Significant Hypotension Research Articles

Angiotensin receptor-neprilysin inhibitor (Sacubitril/Valsartan) in cancer therapy-related cardiac dysfunction: real-world experience from a nurse-led cardio-oncology clinic

Abstract Introduction Cancer therapy-related cardiac dysfunction (CTRCD) is a common toxicity amongst patients receiving anti-cancer treatment1. Angiotensin receptor-neprilysin inhibitor (ARNI) Sacubitril/Valsartan is recommended to reduce Heart Failure (HF) admissions and cardiovascular mortality2. However, patients with active cancer were excluded from the key trials of ARNI. This study aims to provide a real-world experience of ARNI prescription and management from the perspective of a nurse-led Cardio-Oncology clinic. Methods This is a single centre, retrospective, observational cohort study performed at a Cardio-Oncology specialist centre between the period of 2021 to 2024. Adult cancer patients receiving anti-cancer therapy were included if they had symptomatic HF or asymptomatic CTRCD, were initiated on ARNI and followed up in the nurse-led Cardio-Oncology clinic. Results Twenty-nine patients were started on ARNI (see Figure 1). The mean age of the patients was 66+11 years and 17 (59%) were male. Cardiovascular risk factors were common: hypertension (45%), hyperlipidaemia (35%), diabetes mellitus (21%), and smoking (17%). Haematological and breast malignancies were most common (31% and 21% respectively), followed by gynaecological malignancies (14%). Twenty-one (72%) were treated with cytotoxic chemotherapy including 10 (35%) received anthracyclines. Five (17%) patients received human epidermal growth factor receptor 2 (HER2) targeted therapies, 3 (10%) were on tyrosine kinase inhibitors, and 2 (7%) received immunotherapy. Twenty-five (86%) patients presented with symptomatic HF while 4 (14%) had asymptomatic CTRCD. The median N-terminal-pro B-type natriuretic peptide (NTproBNP) level was elevated at 1325(806-4330)ng/L. Thirteen (45%) patients tolerated the maximum dose of 200mg twice daily, while 16 (56%) could only tolerate middle and lowest dosages. ARNI dose up titration to the maximum tolerated dose took 26 (15-79) days. Twenty-eight (97%) patients were on beta blockers, 26 (90%) received SGLT2 inhibitors, 25 (86%) on mineralocorticoid receptor antagonists, and 10 (35%) patients required diuretics. The most common side effect was symptomatic hypotension in 11 (38%) patients. Two (7%) had hyperkalemia, 1 (3%) acute kidney injury following initiation, and 1 (3%) had dizziness without significant hypotension. Nine (31%) required dose reduction allowing ARNI to be continued, while 3 (10%) patients had to permanently discontinue ARNI. There were no cardiovascular deaths, cancer deaths or HF admissions. Conclusion The Cardio-Oncology nurse-led clinic permits rapid up-titration of ARNI to target dosages in patients with CTRCD, resulting in significant improvements in cardiac function. The nurse lead clinic education, support and side effect management allowed uninterrupted continuation of cancer treatment. Whether this approach translates into be better cardiac and cancer outcomes requires further study.

