Mean Arterial Pressure In Patients Research Articles

Increased Neutrophil Count Related to Bleeding Volume in Intracerebral Hemorrhage Cerebrovascular Accident

Background: Cerebrovascular accidents (CVA) was increasing per year. In Indonesia reached 550.000 cases per year. Ten to fifteen percent are types of CVA bleeding (CVA-B). Death and disability as complications of CVA-B are more often compared to an ischemic type. Early diagnosis of CVA-B is key to decreasing it’s complications. Unfortunately, diagnosis of early CVA-B requires excellent effort and spending more expense when using an advanced CT scan. Previous research has shown a relationship between leucocyte count and CVA, but there is no adequate data relating leukocyte count and mean arterial pressure (MAP) with bleeding volume in CVA-B patients.Objective: This study aimed to answer whether Leukocyte count combined with MAP can be a choice to diagnose CVA-B at an early stage.Methods: Analytic observational research was conducted with a cross-sectional approach. The population of this study was all patients with CVA intracerebral bleeding at Ulin Hospital of Banjarmasin. The patient's medical records and CT scans were used to assess the bleeding volume. The number of leukocytes and the patient's mean arterial pressure were tabulated and analyzed to their relationship with bleeding volume.Results: In this study, there was a significant relationship between the number of leukocytes and the volume of intracerebral hemorrhage (r=0.801, p=0.000). There was no significant relationship between the MAP and the volume of intracerebral hemorrhage (r=0,17, p=0,361)Conclusion: There is a strong relationship with a significant relationship between the number of leukocytes and the volume of bleeding in patients with intracerebral hemorrhage but no relationship with MAP.

Effect of intravenous low-dose norepinephrine on blood loss in non-tourniquet total knee arthroplasty under general anesthesia: a randomized, double-blind, controlled, single-center trial

ObjectiveThis prospective trial aimed to evaluate the effects of low-dose intravenous norepinephrine (NE) on intraoperative blood loss and bleeding from osteotomy sites during non-tourniquet total knee arthroplasty (TKA) under general anesthesia.MethodsA total of 120 patients who underwent TKA between December 2020 and May 2022 were enrolled and randomly assigned to the intravenous low-dose NE Group (NE Group) or the control group (C Group). During surgery, NE Group received 0.05–0.1 μg/(kg min) of NE intravenously to raise and maintain the patient's mean arterial pressure (MAP). C Group received the same dose of saline as placebo. Intraoperative blood loss, bleeding score at osteotomy sites, Δlactate levels (Lac), postoperative complications, and transfusion rate during hospitalization were compared between groups.ResultsIntraoperative and osteotomy blood loss was significantly lower in the NE Group than in the C Group (P < 0.001). No significant difference was observed in ΔLac between groups (P > 0.05). There was no significant difference in complications between the groups 3 days after surgery (P > 0.05). In addition, there was no significant difference in blood transfusion rates between the two groups during hospitalization (P > 0.05).ConclusionIn non-tourniquet TKA under general anesthesia, low-dose intravenous NE safely and effectively reduced intraoperative blood loss and provided a satisfactory osteotomy site while maintaining a higher MAP.

Frequency of intraoperative hypotension after the induction of anesthesia in hypertensive patients with preoperative angiotensin converting enzyme inhibitors

Objective: is to evaluate the intraoperative hypotension after anesthesia induction in controlled hypertensive patients who have been taking ACE inhibitors preoperatively.&#x0D; Methodology: Prospective study conducted at department of anesthesia and ICU Jinnah Postgraduate Medical Institute, Karachi, Pakistan from 1st march 2021 to 28th February 2022. Before the surgery, the patient's mean arterial pressure and blood pressure (systolic, diastolic) were recorded in the preoperative holding area. During the surgery, the primary anesthesia team maintained an intraoperative monitoring chart. After the surgery, patient was shifted to recovery room, patient was monitored for blood pressure, for at least 10 minutes after the shifting from operation theater.&#x0D; Results: There were 73.1% males and 26.9% females, 57.7% patients had hypotension. The mean age, BMI and duration of anesthesia of the patients was 54.07±6.85 years, 26.52±4.45 kg/m2 and 82.19±3.16 minutes, respectively. There were 74.7% patients had hypotension and on antihypertensive drugs other than ACE inhibitor and hypotension was occurred in 74.5% of patients who are using ACE inhibitors as antihypertensive drugs (p&gt;0.050).&#x0D; Conclusion: Higher incidence of intraoperative hypotension in patients with controlled hypertension who are taking ACE (Angiotensin-Converting Enzyme) inhibitors. So, controlled hypertension with ACE inhibitors is a significant risk factor for intraoperative hypotension.&#x0D; Keywords: Intraoperative hypotension, ACE inhibiotrs, Hypertensive, Anesthesia, Antihypertensive

Optic nerve sheath diameter and pulsatility index for the diagnosis and follow-up in pediatric traumatic brain injury: a prospective observational cohort study.

