Mean Arterial Pressure Readings Research Articles

Comparison of Hemodynamic Effect of Propofol and Ketofol during Induction of Anaesthesia in General Surgery Patients

Objective: To determine the comparison of homodynamic effect of propofol and ketofol duringinduction in general surgery patients.Study design: Randomized control trialSetting: Department of Anesthesia, Surgical ICU and Pain management, Civil Hospital Karachi.Duration: Seven months from June 2019 to January 2020.Methods: Patients scheduled for elective general surgery procedures, aged 20 to 60 years, bothmale and female patients were included. Patients were randomly allocated into two groups.Group A received a combination of ketofol while Group B received propofol as the inductionagent. After recording of the base line values of mean arterial pressure patient was induced usingpropofol or ketofol. Mean arterial pressure readings were noted at 30 seconds after druginjection, as well as at 1 minute, 5 minutes, and 10 minutes after intubation, to capture theimmediate hemodynamic effects of the drugs and to observe any potential changes over timefollowing intubation.Results: The average age of the patients was 37.38±13.78 years. Out of 64 patients, 30(46.9%)were male and 34(53.1%) were female. Homodynamic effect was significantly high in thosepatients who received ketofol than those who received propofol (100% vs. 59.4% p=0.0005).The findings observed also with significant differences in hemodynamic effects between the twogroups, even after controlling for age, gender, and ASA classification (p-<0.05).Conclusion: Combination of Ketofol with ketofol was observed to be the betterhemodynamically as compared to Propofol. Additionally, the use of ketofol reduces the cost ofinduction and decreasing the economic burden on the patient.

Effect of 24-h blood pressure dysregulations and reduced ocular perfusion pressure in open-angle glaucoma progression.

Low ocular perfusion pressure (OPP), which depends on the mean arterial pressure (MAP) and intraocular pressure (IOP), is associated with glaucoma. We studied 24-h MAP dysregulations and OPP in relation to the progression of glaucoma damage. We retrospectively analyzed 155 normal-tension glaucoma (NTG) and 110 primary open-angle glaucoma (POAG) patients aged 18 years old followed at the University Hospital Leuven with repeated visual field tests (n = 7000 measures, including both eyes) who underwent 24-h ambulatory blood pressure monitoring. Twenty-four-hour MAP dysregulations were variability independent of the mean (VIM), and the five lowest dips in MAP readings over 24 h. OPP was the difference between 2/3 of the MAP and IOP. Glaucoma progression was the deterioration of the visual field, expressed as decibel (dB) changes in mean deviation analyzed by applying multivariable linear mixed regression models. The mean age was 68 years (53% were women). High 24-h VIMmap was associated with glaucoma progression in POAG (P < 0.001) independently of the 24-h MAP level. The estimated changes in mean deviation in relation to dip MAP measures ranged from -2.84 dB [95% confidence interval (CI) -4.12 to -1.57] to -2.16 dB (95% CI -3.46 to -0.85) in POAG. Reduced OPP along with high variability and dips in MAP resulted in worse mean deviation deterioration. The progression of glaucoma damage associates with repetitive and extreme dips in MAP caused by high variability in MAP throughout 24 h. This progression exacerbates if 24-h MAP dysregulations occur along with reduced OPP.

Ultrasound-guided ilioinguinal/iliohypogastric nerve block compared to posterior quadratus lumborum block in patients undergoing inguinal hernia repair

ABSTRACT Background “Ilioinguinal/iliohypogastric nerve block” (IINB) has been described as effective regional anesthetic method for providing analgesia after inguinal hernia operations. Other studies have also reported that the “posterior quadratus lumborum block” (PQLB) is an effective analgesic option for lower abdominal surgeries. Herein, we compared the previous two block techniques for postoperative pain management in adults undergoing unilateral inguinal hernia repair. Methods According to the block technique, 76 adult patients scheduled for inguinal hernioplasty under general anesthesia were randomly enrolled into two groups; the PQLB and IINB groups. The block was performed after skin closure and before patient extubation. Postoperative analgesic profiles were recorded in both groups. Results The PQLB had lower heart rate and mean arterial pressure readings during postoperative assessment compared to the other group. Pain scores showed a significant decline in association with the PQLB during the first postoperative day, which resulted in a significant decline in pethidine consumption (49.17 vs. 70 mg in the IINB group) and better patient satisfaction. The duration to the first analgesic request significantly increased in association with the PQLB (13.25 vs. 8.42 hours in the IINB group). The incidence of nausea and vomiting increased significantly in the IINB group secondary to increased pethidine requirements. Conclusion PQLB is superior to IINB in providing analgesia for patients undergoing inguinal hernia repair.

