Mean Arterial Pressure Variability Research Articles

Diagnostic Accuracy Comparison between Automatic and Conventional Blood Pressure Measuring Devices in Adults with Hypertension

Background Blood pressure measurement is a main clinical procedure used for the detection of Systemic Arterial Hypertension. Mercury sphygmomanometer, in combination with auscultation technique, is still recognized as the gold standard for non-invasive blood pressure measurement. Objective The objective of this study is to compare the diagnostic accuracy between automatic non-invasive blood pressure measurement devices versus mercury sphygmomanometers in hospitalized patients. Methods A prospective, analytical and cross-sectional diagnostic method study was designed to compare the concordance, positive and negative predictive value, the sensitivity and specificity of automatic non-invasive blood pressure measurement devices and the mercury sphygmomanometer. The devices were divided into two groups: the reference standard which was mercury sphygmomanometer (n=150), versus the index tests, that were wrist device (n=150), semi-automatic sphygmomanometer (n=150) and vital signs monitor (n=150). Results The monitor detected more cases (69%) of systemic arterial hypertension (p 0.0019, OR 5.3). The semiautomatic sphygmomanometer identified more true positives (n=22) and true negatives (n=113). It also showed a higher diagnostic accuracy: 67% sensitivity (p 0.0576, OR 0.5) and 97% specificity (p 0.088, OR 3.2). A mean arterial pressure variation <5mmHg of 65% was found with the semiautomatic sphygmomanometer (p <0.0001, OR 0.02) and 61% with the vital signs monitor (p <0.0001, OR 0.12). Best concordance of blood pressure between reference standard versus index test was obtained in the following order: Semi-automatic sphygmomanometer, Vital signs monitor, and Wrist device. Conclusion The use of vital signs monitor to measure blood pressure is recommended in all patients, although semiautomatic sphygmomanometer is more sensitive for the detection of systemic arterial hypertension.

Post-anesthesia care unit delirium in children with moyamoya disease undergoing indirect revascularization: incidence and risk factors.

Delirium in the post-anesthesia care unit (PACU) may be associated with worse outcomes in children with moyamoya disease (MMD). This retrospective study aimed to describe the prevalence of PACU delirium in children with MMD and investigate its risk factors. Patients with MMD aged < 15 years who underwent indirect revascularization between January 2014 and October 2023 were included in this study. Delirium was assessed using the Pediatric Anesthesia Emergence Delirium Scale. Potential risk factors for PACU delirium were evaluated using multivariate logistic regression. PACU delirium occurred in 245 (33%) of the 750 hemispheric procedures performed in 522 patients. Delirium was associated with a higher incidence in patients undergoing the first revascularization (37%) than in those undergoing the second (25%; P = 0.002). Cerebral infarction as the initial presentation (odds ratio [OR] 4.64, first revascularization), high pediatric moyamoya magnetic resonance imaging (MRI) score (OR 2.75, first revascularization; OR 3.50, second revascularization), and high intraoperative mean arterial pressure variability (mmHg/min) (OR 9.17, first revascularization; OR 8.82, second revascularization) were associated with PACU delirium. Conversely, total intravenous anesthesia (TIVA) was associated with a lower incidence of PACU delirium (OR 0.46, first revascularization; OR 0.25, second revascularization). A significant proportion of patients with MMD developed delirium in the PACU. High intraoperative blood pressure variability and preoperative MRI lesions are independent risk factors for PACU delirium in children with MMD. TIVA may exert a protective effect against PACU delirium. Further studies are required to clarify the causality of these associations.

Effects of Nebulization With Ketamine and Budesonide on Postoperative Sore Throat in Patients Undergoing Elective Surgeries Under General Anesthesia: A Randomized Controlled Comparative Clinical Study.

Background Postoperative sore throat (POST) is a frequent issue after endotracheal intubation, caused by irritation and minor trauma to the throat. Various medications are used to prevent POST by reducing inflammation. This study evaluates the effectiveness of preoperative nebulization with ketamine and budesonide in minimizing POST over time. Methods This hospital-based, prospective, double-blinded randomized control trial was conducted with 100 patients aged 18 to 60 years undergoing elective surgeries requiring endotracheal intubation, aiming to compare the effectiveness of nebulization with ketamine and budesonide in reducing POST after oral endotracheal intubation.Patients were randomized into two groups, and POST was assessed using a four-point scale at multiple intervals post-extubation. Hemodynamic parameters were also monitored. Data were analyzed using IBM SPSS Statistics, with significance set at p < 0.05. Results In this study, the mean age of the participants was 41.34 ± 12.84 years in one group and 38.84 ± 13.95 years in the other. Heart rate (HR) readings were higher in the ketamine (Group K) group compared to the budesonide (Group B) group, although the difference was not statistically significant. A slight variation in mean arterial pressure (MAP) was observed between the groups at different time intervals. The incidence of sore throat was highest immediately after extubation but decreased over time. At zero hours, two patients in Group B and none in Group K had a sore throat. At two hours, four patients in Group K and five in Group B reported sore throats. At four hours, both groups had three patients with sore throats. At six hours, one patient in Group K and three in Group B reported sore throats. By 12 hours, only one patient in Group B had a sore throat, and none of the patients reported it at 24 hours. The ketamine group had a higher incidence of hallucinations compared to the budesonide group. Conclusion Nebulized ketamine and budesonide both effectively reduce POST, with ketamine showing lower severity but higher hallucination rates. Budesonide was associated with fewer complications, making it a preferable option for managing postoperative discomfort.

