Risk Of Hemodynamic Instability Research Articles

A screening for cerebral deoxygenation during VT ablations in patients with structural heart disease.

Patients undergoing ventricular tachycardia (VT) ablation often present with structural heart disease (SHD) and reduced ejection fraction. Inducing VT by programmed electrical stimulation (PES) puts these patients at risk for hemodynamic instability and cerebral hypoperfusion. The present study screens for cerebral oxygen desaturation phases (ODPs) in patients undergoing VT ablation. Forty-seven patients (age 61 ± 14years, 72% males) underwent ablation of sustained VT with simultaneous neuromonitoring using near-infrared spectroscopy (NIRS). Analysis of NIRS signal identified ODPs in 29 patients (62%). ODPs were associated with a higher prevalence of ischemic heart disease (IHD) (45% vs. 11%, p = 0.024), previous VT episodes (n = 16 vs. 4, p = 0.018), and VTs inducible by PES (n = 2.4 vs. 1.2, p = 0.004). Patients with ODPs were more likely to be admitted to intensive care unit (ICU) (78% vs. 33%, p = 0.005) and had more in-hospital VT recurrences (24% vs. 0%, p = 0.034). No differences were observed in VT recurrencerates after hospital discharge (41.4% vs. 44.4%, p = 0.60) and left ventricularejection fraction (34% vs. 38%, p = 0.567). IHD (OR: 32.837, p = 0.006), ICU admission (OR: 14.112, p = 0.013), and the number of VTs inducible at PES (OR: 2.705, p = 0.015) were independently associated with ODPs. This study registers episodes of cerebral hypoperfusion in 62% of patients undergoing VT ablation and identifies IHD and the number of VTs inducible at PES as possible risk factors for these episodes.

Side-specific factors for intraoperative hemodynamic instability in laparoscopic adrenalectomy for pheochromocytoma: a comparative study

BackgroundAdrenalectomy for pheochromocytoma (PHEO) is challenging because of the high risk of intraoperative hemodynamic instability (HDI). This study aimed to compare the incidence and risk factors of intraoperative HDI between laparoscopic left adrenalectomy (LLA) and laparoscopic right adrenalectomy (LRA).MethodsWe retrospectively analyzed two hundred and seventy-one patients aged > 18 years with unilateral benign PHEO of any size who underwent transperitoneal laparoscopic adrenalectomy at our hospitals between September 2016 and September 2023. Patients were divided into LRA (N = 122) and LLA (N = 149) groups. Univariate and multivariate logistic regression analyses were used to predict intraoperative HDI. In multivariate analysis for the prediction of HDI, right-sided PHEO, PHEO size, preoperative comorbidities, and preoperative systolic blood pressure were included.ResultsIntraoperative HDI was significantly higher in the LRA group than in the LLA (27% vs. 9.4%, p < 0.001). In the multivariate regression analysis, right-sided tumours showed a higher risk of intraoperative HDI (odds ratio [OR] 5.625, 95% confidence interval [CI], 1.147–27.577, p = 0.033). The tumor size (OR 11.019, 95% CI 3.996–30.38, p < 0.001), presence of preoperative comorbidities [diabetes mellitus, hypertension, and coronary heart disease] (OR 7.918, 95% CI 1.323–47.412, p = 0.023), and preoperative systolic blood pressure (OR 1.265, 95% CI 1.07–1.495, p = 0.006) were associated with a higher risk of HDI in both LRA and LLA, with no superiority of one side over the other.ConclusionLRA was associated with a significantly higher intraoperative HDI than LLA. Right-sided PHEO was a risk factor for intraoperative HDI.

Impact of intravenous dexmedetomidine on postoperative gastrointestinal function recovery: an updated meta-analysis.