Invasive neuromonitoring could be difficult in children with traumatic brain injury (TBI). This study aimed to determine whether noninvasive intracranial pressure (nICP), calculated via pulsatility index (PI) and optic nerve sheath diameter (ONSD) had correlated with each other and patient outcome. All moderate-severe TBI patients were eligible. Patients with a diagnosis of intoxication that did not affect the mental status or cardiovascular system were enrolled as controls. The PI measurements were routinely performed bilaterally on the middle cerebral artery. A software (QLAB's Q-Apps) was used to calculate PI, which further placed the ICP equation of Bellner et al. Linear probe with a 10MHz frequency transducer to measure ONSD, which further placed the ICP equation of Robba et al. All measurements were performed by a point-of-care ultrasound certified pediatric intensivist under the supervision of a neurocritical care specialist, before and 30min after a hypertonic saline (HTS) infusion for every 6h when the patient's mean arterial pressure, heart rate, body temperature, hemoglobin, and blood CO2 levels were within normal ranges. The secondary outcome was the effect of hypertonic saline (HTS) on nICP. Delta-sodium values of each HTS infusion were calculated as a difference between pre- and post-measurements. Twenty-five TBI patients (200 measurements) and 19 controls (57 measurements) were included. Median nICP-PI and nICP-ONSD on admission were significantly higher in the TBI group (11.03 (9.98-12.63), p = 0.004, and 13.14 (12.27-14.64), p < 0.001, respectively). Median nICP-ONSD of severe TBI patients were higher than moderate TBI patients (13.58 (13.14-15.71) and 12.30 (9.83-13.14), respectively, p = 0.013). The median nICP-PI was the same across the type of injury (falls and motor vehicle accidents), while the median nICP-ONSD of the motor vehicle accident group was higher than falls. The first nICP-PI and nICP-ONSD measurements in PICU and admission pGCS were negatively correlated (r = - 0.562, p = 0.003 and r = - 0.582, p = 0.002, respectively). The mean nICP-ONSD during the study period and admission pGCS and GOS-E peds score significantly correlated. However, the Bland-Altman plots showed significant bias between the two methods of ICP except after 5th dose of HTS. All nICP values significantly decreased in time, and it was most obvious after the 5th dose of HTS. No significant correlations were found between delta sodium levels and nICP. Noninvasive estimation of ICP is helpful for the management of pediatric severe TBI patients. nICP driven by ONSD is more consistent with clinical findings of increased ICP but not useful as a follow-up tool in acute management because of slow circulation of CSF around the optic sheath. The correlation between admission GCS scores and GOS-E peds score favors ONSD as a good candidate for determining disease severity and predicting long-term outcomes.

Normalizing arterial blood pressure in patients with aortic stenosis does not prevent grading discrepancies between pre-cardiopulmonary bypass transesophageal echocardiography and transthoracic echocardiography.

Aortic stenosis (AS) grading discrepancies exist between pre-cardiopulmonary (pre-CPB) transesophageal echocardiography (TEE) and preoperative transthoracic echocardiography (TTE). Prior studies have not systematically controlled blood pressure. We hypothesized that normalizing arterial blood pressure during pre-CPB TEE for patients undergoing valve replacement for AS would result in equivalent grading measurements when compared to TTE. Single University Hospital. Prospective, Interventional. Thirty-five adult patients underwent procedures for valvular AS between February 2017 and December 2020 at Medical University of South Carolina. Study participants had a TTE within 90 days of their procedure that documented blood pressure, peak velocity (Vp), mean gradient (PGm), aortic valve area (AVA), and dimensionless index (DI). During pre-CPB TEE, if a patient's mean arterial pressure (MAP) fell more than 20% below their baseline blood pressure obtained during TTE, measurements were recorded as "out of range." Phenylephrine was administered to restore MAP to the baseline range and repeat TEE measurements were recorded as "in-range." Differences between imaging modalities and grading parameters were examined using a series of linear mixed models. P values were Bonferroni-adjusted to account for multiple comparisons. Significant discrepancies between TEE and TTE were observed for Vp, PGm, and DI despite blood pressure normalization across all subjects and for out-of-range measures and corrected measures. There were no statistically significant differences between TEE and TTE for AVA. Blood pressure normalization during pre-CPB TEE is not sufficient to avoid AS grading discrepancies with preoperative TTE.

