Perioperative Hemodynamic Instability Research Articles

Age- and sex-related differences in risk factors for perioperative intra-aortic balloon pump application in patients undergoing coronary artery bypass grafting.

An intra-aortic balloon pump (IABP) is a mechanical circulatory device frequently used in patients undergoing coronary artery bypass grafting (CABG). As a treatment for perioperative haemodynamic instability, IABP insertion often implicates an adverse outcome. This study aimed to investigate the age- and sex-related disparity in risk factors for perioperative IABP insertion in CABG patients. A total of 2,460 CABG patients were included and divided into subgroups by age (elderly subgroup, ≥65 years; young subgroup, <65 years) and sex. Basic characteristics were compared between IABP and non-IABP patients in the overall patient group and the subgroups. Multivariate logistic analysis was used to investigate the significant risk factors for perioperative IABP application, and interaction effects among the potential risk factors were analysed. Combined receiver operating characteristic analysis was used to evaluate the prediction value of combined risk factors. The overall patient group had a mean age of 61.5 years. The application rate of perioperative IABP was 8.0%. A left ventricular ejection fraction (LVEF) <50% significantly correlated with perioperative IABP application in the overall patient group and the subgroups. Traditional factors such as myocardial infarction history, atrial fibrillation history, and intraoperative estimated blood loss were significant risk factors in certain subgroups. Small dense low-density lipoprotein levels were significantly associated with IABP insertion in the male subgroup and young subgroup. The area under the curve of combined risk factors was significantly higher than that of LVEF <50% alone in the overall patient group and subgroups. Age- and sex-related differences were present in the risk factor distribution for perioperative IABP insertion in CABG patients.

Intra-operative Predictors of Neurological Outcomes After Cardiac Surgery

Abstract Background: Despite the advancement in surgical techniques, neurological complications encountered post-cardiac surgery remain significant. Stroke, seizure, and deep coma are major postoperative neurological complications reported in numerous patients. This study aims to identify perioperative predictors for neurological complications and focus on the relationship between these predictors and major neurological complications, particularly stroke, seizure, and deep coma. Materials and Methods: This retrospective cohort study was conducted among patients who underwent cardiac surgery between January 2014 and December 2020 at King Fahd Hospital of University, Khobar, Saudi Arabia. Out of 432 patients who had surgery, only 331 patients met the inclusion criteria. A comparison was made between patients who developed postoperative neurological complications and those who did not. The collected data was analyzed using the Statistical Package of Social Sciences program version 29 (Armonk, NY: IBM Corp. USA). Results: There were 50 patients with postoperative neurological complications compared to 281 patients with no complications. The rate of perioperative haemodynamic instability was higher in the complication group (14/48, 29.2%) compared to the non-complication group (47/238, 19.7%). Stroke was the highest neurological complication encountered (14/50, 28%). Conclusions: Perioperative haemodynamic instability is more common in patients with postoperative neurological complications compared to patients with no complications. Additionally, stroke is the most common major neurological complication. Aortic surgeries, combined surgeries, and haemodynamic instability are the most common perioperative predictors of stroke.

Perioperative Hemodynamic Instability: The APSF Consensus.

Perioperative Hemodynamic Instability: The APSF Consensus.

Perioperative Patients With Hemodynamic Instability: Consensus Recommendations of the Anesthesia Patient Safety Foundation.

In November of 2022, the Anesthesia Patient Safety Foundation held a Consensus Conference on Hemodynamic Instability with invited experts. The objective was to review the science and use expert consensus to produce best practice recommendations to address the issue of perioperative hemodynamic instability. After expert presentations, a modified Delphi process using discussions, voting, and feedback resulted in 17 recommendations regarding advancing the perioperative care of the patient at risk of, or with, hemodynamic instability. There were 17 high-level recommendations. These recommendations related to the following 7 domains: Current Knowledge (5 statements); Preventing Hemodynamic Instability-Related Harm During All Phases of Care (4 statements); Data-Driven Quality Improvement (3 statements); Informing Patients (2 statements); The Importance of Technology (1 statement); Launch a National Campaign (1 statement); and Advancing the Science (1 statement). A summary of the recommendations is presented in Table 1 .