8634 Ogilvie Syndrome As A Rare Complication Of Metastatic Pheochromocytoma

Abstract Disclosure: S.K. Beeby: None. J.C. Marcayata, MD: None. D.P. Di Matteo, MD: None. F.F. Souza, MD: None. I.C. Souza, MD: None. M.F. Azevedo, MD: None. F.M. Coelho, MD: None. A. Latronico, MD: None. B.B. Mendonca: None. M.C. Fragoso: None. M.Q. Almeida: None. Background: Ogilvie's Syndrome (acute colonic pseudo-obstruction) is a rare manifestationof pheochromocytoma and paraganglioma. Its pathophysiology can be explained by thehypersecretion of catecholamines, which may reduce peristaltic activity of the gastrointestinaltract due to alpha-adrenergic stimulation. We present here the case of a patient with acuteintestinal pseudo-occlusion due to metastatic pheochromocytoma. Clinical Case: A 60-year-old male with local recurrence of pheochromocytoma presentedwith abdominal pain, anorexia, nausea, vomiting and constipation for 2 weeks. The patientunderwent left adrenalectomy and nephrectomy to resect a 7.5 cm pheochromocytoma 6years ago. On examination, his blood pressure was 186 x 122 mmHg and heart rate was 112bpm. There was abdominal distention and diminished bowel sounds. Diaphoresis was notedmainly at night. Plasma fractionated metanephrines were markedly elevated, withnormetanephrine of 50.2 nmol/L (reference range <0.9 nmol/L) and metanephrine of 0.4nmol/L (reference range <0.5 nmol/L). Abdominal CT scan showed neoplastic lesionoccupying the left adrenal space, measuring 9.0 x 5.0 x 5.5 cm, infiltrating the spleen andpancreatic tail, and para-aortic and aorto-caval lymphomegaly of 1.3 cm. The large intestinewas distended with gas and lodged stool without evident obstructive factors. He was thenstarted on a high-sodium diet and alpha-blocker doxazosin 2 mg tid and propranolol 40 mgtid. Due to the presence of significant orthostatic hypotension, amlodipine 5 mg bid wasinitiated to control blood pressure. Laxatives and enemas were not effective in relieving hissymptoms and decompression with a nasogastric tube was necessary. The patient was thenput on subcutaneous neostigmine, an acetylcholinesterase inhibitor. Unfortunately, colonicpseudo-obstruction did not revert with pharmacological treatment and parenteral nutritionwas started. Since a complete tumor resection was not possible due to extensive invasion oflarge vessels, systemic cytotoxic chemotherapy (cyclophosphamide, vincristine anddacarbazine) was initiated as an attempt to treat the colonic pseudo-obstruction. Clinical lessons: Functioning pheochromocytoma and paraganglioma should be consideredin the differential diagnosis of constipation and acute intestinal obstruction, particularly whenaccompanied by other signs and symptoms of catecholamine excess. This condition should bepromptly diagnosed and managed, as it can lead to bowel perforation with seriouscomplications. Medical management includes alpha-blocking agents and, when feasible,tumor resection has been associated with good response. Support: This work was supported by Sao Paulo Research Foundation (FAPESP) grant2019/15873-6 (to M.Q. Almeida). M.Q.A was also supported by National Council forScientific and Technological Development (CNPq) 304091/2021-9. Presentation: 6/1/2024

50516 Spironolactone treatment for dermatologic indications is not associated with clinically significant hypotension in a single-center retrospective study

50516 Spironolactone treatment for dermatologic indications is not associated with clinically significant hypotension in a single-center retrospective study

Finger SBP measurement as a way to manage hypertension in patients with markedly calcified arteries: a case report.

Overestimation of blood pressure (BP) resulting from medial artery calcification (MAC) is a cause of pseudoresistant hypertension. In this condition, there is no noninvasive way to reliably assess the BP. We report the case of a 62-year-old man who had a four-limb MAC, hypertension despite five antihypertensive molecules, and significant orthostatic hypotension following the addition of the fifth drug. Hypotension symptoms resolved after discontinuation of two treatments. Subsequently, measurement of finger SBP (FSBP) by laser Doppler flowmeter (LDF) was used to estimate upper-limb SBP. While the brachial SBP was greater than 170 mmHg, the FSBP was always less than 140 mmHg. In the absence of upper-limb artery disease, by evidencing the discrepancy between FSBP and brachial SBP, LDF-obtained FSBP could be a reliable tool to ascertain pseudohypertension and monitor the antihypertensive treatment.

A Comparative Study of Combined Spinal Epidural Anesthesia Versus Spinal Anesthesia in Major Lower Limb Orthopedic Surgeries.

Background Neuraxial blockade includes epidural and spinal anesthesia (SA) that have gained wide acceptance for major lower limb orthopedic surgery. Both techniques are competent in rendering surgical anesthesia and pain relief, with specific advantages and disadvantages. SA has the merits of rapid onset and adequate anesthesia with a small volume of the drug but has significant hypotension and unpredictable duration. Epidural anesthesia allows for finer control over analgesia and the duration of anesthesia but requires more substantial volumes of drugs and is slower in onset. Combined spinal-epidural anesthesia (CSEA) combines the rapid commencement of action of SA with flexibility in epidural anesthesia, thus optimizing the management of the intraoperative and postoperative phases. This study aims to evaluate hemodynamic changes, compare the severity and duration of sensory and motor block, and track any problems related to CSEA and SA in major lower limb orthopedic procedures. Additionally, this study contrasts the hemodynamic, motor, and sensory changes in the two groups. Methodology A total of 30 individuals were randomized to one of two groups in this prospective comparative trial, which included 60 patients receiving major lower limb orthopedic surgery and meeting the American Society of Anesthesiologists physical status I-II criteria. Group A received CSEA, and Group B received SA. The degree and duration of sensory and motor blockade, hemodynamic changes, and complications were all recorded. A p-value of less than 0.05 was used to evaluate statistical significance using Student's t-test and chi-square test. Results The onset of sensory block in our study was earlier in Group B compared to Group A. In both groups, hemodynamic stability was maintained throughout the study. We recorded the onset/duration of sensory and motor block and hemodynamic changes and took mean values to find any significant difference. Postoperative complications and rescue analgesic requirements were monitored and managed and were a part of our study. Conclusions This study compared CSEA and SA regarding the severity and duration of sensory and motor block, hemodynamic stability, and associated complications in major lower limb orthopedic surgeries. The results shed light on the advantages and shortcomings of each anesthesia technique and, therefore, will help choose the correct method of anesthesia in a given surgery.