Postoperative ileus (POI) is a complication that may occur after abdominal or nonabdominal surgery. Intravenous dexmedetomidine (Dex) has been reported to accelerate postoperative gastrointestinal function recovery; however, updated evidence is required to confirm its robustness. To identify randomized controlled trials examining the effects of perioperative intravenous Dex on gastrointestinal function recovery in patients undergoing noncardiac surgery, databases including MEDLINE, EMBASE, Google Scholar, and Cochrane Library were searched on August 2023. The primary outcome was time to first flatus. Secondary outcomes included time to oral intake and defecation as well as postoperative pain scores, postoperative nausea/vomiting (PONV), risk of hemodynamic instability, and length of hospital stay (LOS). To confirm its robustness, subgroup analyses and trial sequential analysis were performed. The meta-analysis of 22 randomized controlled trials with 2566 patients showed that Dex significantly reduced the time to flatus [mean difference (MD):-7.19h, P <0.00001), time to oral intake (MD: -6.44h, P =0.001), time to defecation (MD:-13.84h, P =0.008), LOS (MD:-1.08 days, P <0.0001), and PONV risk (risk ratio: 0.61, P <0.00001) without differences in hemodynamic stability and pain severity compared with the control group. Trial sequential analysis supported sufficient evidence favoring Dex for accelerating bowel function. Subgroup analyses confirmed the positive impact of Dex on the time to flatus across different surgical categories and sexes. However, this benefit has not been observed in studies conducted in regions outside China. Perioperative intravenous Dex may enhance postoperative gastrointestinal function recovery and reduce LOS, thereby validating its use in patients for whom postoperative ileus is a significant concern.

Ultrasound guided erector spinae plane block versus intrathecal morphine for analgesia following major hepatopancreaticobiliary surgery

ABSTRACT Background Intrathecal morphine (ITM) has been evidenced to provide efficient analgesia for hepatopancreaticobiliary surgery (HPB) in the postoperative period. Despite its benefits, ITM carries certain risks, such as pruritus, postoperative nausea and vomiting, and of utmost importance, the possibility of delayed respiratory depression. We conducted this study to compare the effectiveness of bilateral erector spinae plane block (ESPB) and ITM for analgesia following major HPB surgery. Our hypothesis was that bilateral ESPB would lead to a significant reduction in opioid consumption within the first 24 hours following surgery, with a lower incidence of side effects. Methods Forty patients with scheduled major HPB surgery were randomly allocated to receive either bilateral ESPB (n = 20) or ITM (n = 20) before general anesthesia induction. The primary outcome was cumulative postoperative nalbuphine consumption in the first 24 hours. Results Cumulative nalbuphine consumption at 24 hours after surgery was significantly lower in the ITM group compared to ESPB (3.05 ± 0.38 versus 6.56 ± 0.88 respectively). However, the ESPB group demonstrated effective pain control as indicated by pain scores of ≤2 at rest and ≤3 when coughing throughout all measured time points. Moreover, ESPB significantly reduced the incidence of postoperative nausea, vomiting (p = 0.03), and pruritus (p = 0.003) within the first 24 hours postoperatively compared to ITM. Conclusions Although bilateral ESPB resulted in higher opioid consumption than ITM in the first 24 hours after major HPB surgery, the adverse effects were less with minimal or no risk of hemodynamic instability.

Efficacy of propofol-based anesthesia against risk of brain swelling during craniotomy: A meta-analysis of randomized controlled studies

Study objectiveThis meta-analysis aimed to compare the risk of brain swelling during craniotomy between propofol-based and volatile-based anesthesia. DesignMeta-analysis of randomized controlled trials (RCTs). SettingOperating room. InterventionPropofol-based anesthesia. PatientsAdult patients undergoing craniotomy. MeasurementsDatabases, including EMBASE, MEDLINE, Google Scholar, and Cochrane Library, were searched from inception to April 2023. The primary outcome was the risk of brain swelling, while the secondary outcomes included the impact of anesthetic regimens on surgical and recovery outcomes, as well as the risk of hemodynamic instability. Main resultsOur meta-analysis of 17 RCTs showed a significantly lower risk of brain swelling (risk ratio [RR]: 0.85, p = 0.03, I2 = 21%, n = 1976) in patients receiving propofol than in those using volatile agents, without significant differences in surgical time or blood loss between the two groups. Moreover, propofol was associated with a lower intracranial pressure (ICP) (mean difference: −4.06 mmHg, p < 0.00001, I2 = 44%, n = 409) as well as a lower risk of tachycardia (RR = 0.54, p = 0.005, I2 = 0%, n = 822) and postoperative nausea/vomiting (PONV) (RR = 0.59, p = 0.002, I2 = 19%, n = 1382). There were no significant differences in other recovery outcomes (e.g., extubation time), risk of bradycardia, hypertension, or hypotension between the two groups. Subgroup analysis indicated that propofol was not associated with a reduced risk of brain swelling when compared to individual volatile agents. Stratified by craniotomy indications, propofol reduced brain swelling in elective craniotomy, but not in emergency craniotomy (e.g., traumatic brain injury), when compared to volatile anesthetics. ConclusionsBy reviewing the available evidence, our results demonstrate the beneficial effects of propofol on the risk of brain swelling, ICP, PONV, and intraoperative tachycardia. In emergency craniotomy for traumatic brain injury and subarachnoid hemorrhage, brain swelling showed no significant difference between propofol and volatile agents. Further large-scale studies are warranted for verification.

