Number Of Hypotensive Episodes Research Articles

Evidence of renal tubular injury in canine patients after elective desexing.

To investigate the frequency of perioperative acute kidney injury (AKI) in American Society of Anesthesiologists (SA) Grade I canine patients undergoing elective desexing using urine microscopy techniques and assess if pre- and intraoperative factors affect risk of developing AKI. Prospective observational clinical study conducted between September 2020 and October 2020. University teaching hospital. Thirty-two female and four male dogs between 5 months and 5 years of age classified as ASA I undergoing elective desexing surgery. Urinalysis was performed preoperatively and 20-24 h postoperatively to identify markers of renal tubular injury (RTI), particularly the presence of granular and renal tubular epithelial cell (RTEC) casts on sediment analysis. Dogs underwent a full physical examination and a preoperative assessment including measurement of urine specific gravity (USG), packed cell volume (PCV), total plasma protein and serum creatinine (sCr) was conducted as a part of the desexing programme. Anaesthetic records were examined for any evidence of intraoperative hypotension, defined as a mean arterial pressure (MAP) of <60 mmHg for any duration of time. MAP was measured using an indirect oscillometric technique. For analysis, animals were subdivided into affected and nonaffected groups, with affected animals those that hadpostoperative increases in granular and RTEC casts. Categorical and comparative analyses were then performed between groups to identify associations of increased casts with pre-, intra- and postoperative variables. A frequency of RTI of 5.6% was identified. This was accompanied by a significant association between increases in casts with total duration (p = 0.027) and number (p = 0.016) of hypotensive episodes. RTI is an anaesthetic consideration in ASA I veterinary patients undergoing elective desexing surgery. The identification of an association between the total duration and number of hypotensive episodes and the frequency of RTI highlights the importance of early detection of hypotension along with prompt and effective intervention in veterinary patients.

Epinephrine vs. phenylephrine infusion for prophylaxis against maternal hypotension after spinal anesthesia for cesarean delivery: a randomized controlled trial.

The hemodynamic effects of relatively low-dose epinephrine and phenylephrine infusions during cesarean delivery under spinal anesthesia were compared. This randomized controlled trial included full-term pregnant women who underwent elective cesarean delivery. After spinal anesthesia, participants received either epinephrine (0.03mcg/kg/min) or phenylephrine (0.4mcg/kg/min) infusion that continued until 5min after delivery. The primary outcome was a composite outcome of the occurrence of any of hypotension, hypertension, bradycardia, and/or tachycardia. Neonatal outcomes, including umbilical artery blood gas and Apgar scores, were assessed. In total, 98 patients in each group were analyzed, and the number of patients with the composite outcome was comparable between the epinephrine and phenylephrine groups (30/98 [31%] vs. 31/98 [32%], respectively; P = 0.877). However, the incidence of hypotension was likely lower in the epinephrine group than in the phenylephrine group (P = 0.066), and the number of hypotensive episodes per patient was lower in the epinephrine group than in the phenylephrine group. On the other hand, the incidence of tachycardia was higher in the epinephrine group than that in the phenylephrine group. The incidence of hypertension was comparable between the two groups and none of the participants developed bradycardia. Neonatal outcomes were comparable between the two groups. Epinephrine and phenylephrine infusion produced comparable maternal hemodynamics and neonatal outcomes. Epinephrine was associated with a higher incidence of maternal tachycardia and likely lower incidence of maternal hypotension than phenylephrine. IRB number: MD-245-2022. This study was registered on May 31, 2023 at clinicaltrials.gov registry, NCT05881915, URL: https://classic. gov/ct2/show/NCT05881915term=NCT05881915&draw=2&rank=1.

Comparison Between 3 Different Norepinephrine Bolus Doses for Management of Postspinal Hypotension During the Caesarean Section for Patients with Preeclampsia: A Randomized Controlled Trial