Pre-or co-SARS-CoV-2 Infections Significantly Increase Severe Dengue Virus Disease Criteria: Implications for Clinicians.

Few studies have investigated whether SARS-CoV-2 infections increase the incidence of dengue haemorrhagic fever/shock syndrome (DHF/DSS) and/or severe dengue (SD) in dengue virus (DENV)-infected patients. This study was performed on a site with high incidences of classical dengue, but relatively few DHF/DSS or SD cases as defined by the WHO 1997 or 2009 criteria, respectively. Clinical, haematological/biochemical, and viral diagnostic data were collected from febrile patients before, during, and after the COVID-19 epidemic to assess whether (a) DENV-infected patients with prior SARS-CoV-2 infections or (b) DENV-SARS-CoV-2-co-infected patients had increased incidences of SD/DHF/DSS using logistic regression and machine learning models. Higher numbers of DHF/DSS/SD occurred during the COVID-19 epidemic, particularly in males and 18-40-year-olds. Significantly increased symptoms in the DENV-SARS-CoV-2-co-infected cases were (a) haemoconcentration (p < 0.0009) and hypotension (p < 0.0005) (DHF/DSS and SD criteria), (b) thrombocytopenia and mucosal bleeding (DHF/DSS-criteria), (c) abdominal pain, persistent vomiting, mucosal bleeding, and thrombocytopenia (SD warning signs) and (d) dyspnoea, but without fluid accumulation. DENV-infected patients with prior SARS-CoV-2 infections had significantly increased incidences of thrombocytopenia (DHF/DSS-criteria) and/or abdominal pain and persistent vomiting and also thrombocytopenia (SD warning signs), but without significant haemoconcentration or hypotension. DENV-SARS-CoV-2 co-infections significantly increased the incidence of DHF/DSS/SD, while DENV-infected patients with prior SARS-CoV-2 infections displayed significantly increased incidences of thrombocytopenia (DHF/DSS-criteria) and three important SD warning signs, which are therefore very important for health workers/clinicians in assessing patients' DHF/DSS/SD risk factors and planning their optimal therapies.

Height Adjusted Dose versus Height-Weight Adjusted Dose of Intrathecal Hyperbaric Bupivacaine for Caesarean Delivery for Preventing Maternal Hypotension: A Prospective, Double-Blinded, Randomized Controlled Study

Background: Spinal anesthesia for cesarean section is associated with significant hypotension due to sympathetic blockade and can cause adverse maternal and fetal outcomes. Although hypotension is considered to be dose-dependent, choosing a dose of bupivacaine to achieve an adequate level of blockade without causing hypotension is a challenge. Methods: Ninety-six eligible parturients posted for elective cesarean section under spinal anesthesia were divided into two groups. Group H received intrathecal bupivacaine dose calculated as per patients’ height and Group HW received intrathecal bupivacaine dose calculated as per patients’ height and weight chart. Heart rate and mean blood pressure were monitored in both groups. Time required to achieve sensory block up to T6, complete motor block, the dose of ephedrine required to treat hypotension, the incidence of complications, and neonatal appearance, pulse, grimace, activity, respiration (APGAR) scores were noted. Results: Hypotension occurred in 35.56% of parturients in Group H and 16.28% of parturients in Group HW, which was statistically significant. The mean dose of 0.5% bupivacaine was 9.12 mg in Group HW and 9.4 mg in Group H (P value = 0.02). The mean dose of Ephedrine was 12 ± 5.8 mg in Group H compared to 6.0 mg in Group HW, which was statistically significant. The time needed to achieve sensory and complete motor block were comparable in both groups. Conclusion: Height-weight-adjusted intrathecal hyperbaric bupivacaine achieved comparable sensory and motor block with lesser incidence and severity of hypotension compared to height-adjusted dose.

