Number Of Hypotensive Episodes Research Articles

Mortality and cardiovascular events in online haemodiafiltration (OL-HDF) compared with high-flux dialysis: results from the Turkish OL-HDF Study

Online haemodiafiltration (OL-HDF) is considered to confer clinical benefits over haemodialysis (HD) in terms of solute removal in patients undergoing maintenance HD. The aim of this study was to compare postdilution OL-HDF and high-flux HD in terms of morbidity and mortality. In this prospective, randomized, controlled trial, we enrolled 782 patients undergoing thrice-weekly HD and randomly assigned them in a 1:1 ratio to either postdilution OL-HDF or high-flux HD. The mean age of patients was 56.5 ± 13.9 years, time on HD 57.9 ± 44.6 months with a diabetes incidence of 34.7%. The follow-up period was 2 years, with the mean follow-up of 22.7 ± 10.9 months. The primary outcome was a composite of death from any cause and nonfatal cardiovascular events. The major secondary outcomes were cardiovascular and overall mortality, intradialytic complications, hospitalization rate, changes in several laboratory parameters and medications used. The filtration volume in OL-HDF was 17.2 ± 1.3 L. Primary outcome was not different between the groups (event-free survival of 77.6% in OL-HDF versus 74.8% in the high-flux group, P = 0.28), as well as cardiovascular and overall survival, hospitalization rate and number of hypotensive episodes. In a post hoc analysis, the subgroup of OL-HDF patients treated with a median substitution volume >17.4 L per session (high-efficiency OL-HDF, n = 195) had better cardiovascular (P = 0.002) and overall survival (P = 0.03) compared with the high-flux HD group. In adjusted Cox-regression analysis, treatment with high-efficiency OL-HDF was associated with a 46% risk reduction for overall mortality {RR = 0.54 [95% confidence interval (95% CI) 0.31-0.93], P = 0.02} and a 71% risk reduction for cardiovascular mortality [RR = 0.29 (95% CI 0.12-0.65), P = 0.003] compared with high-flux HD. The composite of all-cause mortality and nonfatal cardiovascular event rate was not different in the OL-HDF and in the high-flux HD groups. In a post hoc analysis, OL-HDF treatment with substitution volumes over 17.4 L was associated with better cardiovascular and overall survival.

Hemodynamic Profile of Target-Controlled Spinal Anesthesia Compared With 2 Target-Controlled General Anesthesia Techniques in Elderly Patients With Cardiac Comorbidities

The impact of anesthesia techniques in patients experiencing hip fracture is controversial. This study compares the effects on blood pressure of 3 anesthesia techniques that are considered safe for the elderly. Forty-five patients older than 75 years, with American Society of Anesthesiologists physical status III or IV, with cardiac comorbidities, and undergoing surgery for hip fracture, were randomized to receive continuous spinal anesthesia (CSA), propofol target-controlled infusion (TCI), or sevoflurane (SEVO). In CSA patients, a T10 metameric level target was achieved by titration of 2.5 mg of bupivacaine boluses. In patients on TCI and SEVO, a bispectral value target of around 50 guided the concentration of propofol or sevoflurane. Analgesia in the TCI and SEVO groups was provided with remifentanil. Hypotension was defined as a 30% decrease in mean arterial pressure and was treated with an intravenous bolus of ephedrine. The number of hypotension episodes was lower in the CSA group: 0 (range, 0-6) versus 11.5 (range, 1-25) in the TCI group and 10 (range, 1-23) in the SEVO group (P < 0.001). Both TCI and SEVO patients needed more ephedrine compared with CSA patients (30.5 [15.5], 26 [23], and 1.5 [2.5] mg, respectively, P < 0.001). The maximal decrease in mean arterial pressure was lower in the CSA group (26% [17%]) compared with that in the TCI group (47% [8%]) and the SEVO group (46% [12%]; P < 0.001). In elderly patients, spinal anesthesia using titrated doses of bupivacaine provided better blood pressure stability than propofol or sevoflurane anesthesia.

