Preoperative Blood Pressure Research Articles

The Role of Acu-TENS in Hemodynamic Recovery after Open-Heart Surgery.

Increased heart rate (HR) and reduced blood pressure (BP) are common consequences of cardiac surgery. This study investigated the effect of transcutaneous electrical nervous stimulation applied over acupuncture points (Acu-TENS) on HR, BP, rate pressure product (RPP) and nausea and vomiting score after open-heart surgery. After open heart surgery, 40 patients were randomly allocated to either an Acu-TENS group, which received a 40-min session of TENS applied bilaterally over the acupuncture point PC6 on postoperative days 1–5, or a Placebo-TENS group, which received identical electrode placement but with no electrical output from the TENS unit, despite an output indicator light appearing activated. HR, systolic and diastolic BPs (SBP and DBP) were recorded and RPP computed. Nausea and vomiting symptoms were quantified using a 4-point Likert scale before and after TENS intervention. Daily HR, BP and antiemetic administration data were recorded from a further 20 consecutive subjects who received no intervention and formed the Control group. A trend of decreasing HR and increasing BP in the Acu-TENS group was observed over the five postoperative days, with all variables returning to preoperative values by Day 4 (P > .2). In the Placebo-TENS and Control groups the HR remained higher (P < .0001), BP lower (P < .05) and RPP higher (P = .01) than respective preoperative values at Day 4. The dose of Maxolon required was lowest in the Acu-TENS group (P = .038). We concluded that Acu-TENS facilitated an earlier return to preoperative BP, HR and RPP values in patients after acute heart surgery.

Vasopressin for the treatment of catecholamine-resistant hypotension during a phaeochromocytoma resection in a 6-year-old child

Vasopressin for the treatment of catecholamine-resistant hypotension during a phaeochromocytoma resection in a 6-year-old child

Positional Blood Pressure Change and the Risk of Hypotension During Spinal Anesthesia for Cesarean Delivery

We investigated whether preoperative positional arterial blood pressure change predicted hypotension and ephedrine requirement during spinal anesthesia for cesarean delivery. Arterial blood pressure was measured in 66 women undergoing cesarean delivery in the supine and the right lateral positions. Positional blood pressure change was defined as the difference between mean blood pressure in the right lateral and supine positions. Hypotension (<80% baseline) was recorded, and severe hypotension (<70% baseline) was treated with ephedrine. The mean (range) positional blood pressure change was 11 (3-29) mm Hg, and the incidence of hypotension was 41%. Positional blood pressure change and heart rate correlated with hypotension (P < 0.001 for both) and ephedrine requirement (P = 0.004). Positional blood pressure change in those who developed hypotension was higher than for those without hypotension (mean (SD), 17 (6) vs. 7 (2) mm Hg, P < 0.001). A preoperative increase in blood pressure after position change may be a good variable to predict hypotension during spinal anesthesia for cesarean delivery.

Assessment of intra-operative haemodynamic changes associated with transhiatal and transthoracic oesophagectomy

Previous comparisons of the different surgical techniques for oesophagectomy have concentrated on mortality, morbidity and survival. There is limited data regarding the intra-operative physiological ramifications of the transhiatal (TH) versus the transthoracic (TT) approach to oesophageal resection. We carried out an in-depth analysis of the intra-operative haemodynamic changes and assessed the potential implications on perioperative outcomes in a matched cohort of patients undergoing TH and TT oesophagectomy. A retrospective case review study of TT and TH oesophageal resection at a high-volume tertiary referral centre for oesophageal diseases. General demographics and outcomes of the patients were accumulated prospectively in an Institutional Review Board (IRB) approved database. Intra-operative haemodynamic measurements were obtained from anaesthetic records. A total of 40 patients (20 TT+20 TH) were retrospectively identified after matching them for age, co-morbidities, tumour stage and American Society of Anesthesiologists (ASA) status. Main outcome measures included perioperative outcomes, operative time, blood loss, intensive care unit (ICU) and hospital length of stay, incidence and types of dysrhythmias, incidence of intra-operative hypotension and vasopressor usage, as well as perioperative morbidity and 90-day mortality. Indications for resection included oesophageal cancer (27 patients), high-grade dysplasia (six patients), laryngopharyngoesophageal cancer (three patients), achalasia (two patients) and scleroderma (1 patient). Nine patents with oesophageal cancer had pT3 tumours (TH1, TT8). The mortality was zero in both groups. The total duration of hospitalisation and ICU care was similar in both groups. The mean estimated blood loss was 213 ml (range 100-400 ml) for the TH group and 216 ml (range 80-500 ml) for the TT group. The median operating times for both approaches were similar (398 min TH vs 382 min TT). Intra-operative dysrhythmias were noted in 11 TH and 15 TT patients. Both groups maintained at least 80% of the pre-operative systolic blood pressure (SBP) intra-operatively (TT 89% vs TH 85%) and required vasopressors in comparable quantities. The comparative statistical analysis of intra-operative incidences of hypotensive episodes below 100, 90 and 80 mm Hg showed no significant differences in both groups. However, the TH group experienced a greater frequency of acute hypotension (acute SBP decreases by ≥ 10 mm Hg per 5-min reading) intra-operatively (TH 25% vs TT 16% of operative time), p=0.02. Phenylephrine infusions were required for longer periods in the TH group (TH 52.7% vs TT 33.6% of operation time), p=0.01. This study demonstrates that intra-operative haemodynamic changes and perioperative outcomes are similar in both TT and TH approaches for oesophagectomy in a well-matched cohort of patients. Patients undergoing the TH approach demonstrated a higher frequency of intra-operative haemodynamic lability. The approaches to oesophageal resection should be based on matching the operation to the patient's pre-existing conditions and tumour characteristics rather than perceived differences in haemodynamic impact.

Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy

Pancreatic fistula (PF) after pancreatoduodenectomy (PD) remains a challenging problem. The only commonly accepted risk factor is the soft consistency of the pancreatic remnant. In all, 100 consecutive patients underwent PD. All data, including commonly accepted risk factors for PF and PF defined according to the International Study Group of Pancreatic Fistula, were collected prospectively. On the pancreatic margin, a score of fibrosis and a score of fatty infiltration were assessed by a pathologist blinded to the postoperative course. PF occurred in 31% of patients. In univariate analysis, male sex, age greater than 58 years, body mass index (BMI) > or =25 kg/m(2), pre-operative high blood pressure, operation for nonintraductal papillary and mucinous neoplasm (IPMN) disease and for ampullary carcinoma, operative time, blood loss, soft consistency of the pancreatic remnant, absence of pancreatic fibrosis, and presence of fatty infiltration of the pancreas were associated with a greater risk of PF. In a multivariate analysis, only BMI > or =25 kg/m(2), absence of pancreatic fibrosis, and presence of fatty pancreas were significant predictors of PF. A score based on the number of risk factors present divided the patient population into 4 subgroups carrying a risk of PF that ranged from 7% (no risk factor) to 78% (3 risk factors) and from 0% to 81%, taking into account only symptomatic PF (grade B and C). The presence of an increased BMI, the presence of fatty pancreas, and the absence of pancreatic fibrosis as risk factors of PF allows a more precise and objective prediction of PF than the consistency of pancreatic remnant alone. A predictive score based on these 3 factors could help to tailor preventive measures.

Clinical outcome after laparoscopic adrenalectomy for primary hyperaldosteronism: The role of pathology

Primary hyperaldosteronism (PHA) is potentially curable by laparoscopic unilateral adrenalectomy (LUA). Pre-operative assessment rarely differentiates adrenal adenoma from hyperplasia. This study aimed to evaluate the results of LUA for PHA according to pathologic findings when an adrenal mass was identified unequivocally on a CT scan. A retrospective analysis of LUA for PHA from July 1997 to May 2008 was performed. The minimal follow-up was 6 months. We considered hypertension to be cured in patients with normal blood pressure without antihypertensive medication (AM). Improvement was defined by a decrease of AM. Fifty-seven patients were included. Thirty-six patients (63%) had an adrenal adenoma and 21 (37%) a hyperplasia. The median follow-up was 6.4 years. Hypokalemia was cured in all patients, 33 patients (58%) were cured of their hypertension, and 23 (96% of the 24 noncured patients) were improved with a reduction of the number of AM. Predictive factors for a cure were: gender, age, BMI, duration of hypertension, number of pre-operative AMs, pre-operative arterial systolic blood pressure, creatinin and plasma renin activity. Postoperative predictive factors were pathology, size of the mass, and systolic and diastolic arterial pressures. In the multivariate analysis the only remaining factor was pathology. LUA for PHA cured all patients from their hypokalemia and cured or improved hypertension in 98%. Pre-operative diagnosis of adenoma or hyperplasia is not mandatory but it is important to warn patients that hypertension can persist after adrenalectomy, especially in case of adrenal hyperplasia, although this hypertension is easier to control.

