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1.
PLoS One ; 19(9): e0310191, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-39250467

RESUMO

Intradialytic hypotension (IDH) is common in hemodialysis patients and can lead to several complications. Risk factors for IDH include demographic characteristics, comorbidities, dialysis procedure factors, and so on. Clinical studies on predictive models for dialysis-induced hypotension have shown inconsistent results. This systematic review aims to evaluate published prediction models for IDH, analyzing their characteristics, predictors, efficacy, and the methodological quality and applicability. The protocol has been prepared using the Preferred Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) guidelines. The systematic review protocol for IDH prediction in hemodialysis patients has been registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY2023110081, DOI: 10.37766/inplasy2023.11.0081). A comprehensive search across five major databases (PubMed, Web of Science, Cochrane Library, CNKI, and Wanfang) will be conducted for studies on prediction models of IDH among hemodialysis patients. Two researchers will independently screen literature, extract data, and evaluate the bias risk and applicability of included studies using prediction modelling study tools. This systematic review will provide critical insights into the efficacy and quality of reporting of the IDH model in hemodialysis patients. This will guide clinical staff in selecting the most appropriate IDH prediction model and inform future research endeavors in IDH prediction.


Assuntos
Hipotensão , Diálise Renal , Revisões Sistemáticas como Assunto , Diálise Renal/efeitos adversos , Humanos , Hipotensão/etiologia , Fatores de Risco
2.
Air Med J ; 43(5): 412-415, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-39293918

RESUMO

OBJECTIVE: Push-dose vasopressors are commonly administered to attenuate peri-intubation hypotension. The aim of this study was to describe the current use of push-dose vasopressors in critical care transport. METHODS: This was a retrospective chart review of adult patients (≥ 18 years) intubated between January 2017 and May 2023 who received push-dose vasopressors. The outcomes were incidence of push-dose vasopressor administration and the frequency of initiation or an increase in continuous vasopressor infusion. RESULTS: Of the 334 patients intubated during this period, 49 (14.7%) received push-dose vasopressors in the peri-intubation period. The mean preintubation shock index was 1.1 ± 0.5. Of those who received push-dose vasopressors, 34 (69.4%) received multiple push doses; the mean number of administrations was 2.5 ± 1.9. Most patients had persistent or recurrent hypotension (n = 39, 79.6%). Fifteen (30.6%) were started on a continuous vasopressor infusion, and 3 (11.1%) had an increase in an existing infusion postintubation. CONCLUSION: Although push-dose vasopressors are convenient and appropriate in many settings, they inadequately address hypotension in critically ill patients with underlying shock. Further investigation is required to better elucidate the role of peri-intubation push-dose and continuous vasopressors in the critical care transport setting.


Assuntos
Cuidados Críticos , Hipotensão , Intubação Intratraqueal , Vasoconstritores , Humanos , Vasoconstritores/uso terapêutico , Vasoconstritores/administração & dosagem , Estudos Retrospectivos , Masculino , Feminino , Pessoa de Meia-Idade , Cuidados Críticos/métodos , Hipotensão/tratamento farmacológico , Idoso , Adulto
3.
J Obstet Gynaecol ; 44(1): 2393379, 2024 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-39166780

RESUMO

BACKGROUND: Spinal anaesthesia is a common anaesthetic method for caesarean sections but often results in hypotension, posing potential risks to maternal and neonatal health. Norepinephrine, as a vasopressor, may be effective in preventing and treating this hypotension. This systematic review and meta-analysis aims to systematically evaluate the efficacy and safety of prophylactic norepinephrine infusion for the treatment of hypotension following spinal anaesthesia in caesarean sections. METHODS: Literature searches were conducted in PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, and VIP databases for relevant studies on prophylactic administration of norepinephrine for the treatment of hypotension after spinal anaesthesia in caesarean delivery. Reference lists of included articles were also searched. The latest search update was on March 20, 2024. Meta-analysis was conducted using R software. The methods recommended by the Cochrane Handbook, Begge's and Egger's tests were used for risk of bias evaluation of the included literature. RESULTS: Nine studies were finally included in this study. The results showed that prophylactic administration of norepinephrine was superior to the control group in four aspects of treating hypotension after spinal anaesthesia in caesarean delivery: the incidence of hypotension was reduced [RR = 0.34, 95%CI (0.27-0.43), P < 0.01]; the incidence of severe hypotension was reduced [RR = 0.32, 95%CI (0.21-0.51), P < 0.01]; and maternal blood pressure was more stable with MDPE [MD = -5.00, 95%CI (-7.80--2.21), P = 0.06] and MDAPE [MD = 4.11, 95%CI (1.38-6.85), P < 0.05], the incidence of nausea and vomiting was reduced [RR = 0.52, 95%CI (0.35-0.77), P < 0.01]. On the other hand, the incidence of reactive hypertension was higher than the control group [RR = 3.58, 95%CI (1.94-6.58), P < 0.01]. There was no difference between the two groups in one aspects: newborn Apgar scores [MD = -0.01, 95%CI (-0.10-0.09, P = 0.85)]. CONCLUSION: Prophylactic administration of norepinephrine is effective in treating hypotension after spinal anaesthesia in caesarean delivery patients; however, it does not provide improved safety and carries a risk of inducing reactive hypertension.


