Intraoperative Hemodynamic Events Research Articles

Norepinephrine prevents hypotension in older patients under spinal anesthesia with intravenous propofol sedation: a randomized controlled trial

Reducing hypotension is crucial as hypotension is the most common side effect of spinal anesthesia, and in older patients with various comorbidities, it can lead to fatality. We hypothesized that continuous infusion of norepinephrine could effectively prevent hypotension in older patients undergoing hip surgery under spinal anesthesia with propofol sedation. The study randomly assigned patients aged ≥ 70 years to either a control (Group C, n = 35) or a norepinephrine group (Group N, n = 35). After spinal anesthesia, continuous infusion of propofol and normal saline or norepinephrine was initiated. The number of hypotensive episodes, the primary outcome, as well as other intraoperative hemodynamic events and postoperative complications were compared. In total, 67 patients were included in the final analysis. The number of hypotensive episodes was significantly higher in Group C than in Group N (p < 0.001). Furthermore, Group C required a greater amount of fluid to maintain normovolemia (p = 0.008) and showed less urine output (p = 0.019). However, there was no difference in postoperative complications between the two groups. Continuous intravenous infusion of prophylactic norepinephrine prevented hypotensive episodes, reduced the requirement of fluid, and increased the urine output in older patients undergoing unilateral hip surgery under spinal anesthesia with propofol sedation.Clinical trial registration number: KCT0005046 (https://cris.nih.go.kr). IRB number: 2020-0533 (Institutional Review Board of Asan Medical Center, approval date: 13/APR/2020).

Effect of surgical pleth index-guided analgesia versus conventional analgesia techniques on fentanyl consumption under multimodal analgesia in laparoscopic cholecystectomy: a prospective, randomized and controlled study

BackgroundThe Surgical Pleth Index (SPI) is an objective tool that can reflect nociception-antinociception balance and guide the use of intraoperative analgesics. Multimodal analgesia has been neglected in many previous studies. The aim of this study was to compare fentanyl consumption using SPI-guided analgesia versus conventional analgesia techniques under multimodal analgesia in laparoscopic cholecystectomy.MethodsA total of 80 patients aged 18–65 years with American Society of Anaesthesiologists (ASA) grade I-II and a body mass index (BMI) of 18.5 to 30 kg/m2 who were scheduled for laparoscopic cholecystectomy under total intravenous anaesthesia from March 2020 to September 2020 were selected. Multimodal analgesia, including local infiltration of the surgical incision, nonsteroidal anti-inflammatory drugs and opioids, was adopted perioperatively. Fentanyl boluses of 1.0 µg/kg were administered to maintain the SPI value between 20 and 50 in the SPI group. By contrast, fentanyl boluses of 1.0 µg/kg were administered whenever the heart rate (HR) or mean arterial pressure (MAP) increased to 20 % above baseline or when the HR was greater than 90 beats per minute (bpm) in the control group. Preoperative and postoperative blood glucose, plasma cortisol and interleukin-6 (IL-6) levels were evaluated. Intraoperative haemodynamic events and propofol and fentanyl doses were noted. The extubation time, postoperative visual analogue scale (VAS) score, use of remedial analgesics and opioid-related adverse reactions were recorded.ResultsIn total, 18 of 80 patients withdrew for various reasons, and data from 62 patients were finally analysed. Intraoperative fentanyl consumption was significantly lower in the SPI group than in the control group (177.1 ± 65.9 vs. 213.5 ± 47.5, P = 0.016). The postoperative extubation time was shorter in the SPI group than in the control group (16.1 ± 5.2 vs. 22.1 ± 6.3, P < 0.001). Preoperative and postoperative blood glucose, plasma cortisol and IL-6 levels, intraoperative haemodynamic changes, postoperative VAS scores, remedial analgesic consumption and opioid-related adverse reactions were comparable in the two groups.ConclusionsLower doses of fentanyl are required intraoperatively with shorter extubation times when SPI is used to guide intraoperative analgesia compared to conventional analgesia techniques under multimodal analgesia in laparoscopic cholecystectomy.Trial registrationChictr.org.cn ChiCTR2000030145. Retrospectively Registered (Date of registration: February 24, 2020).

Effects of pupillary reflex dilation-guided opioid administration on remifentanil and morphine consumption during laparoscopic surgery: A randomised controlled trial.