Correlation between Mean Arterial Pressure and Regional Cerebral Oxygen Saturation on Cardiopulmonary Bypass in Pediatric Cardiac Surgery.

Some pediatric cardiac patients might experience low regional cerebral oxygen saturation (rSO2) during surgery. We investigated whether a pediatric patient's mean arterial pressure (MAP) can affect the rSO2 value during cardiopulmonary bypass (CPB). We retrospectively analyzed the cases of the pediatric patients who underwentcardiac surgery at our hospital (Jan. -Dec. 2019; n=141). At each MAP stage, we constructed line charts through the mean of the rSO2 values corresponding to each MAP and then calculated the correlation coefficients. We next divided the patients into age subgroups (neonates, infants, children) and into cyanotic congenital heart disease (CHD) and acyanotic CHD groups and analyzed these groups in the same way. The analyses of all 141 patients revealed that during CPB the rSO2 value increased with an increase in MAP (r=0.1626). There was a correlation between rSO2 and MAP in the children (r=0.2720) but not in the neonates (r=0.06626) or infants (r=0.05260). Cyanotic CHD or acyanotic CHD did not have a significant effect on the rSO2/MAP correlation. Our analysis demonstrated different patterns of a correlation between MAP and rSO2 in pediatric cardiac surgery patients, depending on age. MAP was positively correlated with rSO2 typically in children but not in neonate or infant patients.

Clinical effects of medical ozone autologous blood transfusion combined with Xingnaojing in the treatment of septic encephalopathy in burns

Objective: To investigate the clinical effects of medical ozone autologous blood transfusion combined with Xingnaojing in the treatment of septic encephalopathy in burns. Methods: The retrospective cohort study was conducted. From August 2015 to May 2019, 90 patients with burn septic encephalopathy and conforming to the inclusion criteria were admitted to Zhengzhou First People's Hospital. Forty-six patients (25 males and 21 females, aged (35±4) years ) treated with Xingnaojing were included in Xingnaojing alone group, and forty-four patients (20 males and 24 females, aged (34±5) years) treated with medical ozone autologous blood transfusion combined with Xingnaojing were included in ozone autologous blood transfusion+Xingnaojing group. Heart rate, body temperature, mean arterial pressure, acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score and Glasgow coma score (GCS) of patients in 2 groups were recorded before treatment and on 7 d after treatment. The blood-brain barrier injury markers including occludin, nitric oxide synthase (NOS), neuron-specific enolase (NSE), central nervous system specific protein S100β, glial fibrillar acidic protein (GFAP), and excitatory amino acid (EAA) in serum of patients in 2 groups were detected before treatment and on 1, 3, and 7 d after treatment. Computer tomography perfusion imaging for brain was performed in patients of 2 groups to calculate the region of interest cerebral blood flow (rCBF), region of interest blood volume (rCBV), and region of interest mean transit time (rMTT) before treatment and on 1, 3, and 7 d after treatment. Data were statistically analyzed with chi-square test, analysis of variance for repeated measurement, independent sample t test, and Bonferroni correction. Results: On 7 d after treatment, heart rate, body temperature, and mean arterial pressure of patients in 2 groups were decreased compared with those before treatment, heart rate of patients in ozone autologous blood transfusion+Xingnaojing group was obviously higher than that in Xingnaojing alone group (t=2.886, P<0.01), body temperature of patients in ozone autologous blood transfusion+Xingnaojing group was obviously lower than that in Xingnaojing alone group (t=5.020, P<0.01), and mean arterial pressure of patients in 2 groups were close (t=0.472, P>0.05). On 7 d after treatment, APACHEⅡ score of patients in ozone autologous blood transfusion+Xingnaojing group was obviously lower than that in Xingnaojing alone group (t=3.797, P<0.01), and GCS of patients in ozone autologous blood transfusion+Xingnaojing group was obviously higher than that in Xingnaojing alone group (t=4.934, P<0.01). On 3 and 7 d after treatment, the levels of occludin, NOS, NSE, S100β, GFAP, and EAA in serum of patients in ozone autologous blood transfusion+Xingnaojing group were significantly lower than those in Xingnaojing alone group (t=2.100, 2.090, 2.691, 2.013, 2.474, 2.635, 2.225, 4.011, 3.150, 2.691, 3.145, 2.781, P<0.05 or P<0.01). On 1, 3, and 7 d after treatment, rCBF and rCBV of patients in ozone autologous blood transfusion+Xingnaojing group were significantly increased compared with those in Xingnaojing alone group (t=3.127, 3.244, 3.883, 7.274, 3.661, 2.777, P<0.01). On 7 d after treatment, rMTT of patients in ozone autologous blood transfusion+Xingnaojing group was (3.02±0.57) s, which was significantly lower than (3.11±1.20) s in Xingnaojing alone group (t=2.409, P<0.05). Conclusions: Transfusion of medical ozone autologous blood combined with Xingnaojing therapy can effectively relieve brain injury and improve cerebral blood perfusion in patients with burn septic encephalopathy, which is with safety and credibility.