Pre-operative screening of diabetic patients for heart rate variability and their hemodynamic responses during induction of general anaesthesia

: Cardiovascular autonomic neuropathy (CAN) is one of the least frequently diagnosed and the most clinically significant complications of Diabetes mellitus (DM). Impaired heart rate variability (HRV) is the earliest indicator of CAN. Peri-operative hemodynamic instability is a major concern during general anaesthesia (GA) in patients with autonomic dysfunction. Purpose of this study was to assess and compare the autonomic function using HRV in diabetic and non-diabetic patients pre-operatively and to study the haemodynamic responses of these patients during induction.: The primary objective was to assess and compare the autonomic function using HRV in diabetic and non-diabetic patients preoperatively. Secondary objective was to study hemodynamic responses of these patients during induction of GA.: We included 68 patients (34 diabetics- group D and 34 non-diabetics- group N) aged between 30 to 65 years, with American society of anaesthesiologists (ASA) physical status 1 and 2 undergoing elective surgeries under GA. All the eligible patients underwent HRV evaluation for 10 minutes on the previous day of surgery and the time &amp; frequency domain variables were evaluated. The hemodynamic parameters were recorded at pre-induction, post-induction, post-intubation and for every 3 minutes thereafter for 15 minutes and analysed.: The diabetics had a significantly lower total power (TP) with p-value 0.003. The post- induction mean arterial pressures (MAP) were comparatively lower in diabetics and the difference was significant at 12 minutes post intubation (p= 0.04). The lower trends in heart rate (HR) were comparatively more in diabetics rather than non-diabetics (p= 0.06) and the ephedrine usage was also higher in diabetics (p= 0.07). The measurement of HRV is a simple tool to evaluate the peri-operative risks in patients with suspected cardiovascular autonomic neuropathy.

SAT311 A Time And Place For Metyrosine: Successful Treatment Of A Pheochromocytoma Presenting With Hypotension And Multisystem Organ Failure

Abstract Disclosure: R. Shafiq: None. J. Giordano: None. Pheochromocytomas are rare neuroendocrine catecholamine-secreting tumors. The surgical excision of pheochromocytoma is definitive management which requires presurgical preparation with an alpha blocker, beta blocker, and sometimes metyrosine to reduce perioperative hemodynamic instability. We present a case of pheochromocytoma complicated with acute on chronic renal failure and acute on chronic heart failure with hypotension requiring metyrosine in presurgical preparation due to hypotension and intolerance to alpha-blocker with successful surgical excision of the tumor. Case: 67 yo M admitted for acute on chronic heart failure and acute on chronic renal failure. He was noted to have an incidental right adrenal mass of 4.3 x 4.5 cm on the CT chest. He denied any prior history of hypertension, episodes of flushing, sweating, palpitations, headaches, or any family history of adrenal malignancies. His labs were consistent with significantly elevated plasma metanephrines to 4.5 nmol/L (normal range &amp;lt; 0.5 nmol/L) and normetanephrine 36 nmol/L (normal range &amp;lt; 0.9 nmol/L). Levels were repeated with slight worsening of metanephrines to 5.6 and normetanephrine to 42. He was hypotensive on presentation initially on milrinone drip that was slowly tapered off. His echo on admission showed left ventricle global hypokinesis with EF 25-30%. He had a worsening renal function on admission and required a few dialysis sessions before being referred to our hospital. He had an MRI adrenal done w/o contrast in the setting of renal failure with a heterogenous mass concerning for pheochromocytoma. PET CT was done which was negative for metastatic disease. Due to strong suspicion of uncontrolled pheochromocytoma as a cause of his heart failure and acute on chronic renal failure, the team and patient opted for unilateral adrenalectomy. He was started on metyrosine pre-surgically as he could not tolerate alpha blockade due to hypotension. His metanephrine levels improved from 5.6 to 1.8 and normetanephrine from 43 to 15 with metyrosine prior to surgery. He had a successful right adrenalectomy and pathology confirmed pheochromocytoma. Of note, he had a history of diabetes with uncontrolled hyperglycemia during admission. Hyperglycemia resolved after adrenalectomy. His plasma metanephrine levels normalized post-adrenalectomy and remained normal on the follow-up visit. Conclusion: Preoperative medical stabilization is a crucial step before surgical resection of pheochromocytoma that traditionally includes an alpha blocker followed by a beta-blocking agent to reduce intra-operative hypertensive crisis. Metyrosine is an often-overlooked agent due to cost, however, should remain in our armamentarium for pheochromocytoma crisis complicated with hypotension when the patient is unable to tolerate an alpha-blocking agent. Presentation: Saturday, June 17, 2023