A comparative study between dexmedetomidine versus magnesium sulphate for controlled hypotensive anesthesia in rhinoplasty surgeries

Background: Rhinoplasty, a widely performed surgical procedure globally, necessitates hypotensive anesthesia to minimize bleeding, which can otherwise compromise surgical outcomes. Controlled hypotension anesthesia enhances the bloodless surgical area, reduces postoperative edema and ecchymosis, and can shorten the duration of the procedure. Many drugs have been used to attain hypotensive anesthesia, including magnesium sulfate, volatile anesthetics, and beta-adrenergic blocking agents. We compared dexmedetomidine with magnesium sulfate for producing hypotensive anesthesia in patients undergoing rhinoplasty. Methodology: We included 42 patients, aged 18-60 y, undergoing rhinoplasty and allocated into Group D and Group M. Group D received dexmedetomidine 1 µg/kg diluted in 50 mL of normal saline, administered IV over 10 min prior to anesthesia. Group M received magnesium sulfate 40 µg/kg diluted as infusion. Both groups received continued infusions afterwards. General anesthesia was induced with propofol and atracurium, intubation done and maintained on sevoflurane in N2O and O2. Vital signs were monitored continuously. The efficacy of hypotensive anesthesia was assessed, along with the recording of postoperative complications and the surgeons’ satisfaction. Results: Group D and Group M showed no significant variation in mean arterial pressure. However, significant variation was observed in heart rate (P &lt; 0.05). Group D had better operating area score compared to Group M. Surgeons; satisfaction was notably elevated in the Group D than in the Group M (P &lt; 0.05). Opioids needed were significantly less in the Group D in contrast to the Group M. The amount of atropine needed was higher in the Group D than in the Group M (P &lt; 0.05). Conclusion: Dexmedetomidine proved to be better than magnesium sulfate in achieving hypotensive anesthesia together with providing optimal surgical field conditions. Although magnesium sulfate necessitated additional nitroglycerine, dexmedetomidine increased the risk of bradycardia but reduced the analgesic requirements compared to magnesium sulfate. These factors are crucial when considering the use of dexmedetomidine in rhinoplasty surgery. Trial Registry: PACTR202408620568675. Keywords: hypotensive anesthesia; magnesium sulphate; dexmedetomidine Citation: Abd Elhalem SAA, Ahmed Abd ElAala El-Shawarby AE, Hakim KYK, Abdel Rahman YA, Khalifa AAG. A comparative study between dexmedetomidine versus magnesium sulphate for controlled hypotensive anesthesia in rhinoplasty surgeries. Anaesth. pain intensive care 2024;28(5):894−900; DOI: 10.35975/apic.v28i5.2537 Received: August 21, 2024; Reviewed: September 6, 2024; Accepted: September 9, 2024

The relative potential contribution of volume load and vascular mechanisms to hypertension in non-dialysis and dialysis chronic kidney disease patients.

Hypertension is highly prevalent and particularly difficult to treat adequately in patients with chronic kidney disease (CKD). The relative contribution of volume overload and vascular mechanisms to blood pressure measures in CKD and whether these effects differ in non-dialysis compared to dialysis patients is unknown. We determined the potential impact of volume load (stroke volume) and vascular mechanisms (inverse of total arterial compliance (inv TAC) and systemic vascular resistance (SVR)) on mean and brachial and aortic systolic blood pressures in 67 non-dialysis and 48 dialysis chronic kidney disease (CKD) patients. Relationships were determined in confounder adjusted regression models. Stroke volume (p value = 0.003) was more strongly associated with mean arterial pressure than SVR (p value = 0.9) (p value for difference = 0.03). When stroke volume and SVR were entered in the same regression model (model R2 = 0.324), they contributed equally to the variation in mean arterial pressure (p value for difference = 0.5). Stroke volume (p value ≤ 0.002) and inv TAC (p value ≤ 0.001) contributed equally to the variation in systolic pressures (p value for difference ≥ 0.9). When stroke volume and inv TAC were entered in the same regression model (model R2 = 0.752 to 0.765), they contributed equally to the variation in systolic blood pressures (p value for difference = 0.7). Stroke volume, TAC and SVR were similar (p value ≥ 0.5) and associated to the same extent with blood pressure measures in non-dialysis and dialysis CKD patients (p value for difference ≥ 0.1). In receiver operator characteristic curve analysis, elevated systolic blood pressure was determined by stroke volume (p value = 0.005) and inv TAC (p value = 0.03) but not SVR (p value = 0.8). The calculated power of the study was 0.999 based on α = 0.05. The present investigation suggests that both volume load and vascular mechanisms should be considered in the management of hypertension among patients with CKD. The extent and relative potential impact of volume load and vascular mechanisms on blood pressure measures are as large in non-dialysis compared to dialysis CKD patients.