A New Real Time Clinical Decision Support System Using Machine Learning for Critical Care Units

Mean arterial pressure (MAP) is an important clinical parameter to evaluate the health of critically ill patients in intensive care units. Thus, the real time clinical decision support systems detecting anomalies and deviations in MAP enable early interventions and prevent serious complications. The state-of-the-art decision support systems are based on a three-phase method that applies offline training, transfer learning, and retraining at the bedside. Their applicability in critical care units is challenging with delay and inaccuracy. In this article, we propose a real time clinical decision support system forecasting the MAP status at the bedside using a new machine learning structure. The proposed system works in real time at the bedside without requiring the offline phase for training using large datasets. It thereby enables timely interventions and improved healthcare services. The proposed machine learning structure includes two stages. Stage I applies online learning using hierarchical temporal memory (HTM) to enable real time stream processing and provides unsupervised predictions. To the best of our knowledge, this is the first time it is applied to medical signals. Stage II is a long short-term memory (LSTM) classifier that forecasts the status of the patient's MAP ahead of time based on Stage I stream predictions. We perform a thorough performance evaluation of the proposed system and compare it with the state-of-the-art systems employing logistic regression (LR). The comparison shows the proposed system outperforms LR in terms of the classification accuracy, recall, precision, and area under the receiver operation curve (AUROC).

Kорелација помеѓу средниот артериски притисок (МАР) и мозочната сатурација (rSO2) кај пациенти подложени на хипотензивна општа анестезија при септо- и ринопластика

Хипотензивната анестезија е таква анестезиолошка техника при која средниот артериски при- тисок на пациентот се намалува за повеќе од 20% од неговата предоперативна вредност. Мотив: да се спречи појава на хипооксија на мозокот при употреба на хипотензивна анестезиолошка техника кај пациенти подложни на септо/ринопластика. Цели на трудот: да се утвр&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; Хипотензивната анестезија е таква анестезиолошка техника при која средниот артериски притисок на пациентот се намалува за повеќе од 20% од неговата предоперативна вредност. Мотив: да се спречи појава на хипооксија на мозокот при употреба на хипотензивна анестезиолошка техника кај пациенти подложни на септо/ринопластика. Цели на трудот: да се утврди просечната вредност на мозочната сатурација кај будни пациенти, да се одреди корелацијата на средниот артериски притисок и мозочната сатурација при умерена хипотензија, и да се анализираат постоперативните несакани ефекти. Материјали и методи: во студијата беа вклучени 20 пациенти, АСА 1, водени со умерена хипотензивна анестезија предизвикана со ремифентанил и севофлуран. Во пет временски интервали (Т1-Т5) се следеа параметрите: MAP, HR, rSO2 и се одреди нивната корелација. Резултати: умерена хипотензија се постигна во Т4 (МАР=69,05±7,09). За просечна базална вредност на мозочната сатурација се утврдија: 73,30 ± 5,44% за левата и 75,30±5,18% за десната мозочна хемисфера. Кривата на мозочната сатурација покажуваше нагорен тренд и пик кој се совпаѓаше со воведот во анестезија, а во понатамошниот тек тенденција кон опаѓање. Се најде слаба до умерена позитивна корелација помеѓу MAP и rSO2 во текот на хипотензивната анестезија, а во целиот тек на мерењето rSO2 беше повисоко од базалната вредност. Заклучок: умерената хипотензија и стабилниот среден артериски притисок придонесуваат за стабилна мозочна сатурација.