Analysis of pupillary reflex dilation (PRD) assesses the balance of nociception--antinociception. Laparoscopic surgery induces haemodynamic variations that are misleading. During laparoscopy, PRD guidance helps differentiate haemodynamic changes because of excess nociception from secondary changes related to the reflex release of endocrine factors. The present study evaluated the effect of PRD-guided antinociception on the administration of intra-operative remifentanil and immediate postoperative morphine consumption in patients undergoing elective laparoscopic surgery. The study was a single-blind, randomised controlled trial. The study took place at two sites at the University Hospital of Nancy from March 2014 to November 2017. A total of 100 patients who underwent scheduled laparoscopic surgery were included. Patients were randomly given remifentanil guided by PRD (PRD-guided) or standard anaesthesia care (control). The primary outcome was intra-operative remifentanil consumption. Secondary outcomes included morphine consumption in the immediate postoperative period and the number of intra-operative haemodynamic events. Data from 95 patients were analysed. Intraoperative remifentanil consumption was lower in the PRD-guided group than in the control group: median [IQR], 0.09 [0.07 to 0.11] vs. 0.14 [0.12 to 0.16] μg kg-1 min-1, with a mean difference (95% confidence Interval, CI) of 0.048 (0.035 to 0.060) μg kg-1 min-1; P < 0.0001. Morphine consumption was 0.13 [0.1 to 0.5] vs. 0.15 [0.11 to 0.4] mg kg-1 (P = 0.52) in the PRD-guided and control groups, respectively. The number of hypertensive and tachycardia events was greater in the PRD-guided group than in the control group: Hypertensive events 60.4% vs. 32.6%, relative risk 1.85 (95% CI, 1.24 to 2.84), P = 0.004; tachycardia events 31.6% vs. 4.3%, relative risk 2.09 (95% CI, 1.45 to 2.84), P < 0.001. When PRD is used to differentiate between haemodynamic events arising from noxious stimuli and those events because of other nonsurgical stimuli, then intra-operative remifentanil administration is reduced intra-operatively during laparoscopic surgery but there was no change in postoperative morphine consumption. Clinicaltrials.gov NCT02116868.

Cocaine-Positive Patients Undergoing Elective Surgery: From Avoiding Case Cancellations to Treating Substance Use Disorders.

Cocaine-Positive Patients Undergoing Elective Surgery: From Avoiding Case Cancellations to Treating Substance Use Disorders.

Effect of preoperative dialysis on intraoperative hemodynamics during living donor kidney transplantation

Background: End-stage renal disease patients on dialysis typically have an advanced disease status and many cardiovascular complications. We aimed to compare the intraoperative hemodynamics between non-preemptive (with preoperative dialysis) and preemptive (without preoperative dialysis) recipients of living donor kidney transplantation (LDKT). Methods: This was a single center retrospective study. The recipients of LDKT were included and all data were collected by electronic medical record. Recipients were divided in two groups: preemptive and non-preemptive kidney transplantation. After comparing the potential risk factors between two groups, we performed a propensity score-matching analysis to reduce the differences of baseline characteristics. The primary outcome was intraoperative hemodynamic events such as the prevalence of the intraoperative hypotension; electrolyte; frequency of inotropes or vasopressors use; and acid-base status. Secondary out come was immediate graft function by nadir creatinine (Cr), time to nadir Cr. Estimated blood loss, surgical time, postoperative bleeding and re-operation were also investigated. Results: We analyzed data from 541 patients after propensity score matching: 388 and 153 patients in non-preemptive and preemptive groups, respectively. The multivariable analysis revealed the AUT of the preemptive group was significantly greater than those of non-preemptive group at thresholds absolute 70 and more inotropes and vasopressors were administered to the preemptive group. Furthermore, base excess in the preemptive group was lower than non-preemptive group. Postoperative nadir Cr concentration, the time to nadir Cr were not different between two groups significantly. Estimated blood loss, surgical time, postoperative bleeding, re-operation were also not different between two groups. Conclusions: Intraoperative hypotension and acidosis occurred more frequently in recipients without preoperative dialysis during LDKT. With this finding in mind, anesthesiologists should prepare for situations where intraoperative hypotension may occur.

The impact of psychological factors on the management of intraoperative haemodynamic events in children

IntroductionPaediatric anaesthesia requires specific theoretical knowledge and practical training. Non-technical skills and psychological factors might influence learning and practice. The aim of this study was to assess personality type and decision-making styles of paediatric anaesthesiology residents during the management of simulated intraoperative life-threatening cases. MethodResidents in anaesthesiology (between 4 and 5 years of training) participated in a simulated hypoxic cardiac arrest in the operating theatre. Their performance was evaluated using a score derived from international recommended management algorithm. They were asked to answer self-assessment questionnaires regarding both their personality (the five personality factors) and their decision-making style. Correlations between performance and personality were investigated. ResultsThirty-eight residents participated in the simulation session and 36 accepted to answer the questionnaires. Good management scoring was positively correlated with agreeableness and conscientiousness personality traits but was negatively correlated with avoidance and spontaneous decision-making styles. DiscussionThe current study identified personality traits and decision-making styles that might influence the management of critical situations during paediatric anaesthesia. The proper identification of these factors might allow targeted personalised training to improve knowledge mobilisation and translation in the clinical context.

