statistically significant decrease in both systolic blood pressure (SBP) and diastolic blood pressure (DBP) started just 5 min. after the initiation of nitroglycerine infusion, while in nifedipine group, the significant decrease in SBP and DBP started 15 min. after oral nifedipine. The SBP and DBP measurements in nitroglycerine group were significantly lower than those in nifedipine group. The feto-maternal safety margin observed was similar in the two study groups. Conclusion: IV infusion of nitroglycerine was effective, safe and alternative therapy for severe pre-eclampsia.

CORONARY VASOSPASM ASSOCIATED WITH 5-FLUOROURACIL CHEMOTHERAPY

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: 5-Fluorouracil (5FU) is the third most commonly used chemotherapeutic agent in the treatment of solid malignancies, particularly colorectal and pancreatic neoplasms. (1,2) Coronary vasospasm associated with 5FU is a known complication. (3) Cardiotoxicity occurs in 1% to 18% of patients receiving 5FU, and the incidence of this complication is on the rise.(4) The objective of this report is to highlight the characteristics of this uncommon complication. CASE PRESENTATION: A 66-year-old male with a past medical history of coronary artery disease status-post 4-vessel coronary artery bypass graft surgery and stage 4 colon adenocarcinoma with metastasis to the liver, presented to the emergency department (ED) with complaints of sudden onset of burning deep sub-sternal chest pain with no radiation. The chest pain began approximately eight hours after his first round of 5FU, leuocorin and eloxatin (FOLFOX) chemotherapy. In the ED he was given aspirin and heparin. EKG was concerning for ST-segment elevation myocardial infarction in the inferior leads. Troponins were negative (<0.01). A subsequent left heart catheterization revealed patent grafts and normal coronary arteries. An echocardiogram showed no acute wall motion abnormalities and an ejection fraction of 65%. The 5FU was discontinued and the patient’s chest pain improved. He was discharged with sublingual nitroglycerin and diltiazem. Two weeks later, the patient returned with similar chest pain after his second cycle with 5FU, leuocorin and eloxatin (FOLFOX). The symptoms of his coronary artery vasospasm were believed to be due to 5FU chemotherapy. He was further instructed to go to the cardiovascular ICU to receive nitroglycerine infusions before each cycle of FOLFOX. Unfortunately, the patient expired two months after starting chemotherapy; from cardiopulmonary arrest secondary to sepsis. DISCUSSION: This is a case of a 66-year-old male with a past medical history of coronary artery disease and stage 4 colon adenocarcinoma on 5-Fluorouracil, leuocorin and eloxatin (FOLFOX) chemotherapy presenting for coronary vasospasm likely from 5-Fluorouracil. Cardiotoxicity related to 5FU is poorly understood. Leading theories of the mechanism of 5FU-induced coronary vasospasm seem to involve 5FU's modification of smooth muscle tone. (5,6) Patients on 5FU with coronary vasospasm may have ECG findings suggestive of occlusion, (3) similar to our patient. Treatment of affected patients is determined by confirmation of 5FU as the definitive cause of the coronary vasospasm, as well as the requirement of 5FU as the only suitable chemotherapeutic agent. If possible, care providers should consider switching to an acceptable chemotherapeutic substitute. CONCLUSIONS: In conclusion, consideration should be given for patients with coronary artery disease starting 5-Fluorouracil chemotherapy. Reference #1: 1. Grem JL. 5-Fluorouracil: forty-plus and still ticking. A review of its preclinical and clinical development. Invest New Drugs 2000; 18: 299-313. 2. Myers CE. The pharmacology of the fluoropyrimidines. Pharmacol Rev 1981; 33: 1-15. 3. de Forni M, Malet-Martino MC, Jailais P, et al. Cardiotoxicity of high-dose continuous infusion fluorouracil: a prospective clinical study. Clin Oncol 1992; 10: 1795-1801. 4. Lestuzzi C, Vaccher E, Talamini R, et al. Effort myocardial ischemia during chemotherapy with 5-fluorouracil: an underestimated risk. Ann Oncol 2014; 25: 1059-1064. 5. Bonetti PO, Lerman LO and Lerman A. Endothelial dysfunction: a marker of atherosclerotic risk. Arterioscler Throb Vasc Biol 2003, 23: 168-175. 6. Reddy KG, Nair RN, Sheehan HM, et al. Evidence that selective endothelial dysfunction may occur in the absence of angiographic or ultrasound atherosclerosis in patients with risk factors for artherosclerosis. I Am Coll Cardio! 1994; 23: 833-843. DISCLOSURES: No relevant relationships by Ahmad ababneh, source=Web Response No relevant relationships by HANAD BASHIR, source=Web Response No relevant relationships by Ahmad JABRI, source=Web Response No relevant relationships by Gauranga Mahalwar, source=Web Response