Atracurium versus cisatracurium: A comparison of efficacy and safety of intubating dose in adult surgical patients

Abstract Background: Our study investigated and compared the properties of atracurium and cisatracurium, nondepolarizing neuromuscular blocking agents from the benzylisoquinolinium group. Both of these agents exhibit an intermediate duration of action. We studied the onset of neuromuscular blockade, intubating conditions, hemodynamic stability, and recovery following intubating doses. Materials and Methods: We conducted a study involving 40 patients undergoing general anesthesia, randomly assigned to two groups. Group A, consisting of 20 patients, received a dose of 0.6 mg/kg of atracurium, while Group C, also with 20 patients, received 0.15 mg/kg of cisatracurium. Throughout the surgery, we observed and recorded the time of onset of neuromuscular blockade, the intubating conditions, and the recovery following the administration of the first dose of neuromuscular blocking agents. Additionally, we continuously monitored the patient’s hemodynamic status until they recovered from the initial dose. Results: Group C exhibited a significantly faster onset of action (231.5 ± 31.2 s) than Group A (291.0 ± 14.1 s) for the administered neuromuscular blocking agents. The recovery duration following the intubating dose was notably shorter in Group A (31 ± 6.20 min) compared to Group C (50.5 ± 3.20 min). Additionally, in the cisatracurium group, all patients (100%) achieved “excellent” intubating conditions, whereas in the atracurium group, this was only the case for 60% of patients, and this difference was statistically significant. Furthermore, the atracurium group showed significantly higher heart rate and mean arterial pressure readings at different intervals than the cisatracurium group. Importantly, no adverse reactions were observed in any of the patients throughout the study. Conclusion: Compared to atracurium (0.6 mg/kg), cisatracurium at a dose of 0.15 mg/kg demonstrates superior effectiveness regarding the onset and duration of neuromuscular blockade and intubating conditions. Furthermore, cisatracurium offers a more favorable hemodynamic profile.

PS-C12-3: OPEN-ANGLE GLAUCOMATOUS OPTIC DAMAGE IN RELATION TO SYSTEMIC AND OCULAR PERFUSION PRESSURE

Objective: Glaucoma is the leading cause of irreversible blindness worldwide. One of the pivotal physiopathological mechanisms involved is reduced ocular perfusion pressure (OPP) at the optic nerve head, which depends on the mean arterial pressure (MAP) and intraocular pressure levels. The interplay association of variability and dips in the 24-h MAP with OPP in relation to glaucoma progression remains undocumented. Therefore, we conducted a retrospective longitudinal study to investigate variability and dips in the 24-h MAP and OPP in relation to the progression of open-angle glaucoma damage. Methods: A total of 265 patients with normal-tension glaucoma (NTG; n = 155) and primary open-angle glaucoma (POAG; n = 110) followed at the University Hospital Leuven with longitudinal visual field tests (n = 7000 measures, including both eyes) who underwent ambulatory blood pressure monitoring were studied. The main outcome was longitudinal changes in the mean deviation (MD), expressed in decibels (dB), which was retrieved from visual field tests. The intraocular pressure (IOP) was measured with applanation tonometry. MAP variability independent of the mean (VIMmap) was computed and the five lowest dips in MAP readings were further analyzed. OPP was the difference between 2/3 of the 24-h MAP minus 24-h intraocular pressure levels. Statistics methods included mixed models. Results: The mean age was 64.0y (53% were women). The IOP during eight years of follow-up was 11.3 mmHg. All IOP measures were higher in POAG than NTG (P &lt; 0.046). POAG patients had lower OPP than NTG (P &lt; 0.045). In adjusted mixed models, higher 24-h VIMmap was associated with longitudinal changes in MD in POAG (-2.07 dB changes, P &lt; 0.001). The longitudinal changes in MD associated with dip measures ranged from -2.84 dB (95% confidence interval [CI], -4.12, -1.57; P &lt; 0.001) to -2.16 dB (95% CI, -3.46,-0.85; P = 0.001) in POAG. Lower 24-h MAP combined with high variability and extreme dips in MAP resulted in worse progression of MD (P = 0.009). Reduced OPP was associated with -2.51 to -2.00 dB changes in the MD (P &lt; 0.001) in POAG. Progression in MD was worse in patients experiencing reduced OPP along with high variability and dips in MAP. Conclusions: Progression of open-angle glaucoma damage is associated with high variability and dips in MAP, and reduced OPP. This progression exacerbates if the lower OPP occurs along with extreme dips in the MAP. 24-h ambulatory blood pressure and intraocular pressure should be implemented in the follow-up of glaucoma patients experiencing progression of the disease despite the intraocular pressure remaining normal.