Hypotension, or low blood pressure, after spinal anaesthesia can threaten the health of both mothers and their babies during caesarean sections. Norepinephrine is a drug that affects heart rate less and does not easily cross the placental barrier, which may reduce its potential negative effects on the baby. However, there are not many studies on using norepinephrine as a preventive measure. Our study systematically evaluated the use of prophylactic norepinephrine infusion to prevent hypotension in caesarean section patients. We found that it is effective in preventing low blood pressure but does not show improved safety and carries some risk of causing high pressure as a reaction.


Assuntos
Anestesia Obstétrica , Raquianestesia , Cesárea , Hipotensão , Norepinefrina , Vasoconstritores , Humanos , Cesárea/efeitos adversos , Raquianestesia/efeitos adversos , Raquianestesia/métodos , Feminino , Hipotensão/prevenção & controle , Hipotensão/etiologia , Hipotensão/tratamento farmacológico , Norepinefrina/administração & dosagem , Norepinefrina/uso terapêutico , Norepinefrina/efeitos adversos , Gravidez , Anestesia Obstétrica/efeitos adversos , Anestesia Obstétrica/métodos , Vasoconstritores/administração & dosagem , Vasoconstritores/uso terapêutico , Adulto
4.
J Transl Med ; 22(1): 725, 2024 Aug 05.
Artigo em Inglês | MEDLINE | ID: mdl-39103852

RESUMO

INTRODUCTION: Intraoperative Hypotension (IOH) poses a substantial risk during surgical procedures. The integration of Artificial Intelligence (AI) in predicting IOH holds promise for enhancing detection capabilities, providing an opportunity to improve patient outcomes. This systematic review and meta analysis explores the intersection of AI and IOH prediction, addressing the crucial need for effective monitoring in surgical settings. METHOD: A search of Pubmed, Scopus, Web of Science, and Embase was conducted. Screening involved two-phase assessments by independent reviewers, ensuring adherence to predefined PICOS criteria. Included studies focused on AI models predicting IOH in any type of surgery. Due to the high number of studies evaluating the hypotension prediction index (HPI), we conducted two sets of meta-analyses: one involving the HPI studies and one including non-HPI studies. In the HPI studies the following outcomes were analyzed: cumulative duration of IOH per patient, time weighted average of mean arterial pressure < 65 (TWA-MAP < 65), area under the threshold of mean arterial pressure (AUT-MAP), and area under the receiver operating characteristics curve (AUROC). In the non-HPI studies, we examined the pooled AUROC of all AI models other than HPI. RESULTS: 43 studies were included in this review. Studies showed significant reduction in IOH duration, TWA-MAP < 65 mmHg, and AUT-MAP < 65 mmHg in groups where HPI was used. AUROC for HPI algorithms demonstrated strong predictive performance (AUROC = 0.89, 95CI). Non-HPI models had a pooled AUROC of 0.79 (95CI: 0.74, 0.83). CONCLUSION: HPI demonstrated excellent ability to predict hypotensive episodes and hence reduce the duration of hypotension. Other AI models, particularly those based on deep learning methods, also indicated a great ability to predict IOH, while their capacity to reduce IOH-related indices such as duration remains unclear.


Assuntos
Hipotensão , Aprendizado de Máquina , Humanos , Hipotensão/diagnóstico , Hipotensão/fisiopatologia , Complicações Intraoperatórias/diagnóstico , Curva ROC
5.
MedEdPORTAL ; 20: 11430, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-39156125

RESUMO

Introduction: Shock is a life-threatening condition amongst hospitalized patients and requires urgent management to avoid mortality. Early exposure is vital for educational and patient safety purposes. Methods: We developed a 90-minute shock day session that provided internal medicine interns with a cognitive framework for the initial diagnosis and management of shock, which they applied to two simulations. The first simulation involved a patient with septic shock, and the second involved a patient with cardiogenic shock. Critical action checklists were used to assess learners and guide structured debriefs after each simulation. Medical decision-making and communication frameworks were presented through a presession video and a chalk talk. The curriculum was evaluated using pre- and postintervention surveys to assess knowledge and confidence. Results: Forty-eight interns participated in the session in 2022 and 2023. We observed an increase in the percentage of learners correctly answering a knowledge-based question regarding the amount of fluid administered to a patient in septic shock (pre: 33%, post: 62%, p < .01), as well as increases in learner-reported confidence in leading a rapid response (pre: 9%, post: 62%) and in managing undifferentiated shock (pre: 13%, post: 56%), septic shock (pre: 20%, post: 83%), cardiogenic shock (pre: 2%, post: 54%), hemorrhagic shock (pre: 20%, post: 73%), and anaphylactic shock (pre: 22%, post: 54%, all ps < .01). Discussion: Employing a variety of pedagogical methods, we demonstrated that intern knowledge and confidence regarding the management of a hypotensive patient during a rapid response can be increased through participation in our curriculum.