Background: There is no established dose for norepinephrine (NE) in the management of postspinal hypotension. The data on its use in women with preeclampsia (PE) are limited. Objectives: This study aimed to compare the effect of using different NE bolus doses for the management of postspinal hypotension during lower segment cesarean section for patients with PE. Methods: This randomized, double-blind trial included mothers with PE scheduled for cesarean delivery who developed postspinal hypotension. Sixty participants were allocated to receive 3, 4, or 5 µg of NE bolus. The primary outcome was the neonatal bicarbonate level. The secondary outcomes were successful management of hypotension, incidence of reactive hypertension, nausea, vomiting, systolic blood pressure (SBP), and heart rate (HR) readings through the operation, umbilical blood gases, and Apgar scores. Results: The number of hypotensive episodes, bradycardia episodes, successfully treated hypotensive episodes, and total NE dose per patient were lower in the 4- and 5-µg groups compared with the 3-µg group. Systolic blood pressure was generally higher in the 4- and 5-µg groups than in the 3-µg group starting from 12 min postspinal till 28 min postspinal. The heart rate decreased compared to the baseline reading starting from 4, 6, and 2 min postspinal in the 3-, 4-, and 5-µg groups, respectively, till 28 min postspinal. Also, HR was higher in the 4- and 5-µg groups compared to the 3-µg group at 6-12 min postspinal. Following the first NE bolus, SBP remained lower than the baseline reading in the 3 groups, and HR decreased compared to the baseline reading in the 3- and 5-µg groups only. Conclusions: The 3-, 4-, and 5-µg doses had comparable efficacy in managing the first hypotensive episode and comparable neonatal outcomes. The 4- and 5-µg doses significantly decreased the total NE requirements and the number of hypotensive episodes. The incidence of maternal bradycardia was not significantly different between the groups.

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).

Bilateral Simultaneous Lumbar Artery Perforator Flaps in Breast Reconstruction: Perioperative Outcomes Addressing Safety and Feasibility.

The lumbar artery perforator (LAP) flap has emerged as an excellent option for breast reconstruction, but its steep learning curve makes it less approachable. Furthermore, length of the operation, flap ischemia time, need for composite vascular grafts, complex microsurgery, multiple position changes, and general concern for safety has led experienced surgeons to stage bilateral reconstructions. In the authors' experience, simultaneous bilateral LAP flaps are feasible, but overall perioperative safety has not been fully explored. Thirty-one patients (62 flaps) underwent simultaneous bilateral LAP flaps and were included in the study (excluding stacked four-flaps and unilateral flaps). Patients underwent two position changes in the operating room: supine to prone and then supine again. A retrospective review of patient demographics, intraoperative details, and complications was performed. The overall flap success rate was 96.8%. Five flaps were compromised postoperatively. The intraoperative anastomotic revision rate was 24.1% per flap (4.3% per anastomosis). The significant complication rate was 22.6%. The number of sustained hypothermic episodes and hypotensive episodes correlated with intraoperative arterial thrombosis ( P < 0.05). The number of hypotensive episodes and increased intraoperative fluid correlated with flap compromise ( P < 0.05). High body mass index correlated with overall complications ( P < 0.05). The presence of diabetes correlated with intraoperative arterial thrombosis ( P < 0.05). Simultaneous bilateral LAP flaps can be performed safely with an experienced and trained microsurgical team. Hypothermia and hypotension negatively affect the initial anastomotic success. In this complex operation, a coordinated approach between the anesthesia and nursing team is paramount for patient safety. Therapeutic, IV.

Clinical effects of low‐dose esketamine for anaesthesia induction in the elderly: A randomized controlled trial

Esketamine is an N-methyl-D-aspartic acid (NMDA) receptor antagonist, which has stronger sedative and analgesic effects and fewer adverse events than ketamine. The effects of low-dose esketamine on haemodynamics and postoperative quality of recovery in elderly patients have not been evaluated. To evaluate whether low-dose esketamine can be safely used for anaesthesia induction in the elderly. Eighty elderly patients were selected for unilateral total knee replacement under general anaesthesia from February 2021 to August 2021. Patients were randomly divided into two groups (n=40): control group (C group) and esketamine group (K group). During induction of anaesthesia, the control group was intravenously injected with normal saline of equal volume, and the esketamine group was intravenously injected with 0.2-mg/kg esketamine. Both groups were induced by etomidate, sufentanil and rocuronium and maintained by combined intravenous and inhaled anaesthesia during operation. HR, SBP, DBP, MAP and BIS values were recorded before induction of anaesthesia (T0 ), immediately before endotracheal intubation (T1 ), 1min(T2 ) and 5min(T3 ) after endotracheal intubation, surgical skin incision (T4 ), 1min(T5 ) and 5min(T6 ) after surgical skin incision. Compared with the C group, SBP, DBP, MAP, HR and BIS of the K group were significantly higher at T1 -T3 (p<0.05). There were no significant differences in SBP, DBP, MAP, HR and BIS between the two groups at T4 -T6 (p>0.05). Compared with T0 , SBP, MAP and BIS values of the two groups at T1 -T6 were decreased (p<0.05). DBP of the K group at T2 was not significantly different from DBP at T0 (p<0.05), but DBP of the C group decreased from T1 to T6 (p<0.05). Compared with T0 , HR in both groups decreased at T1 , T3 , T4 , T5 and T6 (p<0.05). Compared with the C group, the incidence of cough in the K group was significantly lower (p<0.05); There was no significant difference in the number of myoclonus during induction between the two groups (p>0.05). Compared with the C group, the number of hypotension episodes in the K group during induction was much smaller (p<0.05). There were no significant differences in the incidence of hypertension, bradycardia and tachycardia (p>0.05). There were no significant differences in postoperative recovery quality and incidence of adverse events between the two groups (p>0.05). Low-dose esketamine for anaesthesia induction in the elderly undergoing knee arthroplasty may better maintain the stability of haemodynamics and has no adverse effect on the quality of early recovery after operation.