Prehospital Cardiovascular Autoregulatory Disturbances Correlate With the Functional Neuroanatomy of Acute Spinal Cord Injury.

Retrospective study. The importance of attenuating the cardiovascular autoregulatory disturbances accompanying acute spinal cord injury (SCI) has long been recognized. This report assembles SCI emergency service data and correlates cardiovascular parameters to preserved functional neuroanatomy. The nascent nature of evidence-based reporting of prehospital cardiovascular autoregulatory disturbances in SCI indicates the need to assemble more information. SCI data for <24 hours were extracted from ambulance and hospital records. The mean arterial pressure (MAP) was calculated. The International Standard for Neurological Classification of SCI (ISNCSCI) evaluates the primary outcome of motor incomplete injury (grades C/D) at acute presentation. Logistic regression was adjusted for multiple confounders that were expected to influence the odds of grade C/D. A cohort of 99 acute SCI cases was retained; mean (SD) age 40.7±20.5 years, 88 male, 84 tetraplegic, 65 grades A/B (motor complete injury), triage time 2±1.6 hours. The lowest recorded prehospital MAP [mean (SD): 77.9±19, range: 45-145mmHg] approached the nadir for adequate organ perfusion. Thirty-four (52%) grade A/B and 10 (30%) C/D cases had MAP readings <85mmHg. In data adjusted for age, injury level, and triage time a 5mmHg increase in the lowest MAP value was associated with a 34% increase in the odds of having motor incomplete injury at acute presentation (adjusted odds ratio=1.34; 95% CI: 1.11-1.61; P =0.002). An important observation with implications for timely and selective cardiovascular resuscitation during SCI prehospital care involves significant negative associations between the depth of systemic hypotension and preserved functional neuroanatomy. Regardless of the mechanism, our confounder-adjusted logistic regression model extends in-hospital evidence and provides a conceptual bedside-bench framework for future investigations.

Arterial site selection for measurement of mean arterial pressure in septic shock patients on high-dose norepinephrine.

The guidelines of the Surviving Sepsis Campaign suggest using invasive blood pressure (IBP) measurement in septic shock patients, without specifying for a preferred arterial site for accuracy in relation to the severity of septic shock. The objective of this study was to determine the mean arterial pressure (MAP) gradient between the femoral and radial artery sites in septic shock patients. This prospective study was carried out at a 20-bed ICU in a university hospital. Simultaneous MAP measurements at femoral and radial arterial sites were obtained in septic shock patients receiving norepinephrine (≥0.1 μg/kg/min), with a pre-planned subgroup analysis for those receiving a high dose of norepinephrine (≥0.3 μg/kg/min). The median norepinephrine dose across all 80 patients studied, including 59 patients on a high dose, was 0.4 (0.28-0.7) μg/kg/min. Overall, simultaneous measurement of MAP (mmHg) at the femoral and radial arterial sites produced mean (95% CI) MAP values of 81 (79-83) and 78 (76-80), respectively, with a mean difference of 3.3 (2.67-3.93), p < 0.001. In Bland-Altman analysis of MAP measurements, the detected effect sizes were 1.14 and 1.04 for the overall and high-dose cohorts, respectively, which indicates a significant difference between the measurements taken at each of the two arterial sites. The Pearson correlation coefficient indicated a weak but statistically significant correlation between MAP gradient and norepinephrine dose among patients receiving a high dose of norepinephrine (r = 0.289; p = 0.026; 95% CI 0.036-0.508). In septic shock patients, MAP readings were higher at the femoral site than at the radial site, particularly in those receiving a high dose of norepinephrine. [ClinicalTrials.gov], identifier [NCT03475667].

Noninvasive Blood Pressure Measurement Using the NICCI Monitor in Adolescents During Intraoperative Anesthetic Care.