Dose Escalation Pharmacokinetic Study of Intranasal Atomized Dexmedetomidine in Pediatric Patients With Congenital Heart Disease.

Atomized intranasal dexmedetomidine is an attractive option when sedation is required for pediatric patients as either premedication or the sole agent for noninvasive, nonpainful procedures. While intranasal dexmedetomidine is used frequently in this population, it is still unclear what dose and time of administration relative to the procedure will result in the optimal effect. Knowledge regarding the maximum concentration (C max ) and time to reach maximum concentration (T max ) of intranasally administered dexmedetomidine is the first step toward this. The risk of hemodynamic instability caused by increasing doses of dexmedetomidine necessitates a greater understanding of the pharmacokinetics in children. Sixteen pediatric patients 2 to 6 years of age undergoing elective cardiac catheterization received 2 or 4 μg/kg dexmedetomidine intranasally. Plasma concentrations were determined by liquid chromatography-tandem mass spectrometry with a validated assay. Descriptive noncompartmental analysis provided estimates of peak concentrations and time to reach peak concentrations. A population pharmacokinetic model was developed using nonlinear mixed-effects modeling. Simulations were performed using the final model to assess dose concentrations with an alternative dosing regimen of 3 µg/kg. A median peak plasma concentration of 413 pg/mL was achieved 91 minutes after 2 μg/kg dosing, and a median peak plasma concentration of 1000 pg/mL was achieved 54 minutes after 4 μg/kg dosing. A 1-compartment pharmacokinetic model adequately described the data. Three subjects in the 4 μg/kg dosing cohort achieved a dose-limiting toxicity (DLT), defined as a plasma dexmedetomidine concentration >1000 pg/mL. None of these subjects had any significant hemodynamic consequences. Simulations showed that no subjects would experience a level >1000 pg/mL when using a dose of 3 µg/kg. Concentrations associated with adequate sedation can be achieved with intranasal dexmedetomidine doses of 2 to 4 µg/kg in children 2 to 6 years of age. However, 50% of our evaluable subjects in this cohort reached a plasma concentration >1000 pg/mL. Doses of 3 µg/kg may be optimal in this population, with simulated concentrations remaining below this previously established toxicity threshold. Further studies correlating concentrations with efficacy and adverse effects are needed.

Hemodynamic Effects of Methamphetamine and General Anesthesia.

Design A retrospective analysis of all anesthetic records at our institution over a two-year period was performed. Setting. Operating room cases under balanced anesthesia. Patients. All patients with ASA class I or II, who did not have trauma or were initially admitted to ICU, aged 18–65, without preexisting cardiac, renal, or pulmonary disease. Patients were divided into three groups: those acutely positive for methamphetamine within 48 hours of surgery (n = 137), those positive for methamphetamine between 48 hours and 7 days of surgery (n = 69), and randomly selected controls who were negative for methamphetamine within 7 days of surgery (n = 159). Measurements. Intraoperative hemodynamic instability was defined as either a drop of more than 40% in MAP for greater than 5 minutes or requirement for significant amount of vasopressors. Main Results. Among the patients who were acutely positive for methamphetamine within 24 hours, 31.4% met the criteria for hemodynamic instability within the first hour of general anesthesia, compared to 26.1% of the subacutely positive patients and 6.3% of controls (p < 0.0001). This was despite lower doses of anesthetic medications in the acutely and subacutely positive groups. Conclusion Patients who present to the operating room with a positive urine drug screen for amphetamines within 2 days of surgery are at increased risk of hemodynamic instability. Postponing surgery up to 7 days somewhat decreases this risk, but not to the levels of patients who do not use methamphetamines.