Relationship between carotid atherosclerotic plaque characteristics in magnetic resonance imaging and perioperative hemodynamic instability

Objective: To analyze the relationship between carotid atherosclerotic plaque characteristics in magnetic resonance imaging (MRI) and perioperative hemodynamic instability in patients with severe carotid artery stenosis undergoing carotid artery stenting (CAS). Methods: A total of 89 patients with carotid artery stenosis who underwent CAS treatment at Beijing Tsinghua Changgung Hospital affiliated to Tsinghua University from January 1, 2017, to December 31, 2021, were prospectively included. Among them, 74 were male and 15 were female, with an age range of 43 to 87 years (mean age: 67.8±8.2 years). Preoperative examinations included carotid artery MRI vessel wall imaging to analyze the existence of large lipid-rich necrotic core (LRNC), intraplaque hemorrhage (IPH), and fibrous cap rupture in carotid artery plaques. Plaques without the above-mentioned risk factors were defined as stable plaque group (34 cases), while those with such risk factors were defined as vulnerable plaque group (55 cases). The number of risk factors present in each plaque was also calculated. Intraoperative changes in blood pressure and heart rate were recorded, and the use of dopamine postoperatively was noted. Using the risk factors that the plaque has as independent variables and the clinical outcomes as dependent variables, the RR values were calculated, and the differences in clinical outcomes of patients with different risk factors were compared. Results: The incidence rates of hypotension and bradycardia were higher in patients with vulnerable plaques than those with stable plaques (60.0% (33/55) vs 14.7%(5/34) and 38.2%(21/55) vs 14.7%(5/34), respectively; both P<0.05). Based on MRI imaging features, the large LRNC was present in 45 cases, with RR values for hypotension and bradycardia of 3.15 (1.69-5.87) and 2.20 (1.07-4.53), respectively; IPH was present in 37 cases, with RR values for hypotension and bradycardia of 2.70 (1.61-4.55) and 2.25 (1.15-4.39), respectively; and fibrous cap rupture was present in 29 cases, with RR values for hypotension and bradycardia of 1.50 (0.94-2.40) and 1.29 (0.67-2.49), respectively. The higher the number of risk factors in vulnerable plaques, the higher the incidence of intraoperative blood pressure and heart rate decrease: when the number of risk factors ranged from 0 to 3, the incidence of blood pressure decrease was 14.7% (5/34), 9/18, 11/18, and 13/19, respectively (P<0.001), and the incidence of heart rate decrease was 14.7% (5/34), 6/18, 7/18, and 8/19, respectively (P=0.022). There was no significant difference in the number of cases of dopamine use between the two groups (P>0.05). Conclusion: Patients with a higher number of risk factors for vulnerable carotid plaques, as indicated by carotid artery MRI vessel wall imaging, are at a higher risk of experiencing blood pressure and heart rate decrease during CAS surgery.

Hemodynamic parameters in patients undergoing surgery for pheochromocytoma/paraganglioma: a retrospective study