Assuntos
Competência Clínica , Tomada de Decisão Clínica , Comunicação , Internato e Residência , Humanos , Internato e Residência/métodos , Adulto , Currículo , Treinamento por Simulação/métodos , Hipotensão , Simulação de Paciente , Medicina Interna/educação , Choque/terapia , Inquéritos e Questionários , Choque Séptico/terapia
6.
Mil Med ; 189(Supplement_3): 268-275, 2024 Aug 19.
Artigo em Inglês | MEDLINE | ID: mdl-39160853

RESUMO

INTRODUCTION: Non-compressible torso hemorrhagic (NCTH) shock is the leading cause of potentially survivable trauma on the battlefield. New hypotensive drug therapies are urgently required to resuscitate and protect the heart and brain following NCTH. Our aim was to examine the strengths and limitations of permissive hypotension and discuss the development of small-volume adenosine, lidocaine, and Mg2+ (ALM) fluid resuscitation in rats and pigs. MATERIALS AND METHODS: For review of permissive hypotension, a literature search was performed from inception up to November 2023 using PubMed, Cochrane, and Embase databases, with inclusion of animal studies, clinical trials and reviews with military and clinical relevance. For the preclinical study, adult female pigs underwent laparoscopic liver resection. After 30 minutes of bleeding, animals were resuscitated with 4 mL/kg 3% NaCl ± ALM bolus followed 60 minutes later with 4 h 3 mL/kg/h 0.9% NaCl ± ALM drip (n = 10 per group), then blood transfusion. Mean arterial pressure (MAP) and cardiac output (CO) were continuously measured via a left ventricular pressure catheter and pulmonary artery catheter, respectively. Systemic vascular resistance (SVR) was calculated using the formula: 80 × (MAP - CVP)/CI. Oxygen delivery was calculated as the product of CO and arterial oxygen content. RESULTS: Targeting a MAP of ∼50 mmHg can be harmful or beneficial, depending on how CO and SVR are regulated. A theoretical example shows that for the same MAP of 50 mmHg, a higher CO and lower SVR can lead to a nearly 2-fold increase in O2 supply. We further show that in animal models of NCTH, 3% NaCl ALM bolus and 0.9% NaCl ALM drip induce a hypotensive, high flow, vasodilatory state with maintained tissue O2 supply and neuroprotection. ALM therapy increases survival by resuscitating the heart, reducing internal bleeding by correcting coagulopathy, and decreasing secondary injury. CONCLUSIONS: In rat and pig models of NCTH, small-volume ALM therapy resuscitates at hypotensive pressures by increasing CO and reducing SVR. This strategy is associated with heart and brain protection and maintained tissue O2 delivery. Translational studies are required to determine reproducibility and optimal component dosing. ALM therapy may find wide utility in prehospital and far-forward military environments.


Assuntos
Adenosina , Hipotensão , Ressuscitação , Animais , Suínos , Ressuscitação/métodos , Ratos , Hipotensão/etiologia , Hipotensão/fisiopatologia , Adenosina/administração & dosagem , Adenosina/farmacologia , Lidocaína/farmacologia , Lidocaína/uso terapêutico , Lidocaína/administração & dosagem , Feminino , Choque Hemorrágico/terapia , Choque Hemorrágico/complicações , Choque Hemorrágico/fisiopatologia
7.
J Cardiothorac Surg ; 19(1): 476, 2024 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-39090732

RESUMO

BACKGROUND: Postoperative delirium (POD), an acute and variable disturbance in cognitive function, is an intricate and elusive phenomenon that occurs after cardiac surgery. Despite progress in surgical techniques and perioperative management, POD remains a formidable challenge, imposing a significant burden on patients, caregivers, and healthcare systems. METHODS: This prospective observational study involved 307 patients who underwent cardiac surgery. Data on the occurrence of delirium, clinical parameters, and postoperative characteristics were collected. A multivariate analysis was performed to assess the relationship between POH and POD. RESULTS: Sixty-one patients (21%) developed delirium, with an average onset of approximately 5 days postoperatively and a duration of approximately 6 days. On multivariate analysis, POH was significantly associated with POD, and the adjusted odds ratios indicated that patients with POH were more likely to develop delirium (OR, 5.61; p = 0.006). Advanced age (OR, 1.11; p = 0.002), emergency surgery (OR, 8.31; p = 0.001), and on-pump coronary artery bypass grafting were identified as risk factors of POD. Patients who developed delirium were typically older, more likely to be male, and had higher morbidity rates than those who did not. CONCLUSION: POH is significantly associated with delirium in critically ill patients after cardiac surgery. Surgical complexity and advanced age contribute to the risk of developing POD and poor postoperative outcomes.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Estado Terminal , Delírio , Hipotensão , Complicações Pós-Operatórias , Humanos , Masculino , Feminino , Estudos Prospectivos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Idoso , Delírio/etiologia , Delírio/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Pessoa de Meia-Idade , Fatores de Risco
8.
J Health Care Poor Underserved ; 35(3): 866-879, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-39129607

RESUMO

The American Diabetes Association (ADA) guidelines prioritize Sodicum-glucose transporter-2-inhibitors (SGLT2i) given cardio-renal and glycemic benefits. This study was conducted to observe clinical factors associated with initial SGLT2i prescription in type 2 diabetes patients eligible for SGLT2i by the ADA. METHODS: A retrospective case-control study was performed in a safety-net clinic and consisted of the initial SGLT2i prescriptions group and the group without. The data from the electronic medical records between July 2021 and December 2022 were analyzed in the regressional models. RESULTS: There was a significant association between A1c ≥8% (OR 3.7, p=.01), heart failure (OR 19.3, p<.0001), a history of hypotension (OR 11.9, p=.01), and sulfonylureas (OR 6.5, p=.003) with the SGLT2i prescription. CONCLUSION: Patients with high A1c levels, heart failure, a history of hypotension, and sulfonylureas were more likely than their counterparts to receive SGLT2i prescriptions. Future research should investigate adherence and provider prescribing behaviors related to SGLT2i to further assess optimal drug use.