Risk factors for haemodynamic instability and its prolongation during laparoscopic adrenalectomy for pheochromocytoma.

Pheochromocytoma is a rare neuroendocrine tumour that secretes catecholamines and originates in the adrenal gland. Although surgical resection is the only curative therapy for pheochromocytoma, it is associated with a risk of haemodynamic instability (HDI), such as extremelyhigh blood pressure and/or post tumour removal hypotension and shock. We investigated the risk factors for HDI during pheochromocytoma surgery. Eighty-two patients who underwent laparoscopic adrenalectomy for pheochromocytoma between July 2002 and February 2020 were examined. We excluded 3 patients with bilateral disease and 11 without detailed 24 hurinary data. We defined HDI as systolic blood pressure ≥ 200or <80 mmHg. We investigated the risk factors for HDI during laparoscopic adrenalectomy for pheochromocytoma. There were 29 males and 39 females with a median age of 50.5 years. Tumours were localised on the right adrenal gland in 28 patients and on the left in 40. The median tumour diameter was 37.5 mm and the median pneumoperitoneum time was 93.5 min. Twenty-five out of sixty-eight patients (37%) developed HDI. A multivariate analysis identified diabetes mellitus (DM; odds ratio: 3.834; 95% confidence interval: 1.062-13.83; p = .04) as an independent predictor of HDI. In terms of hormonal data, median 24 hurinary epinephrine levels (p = .04) and metanephrine levels (p = .01) were significantly higher in the HDI group. DM was also considered as a risk factor for prolonged HDI (p = .02). Surgeons and anaesthesiologists need to be aware of the risk of HDI and its prolongation during laparoscopic adrenalectomy for pheochromocytoma for DM patients.

Aortic Valve Disease and Associated Complex CAD: The Interventional Approach.

Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis (AS). The management of CAD is a central aspect of the work-up of patients undergoing transcatheter aortic valve implantation (TAVI), but few data are available on this field and the best percutaneous coronary intervention (PCI) practice is yet to be determined. A major challenge is the ability to elucidate the severity of bystander coronary stenosis independently of the severity of aortic valve stenosis and subsequent impact on blood flow. The prognostic role of CAD in patients undergoing TAVI is being still debated and the benefits and the best timing of PCI in this context are currently under evaluation. Additionally, PCI in the setting of advanced AS poses some technical challenges, due to the complex anatomy, risk of hemodynamic instability, and the increased risk of bleeding complications. This review aims to provide a comprehensive synthesis of the available literature on myocardial revascularization in patients with severe AS undergoing TAVI. This work can assist the Heart Team in individualizing decisions about myocardial revascularization, taking into account available diagnostic tools as well as the risks and benefits.

Electrolyte-based calculation of fluid shifts after infusing 0.9% saline in severe hyperglycemia

BackgroundEarly treatment of severe hyperglycemia involves large shifts of body fluids that entail a risk of hemodynamic instability. We studied the feasibility of applying a new electrolyte equation that estimates the degree of volume depletion and the distribution of infused 0.9% saline in this setting.MethodsThe new equation was applied to plasma and urinary concentrations of sodium and chloride measured before and 30 min after a 30-min infusion of 1 L of 0.9% saline on two consecutive days in 14 patients with severe hyperglycemia (mean age 50 years). The extracellular fluid (ECF) volume was also estimated based on the volume dilution kinetics of chloride.ResultsOn day 1, the baseline ECF volume amounted to 11.5 L. The saline infusion expanded the ECF space by 160 mL and the intracellular fluid space by 375 mL. On day 2, the ECF volume was 15.5 L, and twice as much of the infused fluid remained in the ECF space. The chloride dilution kinetics yielded baseline ECF volumes of 11.6 and 15.2 L on day 1 and day 2, respectively. No net uptake of glucose to the cells occurred during the two 1-h measurement periods despite insulin administration in the intervening time period.ConclusionsThe electrolyte equation was feasible to apply in a group of hyperglycemic patients. The ECF space was 3 L smaller than expected on admission but normal on the second day. Almost half of the infused fluid was distributed intracellularly.