Association between intraoperative mean arterial pressure variability and postoperative delirium after hip fracture surgery: a retrospective cohort study

BackgroundPostoperative delirium (POD) is a common complication in elderly patients after hip fracture surgery. Our study was to investigate whether intraoperative mean arterial pressure variability (MAPV) was associated with POD in elderly patients after hip fracture surgery.MethodsIn this retrospective cohort study, patients aged 65 years and older undergoing hip fracture surgery were included. The correlation between MAPV and POD was investigated using univariate and multivariate logistic regression. Covariate-related confounding effects were eliminated with propensity score matching (PSM) analysis. Then, a subgroup analysis was conducted to further examine the associations between MAPV and POD.ResultsNine hundred sixty-three patients with a median age of 80 years (IQR: 73–84) were enrolled. POD occurred in 115/963 (11.9%) patients within 7 days after surgery. According to multivariate regression analysis, MAPV > 2.17 was associated with an increased risk of POD (OR: 2.379, 95% CI: 1.496–3.771, P < 0.001). All covariates between the two groups were well balanced after PSM adjustment. A significant correlation between MAPV and POD was found in the PSM analysis (OR: 2.851, 95% CI: 1.710–4.746, P < 0.001).ConclusionsAn increased intraoperative MAPV may be a predictor for POD.

Abstract 16656: Association of Mean Arterial Pressure Variability With Kidney Function in Living Kidney Donors

Introduction: While mean arterial pressure (MAP) is associated with poor kidney function, the association of MAP variability with kidney function in living kidney donors (LKD) is unknown. We aim to evaluate the association between MAP variability and kidney function post-donation. Hypothesis: Wide MAP variability is associated with worsening kidney function post-donation. Methods: A retrospective cohort study utilizing OPTN/SRTR included adult LKD undergoing donation between 6/1972 and 9/2022. MAP variability is assessed by the average real variability of MAP (ARV-MAP) defined byan average of absolute difference in consecutive MAP at 6, 12, and 24 months post-donation. The risk of ≥35% decrease in post-donation eGFR from pre-donation eGFR among quartiles (Q) for AVR-MAP was examined by multivariable Cox regression. Results: Of 136,984 LKD, mean±SD age was 42±12 years and 61% were female. Mean pre-donation SBP, DBP, and MAP were 122±13, 74±9, and 90±10 mmHg, respectively. Mean post-donation BP at 6, 12, and 24 months were 120±13 / 75±9, 120±13 / 75±9, and 120±12 / 75±9 mmHg, respectively and corresponding mean post-donation MAP were 89.7±9.1, 89.8±9.0, and 90.2±9.0, respectively. Median (IQR) ARV-MAP was 6 (3, 10) mmHg. Mean pre-donation eGFR was 102.1±29.1 ml/min/1.73 m 2 and eGFR at 6-, 12-, and 24-months post-donation were 60.7±42.6, 62.4±43.9, and 64.4±44.9 ml/min/1.73 m 2 , respectively. The incidence rate of the event was 8.21 per 100 person-months. Compared to Q1 of the ARV-MAP, only Q3 had a 3.8% higher risk for declined eGFR (HR Q3 (95%CI) 1.04 (1.00, 1.08)). After adjusting for age, gender, race/ethnicity, U.S. citizenship status, level of education, history of hypertension, pre-donation BMI, pre-donation MAP, eGFR, and post-donation proteinuria, Q2, Q3, and Q4 have a 6.3%, 8.3%, and 6.9% significantly greater risk of the event, respectively (HR Q2 1.06 (1.00, 1.12); HR Q3 1.08 (1.02, 1.14); HR Q4 1.07 (1.01, 1.13)). There is no effect modification of the covariates for the ARV-PP - post-donation eGFR association. Conclusions: The risk for a 35% decline in post-donation kidney function is associated with ARV-MAP. DBP and PP may involve in kidney function after unilateral nephrectomy in LKD who develop post-donation glomerular hyperfiltration.

Hypertension, Blood Pressure Variability, and Acute Kidney Injury in Hospitalized Children.

