Risk Factors For Hypotension Research Articles

Incidence and risk factors for hypotension after carotid artery stenting: Systematic review and meta-analysis.

Hypotension is recognized as a common complication after carotid artery stenting, but its incidence and the risk factors associated with it are uncertain. Therefore, we performed a systematic review and meta-analysis to investigate and identify risk factors for hypotension after surgery. We retrieved risk factors from eight databases for case-control and cross-sectional studies of hypotension after carotid artery stenting according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on 28 November 2022. Data were analyzed by using R4.2.1 and Review Manager 5.3. A total of 2843 samples were searched, and 17 publications were included in the analysis. The meta-analysis results showed that the incidence of hypotension after surgery was 28.6% (95% confidence interval [CI] (0.225, 0.347)). Age ⩾ 65 years (odds ratio [OR] = 4.55, 95% CI (2.50, 8.29), P < 0.00001), stenosis site (bulb) (OR = 4.41, 95% CI (2.50, 7.79), P < 0.00001), severe stenosis (OR = 3.56, 95% CI (1.62, 7.85), P = 0.002), stenosis proximity (⩽ 10 mm) to bifurcation (OR = 2.69, 95% CI (1.74, 4.15), P < 0.00001), calcified plaques (OR = 4.64, 95% CI (1.93, 11.14), P = 0.0006), post-balloon dilation (OR = 5.95, 95% CI (2.31, 15.31), P = 0.0002), bilateral carotid stenting (OR = 30.51, 95% CI (2.33, 399.89), P = 0.009), and intravenous fluid intake/mL on the first postoperative day (mean difference = 444.99, 95% CI (141.40, 748.59), P = 0.004) were risk factors for hypotension after surgery. A high incidence of hypotension was observed after carotid artery stenting. Age, stenosis site, severe stenosis, stenosis proximity to bifurcation, calcified plaques, post-balloon dilation, type of surgery, and intravenous fluid intake were identified as risk factors.

Incidence, characteristics and risk factors for alveolar recruitment maneuver-related hypotension in patients undergoing laparoscopic colorectal cancer resection.

Alveolar recruitment maneuvers (ARMs) may lead to transient hypotension, but the clinical characteristics of this induced hypotension are poorly understood. We investigated the characteristics of ARM-related hypotension in patients who underwent laparoscopic colorectal cancer resection. To investigate the characteristics of ARM-related hypotension in patients who underwent laparoscopic colorectal cancer resection. This was a secondary analysis of the PROtective Ventilation using Open Lung approach Or Not trial and included 140 subjects. An ARM was repeated every 30 min during intraoperative mechanical ventilation. The primary endpoint was ARM-related hypotension, defined as a mean arterial pressure (MAP) < 60 mmHg during an ARM or within 5 min after an ARM. The risk factors for hypotension were identified. The peri-ARM changes in blood pressure were analyzed for the first three ARMs (ARM1,2,3) and the last ARM (ARMlast). Thirty-four subjects (24.3%) developed ARM-related hypotension. Of all 1027 ARMs, 37 (3.61%) induced hypotension. More ARMs under nonpneumoperitoneum (33/349, 9.46%) than under pneumoperitoneum conditions (4/678, 0.59%) induced hypotension (P < 0.01). The incidence of hypotension was higher at ARM1 points than at non-ARM1 points (18/135, 13.3% vs 19/892, 2.1%; P < 0.01). The median percentage decrease in the MAP at ARM1 was 14%. Age ≥ 74 years, blood loss ≥ 150 mL and peak inspiratory pressure under pneumoperitoneum < 24 cm H2O were risk factors for ARM-related hypotension. When the ARM was repeated intraoperatively, a quarter of subjects developed ARM-related hypotension, but only 3.61% of ARMs induced hypotension. ARM-related hypotension most occurred in a hemodynamically unstable state or a hypovolemic state, and in elderly subjects. Fortunately, ARMs that were performed under pneumoperitoneum conditions had less impact on blood pressure.