Monitored anaesthesia care - Comparison of nalbuphine/dexmedetomidine versus nalbuphine/propofol for middle ear surgeries: A double-blind randomised trial.

Background and Aims:Middle ear surgeries (MESs) are usually performed under sedation with local anaesthesia and can be well tolerated by the patient with minimal discomfort. In the present study, we compare the effect of nalbuphine/dexmedetomidine combination with nalbuphine/propofol on sedation and analgesia in monitored anaesthesia care.Methods:One hundred adult patients undergoing MESs under monitored anaesthesia care (MAC) were randomly allocated into two groups. All patients in both groups received injection nalbuphine 50 μg/kg intravenously (IV). Group D received a bolus dose of injection dexmedetomidine 1 μg/kg IV over 10 min followed by an infusion started at 0.4 μg/kg/h IV. Group P received a bolus dose of injection propofol 0.75 mg/kg followed by an infusion started at 0.025 mg/kg/min IV. Sedation was titrated to Ramsay Sedation Score (RSS) of 3. Patient's mean arterial pressure, heart rate, saturation peripheral pulse and need for intraoperative rescue sedation/analgesia were recorded and compared. The data analysis was carried out with Z test and Chi-square test.Results:Mean RSS was significantly more in Group D (4.24 ± 1.54) as compared to Group P (2.58 ± 0.95). Overall VAS score was also significantly less in Group D (3.5 ± 1.7) than in Group P (5.4 ± 1.8). In total, 16 patients (32%) in Group D had hypotension whereas 7 patients (14%) only in Group P had hypotension.Conclusion:Nalbuphine/dexmedetomidine combination is superior to nalbuphine/propofol in producing sedation and decreasing VAS in patients undergoing MESs under MAC. Better surgeon and patient satisfaction were observed with nalbuphine/dexmedetomidine. Haemodynamics need to be closely monitored.

An Approach for Prediction of Acute Hypotensive Episodes via the Hilbert-Huang Transform and Multiple Genetic Programming Classifier

Acute hypotensive episodes (AHEs) are one of the hemodynamic instabilities with high mortality rate that is frequent among many groups of patients. This study presents a methodology to predict AHE for ICU patients based on big data time series. The experimental data we used is mean arterial pressure (MAP), which is transformed from arterial blood pressure (ABP) data. Then, the Hilbert-Huang transform method was used to calculate patient's MAP time series and some features, which are the bandwidth of the amplitude modulation, the frequency modulation, and the power of intrinsic mode function (IMF), were extracted. Finally, the multiple genetic programming (Multi-GP) is used to build the classification models for detection of AHE. The methodology is applied in the datasets of the 10th PhysioNet and Computers Cardiology Challenge in 2009 and Multiparameter Intelligent Monitoring for Intensive Care (MIMIC-II). We achieve the accuracy of 83.33% in the training set and 91.89% in the testing set of the 2009 challenge's dataset and the 84.13% in the training set and 82.41% in the testing set of the MIMIC-II dataset.

Impact of Pulsatility and Flow Rates on Hemodynamic Energy Transmission in an Adult Extracorporeal Life Support System.