Background Although hypertensive blood pressure measurements are common in hospitalized children, the degree of inpatient hypertension and blood pressure variability (BPV) associated with end organ complications like acute kidney injury (AKI) is unknown. Methods and Results All analyses are based on a retrospective cohort of children aged 1 to 17 years with ≥2 creatinine measurements during admission from 2014 to 2018. We used time-updated Cox models to evaluate the association between BPV and hypertension with AKI. Time-varying BPV and hypertension were based on blood pressure in the preceding 72 hours. For the analysis of hypertension and AKI, we excluded patients on vasopressors to ensure comparison between hypertensive and normotensive patients. During 5425 pediatric encounters, 258 430 blood pressure measurements were recorded (median [interquartile range] 22 [11-47] readings per encounter). Among all measurements, 32.7% were ≥95th percentile and 18.9% were ≥99th percentile for age, sex, and height. AKI occurred in 389 (7.2%) encounters. We observed a U-shaped relationship between mean blood pressure and incident AKI. BPV was associated with AKI, with the largest effect sizes in the systolic and mean arterial pressure variability measures. Multiple hypertension thresholds were associated with AKI after controlling for confounders. In an additional multivariable model adjusted for BPV, the association between hypertension and AKI was attenuated but remained significant for hypertension defined as three stage 2 measurements in 1 day (hazard ratio, 1.43 [95% CI, 1.01-2.01]). Conclusions Hypertension and BPV are associated with AKI in hospitalized children. Future studies are needed to determine how pharmacologic and nonpharmacologic interventions modify AKI risk in pediatric inpatients with hypertension.

Thoracic paravertebral block vs mid-point transverse process to pleura block in thoracic surgery. Preliminary evaluation of effectiveness and safety

Mid-point Transverse process to Pleura Block (MTPB) is an alternative approach to paravertebral block. We retrospectively assessed hemodynamic stability, inadvertent pleural puncture and antalgic effectiveness of this approach compared with traditional paravertebral block. Moreover, being used to add methylene bleu to local anesthetic solution as a tracer, we compared the diffusion pattern in paravertebral space of the two techniques. We reported retrospectively 40 patients underwent lung lobectomy from July to October 2021 in Monaldi Hospital (Naples, Italy) receiving thoracic paravertebral block (n=20) or mid-point transverse process to pleura block (n=20). The primary outcomes were a 20% mean arterial pressure variation from the base line, chest wall or pleural hematoma and technique failure. Analgesic effectiveness was assessed comparing remifentanil consumption to keep nociception index level &lt; 25 and patient’s VAS in post anesthesia care unit or daycare surgical unit at 60’. Also the methylene blue spread was assessed by a surgeon, blinded to patient’s name reviewing surgery videorecord of every cases. MAP decrease &gt; 20% was greater in the TPVB. No significative differences were reported for pleural punctures, chest wall hematomas or failure of the technique in the two groups. Methylene blue was evident in all patients of the TPVB, while it was not visible in any of the patients of the MTPB group. Remifentanil consumption, nociception index level and postoperative 60’ VAS were greater in the MTPB.Antalgic power and local anesthetic spread of TPVB seems to be superior to the MTPB, even if the safety profile of the latter seems to be better. Due to the retrospective nature of the study and the small number of cases in the sample, further studies are needed.

STABLE INTRAOPERATIVE PULSE OXIMETRY VALUES DO NOT PROTECT AGAINST A DECREASE IN REGIONAL CEREBRAL OXYGEN SATURATION IN PATIENTS UNDERGOING PRIMARY HIP ARTHROPLASTY. A PILOT STUDY

Background and Study objective: Continuous perioperative monitoring of blood oxygen saturation via pulse oximetry is an established standard of care. The incidence of postoperative cognitive dysfunction (POCD) in orthopedic patients is higher when compared to any other group of hospitalized patients. Although its etiology remains unclear, factors such as thromboembolic complications may play a role. Thromboembolic material, including that released from the surgery site, enters the bloodstream and then travels to the brain. The decrease in blood flow in the involved cerebral vessels may decrease cerebral oxygen saturation. Considering this, we decided to determine if the regional cerebral saturation monitored by near-infrared spectroscopy corresponds with readings of blood oxygen saturation monitored by pulse oximetry in patients who underwent primary total hip arthroplasty. Methods: A total of 20 patients scheduled for elective total hip arthroplasty were enrolled in the study. All orthopedic procedures were performed under spinal anesthesia and intravenous sedation. Monitoring of regional cerebral oxygen saturation (rSO2) was carried out from the time of the initiation of spinal anesthesia until the end of the surgery, using the near-infrared spectroscopy method. In all, 15 patients were analyzed. Results and Conclusions: We found the following: (1) rSO2 values decreased continuously over the surgery, and (2) rSO2 value changes were not related to mean arterial pressure variations or to hemoglobin saturation as analyzed by pulse oximetry.

Hemodynamic Variability During Drainage of Large Volumes of Malignant Ascites in Patients With Cancer.