Predictors of hypotension during anesthesia induction in patients with hypertension on medication: a retrospective observational study

BackgroundHypotension during anesthesia induction is a common event, and occurs more frequently in patients with hypertension than in healthy individuals. Intraoperative hypotension in non-cardiac surgery is reportedly associated with various postoperative complications. However, the predictors of hypotension during anesthesia induction in patients with hypertension have not yet been ascertained. Therefore, we aimed to determine the predictors of hypotension during anesthesia induction in patients with hypertension on medication focusing on the half-life of the medication used.MethodsIn this retrospective observational study, we enrolled patients with hypertension on medication who underwent general anesthesia for oral and maxillofacial surgery between January 1, 2013, and December 31, 2019. Multivariable logistic regression analysis was conducted to test for associations between clinical factors and hypotension during anesthesia induction in patients with hypertension on medication.ResultsA total of 395 patients were included in this study. The risk factors for hypotension during anesthesia induction in patients with hypertension on medication were pre-induction mean arterial blood pressure (adjusted unit odds ratio, 0.96 [95% confidence interval, 0.94 to 0.98]), female sex (adjusted odds ratio [aOR], 1.63 [1.03 to 2.57]), regular use of angiotensin receptor blockers (ARBs)/angiotensin-converting enzyme inhibitors (ACE-Is) with a long half-life (vs. no regular use of ARBs/ACE-Is aOR, 4.02 [1.77 to 9.12]; vs. regular use of ARBs/ACE-Is with a short-to-middle half-life aOR, 3.17 [1.46 to 6.85]), and regular use of beta blockers (aOR, 2.45 [1.19 to 5.04]). Regular use of calcium channel blockers (aOR, 0.44 [0.25 to 0.77]) was a suppressive factor for hypotension during anesthesia induction in patients with hypertension.ConclusionsIn patients with hypertension on medication, regular use of ARBs/ACE-Is with a long half-life, regular use of beta blockers, low pre-induction mean arterial blood pressure, and female sex were risk factors for hypotension during anesthesia induction. Notably, regular use of ARBs/ACE-Is with a long half-life was a high-risk factor for hypotension during anesthesia induction in patients with hypertension on medication even after a 24-h preoperative withdrawal period.

Frequent hypotension during hemodialysis in a patient with cutis laxa

Abstract Rationale: Cutis laxa is a rare disorder characterized by redundant, loose, and inelastic skin. Its chief histological feature is the reduction of elastic fibers in the dermal layer. Hypotension on dialysis is defined as a decrease in systolic blood pressure of ≥20 mm Hg or a decrease in mean arterial pressure of 10 mm Hg, accompanied by a clinical event requiring therapeutic intervention. Patient concerns: A 49-year-old female patient with cutis laxa who had frequent episodes of hypotension during hemodialysis. Diagnoses: A skin biopsy revealed changes typical of cutis laxa. Physical examination of the patient revealed systemic skin laxity with a presenile appearance. Interventions: We replaced conventional hemodialysis with hemodiafiltration. Outcomes: The hypotension improved after the patient started hemodiafiltration. Lessons: Cutis laxa may be a risk factor for hypotension during hemodialysis. Hemodiafiltration increases systemic vascular resistance and norepinephrine plasma levels in patients with cutis laxa, thereby stabilizing blood pressure. In a patient with cutis laxa, replacing conventional hemodialysis with hemodiafiltration resulted in an improvement in hypotension.

Arterial stiffness as a risk factor for hypotension during induction of general anesthesia

IntroductionHypotension after induction of general anaesthesia is identified as an independent factor in predicting adverse clinical outcomes. Preoperative evaluation of arterial stiffness could identify patients with an impaired vascular function and an altered haemodynamic response to induction of general anaesthesia. The purpose of this study is to investigate the relationship between arterial stiffness and blood pressure variation during induction of general anaesthesia.Material and methodsThis was an observational study that included patients who underwent surgical procedures under general anaesthesia. We used several systolic arterial pressure and mean arterial pressure thresholds for defining hypotension. Both absolute thresholds and thresholds relative to a baseline blood pressure were chosen based on the most frequently used definitions. Patient carotid-femoral pulse wave velocity determination, preoperative preparation, and induction of general anaesthesia were standardized.ResultsOur study included 115 patients. Both univariate and multivariate analysis showed that carotid-femoral pulse wave velocity was significantly associated with post-induction hypotension when defined as a systolic arterial pressure decrease of &gt; 30% or &gt; 40% from baseline or as a mean arterial pressure decrease of &gt; 40% from baseline. Also, carotid-femoral pulse wave velocity was positively associated with duration of post-induction hypotension.ConclusionsPreoperative assessment of arterial stiffness identifies patients at risk of a pronounced decrease in blood pressure during induction of general anaesthesia.