Severe amlodipine toxicity: A medical dilemma managed with therapeutic plasma exchange

Amlodipine poisoning is a nightmare for treating clinicians because of the intractable hypotension and bradycardia induced by the drug, which requires a balanced treatment algorithm. We encountered a case of severe Amlodipine toxicity (450 mg) who presented with complaints of nausea, multiple episodes of vomiting, and chest discomfort. On arrival at the EMD, the patient had significant hypotension (80/46 mmHg), bradycardia (40 beats/min), and a fall in oxygen saturation (75 %). He was symptomatically managed with inotropes, IV calcium, IV fluids, and oxygen supplementation. We decided to go forward with Therapeutic Plasma Exchange (TPE) in an attempt to remove the inciting agent. Two sessions of TPE were performed and the patient showed significant improvement post-procedure which led to the discharge of the patient within 10 days of admission. This case report highlights the noteworthiness of TPE in treating significantly high doses of drug poisoning.

Chronic Cervical Midline Contusion in Rats Disrupts Multiple Facets of Cardiovascular Function

Cardiovascular dysfunction is the leading cause of morbidity and mortality following spinal cord injury (SCI). There are a limited number of studies assessing cardiovascular deficits after cervical SCI. This study aimed to assess disrupted cardiovascular function following a chronic severe incomplete C8 SCI in rats, via damaging descending sympathetic projections to the spinal sympathetic preganglionic neurons. Rats were first trained on the isometric pull task before receiving a C8 midline contusion (Infinite Horizon Impact Device; 250 kilodynes; 0 s dwell time) or laminectomy and were tested one day per week from weeks 7-13 following surgery. Isometric forelimb strength and correlates of muscle endurance were monitored during pull task sessions. Cardiovascular function was evaluated 16 weeks post-surgery. Tilt table testing was used to induce an orthostatic challenge by tilting rats 90 degrees head-up from a supine position and 90 degrees head-down from supine position as a control. Following tilt table testing, dobutamine (DOB; 2 μg/kg/min and 10 μg/kg/min) and norepinephrine (NE; 1 μg/kg/min and 4 μg/kg/min) were infused into the femoral vein separately to assess cardiovascular responses to a pharmacological challenge. We monitored cardiovascular physiology during all terminal testing. A blood pressure catheter was inserted into the left common carotid artery and advanced to the aortic arch to monitor interatrial blood pressure, 2 pairs of impedance cardiography (ICG) electrodes were placed on the left side of the thorax to evaluate inotropic correlates of cardiac function, and 2 photoplethysmography (PPG) sensors were affxed over the forelimbs flexor muscles to examine peripheral hemodynamics. To verify the accuracy of ICG-derived cardiac function, rats were examined by echocardiography at week 15. Spinal cords were collected for lesion analysis and were also stained for tyrosine hydroxylase. Our preliminary results demonstrate that chronic severe incomplete C8 SCI resulted in a significant and sustained hypotension during the 3-minute period of 90 degrees head-up tilting (systolic blood pressure = ~ -22 mmHg; diastolic blood pressure = ~ -19 mmHg) compared to laminectomy. There were also significant differences in left ventricular ejection time, heart rate, and stroke volume across groups, whereas forelimb hemodynamics did not differ across groups. Additionally, correlates of forelimb muscle endurance significantly decreased in SCI rats, despite similar isometric forelimb strength across groups. Intravenous infusion of DOB and NE demonstrated significant and dose-dependent effects on cardiovascular parameters. Overall, our data demonstrate that chronic severe C8 SCI in rats leads to orthostatic hypotension and also impairs multiple additional aspects of function. This study was supported by: NIH (R01 NS131493) and Florida Department of Health (COPBC). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Inhalation of Aerosolized Fentanyl Induces Respiratory Disorder and Sudden Death in Anesthetized Rats