Efficacy of Glyceryl trinitrate (GTN) to facilitate the rewarming process during cardiopulmonary bypass

BackgroundDoes Glyceryl trinitrate (GTN) administered during rewarming on cardiopulmonary bypass (CPB) impact: time to completion of rewarming prior to separation from CPB circuit, early post-op patient peripheral – core temperature gradient, time to maintenance of normothermia (core temperature > 36.5 °C) for minimum of 2 h in the initial post-op period, and plasma lactate concentrations initially post-CPB.MethodsSingle centre prospective randomized trial conducted in the Mater Misericordiae University teaching hospital in Dublin Ireland. Trial registration: ISRCTN registry, ISRCTN10480871, registered 16th of August 2017. 82 patients enrolled. Patients randomised to low dose GTN infusion (0.01 mcg/kg/min) or higher dose GTN infusion (0.5 mcg/kg/min) during rewarming on CPB.Measurements and Main resultsThere was no significant difference between the treatment arms for the total time to being rewarmed, U = 759.0, p = 0.84. There were also no differences between the treatment arms for the time to achieve core temperature greater than 36.5 after two hours, U = 714.0, p = 0.52, the time to achieve plateau core skin temperature, U = 688.0, p = 0.37, and the post-intervention protamine lactate, U = 721.0, p = 0.56.ConclusionsHigher dose GTN infusion during rewarming on CPB does not improve peripheral-core temperature gradient post operatively and has no effect on post-operative lactate concentrations.

Comparative study between magnesium sulphate and dexmedetomidine in controlled hypotension during functional endoscopic sinus surgery: a prospective randomized study

BackgroundFunctional endoscopic sinus surgery (FESS) has been proposed as a selected treatment used in patients with chronic sinusitis that have not responded to medical therapy. Due to the nature of the location of endoscopic sinus surgery, even a small amount of bleeding can reduce the operative visibility. The aim of the work was to compare between dexmedetomidine and magnesium sulphate regarding their efficacy as a hypotensive agent in FESS in adult patients to obtain a bloodless surgical field.Patients and methodsSixty patients were randomly assigned into two groups, (D group) for dexmedetomidine (n = 30) and (M group) for magnesium sulphate (n = 30). In (D group), patients received 1 μg/kg dexmedetomidine in 100 ml saline solution as the loading dose 10 min before induction and 0.5–1 μg/kg/h infusion via syringe pump during surgery. In (M group), patients received 40 mg/kg magnesium sulphate in 100 ml saline solution over 10 min as the intravenous loading dose 10 min before induction, with a subsequent 10–15 mg/kg/h infusion. If there is an increase in the arterial blood pressure greater than the targeted MAP (55–65 mmHg), nitroglycerine infusion was started by 0.5 μg/kg/min. The surgeon estimated the quality of the surgical field and recorded it. The total blood loss was measured. In recovery, time to reach Aldrete score ≥ 9 was recorded to fulfill the discharge criteria. Pain score was assessed by the NRS numerical rating score. The time needed to first analgesia requirement was recorded. Sedation score was recorded using Ramsay sedation score.ResultsThere was no statistically significant difference between both groups regarding MAP except at 30 min postoperatively as there was a statistically significant decrease in the MAP among the dexmedetomidine (D group) (p = 0.039). Nitroglycerine was required in eight cases in the magnesium sulphate (M group) to reach the targeted MAP which was statistically significant compared to the (D group). Patients in the (D group) had a statistically significant decrease in heart rate than in the (M group) during and after the operation (p = 0.35). The quality of the surgical field was significantly better among the (D group) (p < 0.05), and accordingly, the surgeon satisfaction was significantly higher in the (D group) (p = 0.001). Time to reach Aldrete score ≥ 9 and time for first analgesic requirement postoperatively were significantly longer in the (D group) (p = 0.023, p = 0.001 respectively). Regarding the Ramsay sedation score (RSS), it was higher in the (D group) which was statistically significant (p ≤ 0.001).ConclusionDexmedetomidine was more effective than magnesium sulphate to achieve controlled hypotension in patients undergoing FESS. Compared with magnesium, dexmedetomidine offers the advantage of better clarity of the field, surgical satisfaction, less bleeding, and prolonged postoperative analgesia.