Hemodynamic effects of intravenous paracetamol in critically ill children with septic shock on inotropic support

BackgroundTreatment with intravenous paracetamol may impair hemodynamics in critically ill adults. Few data are available in children. The aim of this study was to investigate the frequency, extent, and risk factors of hypotension following intravenous paracetamol administration in children with septic shock on inotropic support.MethodsWe retrospectively reviewed the electronic medical charts of all children aged 1 month to 18 years with septic shock who were treated with intravenous paracetamol while on inotropic support at the critical care unit of a tertiary pediatric medical center in 2013–2018. Data were collected on patient demographics, underlying disease, Pediatric Logistic Organ Dysfunction (PELOD) score, hemodynamic parameters before and up to 120 min after paracetamol administration, and need for inotropic support or intravenous fluid bolus. The main outcome measures were a change in blood pressure, hypotension, and hypotension requiring intervention.ResultsThe cohort included 45 children of mean age 8.9 ± 5.1 years. The mean inotropic support score was 12.1 ± 9.5. A total of 105 doses of paracetamol were administered. The lowest mean systolic pressure (108 ± 15 mmHg) was recorded at 60 min (p = 0.002). Systolic blood pressure decreased at 30, 60, 90, and 120 min after delivery of 50, 67, 61, and 59 drug doses, respectively. There were 5 events of systolic hypotension (decrease of 1 to 16 mmHg below systolic blood pressure hypotensive value). Mean arterial pressure decreased by ≥ 15% in 8 drug doses at 30 min (7.6%, mean − 19 ± 4 mmHg), 18 doses at 60 min (17.1%, mean − 20 ± 7 mmHg), 16 doses at 90 min (15.2%, mean − 20 ± 5 mmHg), and 17 doses at 120 min (16.2%, mean − 19 ± 5 mmHg). Mean arterial hypotension occurred at the respective time points in 2, 13, 10, and 9 drug doses. After 12 drug doses (11.4%), patients required an inotropic dose increment or fluid bolus.ConclusionsHypotensive events are not uncommon in critically ill children on inotropic support treated with intravenous paracetamol, and physicians should be alert to their occurrence and the need for intervention.

Moderate-to-Deep Sedation Using Target-Controlled Infusions of Propofol and Remifentanil: Adverse Events and Risk Factors: A Retrospective Cohort Study of 2937 Procedures.

In the University Medical Center Groningen in Groningen, the Netherlands, moderate-to-deep sedation is provided by nursing staff trained and supervised by the anesthesia department using protocol-based target-controlled infusions (TCIs) of propofol and remifentanil. The aim of this retrospective cohort study was to investigate the incidence of events with potential adverse health consequences within this service model and the risk factors for the occurrence of these events. We retrospectively interrogated a database containing the computerized anesthetic records of 2937 procedures where moderate-to-deep sedation was provided using TCI administration of propofol and remifentanil between May 2014 and October 2017. The primary outcome measures were the incidence of sedation-related events with potential adverse health consequences and risk factors for the occurrence of such events. The events under investigation were unplanned intensive care unit (ICU) admission, need for cardiopulmonary resuscitation (CPR), death on the day of the procedure due to sedation-related events, cardiovascular events (arrhythmias, hypertension, and hypotension), pulmonary events (aspiration, desaturation, unplanned tracheal intubation), anaphylactic or allergic reactions, and the termination of the procedure due to sedation-related events. Cardiovascular and pulmonary events were classified as severe, significant, or moderate. Events were identified by using computer algorithms to search the computerized records from all included procedures. Data from 2937 procedures were analyzed. No patients suffered catastrophic events (death, need for CPR, or unplanned ICU admission). Thirty-two severe sedation-related events occurred in 32 procedures. Severe desaturation (0.6%; 95% confidence interval [CI], 0.4-0.9) and severe hypertension (0.2%; 95% CI, 0.04-0.37) were the most common severe events. Significant hypotension (8.8%; 95% CI, 7.73-9.77) and significant desaturation (1.6%; 95% CI, 1.12-2.02) were found to be the most common events with potential adverse health consequences. No patient suffered lasting health consequences. Average mean and maximum targeted effect-site concentrations (Cet) for propofol were 2.6 ± 0.83 and 3.3 ± 1.09 µg·mL, respectively, and for remifentanil 0.84 ± 0.18 and 0.99 ± 0.22 ng·mL, respectively. Maximum Cets of propofol were lower among patients with higher body mass index (BMI) and were higher among patients of younger age. Higher BMI was a risk factor for desaturation. Increased age and lower BMI were risk factors for hypotension. Longer procedure time was a risk factor for both desaturation and hypotension. Moderate-to-deep sedation by propofol and remifentanil TCI has a low incidence of catastrophic and severe events.