Are Peripartum Stress-Dose Steroids Necessary?

(Obstet Gynecol. 2020;135:522–525) The practice of administering stress-dose steroids for all corticosteroid-treated patients undergoing vaginal or cesarean delivery has been in place since the 1950s, despite the inconsistencies in the research that recommends this tradition. Present-day studies, such as a 2014 study by Zaghiyan and colleagues, indicate that perioperative corticosteroids do not have a measurable effect on a patient’s risk of hemodynamic instability. Sylvester-Armstrong and colleagues have examined a number of studies related to steroid administration to assert that stress-dose steroids are unnecessary for labor and delivery and the aforementioned practice should be retired.

P0627INTRAOPERATIVE DIALYSIS DURING LIVER TRANSPLANTATION IS SAFE AND BENEFICIAL

Abstract Background and Aims Orthotopic liver transplantation (OLt) is a technically complex surgical procedure associated with a major risk of hemodynamic instability and metabolic derangement, especially in patients with coexisting renal dysfunction. It remains uncertain if intraoperative renal replacement therapy (ioRRT) during OLt could be beneficial and in which subset of patients. Method A retrospective observational study of all adult patients undergoing intraoperative renal replacement therapy during OLt in our center from January 2010 till December 2018. IoRRT consisted of dialysis performed with the use of mobile Genius® single-pass batch dialysis system. Results 1319 OLts were conducted during the study period and 129 patients (9,8%) were treated with intraoperative dialysis. Seven patients with incomplete documentation were excluded from the study. The mean age of the cohort was 47,8±14,7 years, and 73 (60%) of patients were men. The mean calculated MELD score was 33,7±12,5. 41 procedures (33,6%) were retransplantations and 7 patients underwent simultaneous liver and kidney transplantation. 18 (14,7%) recipients had fulminant liver failure. 66 (54,1%) of patients were admitted to Intensive Care Unit before transplantation. The mean preoperative serum creatinine level was 2,95±1,15 mg/dl and 95 (78%) patients were undergoing renal replacement therapy or had creatinine level ≥2 mg/dl preoperatively. Others required emergent ioRRT due to intraoperative complications and development of significant hyperkalemia or acidosis. The mean preoperative serum potassium concentration was 4,23±0,68 mmol/l and the mean bicarbonate level was 19,8±4,5 mmol/l. Intraoperative dialysis was performed without anticoagulation. The mean surgical time was 400±90,6 minutes and the mean ioRRT duration remained 308 ±109 minutes. Dialysis circuit clotting occurred in 9 (7,3%) cases. There were no other adverse events of ioRRT. Achieved mean arterial bicarbonate and potassium levels after graft reperfusion were 18,5±3,6 and 3,8±0,95 mmol/l, respectively. In 111 cases dialysis was initiated at least 15 minutes before reperfusion. 13% of this subgroup (16 pts) experienced post-reperfusion syndrome (defined as a decrease in the mean arterial pressure of more than 30% of the baseline, occurring within first 5 minutes after the reperfusion of the graft and lasting at least 1 minute). Conclusion Our data suggests that intraoperative dialysis in severely ill patients with high MELD score is safe and effective. Lower than expected post-reperfusion syndrome occurrence needs to be confirmed in a study designed with appropriate control group.

The role of serratus anterior plane and pectoral nerves blocks in cardiac surgery, thoracic surgery and trauma: a qualitative systematic review.