BackgroundPheochromocytoma (PHEO) and paraganglioma (PGL) are rare neuroendocrine tumors characterized by hemodynamic instability, caused by the paroxysmal release of catecholamines. Patients may develop cardiovascular complications in the perioperative phase due to the massive release of catecholamines, particularly during anesthetic induction and surgical manipulation of the tumor. The aim of this retrospective study was to evaluate the risk factors involved in perioperative hemodynamic instability in patients who underwent surgery for chromaffin tumors.MethodsForty patients (median age 55 [36.50–64.50]) undergone surgery for PHEO/abdominal PGL from January 2011 to December 2016 at the AOU Careggi (Florence, Italy) were retrospectively evaluated. Systolic, diastolic, and mean blood pressure were considered at baseline and during surgery. Patients with blood pressure steadily < 140/90 mmHg before surgery were considered “adequately prepared”. A preoperative therapy with doxazosin, a selective alpha-1 blocker, was started in all patients for at least 14 days prior to the surgery. The presence of hemodynamic instability was reported.ResultsComparing males and females, a significant difference in doxazosin daily dose (p = 0.018), systolic blood pressure (p = 0.048), and in the proportion of adequately prepared patients (p = 0.031) emerged. A positive correlation between preoperative daily dose of doxazosin, tumor size (B = 0.60, p < 0.001), and urinary normetanephrine levels (B = 0.64, p < 0.001) was also observed. Hemodynamic instability occurred in 30.0% of patients. The absence of adequate preparation (p = 0.012) before surgery, urinary normetanephrine levels (NMNur p = 0.039), and surgery time (minutes) (p = 0.021) resulted as risk factors of hemodynamic instability in our series. The use of intraoperative drugs was higher in patients with hemodynamic instability (p < 0.001). A pre-surgical SBP level of > 133 mmHg (OR = 6 CI95% 1.37–26.20, p = 0.017) and an intraoperative SBP and MBP levels of > 127 mmHg (OR = 28.80 CI95% 2.23–371.0, p = 0.010) and > 90 mmHg (OR = 18.90 CI95% 1.82–196.0, p = 0.014), respectively, were identified as effective thresholds to recognize patients at higher risk of HI.ConclusionsA preoperative therapy with alpha-blockers is useful, but not sufficient to avoid surgical risks. Patients with higher pre-surgical levels of NMNur, pre-surgical SBP > 133 mmHg, and/or intraoperative SBP > 127 mmHg and MBP > 90 mmHg, should be carefully monitored. A multidisciplinary approach is indispensable to optimize the management of PHEOs/abdominal PGLs in order to reduce surgical complications.

Influence of duration of preoperative treatment with phenoxybenzamine and secretory phenotypes on perioperative hemodynamics and postoperative outcomes in pheochromocytoma and paraganglioma.

Resection of pheochromocytoma and paraganglioma (PPGL) carries risks with perioperative hemodynamic instability. Phenoxybenzamine (PXB) is a commonly used α-blockade to prevent it. It is unclear whether lengthening the preoperative duration of PXB is better for hemodynamic stability and postoperative outcomes. Furthermore, different types of catecholamines have varying effects on perioperative hemodynamics. Thus, our study aimed to investigate the impact of the duration of preoperative preparation with PXB and secretory phenotypes of the patients on intraoperative hemodynamic stability and postoperative complications in PPGL. Between Dec 2014 and Jan 2022, 166 patients with PPGL were operated on by the same team at Sun Yat-sen Memorial Hospital. They were divided into group A(1-14d), Group B(15-21d), and Group C(>21d) based on the duration of management with PXB and into the adrenergic and the noradrenergic phenotype group based on secretory profiles. Data on intraoperative hemodynamics and postoperative outcomes were collected and compared among groups. A total of 96 patients occurred intraoperative hemodynamic instability, and 24 patients had 29 postoperative complications related to the surgery. Among the 145 patients treated with PXB, no significant differences were found in the cumulative time outside the target blood pressure(6.67%[0-17.16%] vs. 5.97%[0-23.08%] vs. 1.22%[0-17.27%], p=0.736) or in the median total HI-score(42.00[30.00-91.00] vs. 89.00[30.00-113.00] vs. 49.00[30.00-93.00], p=0.150) among group A(n=45), B(n=51) and C(n=49). Multivariate analysis demonstrated that the level of plasma-free metanephrine(MN) was an independent risk factor for intraoperative hemodynamic instability. And the median cumulative time outside of the target blood pressure in the adrenergic phenotype group was significantly greater than that in the noradrenergic phenotype group(8.17%[0-26.22%] vs. 1.86%[0-11.74%], p=0.029). However, the median total HI-score(99.50[85.00-113.25] vs. 90.00[78.00-105.00], p=0.570) and postoperative outcomes showed no differences between the two groups. A preoperative duration of nearly 14 days with PXB is sufficient for ensuring intraoperative hemodynamic stability in PPGL. And lengthening the preparation duration may not provide additional benefits in the era of widespread application and advanced techniques of laparoscopic surgery. Additionally, patients with the adrenergic phenotype are more prone to intraoperative hemodynamic instability than the noradrenergic phenotype. Thus, more attention should be given to the adrenergic phenotype during surgery.

PD03-09 WHAT ARE THE PREOPERATIVE RISK FACTORS OF HEMODYNAMIC INSTABILITY DURING ADRENALECTOMY FOR PHEOCHROMOCYTOMA?