An Observational Study of Proportion and Risk Factors of Hypotension in Parturients Undergoing Spinal Anaesthesia for Caesarean Section

An Observational Study of Proportion and Risk Factors of Hypotension in Parturients Undergoing Spinal Anaesthesia for Caesarean Section

Risk factors for hypotension in regional spinal anesthesia for cesarean section. Role of the Waist-to-Hip Ratio and Body Mass Index

Risk factors for hypotension in regional spinal anesthesia for cesarean section. Role of the Waist-to-Hip Ratio and Body Mass Index

Incidence and risk factors of hypotension after intravenous fosphenytoin administration.

Fosphenytoin (FOS) administered intravenously offers several benefits over intravenously administered phenytoin, including a faster infusion rate, decreased pain and irritation at the infusion site, and fewer cardiovascular complications. However, some studies suggest that the intravenous administration of FOS in some patients may also induce adverse cardiovascular events. Here, we investigated the clinical characteristics of patients who experienced hypotension following an intravenous infusion of a FOS loading dose. We reviewed the medical records of consecutive patients who received an intravenous (IV) dose of FOS between July 2013 and June 2015. Various clinical and demographic parameters were analysed, including comorbidities, drug history, seizure aetiology and type, incidence of hypotension/cardiac arrhythmia and the dosing data (ie the total dose, concentration and FOS IV infusion rate). Hypotension was defined as a ≥20mm Hg decrease in systolic blood pressure or a ≥10mm Hg decrease in diastolic blood pressure during or after FOS IV infusion. These parameters were compared between patients with and without hypotension. Of the 28 included patients, 11 (39%) had hypotension associated with an IV infusion of FOS, two of whom also had an atrioventricular block. Most patients (22/28, 79%) who received an IV infusion of FOS had status epilepticus (SE). The presence of SE was significantly associated with the development of hypotension (P=.026); hypotension occurred in half of the patients with SE, but did not occur in six patients without SE. Hypotension was also associated with old age (≥60years, P=.034) and the presence of a systemic infection (P=.04). Our study shows that hypotension associated with an IV infusion of FOS is not a rare adverse event, especially in patients with SE. Moreover, we found that old age and the presence of a systemic infection increased the risk of hypotension. These findings suggest that FOS should be infused under careful cardiovascular monitoring, especially in patients who are at higher risk of developing hypotension.

Post-medication Hypotension after Administration of Sedatives and Opioids during Critical Care Transport

Objective. Identification of modifiable risk factors for hypotension during critical care transport is important to optimize patient preparation, crew training, and patient safety. We set out to determine the incidence of hemodynamic deterioration after administration of opioids or sedatives during critical care transport, and identify patient- and transport-level predictors. Methods. We assembled a retrospective cohort of adults undergoing urgent critical care transport between January 1, 2005, and December 31, 2010. The primary outcome was post-medication hypotension, defined by new hypotension or new vasopressor within 10 minutes of medication administration. Results. Opioids or sedatives were administered 28,592 times in 8,328 patient transports, with 159 episodes of post-medication hypotension (0.6% of all medication administrations). Mechanical ventilation (adjusted odds ratio [OR] 4.9; 95% confidence interval [95%CI] 2.7–8.9), baseline vasopressor requirement (adjusted OR 2.1; 95%CI 1.3–3.4), transport duration (adjusted OR 1.5; 95%CI 1.1–2.2) per log unit increment of duration), surgical diagnosis (adjusted OR 4.1; 95%CI 1.6–10.7 compared to trauma), and ACP crew level (adjusted OR 2.4 compared to baseline of CCP; 95%CI 1.5–3.8) were all associated with an increased odds of post-medication hypotension. ACP crew level remained associated with increased post-medication hypotension in a sensitivity analysis of 1,242 propensity-matched pairs (crude OR for ACP vs. CCP 3.0; 95%CI 1.4–6.5). Conclusions. Post-medication hypotension occurred once in every 160 drug administrations and was associated with mechanical ventilation, baseline hemodynamic instability, transport duration, surgical diagnosis, and ACP crew. These findings provide targets for improvements in patient preparation, crew training, and clinical practices.