Serratus anterior plane and pectoral nerves blocks are recently described alternatives to established regional anaesthesia techniques in cardiac surgery, thoracic surgery and trauma. We performed a systematic review to establish the current state of evidence for the analgesic role of these fascial plane blocks in these clinical settings. We identified relevant studies by searching multiple databases and trial registries from inception to June 2019. Study heterogeneity prevented meta-analysis and studies were instead qualitatively summarised and stratified by type of surgery and comparator. We identified 51 studies: nine randomised control trials; 13 cohort studies; 19 case series; and 10 case reports. The majority of randomised controlled trials studied the serratus anterior plane block in thoracotomy or video-assisted thoracoscopic surgery, with only two investigating pectoral nerves blocks. The evidence in thoracic trauma comprised only case series and reports. Results indicate that single-injection serratus anterior plane and the pectoral nerves blocks reduce pain scores and opioid consumption compared with systemic analgesia alone in cardiothoracic surgery, cardiac-related interventional procedures and chest trauma for approximately 6-12h. The duration of action appears longer than intercostal nerve blocks but may be shorter than thoracic paravertebral blockade. Block duration may be prolonged by a continuous catheter technique with potentially similar results to thoracic epidural analgesia. There were no reported complications and the risk of haemodynamic instability appears to be low. The current evidence, though limited, supports the efficacy and safety of serratus anterior plane and the pectoral nerves blocks as analgesic options in cardiothoracic surgery.

Gestational gigantomastia

Introduction: Gigantomastia is a disease of unknown etiology, which can occur in two different situations: gestational and non-gestational phases. The gestational type is a rare complication that affects 1:28,000 to 1:100,000 pregnancies and is usually bilateral. It consists of a diffuse, massive breast increase during pregnancy. In a normal pregnancy, the breasts double in size without sequelae; however, in this disease, the breast tissue may experience a 10 to 20-fold increase. The treatment varies from drug therapy to plastic surgery (mammaplasty) and radical surgery (mastectomy). Objectives: To report a case of gestational gigantomastia, its treatment approach, and outcome. Methods: Data from this study were obtained from a multidisciplinary clinical experience, image records, and literature search. Case Report: An 18-year-old patient, admitted to the mastology department of Hospital Guilherme Álvaro, in Santos, Southeastern Brazil, was diagnosed with gigantomastia in her 23rd week of pregnancy. The exacerbated breast growth during the gestational period caused pain and functional impairment to the patient. Bilateral mastectomy was performed at 27 weeks of pregnancy due to the worsening of her pulmonary condition, leading to the risk of maternal and fetal death. Macroscopic anatomopathological examination revealed breasts with a total weight of 27 kg, lobular hyperplasia, pronounced stromal hyperplasia, and necrosis of the breast parenchyma. She stayed in the intensive care unit during the postoperative period with good progression. The patient had a normal delivery at 38 weeks of gestation with a live fetus. Discussion: The ideal management for gestational gigantomastia is not clear. The treatment includes surgeries (reduction mammaplasty and total mastectomy with or without reconstruction), medications, or a combination of both. In the current case, the treatment chosen was mastectomy during pregnancy due to respiratory distress and the risk of sepsis by ischemic tissue necrosis. During the surgical procedure, there was a risk of hemodynamic instability, given the large volume of breast removed, representing 40% of the total weight of the patient. Conclusion: Gestational gigantomastia is an exceptionally rare condition, and the literature has few reports on the subject. The therapeutic management depends on factors intrinsic to the patient, so each case requires individualization. The therapeutic decision aims at the best prognosis, taking into account possible complications and a reduction in maternal and fetal morbidity.

Umbilical Cord Blood Gas in Newborns with Prenatal Diagnosis of Congenital Heart Disease: Insight into In-Utero and Delivery Hemodynamics.

The primary objective was to determine if newborns with congenital heart disease (CHD) are at a higher risk for acidosis at delivery as determined by cord blood gas analysis. The secondary objective was to determine whether specific fetal cardiac diagnosis, delivery method, or duration of labor is associated with an increased risk for acidosis. This was a retrospective study of newborns with CHD diagnosed prenatally and comparable patients without a CHD diagnosis. Study participants included 134 CHD-affected newborns and 134 controls. Median UA pH in CHD newborns was 7.22 (CI 7.2-7.4) and in controls it was 7.22 (CI 7.21-7.24), p = 0.91. There was no difference in median UA pH comparing newborns with single-ventricle CHD and two-ventricle CHD [7.23 (CI 7.2-7.26) vs. 7.22 (CI 7.22-7.24), p = 0.77], or newborns with CHD with aortic obstruction and those without aortic obstruction [7.23 (CI 7.21-7.26) vs. 7.22 (CI 7.2-7.24), p = 0.29]. After controlling for delivery method and duration of labor, CHD patients who underwent a spontaneous vaginal delivery were found to have a declining median UA pH as labor progressed. Our results show that newborns with CHD have a normal UA pH at delivery suggesting a compensated circulation in utero. Spontaneous vaginal delivery with a progressively longer duration of labor in CHD newborns was associated with lower UA pH. This suggests that fetuses with CHD may be at risk for hemodynamic instability at birth with a longer duration of labor as a potentially modifiable factor to improve outcome.