Spinal anesthesia for intrapartum Cesarean delivery following epidural labor analgesia: a retrospective cohort study

Failed conversion of epidural labor analgesia (ELA) to epidural surgical anesthesia (ESA) for intrapartum Cesarean delivery (CD) has been observed in clinical practice. However, spinal anesthesia (SA) in parturients experiencing failed conversion of ELA to ESA has been associated with an increased incidence of serious side effects. In this retrospective cohort analysis, we examined our routine clinical practice of removing the in situ epidural, rather than attempting to convert to ESA, prior to administering SA for intrapartum CD. Hemodynamic data, frequencies of either high or total spinal block, and maternal and neonatal outcome data were gathered from the anesthesia records of all parturients at the Amphia Hospital, undergoing intrapartum CD between January 1, 2001 and May 1, 2005. Complete data were available for 693 patients (97.6%) of the 710 medical records that were identified. Of the 693 patients, 508 (73.3%) had no ELA and received SA, 128 patients (18.5%) received SA following epidural anesthesia for labor, 19 (2.7%) underwent conversion of ELA to ESA, and 38 (5.5%) received general anesthesia. When comparing both SA groups, no clinically relevant differences were observed regarding the incidence of total spinal block (0% in both groups) or high spinal block (0.2 vs 0.8%, P = 0.36). The number of hypotensive episodes, the total amount of ephedrine administered, and the Apgar scores recorded at 5 and 10 min were similar amongst groups. The incidence of serious side effects associated with SA for intrapartum CD following ELA is low and not different compared to SA only.

Clinical application of fuzzy‐controlled blood pressure stabilization in patients prone to hypotension during hemodialysis

AbstractBACKGROUNDThe prevalence of intradialytic hypotensive events is still high in patients undergoing hemodialysis (HD). A biofeedback control system to prevent hypotensive destabilization of the patient during hemodialysis was developed.METHODSA blood pressure (BP)–guided closed‐loop system consists of a non‐invasive blood pressure measurement device connected to a fuzzy controller (FC). It regulates ultrafiltration rate (UFR) and dialysate conductivity (DC) depending on the actual BP and its short‐ and long‐term trends as well. Twenty‐eight HD patients prone to hypotension were selected for the study. In 102 HD sessions it was proven whether an increase in DC from 14.3 mS/cm to a maximum of 17.0 mS/cm infl uenced the serum sodium concentration of the patients and interdialytic weight gain (IDGW), when DC was reset to 14.3 mS/cm for the remaining 60 minutes of treatment. In the next step, 69 conventional HD sessions without the fuzzy controller and 144 sessions with fuzzy‐controlled ultrafiltration were compared with 32 sessions with simultaneous fuzzy‐controlled ultrafiltration and modification of dialysate conductivity.RESULTSNo significant differences in serum sodium concentration and weight gain were observed when DC was reset for the remaining 60 minutes of treatment. In conventional HD the frequency of low blood pressure situations, &lt;90 mmHg, increased progressively toward the end of the treatment. The HD treatments with fuzzy‐controlled UFR resulted in no increases in the number of hypotensive episodes. Moreover, there was a significant decrease in the third and fourth treatment hours. The simultaneous fuzzy control of UFR + DC resulted in the lowest occurrence of BP drops.CONCLUSIONSFuzzy control of HD treatments provides reliable blood pressure stabilization in patients prone to hypotension. This kind of treatment is safe because significant changes in body weight and serum sodium concentration do not occur. The cost of this treatment is limited because no special disposables are necessary.

Clinical nursing reseach in prevention of intradialytic hypotension with hemodiaffitration

Objective To compare the effect of hemodiafiltration(HDF) on the incidence rate of intradialytie hypotension. Methods We followed up eighteen patients with symptomatic hypotension history and divided them into group A and group B.Group A was treated with conventional hemodialysis(CHD) and HDF, Group B adopted HDF with low temperture hemodialysis. The number of hypotensive episodes, blood temperature during cardiopulmonary bypass, energy transfer rates were assessed. Results The incidence of symptomatic hypotension of patients was found lower in CHD (40%) than in HDF (6%),P<0.01. Energy transfer rates were founded higher in CHD than in HDF and low temperture hemodialysis, P<0.01. Conclusions HDF significantly reduced hemodialysis-related side effects and increased the tolerance ability of patients. Key words: Hemodiafiltration; Intradialytie hypotension; Nursing Besearch

297: The comparison of intratechal isobaric ropivacaine and isobaric ropivacaine-clonidine for caesarean delivery