Neonatal outcomes following phenylephrine or norepinephrine for treatment of spinal anaesthesia-induced hypotension at emergency caesarean section in women with fetal compromise: a randomised controlled study

BackgroundNorepinephrine is as effective as phenylephrine for management of spinal anaesthesia-induced hypotension. Most of the studies comparing these vasopressors have been conducted in healthy pregnant women undergoing elective caesarean section. In the current study, we tested the null hypothesis that there is no difference in neonatal outcome when phenylephrine or norepinephrine is used to treat spinal anaesthesia-induced hypotension in women undergoing emergency caesarean section for fetal compromise. MethodsPatients undergoing caesarean section for fetal compromise who developed spinal anaesthesia-induced hypotension were randomised to receive phenylephrine 100 μg or norepinephrine 8 μg for treatment of each hypotensive episode, defined as systolic blood pressure <100 mmHg. Umbilical cord arterial and venous blood samples were obtained for blood gas analysis. The primary outcome measure was umbilical artery pH. ResultsOne hundred patients (50 in each group) were studied. There was no significant difference in umbilical artery pH between the two groups (mean difference 0.001; 95% CI −0.032 to 0.034). The number of hypotensive episodes, vasopressor boluses required, the incidence of bradycardia, heart rate and blood pressure trends following vasopressor administration, and the incidence of nausea/vomiting were not significantly different between groups. ConclusionPhenylephrine 100 μg and norepinephrine 8 μg were not significantly different in terms of neonatal outcome when administered as intravenous boluses for treatment of spinal anaesthesia-induced hypotension in parturients undergoing emergency caesarean sections for fetal compromise.

Colloid coload versus crystalloid coload to prevent maternal hypotension in women receiving prophylactic phenylephrine infusion during caesarean delivery: a randomised controlled trial

BackgroundThe optimal fluid strategy to prevent maternal hypotension during caesarean delivery remains unclear. This study aim was to compare the incidence of post-spinal anaesthesia hypotension in women receiving either colloid or crystalloid coload in the setting of prophylactic phenylephrine infusion during caesarean delivery. MethodsHealthy mothers undergoing elective caesarean delivery under spinal anaesthesia were randomised to receive a rapid intravenous coload with 6% hydroxyethyl starch 130/0.4 10 mL/kg (colloid group) or balanced crystalloid solution (Plasma Solution A) 10 mL/kg (crystalloid group) during spinal anaesthesia. All women had a prophylactic phenylephrine infusion initiated at 25 μg/min immediately after the subarachnoid block and titrated to systolic blood pressure using a standardised protocol. The primary outcome was the incidence of hypotension (systolic blood pressure <80% of baseline) until delivery. ResultsThe incidence of hypotension was 50% in the colloid group and 62% in the crystalloid group (absolute difference, −12% [95% CI −33% to 9%]; relative risk, 0.8 [95% CI 0.56 to 1.14]; P=0.314). No significant difference between groups was found in the number of hypotensive episodes (median 0.5 [IQR 0 to 1] vs 1 [0 to 2], P=0.132) or phenylephrine dose (675 [IQR 425 to 975] μg vs 750 [625 to 950] μg, P=0.109). The incidence of severe hypotension, symptomatic hypotension, bradycardia, nausea, and the neonatal outcomes were not significantly different. ConclusionsThis study found no benefit of colloid coload compared with crystalloid coload for preventing maternal hypotension in the presence of prophylactic phenylephrine infusion during caesarean delivery.