Risk factors and prognosis of hypotension in postoperative sedation patients

To explore the risk factors and prognosis of hypotension in postoperative sedation patients. A total of 175 patients with postoperative sedation at our department from May 2013 to March 2014 were retrospectively reviewed. Patients with age <18 years, cardiac surgery, pheochromocytoma surgery, hemorrhagic shock, septic shock or cardiogenic shock were excluded. APACHE II, dosage and duration of sedative drug, mean arterial pressure at baseline and after sedation, central venous pressure, fluid balance, dosage and duration of norepinephrine, endotracheal intubation time and length of intensive care unit (ICU) stay were recorded. Blood pressures decreased significantly after administration of sedation (77.2 ± 11.2 vs 82.6 ± 9.3 mmHg, P = 0.000). Compared to those with lower disease severity (APACHEII ≤ 10), the patients with APACHEII.>10 required higher norepinephrine dosage and longer time of infusion. A longer time of norepinephrine infusion was needed for patients with coronary heart disease. Patients undergoing thoracic, abdominal or pelvic surgery, or those with hepatic dysfunction had a higher norepinephrine dosage. Decrement of blood pressure and norepinephrine duration were independent risk factors of endotracheal intubation time. And dosage and duration of norepinephrine were independent risk factors of ICU time. Disease severity, past history of heart disease, surgical site and liver function are risk factors of hypotension in postoperative sedation patients. It is important to pay attention to dosage and administrative route of sedative drug. Norepinephrine duration after sedation is an independent risk factor of endotracheal intubation time and ICU time.

Risk factors for development of hypotension during craniotomy in patients with severe traumatic brain injury

Objective To identify the risk factors for the development of hypotension during craniotomy in patients with severe traumatic brain injury (TBI).Methods One hundred and seventy-five patients,aged ≥ 18 yr,undergoing emergency craniotomy for TBI,were selected.According to the occurrence of intraoperative hypotension (systolic pressure ＜ 90 mm Hg or the decreased amplitude ＞ 30％ of the baseline),all the patients were divided into 2 groups:hypotension group and non-hypotension group.The data including gender,age,preoperative Glasgow Coma Scale (GCS) score,pupils,preoperative systolic pressure,application of mannitol,hyperventilation,methods for induction of anesthesia,and decrease in intracranial pressure were recorded.The risk factors of which P values were less than 0.05 would enter the multi-factor logistic regression analysis to stratify the independent risk factors for intraoperative hypotension.Results Fifty patients developed intraoperative hypotension,and the incidence was 28.57％.There was significant difference in preoperative systolic pressure,GCS score and changes in pupils between hypotension group and non-hypotension group (P ＜ 0.05).Logistic regression analysis showed that preoperative systolic pressure was the independent risk factor for hypotension during craniotomy in patients with severe TBI (P ＜ 0.05),and OR value (95％ confidence interval) was 1.019 (1.005-1.033),and regression coefficient was 0.019.Conclusion Preoperative systolic pressure is the independent risk factor for hypotension during craniotomy in patients with severe TBI. Key words: Craniocerebral trauma; Hypotension; Intraoperative complications; Risk factors

Clinical evaluation of propofol as sedative for endotracheal intubation in neonates