Safety and Feasibility of Prehospital Treatment of Acute Pulmonary Edema with Intravenous Bolus Nitroglycerin

Objective Prompt afterload reduction with high dose nitrates remains the cornerstone of treatment for decompensated heart failure with acute pulmonary edema (APE). Nitrate therapy in the prehospital setting is often limited to relatively low doses of sublingual nitroglycerin (NTG), which has poor bioavailability and is challenging to administer with concurrent use of non-invasive ventilation. Conversely, treatment in the Emergency Department typically consists of high doses of nitroglycerin, either by continuous intravenous (IV) infusion or by IV bolus (IVB NTG). A growing body of evidence suggests the safety and efficacy of large doses of IVB NTG in the hospital and prehospital settings. In this study, we assessed the safety and effectiveness of a prehospital bundle of care, which included IVB NTG followed by maintenance IV infusion of NTG for the treatment of decompensated heart failure with acute pulmonary edema. Methods This is a retrospective chart review of patients who received IVB NTG for decompensated heart failure with APE between May 1, 2019 and January 31, 2020 in a large, geographically diverse EMS system in Minnesota and Wisconsin. Inclusion criteria for treatment under this protocol included a working diagnosis of APE, a systolic blood pressure ≥120 mmHg and SpO2 ≤93% following 0.8 mg of SL NTG. Treatment consisted of a 400-mcg IV bolus of NTG, repeated every 2 minutes as needed during transport if SBP ≥120 mmHg. For transport times ≥10 minutes, an intravenous infusion of NTG was initiated at 80 mcg/min and titrated as needed to improve symptoms. Hypotension was defined as a systolic blood pressure ≤ 90 mmHg or a MAP ≤ 65 mmHg. Results During the study period, 45 patients were treated with IVB NTG. 25 patients were treated with IVB NTG alone. The median (IQR) total bolus dose was 400 mcg (400-1200 mcg). 20 patients were treated with a NTG infusion following IVB NTG. The median (IQR) infusion dose was 80 mcg/min (80-100 mcg/min). For all patients, the initial median (systolic IQR) blood pressure was 191/113 mmHg (169-217), 5 minutes following IVB NTG was 158/94 mmHg (141-178), and on arrival to the ED was 152/89 mmHg (129-172). 5 minutes after the initial dose of IVB NTG, there was an increase in median (IQR) oxygen saturation (SpO2) to 92% (88-96) from an initial reading of 88% (78-93). Median (IQR) SpO2 at hospital arrival was 94% (90-98). Median (IQR) transport time was 14 minutes (8.5-19). One episode of transient hypotension occurred during EMS transport and resolved without intervention. There were no cases requiring prehospital advanced airway management in this series. Conclusion Patients treated with IVB NTG by paramedics for APE had reduction in blood pressure and improvement in SpO2compared to their original presentation. There was one instance of transient hypotension that resolved without intervention en route. There were no cases requiring advanced airway management.

Alterations in Functional Connectivity During Different Phases of the Triggered Migraine Attack.

