Mean Arterial Pressure Research Articles

Venous return physiology applied to post-cardiac arrest haemodynamic management: a post hoc analysis of the NEUROPROTECT trial

BackgroundThe European Resuscitation Council 2021 guidelines for haemodynamic monitoring and management during post-resuscitation care from cardiac arrest call for an individualised approach to therapeutic interventions. Combining the cardiac function and venous return curves with the inclusion of the mean systemic filling pressure enables a physiological illustration of intravascular volume, vasoconstriction and inotropy. An analogue mean systemic filling pressure (Pmsa) may be calculated once cardiac output, mean arterial and central venous pressure are known. The NEUROPROTECT trial compared targeting a mean arterial pressure of 65 mmHg (standard) versus an early goal directed haemodynamic optimisation targeting 85 mmHg (high) in ICU for 36 h after cardiac arrest. The trial data were used in this study to calculate post hoc Pmsa and its expanded variables to comprehensively describe venous return physiology during post-cardiac arrest management. A general estimating equation model was used to analyse continuous variables split by standard and high mean arterial pressure groups.ResultsData from 52 patients in each group were analysed. The driving pressure for venous return, and thus cardiac output, was higher in the high MAP group (p < 0.001) along with a numerically increased estimated stressed intravascular volume (mean difference 0.27 [− 0.014–0.55] L, p = 0.06). The heart efficiency was comparable (p = 0.43) in both the standard and high MAP target groups, suggesting that inotropy was similar despite increased arterial load in the high MAP group (p = 0.01). The efficiency of fluid boluses to increase cardiac output was increased in the higher MAP compared to standard MAP group (mean difference 0.26 [0.08–0.43] fraction units, p = 0.01).ConclusionsCalculation of the analogue mean systemic filling pressure and expanded variables using haemodynamic data from the NEUROPROTECT trial demonstrated an increased venous return, and thus cardiac output, as well as increased volume responsiveness associated with targeting a higher MAP. Further studies of the analogue mean systemic filling pressure and its derived variables are warranted to individualise post-resuscitation care and evaluate any clinical benefit associated with this monitoring approach.

Comparison of the efficacy of remimazolam and propofol on hemodynamics and quality of early postoperative recovery in elderly patients with frailty undergoing endoscopic retrograde cholangiopancreatography

Objective: To compare the efficacy of remimazolam and propofol on hemodynamics and quality of early postoperative recovery in elderly patients with frailty undergoing endoscopic retrograde cholangiopancreatography (ERCP). Methods: A total of 108 elderly patients with frailty (aged≥75 years) undergoing elective ERCP in the General Hospital of Northern Theater Command were prospectively enrolled from November 2022 to May 2023. According to the different anesthetic drugs used, the patients were divided into two groups by random number table method: remimazolam group (group R) and propofol group (group P). The group R was given remimazolam 0.15-0.20 mg/kg and alfentanil 5.0 μg/kg for anesthesia onset, and then was pumped remimazolam 0.4-0.8 mg·kg-1·h-1 and alfentanil 0.5 μg·kg-1·min-1 to maintain sedation. The group P was given propofol 1.0-1.5 mg/kg and alfentanil 5.0 μg/kg, and was pumped propofol 2.0-6.0 mg·kg-1·h-1 and alfentanil 0.5 μg·kg-1·min-1. The primary outcome was the incidence of intraoperative hypotension [mean arterial pressure (MAP)<65 mmHg (1 mmHg=0.133 kPa) or MAP>20% decrease from baseline value] and severe hypotension (MAP<55 mmHg) in both groups, and other outcomes included: MAP, heart rate, pulse oxygen saturation (SpO2) and bispectral index (BIS) values of patients at each time of before anesthesia induction (T0), 1 min after anesthesia induction (T1), endoscope through the oropharynx (T2), immediate lithotomy (T3), endoscope withdrawal from the oropharynx (T4), and patients awake (T5); the use of vasoactive drug during operation; the incidence of bradycardia, hypoxemia and injection pain; and the postoperative 15-item Quality of Recovery (QoR-15) score. Results: Group R included 33 males and 20 females, aged (81.5±4.9) years. Group P included 26 males and 29 females, aged (82.3±6.0) years. The incidence of intraoperative hypotension in group R was 24.5% (13/53), which was lower than 43.6% (24/55) in group P (P=0.036), there was no significant difference of the incidence of severe hypotension which was 0 (0/53) and 5.5% (3/55) (P=0.225). Compared with T0, MAP and BIS decreased at T1-T4 (both P<0.05); heart rate and SpO2 decreased at T1-T2 in both groups (both P<0.05). Compared with group P, MAP increased at T1-T4; heart rate, SpO2 and BIS increased in group R (all P<0.05). The use of intraoperative vasoactive drug in group R was (93.9±21.4) μg, lower than (123.3±29.7) μg in group P (P<0.001), and the incidence of bradycardia, hypoxemia and injection pain in group R was 5.7% (3/53), 13.2% (7/53), and 3.8% (2/53), lower than 18.2% (10/55), 30.9% (17/55), and 16.4% (9/55) in group P (all P<0.05). There was no significant difference in the incidence of bucking or involuntary body movement and hiccuping in both groups (both P>0.05). The awakening time in group R was (11.8±3.0) min, longer than (10.3±3.3) min in group P (P=0.016), and the incidence of emergence agitation was 3.8% (2/53), lower than 16.4% (9/55) (P=0.031). There was no significant difference in postanesthesia care unit (PACU) stay duration and the incidence of postoperative nausea and vomiting in both groups (all P>0.05). The postoperative QoR-15 scores at 1 d were (131.9±4.7) and (129.3±5.7) with statistically significant difference (P=0.010), and QoR-15 scores at 3 d were (134.8±3.3) and (133.6±5.0) with no significant difference (P=0.205). Conclusions: Compared with propofol, remimazolam reduces the incidence of intraoperative hypotension, bradycardia, injection pain and the use of intraoperative vasoactive drug on elderly patients with frailty undergoing ERCP. Remimazolam has relatively stable hemodynamics, it prolongs the recovery time but does not significantly affect the quality of early postoperative recovery.