Aim: We investigated the effects of intrathecal isobaric 0.5% ropivacaine and isobaric 0.5% ropivacaine-clonidine combination in women undergoing caesarean deliveries. Methods: Twenty-five parturients received 17.5 mg ropivacaine (group R) and twenty five parturients received 15 mg ropivacaine and 30 μg clonidine (group RC) for spinal anaesthesia. Sensory and motor block properties; haemodynamics, postoperative analgesia, foetal outcomes and side effects were evaluated. Unpaired and paired-t-tests and chi-square and Mann-Whitney-U tests were used where appropriate (p<0.05). Results: Intrathecal ropivacaine and ropivacaine-clonidine provided effective sensory anaesthesia and motor block. S2 dermatome regression time was longer in ropivacaine-clonidine combination. First minute APGAR was lower in group RC (mean 8.8±0.7) than group R (mean 9.3±1.0). Umbilical venous pH and fifth minute APGAR scores were similar between the groups. Postoperative analgesia was prolonged by clonidine. Although intraoperative ephedrine requirements (mg) were higher in ropivacaine-clonidine group, the number of patients requiring ephedrine and the number of hypotension episodes were similar. Dry mouth was observed more with clonidine. Conclusion: We concluded that, intrathecal 17.5 mg 0.5% isobaric ropivacaine provides efficient and safe anaesthesia for caesarean section delivery. The addition of 30 g clonidine to 15 mg 0.5% isobaric ropivacaine results in longer complete and effective analgesia with similar block properties. In both groups, hypotension was easily treated with ephedrine and did not affect maternal and neonatal outcome.

Similar incidence of hypotension with combined spinal-epidural or epidural alone for knee arthroplasty

We hypothesized that the incidence of hypotension during total knee replacement (TKR) surgery is lower in patients given combined spinal-epidural (CSE) anesthesia vs those receiving epidural anesthesia alone.In a prospective study, 80 American Society of Anesthesiologists I-II patients (aged 40-80 yr), undergoing elective TKR surgery were randomly assigned to either CSE anesthesia (CSE, n = 40) or epidural anesthesia alone (Epidural, n = 40). Hemodynamic measurements included oscillometric mean arterial blood pressure (MAP), heart rate (HR), and cardiac index (CI) as determined by thoracic bioimpedance; systemic vascular resistance (SVR) was calculated. Our primary endpoint (outcome) was the number of hypotension episodes (defined as MAP < 70 mmHg).Using univariate analysis, we found no differences between the groups in regards to MAP, HR, CI, or SVR during the perioperative period. The incidence of hypotension was similar in both groups (two patients in each group), as was the incidence of bradycardia (12 patients in CSE, 7 in Epidural; P = 0.2). There were no differences between groups in other hemodynamic measurements including CI and calculated SVR. Analgesia supplementation with fentanyl was more frequently required in the Epidural group (20 vs 6 patients - P = 0.03).Combined spinal-epidural anesthesia and epidural anesthesia alone during TKR surgery are associated with the same incidence of hypotension with statistically and clinically similar hemodynamic responses.

Newer Aspects of Carnitine Metabolism in Uremia

New knowledge on the physiologic role of L-carnitine and on the rationale of its use in patients on maintenance hemodialysis is provided. In particular, carnitine normalizes plasma and muscle carnitine levels and modifies both enzymatic pattern of muscle and morphology of single fibers, improving exercise tolerance. In addition, carnitine reduces erythropoietin requirements, the number of hypotensive episodes, improves ejection fraction, and decreases hospitalization.

Prostate anaesthetic block with ropivacaine for urologic surgery

The aim of this study was to evaluate prostate anaesthetic block for haemodynamic tolerance and quality of analgesia during and after transurethral surgery. Ninety adult males, ASA III/IV, were randomly assigned to receive a prostate anaesthetic block (n = 45) or spinal anaesthesia (n = 45). The main outcome measurement during anaesthesia, surgery and recovery was haemodynamic tolerance (number of hypotensive episodes, heart rate, systolic and mean blood pressures). Other outcome variables were pain scores during anaesthesia, surgery and every 4 h until 24 h after the end of surgery and amount of oral morphine required during the 24-h postoperative period. Sixty-six patients were ASA III and 24 ASA IV. Ongoing cardiovascular therapies were comparable between groups. All surgical procedures were performed under good conditions. For patients receiving prostate anaesthetic block, the blood pressure and heart rate did not change significantly during the study period. For patients receiving spinal anaesthesia, the hypotension rate was 55.6% (n = 25) compared to 0 in the prostate anaesthetic block group (P < 0.001); 25 and 4 patients, respectively, required vascular filling and additional ephedrine administration. In both groups, all pain scores were <40 (100 mm visual analogue scale) during the study period. Oral morphine was given during the postoperative period to two prostate anaesthetic block patients and four who had received spinal anaesthesia (not significant). Transurethral surgery under prostate anaesthetic block is safe and assures adequate analgesia during and after surgery.