To understand the changes in functional connectivity between brain areas of potential importance in migraine during different phases of the attack. Migraine is a symptomatically heterogeneous disorder. Understanding the possible changes in brain function and, therefore, neurobiology during different phases of the migraine attack is important in developing disease biomarkers and advancing therapeutics. Randomized, double-blind, placebo-controlled, multi-visit experimental study. Subjects aged 18-50years with migraine with and without aura (≤22 headache days per month) were recruited from across the UK using advertising, from both population and hospital clinic samples (n=53). Consented subjects were randomized to a 0.5µg/kg/min nitroglycerin infusion or to placebo over 20minutes across different study visits, during the period February 2015-July 2017.* All subjects were exposed to a nitroglycerin infusion at least on 1 occasion at screening.** For those subjects who consented to participate in imaging visits (n=25), structural T1, T2 and FLAIR sequences and resting state blood oxygen level dependant contrast (rsBOLD) time series, using a multiecho EPI sequence, were conducted over 30-40minutes at baseline and rsBOLD during premonitory symptoms and migraine headache on a 3T General Electric MR750 MRI scanner. For the placebo visit, the imaging was conducted at the same times following infusion in the absence of symptoms. Montreal Neurological Institute (MNI) coordinates were used to characterize identified brain areas of connectivity change. Using repeated measures ANOVA models with time (visit number) and trigger substance (nitroglycerin/placebo) as factors, significant positive functional coupling was found between the thalami bilaterally and the right precuneus and cuneus regions during the nitroglycerin-triggered premonitory phase (T=3.23, peak connectivity change at [-6, -68, 40] for left thalamus, P=0.012 and [-4, -68, 40] for right thalamus, P=0.019). The nitroglycerin-triggered premonitory phase was associated with a change in the direction of connectivity from positive to negative between the pons and the limbic lobe (T=3.47, peak connectivity change at [2, 8, 50], P<0.001). The headache phase of the nitroglycerin-triggered migraine attack was associated with ongoing negative functional coupling between the pons and the cingulate and frontal cortices, and positive functional coupling between the pons and the cerebellar tonsils and medulla (T=3.47, peak connectivity change at [-8, -52, -58], P=0.007). Understanding the functional reorganization between subcortical and cortical brain areas in different phases of the migraine attack provides novel insights into the abnormal sensory processing and integration during migraine, as well as functional correlation with clinical symptoms displayed during each phase. [*Correction added on July 22, 2020 after first online publication: This sentence was revised from, "Consented subjects had a 0.5 μg/kg/min nitroglycerin infusion…".] [**Correction added on July 22, 2020 after first online publication: This sentence was revised from, "… at least on 1 occasion at screening."].

Study protocol for an exploratory interventional study investigating the feasibility of video-based non-contact physiological monitoring in healthy volunteers by Mapping Of Lower Limb skIn pErfusion (MOLLIE)

IntroductionSkin perfusion varies in response to changes in the circulatory status. Blood flow to skin is reduced during haemodynamic collapse secondary to peripheral vasoconstriction, whereas increased skin perfusion is frequently...

Premonitory symptoms in glyceryl trinitrate triggered migraine attacks: a case-control study.

Spontaneous and pharmacologically provoked migraine attacks are frequently preceded by nonheadache symptoms called premonitory symptoms. Here, we systematically evaluated premonitory symptoms in migraine patients and healthy controls after glyceryl trinitrate (GTN) infusion. In women with migraine without aura (n = 34) and age-matched female controls (n = 24), we conducted systematically a semistructured interview assessing 21 possible premonitory symptoms every 15 minutes in the 5 hours after GTN infusion (0.5 µg/kg/min over 20 minutes). Migraine-like headaches occurred in 28/34 (82.4%) migraineurs (GTN responders). After GTN, 26/28 (92.9%) responders, 6/6 (100%) nonresponders, and 13/24 (54.2%) controls reported at least one possible premonitory symptom. Concentration difficulties (P = 0.011), yawning (P = 0.009), nausea (P = 0.028), and photophobia (P = 0.001) were more frequently reported by those migraineurs who developed a migraine-like attack vs healthy controls. Importantly, concentration difficulties were exclusively reported by those who developed a migraine-like attack. Thus, our findings support the view that GTN is able to provoke the naturally occurring premonitory symptoms and show that yawning, nausea, photophobia, and concentration difficulties are most specific for an impending GTN-induced migraine-like headache. We suggest that these symptoms may also be helpful as early warning signals in clinical practice with concentration difficulties exclusively reported by those who develop a migraine-like attack.

Unusual Case of Acute Pulmonary Edema as a Manifestation of Postpartum Preeclampsia: A Case Report