Effects of different doses of alfentanil on cardiovascular response to rapid sequence intubation in elderly patients: a parallel-controlled randomized trial

BackgroundRapid sequence intubation (RSI) have been shown to be effective in preventing reflux aspiration in patients with a full stomach during anaesthesia induction and endotracheal intubation. However, there is currently no standardized operation protocol or anaesthesia induction drug standard for RSI. Furthermore, there is a lack of evidence regarding the use of RSI in patients older than 65. In this study, we aimed to investigate the cardiovascular effects of different doses of alfentanil combined with propofol and etomidate during RSI in elderly patients aged 65–80 years.MethodsA total of 96 patients aged 65–80 years who underwent general anaesthesia with tracheal intubation were selected for this study. The patients were randomly assigned to one of four groups using a random number table. Group A patients received an induction dose of 10 µg/kg alfentanil, group B patients received 15 µg/kg alfentanil, group C patients received 20 µg/kg alfentanil, and group D patients received 25 µg/kg alfentanil. Heart rate (HR), mean arterial pressure (MAP), cardiac index (CI), and ejection fraction (EF) were measured at three time points: 5 min before anaesthesia induction (T0), 1 min after endotracheal intubation (T1), and 5 min after endotracheal intubation (T2). Concurrently, 4 ml of arterial blood was collected from patients at three time points, and the concentrations of norepinephrine (NE) and cortisol (Cor) in plasma were detected. Occurrences of hypertension, hypotension, bradycardia and tachycardia during anesthesia induction to 5 min after tracheal intubation were noted.ResultsCompared with T0, the HR, MAP, NE and Cor concentrations in group A and group B were increased at the T1 and T2 time points, CI and EF values were decreased (P < 0.05). HR and MAP in groups C and D were increased at the T1 time point, while they were decreased at the T2 time point in group D (P < 0.05). The changes in CI and EF values, concentrations of NE and Cor, were not significant at T1 and T2 time points in group C (P > 0.05). Additionally, they were not significant in group D at the T1 time point (P > 0.05), but decreased at the T2 time point (P < 0.05). Compared with group A, the HR, MAP, NE and Cor concentrations in groups C and D were decreased at T1 and T2 time points (P < 0.05). The CI and EF values of groups C and D were increased at T1 time point but decreased at T2 time point in group D (P < 0.05). The incidence of hypertension and tachycardia in group A was significantly higher than that in group C and group D (P < 0.05), and the incidence of hypotension and bradycardia in group D was significantly higher than that in group A and group B (P < 0.05).ConclusionAlfentanil 20 µg/kg for RSI in elderly patients, can effectively inhibit the violent cardiovascular reaction caused by intubation, and avoid the inhibition of cardiovascular system caused by large dose, hemodynamics more stable.Trial registrationChiCTR2200062034 (www.chictr.org.cn).

Agreement between non-invasive and invasive arterial blood pressure during surgery in the prone position: an error grid analysis.

Prone position has recently gained renewed importance as a treatment for acute respiratory distress syndrome and spine and brain surgeries. Our study aimed to perform an error grid analysis to examine the clinical discrepancies between arterial blood pressure (ABP) and non-invasive blood pressure (NIBP) in the prone position and to investigate the risk factors influencing these differences. Error grid analysis was performed retrospectively on 1389 pairs of 100 consecutive prone positioning cases. This analysis classifies the difference between the two methods into five clinically relevant zones, from "no risk" to "dangerous risk". Additionally, multivariable ordinal logistic regression analysis was conducted to evaluate the relationship between the risk zones of mean blood pressure (MBP), as classified by error grid analysis and the covariate of interest. Error grid analysis showed that the proportions of measurement pairs in risk zones A-E for systolic blood pressure were 96.8%, 3.2%, 0.1%, 0%, and 0%, respectively. In contrast, the MBP proportions were 74.0%, 25.1%, 0.9%, 0.1%, and 0%. Multivariable ordinal logistic regression analysis revealed that the position of arms (next to the head) was a significant factor (adjusted odds ratio: 4.35, 95% CI: 2.38-8.33, P < 0.001). Error grid analysis revealed a clinically unacceptable discrepancy between ABP and NIBP for MBP during prone positioning surgery. The position of the arms next to the head was associated with increased clinical discrepancy between the two MBP measurement methods.

Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Disease: Success Rate and Complications among Different Patient Populations.