This study compared the variability in mean arterial pressure (MAP) during drainage of ascites in patients with cancer who underwent drainage of a large (5-10 L) or small (<5 L) volume of ascites. We prospectively enrolled 50 patients scheduled for cell-free and concentrated ascites reinfusion therapy. Equivalence was considered to be established if the 95% confidence interval (95% CI) for the highest variability rate of MAP was within ±20%. The median volume of ascites removed was 3.30 L (95% CI [2.84, 4.40]) in the small-drainage-volume group (n = 15) and 6.75 L (95% CI [6.40, 7.30]) in the large-drainage-volume group (n = 34). The 95% CIs for the highest variability rates in MAP ranged from -19.60 to -6.23 and from -19.16 to -12.95 (p = .594), respectively, indicating equivalence. These findings indicate that variability in MAP during drainage of ascites is not dependent on drainage volume.

Exploring metrics for the characterization of the cerebral autoregulation during head-up tilt and propofol general anesthesia.

Techniques grounded on the simultaneous utilization of Tiecks' second order differential equations and spontaneous variability of mean arterial pressure (MAP) and mean cerebral blood flow velocity (MCBFV), recorded from middle cerebral arteries through a transcranial Doppler device, provide a characterization of cerebral autoregulation (CA) via the autoregulation index (ARI). These methods exploit two metrics for comparing the measured MCBFV series with the version predicted by Tiecks' model: normalized mean square prediction error (NMSPE) and normalized correlation ρ. The aim of this study is to assess the two metrics for ARI computation in 13 healthy subjects (age: 27±8yrs., 5 males) at rest in supine position (REST) and during 60° head-up tilt (HUT) and in 19 patients (age: 64±8yrs., all males), scheduled for coronary artery bypass grafting, before (PRE) and after (POST) propofol general anesthesia induction. Analyses were carried out over the original MAP and MCBFV pairs and surrogate unmatched couples built individually via time-shifting procedure. We found that: i) NMSPE and ρ metrics exhibited similar performances in passing individual surrogate test; ii) the two metrics could lead to different ARI estimates; iii) CA was not different during HUT or POST compared to baseline and this conclusion held regardless of the technique and metric for ARI estimation. Results suggest a limited impact of the sympathetic control on CA.

Intraoperative Analgesia with Magnesium Sulfate versus Remifentanil Guided by Plethysmographic Stress Index in Post-Bariatric Dermolipectomy: A Randomized Study.

Magnesium sulfate reduces pain scores and analgesic consumption. Its use as an analgesic resource in opioid-free or opioid-sparing techniques have also been tested. The evaluation of the antinociceptive potency of drugs and doses indirectly, through hemodynamic oscillations has been questioned. A relatively new algorithm called the plethysmographic stress index has been considered sensitive and relatively specific as a parameter for assessing the need for intraoperative analgesia. The aim of this trial was to assess the intraoperative analgesic capacity of magnesium sulfate compared to remifentanil. The secondary objectives were propofol consumption and its latency, the consumption of opioids, ephedrine, and cisatracurium. Patients and Methods. Forty patients scheduled for post-bariatric dermolipectomy were randomly assigned to two groups to receive total intravenous anesthesia with target-controlled hypnosis induced with propofol. Analgesia was obtained in the remifentanil group with remifentanil at an initial dose of 0.2 μg·kg-1·min-1 and in the magnesium sulfate group with magnesium sulfate 40 mg·kg-1 + 10 mg·kg-1·h-1. There was no statistical hemodynamic difference between the groups before and after orotracheal intubation (p = 0.062) and before and after the surgical incision (p = 0.656). There was also no statistical difference in the variation of mean arterial pressure before and after intubation (p = 0.656) and before and after the surgical incision (p = 0.911). There was similar consumption of cisatracurium, ephedrine, and postoperative opioids between the groups. Some patients in the magnesium sulfate group needed more intraoperative fentanyl and propofol, although the latency of propofol was similar in both the groups. We conclude that using magnesium sulfate in intravenous general anesthesia for post-bariatric dermolipectomy is related to a significant reduction in opioid consumption without compromising hemodynamic stability. Overall, PSI monitoring was helpful in driving the analgesic strategy. The use of magnesium sulfate proved to be an important adjunct in the scenario presented, allowing the use of opioids to be avoided in certain cases. We found no statistical differences in the consumption of neuromuscular blocker and vasoconstrictor. Substituting opioids for magnesium sulfate leads to an increase in propofol consumption in the scenario presented. Studies with a larger sample are needed to corroborate the results presented and evaluate other potential advantages in reducing opioid consumption.

Increased variability of mean arterial pressure is associated with increased risk of short-term mortality in intensive care unit: A retrospective study.