Comparative Evaluation of Hemodynamic Changes in Different Positions in Normotensive Versus Hypertensive Patients Undergoing Percutaneous Nephrolithotomy (PCNL) Under Regional Anaesthesia

Background: Hemodynamic changes occur with position change, are exaggerated under anesthesia and differ in magnitude between normotensive and hypertensive patients. Aim: To evaluate hemodynamic changes in different positions in 2 groups of patients: Normotensive versus Hypertensive undergoing PCNL under regional anaesthesia (RA). Methods: After ethical committee’s approval, a comparative study was conducted at a tertiary healthcare center, included 50 consenting patients &gt;25 years age of ASA Class 1 and 2 undergoing PCNL under RA and divided into two groups of 25 patients each, Group 1-Normotensive patients and Group 2- Hypertensive patients. Hemodynamic variables (heart rate, Systolic, Diastolic and Mean arterial pressures, Electrocardiogram) were monitored throughout surgery and were recorded at Baseline (before instituting RA), Supine to Lithotomy, Lithotomy to Supine, Supine to Prone and Prone to Supine. Hypotensive episodes (Fall in systolic blood pressure (SBP) &gt;20% from baseline) and vasopressor requirement (If SBP &lt;80mm Hg then Inj. Ephedrine IV 5 mg given) were recorded in both the groups. Results: Statistical analysis was done using Chi-Square test and independent sample t test. Inter group comparison of hemodynamic parameters were comparable and statistically insignificant for all positions. Intragroup comparison of hemodynamic parameters showed lower readings as compared to baseline in all with respect to position change. Number of hypotensive episodes and vasopressor usedid not differ significantly betweentwo study groups. Conclusion: A well-controlled hypertensive patient behaves like a normotensive patient hemodynamically with respect to position change under anesthesia. Therefore, preoperative control of hypertension is essential. Keywords: PCNL; Regional anesthesia; Position change; Hypertension. Key Message: Control of hypertension enables a hypertensive patient to behave like a normotensive patient hemodynamically with respect to position change under anesthesia.

A randomised double-blind comparison of phenylephrine and norepinephrine for the management of postspinal hypotension in pre-eclamptic patients undergoing caesarean section.

Studies comparing phenylephrine and norepinephrine for the treatment of postspinal hypotension in pre-eclamptic patients are limited. To compare bolus doses of phenylephrine and norepinephrine for treating hypotension in pre-eclamptic mothers undergoing caesarean section under spinal anaesthesia. It was hypothesised that norepinephrine and phenylephrine use would be associated with similar neonatal outcome. Randomised controlled study. Single centre, tertiary care, university teaching hospital, from December 2018 to March 2020. A total of 86 women with pre-eclampsia and a singleton pregnancy who developed postspinal hypotension during caesarean section. Patients received intravenous phenylephrine (50 μg) or norepinephrine (4 μg) for treatment of hypotension, defined as a fall in baseline systolic BP by ≥ 20% or an absolute value < 100 mmHg. The primary outcome was umbilical artery pH. Secondary outcomes included Apgar scores, the number of hypotensive episodes, vasopressor requirements, the incidence of tachycardia/bradycardia/arrhythmias/hypertension and maternal complications. Umbilical artery pH was not different between the phenylephrine and norepinephrine groups (7.26 ± 0.06 and 7.27 ± 0.06, respectively; P = 0.903). The median [IQR] number of hypotensive episodes was higher in the norepinephrine than the phenylephrine group: 2 [1 to 3] vs 1 [1 to 2], respectively; P = 0.014. Apgar scores, total number of vasopressor boluses required, systolic BP trends and the incidence of maternal complications were comparable in the two groups. Heart rate (HR) values were lower in phenylephrine group (P = 0.026), and one patient in phenylephrine group and none in the norepinephrine group developed bradycardia (HR < 50 bpm), P = 1.000. In women with pre-eclampsia undergoing caesarean section, bolus doses of phenylephrine (50 μg) and norepinephrine (4 μg) used to treat hypotension after spinal anaesthesia are equally effective with similar neonatal and maternal outcomes. CTRI/2018/11/016478.

Impact of intra-operative hypotension on mortality rates and post-operative complications in dogs undergoing cholecystectomy.