You have accessJournal of UrologyCME1 Apr 2023PD03-09 WHAT ARE THE PREOPERATIVE RISK FACTORS OF HEMODYNAMIC INSTABILITY DURING ADRENALECTOMY FOR PHEOCHROMOCYTOMA? Mokhtar Bibi, Yassine Ouanes, Kays Chaker, Mohamed Anouer Madani, Yosri Messoudi, Boutheina Mosbahi, Selma Trabelsi, Kheireddine Mourad Dali, Moez Rahoui, and yassine Nouira Mokhtar BibiMokhtar Bibi More articles by this author , Yassine OuanesYassine Ouanes More articles by this author , Kays ChakerKays Chaker More articles by this author , Mohamed Anouer MadaniMohamed Anouer Madani More articles by this author , Yosri MessoudiYosri Messoudi More articles by this author , Boutheina MosbahiBoutheina Mosbahi More articles by this author , Selma TrabelsiSelma Trabelsi More articles by this author , Kheireddine Mourad DaliKheireddine Mourad Dali More articles by this author , Moez RahouiMoez Rahoui More articles by this author , and yassine Nouira yassine Nouira More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003220.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Adrenalectomy for pheochromocytoma is considered to be a challenging procedure because of the risk of hemodynamic instability (HI), which is poorly defined and unpredictable. Our study aimed to determine the predictive factors for perioperative HI in patients undergoing unilateral adrenalectomy for pheochromocytoma. METHODS: Between January 2005 and December 2021, 45 patients underwent unilateral adrenalectomy for pheochromocytoma in department of urology La Rabta Hospital. HI was defined as an occurrence of intraoperative episodes of systolic blood pressure above 200 mmHg, mean arteral pressure under 60 mmHg or vasoactive drug administration. Patients were divided into 2 groups depending on presence or absence of intraoperative HI. Patient demographics, tumor characteristics and perioperative hemodynamics were noted. A multivariable logistic regression analysis was performed to determine the independent preoperative risk factors for HI. RESULTS: There was no postoperative mortality, and HI was noted 71.1% (32 patients). Open and laparoscopic adrenalectomy were performed in 36 and 9 patients respectively. Mean tumor size was 54.52 mm. Univariate analysis showed that gender, tumor size, tumoral necroses, B blockers treatment were significantly associated with Hi (p=0.019, p=0.00 01, p=0.0001, p=0.01, respectively). IH was correlated with Systolic blood pressure at incision, adrenal artery clamping and tumour removal (p=0.018, p=0.001, p=0.046, p=0.048, respectively). The multivariate logistic regression analysis showed that tumor size was an independent risk factors for intraoperative hemodynamic instability (OR 2.79, 95% CI: 1-61.8, p=0.008). CONCLUSIONS: Tumour size was the independant predictive factor with hemodynamic instability during adrenalectomy for pheochromocytoma. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e78 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mokhtar Bibi More articles by this author Yassine Ouanes More articles by this author Kays Chaker More articles by this author Mohamed Anouer Madani More articles by this author Yosri Messoudi More articles by this author Boutheina Mosbahi More articles by this author Selma Trabelsi More articles by this author Kheireddine Mourad Dali More articles by this author Moez Rahoui More articles by this author yassine Nouira More articles by this author Expand All Advertisement PDF downloadLoading ...

Perioperative haemodynamic instability caused by Takotsubo cardiomyopathy

Perioperative haemodynamic instability caused by Takotsubo cardiomyopathy

Perioperative hemodynamic management in surgery for phaeochromocytoma: A narrative review

Pheochromocytomas are rare adrenal tumors that produce excessive catecholamines and their surgical removal poses significant risks of intraoperative hemodynamic instability (HI) due to catecholamine release. This review article discusses the perioperative factors that impact hemodynamic lability and its management in patients undergoing surgical removal. A literature review was conducted by searching the electronic databases - Ovid MEDLINE, Embase, and Cochrane Library using appropriate Medical Subject Heading terms and keywords such as phaeochromocytoma, HI, and perioperative hemodynamic monitoring. The advancements in surgical and anesthetic techniques and appropriate preoperative medical optimization have contributed to a significant decrease in mortality rates. However, perioperative HI remains the biggest surgical and anesthetic challenge in treating pheochromocytomas. Patients with larger and more hormonally active tumors are at higher risk for extreme hypertensive episodes during surgery. Preoperative α-blockade, higher phenoxybenzamine doses, and laparoscopic approach improve the outcomes in phaeochromocytoma removal. Anesthetic techniques and drugs used during surgery may help prevent HI, but careful intraoperative management is essential. Perioperative HI can lead to increased surgical blood loss, patient morbidity, and prolonged intensive care unit (ICU) and hospital stay. Therefore, a multidisciplinary approach involving the surgeon, anesthesiologist, and ICU team is essential to ensure optimal perioperative management of patients with pheochromocytoma. Intensive hemodynamic monitoring may be required in the postoperative period to manage hypotension seen after tumor removal. In conclusion, perioperative HI is a significant risk during the surgical removal of pheochromocytomas, even with preoperative pharmacological treatment. Therefore, the use of appropriate preoperative medical optimization, surgical and anesthetic techniques, and careful intraoperative management can significantly improve the outcomes.