BackgroundThe intermittent measurement of blood pressure (BP) remains the standard of care during anesthesia or procedural sedation. To improve the early identification of hemodynamic compromise, various noninvasive BP devices have been developed which provide a continuous BP reading. The current study evaluates the accuracy of a novel continuous BP device, the NICCI system, in adolescents weighing 40 - 80 kg.MethodsDuring intraoperative anesthetic care, BP readings (systolic, diastolic, and mean) were captured from the arterial cannula and the NICCI device every second.ResultsThe study cohort included 44 pediatric patients undergoing major orthopedic, cardiac, and neurosurgical procedures. A total of 383,126 pairs of systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) values from the arterial cannula and the NICCI device were analyzed. The absolute difference for SBP, DBP, and MAP values from the NICCI monitor and the arterial cannula were 10 ± 8, 9 ± 7, and 9 ± 7 mm Hg, respectively. The difference between the BP values from the NICCI and the arterial cannula was ≤ 10 mm Hg for 60% of the SBP readings, 67% of the DBP readings, and 56% of the MAP readings. Using Bland-Altman analysis, the bias was 2, 3, and 4 mm Hg for the SBP, DBP, and MAP.ConclusionsAlthough there were technical limitations related to patient size that affected its ability to meet the strict accuracy criteria set by the American National Standards Institute/Association for the Advancement of Medical Instrumentation standards for noninvasive BP measurement (ANSI/AAMI SP10), the NICCI system provided a continuous noninvasive beat-to-beat BP measurement which was clinically relevant during a significant portion of intraoperative care.

Accuracy of oscillometric blood pressure measurement at both arms in the lateral position.

To evaluate the accuracy of noninvasive blood pressure (NIBP) measurement at the dependent- and nondependent arms in the lateral position, using invasive blood pressure (IBP) as reference. This prospective observational study included 42 adult patients undergoing surgery in the lateral position. Paired readings of IBP and NIBP were obtained at either arm. The accuracy of both arms in detecting mean arterial pressure (MAP) <70 mmHg was evaluated using the area under the receiver operating characteristic curve (AUC). The agreement between the IBP and NIBP was evaluated using the Bland-Altman and error grid analyses. We analyzed 350 and 347 paired readings at the dependent- and nondependent arms. The AUC for detecting hypotension was comparable in both arms. The negative and positive predictive values (95% confidence interval) were 100% (99-100%) and 24% (14-34%), respectively for the dependent arm at cutoff value MAP ≤86 mmHg; and were 99% (96-100%) and 21% (13-30%), respectively for the nondependent arm at cutoff value MAP ≤75 mmHg. The mean bias for MAP was -6.0 ± 9.1 and 6.3 ± 10.1 mmHg; and for systolic blood pressure was 0.3 ± 11.6 and 13.2 ± 12.6 mmHg, in the dependent- and nondependent arm, respectively. Error grid analysis showed that the proportions of paired MAP readings in risk zone A were 71 and 82% in the dependent- and the nondependent arms, respectively. In the lateral position, the NIBP readings at both arms are not interchangeable with the corresponding IBP readings. However, NIBP measurement at both arms can be used to accurately rule out hypotension.

Oculocardiac reflex in phacoemulsification: Peribulbar vs topical anesthesia.

Purpose:This study compares the vital parameters and pain experienced during phacoemulsification under peribulbar and topical anesthesia to determine the incidence of OCR.Methods:One hundred six patients are enrolled for phacoemulsification in a prospective and randomized study. Fifty-two patients undergo surgery in a peribulbar block (Group PB) and 54 in topical anesthesia (Group TA). Mean arterial pressure (MAP) and pulse rate are recorded during a preoperative check-up and at four other steps of surgery. Pain experienced during surgery and on a postoperative day, 5, is graded with a verbal analogue scale. OCR defined as a decrease in pulse rate by greater than 20% is calculated. Chi-square test, Fisher‘s exact test, paired t test and the comparison of means give the statistical analysis. A value of P < 0.05 was taken as significant.Results:MAP readings at baseline versus MAP at other steps of surgery show a trend towards rising with a P value of < 0.05 in both groups. Pulse rate measured at all steps of surgery versus baseline pulse rate in Group TA shows P < 0.05. OCR is present in nine patients in peribulbar block verses eleven patients in topical anesthesia with P value of 0.687. The pain scores using verbal analogue scale were higher in Group TA compared with Group PB with a P < 0.0001.Conclusion:Oculocardiac reflex can occur during phacoemulsification under both peribulbar block and topical anesthesia, and the difference is not significant.