Background: Hypertensive disease of pregnancy remains a leading cause of maternal morbidity and mortality. Four subcategories of hypertensive disorders of pregnancy are recognized by the international society for the study of hypertension in pregnancy: chronic hypertension; gestational hypertension, pre-eclampsia, & white coat hypertension. Pre-eclampsia is defined as systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 on two occasions at least 4 hours apart after 20 weeks of gestation with accompanying signs of end organ damage in a woman with previously normal blood pressure. The majority of cases present ante-partum or immediately post-partum. I review the case of a woman diagnosed with pre-eclampsia at 2 weeks post-partum. Case presentation: A 38-year-old woman presented with increasing dyspnea, orthopnea, intermittent palpitations, and central chest pain 2 weeks after an uncomplicated vaginal delivery. On arrival, she was hypertensive at 168/117, spO2 of 100% on BiPAP. Exam was notable for diffuse rales, a regular rhythm, no JVD, and 1+ peripheral edema. Urine was positive for hemoglobin and protein and the liver panel revealed transaminitis (AST=50 ALT=53), Chest X-ray demonstrated increased pulmonary vasculature congestion, confirmed on CT angiography which was negative for venous thromboembolism. Echocardiography found a preserved ejection fraction without diastolic dysfunction or valvular abnormalities. She was managed with a nitroglycerin infusion and parenteral diuresis with resolution of her pulmonary edema. Conclusion: Pre-eclampsia affects 4-9% of all pregnancies and confers a high risk for both fetal and maternal morbidity and mortality. The definitive treatment for preeclampsia is delivery of fetus and placenta but there is limited information to guide the management of post-partum pre-eclampsia. It has been hypothesized that activation of maternal platelets in the placental bed play a role in preeclampsia through activation of inflammasomes such as sFlt-1. Yes, further research is needed to explore the benefit of suppressing these inflammasomes. Although peri-partum cardiomyopathy and venous thromboembolism usually come to mind in women with cardio-pulmonary complaints post-partum. In the appropriate setting, post-partum pre-eclampsia should also be entertained in the differential.

Modeling and optimized controller for cardiac drug infusion system

Background: Manual drug infusion during surgeries is inaccurate and timeconsuming which has been adopted technique in most of the hospitals. Methods: Based on clinical data, it is evident that the manual control is inaccurate and takes prolonged time to bring into effect, if any change in infusion rate is required during clinical practice. Considering this drawback, the modeling of cardiovascular system (CVS) and baroreceptor (BR) is developed using miscellaneous differential equations based on compartmental approach. The control variables are mean arterial pressure (MAP) and cardiac output (CO) obtained from CVS-BR model. Findings: The manipulated variables are noradrenaline (NAR) and nitroglycerine (NG) infusion rate which is modeled using the relationship between volume and drug mass effect equations on CVS-BR model. For the open loop transfer function derived from the model, relative gain array (RGA) analysis is performed to identify the influence of maximum effect of manipulated variables on the physiological parameters. The simulation results obtained from MATLAB are correlated using time domain specifications and error criteria. The performance index reveals the least error and facilitates in accurate infusion of drugs to the patient during cardiovascular surgeries. Novelty: The automatic controller during surgery provides safe operating condition and speedy recovery of the patients and also helps the anaesthetist to monitor and regulate the physiological variables. Keywords: Control strategy; Error criteria; Drug infusion; Modeling; Relative gain array; Simulation

Headache and non-headache symptoms provoked by nitroglycerin in migraineurs: A human pharmacological triggering study.

BackgroundStudying a spontaneous migraine attack is challenging, particularly the earliest components. Nitroglycerin is a potent, reliable and reproducible migraine trigger of the entirety of the migraine attack, making its use experimentally attractive.MethodsFifty-three subjects with migraine with a history of spontaneous premonitory symptoms were exposed to a 0.5 mcg/kg/min nitroglycerin infusion. Eighty-three percent (n = 44) developed typical premonitory and headache symptomatology. Fifty-seven percent (n = 25) were invited back to further study visits, during which they were re-exposed to nitroglycerin or placebo infusion in a double-blind randomised design. The phenotype of premonitory symptoms and headache was captured and compared to spontaneous attacks and between triggered attacks using agreement analysis.ResultsMore premonitory symptoms were triggered with nitroglycerin than placebo (mean symptom difference = 4, t20 = 7.06, p < 0.001). The agreement in triggering for the most commonly reported premonitory symptoms (concentration difficulty and tiredness) was >66%. The retriggering agreement for all but one premonitory symptom was >60%. The agreement in timing to onset of premonitory symptoms was reliable across two triggered attacks. The agreement with spontaneous attacks and between attacks for headache and its associated symptoms, including laterality, was less reliable.ConclusionsNitroglycerin can reliably and reproducibly provoke premonitory symptomatology associated with migraine. This forms an ideal model to study the earliest manifestations of migraine attacks.