Assuntos
Diabetes Mellitus Tipo 2 , Inibidores do Transportador 2 de Sódio-Glicose , Humanos , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Estudos de Casos e Controles , Idoso , Insuficiência Cardíaca/tratamento farmacológico , Hemoglobinas Glicadas/análise , Hipotensão/induzido quimicamente , Adulto , Hipoglicemiantes/uso terapêutico
9.
Hum Vaccin Immunother ; 20(1): 2372149, 2024 12 31.
Artigo em Inglês | MEDLINE | ID: mdl-39171563

RESUMO

The COVID-19 outbreak has been declared the sixth Public Health Emergency of International Concern certified by the World Health Organization. With the extensive application of COVID-19 vaccines, rare but serious adverse reactions have gradually emerged, among which systemic capillary leak syndrome (SCLS) deserves our attention. SCLS is difficult to diagnose. Not only can it exacerbate various diseases, but also can lead to pulmonary edema, kidney failure, and even death. We summarized and discussed case reports of SCLS induced by COVID-19 vaccines to raise awareness of COVID-19 vaccine-associated rare diseases. We conducted a comprehensive search in Web of Science, PubMed and Embase and collected case reports of SCLS induced by COVID-19 vaccine before February 19, 2024. We identified and analyzed 12 articles, encompassing 15 cases. We synthesized the data to summerize possible mechanisms of SCLS, clinical manifestations, differential diagnoses, and therapeutic approaches. Most SCLS occurred after vaccination with the Pfe-Biontech mRNA vaccine (9/15) and following the second vaccination (10/15). Almost all patients experienced hypotension (13/15) and tachycardia (11/15). Most patients received intravenous fluids (9/15) and corticosteroids (9/15). 11 patients were recovered and were discharged, while 4 patients died. Inflammation and endothelial cell damage may be linked to SCLS and COVID-19 vaccines. These findings highlight the necessity of focusing on serious adverse reactions of COVID-19 vaccines and the urgency to reconsider the safety of COVID-19 vaccines.


Assuntos
Vacinas contra COVID-19 , COVID-19 , Síndrome de Vazamento Capilar , Humanos , Síndrome de Vazamento Capilar/etiologia , Vacinas contra COVID-19/efeitos adversos , COVID-19/prevenção & controle , COVID-19/complicações , Pessoa de Meia-Idade , Feminino , Masculino , Idoso , Adulto , SARS-CoV-2/imunologia , Vacinação/efeitos adversos , Hipotensão/etiologia
10.
J Clin Anesth ; 98: 111580, 2024 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-39126872

RESUMO

STUDY OBJECTIVE: There is scarce evidence on the hemodynamic stability of remimazolam during anesthetic induction in patients with significant coronary artery disease. This study aims to compare the effects of remimazolam and propofol on post-induction hypotension in patients undergoing coronary artery bypass grafting (CABG). DESIGN: Randomized controlled trial. SETTING: Tertiary teaching hospital. PATIENTS: Adult patients undergoing isolated CABG. INTERVENTIONS: Patients were randomly allocated to received either remimazolam (n = 50) or propofol (n = 50) for anesthetic induction. The remimazolam group received an initial infusion at 6 mg/kg/h, which was later adjusted to 1-2 mg/kg/h to maintain a bispectral index of 40-60 after loss of consciousness. In the propofol group, a 1.5 mg/kg bolus of propofol was administered, followed by 1-1.5% sevoflurane inhalation as needed to achieve the target bispectral index. MEASUREMENTS: The primary outcome was the area under the curve (AUC) below the baseline mean arterial pressure (MAP) during the first 10 min after anesthetic induction. Secondary outcomes included the AUC for MAP <65 mmHg and the requirement for vasopressors. MAIN RESULTS: The remimazolam group demonstrated a significantly lower AUC under the baseline MAP compared to the propofol group (mean [SD], 169.8 [101.0] mmHg·min vs. 220.6 [102.4] mmHg·min; mean difference [95% confidence interval], 50.8 [10.4-91.2] mmHg·min; P = 0.014). Additionally, the remimazolam group had a reduced AUC for MAP <65 mmHg (7.3 [10.3] mmHg·min vs. 13.9 [14.9] mmHg·min; P = 0.007) and a lower frequency of vasopressor use compared to the propofol group (60% vs. 88%, P = 0.001). CONCLUSIONS: Remimazolam may offer improved hemodynamic stability during anesthetic induction in patients undergoing CABG, suggesting its potential advantage over propofol for patients with significant coronary artery disease in terms of hemodynamic stability.