In synthetic opioids, fentanyl (FNT) is the deadliest in clinical settings, resulting from respiratory disorder (RD) including ventilatory depression (dVE) and apnea. Rapid intravenous injection of FNT has been reported to cause immediately central and upper airway obstructive apnea that is mediated by vagal afferents in anesthetized rat (Zhuang J et al, 2012 and 2023). Here we asked whether acute inhalation of FNT also induced similar RD. EMGs of the internal and external intercostal muscles and thyroarytenoid muscles (EMGII, EMGEI, and EMGTA), minute ventilation (VE), heart rate and arterial blood pressure were recorded in anesthetized rats exposed to aerosolized FNT for 10 min. Immediately after exposure to FNT at 100 mg/m3, the rats showed apneas and remarkable prolongation of expiratory duration (TE) associated with hypotension and bradycardia. The apneas were characterized by cessation of EMGEI activity (central apnea) with enhanced tonic discharges of EMGTA (vocal closure, i.e., obstructive apnea) and EMGII (expiratory muscle constriction, i.e., chest wall rigidity). After a brief rebound at ~0.5 min exposure when the cardiorespiratory activities almost recovered to the baseline level, the rats presented gradual dVE by reduction of VT and fR, lasting for approximately 10 min. Apneas and ventilatory arrest subsequently occurred, leading to cardiac arrest a few minutes later. In contrast, FNT at 50 mg/m3 initially failed to significantly change VE, but subsequently developed gradual dVE (70% reduction) with significant TE prolongation, bradycardia and hypotension. These cardiorespiratory responses disappeared 30 min later. Our results suggest that acute exposure to a lethal dose of aerosolized FNT initially induces both central and upper airway obstructive apnea followed by dVE and ventilatory arrest, which is responsible for the sudden death in anesthetized rats. Supported by NIH R01 grants HL163512 and DA059063. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Evaluation of the Effects of Magnesium Sulphate versus Normal Saline on Hemodynamics in Patients Undergoing Laparoscopic Cholecystectomy

Introduction: Numerous studies have shown that giving magnesium sulphate intravenously before carbon dioxide pneumoperitoneum is produced reduces the adverse hemodynamic response in patients undergoing elective laparoscopic cholecystectomy. &#x0D; Objective: To examine the effects on hemodynamics in patients undergoing laparoscopic cholecystectomy between magnesium sulphate and normal saline.&#x0D; Methodology:The Department of Anaesthesia at the Pakistan Institute of Medical Sciences, SZABMU, Islamabad, conducted a Randomised Clinical Trial. The study involved the enrolment of 108 adult patients, regardless of gender, who were admitted for elective laparoscopic cholecystectomy and ranged in age from 18 to 65. Every patient who was enrolled was in ΑSΑ classes I and II. Patients were randomised equally to Group M, which received an IV slow bolus of magnesium sulphate (28 mg/kg) over a 20-minute period, and Group N, which received a 0.9% normal saline solution. The patient was tilted right and up by 15 degrees.&#x0D; Results:Both groups' baseline characteristics were comparable. The mean age of groups M and N was 42.2 years ± 7.6SD and 40.5 years ± 8.4SD, respectively (Ρ-value t-test=0.258). 22 (40.7%) men and 32 (59.3%) women made up group M, while 20 (37.0%) men and 34 (63.0%) women made up group N (Ρ-value chi-square = 0.693). Both groups' baseline and pre-pneumoperitoneum hemodyanamic parameters (HR, Systolic, BΡ, Diastolic BΡ, and MAΡ) were similar (Ρ-value t-test &gt; 0.05).&#x0D; Conclusions:The adverse hemodynamic response caused by pneumoperitoneum was significantly attenuated by pretreatment with intravenous magnesium sulphate. Heart rate, systolic blood pressure, diastolic blood pressure, and MTH were all significantly lower than baseline. Significant hypotension and bradycardia, however, were not seen.

Predicting Peri-Operative Cardiorespiratory Adverse Events in Children with Idiopathic Pulmonary Arterial Hypertension Undergoing Cardiac Catheterization Using Echocardiography: A Cohort Study.

General anesthesia in children with idiopathic pulmonary arterial hypertension (PAH) carries an increased risk of peri-operative cardiorespiratory complications though risk stratifying individual children pre-operatively remains difficult. We report the incidence and echocardiographic risk factors for adverse events in children with PAH undergoing general anesthesia for cardiac catheterization. Echocardiographic, hemodynamic, and adverse event data from consecutive PAH patients are reported. A multivariable predictive model was developed from echocardiographic variables identified by Bayesian univariable logistic regression. Model performance was reported by area under the curve for receiver operating characteristics (AUCroc) and precision/recall (AUCpr) and a pre-operative scoring system derived (0-100). Ninety-three children underwent 158 cardiac catheterizations with mean age 8.8 ± 4.6years. Adverse events (n = 42) occurred in 15 patients (16%) during 16 catheterizations (10%) including cardiopulmonary resuscitation (n = 5, 3%), electrocardiographic changes (n = 3, 2%), significant hypotension (n = 2, 1%), stridor (n = 1, 1%), and death (n = 2, 1%). A multivariable model (age, right ventricular dysfunction, and dilatation, pulmonary and tricuspid regurgitation severity, and maximal velocity) was highly predictive of adverse events (AUCroc 0.86, 95% CI 0.75 to 1.00; AUCpr 0.68, 95% CI 0.50 to 0.91; baseline AUCpr 0.10). Pre-operative risk scores were higher in those who had a subsequent adverse event (median 47, IQR 43 to 53) than in those who did not (median 23, IQR 15 to 33). Pre-operative echocardiography informs the risk of peri-operative adverse events and may therefore be useful both for consent and multi-disciplinary care planning.