To determine the effects of propofol for endotracheal intubation in neonates in daily clinical practice. We prospectively studied the pharmacodynamic effects of intravenous propofol administration in neonates who needed endotracheal intubation at the neonatal intensive care unit. Propofol was used for 62 intubations in neonates with postmenstrual ages ranging from 24+3weeks to 44+5weeks and bodyweights ranging from 520 to 4380g. A 2mg/kg bodyweight propofol starting dose was sufficient in 37% of patients; additional propofol was needed less often on the first postnatal day. The mean amount of propofol used was 3.3 (±1.2) mg/kg. The success rate of intubation depended on the experience of the physician and was related to the total administered amount of propofol. Hypotension occurred in 39% of patients and occurred more often at the first postnatal day. In 15% of procedures, propofol mono therapy was insufficient. This study shows that high doses of propofol are needed to reach effective sedation in neonates for intubation, with hypotension as a side effect in a considerable percentage of patients. Further research in newborn patients needs to identify optimal propofol doses and risk factors for hypotension.

Risk factors for hypotension in urgently intubated burn patients

BackgroundWhen urgently intubating patient in the burn intensive care unit (BICU), various induction agents, including propofol, are utilized that may induce hemodynamic instability. MethodsA retrospective review was performed of consecutive critically ill burn patients who underwent urgent endotracheal intubation in BICU. Basic burn-related demographic data, indication for intubation, and induction agents utilized were recorded. The primary outcomes of interest were clinically significant hypotension requiring immediate fluid resuscitation, initiation or escalation of vasopressors immediately after intubation. Secondary outcomes included ventilator days, stay length, and in-hospital mortality. ResultsBetween January 2003 and August 2010, we identified 279 urgent intubations in 204 patients. Of these, the criteria for presumed sepsis were met in 60% (n=168) of the intubations. After intubation, 117 patients (42%) experienced clinically significant hypotension. Propofol (51%) was the most commonly utilized induction agent followed by etomidate (23%), ketamine (15%), and midazolam (11%). On multiple logistic regression, %TBSA (OR 1.016, 95% CI 1.004–1.027, p<0.001) and presumed sepsis (OR 1.852, 95% CI 1.100–3.117, p=0.02) were the only significant predictors of hypotension. None of the induction agents, including propofol, were significantly associated with hypotension in patients with or without presumed sepsis. ConclusionsIn critically ill burn patients undergoing urgent endotracheal intubation, specific induction agents, including propofol, were not associated with clinically significant hypotension. Presumed sepsis and %TBSA were the most important risk factors.

Correlation between the Body Mass Index (BMI) of Pregnant Women and the Development of Hypotension after Spinal Anesthesia for Cesarean Section

Very few publications correlate hypotension in obese pregnant women, and especially morbidly obese, after spinal anesthesia for cesarean section. The objective of the present study was to evaluate the incidence of hypotension according to the BMI. Forty-nine patients with pregestational BMI below 25 kg.m(-2) were included in the Eutrophia group, and 51 patients with BMI ≥ 25 kg.m(-2) were included in the Overweight group. After spinal anesthesia, blood pressure, volume of crystalloid infused, and dose of vasopressors used until delivery were recorded. A fall in systolic blood pressure below 100 mmHg or 10% reduction of the initial systolic blood pressure (SBP) was considered as hypotension and it was corrected by the administration of vasopressors. Episodes of hypotension were fewer in the Eutrophia group (5.89 ± 0.53 vs. 7.80 ± 0.66, p = 0.027), as well as the amount of crystalloid administered (1,298 ± 413.6 mL vs. 1,539 ± 460.0 mL; p = 0.007), and use of vasopressors (5.87 ± 3.45 bolus vs. 7.70 ± 4.46 bolus; p = 0.023). As for associated diseases, we observed higher incidence of diabetes among obese pregnant women (29.41% vs. 9.76%, RR 1.60, 95%CI: 1.15-2.22, p = 0.036), however, differences in the incidence of pregnancy-induced hypertension (PIH) were not observe between both groups (overweight: 21.57%, normal weight: 12.20%, RR 1.30, 95%CI: 0.88-1.94, p = 0.28). In the study sample, pregestational BMI ≥ 25 kg.m(-2) was a risk factor for hypotension after spinal anesthesia in patients undergoing cesarean section. The same group of patients required higher doses of vasopressors. Those results indicate that the anesthetic techniques in those patients should be improved to reduce the consequences of post-spinal anesthesia hypotension, both in pregnant women and fetuses.