To report the mortality rate within a cohort of dogs undergoing cholecystectomy and investigate the impact of intra-operative hypotension on mortality. Clinical records at five UK referral centres were reviewed for dogs undergoing cholecystectomy. Data collected included presenting signs, pre-operative blood test results, intra-operative data including frequency and duration of hypotension and the incidence and type of post-operative complications. Data from 119 dogs were included. Sixteen dogs (13%) died before discharge and by 28 days after surgery the total mortality was 19 dogs (17%). Hypotension lasting over 10minutes during general anaesthesia occurred in 65 dogs (54.6%), with a mean ± sd duration of 36.1 ± 30.0minutes. Intra-operative hypotension or the number of hypotensive episodes did not appear to be associated with in-hospital or 28-day mortality. American Society of Anaesthesiologists grade (of fitness for surgery) was significantly associated with both in-hospital and 28-day mortality on univariable analysis, as were post-operative hypoproteinaemia, ileus and pancreatitis. However on multivariable analysis, only ileus and pancreatitis were found to significantly impact mortality. Dogs presenting with a higher American Society of Anaesthesiologists grade appear to have a higher risk of mortality, although intra-operative hypotension did not appear to be part of this risk.

P1267EFFECT OF SODIUM AND ULTRAFILTRATION MODELING VERSUS LOW TEMPERATURE DIALYSATE IN PREVENTION OF INTRADIALYSIS HYPOTENSION: A SINGLE CENTRE STUDY FROM INDIA

Abstract Background and Aims Symptomatic intradialytic hypotension is the most frequent complication in patients receiving hemodialysis. It complicates 5 to 30 percent of all dialysis treatments. In our study, we aimed to compare the effect of sodium and ultrafiltration modeling versus low-temperature dialysate on the occurrence of intradialytic hypotensive episodes. Method Single center, prospective, randomized trial. Patients with chronic kidney disease (CKD) stage V on maintenance hemodialysis (HD) for at least twice weekly for a minimum of 3 months were observed for the occurrence of ≥1 intradialytic hypotensive episode per month. After full filling the inclusion and exclusion criteria, patients were randomized 1:1 ratio into two groups based on computer-generated randomization numbers allotted to them by the dialysis coordinator. Group 1: Underwent dialysis with sodium and Ultrafiltration modeling (Linearly decreasing dialysate sodium from 141 mmol/L to 128 mmol/L and linearly decreasing ultrafiltration rate). Group 2: Underwent dialysis with low-temperature dialysate (36 degrees Celsius). Primary outcome was number of hypotensive episodes per month. Secondary outcomes were interdialytic weight gain and ultrafiltration volume per session. Results A total of 320 patients were observed for 3 months in our centre. Intradialytic hypotension was found in 18.75 % of patients. Diabetic nephropathy (61.66%) was the leading cause of end-stage renal disease in these patients. There was no significant difference between the two groups in mean arterial blood pressure, hemoglobin, cardiac status, and serum albumin before dialysis. Both groups had a similar incidence of intradialytic hypotensive episodes (P &amp;gt;0.05). Interdialytic weight gain and ultrafiltration volume removed per session were also similar in both groups. Conclusion Sodium and ultrafiltration modeling and low-temperature dialysate were both equally effective in the prevention of intradialytic hypotensive episodes.

Low dose spinal anaesthesia for caesarean section in parturients having pregnancy induced hypertension: Effect on haemodynamicre sponse and vasopressor requirement: A prospective randomized double blind case control study

Currently, the safety of spinal anaesthetic techniques is well established for caesarean section in pregnancy induced hypertension (PIH) patient. Addition of fentanyl to local anaesthetic allows achievement of adequate anaesthesia with lower dose of local anaesthetic in spinal anaesthesia, thereby reducing the occurence of hypotension and need for vasopressor. A prospective, randomized, double blind, case control study was carried out in 80 parturients having PIH undergoing caesarean section in spinal anaesthesia were randomized into 2 groups depending on intrathecal drug received by them as Group C (Conventional dose group- received hyperbaric bupivacaine 10 mg)and Group L{low dose group, hyperbaric bupivacaine (7.5 mg) with fentanyl (25 mcg)} and compared regarding sensory- motor block characteristics, incidence of hypotension (fall in MAP &amp;#62; 25% from baseline) vasopressor requirement Phenylephrine and Ephedrine. Patient in Group L had significantly less number of hypotension episodes as compared to Group C(20 vs 31, p= 0.011). Hence vasopressor requirement was also significantly less in Group L than in Group C [Phenylephrine (1600 mcg vs 2500 mcg, p=0.044), Ephedrine (66 mg vs 18 mg, p= 0.030)].Low dose spinal anaesthesia using 7.5 mg hyperbaric bupivacaine with 25 mcg fentanyl seems to be superior alternative to conventional dose of 10 mg hyperbaric bupivacaine for caesarean section in parturients having pregnancy induced hypertension, because it was associated with better hemodynamic stability, reduced vasopressor requirement.