A Novel Method of Evaluating the Impact of Secondary Brain Insults on Functional Outcomes in Traumatic Brain-injured Patients

Prior studies suggest that the emergency department (ED) occurrence of secondary brain insults (SBIs), such as systemic hypotension and hypoxia, worsens outcome in patients with traumatic brain injury. However, previous methods of assessing SBIs have been relatively crude, generally only determining the incidence and duration of events. The authors hypothesized that a new method that accounts for the cumulative depth and duration of SBIs would provide a more informative measure that better correlates with outcome. The authors developed a computer algorithm to calculate the total "dose" of an SBI (in this case, hypotension and hypoxia) as the area under the curve between a cut-point value and a measured vital sign over time. To test this method, the authors used an existing data set of head trauma patients for whom occurrence in the ED of any hypotension had been shown to be associated with in-hospital mortality. The authors applied the algorithm using the cut-point values from the prior study (systolic blood pressure </=90 mm Hg and oxygen saturation </=92%). The effects of SBIs on in-hospital mortality and three-month Glasgow Outcome Scale score were evaluated. Of 107 patients overall, 26 had hypotension (dose range 0.2-898 mm Hg . min) and 40 had hypoxia (dose range 0.005-6.7% . min). Moderate and high doses of hypotension were more strongly associated with outcome than the measures from the initial study (any hypotension and number of hypotensive episodes). Hypoxia had no effect. New methods of measuring SBIs that take into account depth and duration of episodes may more accurately reflect the influence of these events on outcome after head trauma.

Comparison of etomidate and midazolam for prehospital Rapid-sequence intubation

ObjectiveThis study compares etomidate with midazolam for prehospital rapid-sequence intubation (RSI). MethodsThe authors conducted a retrospective review of consecutive intubations at a university-based air medical program from January 1995 to December 2000. Exclusion criteria were patients not undergoing RSI, age <15 years, and incomplete chart data. Outcome measures included intubation success, incidence of hypotension, and percentage of change in heart rate (HR) and systolic blood pressure (SBP). ResultsThe intubation success rate was 110 out of 112 (98%) with etomidate, and 96 out of 97 (99%) with midazolam. Mean ages, patient gender distributions, and initial SBPs and HRs did not differ between the two groups. The mean dose of etomidate was 24 mg, the mean percentage of change in HR was −1% (95% confidence interval [CI], −6 to 4), and the mean percentage of change in SBP was 2% (95% CI, −3 to 7). The mean dose of midazolam was 3.5 mg, the mean percentage of change in HR was 1% (95% CI, −5 to 7), and the mean percentage change in SBP was 3% (95% CI, −3 to 9). The number of hypotensive episodes with etomidate (7 out of 74) compared with midazolam (3 out of 56) did not differ significantly (Fisher's exact test, p=0.51). ConclusionIntubation success rate was very high with both etomidate (98%) and midazolam (99%). There was no statistically significant mean percentage of change in SBP or HR with either agent. The authors found a low incidence of hypotension with both agents, although the mean dose of midazolam used was considerably less than typically recommended for induction.

COMPARISON OF ETOMIDATE AND MIDAZOLAM FOR PREHOSPITAL RAPID-SEQUENCE INTUBATION

Objective. This study compares etomidate with midazolam for prehospital rapid-sequence intubation (RSI). Methods. The authors conducted a retrospective review of consecutive intubations at a university-based air medical program from January 1995 to December 2000. Exclusion criteria were patients not undergoing RSI, age <15 years, and incomplete chart data. Outcome measures included intubation success, incidence of hypotension, and percentage of change in heart rate (HR) and systolic blood pressure (SBP). Results. The intubation success rate was 110 out of 112 (98%) with etomidate, and 96 out of 97 (99%) with midazolam. Mean ages, patient gender distributions, and initial SBPs and HRs did not differ between the two groups. The mean dose of etomidate was 24 mg, the mean percentage of change in HR was −1% (95% confidence interval [CI], −6 to 4), and the mean percentage of change in SBP was 2% (95% CI, −3 to 7). The mean dose of midazolam was 3.5 mg, the mean percentage of change in HR was 1% (95% CI, −5 to 7), and the mean percentage change in SBP was 3% (95% CI, −3 to 9). The number of hypotensive episodes with etomidate (7 out of 74) compared with midazolam (3 out of 56) did not differ significantly (Fisher's exact test, p = 0.51). Conclusion. Intubation success rate was very high with both etomidate (98%) and midazolam (99%). There was no statistically significant mean percentage of change in SBP or HR with either agent. The authors found a low incidence of hypotension with both agents, although the mean dose of midazolam used was considerably less than typically recommended for induction.