The effect of low central venous pressure on hepatic surgical field bleeding and serum lactate in patients undergoing partial hepatectomy: a prospective randomized controlled trial

BackgroundThis prospective randomized controlled study was designed to evaluate the effect of fluid restriction alone versus fluid restriction + low central venous pressure (CVP) on hepatic surgical field bleeding, intraoperative blood loss, and the serum lactate concentration in patients undergoing partial hepatectomy.MethodsOne hundred forty patients undergoing partial hepatectomy with intraoperative portal triad clamping were randomized into a fluid restriction group (Group F) or fluid restriction + low CVP group (Group L). Both groups received limited fluid infusion before the liver lesions were removed. Ephedrine was administered if the systolic blood pressure (SBP) decreased to <90 mmHg for 1 min. When the urine output was <20 ml/h or the SBP was <90 mmHg for 1 min more than three times, an additional 200 ml of crystalline solution was quickly infused within 10 min. In addition to fluid restriction, patients in Group L received continuous nitroglycerin and esmolol infusion to maintain a low CVP. The duration of portal triad clamping, frequency of additional fluid infusion, frequency of ephedrine administration, intraoperative blood loss, extent of liver resection, and bleeding score of the hepatic surgical field were recorded. Arterial blood gas analysis was performed before anesthesia (T1), after liver dissection and immediately before liver resection (T2), 10 min after removal of the liver lesion (T3), and before the patient was discharged from the postanesthesia care unit (T4).ResultsBeing in the fluid restriction Group (Group F) (odds ratio = 5.04) and cirrhosis (odds ratio = 3.28) were risk factors for hepatic surgical field bleeding. Factors contributing to intraoperative blood loss were the operation time, duration of portal triad clamping, and extent of resection. No significant between-group difference was observed for blood loss or blood transfusion. The serum lactate concentration peaked at T3 in both groups.ConclusionsMaintaining a lower CVP during hepatectomy provides an optimal surgical field but has no significant effect on intraoperative blood loss. Moreover, lower CVP does not increase the serum lactate concentration.Trial registration“A comparative study of the effect fluid restriction and low CVP pressure on the oozing of blood in liver wounds and blood lactate in patients undergoing partial hepatectomy” was prospectively registered as a trial (registration number: ChiCTR-INR-17014172, date of registration: 27 December 2017).

Anterior Mediasten Feokromasitoma Vakasında Anestezi Yönetimi

Paraganglioma can be found in different parts of the body. In this case report, a rare case of anterior mediastinal paraganlioma was examined. Pheochromocytoma can pose problems in intraoperative anesthesia management. A 17-year-old male patient with an anterior mediastinal mass was first scheduled for thoracoscopic tumor resection, and then proceeded with open thoracotomy. The patient, who was diagnosed with preoperative pheochromocytoma, had a history of dual antihypertensive drug use. The patient, who showed an intraoperative labile course, had episodes of hypertension (270/140 mmHg) and tachycardia (200 bpm). Esmolol and nitroglycerin infusion was applied and intervened. Diagnosis of paraganglioma-related pheochromocytoma can be challenging. Risks can be minimized by making appropriate decisions and interventions before and during the operation.

Pregabalin effects on hypotensive anesthesia during spine surgery

Background Elective lumbar spine surgeries are commonly performed under controlled hypotensive general anesthesia to ameliorate intraoperative blood loss and improve the surgical field. Purpose To demonstrate the effect of preoperative 150 mg oral pregabalin on facilitation of induced hypotension during spine surgery evaluated by the total intraoperative consumption of nitroglycerin required to maintain the targeted mean arterial blood pressure. Patients and methods This prospective, randomized, controlled, double-blinded study included two groups of adult patients, who had undergone elective spinal surgery: the pregabalin group (n=53): received oral pregabalin capsule 150 mg 1 h before general anesthesia and the control group (n=53): received oral placebo capsule. The intraoperative invasive mean arterial blood pressure was maintained at the targeted range of 55–65 mmHg by nitroglycerin infusion titration. The intraoperative hemodynamics, blood loss and postoperative sedation, pain scores, and morphine consumption were recorded. Results There was a statistically significant decrease in the consumption of both intraoperative nitroglycerin and postoperative morphine in the pregabalin group compared with the control group, but there was no concomitant decrease in intraoperative blood loss. Also, there was a statistically significant suppression of stress response to intubation in the pregabalin group. Conclusion Premedication with oral 150 mg pregabalin before elective spinal surgery facilitated induced hypotension. Furthermore, it attenuated the stress response to tracheal intubation and enhanced postoperative analgesia.