A Positive Cocaine Urine Toxicology Test and the Effect on Intraoperative Hemodynamics Under General Anesthesia.

Cocaine has a short biological half-life, but inactive urine metabolites may be detectable for a week following use. It is unclear if patients who test positive for cocaine but have a normal electrocardiogram and vital signs have a greater percentage of hemodynamic events intraoperatively. A total of 328 patients with a history of cocaine use who were scheduled for elective noncardiac surgery under general anesthesia were enrolled. Patients were categorized into cocaine-positive versus cocaine-negative groups based on the results of their urine cocaine toxicology test. The primary aim of this study was to evaluate whether asymptomatic cocaine-positive patients had similar percentages of intraoperative hemodynamic events, defined as (1) a mean arterial blood pressure (MAP) of <65 or >105 mm Hg and (2) a heart rate (HR) of <50 or >100 beats per minute (bpm) compared to cocaine-negative patients. The study was powered to assess if the 2 groups had an equivalent mean percent of intraoperative hemodynamic events within specific limits using an equivalence test of means consisting of 2 one-sided tests. The cocaine-positive group had a blood pressure (BP) that was outside the set limits 19.4% (standard deviation [SD] 17.7%) of the time versus 23.1% (SD 17.7%) in the cocaine-negative group (95% confidence interval [CI], 0.5-7.0). The cocaine-positive group had a HR outside the set limits 9.6% (SD 16.2%) of the time versus 8.2% (SD 14.9%) in the cocaine-negative group (95% CI, 4.3-1.5). Adjusted for age, sex, body mass index (BMI), smoking status, and the presence of comorbid hypertension, renal disease, and psychiatric illness, the cocaine-positive and cocaine-negative patients were similar within a 7.5% margin of equivalence for MAP data (β coefficient = 2%, P = .003, CI, 2-6) and within a 5% margin of equivalence for HR data (β coefficient = 0.2%, P < .001, CI, 4-3). Asymptomatic cocaine-positive patients undergoing elective noncardiac surgery under general anesthesia have similar percentages of intraoperative hemodynamic events compared to cocaine-negative patients.

Recent cocaine use and the incidence of hemodynamic events during general anesthesia: A retrospective cohort study

Study objectiveTo evaluate the intraoperative hemodynamics and medication requirements of cocaine-positive patients compared to matched cocaine-negative controls. DesignRetrospective cohort study. SettingPublic county hospital. Patients821 patients undergoing general anesthesia. MeasurementsIncidence of hemodynamic events, defined by a mean arterial pressure of <65 mmHg or >105 mmHg or a heart rate of <50 beats per minute or >100 beats per minute. Main resultsCocaine-positive patients did not experience a higher incidence of hemodynamic events when compared with matched cocaine-negative patients. Cocaine-positive patients were not more likely to be administered vasopressors intraoperatively but did receive more anti-hypertensive agents. The minimum alveolar concentration of anesthetics used was similar between the two groups. Anesthesia duration, length of stay, and in-hospital mortality did not significantly differ between the two cohorts. ConclusionsCocaine-positive patients did not demonstrate more intraoperative hemodynamic events or adverse short-term outcomes as compared to matched cocaine-negative controls.

Intraoperative ketamine administration to prevent delirium or postoperative cognitive dysfunction: A systematic review and meta-analysis.