English

BACKGROUND Central Venous Cannulation is a very important technique needed intra operatively and in critical care setting. Most commonly accessed is the right internal jugular vein due to lesser incidence of complications and easy accessibility. Ultrasound guidance improves the successful insertion rate than blind technique. Increasing the cross-sectional area (CSA) of IJV improves the success rate and decreases complications. Several manoeuvres such as Trendelenburg’s position, Valsalva’s manoeuvre, hepatic compression and positive end-expiratory pressure have been used to increase the diameter of the IJV. Application of PEEP of 10–12 cm H2O in supine position has been found to increase the CSA of right IJV in various studies. The aim of the study is to determine the optimal PEEP which increases size of IJV without complications. METHODS This is an observational study conducted in the Government Medical College, Thrissur. The groups were chosen from instances where three different levels of PEEP were used. A total of 90 ASA PS 1 &amp; 2 patients who received general anaesthesia for elective surgeries where assigned to three groups - P0, P5 and P10 with different values of PEEP- 0, 5, and 10 cm of H2O respectively. Patients with obesity, raised intracranial pressure, previous neck surgery were excluded from the study. After application of PEEP for 2 minutes, the diameter of Right Internal Jugular was sonologically measured. The increase in cross sectional area of IJV in each group was analysed. Application of PEEP affects heart rate and mean arterial pressure in patients. So, the heart rate and mean arterial pressure readings were taken at the time of measurement of IJV. These were also analysed statistically. RESULTS The three groups P0, P5 and P10 were comparable in demographic parameters like age and weight. Cross-sectional area of three groups was compared. The mean CSA in P0 was 1.3345, P5 was 1.399 and P10 was 1.443 cm2. (p .001). There was a statistically significant increase in cross-sectional area of IJV when PEEP was applied. Increase in CSA was significantly higher with higher PEEP (p .001). CONCLUSIONS The application of PEEP of 5 to 10 cm of H2O is a safe method to increase the area of IJV for successful cannulation. This value of PEEP did not cause clinically significant haemodynamic effects. KEYWORDS PEEP, Cross-Sectional Area of IJV, Sonoanatomy, IJV Cannulation

Age-Based Percentiles of Measured Mean Arterial Pressure in Pediatric Patients in a Hospital Setting.

To develop and validate age-specific percentile curves of measured mean arterial pressure for children in a hospital setting. Retrospective observational study of electronic records. Tertiary care, freestanding pediatric hospital in Seattle, WA. Nonpremature children, birth to 18 years old, evaluated in the emergency room, or admitted to either acute care or critical care units. Oscillometric blood pressure data collected from February 2012 to June 2016 were examined for documentation of systolic, diastolic, and mean arterial pressure values. Quantile curves were developed using restricted cubic splines and validated with two sets of patient data. The effects of birth sex and behavioral state on the curves were examined. The frequency of values less than 5th percentile for mean arterial pressure within a population was compared with four published criteria for hypotension. Eighty-five-thousand two-hundred ninety-eight patients (47% female) provided 2,385,122 mean arterial pressure readings to develop and validate age-based distributions to create percentile curves and a reference table. The behavior state of patients affected the curves, with disturbed behavior state more prevalent in toddler-aged patients. There was no clinical difference between females and males within age brackets. Mean arterial pressure quantiles identified additional hypotensive episodes as compared with systolic blood pressure thresholds and predicted mean arterial pressure values. Code and data available at: https://osf.io/upqtv/. This is the first study reporting age-specific quantiles of measured mean arterial pressure in children in a hospital setting. The percentile curves may guide care in illnesses when perfusion pressure is critical and serve as parameter for bedside and electronic record-based response to clinical change. Future work to correlate threshold mean arterial pressure values with outcomes would be feasible based on quantile curves.

Comparison of Doppler ultrasonic and oscillometric devices (with or without proprietary optimisations) for non-invasive blood pressure measurement in conscious cats.