Assuntos
Anestésicos Intravenosos , Ponte de Artéria Coronária , Hipotensão , Propofol , Humanos , Propofol/administração & dosagem , Propofol/efeitos adversos , Masculino , Feminino , Ponte de Artéria Coronária/efeitos adversos , Hipotensão/prevenção & controle , Pessoa de Meia-Idade , Idoso , Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/efeitos adversos , Benzodiazepinas/administração & dosagem , Benzodiazepinas/efeitos adversos , Sevoflurano/administração & dosagem , Sevoflurano/efeitos adversos , Pressão Arterial/efeitos dos fármacos , Monitores de Consciência , Doença da Artéria Coronariana/cirurgia
11.
Am J Emerg Med ; 84: 158-161, 2024 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-39128170

RESUMO

Traumatic brain injury (TBIs) necessitates a rapid and comprehensive medical response to minimize secondary brain injury and reduce mortality. Emergency medical services (EMS) clinicians serve a critical role in the management of prehospital TBI, responding during an initial phase of care with significant impact on patient outcomes. We used versions two and three of the Brain Trauma Foundation (BTF) Prehospital Guidelines for the Management of Traumatic Brain Injury and the NASEMSO National Model Clinical Guidelines to determine key elements for a TBI prehospital protocol and included common factors across sources such as recommendations concerning patient monitoring, hypoxia, hypotension, hyperventilation, cerebral herniation, airway management, hyperosmolar therapy, and transport destination. We then conducted a cross-sectional evaluation of publicly available statewide EMS clinical protocols in the US to determine the degree of alignment with national guidelines. We calculated descriptive statistics for each factor in the state protocols. Despite adoption of some evidence-based recommendations for a standard approach to the prehospital management of patients with TBI, we found significant variability in statewide EMS treatment protocols for management of severe TBI, especially in the recommended frequency of patient reassessment and for the management of suspected herniation. Most statewide protocols provided guidance regarding oxygenation, ventilation, and blood pressure management that aligned with evidence-based guidelines. While most protocols did address management of oxygenation and ventilation, one in four protocols had no specific guidance for managing hypoxia and only 31% of protocols recommended avoiding hyperventilation. For the management of suspected cerebral herniation, over half of statewide protocols recommended hyperventilation, whereas only 31% explicitly advised against hyperventilation regardless of TBI severity. Interestingly, 94% of protocols do not mention the use of hyperosmolar therapy for TBI patients, neither recommending use or avoidance of hyperosmolar therapy. In conclusion, we found inconsistent adoption of national recommendations in available statewide protocols for prehospital TBI management. We identified significant gaps and variation in statewide protocols regarding patient monitoring and reassessment, as well as in several key areas of severe TBI management.


Assuntos
Lesões Encefálicas Traumáticas , Protocolos Clínicos , Serviços Médicos de Emergência , Humanos , Lesões Encefálicas Traumáticas/terapia , Serviços Médicos de Emergência/normas , Estados Unidos , Guias de Prática Clínica como Assunto , Estudos Transversais , Hipotensão/terapia , Hipotensão/etiologia , Fidelidade a Diretrizes/estatística & dados numéricos
12.
J Cardiothorac Vasc Anesth ; 38(10): 2269-2277, 2024 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-39098542

RESUMO

OBJECTIVES: Compare hemodynamics between 4% albumin and Ringer's acetate. DESIGN: Exploratory analysis of the double-blind randomized ALBumin In Cardiac Surgery trial. SETTING: Single-center study in Helsinki University Hospital. PARTICIPANTS: We included 1,386 on-pump cardiac surgical patients. INTERVENTION: We used 4% albumin or Ringer's acetate administration for cardiopulmonary bypass priming, volume replacement intraoperatively and 24 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Hypotension (time-weighted average mean arterial pressure of <65 mmHg) and hyperlactatemia (time-weighted average blood lactate of >2 mmol/L) incidences were compared between trial groups in the operating room (OR), and early (0-6 hours) and late (6-24 hours) postoperatively. Associations of hypotension and hyperlactatemia with the ALBumin In Cardiac Surgery primary outcome (≥1 major adverse event [MAE]) were studied. In these time intervals, hypotension occurred in 118, 48, and 17 patients, and hyperlactatemia in 313, 131, and 83 patients. Hypotension and hyperlactatemia associated with MAE occurrence. Hypotension did not differ between the groups (albumin vs Ringer's: OR, 8.8% vs 8.5%; early postoperatively, 2.7% vs 4.2%; late postoperatively, 1.2% vs 1.3%; all p > 0.05). In the albumin group, hyperlactatemia was less frequent late postoperatively (2.9% vs 9.1%; p < 0.001), but not earlier (OR, 22.4% vs 23.6%; early postoperatively, 7.9% vs 11.0%; both p > 0.025 after Bonferroni-Holm correction). CONCLUSIONS: In on-pump cardiac surgery, hypotension and hyperlactatemia are associated with the occurrence of ≥1 MAE. Compared with Ringer's acetate, albumin did not decrease hypotension and decreased hyperlactatemia only late postoperatively. Albumin's modest hemodynamic effect is concordant with the finding of no difference in MAEs between albumin and Ringer's acetate in the ALBumin In Cardiac Surgery trial.