Sustained Hypotension With Initial Low Dose of Quetiapine in a Middle-Aged Man Receiving an Antihypertensive Agent

To the Editor: Quetiapine may induce orthostatic hypotension associated with dizziness, tachycardia, and, in some patients, syncope especially during the initial dose titration period.1 Sustained hypotension (defined as a systolic blood pressure 60 minutes) with quetiapine has been described only in significant overdoses.2–4 Due to its potential for inducing hypotension, quetiapine may enhance the effects of certain antihypertensive medications.1 We present a case of sustained hypotension in a middle-aged man on an antihypertensive agent with a single low dose of quetiapine. Case report. Mr A, a 46-year-old man, presented in 2010 with the police following self-inflicted lacerations to his wrists and a polypharmacy overdose of acetaminophen, codeine phosphate, and paroxetine in the context of marital discord. He described depressive symptoms, episodic severe anxiety symptoms, and a passive wish to die over the preceding 2 weeks. He had a history of hypertension (controlled well on irbesartan 300 mg/d and hydrochlorothiazide 12.5 mg/d combination; blood pressure at presentation was 139/94 mm Hg). On examination, he presented as markedly distressed, crying, preoccupied with current stressors, and expressing ideas of hopelessness and suicidal ideas with intent. There was a mild derangement of his renal and liver functions, attributable to the overdose, that did not require medical intervention. He was diagnosed with an adjustment disorder with depressed mood (DSM-IV criteria), and the treatment prescribed was escitalopram 10 mg in the morning and quetiapine 50 mg bid for agitation. His antihypertensive medication was unchanged. On the morning that this treatment was initiated, he had a fall 40 minutes after he received his first dose of escitalopram and quetiapine. He had taken his antihypertensive medication as usual that morning, and his blood pressure was within normal limits. On examination at the time of the fall, blood pressure was recorded as 65/43 mm Hg, and his electrocardiogram revealed no abnormalities. There was no loss of consciousness, and he had a full recollection of events afterward. Findings of the rest of the examination were completely within normal limits. Over the next 8 hours, he received intensive medical care, intravenous fluids, gelofusine, and metaraminol 0.5 mg. At the end of 1 hour of this treatment, his systolic blood pressure was 55 mg Hg, and at the end of 8 hours, he achieved a blood pressure of 105/70 mm Hg. Over the next 16 hours, his blood pressure continued to remain unstable, finally stabilizing about 24 hours after the fall at about 120/76 mm Hg. Both the antihypertensive medication and quetiapine were stopped. He maintained his improvement and was discharged from the hospital 10 days later. The patient was being treated with an angiotensin II receptor antagonist and thiazide diuretic for hypertension. Irbesartan blocks the potent vasoconstrictor and aldosterone-secreting effects of angiotensin II, and hydrochlorothiazide has diuretic, natriuretic, and antihypertensive effects.1 This combination is known to potentiate the antihypertensive actions of ganglionic or peripheral adrenergic-blocking drugs, like quetiapine, which has high antagonistic activity at α-adrenergic receptors.1 No other risk factors for hypotension were operative in this case. It is noteworthy that the hypotension was severe and sustained given that the patient had received only his first dose of 50 mg quetiapine and that, prior to receiving this dose, his blood pressure was normal and stable. This suggests caution when initiating the use of quetiapine in individuals receiving antihypertensive medication(s), even in the absence of cardiovascular or other risk factors for hypotension. In such circumstances, we suggest initiation of quetiapine therapy at a dose of 12.5 or 25 mg, slow upward titration, and careful monitoring of blood pressure. This caution is all the more important as quetiapine is increasingly being used for indications other than psychosis, in a variety of treatment settings.5

Maternal Hypotension During Elective Cesarean Section and Short-term Neonatal Outcome

Objective To investigate the extent and risk factors for hypotension among women undergoing elective cesarean section, and whether maternal hypotension has any impact on perinatal infant outcome. Study Design Retrospective analysis of data on 919 mother-infant pairs after elective cesarean section that involved the use of regional anesthetic. Data collection included information on maternal blood pressure during the cesarean section procedure and any infant perinatal complications. Results Nearly one-half of the mothers underwent a decrease in their mean arterial blood pressure by ≥30%. The risk factors for hypotension included preoperative hypertension, older age, type of spinal anesthesia, and a higher infant birthweight. A drop in the maternal mean arterial blood pressure exceeding 30% or even 50% compared with the preoperative value was not found to predict any perinatal complications. Conclusion Despite a very high prevalence of maternal hypotension during cesarean sections, term infants tend to tolerate this placental blood perfusion challenge without any major sequel.