Reduction of hypotensive side effects during online-haemodiafiltration and low temperature haemodialysis

This study compares the effect of online-haemodiafiltration (o-HDF, post-dilution mode) with conventional haemodialysis (HD) and 'temperature-controlled' HD (Temp-HD) on the haemodynamic stability of hypotension-prone patients. Seventeen patients with a history of frequent hypotensive episodes during dialysis sessions were studied, each patient serving as his or her own control. The first 25 HD treatments in comparison with 25 o-HDF sessions were evaluated using identical dialysate temperature. In the second part of the study, o-HDF (n = 25) was compared with Temp-HD (n = 25). In the latter method, the temperature of the dialysate was adjusted to result in identical energy transfer rates to those in the corresponding o-HDF. The number of hypotensive episodes, blood temperature and blood volume regulation were assessed. Symptomatic hypotension was much more frequent during HD (40%) than during o-HDF (4%) (P < 0.001). During o-HDF, an enhanced energy loss within the extracorporeal system occurred (o-HDF, 16.6 +/- 4.0 W; HD, 5.4 +/- 5.1 W; P < 0.0001), despite identical temperature settings for dialysate and substitution fluid. As a result, the blood returning to the patient was cooler during o-HDF than during HD (o-HDF 35 +/- 0.2 degrees C vs HD 36.5 +/- 0.3 degrees C; P < 0.0001). In o-HDF, even in the patients' circulation, the mean blood temperature was lower (o-HDF 36.7 +/- 0.2 degrees C vs HD 36.9 +/- 0.3 degrees C; P < 0.0001) and blood volume was significantly more reduced (o-HDF, 91.8 +/- 3.1%; HD, 94.0 +/- 3.2%; P < 0.05). Energy transfer rates and blood temperature did not differ significantly between o-HDF and Temp-HD. The rate of hypotensive episodes was low and not different between o-HDF (4%) and Temp-HD (4%). Neither was there any significant difference in blood volume reduction. O-HDF showed a significant reduction of hypotensive episodes compared with HD. Surprisingly, o-HDF resulted in cooling of the blood via enhanced thermal energy losses within the extracorporeal system, despite use of replacement fluid prepared from pre-warmed dialysate. The incidence of symptomatic hypotension was reduced to that of o-HDF by using cooler Temp-HD. Thus, unexpected blood cooling appears to be the main blood pressure-stabilizing factor in o-HDF.

Effect of sertraline hydrochloride on dialysis hypotension

Hemodialysis hypotension (HH) is a very common disorder and has a multifactorial etiology. Autonomic dysfunction occurs in up to 50% of patients with end-stage renal disease (ESRD) and plays a key role in HH in some patients. Sertraline hydrochloride, a central nervous system serotonin reuptake inhibitor, has been shown to be an effective treatment of hypotension caused by autonomic dysfunction in disorders such as neurocardiogenic syncope and idiopathic orthostatic hypotension. This study sought to determine whether sertraline was effective in ameliorating HH. A retrospective chart analysis was performed that included nine consecutive patients (aged > or = 54 years, time on hemodialysis > or = 2.2 years) placed on sertraline (50 to 100 mg/d) for depression who also had HH (defined as prehemodialysis systolic blood pressure [SBP] < or = 100 mm Hg, > or = 40 mm Hg decrease in SBP during hemodialysis, SBP <90 mm Hg, any diastolic blood pressure <40 mm Hg, or a decrease in blood pressure-causing symptoms) before treatment with sertraline. The data from a 6-week pre-sertraline period were compared with the data from a 6-week sertraline period (defined as 6 weeks after drug begun). Blood pressure medications were unchanged during the trial period of sertraline. However, nadir mean arterial pressure recorded during a given dialysis session in the pre- sertraline period (55+/-4 mm Hg) was significantly lower than that recorded in the sertraline period (68+/-5 mm Hg; P < 0.05). In addition, the number of hypotensive episodes (same definition as HH) per dialysis session during the sertraline period was significantly lower than that during the pre-sertraline period (mean, 0.6+/-0.2 episodes per session v 1.4+/-0.3 episodes per session; P < 0.005). The number of therapeutic interventions required for hypotension during the sertraline period was also significantly less than that during the pre- sertraline period (mean, 1.7+/-0.8 interventions v 11.0+/-3.0 interventions; P < 0.005). The urea reduction ratio (62.7%+/-4.7% v 63.1%+/-9.3%; P = NS) and hematocrit (28.9%+/-0.8% v 29.5%+/-1.0%; P = NS) did not change significantly. It is concluded that the short-term (6 weeks) use of sertraline hydrochloride reduces HH in some patients with ESRD. A possible mechanism for this effect is sertraline-induced attenuation of the paradoxical sympathetic withdrawal that may underlie HH in some patients with ESRD. (Am J Kidney Dis 1998 Apr;31(4):624-30)