Assuntos
Albuminas , Procedimentos Cirúrgicos Cardíacos , Hemodinâmica , Hipotensão , Soluções Isotônicas , Humanos , Hemodinâmica/efeitos dos fármacos , Hemodinâmica/fisiologia , Masculino , Feminino , Método Duplo-Cego , Pessoa de Meia-Idade , Albuminas/administração & dosagem , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Idoso , Soluções Isotônicas/administração & dosagem , Ponte Cardiopulmonar/métodos , Ponte Cardiopulmonar/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Hiperlactatemia/sangue
14.
Clin Toxicol (Phila) ; 62(8): 533-535, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-39163090

RESUMO

INTRODUCTION: Carbamazepine causes dose-dependent toxicity in overdose. Resources commonly state that severe toxicity occurs with ingestions >50 mg/kg without supporting evidence. We aimed to compare ingested dose with clinical toxicity. METHODS: This was a retrospective series of patients reportedly ingesting carbamazepine >2,000 mg referred to a clinical toxicology unit and state poisons information centre. Medical records were reviewed to extract patient demographics, ingestion details, clinical effects and management. Severe toxicity was defined as the presence of coma (Glasgow Coma Scale <9), seizure, or hypotension (systolic blood pressure <90 mmHg). RESULTS: There were 69 presentations in 42 patients with a median ingested carbamazepine dose of 113 mg/kg (IQR: 71-151 mg/kg). Coma occurred in 10 cases, eight having ingested >200 mg/kg and the remaining two ingesting 113 mg/kg and 151 mg/kg, respectively. Seizures occurred in four cases (lowest ingested dose 143 mg/kg). Hypotension occurred in five cases (lowest ingested dose 113 mg/kg). DISCUSSION: Severe carbamazepine toxicity did not occur with reported ingestions <100 mg/kg and was uncommon in ingestions <200 mg/kg. CONCLUSION: Severe toxicity was common in ingestions >200 mg/kg. Using the suggested threshold of severe toxicity of >50 mg/kg appeared overly conservative in this series.


Assuntos
Anticonvulsivantes , Carbamazepina , Relação Dose-Resposta a Droga , Overdose de Drogas , Hipotensão , Convulsões , Humanos , Carbamazepina/intoxicação , Carbamazepina/administração & dosagem , Estudos Retrospectivos , Masculino , Feminino , Adulto , Convulsões/induzido quimicamente , Pessoa de Meia-Idade , Anticonvulsivantes/intoxicação , Anticonvulsivantes/administração & dosagem , Hipotensão/induzido quimicamente , Adulto Jovem , Centros de Controle de Intoxicações/estatística & dados numéricos , Coma/induzido quimicamente , Adolescente , Idoso
15.
JACC Heart Fail ; 12(9): 1625-1635, 2024 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-39093257

RESUMO

BACKGROUND: The prognostic implications of phenotypes along the preshock to cardiogenic shock (CS) continuum remain uncertain. OBJECTIVES: This study sought to better characterize pre- or early shock and normotensive CS phenotypes and examine outcomes compared to those with conventional CS. METHODS: The CCCTN (Critical Care Cardiology Trials Network) is a registry of contemporary cardiac intensive care units. Consecutive admissions (N = 28,703 across 47 sites) meeting specific criteria based on hemodynamic variables, perfusion parameters, and investigator-reported CS were classified into 1 of 4 groups or none: isolated low cardiac output (CO), heart failure with isolated hypotension, normotensive CS, or SCAI (Society of Cardiovascular Angiography and Intervention) stage C CS. Outcomes of interest were in-hospital mortality and incidence of subsequent hypoperfusion among pre- and early shock states. RESULTS: A total of 2,498 admissions were assigned to the 4 groups with the following distribution: 4.8% isolated low CO, 4.4% isolated hypotension, 12.1% normotensive CS, and 78.7% SCAI stage C CS. Overall in-hospital mortality was 21.3% (95% CI: 19.7%-23.0%), with a gradient across phenotypes (isolated low CO 3.6% [95% CI: 1.0%-9.0%]; isolated hypotension 11.0% [95% CI: 6.9%-16.6%]; normotensive CS 17.0% [95% CI 13.0%-21.8%]; SCAI stage C CS 24.0% [95% CI: 22.1%-26.0%]; global P < 0.001). Among those with an isolated low CO and isolated hypotension on admission, 47 (42.3%) and 56 (30.9%) subsequently developed hypoperfusion. CONCLUSIONS: In a large contemporary registry of cardiac critical illness, there exists a gradient of mortality for phenotypes along the preshock to CS continuum with risk for subsequent worsening of preshock states. These data may inform refinement of CS definitions and severity staging.


Assuntos
Mortalidade Hospitalar , Sistema de Registros , Choque Cardiogênico , Humanos , Choque Cardiogênico/terapia , Choque Cardiogênico/mortalidade , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Cuidados Críticos , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Prognóstico , Fenótipo , Hipotensão/epidemiologia , Unidades de Cuidados Coronarianos/estatística & dados numéricos
16.
Pain Physician ; 27(5): E579-E587, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-39087967