Balloon pulmonary angioplasty (BPA) is an effective intervention for patients with chronic thromboembolic pulmonary disease (CTEPD). We aimed to identify the patient group with a low success rate or high complication rate of BPA, which is still unclear. Both CTEPD patients with or without pulmonary hypertension (CTEPH and NoPH-CTEPD) were included. CTEPH patients were divided into groups with or without pulmonary endarterectomy (PEA-CTEPH and NoPEA-CTEPH). The efficacy and safety of BPA were compared among the groups. There were 450, 66, and 41 sessions in the NoPEA-CTEPH, PEA-CTEPH, and NoPH-CTEPD groups, respectively. The success rate (≥1 degree improvement in flow grade) in the PEA-CTEPH group was 94.5%, significantly lower than that in the NoPEA-CTEPH (97.1%) and NoPH-CTEPD (98.4%) groups (p = 0.014). The percentage of complete flow recovery in treated vessels was also lower in PEA-CTEPH group. BPA-related complication rate in NoPEA-CTEPH, PEA-CTEPH, and NoPH-CTEPD patients was 6.1%, 6.0%, and 0.0%, respectively (p = 0.309). One BPA-related death occurred (solely in NoPEA-CTEPH). Mean pulmonary artery pressure ≥41.5 mm Hg was a predictor of BPA-related complications. NoPEA-CTEPH patients had more improvement in 6-min walk distance (6MWD, 87 ± 93 m NoPEA-CTEPH vs. 40 ± 43 m PEA-CTEPH vs. 18 ± 20 m NoPH-CTEPD, p = 0.012). BPA was safe and effective for all CTEPD groups with less improvement for the PEA-CTEPH and NoPH-CTEPD groups. The success rate of BPA was lower in the PEA-CTEPH group and the complication rate was lower in the NoPH-CTEPD group. Pre-BPA treatment to lower pulmonary artery pressure should not be overlooked in CTEPD patients.

Glucose metabolism disorders and changes in cardiovascular risk among adult Peruvian population

Background Rates of cardiovascular diseases are increasing annually, and glucose metabolism disorders play an important role in cardiovascular risk. This study aimed to assess changes in cardiovascular risk over time according to the levels of blood glucose, especially prediabetes and type 2 diabetes. Methods Prospective cohort study conducted in the northern Peru. Two were the outcomes of interest, evaluated at the cohort’s baseline and six years after: cardiovascular risk (in percentage), defined using the laboratory-free risk score (HEARTS from the World Health Organization), and the mean arterial pressure (in mmHg); whereas the exposure was glucose metabolism disorder, especially prediabetes and type 2 diabetes, compared to normoglycaemia. Associations were evaluated using mixed linear regression models, and coefficients (β) and 95% confidence intervals (95% CI) were reported. Results A total of 1607 subjects were recruited, with a mean age of 48.0 (standard deviation [SD]: 10.5) years, and 50.3% women. Baseline prevalence of prediabetes and type 2 diabetes was 16.9% (95%CI: 15.1%-18.9%) and 11.0% (95%CI: 9.5%-12.6%), respectively; whereas the average of the cardiovascular risk and mean arterial pressure was 3.0% (SD: 2.5%) and 93.1 (SD: 11.9) mmHg, respectively. At baseline, those with prediabetes and type 2 diabetes had a higher cardiovascular risk (0.31% and 0.33%, respectively) and a higher mean arterial pressure (3.3 and 4.2 mmHg, respectively) than those with normal glycaemia. No significant change was found in cardiovascular risk between baseline and follow-up; however, there was a reduction in mean arterial pressure levels, greater among those with normoglycaemia than in cases of prediabetes and type 2 diabetes. Conclusions Glucose metabolism disorders were associated with an increased cardiovascular risk and mean arterial pressure at baseline, but only with higher levels of mean arterial pressure at follow-up. These findings suggest the need for cardiovascular risk assessment in patients with prediabetes and type 2 diabetes.

Analysis of the Necessity of Stellate Ganglion Block after Anesthesia to Reduce the Risk of Cardiovascular Accidents in Coronary Heart Disease

Objective: To adjust the sympathetic nervous system through preoperative ultrasound-guided stellate ganglion block and to explore and analyze the situation and necessity of postanesthesia stellate ganglion block to reduce the risk of cardiovascular accidents in coronary heart disease. Methods: 80 patients with cardiovascular risk factors in Songshan Hospital of Chifeng were selected, and the time span would cover from October 2022 to June 2024, with 80 cases of elective surgery and combined coronary heart disease. They will be randomly divided into blocked groups and conventional groups, 40 cases each. Conventional block was performed after anesthesia in patients in the conventional group, and planetary ganglion block was performed after anesthesia in patients in the blocked group. The cardiovascular responses of patients in the two groups were observed, and the number of intraoperative cardiovascular active drugs and the occurrence of cardiovascular adverse events were recorded in patients in the two groups. Results: Analysis of the mean arterial pressure (MAP) and heart rate (HR) values of the two groups of patients at the time points before anesthesia (T0), the moment of tracheal intubation (T1), the moment of surgical skin cutting (T2), the end of the operation (T3), and the 6h postoperative period (T4) showed that the MAP and HR of the blocked group were lower than those of the conventional group at the time points of T1 to T4, and the differences in MAP and HR values of the two groups in different time points compared with the T0 time point were statistically significant (P &lt; 0.05) and the differences in cardiovascular response (P &lt; 0.05) were statistically significant (P &lt; 0.05). significance (P &lt; 0.05). The number of intraoperative cardiovascular active drugs used in the blocked group was shorter than that in the conventional group, and the incidence of cardiovascular adverse events was lower than that in the conventional group, with a statistically significant difference (P &lt; 0.05). Conclusion: By implementing preoperative ultrasound-guided stellate ganglion block in patients with cardiovascular risk factors, the frequency and degree of coronary heart disease symptoms will be reduced, thus reducing the risk of patients, which is worth promoting.