Multicenter trial of automated nitroprusside infusion for postoperative hypertension

Hypertension is common after a cardiac operation and may result in postoperative hemorrhagic and other complications. Most often this problem has been treated using manually controlled doses of intravenous sodium nitroprusside. To evaluate the clinical impact of an automated closed-loop administration system on patients after cardiotomy, a prospective trial was conducted at nine clinical centers. Patients with hypertension were managed by either manual nitroprusside titration (n = 532) or a closed-loop automated titration system (n = 557). Patient groups were not significantly different in age, weight, or height. Moreover, the types of surgical procedures were comparable: primary coronary artery bypass grafting, 59.2% and 58.9%, manual group versus automated group; repeat coronary artery bypass grafting, 10.5% and 8.6%, respectively; valve procedures, 11.3% and 15.1%, respectively; and other cardiac procedures, 19.0% and 17.4%, respectively (all p = not significant). The automated group showed a significant reduction in the number of hypertensive episodes per patient (1.8 ± 0.2 versus 0.6 ± 0.07; p = 0.0001. At the same time, the number of hypotensive episodes per patient was reduced with automated closed-loop titration (0.40 ± 0.05 versus 0.30 ± 0.03; p = 0.02). Chest tube drainage (866 ± 37 mL versus 693 ± 23 mL [mean ± standard error of the mean]; p = 0.0001), percentage of patients receiving transfusion (40.0% versus 33.0%; p = 0.02), and total amount transfused (2.4 ± 0.12 units versus 2.0 ± 0.10 units; p = 0.0003) were all reduced significantly by the use of an automated titration system. Finally, of the 3.3% of all patients in the series who required reexploration for bleeding, almost twice as many had been managed by manual infusion compared with automated titration. These data suggest that the automated control of nitroprusside infusion may result in improved patient outcome through more effective control of hypertension, a decreased incidence of therapy-induced hypotension, a reduction in postoperative bleeding, decreased transfusion requirements, and a probable decreased incidence of reexploration for post-operative bleeding.

Acute intradialytic well-being: Results of a clinical trial comparing polysulfone with cuprophan

We conducted a multicenter, randomized, double-blind, controlled clinical trial to compare the effects of a synthetic, high-flux polysulfone membrane with a standard cuprophan one on acute clinical complications during a diffusive dialysis procedure. The principal end-point, that is, the number of hypotensive episodes, was similar in polysulfone (39; 23.8%) and cuprophan (32; 19.5%). Likewise, no significant difference was found between the two membranes as far as the secondary end-point was concerned, that is, the effect on headache, nausea, pruritus and sense of well-being. We conclude that high-flux polysulfone, acutely used in standard diffusive dialysis, has no favorable influence on hypotensive episodes and does not affect some typical dialysis-related symptoms any differently from cuprophan membrane. The need is stressed for well-controlled studies specifically designed to assess the worth of new dialysis techniques and materials that may vastly raise the cost of dialysis treatment.