BackgroundIn intensive care unit (ICU), what thresholds of MAP variability are effective in distinguishing low- and high-risk patients for short-term mortality (in-hospital and 28-day) remains unclear.MethodsFifteen thousand five hundred sixty adult subjects admitted to ICU at Beth Israel Deaconess Medical Center (Boston, USA) between 2001 and 2012 were included in this retrospective study from MIMIC-III database. MAP within the first 24 h after admission were collected. Quantiles of MAP variability from 10% to 90% with 10% increasement each were considered to divide study participants into two groups, either having coefficients of variation of MAP greater or less than the given threshold. The threshold of MAP variability was identified by maximizing the odds ratio associated with increased risk of short-term mortality (in-hospital and 28-day). Logistic regression and Cox regression models were further applied to evaluate the association between increased variability of MAP and short-term mortality (in-hospital and 28-day).Results90% quantile of MAP variability was determined as the threshold generating the largest odds ratio associated with the increased risk of short-term mortality. Increased MAP variability, especially over 90% of MAP variability, was associated with increased risk of in-hospital mortality (odds ratio: 2.351, 95% CI: 2.064–2.673), and 28-day mortality (hazard ratio: 2.064, 95% CI: 1.820–2.337).ConclusionIncreased MAP variability, especially over 90% of MAP variability, is associated with short-term mortality. Our proposed threshold of MAP variability may aid in the early identification of critically ill patients with a high risk of mortality.

Variation in Mean Arterial Pressure Increases Falls Risk in Elderly Physically Frail and Prefrail Individuals Treated With Antihypertensive Medication.

Impaired cerebral blood flow has been associated with an increased risk of falls. Mean arterial pressure (MAP) and variability in MAP have been reported to affect cerebral blood flow but their relationships to the risk of falls have not previously been reported. Utilising data from the Aspirin in Reducing Events in the Elderly trial participants, we estimated MAP and variability in MAP, defined as within-individual SD of MAP from baseline and first 2 annual visits. The relationship with MAP was studied in 16 703 participants amongst whom 1539 falls were recorded over 7.3 years. Variability in MAP was studied in 14 818 of these participants who experienced 974 falls over 4.1 years. Falls were confined to those involving hospital presentation. Cox regression was used to calculate hazard ratio and 95% CI for associations with falls. Long-term variability in MAP was not associated with falls except amongst frail or prefrail participants using antihypertensive medications. Within this group each 5 mm Hg increase in long-term variability in MAP increased the risk of falls by 16% (hazard ratio, 1.16 [95% CI, 1.02-1.33]). Amongst the antihypertensive drugs studied, beta-blocker monotherapy (hazard ratio, 1.93 [95% CI, 1.17-3.18]) was associated with an increased risk of falls compared with calcium channel blockers. Higher levels of long-term variability in MAP increase the risk of serious falls in older frail and prefrail individuals taking antihypertensive medications. The observation that the relationship was limited to frail and prefrail individuals might explain some of the variability of previous studies linking blood pressure indices and falls.

Influence of posttraumatic blood pressure variability on post-traumatic stress disorder

To investigate the relationship between blood pressure variability (BPV) and incidence of post-traumatic stress disorder (PTSD) in trauma patients. Patients admitted to the department of emergency medicine of the Affiliated Hospital of Xuzhou Medical University for acute trauma from January 2018 to December 2021 were enrolled. The clinical data and blood pressure at admission (T1), 10 minutes before anesthesia (T2), 60 minutes after surgery (T3), and 24 hours after surgery (T4) were collected. Coefficient of variation of blood pressure variation [CV-BP, including coefficient of variation of systolic blood pressure (CV-SBP), coefficient of variation of diastolic blood pressure (CV-DBP), coefficient of variation of mean arterial pressure (CV-MAP)] and its quartile were calculated. Patients were divided into Q1 group (CV-MAP ≤ 7.27), Q2 group (7.27 < CV-MAP ≤ 9.50), Q3 group (9.50 < CV-MAP ≤ 14.05) and Q4 group (CV-MAP > 14.05) according to CV-MAP quartile. The PTSD symptoms of the patients were evaluated using the PTSD scale (PCL-5) one month later, and the patients were divided into the PTSD group and the non-PTSD group according to whether PCL-5 score higher than 38. Then the differences of the above indicators were compared and analyzed. Spearman correlation analysis was used to analyze the relationship between each index and PCL-5 score; the risk factors of PTSD were analyzed by univariate binary Logistic regression. Variables with P < 0.05 were included in the multivariate binary Logistic regression model. The receiver operator characteristic curve (ROC curve) was drawn to analyze the predictive value of CV-MAP on the incidence of PTSD. A total of 112 patients were enrolled, including 24 in PTSD group and 88 in non-PTSD group. Compared with non-PTSD group, the proportion of women, T1 shock index, proportion of intraoperative and postoperative blood transfusion in PTSD group was higher. Besides, PTSD group also had longer PT, more intraoperative and postoperative blood transfusion, and lower postoperative hemoglobin (Hb) level (all P < 0.05). The T1 SBP, DBP, MAP and T4 MAP of patients in PTSD group were significantly lower than those in non-PTSD group [T1 SBP (mmHg, 1 mmHg ≈ 0.133 kPa): 105.0 (86.3, 121.3) vs. 122.0 (112.0, 132.8), T1 DBP (mmHg): 62.5 (50.0, 77.3) vs. 76.0 (68.5, 82.8), T1 MAP (mmHg): 77.8 (60.4, 91.3) vs. 93.3 (82.5, 99.0), T4 MAP (mmHg): 83.8±9.1 vs. 88.7±10.4, all P < 0.05], CV-SBP, CV-DBP and CV-MAP were higher than those in the non-PTSD group [CV-SBP: 12.80 (10.12, 19.16) vs. 9.30 (6.07, 12.95), CV-DBP: 16.62±6.47 vs. 12.40±5.61, CV-MAP: 14.10 (9.25, 18.85) vs. 8.90 (6.93, 13.29), all P < 0.05]. Spearman correlation analysis showed that there was a positive correlation between CV-MAP and PCL-5 scores in patients with acute trauma (r = 0.429, P < 0.001); multivariate binary Logistic regression analysis showed that only CV-MAP [odds ratio (OR) = 1.128, 95% confidence interval (95%CI) was 1.015-1.254, P = 0.025] and CV-DBP (OR = 1.114, 95% confidence interval (95%CI) was 1.016-1.221, P = 0.022) was the risk factor for PTSD in acute trauma patients. Compared with Q1 group, Q4 group was significantly more likely to develop PTSD (OR = 18.6, 95%CI was 1.9-179.1, P = 0.012). CV-SBP, CV-DBP and CV-MAP had certain predictive value on PTSD diagnosis in patients with acute trauma according to ROC curve analysis results [area under the ROC curve (AUC) was 0.713, 0.682 and 0.726, respectively], among which CV-MAP has the highest predictive value. When the cut-off value of CV-MAP was 12.158, the sensitivity was 75.0% and the specificity was 69.3%. Higher BPV after trauma is a risk factor for PTSD. Maintaining stable blood pressure in trauma patients is of great significance for prevention and treatment of PTSD.