The association of cumulative vasoactive drugs and neurodevelopmental outcomes in preterm Infants

To assess the effect of cardiovascular medications on the neurodevelopment of preterm infants, as measured by calculated cumulative time of vasoactive-inotropic score (VISct). A retrospective study was conducted on preterm infants who developed significant hypotension defined as a mean BP more than 2SDs below the mean for GA and received treatment with duration > 6 hours for each hypotensive episode, we calculated the vasoactive inotropic score (VIS) and cumulative exposure to cardiovascular medications over time (VISct). The composite Bayley III was reported from the high-risk follow-up clinic for the surviving infants between 18 to 21 months corrected age. VISct was significantly higher in infants with abnormal neurodevelopment. Cognitive Bayley was the most affected component with median (IQR) VISct 882.5(249,2047) versus 309(143,471) (p-value 0.012), followed by language function with VISct 786(261,1563.5), versus 343(106.75,473.75) (p-value 0.016) when those with Bayley III <85 were compared with those with normal Bayley IIIs. High VISct scores may have negative effect on cognitive and language neurodevelopmental outcomes.

Comparison of Postoperative Analgesic Effect of Dexmedetomidine and Morphine as an Adjuvant to Intrathecal Bupivacaine in Infraumbilical Surgeries: A Randomised Clinical Trial

Introduction: Regional anaesthesia is the standard technique for lower limb infraumbilical procedures. To provide a better analgesic profile, adjuvants are added to local anaesthetics to enhance their action. Opioids have been used as an adjuvant for a long-time. With evolving pharmacology, various drugs satisfy the criteria of being an adjuvant. One such drug is Dexmedetomidine, a novel alpha-2 agonist. Aim: To compare the duration of analgesia of intrathecal Morphine and Dexmedetomidine as an adjuvant to bupivacaine in a subarachnoid block for lower limb infraumbilical surgeries. Materials and Methods: In this randomised clinical, doubleblinded study conducted in a multispecialty hospital over the period of June 2020 to February 2021, 70 patients were randomly divided into two groups: Group M received Morphine 125 µg, and Group D received dexmedetomidine 5 µg as an adjuvant to 15 mg of 0.5% hyperbaric bupivacaine. The primary outcome was to compare the duration of postoperative analgesia. The secondary results assessed the block characteristics, haemodynamic parameters, rescue analgesic consumption, sedation score, and side-effects like bradycardia, hypotension, nausea, vomiting, pruritus, and respiratory depression. Data was spread in an Excel sheet and descriptive analysis done. Normally distributed continuous variables were compared using a Student’s t-test, and discrete variables were compared using a Chi-square test. A p-value of &lt;0.05 was considered significant. Results: Both groups were similar with respect to age, sex, body mass index, American Society of Anaesthesiologists grading, and duration of surgery. The duration of analgesia was 956.97±120.043 minutes in group M and 392.83±50.354 minutes in group D (p-value &lt;0.001). The total consumption of paracetamol was 1984.71±499.111 mg in group M and 3543.86±406.17 mg in group D. The onset and regression were significantly faster in group D. There was significant hypotension and bradycardia up to the 40th minute and an increase in heart rate, respiratory rate, and mean arterial pressure between 5-7 hours in group D. The sedation score was more in group D for the initial two hours. Postoperatively, the incidence of nausea, vomiting, and pruritus was more in group M. Conclusion: It can be concluded that 125 µg of intrathecal morphine is a better adjuvant to spinal bupivacaine, providing excellent postoperative analgesia compared to 5 µg of intrathecal dexmedetomidine. However, dexmedetomidine had more incidence of hypotension, bradycardia, and sedation when compared to morphine intrathecally.

The role of periprocedural hemodynamic variables during carotid stenting for the mid-term general mortality in advanced age patients.

Carotid stenting may produce significant bradycardia and/or hypotension. This may have negative short- and long-term effects for the elderly high-risk patients. Their cerebral hemodynamics is with exhausted adaptive capacity because of the multiple cardiovascular risk factors, advanced age, and significant stenosis.