Are Fractures Secondary to LHRH Agonist Therapy in Prostate Cancer a Significant Problem?

Are Fractures Secondary to LHRH Agonist Therapy in Prostate Cancer a Significant Problem?

Incidence of preoperative high blood pressure in cataract surgery among hypertensive and normotensive patients

Incidence of preoperative rise in blood pressure (BP) in cataract surgery among hypertensive and normotensive patients.Objective:To study the incidence of preoperative rise in BP in cataract surgery among normotensive individuals and hypertensive patients with historic good BP control in a population without other major chronic diseases.Settings:Ophthalmology Service of a University Hospital.Materials and Methods:A prospective study with 822 patients older than 40 years of age, with cataract surgery indication, and without major chronic diseases other than hypertension. The patients were divided in two groups: hypertensive and normotensive. Preoperative data, physical exams and medical adverse events were recorded in an evaluation questionnaire.Results:The sample included 427 normotensive (52%) and 395 hypertensive patients (48%). The two groups had similar proportions of operations that were cancelled and not subsequently rescheduled, 2% (eight patients) in each group. The incidence of preoperative rise in BP was 3.7% in the normotensive group and 10.9% in the hypertensive group (P < 0.001).Conclusion:Hypertensive patients with historic good BP control and without other major co-morbidities present a larger incidence of preoperative rise in BP than normotensive individuals in cataract surgery.

Influence of psychological nursing on perioperative irritated response of patients undergoing gyne-cological surgeries

Objective To observe influence of psychological nursing on perioperative irritated response of patients undergoing gynecological surgeries. Methods One hundred and twenty gynecological surgical pa-tients were randomly divided into the psychological nursing group and the control group, each group included 60 cases. Patients in the control group were given routine nursing. In addition of routine nursing, patients in the psychological nursing group were given perioperative psychological nursing intervention. The change of psycho-logical reaction, heart rate and blood pressure of the two groups were compared. Results Compared with the control group, number of patients with 3 to 4 grade of anxiety and terror in the psychological nursing group was significantly lower. Compared with that of preoperative day, heart rate and blood pressure in the control group evidently increased 5 minutes after entering the operation room, while in the psychological nursing group, except heart rate increasing, blood pressure was more stable. Conclusions Psychological nursing can alleviate anxi-ety of patients undergoing gynecological surgeries, maintain normal hemodynamics and promote early recovery of patients. Key words: Irritated response; Perioperation; Gynecological surgery; Psychological nursing

Preoperative Preparation for Pheochromocytoma Resection: Physician Survey and Clinical Practice

The objectives of this study are to assess the perceptions of endocrinologists regarding sufficient preoperative preparation for resection of pheochromocytoma (PHEO) and to evaluate how patients with PHEO are actually managed preoperatively. A survey on methods of preoperative preparation was sent to all 39 endocrinologists who had privilege at a large academic hospital. The charts of 43 patients who underwent adrenalectomy for PHEO resection at this hospital between 1997 and 2007 were reviewed. Age, tumor size, blood pressure medications, volume assessment and repletion, duration of preparation, preoperative and intraoperative blood pressures, and length of stay were recorded. Sixteen endocrinologists (41%) returned surveys, with 15 questionnaires completely answered. Seven endocrinologists who saw more PHEOs (5.9 cases per 5 years) indicated they would manage preoperative preparation themselves while 8 endocrinologists who saw 0.4 case per 5 years would refer the care to a subspecialist. Six of the 7 self-managing endocrinologists recognized all important components of preoperative preparation. All 43 patients received appropriate anti-hypertensive medications for PHEO and had blood pressure well controlled preoperatively; however volume status was not addressed in medical records of 65% of patients and only about 50% of patients received preoperative preparation that lasted longer than 1 week. Suboptimal preoperative preparation was associated with longer length of stay but not with intraoperative or postoperative labile blood pressure. We conclude that most endocrinologists possess correct judgment and knowledge on preoperative preparation for PHEO resection. In clinical practice, however, a significant number of patients are not optimally managed preoperatively. Endocrinologists should pay more attention to volume repletion and adequate duration of preparation in clinical practice.

