Risk Factors for Intravenous Propacetamol-Induced Blood Pressure Drop in the Neurointensive Care Unit: A Retrospective Observational Study.

BACKGROUND: Intravenous propacetamol is commonly used to control fever and pain in neurocritically ill patients in whom oral administration is often difficult. However, several studies reported that intravenous propacetamol may cause blood pressure drop. Thus, we aimed to investigate the occurrence and risk factors for intravenous propacetamol-induced blood pressure drop in neurocritically ill patients. METHODS: This retrospective study included consecutive patients who were administered intravenous propacetamol in a neurointensive care unit at a single tertiary academic hospital between April 2013 and June 2020. The exact timing of intravenous propacetamol administration was collected from a database of the electronic barcode medication administration system. Blood pressure drop was defined as a systolic blood pressure below 90 mm Hg or a decrease by 30 mm Hg or more. Blood pressure, pulse rate, and body temperature were collected at baseline and within 2 h after intravenous propacetamol administration. The incidence of blood pressure drop was evaluated, and multivariable logistic regression analysis was performed to identify risk factors for blood pressure drop events. RESULTS: A total of 16,586 instances of intravenous propacetamol administration in 4916 patients were eligible for this study. Intravenous propacetamol resulted in a significant decrease in systolic blood pressure (baseline 131.1 ± 17.8 mm Hg; within 1 h 124.6 ± 17.3 mm Hg; between 1 and 2 h 123.4 ± 17.4 mm Hg; P < 0.01). The incidence of blood pressure drop events was 13.5% within 2 h after intravenous propacetamol. Older age, lower or higher baseline systolic blood pressure, fever, higher Acute Physiology and Chronic Health Evaluation II score, and concomitant administration of vasopressors/inotropes or analgesics/sedatives were significant factors associated with the occurrence of blood pressure drop events after intravenous propacetamol administration. CONCLUSIONS: Intravenous propacetamol can induce hemodynamic changes and blood pressure drop events in neurocritically ill patients. This study identified the risk factors for blood pressure drop events. On the basis of our results, judicious use of intravenous propacetamol is warranted for neurocritically ill patients with risk factors that make them more susceptible to hemodynamic changes.

Calcium channel blockers, angiotensin II receptor antagonists and alpha-blockers accentuate blood pressure reducing caused by dental local anesthesia.

OBJECTIVE: The primary aim of this study was to investigate the effect associated with patients' factor such as systemic disease on the blood pressure of patients in dental procedure. The secondary aim of this study was to investigate the effect associated with systemic disease and antihypertensive on the blood pressure changes with local anesthesia. METHODS: The blood pressure was measured before and after local anesthesia injection for dental treatment. The effect associated with patients' factor such as systemic disease on the blood pressure and the effect on blood pressure changes of the type of antihypertensive drugs and the systemic disease were analyzed using a multivariate analysis of variance test. RESULTS: We analyzed 1306 patients scheduled for the dental procedure. Age and some systemic diseases such as hypertension and angina pectoris affected blood pressure before local anesthesia. On the other hand, age and systemic diseases did not affect blood pressure changes. And, some antihypertensive affected systolic blood pressure changes. CONCLUSIONS: The blood pressure change with local anesthesia was not associated with systemic diseases and age but was associated with antihypertensive agents. In particular, calcium channel blockers, angiotensin II receptor antagonists and alpha-blockers accentuate blood pressure reducing caused by local anesthesia. CLINICAL RELEVANCE: The blood pressure change with local anesthesia was associated with antihypertensive agents. This study was registered with the University Hospital Medical Information Network Clinical Trials Registry (number UMIN000030695).

The Hemodynamic Effects of Different Pacing Modalities After Cardiopulmonary Bypass in Patients With Reduced Left Ventricular Function.