Hypertension Restricts Leg Blood Flow and Aggravates Neuromuscular Fatigue during Human Locomotion in Males.

Patients with hypertension (HTN) are characterized by exaggerated vascular resistance and mean arterial pressure (MAP), and a compromised leg blood flow (QL) response to exercise recruiting a small muscle mass. However, the impact of hypertension on peripheral hemodynamics and the development of neuromuscular fatigue during locomotor activities, which critically depends on QL, remain unknown. Eight HTN (143±11mmHg / 95±6mmHg; 45±13years) and 8 matched (age, activity) controls (120±6mmHg / 77±7mmHg; CTRL) performed constant-load cycling exercise at 25, 50, and 75W (for 4-min each), and at 165±41W (for 5-min). Exercise-induced locomotor muscle fatigue was quantified as the pre- to post-exercise change in quadriceps twitch-torque (∆Qtw, peripheral fatigue) and voluntary activation (∆VA%, central fatigue). QL (Doppler-ultrasound) and leg vascular conductance (LVC) were determined during cycling at 25, 50, and 75W. Heart Rate and ventilatory responses were recorded during all intensities. MAP during exercise was, on average, ~21mmHg higher (P=0.002) and LVC ~39% lower (P=0.001) in HTN compared to CTRL. QL was consistently between 20-30% lower (P=0.004) and heart rate was significantly higher in HTN. Exercise-induced peripheral (∆Qtw: -53±19% vs -25±23%) and central (∆VA%: -7±5% vs -3±2%) fatigue were significantly greater in HTN compared to CTRL. In addition to an exaggerated MAP, LVC and QL were lower during exercise in HTN compared to CTRL. Given the critical role of QL in determining the development of neuromuscular fatigue, these hemodynamic impairments likely accounted for the faster development of neuromuscular fatigue characterizing hypertensive individuals during locomotor exercise.

Detecting heart stress using NT-proBNP in patients with type 2 diabetes mellitus and hypertension or high-normal blood pressure: a cross-sectional multicentric study

BackgroundWe evaluated the prevalence of “heart stress” (HS) based on NT-proBNP cut-points proposed by the 2023 Consensus of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) in asymptomatic patients with T2DM and hypertension or high-normal blood pressure (BP) eligible for SGLT2 inhibitors (SGLT2i) and/or GLP-1 receptor agonists (GLP1-RA), drugs with proven benefits on reducing the incidence of HF, hospitalizations, cardiovascular events and mortality.MethodsA cross-sectional multicentric study was conducted on 192 consecutive outpatients, aged ≥ 55 years, with hypertension or high-normal BP, referred to three diabetology units. NT-proBNP was collected before starting new anti-diabetic therapy. Patients with known HF were excluded, and participants were classified based on the age-adjusted NT-proBNP cut-points.ResultsMean age: 70.3 ± 7.8 years (67.5% males). Patients with obesity (BMI ≥ 30 Kg/m2): 63.8%. Median NT-proBNP: 96.0 (38.8–213.0) pg/mL. Prevalence of chronic kidney disease (CKD, eGFR < 60 mL/min/1.73m2): 32.1%. Mean arterial BP: 138.5/77.0 ± 15.8/9.9 mmHg. The NT-proBNP values, according to the proposed age-adjusted cut-points, classified 28.6% of patients as “HS likely” (organize elective echocardiography and specialist evaluation), 43.2% as “HS not likely” (a grey area, repeat NT-proBNP at six months) and 28.2% as “very unlikely HS” (repeat NT-proBNP at one year). The presence of CKD and the number of anti-hypertensive drugs, but not glycemic parameters, were independently associated with HS.ConclusionsAccording to NT-proBNP, over a quarter of T2DM patients with hypertension/high-normal BP, among those eligible for SGLT2i and/or GLP1-RA, were already at risk of cardiac damage, even subclinical. Most would receive an indication to echocardiogram and be referred to a specialist, allowing the early implementation of effective strategies to prevent or delay the progression to advanced stages of cardiac disease and overt HF.

Accessing the efficacy and peri-operative adverse effects of three different hyperbaric bupivacaine 0.5% dosages for spinal anesthesia induction in lower limb orthopedic surgeries: a randomized clinical trial