Acute Hemodynamic Compromise After Transcatheter Aortic Valve Replacement Due to Dynamic Left Ventricle Obstruction: A Systematic Review

Acute hemodynamic compromise post-TAVR due to dynamic left ventricle obstruction (LVO), also known as “Suicide left ventricle” is an infrequent but severe complication of transcatheter aortic valve replacement (TAVR) that is poorly defined in the literature.Understanding this complication is essential for its prompt diagnosis and optimal treatment.We conducted a systematic literature review using PubMed, Embase, Web of Science and Medline databases for studies describing acute hemodynamic compromise post-TAVR due to dynamic LVO or suicide left ventricle. Each study was reviewed by two authors individually for eligibility, and a third author resolved disagreements.From a total of 506 studies, 25 publications were considered for the final analysis. The majority of patients suffering from this condition were women, demonstrating a hypertrophic septum, a small ventricle, and hyperdynamic contractility on pre-TAVR echocardiographic assessment. An intraventricular gradient pre-TAVR was found in half of the cases. Acute hemodynamic compromise post-TAVR due to dynamic LVO manifested mainly as significant hypotension and occurred most often immediately after valve deployment. The left ventricle outflow tract (LVOT) was the most common site of obstruction. Advanced therapies were required in nearly 65% of the cases.In conclusion, acute hemodynamic compromise post-TAVR due to dynamic LVO occurred almost invariably in women. Echocardiography prior to TAVR may offer essential information to anticipate this complication. LVOT obstruction appears to carry the highest risk of developing this phenomenon. Advanced therapies should be promptly considered as a bailout strategy in patients with hemodynamic collapse refractory to medical therapy.

Reação de hipersensibilidade após administração intravenosa de meloxicam em cães - relato de casos

ABSTRACT Although rarely reported in veterinary medicine, this article shows three cases of dogs that presented anaphylactic reactions after intravenous administration of meloxicam at therapeutic doses. Three dogs of different breeds and ages were submitted to anesthesia for surgical procedures of ovariohysterectomy and repair of patellar luxation. The animals were classified as ASA I and did not present changes in clinical and laboratory tests. All dogs were anesthetized and monitored by anesthesiologists, with careful multiparametric evaluation. Near the end of the procedures, meloxicam was administered intravenously in all dogs, and the drug used had the same commercial presentation and concentration, but with different lot numbers and with different months. For less than a minute, the animals showed significant hypotension, with pressure values close to 30 mmHg or inaudible by Doppler. The animals had no skin signs, only hypotension and a decrease in heart rate in one of them. All dogs were immediately treated with intravenous ephedrine and atropine in the bradycardic patient. After the emergency treatment, the dogs showed stabilized vital signs, with no complications or need for additional intervention. After the event, the three dogs showed no signs of clinical, behavioral or laboratory changes.

Angiotensinergic and GABAergic transmission in the medial preoptic area: role in urinary bladder and cardiovascular control in female rats.

Introduction: The medial preoptic area (mPOA) participates in thermoregulatory control and blood pressure modulation as shown by studies with electrical stimulation of this area or cobalt chloride injection, a non-selective synapse inhibitor. This study aimed to investigate whether angiotensin II (Ang II) and GABA could act or not in the mPOA to mediate the cardiovascular and micturition control pathways. Methods: Female Wistar rats were submitted to stereotaxic surgery for implantation of a guide cannula into the mPOA 7days prior to the experiments. Afterwards, the animals were isoflurane- anesthetized and submitted to the catheterization of the femoral artery and vein and urinary bladder cannulation for mean arterial pressure (MAP), heart rate (HR), and intravesical pressure (IP) recordings, respectively. After the baseline MAP, HR, and IP recordings for 15min, Ang II (0.1nM, 1μL), losartan (AT-1 receptor antagonist, 100nM, 1μL), GABA (50mM, 1μL) or saline (1μL) were injected into the mPOA, and the variables were measured for additional 30min. In a different group of rats, the AT-1 receptor, angiotensin II converting enzyme (ACE), and GABAa receptor gene expression was evaluated in mPOA samples by qPCR. The data are as mean ± SEM and submitted to One-way ANOVA (Tukey posttest) or paired Student t-test (P <0.05). Results: The injection of Ang II into the mPOA evoked a significant hypotension (-37±10mmHg, n = 6, p = 0.024) and bradycardia (-47 ± 20bpm, p = 0.030) compared to saline (+1 ± 1mmHg and +6 ± 2bpm, n = 6). A significant increase in IP was observed after Ang II injection into the mPOA (+72.25 ± 17.91%, p = 0.015 vs. -1.80 ± 2.98%, n = 6, saline). No significant changes were observed in MAP, HR and IP after the losartan injection in the mPOA compared to saline injection. Injection of GABA into the mPOA evoked a significant fall in MAP and HR (-68 ± 2mmHg, n = 6, p < 0.0001 and -115 ± 14bpm, n = 6, p = 0.0002 vs. -1 ± 1mmHg and +4 ± 2bpm, n = 6, saline), but no significant changes were observed in IP. The AT-1 receptor, ACE and GABAa receptor mRNA expression was observed in all mPOA samples. Discussion: Therefore, in female rats, Ang II mediated transmission in the mPOA is involved in the cardiovascular regulation and in the control of central micturition pathways. A phasic control dependent on AT-1 receptors in the mPOA seems to be involved in the regulation of those cardiovascular and intravesical 3 parameters. In contrast, GABAergic transmission in the mPOA participates in the pathways of cardiovascular control in anesthetized female rats, nevertheless, this neurotransmission is not involved in the micturition control.