RESUMO

BACKGROUND: Hip fracture surgeries in elderly patients often require spinal or general anesthesia, posing risks of severe hypotension and inadequate pain management. The optimal anesthesia type for minimizing these risks remains undetermined. Preliminary studies suggest that a combination of fascia iliaca block (FIB) and low-dose low-specific-gravity spinal anesthesia (LLSA) might offer a solution, but comprehensive evidence is lacking. OBJECTIVES: This study aimed to assess the efficacy of combining FIB with LLSA for reducing severe hypotension and enhancing analgesia during hip fracture surgery in elderly patients. STUDY DESIGN: A prospective, randomized controlled trial was conducted. SETTING: An operating theatre of a tertiary hospital. METHODS: The study comprised 68 patients. They were separated into 2 equal parallel groups 34 patients each: the FIB+LLSA group and the general anesthesia (GA) group. Patients aged 75-96 undergoing primary hip arthroplasty for hip fracture were randomized to receive either FIB+LLSA or GA. The primary outcome was the incidence of severe hypotension; secondary outcomes included postoperative pain, use of rescue analgesia, vasopressor dosage, and complications. RESULTS: We found a significantly lower incidence of severe hypotension in the FIB+LLSA group compared to the GA group (32.4% vs 67.6%). Additionally, postoperative pain scores were significantly lower, and the need for rescue analgesia was reduced in the FIB+LLSA group. Vasopressor use during surgery was also significantly lower in the FIB+LLSA group. The hospital stay was shorter in the FIB+LLSA group, with an average of 5.9 days compared to 6.7 days in the GA group. LIMITATIONS: The study's limitations include its single-center nature, which may limit the generalizability of the findings. Additionally, the inability to conduct a double-blind study could introduce biases, though measures were taken to minimize this. The sample size might not be sufficient to determine the broader implications of LLSA. CONCLUSIONS: Combining FIB with LLSA for elderly patients undergoing hip fracture surgery significantly reduces the incidence of severe intraoperative hypotension and postoperative pain. It also decreases the need for rescue analgesia and shortens hospital stays, suggesting that FIB+LLSA could be a beneficial regional anesthesia technique for elderly hip fracture surgery patients, aligning with enhanced recovery protocols.


Assuntos
Raquianestesia , Fraturas do Quadril , Hipotensão , Bloqueio Nervoso , Humanos , Fraturas do Quadril/cirurgia , Idoso , Raquianestesia/métodos , Raquianestesia/efeitos adversos , Idoso de 80 Anos ou mais , Feminino , Masculino , Bloqueio Nervoso/métodos , Estudos Prospectivos , Dor Pós-Operatória/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Analgesia/métodos , Fáscia
17.
Medicine (Baltimore) ; 103(35): e39510, 2024 Aug 30.
Artigo em Inglês | MEDLINE | ID: mdl-39213244

RESUMO

RATIONALE: Primary hyperparathyroidism (PHPT), which is characterized by increased parathyroid hormone secretion, typically manifests as hypercalcemia and hypertension. Here, we report a case of severe hypotension following tracheal intubation during anesthesia induction in a patient with PHPT, in contrast to the expected hypertensive response. PATIENT CONCERNS: A 52-year-old man presented with nausea after eating, leg pain when walking, and headaches. DIAGNOSIS: Based on the blood test and computed tomography results, he was diagnosed with PHPT. INTERVENTIONS: The patient underwent parathyroidectomy under general anesthesia. After induction anesthesia and tracheal intubation, severe acute hypotension and tachycardia suddenly developed. To treat hypotensive shock, we immediately administered ephedrine and phenylephrine and infused Ringer solution. OUTCOMES: The symptoms of hypotensive shock were alleviated by this intervention. LESSONS: We speculate that the cause of his severe hypotension was vasodilation due to the transient release of parathyroid hormone from mechanical stimulation by anesthetic procedures, such as tracheal intubation, combined with hypercalcemia-induced severe dehydration. Moreover, we speculate that fluid resuscitation stabilized his condition and helped achieve a successful surgical outcome. The possibility of severe hypotension after anesthesia induction should be anticipated, and management of cases with severe dehydration should be optimized during the anesthetic management of patients with PHPT.


Assuntos
Hiperparatireoidismo Primário , Hipotensão , Intubação Intratraqueal , Paratireoidectomia , Humanos , Masculino , Pessoa de Meia-Idade , Hiperparatireoidismo Primário/complicações , Hiperparatireoidismo Primário/cirurgia , Hiperparatireoidismo Primário/terapia , Intubação Intratraqueal/efeitos adversos , Hipotensão/etiologia , Hipotensão/terapia , Paratireoidectomia/efeitos adversos , Paratireoidectomia/métodos , Anestesia Geral/efeitos adversos , Anestesia Geral/métodos
18.
Sci Rep ; 14(1): 17088, 2024 07 24.
Artigo em Inglês | MEDLINE | ID: mdl-39048628

RESUMO

To investigate the effect of low-doses esketamine on spinal anesthesia-induced hypotension in women with preoperative anxiety undergoing elective cesarean section, the randomized controlled trial enrolled 120 women aged 18-35 years who preoperative State-Trait Anxiety Inventory State scores > 40, conducted from September 2022 to August 2023 in Xuzhou Central Hospital, China. Women in the esketamine group received a single intravenous injection of 0.2 mg/kg esketamine after sensory block level achieved. The incidence of hypotension in the esketamine group was significantly lower than the control group at T2 (10% [6 of 60]; P < 0.001), T3 (5.0% [3 of 60]; P = 0.007) and T4(5.0% [3 of 60]; P = 0.004). Despite being higher in the esketamine group, the overall rates of hypertension (11.7% [7 of 60]; P = 0.186), tachycardia (23.3% [14 of 60]; P = 0.246), and bradycardia (0.0% [0 of 60]; P = 0.079) were no significantly difference between the two groups. STAI-S scores was significantly lower in the esketamine group (mean [SD] 37.52[7.14]) than in the control group (mean [SD] 41.03[9.66], P = 0.39) in postoperative day 1. Spinal anesthesia combined with intravenous low-doses esketamine infusion can significantly reduce the incidence of hypotension in women with preoperative anxiety undergoing elective cesarean section.