BackgroundSpinal anesthesia (SA) is a conventional method for proper nerve block in abdominopelvic and lower extremity surgeries. Compared to general anesthesia, SA has reduced perioperative complications significantly. The hyperbaric type of bupivacaine hydrochloride (HB) induces spinal anesthesia more efficiently with a lower incidence of life-threatening adverse reactions like Perioperative hemodynamic changes and respiratory depression. More investigations are needed to define the best dosage that provides adequate anesthesia while reducing adverse effects for each surgical procedure.MethodsThis double-blinded randomized clinical trial compared the consequences of the (12.5mg,15mg,20mg) dosages of HB-bupivacaine in elective lower limb orthopedic surgery. Using block randomization, we allocated 60 participants to three (n = 20) study groups. Utilizing the same protocol of anesthesia induction, outcome variables assumed and measured as the incidence of the adverse effects (Hypotension, Anxiety, Bradycardia, Nausea and Vomiting(N/V), Hypoventilation, and Decreased o2 saturation), and the requirement for intervention to control the unwanted reaction. Addressing that, outcome variables were measured 10 times perioperatively. One-way ANOVA test, the chi2 test, or repeated measures ANOVA test with the Bonferroni adjustment were utilized as appropriate.ResultsWe found that the incidence of hypotension (P-value:0.02) and the N/V (P-value < 0.001) are associated with the HB-bupivacaine dosage. Contrary, our findings indicate that the incidence of apnea, bradycardia, and hypoventilation did not exhibit a significant dose-dependent pattern between the groups. Repeated measures analysis revealed significant intergroup differences for Herat rate, systolic, diastolic, and mean arterial pressure (group*time Pvalue < 0.001). The observed differences were more prominent 10–30 min after injection of HB-bupivacaine. The regression model claimed that gender (P-value:0.002) and drug dosage (P-value:0.03) significantly predict the incidence of adverse effects.ConclusionOur results, suggest that the administration of the 12.5mg HB-bupivacaine provides adequate anesthesia while minimizing the risk of adverse events for lower limb orthopedic surgeries lasting up to 180 min.Trial registrationThe study was registered at the Clinical Trial Registry Center (IRCT20160202026328N7), Registered on 2022.01.10.

Combined treatment with vitamin C, hydrocortisone and thiamine does not attenuate morbidity and mortality of septic sheep

BackgroundSepsis is associated with a highest mortality rate in the ICU. Present study tests the efficacy of combined therapy with vitamin C, hydrocortisone and thiamine (combined therapy) in the ovine model of sepsis induced by Pseudomonas aeruginosa. In this study, sepsis was induced in sheep by instillation of Pseudomonas aeruginosa (1 × 1011 CFU) into the lungs via bronchoscope, under anesthesia. Nine hours after injury, intravenous infusion of vitamin C (0.75 g every 6 h), hydrocortisone (25 mg every 6 h), and thiamine (100 mg every 12 h) or saline was given to the treatment and control groups. Cardiopulmonary variables were recorded.ResultsThe survival rate was 16.7% in control and 33.3% in treatment groups. In the control group, mean arterial pressure dropped from 93.6 ± 8.6 to 75.5 ± 9.7 mmHg by 9 h, which was not affected by the combined therapy. Pulmonary dysfunction was not attenuated by the combined therapy either. The combined therapy had no effect on increased extravascular lung water content and fluid effusion into thoracic cavity. The bacterial number in the bronchoalveolar lavage fluid was significantly increased in the treatment group than the control group. The blood bacterial number remained comparable between groups.ConclusionsCombined vitamin C, hydrocortisone, and thiamine did not attenuate severity of ovine sepsis.

The modified Surgical Apgar Score predictive value for postoperative complications after robotic surgery for rectal cancer.

The Surgical Apgar Score quantifies three intraoperative parameters: lowest heart rate, lowest mean arterial pressure, and estimated blood loss (EBL). This scoring system predicts postoperative complications based on these measured factors. The aim of this study was to investigate the value of modified Surgical Apgar Score (mSAS) in predicting postoperative complications in patients with rectal cancer treated with robotic surgery in order to improve the survival and quality of life of rectal cancer patients. The study included patients with rectal cancer who underwent robotic surgery in the Department of Gastrointestinal Surgery at the First Affiliated Hospital of Nanchang University from January 2015 to December 2023. In minimally invasive surgery, we developed a modified Surgical Apgar Score (mSAS) tailored for robotic rectal cancer surgery, incorporating an adjusted threshold for EBL. This threshold was derived from quartile analysis of a cohort of 524 patients, with a median EBL of 100mL (IQR 80-130mL). We analyzed the association of postoperative complications with low mSAS. This study included 524 patients, of which 91 (17.4%) experienced complications and 22 (4.2%) suffered severe complications. mSAS of 6 provided maximal Youden index and were determined as the cut-off values. The area under the ROC curve for predicting complications using the mSAS was 0.740. Univariate and multivariate analyses indicated that an older age, lower tumor localization, longer operation time, radiotherapy alone, combined chemoradiotherapy, and lower mSAS as independent risk factors for complications. The AUC of the prediction nomogram was 0.834 (95% CI 0.774-0.867). The calibration curve demonstrated excellent concordance with the nomogram, indicating the prediction curve ft the diagonal well. This study suggests that mSAS might be a valuable predictive indicator for postoperative complications following robotic rectal cancer surgery, with potentially higher clinical utility.

Intranasal Atomized Dexmedetomidine in Combination with Intranasal Atomized Butorphanol for dressing change sedation and analgesia in adult burn patients: A Randomized Clinical Trial.