The Relationship Between Short-Term Mean Arterial Pressure Variability and Mortality in Critically Ill Patients.

BackgroundIncreased or decreased blood pressure variability may affect the perfusion of tissues and organs, leading to acute kidney injury and death. This study was conducted to explore the relationship between mean arterial pressure variability and short- and long-term mortality in critically ill patients.MethodsWe used patient data from the MIMIC-III database for cohort study. According to the recorded mean arterial pressure during the first 24 h in the intensive care unit, we calculated each patient’s two variability parameters –coefficient of variation and average real variability. The primary outcome was in-hospital mortality and the secondary outcomes were 28-day mortality and 1-year mortality. We conducted smooth spline models to examine the possible nonlinear associations between blood pressure variability and mortality. According to the smoothing curve, we further developed a two-piecewise linear regression model to find out the threshold effect. Multivariable logistic regression or Cox proportional hazards model was used to evaluate the relationship. Kaplan–Meier survival analysis for 28-day and 1-year mortality was performed. Subgroup analysis explored the factors modifying the relationship between them.ResultsA total of 12,867 patients were enrolled in the study, 1,320 in-hospital death, 1,399 28-day death, and 2,734 1-year death occurred. The smooth spline showed death risk was the lowest when average real variability was around 7.2 mmHg. After adjusting for covariates, logistic or Cox regression showed the highest MAP variability level was strongly associated with increased mortality in the hospital (odds ratio: 1.44; 95% CI, 1.21∼1.72), at 28 days (hazard ratio: 1.28; 95% CI, 1.1∼1.5), and at 1 year (hazard ratio: 1.27; 95% CI, 1.14∼1.42) compared with the second level of average real variability group. The survival curve plot showed patients with higher average real variability had a higher risk of 28-day and 1-year mortality. This relationship remained remarkable in patients with low or high Sequential Organ Failure Assessment scores in the sensitivity analysis. The two-piecewise linear regression model showed that lower ARV was a risk factor for 28-day (HR 0.72, 95% CI, 0.57∼0.91) and 1-year mortality (HR 0.81, 95% CI, 0.68∼0.96) when ARV was less than 7.2 mmHg, higher ARV was a risk factor for 28-day mortality (HR 1.1, 95% CI, 1.04∼1.17) and 1-year mortality (HR 1.07, 95% CI, 1.02∼1.12) when ARV was greater than 7.2 mmHg.ConclusionBlood pressure variability predicts mortality in critically ill patients. Individuals with higher or lower mean arterial pressure average real variability during the first day in ICU may have an increased risk of death.

Preload Dependence Fails to Predict Hemodynamic Instability During a Fluid Removal Challenge in Children.