ObjectivesThis study compared Doppler and oscillometric (PetMAP+) devices (with or without proprietary optimisations) for the non-invasive measurement of blood pressure in conscious cats.MethodsTwenty-three cats were enrolled; however, five were excluded as fewer than five measurements were obtained for each assessment. All measurements were obtained according to American College of Veterinary Internal Medicine consensus guidelines. Oscillometric device modes A and B were operated according to the manufacturer’s guidelines. Doppler and oscillometric devices were used alternately as the first device.ResultsSystolic arterial blood pressure (SAP) measurements were obtained by Doppler (SAPd) and oscillometry; the mean of each set of five values was used for statistical analysis. There was a significant difference between SAPd and SAP measurements in oscillometric modes A (P <0.001) and B (P <0.001). While both modes measured SAP higher than SAPd, B had a smaller bias (+15.72 mmHg) and narrower limits of agreement (LOA). There was also a significant difference between SAPd and mean arterial pressure (MAP) on oscillometric modes A (P = 0.002) and B (P <0.001). Both modes’ MAP readings were lower than SAPd and oscillometric A MAP was closer to SAPd (–14.94 mmHg), with a smaller bias and narrower LOA.Conclusions and relevanceThe findings support that Doppler and oscillometric devices cannot be used interchangeably, with or without proprietary optimisations. Methodology should always be taken into account and reference intervals (RIs) need to be defined for the different methodologies. Until methodology-specific RIs are published, definitive diagnosis of hypertension and sub-staging of patients with kidney disease according to the International Renal Interest Society guidelines remains challenging.

Exercise is feasible in patients receiving vasoactive medication in a cardiac surgical intensive care unit: A prospective observational study

BackgroundPatients may require vasoactive medication after cardiac surgery. The effect and safety profile of exercise on haemodynamic parameters in these patients is unclear. ObjectivesThe objective of this study was to measure the effect of upright positioning and low-level exercise on haemodynamic parameters in patients after cardiac surgery who were receiving vasoactive therapy and to determine the incidence of adverse events. MethodsThis was a prospective, single-centre, observational study conducted in an adult intensive care unit of a tertiary, cardiothoracic university–affiliated hospital in Australia. The Flotrac-Vigileo™ system was used to measure haemodynamic changes, including cardiac output, cardiac index, and stroke volume. Normally distributed variables are presented as n (%) and mean (standard deviation), and non-normally distributed variables are presented as median [interquartile range]. ResultsThere were a total of 20 participants: 16 (80%) male, with a mean age of 65.9 (10.6) years. Upright positioning caused significant increases (p = 0.018) in the mean arterial pressure (MAP), with MAP readings increasing from baseline (supine), from 72.31 (11.91) mmHg to 77.44 (9.55) mmHg when back in supine. There were no clinically significant changes in cardiac output, heart rate, stroke volume, or cardiac index with upright positioning. The incidence of adverse events was low (5%). The adverse event was transient hypotension of low severity. ConclusionsLow-level exercise in patients after cardiac surgery receiving vasoactive medication was well tolerated with a low incidence of adverse events and led to significant increases in MAP. Upright positioning and low-level exercise appeared safe and feasible in this patient cohort.

Abstract WP367: Effect of Early Blood Pressure Reduction on Infarct Size in Patients With Large Vessel Occlusion

Introduction: In patients with large vessel occlusion presenting with acute ischemic stroke, cerebral perfusion is a major determinant of stroke severity. However, limited data exists to guide hemodynamic management of these patients early after presentation. In this study, we aim to evaluate the effect of blood pressure reductions during the hyper-acute period on infarct size. Methods: From a clinical stroke registry at a single comprehensive stroke center, we reviewed patients with middle cerebral artery (M1) or internal carotid artery occlusion who underwent hyperacute magnetic resonance imaging (MRI) for endovascular treatment decision in 2018. Infarct volume was determined by area of reduced apparent diffusion coefficient using RAPID software. Collateral circulation was scored based on baseline CT angiogram (good collaterals constituted &gt;50% filling, poor collaterals ≤50% filling). Average mean arterial pressure (MAP) readings from the first hour of presentation were compared to average MAP readings from the hour prior to magnetic resonance imaging. For the purposes of our study, a drop of &gt; 20% in the average MAP was regarded as a significant decrease. We hypothesized that both significant drop in MAP and the presence of good collateral circulation were independent predictors of infarct volume expressed as a logarithmic value in multivariable regression model. Results: Of the 35 patients (mean age 67, mean NIHSS 16) meeting inclusion criteria, 11% of patients experienced an early significant drop in MAP prior to time of MRI. Among patients with a significant drop in MAP, the average decrease was 35 mm Hg ±3.3 among those with significant drop from a baseline mean MAP of 125 mm Hg. In the multivariable analysis adjusting for collateral status, a significant drop in average MAP was independently associated with an increase in infarct volume (β = -0.727, p=0.0306). Collateral status also independently predicted infarct size (β=0.775, p=0.0007). Conclusion: Among ischemic stroke patients with large vessel occlusion, a &gt;20% drop in MAP during the hyper-acute period is associated with larger infarct volumes. Further studies are needed to optimize early blood pressure management in these patients.