A COMPARATIVE STUDY OF THE EFFICACY OF INTRAVENOUS PARACETAMOL AND DEXMEDETOMIDINE ON PERI OPERATIVE HEMODYNAMICS AND POST OPERATIVE ANALGESIA FOR PATIENTS UNDERGOING LAPAROSCOPIC SURGERY

Perioperative hemodynamic instability is one of the known complication ofLaproscopic surgeries. CO2 insufation causes increased abdominal pressure and hypercapnia which will contribute to undesirable hemodynamic changes. Dexmedetomidine when administered as a loading dose causes sedative , hypnotic, anxiolytic, analgesic and sympatholytic effect. In ths study 60 Patients were randomised in two groups 30 each . Group 1/ Group P recieved 1gm paracetamol diluted in 100 ml 0.9% Normal saline IV over 10 minutes before induction. Group 2/Group D Bolus -1mcg/ kg diluted in 100 ml 0.9% Normal saline IV over 10 minutes before induction. Perioperative Hemodynamic parameters , post operative analgesia were compared. Increase in heart rate , blood pressure were found to be more in Group 1/Group P compared to Group 2/ Group 2/ Group D. Patients in both groups had moderated pain postoperatively and requires rescue analagesia after extubation. We observed the use of Dexmedetomidine is very effective in managing Perioperative Hemodynamic instability when compared to paracetamol

Hemodynamic Instability during Surgery for Pheochromocytoma: A Retrospective Cohort Analysis.

Perioperative hemodynamic instability is one of the most common adverse events in patients undergoing adrenalectomy for pheochromocytoma. The aim of this study was to analyze the impact of perioperative severe hemodynamic instability. We present a retrospective, single-center analysis in a major tertiary hospital of all consecutive patients undergoing elective adrenalectomy from 2005 to 2019 for pheochromocytoma. Severe perioperative hypertension and hypotension were evaluated, defined as changes in blood pressure larger than 30% of the preoperative patient-specific mean arterial pressure (MAP). Unilateral adrenalectomy was performed in 67 patients. Intraoperative episodes of hemodynamic instability occurred in 97% of all patients (n = 65), severe hypertension occurred in 24 patients (36%), and severe hypotensive episodes occurred in 62 patients (93%). Patients with more than five severe hypotensive episodes (n = 29) received higher preoperative alpha-adrenergic blockades (phenoxybenzamine 51 ± 50 mg d-1 vs. 29 ± 27 mg d-1; p = 0.023) and had a longer mean ICU stay (39.6 ± 41.5 h vs. 20.6 ± 19.1 h, p = 0.015). Intraoperative hypotensive, rather than hypertensive, episodes occurred during adrenalectomy. The occurrence of more than five hypotensive episodes correlated well with a significantly longer hospital stay and ICU time.

Perioperative Acute Myocardial Infarction and Ischemia After Noncardiac Surgery: Pathophysiology, Prevention, and Nursing Implications.

Perioperative acute myocardial infarction (AMI) after noncardiac surgery increases the mortality rate of patients who experience it. Depending on the definition of AMI used and the patient population studied, perioperative AMI occurs in 0.01% to 10% of patients. Most instances of perioperative AMI occur within the first two days after surgery, do not present with classic myocardial infarction symptoms, and are the result of myocardial oxygen supply versus oxygen demand mismatch. Older patients; those with preexisting cardiovascular conditions; those undergoing thoracic, upper abdominal, or major vascular procedures; and those who experience perioperative hemodynamic instability are at particular risk. This article provides a clinically based review of the pathophysiology, perioperative risks, treatment options, outcomes, and nursing implications of perioperative AMI and ischemia. It provides evidence to assist perioperative nurses with meeting the physiologic and safety needs of their patients and highlights the evolving scientific understanding and clinical guidelines to promote current practice.