Fluid overload increases morbidity and mortality in PICU patients. Active fluid removal improves the prognosis but may worsen organ dysfunction. Preload dependence in adults does predict hemodynamic instability induced by a fluid removal challenge (FRC). We sought to investigate the diagnostic accuracy of dynamic and static markers of preload in predicting hemodynamic instability and reduction of stroke volume during an FRC in children. We followed the Standards for Reporting of Diagnostic Accuracy statement to design conduct and report this study. Prospective noninterventional cohort study. From June 2017 to April 2019 in a pediatric cardiac ICU in a tertiary hospital. Patients 8 years old or younger, with symptoms of fluid overload after cardiac surgery, were studied. We confirmed preload dependence by echocardiography before and during a calibrated abdominal compression test. We then performed a challenge to remove 10-mL/kg fluid in less than 120 minutes with an infusion of diuretics. Hemodynamic instability was defined as a decrease of 10% of mean arterial pressure. We compared patients showing hemodynamic instability with patients remaining stable, and we built receiver operative characteristic (ROC) curves. Among 58 patients studied, 10 showed hemodynamic instability. The area under the ROC curve was 0.55 for the preload dependence test (95% CI, 0.34-0.75). Using a threshold of 10% increase in stroke volume index (SVi) during calibrated abdominal compression, the specificity was 0.30 (95% CI, 0.00-0.60) and the sensitivity was 0.77 (95% CI, 0.65-0.88). Mean arterial pressure variation and SVi variation were not correlated during fluid removal; r = 0.19; 95% CI -0.07 to 0.43; p = 0.139. Preload dependence is not accurate to predict hemodynamic instability during an FRC. Our data do not support a reduction in intravascular volume being mainly responsible for the reduction in arterial pressure during an FRC in children.

Evaluation of analgesic effects and hemodynamic responses of epidural ropivacaine in laparoscopic abdominal surgeries: Randomised controlled trial.

Background and Aims:The role of epidural analgesia in laparoscopic surgeries remains controversial. We evaluated intraoperative analgesic effects of epidural ropivacaine versus intravenous fentanyl in laparoscopic abdominal surgery and assessed postoperative analgesic requirements, hemodynamic changes, time to ambulation, and length of stay (LOS) in the ICU.Material and Methods:Seventy-two American Society of Anesthesiologists physical status I–III adult patients undergoing elective laparoscopic abdominal surgeries were randomized to either 0.5 mg/kg/h intravenous fentanyl (Group C) or 0.2% epidural ropivacaine at 5–8 mL/h (Group E) infusions intraoperatively and 0.25 m/kg/h fentanyl and 0.1% epidural ropivacaine infusions respectively postoperatively. Variations in mean arterial pressure (MAP) of 20% from baseline were points of intervention for propofol and analgesia with fentanyl or vasopressors. The number of interventions and total doses of fentanyl and vasopressors were noted. Postoperative analgesia was assessed at 0, 6, 12, and 24 h and when pain was reported with numerical rating scale and objective pain scores. Chi-square test and Student’s t-test were used for categorical and continuous variable analysis.Results:Intraoperatively, 14 patients versus 4 needed additional fentanyl and 26 versus 14 needed additional propofol in groups C and E respectively (P = 0.007, P = 0.004). MAP at 0, 6 and 18 h was lower in Group E. Pain scores were better in Group E at 6,18, and 24 h postoperatively. Time to ambulation was comparable but LOS ICU was prolonged in Group E (P = 0.05)Conclusion:Epidural ropivacaine produces superior intraoperative analgesia and improved postoperative pain scores without affecting ambulation but increases vasopressor need and LOS ICU in comparison with intravenous fentanyl in laparoscopic abdominal surgeries.

Dynamic cerebrovascular autoregulation in patients prone to postural syncope: Comparison of techniques assessing the autoregulation index from spontaneous variability series.

Three approaches to the assessment of cerebrovascular autoregulation (CA) via the computation of the autoregulation index (ARI) from spontaneous variability of mean arterial pressure (MAP) and mean cerebral blood flow velocity (MCBFV) were applied: 1) a time domain method (TDM); 2) a nonparametric method (nonPM); 3) a parametric method (PM). Performances were tested over matched and surrogate unmatched pairs. Data were analyzed at supine resting (REST) and during the early phase of 60° head-up tilt (TILT) in 13 subjects with previous history of postural syncope (SYNC, age: 28±9yrs.; 5 males) and 13 control individuals (noSYNC, age: 27±8yrs.; 5 males). Analysis was completed by computing autonomic markers from heart period (HP) and systolic arterial pressure (SAP) variability series via spectral approach. HP and SAP spectral indexes suggested that noSYNC and SYNC groups exhibited different autonomic responses to TILT. ARI analysis indicated that: i) all methods have a sufficient statistical power to separate matched from unmatched pairs with the exception of nonPM applied to impulse response; ii) ARI estimates derived from different methods might be uncorrelated and, even when correlated, might exhibit a significant bias; iii) orthostatic stressor did not induce any evident ARI change in either noSYNC or SYNC individuals; iv) this conclusion held regardless of the method. Methods for the ARI estimation from spontaneous variability provide different ARIs but none indicate that noSYNC and SYNC subjects have different dynamic component of CA.