552-P: Baroreflex Function and Postprandial Hypotension in Older Adults With and Without Type 2 Diabetes

Background: Type 2 diabetes (T2DM) is a common etiology of postprandial hypotension (PPH), possibly as a result of autonomic neuropathy resulting in baroreflex dysfunction. We examined baroreflex function in older adults with PPH (with and without T2DM) during a standardized meal test. Methods: 57 adults with PPH (age &amp;gt;= 65; 30 without T2DM, 27 with T2DM) were recruited sequentially from a geriatric medicine clinic (mean age 77.9±0.9 years, 54% female) and had meal tests performed. A Finometer (Finapres Medical Systems) was used to monitor blood pressure. The baroreflex effectiveness index (BEI, percent) was calculated using the sequence method. Results: Baseline BEI showed no association with the average PPH response (p=0.521), the maximal PPH response (p=0.282), or the number of hypotensive episodes (p=0.859). As shown in Figure 1, baseline BEI was lower in subjects with T2DM than in those without T2DM (p&amp;lt;0.001), but this impairment in baroreflex function was not observed postprandially. There was no significant difference in the average PPH response between those with and without T2DM (p=0.358). Conclusions: Although older subjects with PPH secondary to T2DM have lower baseline baroreflex function than older subjects with PPH without T2DM, this baroreflex impairment was not associated with the size of the PPH response. This suggests that PPH in the T2DM is not due to impairments in the arterial baroreflex. Disclosure K.M. Madden: None. B. Feldman: None. G.S. Meneilly: Advisory Panel; Self; Merck Sharp &amp; Dohme Corp., Novo Nordisk Inc. Funding Allan M. McGavin Foundation; Canadian Diabetes Association

Detection of orthostatic hypotension with ambulatory blood pressure monitoring in parkinson's disease.

We sought to test the accuracy of 24-hours ambulatory blood pressure (BP) monitoring (ABPM) for the detection of orthostatic hypotension (OH) in Parkinson's disease (PD). A total of 113 patients referred for autonomic testing between January 2015 and June 2017 underwent ABPM and office BP measurements in supine and standing positions. The study population consisted of 81 males and 32 females with PD duration of 6.5 ± 4.1 years and Hoehn and Yahr staging of 1 (13.3%), 1.5 (20.4%), 2 (27.4%), 2.5 (23.9%), 3 (13.3%), and 4 (1.8%). Motor fluctuations were present in 44% of patients. The data from office BP recordings were compared to selected ABPM parameters, and the results showed an association between OH and (a) ABPM-detected hypotensive episodes (Hypo-ep) and (b) ABPM-detected awakening hypotension (Hypo-aw). Having 2 or more Hypo-ep episodes ≤15 mmHg (systolic) compared to average 24-h systolic BP [Formula: see text] yielded 75% diagnostic accuracy for OH, while the presence of at least one [Formula: see text] within 90 min after getting up [Formula: see text] yielded 93% specificity for OH. A diagnostic accuracy of 87.6% was achieved when including daytime and nighttime ABPM values, weighted BP variability, systolic and diastolic BP loads, nocturnal dipping, and postprandial hypotension in a computerized prediction algorithm. In conclusion, our findings suggest that selected ABPM parameters, such as the number of hypotensive episodes and the presence of awakening hypotension, may be used to screen patients for OH, while using a computerized prediction algorithm that includes all ABPM parameters provides the greatest diagnostic accuracy.

A randomised controlled trial of phenylephrine and noradrenaline boluses for treatment of postspinal hypotension during elective caesarean section.