This study investigated the total hemodynamic energy (THE) and surplus hemodynamic energy transmission (SHE) of a novel adult extracorporeal life support (ECLS) system with nonpulsatile and pulsatile settings and varying pulsatility to define the most effective setting for this circuit. The circuit consisted of an i-cor diagonal pump (Xenios AG, Heilbronn, Germany), an XLung membrane oxygenator (Xenios AG), an 18 Fr Medos femoral arterial cannula (Xenios AG), a 23/25 Fr Estech RAP femoral venous cannula (San Ramon, CA, USA), 3/8 in ID × 140 cm arterial tubing, and 3/8 in ID × 160 cm venous tubing. Priming was done with lactated Ringer's solution and packed red blood cells (HCT 36%). The trials were conducted at flow rates 1-4 L/min (1 L/min increments) under nonpulsatile and pulsatile mode, with differential speed values 1000-4000 rpm (1000 rpm increments) at 36°. The pseudo patient's mean arterial pressure was kept at 100 mm Hg using a Hoffman clamp during all trials. Real-time flow and pressure data were collected using a custom-based data acquisition system. Mean pressures across the circuit increased with increasing flow rates, but increased insignificantly with increasing differential speed values. Mean pressure did not change significantly between pulsatile and nonpulsatile modes. Pulsatile flow created more THE than nonpulsatile flow at the preoxygenator site (P < 0.01). Of the different components of the circuit, the arterial cannula created the greatest THE loss. THE loss across the circuit ranged from 24.8 to 71.3%. Still, under pulsatile mode, more THE was delivered to the pseudo patient at low flow rates. No SHE was created with nonpulsatile flow, but SHE was created with pulsatile flow, and increased with increasing differential speed values. At lower flow rates (1-2 L/min), the arterial cannula contributed the most to SHE loss, but at higher flow rates the arterial tubing created the most SHE loss. The circuit pressure drop values across all flow rates were 33.1-246.5 mm Hg, and were slightly higher under pulsatile mode than nonpulsatile mode. The i-cor diagonal pump creates satisfactory pulsatile and nonpulsatile flows, and can easily change the pulsatile amplitude and energy transmission. The attributes of the XLung membrane oxygenator include low resistance, low energy loss, and low pressure drops at all flow rates and differential speed values. The arterial cannula created the highest pressure drop of all components of the circuit. Pulsatile flow improved the transmission of hemodynamic energy to the pseudo patient without significantly affecting the pressure drops across the circuit.

Glycine induced retinotoxicity is avoidable.

Sir, We read the article ‘glycine induced acute transient post-operative visual loss’ by Pramod et al.[1] and agree with the authors that the absorption of large amount of glycine and application of higher than the recommended pressure were responsible for the glycine induced retinotoxicity. The ‘American Association of Gynecologic Laparoscopists’ guidelines[2] for hysteroscopic surgery published in 2013 recommend avoidance of intrauterine distension pressure more than the patient's mean arterial pressure, and use of intra-cervical vasopressin (8 ml of 0.05 U/ml) to reduce the absorption of irrigation fluid. Similar to transurethral resection of prostate (TURP) syndrome, use of neuraxial blockade in this case could have preserved consciousness of the patient and helped to detect the clinical features of volume overload and glycine toxicity at an earlier stage.[3,4] Patients undergoing TURP, hysteroscopy, or surgery in prone position should be informed pre-operatively about the possibility of post-operative temporary and permanent vision loss and such complaint by the patient in the post-operative period warrant urgent assessment and intervention. Hence, we believe that use of neuraxial blockade, intra-cervical injection of vasopressin and adherence to the standard recommendations, could have avoided the complication.

The use of regional cerebral oximetry monitoring during controlled hypotension: a case series

Regional cerebral oximetry monitoring was used to guide nitroglycerin infusion and IV fluid administration during controlled hypotension in order to optimize each individual patient's mean arterial pressure in a series of 20 consecutive patients who underwent major open urological or abdominal surgery. Although controlled hypotension offers a definite benefit in patients undergoing complex surgery where blood loss will be elevated or would severely compromise the surgical field, it is not without risk as low arterial pressure may compromise tissue perfusion and promote ischemia. In this case series, despite an average mean arterial pressure decrease of 19.5 % (p < 0.001), cerebral oximetry values increased by an average of 22.7 % (p < 0.001) after the nitroglycerin infusion had been initiated (220 mcg/min average). Patients received an average of 3.15L crystalloid and 437 ml albumin in fluid resuscitation.

OB Hemorrhage Complicated by DIC: Are You Ready?