Perioperative outcomes of pheochromocytoma/paraganglioma surgery preceded by Takotsubo-like cardiomyopathy

BackgroundPheochromocytomas and paragangliomas can induce severe cardiovascular manifestations such as Takotsubo-like cardiomyopathy. What the perioperative outcomes are of patients presenting with pheochromocytomas/paragangliomas preceded by Takotsubo-like cardiomyopathy remains an unresolved question. MethodsFrom 2006 to 2019, all patients who underwent surgery for pheochromocytomas/paragangliomas preceded by Takotsubo-like cardiomyopathy were included from 3 high-volume centers, with specific attention to perioperative hemodynamic instability and postoperative outcomes. ResultsOverall, 37 patients were included, with a median age of 45 years. Patients were operated on 2 months (1–4) after a Takotsubo-like cardiomyopathy episode; 33 (89%) had a laparoscopic approach. All those who underwent surgery presented in a hemodynamically stable situation. All except 1 of the pheochromocytomas/paragangliomas patients had at least 1 antihypertensive treatment at the time of surgery. The median preoperative systolic blood pressure in the Takotsubo-like cardiomyopathy group was 120 mm Hg (95–132). Overall, 27/34 (79%) of patients required vasoactive drugs during surgery with nicardipine (n = 22), esmolol (n = 12), and/or norepinephrine (n = 8). No patient presented a catecholamine-induced life-threatening complication such as hypertensive crisis, cardiac arrhythmias, pulmonary edema, cardiac ischemia, or Takotsubo-like cardiomyopathy in the perioperative period. Severe morbi-mortality was nil. The systematic review identified 5 studies including 38 pheochromocytomas/paragangliomas patients with at least 1 episode of acute heart failure considered as Takotsubo-like cardiomyopathy before surgery, of which 28 patients had delayed surgery with 1 postoperative death. ConclusionHemodynamically stabilized patients with pheochromocytomas/paragangliomas preceded by Takotsubo-like cardiomyopathy can be safely scheduled for an elective pheochromocytomas/paragangliomas surgery, with similar intra and postoperative outcomes as those without Takotsubo-like cardiomyopathy.

Effect of Clemastine Fumarate on Perioperative Hemodynamic Instability Mediated by Anaphylaxis During Cardiopulmonary Bypass Surgery

BackgroundPerioperative hemodynamic instability mediated by anaphylaxis is a life-threatening complication in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). This study aimed to evaluate the effect of clemastine fumarate in this specific patient population.Material/MethodsWe enrolled 100 participants who met the inclusion criteria and randomly allocated them to the treatment group and the placebo group. Participants in the treatment group and the placebo group were treated separately with an injection of clemastine fumarate and saline, respectively. Plasma histamine concentration and blood pressure were quantified at 5 timepoints during the perioperative period, and differences between the 2 groups were assessed by repeated-measures ANOVA. The postoperative complications and in-hospital mortality also were evaluated. All participants were followed up for 7 days after cardiac surgery.ResultsPlasma histamine concentrations increased in both groups but were statistically significantly lower in the treatment group during the perioperative period (P=0.007). Diastolic blood pressure (P=0.014) and mean arterial pressure (P=0.024) in the treatment group were significantly higher than in the placebo group during the perioperative period. The coefficients of variation for systolic (13.9±4.2% vs 17.2±4.4%, P<0.01) and diastolic (12.9±4.9% vs 15.3±5.2%, P=0.02) blood pressure were significantly lower in the treatment group compared with the placebo group.ConclusionsPretreatment with clemastine fumarate restrains the increase in histamine concentration and provides safer hemodynamics in patients undergoing cardiac surgery with CPB.