Phenylephrine is currently the vasopressor of choice during elective caesarean section, but it can cause reflex bradycardia. Noradrenaline, a potent α-agonist and weak β-agonist, may be associated with a lower incidence of bradycardia. However, comparative information is limited. This double-blind randomised controlled trial compared the effects of 100μg phenylephrine and 5μg noradrenaline administered as boluses for the treatment of postspinal hypotension during elective caesarean section in women with an uncomplicated singleton pregnancy. Hypotension was defined as a decrease of ≥20% from baseline systolic arterial pressure, or an absolute value <100mmHg. Ninety women were included in the study. The primary outcome was the incidence of maternal bradycardia <60beats.min-1 . There was no difference in the incidence of bradycardia (37.8% with phenylephrine vs. 22.2% with noradrenaline; p=0.167), number of hypotensive episodes, number of boluses required to treat the first hypotensive episode or reactive hypertension. The total number of boluses used was higher in the phenylephrine group (p=0.01). Maternal heart rate at 1min after vasopressor administration was non-significantly lower using phenylephrine vs. noradrenaline (p=0.034, considering p<0.01 as statistically significant). The umbilical artery pH was higher using phenylephrine than with noradrenaline (p=0.034). In conclusion, both vasopressors reversed postspinal hypotension without a statistically significant difference in maternal bradycardia. However, in view of the lower umbilical artery pH when using noradrenaline, further research is warranted to study its placental transfer and fetal metabolic effects.

Spinal versus general anesthesia for lumbar spine surgery in high risk patients: Perioperative hemodynamic stability, complications and costs

ObjectiveMore stable perioperative hemodynamic conditions, lower costs and a lower perioperative complication rate were reported in young healthy patients undergoing lumbar spine surgery in spinal anesthesia (SA) compared to general anesthesia (GA). However, the benefits of SA in high risk patients (ASA≥II suffering from cardiovascular and/or pulmonary pathologies) undergoing this surgery are unclear. Our objective was to analyze whether SA leads to an improved perioperative hemodynamic stability and to a more cost-effective management compared to GA in high risk patients undergoing this surgery. MethodsIn a retrospective analysis 146 ASA II-III patients who underwent lumbar spine surgery in SA were compared with 292 ASA I-III patients who were operated in GA between 2000 and 2014. Hemodynamic effects, hospitalization times, complications, and costs according to the Swiss billing system were assessed. The data extraction was conducted according to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative for cohort studies. ResultsThe patients in the SA group were older (75years (±9.6) vs 69 (±11.5), p<0.001), had a lower BMI (25.8kg/m2 (±4.8) vs 27.2 (±4.7), p=0.003) and showed a higher ASA score (3 vs 2, p<0.001). However, SA was associated with significantly better perioperative hemodynamic stability with less need for intraoperative vasopressors (15% vs 57%, p<0.001), volume supplementation (1113ml ±458 vs 1589±644, p<0.001) and transfusions (0% vs 4%, p<0.001). Additionally, the number of hypotension episodes was lower in the SA group (15% vs 47%, p<0.001). Furthermore, the SA group showed a significantly shorter duration of surgery (70min (±1.2) vs 91 (±41), p<0.001), lower postoperative nausea and vomiting (PONV) (4% vs 28%, p<0.001) and pain in the post anesthesia care unit (PACU) (visual analogue scale (VAS) 2.3 (±1.1) vs 0.8 (±0.8), p<0.001), whereas pain after 24h did not differ (VAS 0.9 (±1) vs 0.8 (±1.1), p=ns). The postoperative complication (7% vs 5%, p=0.286) and revision rates (4% vs 5%, p=0.626) were similar in both groups. Total costs (United States Dollars (USD) 6377 (±2332) vs 7018 (±4056), p=0.003) and PACU time were significantly lower in the SA group (35min (±12) vs 109 (±173), p<0.001). ConclusionsLumbar spine surgery in cardiovascular high risk patients with SA is safe, allows good perioperative hemodynamic stability and might lead to lower health care costs. Further prospective studies are needed to confirm these findings.

Randomized double-blind comparison of ephedrine and phenylephrine for management of post-spinal hypotension in potential fetal compromise

BackgroundMost studies comparing phenylephrine and ephedrine have been conducted during elective caesarean sections in healthy mothers with no fetal compromise. The effect of vasopressors on fetal outcome may differ between healthy and compromised fetuses. There has been little research into the effect of phenylephrine and ephedrine, when used for management of post-spinal hypotension in the presence of potential fetal compromise. MethodsHealthy women with a singleton pregnancy undergoing emergency caesarean section for fetal compromise under spinal anaesthesia were studied. One-hundred-and-six consecutive subjects, who developed hypotension after spinal anaesthesia, were randomly allocated to two groups of 53 each, to receive either phenylephrine (Group P) or ephedrine (Group E). For every systolic blood pressure reading <100mmHg patients received phenylephrine 100μg or ephedrine 8mg depending on group allocation. Umbilical blood gas parameters and Apgar scores were recorded. ResultsThere was no statistically significant difference in umbilical arterial pH (P=0.79), umbilical venous pH (P=0.98), other blood gas parameters, incidence of fetal acidosis (P=1.00) and Apgar scores. The number of hypotensive episodes, vasopressor doses for treatment of the first hypotensive episode and the total number of doses used during the study period were comparable. The median [IQR] total number of doses of phenylephrine and ephedrine used before delivery were 2 [1–2] and 2 [1–2], respectively (P=0.67). More patients receiving ephedrine (24.5%) developed tachycardia than those receiving phenylephrine (3.8%) (P=0.004). Bradycardia was more common with phenylephrine, with 39.6% of patients in Group P as compared to only 1.9% of patients in Group E developing a heart rate <60beats/min after vasopressor administration (P=0.001). ConclusionsBoth phenylephrine 100μg and ephedrine 8mg boluses are equally efficacious when treating post-spinal hypotension in the presence of potential fetal compromise. However, phenylephrine may be a better choice in the presence of maternal tachycardia.