Assuntos
Raquianestesia , Ansiedade , Cesárea , Procedimentos Cirúrgicos Eletivos , Hipotensão , Ketamina , Humanos , Feminino , Ketamina/administração & dosagem , Cesárea/efeitos adversos , Adulto , Método Duplo-Cego , Gravidez , Raquianestesia/efeitos adversos , Raquianestesia/métodos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Adolescente , Adulto Jovem , Período Pré-Operatório , China/epidemiologia
19.
BMC Anesthesiol ; 24(1): 221, 2024 Jul 03.
Artigo em Inglês | MEDLINE | ID: mdl-38961365

RESUMO

BACKGROUND: This study aimed to evaluate the accuracy of ankle blood pressure measurements in relation to invasive blood pressure in the lateral position. METHODS: This prospective observational study included adult patients scheduled for elective non-cardiac surgery under general anesthesia in the lateral position. Paired radial artery invasive and ankle noninvasive blood pressure readings were recorded in the lateral position using GE Carescape B650 monitor. The primary outcome was the ability of ankle mean arterial pressure (MAP) to detect hypotension (MAP < 70 mmHg) using area under the receiver operating characteristic curve (AUC) analysis. The secondary outcomes were the ability of ankle systolic blood pressure (SBP) to detect hypertension (SBP > 140 mmHg) as well as bias (invasive measurement - noninvasive measurement), and agreement between the two methods using the Bland-Altman analysis. RESULTS: We analyzed 415 paired readings from 30 patients. The AUC (95% confidence interval [CI]) of ankle MAP for detecting hypotension was 0.88 (0.83-0.93). An ankle MAP of ≤ 86 mmHg had negative and positive predictive values (95% CI) of 99 (97-100)% and 21 (15-29)%, respectively, for detecting hypotension. The AUC (95% CI) of ankle SBP to detect hypertension was 0.83 (0.79-0.86) with negative and positive predictive values (95% CI) of 95 (92-97)% and 36 (26-46)%, respectively, at a cutoff value of > 144 mmHg. The mean bias between the two methods was - 12 ± 17, 3 ± 12, and - 1 ± 11 mmHg for the SBP, diastolic blood pressure, and MAP, respectively. CONCLUSION: In patients under general anesthesia in the lateral position, ankle blood pressure measurements are not interchangeable with the corresponding invasive measurements. However, an ankle MAP > 86 mmHg can exclude hypotension with 99% accuracy, and an ankle SBP < 144 mmHg can exclude hypertension with 95% accuracy.


Assuntos
Anestesia Geral , Tornozelo , Determinação da Pressão Arterial , Humanos , Feminino , Anestesia Geral/métodos , Masculino , Estudos Prospectivos , Pessoa de Meia-Idade , Determinação da Pressão Arterial/métodos , Tornozelo/irrigação sanguínea , Idoso , Oscilometria/métodos , Pressão Sanguínea/fisiologia , Hipertensão/fisiopatologia , Hipertensão/diagnóstico , Hipotensão/diagnóstico , Hipotensão/fisiopatologia , Adulto , Posicionamento do Paciente/métodos
20.
Hum Cell ; 37(5): 1306-1315, 2024 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-38985392

RESUMO

The Na-Cl cotransporter (NCC) is a well-recognized regulator of ion transportation in the kidneys that facilitates Na+ reabsorption in the distal convoluted tubule. It is also the pharmacologic inhibitory target of thiazide diuretics, a class of front-line antihypertensive agents that have been widely used for decades. NCC is a potent regulator of Na+ reabsorption and homeostasis. Hence, its overactivation and suppression lead to hypertension and hypotension, respectively. Genetic mutations that affect NCC function contribute to several diseases such as Gordon and Gitelman syndromes. We summarized the role of NCC in various physiologic processes and pathological conditions, such as maintaining ion and water homeostasis, controlling blood pressure, and influencing renal physiology and injury. In addition, we discussed the recent advancements in understanding cryo-EM structure of NCC, the regulatory mechanisms and binding mode of thiazides with NCC, and novel physiologic implications of NCC in regulating the cross-talk between the immune system and adipose tissue or the kidneys. This review contributes to a comprehensive understanding of the pivotal role of NCC in maintaining ion homeostasis, regulating blood pressure, and facilitating kidney function and NCC's novel role in immune and metabolic regulation.


Assuntos
Pressão Sanguínea , Homeostase , Hipertensão , Rim , Humanos , Rim/metabolismo , Hipertensão/metabolismo , Pressão Sanguínea/fisiologia , Síndrome de Gitelman/metabolismo , Síndrome de Gitelman/genética , Membro 3 da Família 12 de Carreador de Soluto/metabolismo , Sódio/metabolismo , Mutação , Transporte de Íons , Tiazidas , Hipotensão/metabolismo , Tecido Adiposo/metabolismo , Animais
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