Childbearing Poster Presentation Background This presentation addresses the management of a patient admitted to Baylor University Medical Center's labor and delivery sustaining massive hemorrhage with resulting disseminated intravascular coagulation (DIC) and peripartum hysterectomy after an induction of labor and forceps assisted vaginal delivery. Prompt recognition, timely intervention, and a collaborative multidisciplinary team approach were required to save this patient's life. Case A 35‐year‐old healthy female, primigravida at 40 1/7 weeks gestation was admitted for oxytocin induction of labor. The patient required a low forceps assisted vaginal delivery for persistent occiput posterior position and delivered a healthy male, weighing 8lb 7oz. Following the repair of a third‐degree midline episiotomy and bilateral sidewall lacerations, the patient had an initial estimated blood loss of 800 ml, with a firm fundus and vaginal packing left in place for a noted friable posterior wall. Over the next hour, after the vaginal packing was placed, the patient's mean arterial pressure showed a significant drop from 89 on admission to 52. Fluid resuscitation was initiated utilizing Lactated Ringer's solution and Hespan, and 2.5 mg of Methergine was administered. Continued bleeding was noted and the patient was taken to the operating room (OR) for further evaluation. A stat hematocrit was 16.6; the patient's starting hematocrit was 32.3. In the OR, the patient was noted to have further deteriorating vital signs and oozing was noted from previous puncture sites. The patient was intubated by anesthesia. Lab work from a hemostasis profile revealed DIC. For the next 2 hours extensive resuscitation with cryoprecipitate, fresh frozen plasma, blood, and platelets were administered in an attempt to correct the DIC, preserve the patient's uterus, and return her to a hemostatic state. Continued bleeding was noted and the decision was made by the physician to proceed with a hysterectomy. Following hysterectomy, the patient was transferred to the intensive care unit in stable condition. Conclusion Massive hemorrhage is a leading cause of maternal death. Prompt recognition, timely, effective communication, and rapid response are crucial for positive outcomes. Case review and debriefing led to quality action items being identified. Simulation training has played a key role in quality improvement initiatives. The ability to activate a massive transfusion protocol was crucial in the above case. Simulation scenarios and in situ drills have been developed through which multidisciplinary collaboration allows identification and improvement in processes without harm to patients.

Ensayo clínico sobre la compresión radial guiada por la presión arterial media

Objective To determine whether a compression procedure guided by the patient's mean arterial pressure value (experimental) is safe and effective and superior to a compression procedure using 15 cubic centimeters of air in the device (standard) in patients undergoing radial artery catheterization. Methods We performed a randomized, single-center study, which included patients undergoing catheterization of the radial artery for diagnosis or percutaneous coronary intervention, in whom the sheath was removed at the end of procedure and the radial artery was compressed for 3 h with a pneumatic device (TR Band™ Terumo ®). The arteries were evaluated between 24 and 72 h after the procedure, using a plethysmography curve with a reverse flow test followed by bidirectional Doppler. Results The percentage of arterial occlusion was measured in 351 patients. Arterial occlusion was found in two patients (1.1%) in the experimental group compared with 21 patients (12%) in the standard group (p=0.0001). No differences were found in the number of complications. Conclusions The compression method, guided by the patient's mean arterial pressure value at the end of catheterization of the radial artery, is safe and effective and reduces arterial occlusion compared with the standard compression method using a pneumatic device.

The Effect of Etomidate on Intracranial Pressure and Systemic Blood Pressure in Pediatric Patients with Severe Traumatic Brain Injury

To evaluate the effects of single-dose etomidate in pediatric patients with intracranial hypertension after severe traumatic brain injury. Patients admitted to the pediatric intensive care unit with severe traumatic brain injury were enrolled with the informed consent of their guardians. The experimental intervention was a single dose of etomidate 0.3 mg/kg intravenously. This dosage was administered only when enrolled patients had acute elevations of intracranial pressure (ICP) to over 20 mm Hg for over 5 minutes. ICP and mean arterial pressure (MAP) were monitored continuously. ICP and MAP values for 6 consecutive 5-minute intervals after etomidate administration were averaged for all patients and compared with baseline. Eight patients were enrolled. Mean ICP after etomidate administration was significantly lower than baseline ICP for each 5-minute interval (P < 0.05). The mean MAP for all patients increased from baseline during the first 5-minute interval, but this change was not statistically significant. No patient's MAP decreased below baseline at any time point. In pediatric patients with severe traumatic brain injury, single-dose etomidate administration resulted in statistically significant reductions in ICP and improvement in cerebral perfusion pressure without significantly altering MAP.