Increased mean arterial pressure goals after spinal cord injury and functional outcome

Introduction:Acute spinal cord injury (SCI) is often treated with induced hypertension to enhance spinal cord perfusion. The optimal mean arterial pressure (MAP) likely varies between patients. Arbitrary goals are often set, frequently requiring vasopressors to achieve, with no clear evidence supporting this practice. We hypothesize that increased MAP goals and episodes of relative hypotension do not affect hospital outcome.Materials and Methods:All cervical and thoracic SCI patients treated at a level one trauma and regional SCI center over at 2.5-year period were retrospectively reviewed. Lowest and average hourly MAP was recorded for the first 72 h of hospitalization, allowing for quantification of mean MAP and the total number of episodic relative hypotensive events. These data were further compared to daily American spinal injury association motor score (AMS), which was used to determine the severity of SCI and improvement/decline during hospitalization. Patient's data were finally analyzed at theoretic MAP set points.Results:One hundred and five patients had complete data during the study period. At higher theoretic MAP set points (85 and 90), increased number of relative hypotensive episodes correlated with lower admission AMS (85 mmHg: <10 episodes, AMS 66.2; >50 episodes, 22.0; P < 0.001) and the need for vasopressors (P < 0.03) but showed no statistical change in AMS by hospital discharge. The need for vasopressors correlated with the number of hypotensive episodes and inversely related to admission AMS at all theoretic MAP goal set points but was not correlated with the change in AMS during the hospitalization.Conclusions:The frequency of relative hypotension and the need for vasopressors are progressively related to more severe SCI, as denoted by lower admission AMS. However, episodes of hypotension and the need for vasopressors did not affect the change in AMS during the acute hospitalization, regardless of theoretic MAP goal set-point. Arbitrarily elevated MAP goals may not be efficacious.

The effect of intra-abdominal pressure on sensory block level of single-shot spinal anesthesia for cesarean section: an observational study

BackgroundIncreased intra-abdominal pressure in pregnancy is thought to affect intrathecal drug spread. However this assumption remains largely untested. The aim of this prospective study was to evaluate the association between intra-abdominal pressure and maximum sensory block level in parturients receiving spinal anesthesia for cesarean section. MethodsParturients having elective cesarean section with single-shot spinal anesthesia using hyperbaric bupivacaine 12.5mg were included. Intra-abdominal pressure was measured via a bladder catheter after establishing a T4 sensory block and at the end of surgery in the supine position with 10° left lateral tilt. We recorded demographic data, descriptive characteristics of pregnancy, self-reported weight gain and weight of the newborn. As secondary outcomes, we evaluated onset of sensory block, maximum sensory block, motor block, number of hypotensive episodes, fluid and ephedrine requirements, time to first analgesic request, time to one-point recovery of motor block and side effects. ResultsThe median value of the maximum sensory block level was T2 in 117 parturients. Median [interquartile range] pre-incision and postoperative intra-abdominal pressure were 13 [11–16] and 9 [6–10]mmHg respectively. No association was observed between maximum sensory block level and pre-incision intra-abdominal pressure (P=0.83). Weight was associated with pre-incision intra-abdominal pressure with an estimated odds ratio of 1.04 per kg (99.4% CI: 1.00–1.08). There was a moderate correlation between pre-incision and postoperative intra-abdominal pressure with a Spearman correlation coefficient of 0.67 (99.5% CI: 0.5–0.79). There was no association between pre-incision intra-abdominal pressure and secondary outcomes. ConclusionsIn parturients, intra-abdominal pressure was not associated with spinal block spread, block onset time, recovery or side effects.