Comment on "The Effect of Nitroglycerine Infusion on Postoperative Pain in Lower Limb Surgery: A Clinical Double-Blind Study".

Comment on "The Effect of Nitroglycerine Infusion on Postoperative Pain in Lower Limb Surgery: A Clinical Double-Blind Study".

A Comparative Study between Nitroglycerin and Magnesium Sulfate during Shoulder Arthroscopic Surgery in the Beach Chair Position

AbstractBackground: This study was designed to compare the efficacy of intravenous infusion of nitroglycerin versus mag-nesium sulfate for controlled hypotensive anesthesia during arthroscopic shoulder surgery in Beach Chair Position (BCP).Aim of Study: To compare the efficacy of nitroglycerin versus magnesium sulfate in inducing deliberate hypotension and satisfactory surgical field in patients undergoing arthro-scopic shoulder surgery.Material and Methods: Fourty patients scheduled for arthroscopic shoulder surgery under general anesthesia in BCP, randomly assigned into two equal groups, nitroglycerin group (NTG group, n=20) received infusion of 0.5-5μg/kg/min and magnesium group (Mg group, n=20) received 40mg/kg, as slow bolus before induction in 100mL saline solution over 10min then 15mg/kg/h by infusion during the operation to achieve a mean arterial blood pressure (MAP) of about 50 to 65mmHg.Results: Controlled hypotension was achieved in both groups. There was no significant difference in MAP between two groups in first 30mins after infusion then magniseum group produced significantly lower MAP values till stopping of infusion. Heart Rate (HR) was significantly lower in mg group compared with the NTG group. More patients required fentanyl consumption intraoperative (p<0.0001) and frequent administration of rocuronium (p=0.001) in NTG group. How-ever, there was longer extubation time and recovery time in Mg group compared with the NTG group. Bleeding score was insignificantly lower in Mg group and surgeon's satisfaction score was significantly better (p=0.035) in the Mg group.Conclusions: Nitroglycerin and magnesium sulfate can effective in achieving hypotensive anesthesia during arthro-scopic shoulder surgery. However, MgSO4 provide a favorable surgical field condition and better surgeon's satisfaction.

Comparison of Mitochondrial Superoxide Detection Ex Vivo/In Vivo by mitoSOX HPLC Method with Classical Assays in Three Different Animal Models of Oxidative Stress.

Background: Reactive oxygen and nitrogen species (RONS such as H2O2, nitric oxide) are generated within the organism. Whereas physiological formation rates confer redox regulation of essential cellular functions and provide the basis for adaptive stress responses, their excessive formation contributes to impaired cellular function or even cell death, organ dysfunction and severe disease phenotypes of the entire organism. Therefore, quantification of RONS formation and knowledge of their tissue/cell/compartment-specific distribution is of great biological and clinical importance. Methods: Here, we used a high-performance/pressure liquid chromatography (HPLC) assay to quantify the superoxide-specific oxidation product of the mitochondria-targeted fluorescence dye triphenylphosphonium-linked hydroethidium (mitoSOX) in biochemical systems and three animal models with established oxidative stress. Type 1 diabetes (single injection of streptozotocin), hypertension (infusion of angiotensin-II for 7 days) and nitrate tolerance (infusion of nitroglycerin for 4 days) was induced in male Wistar rats. Results: The usefulness of mitoSOX/HPLC for quantification of mitochondrial superoxide was confirmed by xanthine oxidase activity as well as isolated stimulated rat heart mitochondria in the presence or absence of superoxide scavengers. Vascular function was assessed by isometric tension methodology and was impaired in the rat models of oxidative stress. Vascular dysfunction correlated with increased mitoSOX oxidation but also classical RONS detection assays as well as typical markers of oxidative stress. Conclusion: mitoSOX/HPLC represents a valid method for detection of mitochondrial superoxide formation in tissues of different animal disease models and correlates well with functional parameters and other markers of oxidative stress.