MON-358 Hypertensive Crisis during CT-Guided Microwave Ablation for Adrenal Metastasis

Introduction We present a previously normotensive patient with history of metastatic esophageal adenocarcinoma to the adrenal gland who developed elevated blood pressure and tachycardia during a CT-guided microwave ablation. Clinical Case 67-year-old male with history of stage IV esophageal adenocarcinoma diagnosed in 2015. He was not a surgical candidate and therefore treated with chemotherapy and radiation. In 1/2017, abdominal magnetic resonance imaging (MRI) was done and revealed a left 3.8 x 4 x 4.7 cm adrenal mass. He had a biopsy of the lesion which was negative for adrenocortical cancer but suspected metastasis from the esophageal cancer. He underwent CT-guided microwave ablation of the adrenal mass and during the procedure developed high blood pressure (160/90) and tachycardia (122 bpm). Post-procedure work up for pheochromocytoma or primary hyperaldosteronism were negative. In 3/2017, he had a PET/CT scan which revealed an increase in size of adrenal mass. CT-guided microwave ablation was planned and pre-procedure, he was treated with Doxazosin titrated to 4 mg daily and then Metoprolol 12.5 mg daily. The ablation was successful without complication. Discussion Microwave ablation is a thermal-based therapeutic intervention used for eradication of tumor or reduce tumor burden. It can be an effective treatment option in various malignancies especially for individuals who are poor surgical candidate. Since it is a targeted procedure, it does carry risk of affecting surrounding tissue which may result in potential adverse event. There are few reports of ablation-induced hypertensive crisis in adrenal mass. It was thought to be due to catecholamine release from the normal adrenal medulla tissue. Catecholamine release will result in heightened sympathetic effect as seen in our patient. If not identified early, there may be a detrimental adverse event including death. It has been shown that pre-treatment with alpha-1-adrenergic antagonist followed by a beta-adrenergic antagonist can decrease catecholamine effect during the procedure. Conclusion CT-guided microwave ablation is an effective treatment in non-functioning adrenal tumor but with a risk for hemodynamic instability which may be prevented with prophylactic alpha-1-adrenergic antagonist before the procedure.

Assessing Clinical Utility of Cerebral Oximetry Monitoring During Pediatric Scoliosis Surgery

Introduction High-quality evidence indicates that active cerebral oximetry monitoring during surgery improves patient outcomes in populations at risk for hemodynamic instability. This project piloted the use of a near-infrared spectroscopy (NIRS) monitor in a pediatric surgical population with similar risk factors. Controlled hypotension is an anesthetic technique used to minimize blood loss during pediatric spinal surgery for scoliosis correction. Consensus for safe blood pressure thresholds does not exist, and cerebral oxygenation may be impeded during this anesthetic technique. Methods Fifteen pediatric patients scheduled for posterior spinal fusion and scoliosis correction received intraoperative NIRS monitoring. Regional cerebral oxygen saturation (rSO2) and blood pressure data were collected. Possible relationships between mean arterial pressure and rSO2 were also explored. Anesthesia provider feedback regarding device use was obtained via a voluntary survey. Results Twenty-four cerebral desaturation events (CDEs) were recorded among four patients (27%) involved in the project. The median CDE duration, nadir rSO2, and percent change from baseline was 3.38 minutes, 69%, and 22.5%, respectively (Interquartile ranges = 8.69, 22, and 22.99). There was no relationship between mean cerebral rSO2 and mean arterial pressure (rs (25) = −0.194, p = .353). Discussion The results support the continued use of NIRS monitoring during pediatric scoliosis surgery. Analysis of individual CDEs reveals that some patients may incur more prolonged and significant CDEs. In addition, cerebral desaturations are difficult to predict using solely blood pressure parameters. Device ease of use, availability, and a high perception of clinical utility among anesthesia providers support adoption of the monitor in this setting.