Postoperative cognitive complications are associated with substantial morbidity and mortality. Ketamine has been suggested to have neuroprotective effects in various settings. This systematic review evaluates the effects of intraoperative ketamine administration on postoperative delirium and postoperative cognitive dysfunction (POCD). Medline, Embase and Central were searched to 4 March 2018 without date or language restrictions. We considered randomised controlled trials (RCTs) comparing intraoperative ketamine administration versus no intervention in adults undergoing surgery under general anaesthesia. Primary outcomes were postoperative delirium and POCD. Non-cognitive adverse events, mortality and length of stay were considered as secondary outcomes. Data were independently extracted. The quality of the evidence (GRADE approach) was assessed following recommendations from the Cochrane collaboration. Risk ratios were calculated for binary outcomes, mean differences for continuous outcomes. We planned to explore the effects of age, specific anaesthesia regimen, depth of anaesthesia and intraoperative haemodynamic events through subgroup analyses. Six RCTs were included. The incidence of postoperative delirium did not differ between groups (4 trials, 557 patients, RR 0.83, 95% CI [0.25, 2.80]), but patients receiving ketamine seemed at lower risk of POCD (3 trials, 163 patients, RR 0.34, 95% CI [0.15, 0.73]). However, both analyses presented limitations. Therefore, the quality of the evidence (GRADE) was deemed low (postoperative delirium) and very low (POCD). The effect of ketamine on postoperative delirium remains unclear but its administration may offer some protection towards POCD. Large, well-designed randomised trials are urgently needed to further clarify the efficacy of ketamine on neurocognitive outcomes.

Acute Kidney Injury in Patients Undergoing Open Abdominal Aortic Aneurysm Repair: A Pilot Observational Trial.

Acute kidney injury (AKI) is a frequent complication after open repair of abdominal aortic aneurysms (AAA). Little research has been done to determine whether intraoperative hemodynamic events may precipitate AKI. Novel biomarkers also may aid in the earlier diagnosis of AKI. A pilot prospective observational trial. A single tertiary academic medical center. Participants were 40 adult patients undergoing open repair of infrarenal AAA. Intraoperative hemodynamic monitoring of heart rate, mean arterial pressure, central venous pressure, and cardiac index was performed on a continuous basis. Blood samples were obtained at baseline and at 24 hours postoperatively for inflammatory biomarkers, including neutrophil gelatinase-associated lipocalin (NGAL). AKI occurred in 20% of patients (8 of 40). Hypotension, including duration (defined as the length of time mean arterial pressure was<65 mmHg) and magnitude (the area under the curve of a mean arterial pressure<65 mmHg), was the only factor associated with postoperative AKI. Urinary NGAL at the conclusion of surgery had excellent ability to predict the development of AKI (area under the curve 0.84, 95% confidence interval = 0.70-0.97). The cytokines pentraxin 3 (PTX3), interleukin-1 receptor antagonist (IL1-RA), macrophage chemotactic protein (MCP), suppressor of tumorigenicity 2 (ST-2), and interleukin-10 (IL-10) also had good ability to predict the development of AKI in the immediate postoperative period. AKI occurs frequently in patients undergoing open repair of AAA. Intraoperative hypotension was the only factor that predicted the development of subsequent AKI. Urinary NGAL and several novel inflammatory biomarkers demonstrated good ability to predict its development. Novel biomarkers also may aid in the early diagnosis of AKI.

Perioperative concerns in pediatric patients undergoing different types of scoliosis correction surgery: A retrospective observational study

Background:Advances in scoliosis surgery have now made it possible for younger patients to be taken up for scoliosis correction.Objectives:To ascertain the patient profile, perioperative complications and need for intensive care management in children undergoing posterior fusion and instrumentation (PF), anterior release (AR), and growth rod (GR) insertion surgery.Patients and Methods:After taking parental consent, data were collected retrospectively for 33 patients who underwent 37 procedures (four patients had both anterior and posterior procedures) on 2 days of the week mainly from August 2008 to February 2010 at a tertiary care institution.Results:Children undergoing GR surgery were younger (8.1 ± 2.1 years) than patients undergoing AR (12.9 ± 1.7 years) or posterior fusion (14.2 ± 2.2 years). AR children had a significantly higher Cobb's angle and more rigid curves. (P = 0.057) Associated congenital abnormalities especially neurological were commoner in the GR children. Surgical duration and blood loss was significantly more for PF (2207.5 ± 1224.13 ml) than GR (456 ± 337.5 ml), or AR (642.85 ± 304.72 ml), (P = 0.0002). PF patients needed Intensive care unit (ICU) care mainly due to the blood loss and prolonged surgery (35%). AR performed via thoracotomy was associated with the need for mechanical ventilation in 28.6%. The GR patients had major intraoperative hemodynamic events and 20% needed ICU care.Conclusions:Post-operative ventilation may be required in 20-35% patients undergoing procedures for scoliosis correction. Despite GR insertion involving lesser blood loss; younger age, congenital abnormalities, positioning, and surgical manipulation resulted in life threatening events in these patients.