The Influence of Intraoperative Hypotension and Perioperative Blood Transfusion on Disease-free Survival in Patients with Complete Resection of Golorectal Liver Metastases

An increased interest in surgical treatment of liver metastases from colorectal origin has evolved recently. However not all patients benefit from this approach, with early recurrence and death still being encountered. To evaluate clinical as well as perioperative factors that might significantly affect the outcome of patients with completely resected colorectal liver metastases, we examined 116 patients who underwent resection between September 1987 and August 1989. Median follow-up time was 13.2 months (0.6 to 31.4 months). The overall survival rate was 91% at 1 year and 75% at 2 years. Median survival was not reached. Median disease-free survival time was 11.5 months, with 49.4% and 21.2% of the patients being free of disease at 1 and 2 years, respectively. By univariate analysis, site of primary colorectal cancer, preoperative carcinoembryonic antigen (CEA) level, size of metastases, number of metastases, length of operation time, percentage mean arterial pressure, number of hypotensive episodes, duration of hypotensive episodes, and whole blood transfusion significantly affected recurrence rate following resection. However only site of primary tumor, CEA, number of metastases, and number of hypotensive episodes remained significant in the multivariate analysis. The most significant single factor that affected recurrence rate was the number of hypotensive episodes during the operative procedure. It is concluded that hypotensive episodes, even when well controlled, should be avoided during operation to maximize the chances of cure and prolong disease-free survival of patients with colorectal liver metastases.

Ultrafiltration followed by haemodialysis. A longterm trial and acute studies.

Separate ultrafiltration followed by haemodialysis (U.F.-H.D.) using Gambro Major or Cordis-Dow hollow-fiber dialyzers were evaluated in 10 dialysis patients over a mean period of 4 1/2 months and 455 U.F.-H.D. procedures. Fluid control was facilitated in oedematous patients but the number of hypotensive episodes during the combined procedure requiring intravenous 5% saline did not significantly decrease. No significant improvement in hypertension was noted. Ultrafiltration (U.F.) alone for acutely water overloaded, azotaemic patients proved very useful. Two to five liters of oedema fluid could be removed asymptomatically in one to three hours using transmembrane pressures of 250 to 500 mmHg and U.F. rates of 10 to 42 ml/min. Two patients became acutely and symptomatically hypotensive. One was an insulin dependent diabetic in whom 3800 ml were removed in 75 minutes and the other a hypertensive patient undergoing treatment with Minoxidil and propranolol.

12 - Drugs and Pregnancy

Most 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.Healthy 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 <100 mmHg patients received phenylephrine 100 μg or ephedrine 8 mg depending on group allocation. Umbilical blood gas parameters and Apgar scores were recorded.There 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 <60 beats/min after vasopressor administration (P=0.001).Both phenylephrine 100 μg and ephedrine 8 mg 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.

Syndrome of intermittent insufficiency of the basilar arterial system.

<h3>Background and Objectives</h3> The impact of anesthesia techniques in patients experiencing hip fracture is controversial. This study compares the effects on blood pressure of 3 anesthesia techniques that are considered safe for the elderly. <h3>Methods</h3> Forty-five patients older than 75 years, with American Society of Anesthesiologists physical status III or IV, with cardiac comorbidities, and undergoing surgery for hip fracture, were randomized to receive continuous spinal anesthesia (CSA), propofol target-controlled infusion (TCI), or sevoflurane (SEVO). In CSA patients, a T10 metameric level target was achieved by titration of 2.5 mg of bupivacaine boluses. In patients on TCI and SEVO, a bispectral value target of around 50 guided the concentration of propofol or sevoflurane. Analgesia in the TCI and SEVO groups was provided with remifentanil. Hypotension was defined as a 30% decrease in mean arterial pressure and was treated with an intravenous bolus of ephedrine. <h3>Results</h3> The number of hypotension episodes was lower in the CSA group: 0 (range, 0–6) versus 11.5 (range, 1–25) in the TCI group and 10 (range, 1–23) in the SEVO group (<i>P</i> &lt; 0.001). Both TCI and SEVO patients needed more ephedrine compared with CSA patients (30.5 [15.5], 26 [23], and 1.5 [2.5] mg, respectively, <i>P</i> &lt; 0.001). The maximal decrease in mean arterial pressure was lower in the CSA group (26% [17%]) compared with that in the TCI group (47% [8%]) and the SEVO group (46% [12%]; <i>P</i> &lt; 0.001). <h3>Conclusions</h3> In elderly patients, spinal anesthesia using titrated doses of bupivacaine provided better blood pressure stability than propofol or sevoflurane anesthesia.