Does intranasal dexmedetomidine provide adequate plasma concentrations for sedation in children: a pharmacokinetic study

BackgroundAtomised intranasal dexmedetomidine administration is an attractive option when sedation is required for paediatric diagnostic procedures, as vascular access is not required. The risk of haemodynamic instability caused by dexmedetomidine necessitates better understanding of its pharmacokinetics in young children. To date, intranasal dexmedetomidine pharmacokinetics has only been studied in adults. MethodsEighteen paediatric patients received dexmedetomidine 1 or 2 μg kg−1 intranasally or 1 μg kg−1 i.v. Plasma concentrations were determined by liquid chromatography/mass spectrometry. Non-compartmental analysis provided estimates of Cmax and Tmax. Volume of distribution, clearance, and bioavailability were estimated by simultaneous population PK analysis of data after intranasal and i.v. administration. Dexmedetomidine plasma concentration-time profiles were evaluated by simulation for intranasal and i.v. administration. ResultsAn average peak plasma concentration of 199 pg ml−1 was achieved 46 min after 1 μg kg−1 dosing and 355 pg ml−1 was achieved 47 min after 2 μg kg−1 dosing. A two-compartment pharmacokinetic model, with allometrically scaled parameters, adequately described the data. Typical bioavailability was 83.8% (95% confidence interval 69.5–98.1%). ConclusionMean arterial plasma concentrations of dexmedetomidine in infants and toddlers approached 100 pg ml−1, the low end reported for sedative efficacy, within 20 min of an atomised intranasal administration of 1 μg kg−1. Doubling the dose to 2 μg kg−1 reached this plasma concentration within 10 min and achieved almost twice the peak concentration. Peak plasma concentrations with both doses were reached within 47 min of intranasal administration, with an overall bioavailability of 84%.

A clinical prediction model to identify patients at high risk of hemodynamic instability in the pediatric intensive care unit

BackgroundEarly recognition and timely intervention are critical steps for the successful management of shock. The objective of this study was to develop a model to predict requirement for hemodynamic intervention in the pediatric intensive care unit (PICU); thus, clinicians can direct their care to patients likely to benefit from interventions to prevent further deterioration.MethodsThe model proposed in this study was trained on a retrospective cohort of all patients admitted to a tertiary PICU at a single center in the United States, and validated on another retrospective cohort of all patients admitted to the PICU at a single center in the United Kingdom. The PICU clinical information system database (Intellivue Clinical Information Portfolio, Philips, UK) was interrogated to collect physiological and laboratory data. The model was trained using a variant of AdaBoost, which learned a set of low-dimensional classifiers, each of which was age adjusted.ResultsA total of 7052 patients admitted to the US PICU was used for training the model, and a total of 970 patients admitted to the UK PICU was used for validation. On the training/validation datasets, the model showed better prediction of hemodynamic intervention (area under the receiver operating characteristic (AUROC) = 0.81/0.81) than systolic blood pressure-based (AUCROC = 0.58/0.67) or shock index-based (AUCROC = 0.63/0.65) models. Both of these models were age adjusted using the same classifier.ConclusionsThe proposed model reliably predicted the need for hemodynamic intervention in PICU patients and provides better classification performance when compared to systolic blood pressure-based or shock index-based models alone. This model could readily be built into a clinical information system to identify patients at risk of hemodynamic instability.

Prognosis and Monitoring of VTE.

Venous thromboembolism (VTE) can present in a variety of different clinical settings and in a diverse, comorbid patient population, both of which will guide the clinician toward the appropriate therapeutic response. Patients who present with pulmonary embolism are at risk for hemodynamic instability, recurrence of VTE, cardiac comorbidities, and increased risk of overall mortality. Prognostication models have been clinically validated for risk stratification and prediction of mortality. Similar to pulmonary embolism, patients with deep vein thrombosis carry a higher risk of VTE recurrence and cardiac comorbidities. Consequently, VTE can be treated by a variety of methods such as anticoagulants or inferior vena cava filters, which bear their own risks and benefits. It is imperative that clinicians monitor patients for complications from VTE and the chosen therapy.