Altered activity in the nucleus raphe magnus underlies cortical hyperexcitability and facilitates trigeminal nociception in a rat model of medication overuse headache

BackgroundThe pathogenesis of medication overuse headache (MOH) involves hyperexcitability of cortical and trigeminal neurons. Derangement of the brainstem modulating system, especially raphe nuclei may contribute to this hyperexcitability. The present study aimed to investigate the involvement of the nucleus raphe magnus (NRM) in the development of cortical and trigeminal hyperexcitability in a rat model of MOH.ResultsChronic treatment with acetaminophen increased the frequency of cortical spreading depression (CSD) and the number of c-Fos-immunoreactive (Fos-IR) neurons in the trigeminal nucleus caudalis (TNC). In the control group, muscimol microinjected into the NRM increased significantly the frequency of CSD-evoked direct current shift and Fos-IR neurons in the TNC. This facilitating effect was not found in rats with chronic acetaminophen exposure. In a model of migraine induced by intravenous systemic infusion of nitroglycerin (NTG), rats with chronic exposure to acetaminophen exhibited significantly more frequent neuronal firing in the TNC and greater Fos-IR than those without the acetaminophen treatment. Muscimol microinjection increased neuronal firing in the TNC in control rats, but not in acetaminophen-treated rats. The number of Fos-IR cells in TNC was not changed significantly.ConclusionChronic exposure to acetaminophen alters the function of the NRM contributing to cortical hyperexcitability and facilitating trigeminal nociception.

Abnormal cardiovascular response to nitroglycerin in migraine.

IntroductionMigraine and vasovagal syncope are comorbid conditions that may share part of their pathophysiology through autonomic control of the systemic circulation. Nitroglycerin can trigger both syncope and migraine attacks, suggesting enhanced systemic sensitivity in migraine. We aimed to determine the cardiovascular responses to nitroglycerin in migraine.MethodsIn 16 women with migraine without aura and 10 age- and gender-matched controls without headache, intravenous nitroglycerin (0.5 µg·kg−1·min−1) was administered. Finger photoplethysmography continuously assessed cardiovascular parameters (mean arterial pressure, heart rate, cardiac output, stroke volume and total peripheral resistance) before, during and after nitroglycerin infusion.ResultsNitroglycerin provoked a migraine-like attack in 13/16 (81.2%) migraineurs but not in controls (p = .0001). No syncope was provoked. Migraineurs who later developed a migraine-like attack showed different responses in all parameters vs. controls (all p < .001): The decreases in cardiac output and stroke volume were more rapid and longer lasting, heart rate increased, mean arterial pressure and total peripheral resistance were higher and decreased steeply after an initial increase.DiscussionMigraineurs who developed a migraine-like attack in response to nitroglycerin showed stronger systemic cardiovascular responses compared to non-headache controls. The stronger systemic cardiovascular responses in migraine suggest increased systemic sensitivity to vasodilators, possibly due to insufficient autonomic compensatory mechanisms.

The use of peripheral perfusion index as a predictor for patient’s response to deliberate hypotension during functional endoscopic sinus surgery. A prospective observational study

ABSTRACTBackground: Peripheral perfusion index (PPI) reflects changes in the vasomotor tone. The aim of this observational study is to explore the potentials of the PPI as a predictor of the response to nitroglycerin-induced hypotensive anesthesia in patients undergoing functional endoscopic sinus surgery (FESS).Methods: Forty-seven patients undergoing FESS were included. Deliberate hypotension was achieved using nitroglycerin infusion titrated to a mean arterial blood pressure (MAP) of 60–65 mmHg. PPI was recorded before induction of anesthesia (baseline), at: 1 minute after induction, 1 minute after endotracheal intubation and just before the initiation of nitroglycerin infusion. The correlation between PPI measured at different time points and the time and the dose requirements of nitroglycerin to achieve the target MAP were evaluated.Results: There was a significant positive correlation between the baseline PPI and the time to reach target MAP (r = 0.68, p < 0.0001), the infusion rate of nitroglycerin (r = 0.67, p < 0.0001) and the total intraoperative nitroglycerin consumption (r = 0.65, p < 0.0001). The baseline PPI was the only predictor of nitroglycerin requirement with a cut-off value of 2.8 and an area under the curve 0.85 (95%CI 0.71–0.94, P < 0.0001). The expected individualized dose requirements of nitroglycerin could be derived from the regression equation based on the baseline PPI value.Conclusion: Baseline PPI is a good predictor for the patients’ response to nitroglycerin-induced hypotensive anesthesia. Lower baseline PPI values are associated with a reduction in the time and the dose of nitroglycerin required to achieve and maintain the target MAP.Clinical trials.gov Identifier No: NCT03007355 Registered on 2 January 2017.