Restenosis after renal artery angioplasty and stenting: Incidence and risk factors

Management of renal artery stenosis (RAS) with primary renal artery percutaneous angioplasty and stenting (RA-PTAS) is associated with a low risk of periprocedural death and major complications; however, restenosis develops in a subset of patients and repeat intervention may be required. We examined the incidence of restenosis after RA-PTAS and associations with clinical factors. Consecutive patients undergoing RA-PTAS for hemodynamically significant atherosclerotic RAS associated with hypertension or ischemic nephropathy, or both, between October 2003 and September 2007 were identified from a registry. Restenosis was defined using duplex ultrasound (DUS) imaging as a renal artery postintervention peak systolic velocity (PSV) >or=180 cm/s. The incidence and temporal distribution of restenosis was analyzed using survival analysis based on treated kidneys. Associations between clinical factors and recurrent stenosis were examined using proportional hazards regression. RA-PTAS was performed on 112 kidneys for atherosclerotic RAS during the study period. Initial postintervention renal artery DUS imaging confirming PSV <180 cm/s in 101 kidneys, which formed the basis of this analysis. Estimated restenosis-free survival was 50% at 12 months and 40% at 18 months. Decreased risk of restenosis was associated with preoperative statin use (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.16-0.74; P = .006) and increased preoperative diastolic blood pressure (DBP; HR, 0.70 per 10-mm Hg increase in preoperative DBP; 95% CI, 0.49-0.99; P = .049). No other factors assessed were associated with restenosis. Restenosis occurs in a substantial number of patients treated with RA-PTAS. Preoperative statin medication use and increased preoperative DBP are associated with reduced risk of restenosis. In the absence of contraindications, statins should be considered standard therapy for patients with atherosclerotic renal artery stenosis.

Anesthésie pour traitement des tumeurs endocrines

Endocrine tumors could be defined by their ability to produce structural proteins or hormones common to nervous and endocrine cells. They might induce physiological transforms or outcome adverse events which should be well known in order to prevent or treat them early. The goal of this review was to describe these changes, to describe preoperative assessment, and to discuss intraoperative monitoring and drugs choice based on the literature from the last 30 years. As an example, it should be noticed that: (1) preoperative blood pressure control is essential to prepare phaeochromocytoma for surgery. It should be followed during anaesthesia by intensive fluid load, reversible anaesthetic drugs and rational cardiovascular medications use (as for example remifentanil, sevoflurane, calcium channel blockers and esmolol), and after surgery by narrow clinical and biological monitoring; (2) after medullar thyroid cancer, main adverse events include cervical compressive haematoma and recurrent laryngeal nerve injury as for any thyroid surgery; (3) during pituitary surgery, air embolism might be expected, whereas water dysregulation (diabetes insipidus), corticotroph insufficiency, cerebrospinal fluid (CSF) leak might occur postoperatively. In acromegaly, difficult endotracheal intubation is possible whereas severe Cushing's syndrome may be complicated with hypertensive cardiac failure, infections, thrombosis, delayed cicatrisation; (4) somatostatine analogs are a keystone in carcinoid tumors preoperative and anaesthetic management.

Submacular haemorrhage after intravitreal bevacizumab compared with intravitreal ranibizumab in large occult choroidal neovascularization

Submacular haemorrhage may occur following intravitreal bevacizumab injection for large occult choroidal neovascularization (CNV) in age-related macular degeneration (AMD). We report the occurrence of submacular haemorrhage following intravitreal ranibizumab compared with intravitreal bevacizumab for large occult CNV in AMD. Retrospective, comparative evaluation of two interventional case series. Evaluation of consecutive patients with occult CNV > or = 15 mm(2) treated with intravitreal bevacizumab (n = 14) and intravitreal ranibizumab (n = 22) over a 2-year period within a single institution. Postoperative submacular haemorrhage, Early Treatment Diabetic Retinopathy Study-derived visual acuity, preoperative blood pressure and anticoagulant use were noted. The two groups were compared using Fisher's exact test. The mean surface area of occult CNV at presentation was 20.9 +/- 5.4 mm(2) in the bevacizumab group and 24.0 +/- 11.0 mm(2) in the ranibizumab group. Fresh submacular haemorrhage was seen in 4 out of 14 patients following bevacizumab compared with 0 out of 22 patients following ranibizumab (P = 0.017, odds ratio = 19.29). Mean preoperative blood pressures were very similar between the groups. 28.6% of patients in the bevacizumab group were on oral anticoagulants compared with 31.8% in the ranibizumab group. None of the patients who developed postoperative haemorrhage were on anticoagulants. Acute submacular haemorrhages appear to be a significant adverse event following intravitreal bevacizumab in occult CNV > or = 15 mm(2). Intravitreal ranibizumab appears to have a significantly lower incidence of postoperative submacular haemorrhage in occult CNV > or = 15 mm(2). Larger studies are required to identify the most appropriate agent for the treatment of large occult CNV.