OBJECTIVES: Patients with decreased left ventricular function undergoing cardiac surgery have a greater chance of difficult weaning from cardiopulmonary bypass and a poorer clinical outcome. Directly after weaning, interventricular dyssynchrony, paradoxical septal motion, and even temporary bundle-branch block might be observed. In this study, the authors measured arterial dP/dtmax, mean arterial pressure (MAP), and cardiac index using transpulmonary thermodilution, pulse contour analysis, and femoral artery catheter and compared the effects between right ventricular (A-RV) and biventricular (A-BiV) pacing on these parameters. DESIGN: Prospective study. SETTING: Single-center study. PARTICIPANTS: The study comprised 17 patients with a normal or prolonged QRS duration and a left ventricular ejection fraction ≤35% who underwent coronary artery bypass grafting with or without valve replacement. INTERVENTIONS: Temporary pacing wires were placed on the right atrium and both ventricles. Different pacing modalities were used in a standardized order. MEASUREMENTS AND MAIN RESULTS: A-BiV pacing compared with A-RV pacing demonstrated higher arterial dP/dtmax values (846 ± 646 mmHg/s v 800 ± 587 mmHg/s, p = 0.023) and higher MAP values (77 ± 19 mmHg v 71 ± 18 mmHg, p = 0.036). CONCLUSION: In patients with preoperative decreased left ventricular function undergoing coronary artery bypass grafting, A-BiV pacing improve the arterial dP/dtmax and MAP in patients with both normal and prolonged QRS duration compared with standard A-RV pacing. In addition, arterial dP/dtmax and MAP can be used to evaluate the effect of intraoperative pacing. In contrast to previous studies using more invasive techniques, transpulmonary thermodilution is easy to apply in the perioperative clinical setting.

Hemodynamic effects of intramyometrial epinephrine injection for blood loss reduction in laparoscopic myomectomy.

PURPOSE: To evaluate changes in hemodynamic effects of intramyometrial epinephrine injection for blood loss reduction in laparoscopic myomectomy. METHODS: A total of 185 women with symptomatic uterine fibroids who underwent laparoscopic myomectomy were enrolled in this study. Eighty-six women (study collective) received an intramyometrial injection of epinephrine and were compared to ninety-nine women (control collective) who underwent laparoscopic myomectomy without an intramyometrial epinephrine injection. Demographic parameters, change of hemodynamic parameters during surgery as well as hemoglobin drop after surgery were analyzed. RESULTS: In the study collective maximum systolic blood pressure (p < 0.001), maximum increase of the systolic blood pressure within 5 min (p = 0.003), duration of hypertension (p = 0.012), maximal (p < 0.001) and mean heart rate (p = 0.005), maximal increase of heart rate within 5 min (p = 0.003) and difference of mean to maximal heart rate (p < 0.001) were higher compared to the control collective. There was no difference in pre- and postoperative hemoglobin levels in both collectives and no intraoperative clinically relevant complication occurred due to intramyometrial epinephrine injection. CONCLUSION: The intramyometrial application of epinephrine seems to be safe but leads to significant alterations of hemodynamic parameters without a significant change in postoperative hemoglobin levels.

Hemodynamic effects of intraoperative anesthetics administration in photothrombotic stroke model: a study using laser speckle imaging.

BACKGROUND: Previous neuroimaging studies have shown the hemodynamic effect of either preconditioning or postconditioning anesthesia in ischemic stroke model. However, the anesthetic effect in hemodynamics during and immediately after the stroke modeling surgery remains unknown due to the lack of appropriate anesthesia-free stroke model and intraoperative imaging technology. In the present study, we utilized our recently developed photothrombotic model of focal cerebral ischemia in conscious and freely moving rats, and investigated transient hemodynamic changes with or without isoflurane administration. Laser speckle imaging was applied to acquire real-time two-dimensional full-field cerebral blood flow (CBF) information throughout the surgical operations and early after. RESULTS: Significantly larger CBF reduction area was observed in conscious rats from 8 min immediately after the onset of stroke modeling, compared with anesthetized rats. Stroke rats without isoflurane administration also showed larger lesion volume identified by magnetic resonance imaging 3 h post occlusion (58.9%), higher neurological severity score 24 h post occlusion (28.3%), and larger infarct volume from 2,3,5-triphenyltetrazolium chloride staining 24 h post occlusion (46.9%). CONCLUSIONS: Our results demonstrated that the hemodynamic features were affected by anesthetics at as early as during the stroke induction. Also, our findings about the neuroprotection of intraoperative anesthetics administration bring additional insights into understanding the translational difficulty in stroke research.

Hemodynamic Effect of Repeated Epinephrine Doses Decreases With Cardiopulmonary Resuscitation Cycle Progression.