We aimed to evaluate the efficacy of the Intranasal Atomized Dexmedetomidine (IAD)+Intranasal Atomized Butorphanol (IAB) combination therapy on adult burn patients undergoing dressing changes. Herein, 46 adult burn patients were enrolled and randomly divided into two groups: Dexmedetomidine-Butorphanol (DB) and Saline-Butorphanol (SB), treated with atomized dexmedetomidine+butorphanol and saline +butorphanol, respectively. The primary outcomes were the Ramsay Sedation Scale (RSS) and the Visual Analog Scale (VAS) scores. The secondary outcomes were Mean Blood Pressure (MBP), Heart Rate (HR), Respiratory Rate (RR), peripheral blood oxygen saturation (SpO2), total butorphanol consumption, and Adverse Effects (AEs). The two groups were comparable in age, sex, weight, and Total Burn Surface Area (TBSA). During dressing changes, the DB group exhibited significantly lower RSS levels (P<0.05). Besides, the two groups showed no significant differences in VAS scores across all measurement time points. Notably, the DB group exhibited decreased MBP at the beginning of the operation (P<0.0001), 10min after (P<0.0001), and 20min after (P=0.0205). HR decreased significantly at the beginning (P=0.0005) and 10min after (P=0.0088) in the DB group. Furthermore, the two groups showed no significant differences in RR and SpO2 levels. Additionally, the rescue butorphanol dose was lower in the DB group (P<0.001). Finally, dizziness and nausea incidences were significantly lower in the DB group (P<0.05). In conclusion, besides its hemodynamic adverse reactions, the IAD+IAB combination therapy exerted a better sedation effect in adult burn patients than IAB treatment alone.

Association of baseline blood pressure and outcomes in etiology subtypes of large vessel occlusion stroke: Data from ANGEL-ACT registry

BackgroundBlood pressure (BP) management at the initial stage of stroke caused by large-vessel occlusion (LVO) remains challenging. We assessed the association between baseline BP and clinical and safety outcomes of endovascular treatment (EVT) in different stroke etiologies. MethodsPatients with acute ischemic stroke and anterior circulation LVO were screened from a prospective, multicenter registry of EVT from November 2017 to March 2019. The primary outcome was poor 90-day outcome (modified Rankin Scale score 3–6). The safety outcome was 24 h post-procedure parenchymal hematoma (PH). The Trial of Org 101072 in Acute Stroke Treatment criteria were used for etiologic stroke classification. Restricted cubic spline and binary logistic regression analysis were performed to examine the association between study outcomes and natural log-transformed BP. ResultsIn subgroup analyses, a U-shaped correlation existed between baseline mean arterial pressure (MAP) and poor outcome in large-artery atherosclerosis stroke only. Higher MAP was an independent risk factor compared with a central reference value (≥ 133 mm Hg vs 96–115 mm Hg; adjusted OR [aOR], 2.50; 95 % CI, 1.09 to 5.71, P = 0.030). Whereas elevated MAP was associated with PH (aOR, 1.58; 95 % CI 1.04 to 2.39, P = 0.030 for a ln10-unit increase in natural log-transformed MAP) in the range <110 mm Hg exclusively for cardioembolic stroke. ConclusionWhether it is cause or epiphenomenon, baseline BP was associated with 90-day outcome in large-artery atherosclerosis stroke, whereas in cardioembolic stroke baseline BP was correlated with post-procedure PH within a certain range. Identifying these features based on etiological subtypes may offer a reference for BP management in acute LVO stroke.

Positive end-expiratory pressure and postoperative pulmonary complications in laparoscopic bariatric surgery: systematic review and meta-analysis

BackgroundThis study compares the effect of positive end-expiratory pressure (PEEP) on postoperative pulmonary complications (PPCs) in patients with obesity undergoing laparoscopic bariatric surgery (LBS) under general anesthesia with mechanical ventilation.MethodsA comprehensive search was conducted in PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, China National Knowledge Internet, Wanfang database, and Google Scholar for studies published up to July 29, 2023, without time or language restrictions. The search terms included “PEEP,” “laparoscopic,” and “bariatric surgery.” Randomized controlled trials comparing different levels of PEEP or PEEP with zero-PEEP (ZEEP) in patients with obesity undergoing LBS were included. The primary outcome was a composite of PPCs, and the secondary outcomes were intraoperative oxygenation, respiratory compliance, and mean arterial pressure (MAP). A fixed-effect or random-effect model was selected for meta-analysis based on the heterogeneity of the included studies.ResultsThirteen randomized controlled trials with a total of 708 participants were included for analysis. No statistically significant difference in PPCs was found between the PEEP and ZEEP groups (risk ratio = 0.27, 95% CI: 0.05–1.60; p = 0.15). However, high PEEP ≥ 10 cm H2O significantly decreased PPCs compared with low PEEP < 10 cm H2O (risk ratio = 0.20, 95% CI: 0.05–0.89; p = 0.03). The included studies showed no significant heterogeneity (I2 = 20% & 0%). Compared with ZEEP, PEEP significantly increased intraoperative oxygenation and respiratory compliance (WMD = 74.97 mm Hg, 95% CI: 41.74-108.21; p < 0.001 & WMD = 9.40 ml cm H2O− 1, 95% CI: 0.65–18.16; p = 0.04). High PEEP significantly improved intraoperative oxygenation and respiratory compliance during pneumoperitoneum compared with low PEEP (WMD = 66.81 mm Hg, 95% CI: 25.85-107.78; p = 0.001 & WMD = 8.03 ml cm H2O− 1, 95% CI: 4.70-11.36; p < 0.001). Importantly, PEEP did not impair hemodynamic status in LBS.ConclusionsIn patients with obesity undergoing LBS, high PEEP ≥ 10 cm H2O could decrease PPCs compared with low PEEP < 10 cm H2O, while there was a similar incidence of PPCs between PEEP (8–10 cm H2O) and the ZEEP group. The application of PEEP in ventilation strategies increased intraoperative oxygenation and respiratory compliance without affecting intraoperative MAP. A PEEP of at least 10 cm H2O is recommended to reduce PPCs in patients with obesity undergoing LBS.Registration numberCRD42023391178 in PROSPERO.