294 - Evaluating Hemodynamic Effects of Clevidipine in Cardiothoracic Surgery Patients with Reduced Ejection Fraction

Background: Clevidipine is an ultra-rapid acting intravenous dihydropyridine calcium channel blocker indicated for the reduction of blood pressure. It is particularly beneficial in the post-operative surgical setting due to its ability for rapid titration. However, there is limited data regarding the efficacy and hemodynamic effects of clevidipine in patients with heart failure with reduced ejection fraction (HFrEF). The primary objective of this study is to evaluate the hemodynamic effects of clevidipine in post-cardiothoracic surgery patients. Secondary objectives include evaluating the percentage of mean arterial pressure readings at goal, intensive care unit (ICU) and hospital length of stay, presence of arrhythmias, and rehospitalization and mortality within 1 year of follow up. Methods: This study was a single center, retrospective chart review of cardiothoracic surgery patients who received clevidipine between December 1, 2012 and November 30, 2016. Patients were included if they underwent cardiothoracic surgery excluding heart transplantation, had invasive hemodynamic monitoring, left ventricular ejection fraction of 40% or less, and were 18 years or older. Patients on extracorporeal membrane oxygenation or concomitant vasopressor or inotropic therapy, with the exception of milrinone and dobutamine, were excluded. Results: A total of 633 patients received clevidipine during the study period. Only 11 patients met all inclusion criteria. The mean clevidipine rate was 5.07 mg/hr with a mean length of infusion of 30.9 hours. The cardiac index increased from baseline to time of clevidipine discontinuation in 7 patients, but the mean change in cardiac index from baseline to time of clevidipine discontinuation was −0.036 L/min/m2. The mean pulmonary artery pressure trended down in most patients (72.7%) when compared at clevidipine initiation and discontinuation. All patients saw a reduction in their mean arterial pressure to a value of 90 mmHg or less within the first 6 hours of clevidipine administration. The mean ICU and hospital length of stay was 15.1 days and 22.3 days. There were 4 patients that developed an arrhythmia during the clevidipine infusion. Serum creatinine remained stable between 0.5 and 1.5 mg/dL in 8 of 11 patients. All patients survived to hospital discharge, with 63.6% of patients discharged to home and the remaining discharged to a rehab facility. No patients died within 1 year of discharge. Conclusions: The results of this study showed that the use of clevidipine in cardiothoracic surgery patients was associated with quick and effective blood pressure management. Patients did not have any sustained adverse effects thought to be contributed to the administration of clevidipine. The main limitation of this study was that concomitant medications may have impacted patient hemodynamic profile and outcomes. Future prospective studies are needed to assess the safety and efficacy of clevidipine in this population.

Clonidine or remifentanil for adequate surgical conditions in patients undergoing endoscopic sinus surgery: a randomized study.

BackgroundDeliberate hypotension is one way to achieve a bloodless surgical field in endoscopic sinus surgery (ESS). We compared two anaesthesia regimens to induce deliberate hypotension and attempted to determine the most efficient one.MethodsFifty-nine patients undergoing ESS were minimized into two groups. In the CLO group, patients received I.V. sufentanil 0.15 µg/kg together with I.V. clonidine 2–3 µg/kg. In the REMI group, patients received remifentanil at a rate of up to 1 µg/kg/min. Fromme scores were collected 15 min after the incision and at the end of the procedure. Mean arterial pressure readings (MAP), heart rate readings, time to eyes opening, time to extubation, pain scores, analgesic requirements, and oxygen needs were collected and compared.ResultsThere were no significant differences in Fromme scores between the two groups. The averaged MAP from 15 min to the end of the procedure was significantly lower in the REMI group; these patients also received more ephedrine. Significantly fewer patients in the CLO group needed oxygen therapy to keep their Pulse Oximeter Oxygen Saturation within 3% of their preoperative values. Patients in this group also needed less piritramide in the recovery room, and their pain scores were lower at discharge from the recovery room.DiscussionAlthough both anaesthesia regimens offered a similar quality of surgical field, this study suggests that clonidine had a better average safety profile. Furthermore, patients who received this regimen required fewer painkillers immediately after surgery.