Factors Determining Cardiovascular and Renal Outcomes after Adrenalectomy in Patients with Aldosterone-Producing Adrenal Adenoma

Primary aldosteronism is an important cause of secondary hypertension, because it is potentially curable, especially in case of unilateral aldosterone-producing adrenal adenoma (APA). However, the information is limited concerning the cardiovascular and renal outcomes in this patient population. We studied 52 patients with APA in order to determine the pre-operative and post-operative factors predicting cardiovascular and renal outcomes. All 52 patients were hypertensive before the operation. Among 35 patients who underwent pre-operative electrocardiogram, 23 patients had left ventricular hypertrophy (LVH). Patients with LVH had lower estimated glomerular filtration rate (eGFR). Adrenalectomy successfully normalized or improved hypertension, hypokalemia, and aldosterone excess. One month after the adrenalectomy, 32 patients (62%) became normotensive, but 20 patients (38%) remained hypertensive. However, after an average follow-up period of 51 months, only 18 patients remained normotensive, while 34 patients were hypertensive. Thus, the rate of recurrent hypertension after adrenalectomy was high (14/32, 43%). Pre-operative systolic blood pressure (BP), diastolic BP, and post-operative plasma aldosterone concentrations were the only variables significantly different between the hypertensive and normotensive patients. Using pre-operative BP 165/110 mmHg as a cutoff has good positive predictive values (73-92%) for post-operative long-term hypertension. Patients whose renal function worsened after adrenalectomy had significantly higher pre-operative plasma active renin levels. Thus, in patients with APA, the presence of LVH is correlated with impaired renal function (lower eGFR). In conclusion, pre-operative BP and post-operative plasma aldosterone are important in predicting post-adrenalectomy hypertension, and a lower pre-operative plasma renin predicts the improvement in renal function after adrenalectomy.

Renal Function of Patients with a Failing Fontan Circuit Undergoing Total Cavopulmonary Revision Surgery

This report characterizes renal dysfunction after total cavopulmonary (TCPC) revision surgery for atriopulmonary Fontan (APF) circulations, a known risk factor for a poor outcome. The perioperative data for 23 consecutively identified patients were reviewed. The preoperative mean glomerular filtration rate (GFR) was 101 +/- 30 ml/min/1.73 m(2), decreasing to 65 +/- 41 ml/min/1.73 m(2) early in the postoperative period. The preoperative GFR was highly correlated with age at APF (r = -0.5; p = 0.024), age at TCPC (r = -0.5; p = 0.01), and mixed venous saturation (r = 0.6; p = 0.01). Three of four patients requiring renal replacement therapy (RRT) died at a median age of 3 months (range, 18 days to 9 months). Determinants of early GFR and RRT were preoperative GFR (p = 0.016) and creatinine (p = 0.035). Younger age at primary Fontan (p = 0.008), higher preoperative mixed venous saturation (p = 0.019), and higher preoperative blood pressure (p = 0.006) independently predicted better GFRs at the latest follow-up evaluation. Renal function declines acutely after TCPC revision, often necessitating RRT. A requirement for RRT marks greater mortality. Higher preoperative creatinine levels identify those at greatest risk.

The role of radiologic studies in the evaluation and management of primary hyperaldosteronism

Surgical treatment of primary hyperaldosteronism (PHA) requires demonstration of unilateral adrenal hypersecretion. Optimal methods for interpretation of imaging and invasive testing are still in development. A retrospective review from 1996-2007 of 106 patients with PHA was undertaken. Patient demographics, biochemical studies, radiologic imaging, operative reports, and pathology were reviewed and comparisons made. Optimal ratios for adrenal vein sampling were tested with regard to sensitivity and specificity. Preoperative and postoperative medication requirements and blood pressures were compared among different treatment groups. Seventy-eight patients (62 surgically treated) met criteria for inclusion. Median arterial blood pressure at diagnosis was 150/86 mm Hg while taking 3 antihypertensive medications. 69.2% required potassium supplementation. Median aldosterone:renin ratio was 107.0. Forty-two AVS procedures changed the management of 15 patients (35.7%) when compared to CT results. AVS accuracy was 96.6 vs 88.9% for NP-59 scintigraphy. Operative patients remained on fewer antihypertensive medications (1 vs 3), and mean systolic pressure was lower (130 vs 146 mm Hg) compared with medically managed patients. When used together, pre-ACTH aldosterone ratios, normalized A/C:A/C ratios, ratios to define contralateral suppression, and post-ACTH stimulated values allowed for capture of episodically secreting tumors and subtle unilateral or bilateral hyperaldosteronism.