Remote Patient Monitoring Is Associated with Improved Outcomes in Hypertension: A Large, Retrospective, Cohort Analysis.

Hypertension (HTN) is a chronic condition that requires careful monitoring and management. Blood pressure readings in the clinic and self-reported blood pressure readings are often too intermittent to allow for careful management. Remote patient monitoring is a solution that may have positive impacts on HTN management. Individuals at cardiac and primary care clinics were prescribed a remote patient-monitoring (RPM) program. Patients were sent blood pressure monitors that were enabled to transmit data over cellular networks. We reviewed trends in HTN management retrospectively in patients who had previously been on conventional therapy for a year and participated in RPM for a minimum of 90 days. There were 6595 patients enrolled, and the mean duration on RPM was 289 days. A total of 4370 participants (66.3%) had uncontrolled HTN, and 2476 (37.5%) had stage 2 HTN. After at least 90 days on the RPM program, the number of patients with uncontrolled HTN reduced to 2648 (40.2%, p < 0.01), and the number of patients with stage 2 HTN reduced to 1261 (19.1%, p < 0.01). Systolic blood pressure improved by 7.3 mmHg for all patients and 16.7 mmHg for stage 2 HTN. There was improvement in mean arterial pressure (MAP) in all patients with uncontrolled HTN by 8.5 mmHg (p < 0.0001). RPM is associated with improved HTN control and provides further evidence supporting telehealth programs which can aid in chronic disease management.

Association between 24-hour blood pressure parameters and 90-day functional outcome in acute ischemic stroke patients with early anticoagulation.

This study aimed to examine the relationship between blood pressure (BP) and blood pressure variability (BPV) during the first 24 hours from admission with 90-day functional outcomes in acute ischemic stroke (AIS) patients whose onset within 24 hours and receiving early argatroban treatment. The study recruited 214 AIS patients. BP was monitored using a cuff at 1-hour fixed intervals, and BP/BPV parameters [standard deviation (SD), coefficient of variation (CV), successive variation (SV), and average real variability (ARV)] were collected. Age, the National Institutes of Health Stroke Scale (NIHSS) score at admission, previous history of diabetes mellitus (DM), and infarction site (located in anterior circulation) were identified as independent factors affecting 90-day outcomes in multiple logistic regression. After adjusting for confounding variables, association between BP/BPV and 90-day modified Rankin Scale (mRS) was assessed using logistic regression models. In model 1 (adjusted for age and NIHSS score at admission), mean-systolic blood pressure (SBP) showed association with 90-day outcomes [1.068 (1.008, 1.131), P = .025]. In model 2 (adjusted for age, NIHSS score at admission, previous history of DM), mean-SBP [1.061 (1.001, 1.123), P = .045] and max-SBP [0.951 (0.906, 0.998), P = .040] showed relatively weak association with outcomes. In model 3 [adjusted for age, NIHSS score at admission, previous history of DM, infarct site (located in anterior circulation)], all BP values were not related with outcomes, meanwhile, none of the BPV parameters calculated from SBP, diastolic blood pressure and mean arterial pressure showed association with 90-day outcomes. Future prospective studies are required to assess the relationship between early BP/BPV parameters with 90-day outcomes and further clarify the reference values for BP parameters. This is important for effective BP/BPV management and improved patient prognosis.

Dexmedetomidine versus labetalol for induced hypotension during functional endoscopic sinus surgery: a randomized, double-blind study

Background &amp; Objective: Functional endoscopic sinus surgery (FESS) is a surgical procedure for treating sinus diseases. Bleeding is a common concern during FESS, so maintaining hemodynamic stability and ensuring quality surgical field visibility is crucial for achieving the best outcomes. The present study compared the time taken to achieve target mean arterial pressure (MAP) when using dexmedetomidine or labetalol during FESS and assessed the quality of the surgical field to establish the better choice of the two. Methodology: The study was conducted as a prospective, randomized, double-blinded clinical study. Sixty patients classified as American Society of Anesthesiologists grade I or II, undergoing FESS under general anesthesia, were divided into two groups, each with 30 patients. Group D patients received dexmedetomidine and Group L received labetalol. The study aimed to maintain the mean arterial pressure (MAP) between 60-70 mmHg. The operative field visibility was assessed using the Fromme and Boezaart scoring system. Emergence time and postoperative first analgesic request time were also recorded. Results: The time taken to achieve target MAP (60-70 mmHg) was less in Group D (15.1 ± 0.2 min) than in Group L (18.2 ± 0.5 min), and it was statistically significant (P &lt; 0.05). Although insignificant, lower MAP were observed in the Group D than Group L. A significantly lower heart rate was observed at defined intervals in Group D than in Group L. The visibility of the surgical field in both groups has comparable results. The first analgesic request time was considerably longer in Group D (52.2 ± 1.9) compared to Group L (10.2 ± 2.1) (P &lt; 0.05). Conclusion: Dexmedetomidine provided better hemodynamic stability and operative field visibility than Labetalol during FESS. Abbreviations: FESS - Functional endoscopic sinus surgery; MAP - Mean arterial pressure; EtCO2 - end-tidal carbon dioxide Keywords: Dexmedetomidine; Labetalol; Controlled Hypotension; Mean Arterial Pressure Citation: Gupta S, Yadav I, Saxena A, Bagla RK, Nazir N. Dexmedetomidine versus labetalol for induced hypotension during functional endoscopic sinus surgery: a randomized, double-blind study. Anaesth. pain intensive care 2024;28(4):652−657; DOI: 10.35975/apic.v28i4.2507 Received: May 19, 2024; Reviewed: June 08, 2024; Accepted: June 08, 2024