Safety and Analgesic Efficacy of General Versus Caudal Block in Pediatric Infra Umbilical Surgery

Background: Caudal analgesia has become popular in the management of intraoperative and postoperative pain management, further with the use of adjuvants to prolong its duration each with varying results. Caudal block is the most preferred postoperative analgesia in pediatrics, despite its limited duration of action. Many additives are used to improve the effectiveness of caudal blocks, such as opioids or a2 agonists. Recently, the use of caudal dexamethasone as an analgesic after surgery has increased. Objectives: The aim of this study is to evaluate the safety and analgesic efficacy of general versus caudal block in pediatric infra umbilical surgery. Methods: This is an observational study. This study was carried out on 50 patients the find out about the population including children in the Department of Anaesthesia, Uttara Adhunik Medical College Hospital, Dhaka, Bangladesh. The duration of the period from January 2022 to December 2022. Statistical evaluation of the results used to be got via the use of a window-based computer software program devised with Statistical Packages for Social Sciences (SPSS-24). Results: The mean duration of postoperative analgesia was 3 times longer in Bupivacaine with preservative free Clonidine Group. Bupivacaine solution Group received significantly more doses of rescue analgesic than Bupivacaine with preservative free Clonidine Group (p-value of 0.004). There was no significant bradycardia, hypotension, sedation or urinary retention in either of the groups. There was no residual motor blockade at 6 hours. Incidence of vomiting was similar in both the groups. Conclusion: Dexamethasone in combination with bupivacaine reduces postoperative pain intensity and total analgesic consumption and prolongs analgesia.

A case report: anteroseptal ST elevation due to acute isolated right ventricular infarction

BackgroundElectrocardiogram (ECG) is the first diagnostic tool physicians use in diagnosing acute myocardial infarction (MI). In this case report, we present a case where the initial ECG diagnosis was that of an acute anteroseptal MI but emergency coronary angiography showed that the infarct-related artery was a small non-dominant right coronary artery (RCA) instead of the anticipated left anterior descending artery (LAD). Isolated right ventricular (RV) infarction from a non-dominant RCA is rarely seen in clinical practice, and it may exhibit ECG changes that can be confused with an acute anteroseptal MI. It is important to appreciate the subtle differences in the ECG changes that occur in either of these two types of MI for appropriate diagnosis and treatment.Case presentationA 49-year-old non-smoking male with prior coronary stent implantation in LAD presented with acute chest pain and his pre-hospital ECG indicated an anteroseptal STEMI possibly due to stent thrombosis, but an emergency angiogram showed patent LAD and Circumflex arteries. There was however thrombotic occlusion of the right, non-dominant coronary artery, which was revascularized with a drug-eluting stent. The patient’s chest pain and ST elevations resolved, and subsequent echo showed moderate RV systolic dysfunction in keeping with RV myocardial infarction.DiscussionRV myocardial infarction is usually due to an occlusion of the dominant RCA proximal to the origin of its RV wall branch, which often results in inferior ST elevation with reciprocal anterior ST depression. The ST elevation over V1 which would accompany RV infarction is often masked due to the more dominant electrical forces of inferior and posterior LV wall infarction. Our case demonstrates that in isolated RV infarction due to non-dominant proximal RCA occlusion, anterior ST elevation can be seen over V1-3, being most prominent in V1, which overlies the right ventricle, and resolved after restoring flow to the RCA. Spatial vector analysis of the ECG or right-sided ECG leads would be helpful to aid the diagnosis of RV infarction when clinical suspicion is present, for example when there is significant hypotension, raised jugular venous pressure but clear lung fields or deterioration after nitrate administration.