ENDOTHELIAL NITRIC OXIDE SYNTHASE G894T (GLU298ASP) POLYMORPHISM IS ASSOCIATED WITH HYPOTENSION IN PATIENTS WITH E. coli BACTEREMIA BUT NOT IN BACTEREMIA CAUSED BY A GRAM-POSITIVE ORGANISM

Nitric oxide (NO) as a vasoactive substance is a crucial element in the pathogenesis of sepsis. Endothelial NO synthase (eNOS) is, in turn, a key regulator of vascular NO production. The eNOS gene polymorphism at position 894 (G>T, Glu298Asp) resulting in T allele has been studied in the context of vascular diseases, but its role in sepsis has not yet been explored. We here studied the effect of eNOS Glu298Asp polymorphism on the clinical course of the disease in patients with bacteremia. The study comprised 147 patients with bacteremia caused by Staphylococcus aureus, Streptococcus pneumoniae, beta-hemolytic streptococci, or Escherichia coli. Laboratory findings and clinical data were registered on admission and during 6 consecutive days. The polymorphism of eNOS gene, G894T, was genotyped. Carriage of the T allele was associated with low MAP (P = 0.004) and high Sequential Organ Failure Assessment score (P = 0.001) in patients with E. coli bacteremia. The effect on blood pressure was most prominent in the early stage of the disease (MAP on admission = 52 mmHg in T-allele carriers vs. 91 mmHg in noncarriers; P < 0.001). However, the same was not detected in bacteremia caused by a gram-positive organism (S. aureus, S. pneumoniae, or beta-hemolytic streptococci). The Glu298Asp polymorphism had no effect on case fatality in any pathogen. Carriage of the T allele of the eNOS gene is a risk factor for hypotension in patients with E. coli bacteremia but not in bacteremia caused by a gram-positive organism.

Factors associated with hypotension and bradycardia after carotid angioplasty and stenting

Acute procedurally induced hemodynamic depression can occur after carotid angioplasty and stenting (CAS). This study was performed to determine the frequency and risk factors for hypotension and bradycardia after the CAS procedure. The study reviewed clinical variables and angiographic data of all patients undergoing elective CAS with neuroprotection during a recent 5-year period. Intravenous atropine was given selectively in cases of bradycardia (heart rate <60 beats/min or a decrease of >20 beats/min). We further defined hemodynamic depression as bradycardia or severe hypotension (systolic blood pressure fall >30 mm Hg). Frequency and potential risk factors for hemodynamic depression were analyzed by logistic regression. During the study period, 416 patients (99% male; mean age, 74 +/- 11 years) underwent the CAS procedure. The median degree of stenosis was 93% (range, 60% to 99%). The frequencies of post-CAS hemodynamic depression include hypotension in 58 (14%), bradycardia in 112 (27%), or both in 21 (5%). All patients with bradycardia received intraprocedural atropine, and all heart rates returned to the baseline level. Persistent hypotension occurred in 45 patients (11%). Increased age was associated with CAS-induced bradycardia or hypotension. Adjusted risk factors associated with hemodynamic depression include age >78 years (odds ratio [OR], 5.25; 95% confidence interval [CI], 2.32 to 15.25; P = .01) and ejection fraction of <25% (OR, 3.25; 95% CI, 0.58 to 6.58; P = .02). CEA-related restenosis was associated with a reduced risk of hemodynamic depression (OR, 0.21; 95% CI, 0.12 to 0.69, P = .001). Persistent hypotension after CAS was associated with an increased risk of an adverse clinical event (44%, P = .001). Hemodynamic depression, including hypotension and bradycardia, is frequent after CAS. However, CAS-induced hemodynamic depression is rare in patients with postendarterectomy stenosis. Patients with compromised ejection fraction and increased age are at a higher risk of presenting with CAS-induced hemodynamic instability, and persistent hypotension after CAS is associated with an increased postprocedural complication rate.