Effect of propofol infusion vs ketamine plus dexmedetomidine infusion on the amplitude of motor evoked potential in pediatric patients undergoing tethered spinal cord surgeries; a randomized, double blind controlled study

Background &amp; objective: The use of intraoperative neurophysiologic monitoring (IOM) has increased over the past two decades for the detection and prevention of iatrogenic neurologic injuries. Motor evoked potentials (MEP) are extremely sensitive to changes in physiological variables and inhalational agents reduce MEPs in a dose dependent manner. So IV anesthetics (propofol or ketamine) and opioids (fentanyl or remifentanil), are frequently used in spinal surgeries under MEPs monitoring. We compared the effects of propofol and fentanyl to those of ketamine, dexmedetomidine, and fentanyl in terms of minimizing their effects on MEP amplitude and hemodynamic stability during surgery Methodology: This double blind, randomized, prospective study was conducted on 46 children, who were randomly allocated into 2 groups Ketamine–dexmedetomidine group: (n = 23) Maintenance throughout the procedure, by infusing Dexmedetomidine (0.4 -0.6 μg/.kg /.hr) ketamine, (1 -2m/.kg/.hr.) and giving bolus of fentanyl, (1-2μg/.kg/ ). Propofol-group:(n = 23) Maintenance throughout the procedure, By infusing propofol (100 ug L/kg/min) and giving bolus of fentanyl, (1-2μg/.kg/ ), with keeping mean arterial blood pressure changes within 25% of the baseline in both groups. Results: Right and left quadriceps muscle measurements were insignificantly different between both groups at base line and were significantly higher in Group KD than Group P at skin incision, surgical manipulation and surgical closure. Right and left adductor hallucis muscle measurements were insignificantly different between both groups at base line and were significantly higher in Group KD than Group P at 5 mins, 10 mins, 15 mins, skin incision, surgical manipulation and surgical closure (P value &lt;0.001). Intraoperative fentanyl consumption was significantly lower in Group KD than Group P. Conclusion: The combination of dexmedetomidine and ketamine infusion is efficacious, safe, and has minimal effect on evoked potentials compared with the propofol-based TIVA group during spine pediatrics surgery. In addition, this combination increases the reliability and accuracy of MEP monitoring with hemodynamic stability and adequate post-operative pain relief. Using dexmedetomidine and ketamine infusions during pediatric spine surgery might successfully replace the typical propofol-based TIVA, although more studies are required . Registration: ClinicalTrials.gov registration number NCT05591001. Keywords: Motor evoked potential, dexmedetomidine, ketamine, propofol. Citation: Saleh AH, Hammad SH, Hassan PF. Effect of propofol infusion vs ketamine plus dexmedetomidine infusion on the amplitude of motor evoked potential in pediatric patients undergoing tethered spinal cord surgeries; a randomized, double blind controlled study. Anaesth. pain intensive care 2024;28(4):692−699; DOI: 10.35975/apic.v28i4.2218 Received: May 08, 2023; Reviewed: February 02, 2024; Accepted: July 03, 2924

The Impact of Hydrogen Sulfide in the Paraventricular Nucleus on the MAPK Pathway in High Salt-Induced Hypertension.

The hypothalamic paraventricular nucleus (PVN) plays a central role in regulating cardiovascular activity and blood pressure (BP). We administered hydroxylamine hydrochloride (HA), a cystathionine-β-synthase (CBS) inhibitor, into the PVN to suppress endogenous hydrogen sulfide (H2S) and investigate its effects on the mitogen-activated protein kinase (MAPK) pathway in high salt-induced hypertension. We randomly divided 40 male Dahl salt-sensitive rats into 4 groups: the NS+PVN vehicle group, the NS+PVN HA group, the HS+PVN vehicle group, and the HS+PVN HA group, with 10 rats in each group. The rats in the NS (normal salt) groups were fed a normal-salt diet containing 0.3% NaCl, while the HS (high salt) groups were fed a high-salt diet containing 8% NaCl. The mean arterial pressure (MAP) was calculated after noninvasive measurement using an automatic sphygmomanometer to occlude the tail cuff once a week. HA or vehicle was infused into the bilateral PVN using Alzet osmotic mini-pumps for 6 weeks after the hypertension model was successfully established. We measured the levels of H2S in the PVN and plasma norepinephrine (NE) using ELISA. Additionally, we assessed the parameters of the MAPK pathway, inflammation, and oxidative stress through western blotting, immunohistochemical analysis, or real-time PCR. In the current study, we discovered that decreased levels of endogenous hydrogen sulfide in the PVN contributed to the onset of high salt-induced hypertension. This was linked to the activation of the MAPK signaling pathway, proinflammatory cytokines, and oxidative stress in the PVN, as well as the activation of the sympathetic nervous system.