Effects of clonidine premedication on perioperative hemodynamic response, anesthetic requirements and postoperative analgesia for patients undergoing laparoscopic gynecological surgeries: A randomized study

The creation of carbon dioxide (CO) pneumoperitoneum is frequent in laparoscopy, but has significant effect on the cardiopulmonary function of the patient. Clonidine by its central sympatholytic action reduces perioperative hemodynamic instability and has several advantages in the postoperative period, hence we consider it to be an effective premedication to contain the stress response to intubation and laparoscopy. With informed consent, 56 patients scheduled for elective laparoscopic gynecological surgeries under general anesthesia were randomly allocated into two groups to receive premedication with either oral Clonidine 100 µg (Group I, n = 28) or Vitamin C as placebo (Group II, n = 28) 90 minutes prior to induction. A balanced general anesthesia was used to manage these patients. Hemodynamic parameters, Sevoflurane concentration, pain and sedation scores, time to request analgesics, 24hr cumulative analgesic requirements and adverse effects between the two groups were collected as data and compared using Two sample t-test and Fisher’s exact test.When compared to the control group, oral Clonidine was found to be considerably superior significantly (p =0.00) in terms of maintaining stable hemodynamics (i.e. In group I, Mean HR ranged from 76.11±12.21 to 94.57±13.75, while in group II, it ranged from 79.04±7.11 to 112.00±12.75 and MAP ranged from 83.07±6.50 to 93.64±14.09 in group I, while in group II, it ranged from 88.04±9.03 to 116.14±13.23), having a Sevoflurane sparing effect and having a longer time (6.5 ± 1.6 hours) between the first request for analgesia postoperatively. In patients undergoing laparoscopic gynecological surgeries, administration of oral Clonidine 100µg as a premedication improves perioperative hemodynamic stability and reduces the intraoperative anesthetic and post-operative analgesic requirements.

Intraoperative Anaphylaxis Following Injection of a Bleomycin-Gelatin Solution for Sclerotherapy

During the perioperative period, the most commonly identified agents that are responsible for acute allergic reactions include antibiotics, neuromuscular blocking agents, opioids, chlorhexidine, and iodinated dyes for radiologic imaging. However, whenever an allergic reaction is suspected, all of the agents to which the patient has been exposed must be considered. Although bleomycin is utilized as the primary agent for sclerotherapy in the treatment of vascular malformations, other substances such as Surgiflo® may be added to the bleomycin solution to increase its efficacy and promote thrombosis of the smaller vessels. These products are derived from animal collagen and contain gelatin which may lead to an allergic reaction. We present an 11-year-old girl undergoing sclerotherapy treatment of an extensive left lower extremity venous malformation who subsequently developed perioperative hemodynamic instability requiring intervention after receiving an injection of a bleomycin and Surgiflo® solution. Further investigation identified gelatin in the Surgiflo® as the causative agent of the allergic event. Previous reports of such reactions are reviewed and the perioperative care and treatment of patients who experience anaphylaxis is addressed.

The association between the type of anesthesia and hemodynamic instability during pheochromocytoma surgery: a retrospective cohort study.

Pheochromocytoma often carries a risk for perioperative hemodynamic instability (HDI). The aim of this study is to evaluate the risk factors of intraoperative HDI during minimally invasive posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma. This retrospective study analyzed the prospectively collected data of 172 patients who underwent laparoscopic PRA or robotic PRA for pheochromocytoma between January 2014 and December 2020 at a single tertiary center. The patients were divided into two groups according to the intraoperative hypertensive event of systolic blood pressure (> 160mmHg). The clinical manifestations and perioperative hemodynamic conditions were analysed. In the multivariate logistic regression analysis, the tumor size (> 3.4cm) [OR 3.14, 95% confidence intervals (CI) (1.48-6.64), p = 0.003], type of preoperative alpha-blocker (selective type) [OR 3.9, 95% CI (1.52-10.02), p = 0.005], preoperative use of beta-blockers [OR 3.94, 95% CI (1.07-14.49), p = 0.039] and type of anesthesia [total intravenous anesthesia (TIVA) vs. balanced anesthesia (BA)] [OR 2.57, 95% CI (1.23-5.38), p = 0.012] were determined as independent risk factors of intraoperative hypertensive events during minimally invasive adrenalectomy. The type of anesthesia was independently associated with intraoperative HDI along with larger tumor size, type of preoperative alpha-blocker and the use of preoperative beta-blockers. TIVA increased the risk of intraoperative hypertensive events compared with BA. Thus, the consideration of the type of anesthesia prior to adrenal surgery for pheochromocytoma along with the use of preoperative non-selective alpha-blockers may be beneficial in minimizing the risk of intraoperative HDI.