Antidepressive Treatment With Monoamine Oxidase Inhibitors and the Occurrence of Intraoperative Hemodynamic Events

To investigate the occurrence of intraoperative hemodynamic events when antidepressive treatment with monoamine oxidase inhibitors (MAOIs) was continued during anesthesia. A retrospective observational cohort study was conducted among patients who were admitted for elective surgery requiring anesthesia in 8 Dutch hospitals (2004-2010). The index group included current users of irreversible (tranylcypromine) and reversible (moclobemide) MAOIs. The reference group included a sample of nonusers matched to the index group on hospital, type and period of surgery, and type of anesthesia (ratio 1:3). The outcome of interest was the occurrence of the following intraoperative hemodynamic events: hypotension or hypertension and tachycardia or bradycardia. Approximately 280,000 surgical procedures were performed in the participating hospitals in the total observational period of 33 years. The index group included 26 and 25 users of tranylcypromine and moclobemide, respectively. The reference groups included 149 nonusers. Intraoperative hypotension occurred less frequently in users of tranylcypromine (46%) than in nonusers (73%) (P = .01). The occurrence of hypertension, bradycardia, and tachycardia during anesthesia was not different between users of tranylcypromine (27%, 50%, and 12%, respectively) and those in the reference group (35%, 61%, and 26%, respectively). The occurrence of hypotension, hypertension, bradycardia, and tachycardia was not different between users of moclobemide and the reference group. Severe adverse hemodynamic events, such as hypertension and tachycardia, did not occur more frequently in users of both the irreversible MAOI tranylcypromine and the reversible MAO-A inhibitor moclobemide compared to nonusers. These findings suggest that there is no longer much justification to discontinue these MAOIs before surgery, with the considerable risk of compromising patients' psychiatric status.

Perioperative Risk Factors, Morbidity, and Outcome of 145 Patients during Phaeochromocytoma Resection

Background : Phaeochromocytoma and paraganglioma resection carries a high perioperative risk. The aim of this study was to determine the risk factors for and frequency of perioperative morbidity and mortality during resection of these tumours.Methods : Computerized surgical, medical, and histopathology records, as well as anaesthesia cards for 145 patients undergoing surgery for phaeochromocytoma resection between 1995 and 2009 were analysed retrospectively. Preoperative notes, adverse intraoperative events, and postoperative complications occurring in the 30 days following surgery were recorded. Preoperative phenoxybensamine and propranolol dose, age, sex, ASA score, catecholamine urinary level and profile, tumour weight, duration of surgery, and malignancy and presence of bilateral tumours were investigated to determine their contribution to major intraoperative haemodynamic events. Univariate comparisons were carried out using the student t-test. The Mann-Whitney test was also used to allow for deviation from normality. Logistic regression with backward removal of insignificant variables was used for multivariate analysis. Spearman test was used for correlation analysis.Results : The only statistically significant factor that increased the probability of intraoperative haemodynamic variability was the duration of surgery (p = 0.025). The most common intraoperative event was transient hypertension, occurring in 59 (40.7%) patients. Sustained hypertension was registered in only 10 (6.9%) patients. No mortality, myocardial infarction, or cerebrovascular incidents were recorded.Conclusions : We found that the severity of perioperative haemodynamic changes significantly correlated with the duration of surgery. Our patients had low perioperative morbidity and no mortality.

Effects of perioperative α1 block on haemodynamic control during laparoscopic surgery for phaeochromocytoma

Laparoscopic surgery for phaeochromocytoma can cause excessive catechol amine release with severe hypertension and sinus tachycardia. i.v. calcium antagonists may be used to prevent increases in blood pressure during phaeochromocytoma resection. We investigated the effects of perioperative alpha(1) adrenergic block with urapidil on intraoperative haemodynamic events. The aim was to block the alpha(1) adrenergic receptors before any acute catecholamine release, to prevent any severe rise in blood pressure. Eighteen patients with a phaeochromocytoma received a continuous i.v. infusion of urapidil 10-15 mg h(-1) for 3 days before surgery and until the adrenal gland had been removed. Plasma catecholamine concentrations were measured before surgery, after induction of anaesthesia, at the end of pneumoperitoneal insufflation, during gland manipulation, after gland resection, and in the recovery room after extubation. Arterial pressure was recorded concomitantly. Hypertensive events were treated with boluses of nicardipine with or without esmolol. All patients had the adrenal tumour removed without any severe rise in blood pressure or other complication. Creation of a pneumoperitoneum and adrenal gland manipulation induced significant catecholamine release associated with hypertension in 6 and 12 patients, respectively. No correlation was found between hypertensive events and plasma catecholamine levels suggesting alpha(1) receptor block with urapidil is efficacious. Perioperative alpha(1) block using i.v. urapidil is a safe and efficient alternative during surgical management of phaeochromocytoma.