Open simple prostatectomy and blood transfusion in Nairobi

Open simple prostatectomy has long been associated with large blood losses; hence allogeneic blood transfusion in this procedure is a standard practice world over. A review of literature suggests significant association between perioperative blood loss accompanying open simple prostatectomy and certain patient factors. The shortage of blood and blood products in our blood transfusion centres as well as the alarming risks of transfusion reactions and disease dissemination demanded a review of these factors with the aim of reducing morbidity associated with peri-operative blood loss and blood transfusion. To assess blood loss, determine blood transfusion rate, and define some of the factors associated with peri-operative blood loss and blood transfusion in open simple prostatectomy. A prospective cohort study. The urology units of Kenyatta National Hospital, Kenya. Ninety five patients who underwent open simple prostatectomy for benign prostatic hyperplasia were enrolled into the study. Their median age was 70 years (Range 50 to 97). The mean decrease in haemoglobin concentration, which was the main indicator of peri-operative blood loss, was 2.1 g/dl (+/- 1.4). The peri-operative blood transfusion rate was 36.8 %. Twenty four (68.6%) of the patients who received either one or two units of blood had a pre-operative haemoglobin level above 13.5g/ dl and a post-operative haemoglobin level above 11.5 g/dl, while 11 (31.4%) had severe peri-operative bleeding, that necessitated immediate surgical re-intervention. A total of 68 units of blood was transfused, 42 (61.8%) allogeneic and 26 (38.2%) autollogous blood. The post-operative median hospitalisation time was eight days (Range 4 to 35). There were two (2.1%) post-operative deaths and both patients had intractable intra- and post-operative bleeding, massive blood transfusion and disseminated intravascular coagulopathy. The factors that were significantly associated with peri-operative blood loss and blood transfusion in open simple prostatectomy were patient's aged above 70 years, pre-operative use of acetylsalicylate or warfarin sodium, pre-operative systolic blood pressure above 140 mmHg, general anaesthesia, Freyer's (transvesical) technique and the weight of resected prostatic tissue above 70 grams. Open simple prostatectomy performed under spinal anaesthesia using Millin's (retropubic) technique is associated with minimal blood loss. The perioperative blood transfusion rate was 36.8%.

Perioperative hemodynamics in pheochromocytoma secreting different types of catecholamine

To analyze the characteristics of perioperative hemodynamics in pheochromocytoma secreting different types of catecholamine, and to discuss how to improve the hemodynamics. The clinical data of 202 patients with pheochromocytoma who had received operation were analyzed. Three classification systems were used to divided the patients: they were, firstly, divided into high and low epinephrine secreting groups (E(high) and E(low)) according to the 24 hours urine catecholamine quantitation; secondly, into high and low norepinephrine secreting groups (NE(high) and NE(low)) according to 24-h urine norepinephrine quantitation; and thirdly, into high and low dopamine secreting groups (DA(high) and DA(low)) according to the 24 hours urine dopamine quantitation. Relationship between the characteristics of perioperative hemodynamics and catecholamine secreting types were analyzed. The highest preoperative systolic blood pressure values of E(high) and NE(high) groups were (201 +/- 40) mm Hg and (205 +/- 38) mm Hg, both significantly higher than those of the E(low) and NE(low) groups [(183 +/- 43) mm Hg, P = 0.003 and (181 +/- 43) mm Hg, P = 0.000]. The range of systolic blood pressure fluctuation during the operation of the E(high) group was 108 +/- 39 mm Hg, significantly larger than that of the E(low) group (91 +/- 33 mm Hg, P = 0.001). The incidence rates of persisting postoperative hypotension of the NE(high) and DA(high) groups were 23.3% (20/86) and 32.7% (17/52) respectively, both higher than those of the NE(low) and DA(low) groups [2.6% (3/116) and 4.0% (6/150) respectively, P = 0.000 and P = 0.000]. Different characteristics of perioperative hemodynamics are present in pheochromocytoma secreting different types of catecholamines. Patients with highly epinephrine secreting pheochromocytoma are apt to have larger blood fluctuation during the operation. Patients with highly norepinephrine and dopamine secreting pheochromocytoma are apt to suffer from persisting postoperative hypotension.