Effect of preoperative Mg sulfate infusion on serum cardiac troponin (cTn) in moderate preeclamptic undergoing elective cesarean section under spinal anesthesia

This study was designed to investigate and compare the effect of preoperative Mg sulfate infusion on serum cardiac troponin (cTn) in moderate preeclampsia undergoing elective cesarean section. A total of fifty parturients having moderate preeclampsia scheduled for elective cesarean section were included. They were randomly allocated into two equal groups 25 each, magnesium group (GMg) received preoperative magnesium sulfate infusion and control group (GC) then both received spinal anesthesia, serum troponin measured preoperative then at 6, 12 and 24 h postoperative. Mean arterial pressure and heart rate were also recorded. Baseline serum cardiac troponin was higher above normal and was comparable at the rest of times in both groups. Mean arterial pressure readings were significantly lower in GMg compared to GC at induction of spinal, skin incision and skin closure (P < 0.05) and were comparable at the rest of times. Serum cardiac troponin (cTn) levels were comparable in parturients received magnesium sulfate infusion preoperatively with those did not receive magnesium sulfate.

Noninvasive and Nonocclusive Blood Pressure Estimation Via a Chest Sensor

The clinical demand for a device to monitor blood pressure (BP) in ambulatory scenarios with minimal use of inflation cuffs is increasing. Based on the so-called pulse wave velocity (PWV) principle, this paper introduces and evaluates a novel concept of BP monitor that can be fully integrated within a chest sensor. After a preliminary calibration, the sensor provides nonocclusive beat-by-beat estimations of mean arterial pressure (MAP) by measuring the pulse transit time (PTT) of arterial pressure pulses travelling from the ascending aorta toward the subcutaneous vasculature of the chest. In a cohort of 15 healthy male subjects, a total of 462 simultaneous readings consisting of reference MAP and chest PTT were acquired. Each subject was recorded at three different days: D, D+3, and D+14. Overall, the implemented protocol induced MAP values to range from 80 ± 6 mmHg in baseline, to 107 ± 9 mmHg during isometric handgrip maneuvers. Agreement between reference and chest-sensor MAP values was tested by using intraclass correlation coefficient (ICC = 0.78) and Bland-Altman analysis (mean error = 0.7 mmHg, standard deviation = 5.1 mmHg). The cumulative percentage of MAP values provided by the chest sensor falling within a range of ±5 mmHg compared to reference MAP readings was of 70%, within ±10 mmHg was of 91%, and within ±15 mmHg was of 98%. These results point at the fact that the chest sensor complies with the British Hypertension Society requirements of Grade A BP monitors, when applied to MAP readings. Grade A performance was maintained even two weeks after having performed the initial subject-dependent calibration. In conclusion, this paper introduces a sensor and a calibration strategy to perform MAP measurements at the chest. The encouraging performance of the presented technique paves the way toward an ambulatory compliant, continuous, and nonocclusive BP monitoring system.

Level of hypertension control: comparison of a rural and urban family practice centre in South Croatia

Arterial hypertension is a serious public health problem because of its frequency and poor management. We compared hypertension control between rural and urban environment over 5 years. Initial hypothesis: arterial pressure control is better in urban (Split) than in rural (Trilj) environment. Historic prospective study was conducted in two family medicine outpatient clinics. Data for the years 2005, 2006, and 2010 were analyzed. One hundred and seventeen subjects diagnosed with arterial hypertension in 2005 were examined: 66 in a rural and 51 in urban outpatient clinic. Their average age was 60.92 ± 10.03 (range 30-82 years). Blood pressure records at the onset of the study, the first, and fifth year of treatment, risk factors, and therapy were analyzed. T-test and χ(2)-test were used in statistical data analysis. In the urban clinic, more subjects were smokers, had positive family history, were overweight, and had registered hyperlipidemia. Initial mean arterial pressure readings were similar in both the clinics. Decrease was recorded in the following 5 years. During this study the use of ACE inhibitors (ACEI) (Split by 45 %, Trilj by 133 %) and calcium channel blockers (CCB) (Split by 76.9 %, Trilj by 525 %) was increased. The number of patients receiving monotherapy was reduced. Better arterial pressure control was recorded in the urban clinic, where, after 5 years, despite increased frequency of additional risk factors, the number of normotensive patients was higher than that in the rural one. Hypertension control in both settings was still poor. Hypertensive patients should participate actively in the treatment.