Cardiac pheochromocytoma

Cardiac pheochromocytoma

Use of Corfolsin Dalopate following Cardiac Surgery in a Neonate

A FEMALE neonate, weighing 2,690 g, developed severe cyanosis immediately after birth, and was diagnosed as having complex heart anomaly (truncus arteriosus, interruption of aortic arch, aortopulmonary septal defect, patent ducts arteriosus, and persistent foramen ovale). Despite support with dopamine, dobutamine, and epinephrine, congestive heart failure developed. Therefore, total correction surgery was scheduled to take place on the patient's twenty-first day of life. Anaesthesia was induced and maintained with fentanyl (25 μg/kg) and midazolam (0.3 mg/kg). Surgery was performed under the moderately hypothermic (25°C) cardiopulmonary bypass (CPB) with a total flow of 2.8 l.min -1 .m 2 , CPB was started 55 min after the anesthetic induction. The interval from the start of CPB to the initial attempt to wean the patient from CPB with sufficient body temperature recovery (36.2°C) was 5 h and 20 min. The attempt was made to discontinue CPB with the aid of dopamine (4 - 8 μg.kg -1 .min -1 ) and dobutamine (5-8 μg.kg -1 .min -1 ). However, decreasing the bypass flow to less than 1.5 l.min -1 .m -2 resulted in sustained hypotension. Adding epinephrine (0.5 μg/kg/min) and isoproterenol (0.1 μg.kg -1 .min -1 ) did not improve the patient's hemodynamics; her systemic mean arterial pressure while still on partial bypass was ≤ 30 mmHg, while her central venous pressure (CVP) was approximately 17 mmHg. The addition of an infusion of milrinone (0.5 (μg.kg -1 .min -1 ) for approximately 40 min also had no significant effect. Echocardiography (using an epicardial probe) showed an adequate surgical repair. At this point, with the patient back on full bypass support all inotropic agents were discontinued. We next administered a combination of colforsin dalopate HCI (0.25 μg.kg -1 .min -1 ') and dopamine (5 μg.kg -1 .min -1 ). The patient's CPB flow rate decreased to 1.0 l.min -1 .m -2 and CVP was controlled at 8-11 mmHg. Over the next 30 min, the patient's mean arterial pressure increased from 35 to 65 mmHg, and her heart rate increased from 140 to 170 beats/min. After approximately 20 min of stable conditions, CPB was successfully discontinued. Her postweaning hemodynamic parameters showed heart rate, mean systemic arterial pressure, and CVP levels in the ranges of 170-180 beats/min, 55-65 mmHg, and 11-13 mmHg, respectively, Arterial blood gas analysis did not show metabolic acidosis, hypercarbia, or hypoxemia, The surgery terminated 2 h after the CPB weaning, Hemodynamic parameters recorded after each attempt to discontinue bypass are summarized in table 1. After being transferred to the intensive care unit, the patient's heart rate continued to increase, reaching 190 beats/min. Her colforsin infusion was discontinued while dopamine was maintained. Two hours later, her mean arterial pressure decreased to 35 mmHg from 60 mmHg, her heart rate decreased to 140 beats/min from 170 beats/min, and CVP increased from 11 mmHg to 17 mmHg. An infusion of epinephrine was added, but without success. Therefore, approximately 1 h later, colforsin dalopate HCl infusion (0.25 μg.kg -1 .min 1 ) was restarted. Mean arterial pressure and heart rate quickly increased to 65 mmHg and 178 beats/min, respectively. Colforsin was discontinued without difficulty 5 h later.

A new paradigm for the closed-loop intraoperative administration of analgesics in humans.

We present a new paradigm for the closed-loop administration of analgesics during general anesthesia. The manipulated variable in the control system is the infusion rate of the opiate alfentanil, administered intravenously through a computer-controlled infusion pump (CCIP). The outputs to be controlled are the patient's mean arterial pressure (MAP) and the drug concentration in the plasma. Maintaining MAP within appropriate ranges provides optimal treatment of the patient's reactions to surgical stimuli. Maintaining plasma drug concentrations close to a reference value specified by the anesthesiologist allows to titrate analgesic administration to qualitative clinical end-points of insufficient analgesia. MAP is acquired invasively through a catheter cannula. Since plasma drug concentrations cannot be measured on-line, they are estimated via a pharmacokinetic model. We describe an explicit model-predictive controller which achieves the above-mentioned objectives. An upper constraint on drug concentrations is maintained to avoid overdosing. Constraints on the MAP are introduced to trigger a prompt controller reaction during hypertensive and hypotensive periods. Measurement artifacts in the MAP signal are rejected to prevent harmful misbehavior of the controller. We discuss the results of the clinical validation of the controller on humans.