Arteriovenous Fistula Closure After Renal Transplantation: A Prospective Study With 24-Hour Ambulatory Blood Pressure Monitoring

We prospectively evaluated the effects of arteriovenous fistula closure on 24-hour ambulatory blood pressure measurements and on left ventricular geometry assessed by echocardiography. Sixteen kidney transplant recipients were studied before and 1 month after surgical fistula closure. The mean of 24-hour diastolic blood pressure increased from 77+/-7 mmHg to 82+/-8 mmHg (P=0.003) without systolic changes. The diastolic blood pressure increase correlated with the reduction in left ventricular mass (P=0.0034). In multivariate analysis, the diastolic blood pressure increase best correlated with preoperative cardiac index (P=0.01). After a similar time delay between two studies, blood pressure remained unchanged in 14 kidney transplant controls with a patent fistula not scheduled for closure. Because the increase in diastolic blood pressure after arteriovenous fistula closure occurred regardless of the preoperative level of diastolic pressure, we suggest that blood pressure should be monitored after fistula closure, particularly when preoperative diastolic blood pressure is borderline or elevated.

Anaesthetic management of Wolff Parkinson White syndrome for caesarean section

We present two cases of WPW syndrome in pregnancy. Risk factors for development of supraventricular tachycardia and the anaesthetic management during caesarean section are discussed. We recommend that regional anaesthesia can be given in patients with WPW syndrome; Phenylephrine is the best vasopressor for treatment of hypotension during spinal blockage and Adenosine is the first line therapy for the acute termination of PSVT. In women of reproductive age, the commonest arrhythmia seen is paroxysmal supraventricular tachycardia (SVT).1 Wolf Parkinson White syndrome accounts for the majority of supraventricular tachycardia in this population; with an incidence of 1.2 per 1000 people. Over half of these patients are asymptomatic.2Patients may complain of palpitation, dizziness, syncope or shortness of breath. The diagnosis is confirmed by E.C.G. The incidence and severity of tachyarrhythmia in these patients may increase during pregnancy. Although reasons for this observation are unclear, some explanations have been proposed. Increased awareness, hemodynamic, hormonal, autonomic and emotional changes related to pregnancy, which may include increase in plasma catecholamine concentrations and adrenergic receptor sensitivity, atrial stretch and increased end diastolic volumes due to intravascular volume expansion have been implicated as some of the reasons.3 We present two cases of Wolf Parkinson White syndrome who underwent caesarean section under regional anaesthesia. A 28 year old female, primigravida, was planned for caesarean section for cephalopelvic disproportion. The patient gave history of palpitations occasionally before pregnancy. But her symptoms increased during pregnancy. The patient did not give any history of syncope, dizziness or chest pain. In preanaesthetic check up, ECG showed features of WPW syndrome. The patient was advised cardiological consultation who confirmed the diagnosis. She was not put on any medication except anxiolytics. She was planned for caesarean section under spinal anaesthesia. Her preoperative heart rate and blood pressure was normal. She was preloaded with 500 ml of normal saline. Routine monitoring included ECG, NIBP and pulse oximetry. Spinal anaesthesia was achieved with 2.5 ml hyperbaric Bupivacaine (12.5 mgs) using 25 G pencil point needle in sitting position. The patient was given a left lateral tilt of 15-20 degrees to prevent supine hypotensive syndrome. A live healthy baby was delivered. Soon after the delivery of the baby, syntocinon 5 units were given as bolus and an infusion of 15 units in 500 ml of normal saline commenced. At this moment patient complained of palpitations and dizziness. Her heart rate increased from 84 to 180 beats / min and her blood pressure dropped to 80 mm Hg. Initially vagal manoeuvres were tried but without any improvement. Injection Phenylephrine 10 μg iv bolus was given which was repeated to treat hypotension. Adenosine 6 mg iv push was given which terminated arrhythmia and sinus rhythm was restored. There were no further episodes of PSVT and post operative period was uneventful. She was discharged after four days and was advised to follow cardiology department. Anaesthetic management of Wolff Parkinson White syndrome for caesarean section