BACKGROUND: Epinephrine is administered to increase coronary perfusion pressure during advanced life support and promote short-term survival. Recent cardiopulmonary resuscitation (CPR) guidelines recommend an epinephrine dosing interval of 3 to 5 minutes during resuscitation; however, scientific evidence supporting this recommendation is lacking. Therefore, we aimed to investigate the hemodynamic effects of repeated epinephrine doses during CPR by monitoring augmented blood pressure after its administration in a swine model of cardiac arrest. METHODS AND RESULTS: A secondary analysis of data from a published study was performed using a swine cardiac arrest model. The epinephrine dose was fixed at 1 mg, and the first dose of epinephrine was administered after no-flow and low-flow times of 2 minutes and 8 minutes, respectively, and subsequently administered every 4 minutes. Four cycles of dosing intervals were defined because a previous study was terminated 26 minutes after the induction of ventricular fibrillation. Augmented blood pressures and corresponding timelines were determined. Augmented blood pressure trends following cycles and the epinephrine effect duration were also monitored. Among the 140 CPR cycles, the augmented blood pressure after epinephrine administration was the highest during the first cycle of CPR and decreased gradually with further cycle repetitions. The epinephrine effect duration did not differ between repeated cycles. The maximum blood pressure was achieved 78 to 97 seconds after epinephrine administration. CONCLUSIONS: Hemodynamic augmentation with repeated epinephrine administration during CPR decreased with cycle progression. Further studies are required to develop an epinephrine administration strategy to maintain its hemodynamic effects during prolonged resuscitation.

Comparison of Acute Effects of E-cigarettes With and Without Nicotine and Tobacco Cigarettes on Hemodynamic and Endothelial Parameters: A Systematic Review and Meta-analysis.

INTRODUCTION: Smoke from traditional cigarettes and e-cigarette aerosols have distinct chemical compositions that may impact blood pressure (BP) and heart rate (HR) differently. AIMS: This study compared the impact of nicotine-containing e-cigarettes (EC+) versus nicotine-free (EC-) on BP, HR and endothelial markers, and assessed if EC+ posed fewer risks than tobacco cigarettes (TC). METHODS: Electronic databases were searched from inception until November 2023 for studies reporting changes in systolic and diastolic BP (SBP, DBP) and HR and endothelial parameters before and after the use of EC+, EC- and TC. Data were analyzed using weighted mean differences (WMDs) and 95% confidence intervals (CIs). RESULTS: Fifteen studies (n = 752) were included in our meta-analysis. We demonstrate that EC+ significantly increased systolic BP (WMD = 3.41, 95% CI [0.1,6.73], p = 0.04], diastolic BP (WMD = 3.42, 95% CI [1.75, 5.09]; p < 0.01], and HR (WMD = 5.36 BPM, 95% CI [1.87, 8.85]; p < 0.01) compared to EC-. However, EC+ was observed to cause less detrimental effect on SBP (WMD = - 4.72 mmHg, 95% CI [- 6.58, - 2.86], p < 0.01), and HR (WMD = - 3.11 BPM, 95% CI [- 4.54, - 1.68]; p < 0.01) as compared to TC with no difference on DBP (WMD = - 1.14 mmHg, 95% CI [- 2.38, 0.1]; p = 0.07). EC+ also led to greater deterioration of endothelial parameters as compared to EC- but to a lesser degree as compared to TC. CONCLUSION: EC+ shows greater impairment in hemodynamic and endothelial parameters than EC- but less than TC. Additional studies are needed to evaluate prolonged effects of EC use.

Acute Hemodynamic Effects of Simultaneous and Sequential Multi-Point Pacing in Heart Failure Patients With an Expected Higher Rate of Sub-response to Cardiac Resynchronization Therapy: Results of Multicenter SYNSEQ Study.

The aim of the SYNSEQ (Left Ventricular Synchronous vs. Sequential MultiSpot Pacing for CRT) study was to evaluate the acute hemodynamic response (AHR) of simultaneous (3P-MPP syn) or sequential (3P-MPP seq) multi-3-point-left-ventricular (LV) pacing vs. single point pacing (SPP) in a group of patients at risk of a suboptimal response to cardiac resynchronization therapy (CRT). Twenty five patients with myocardial scar or QRS ≤ 150 or the absence of LBBB (age: 66 ± 12 years, QRS: 159 ± 12 ms, NYHA class II/III, LVEF ≤ 35%) underwent acute hemodynamic assessment by LV + dP/dtmax with a variety of LV pacing configurations at an optimized AV delay. The change in LV + dP/dt max (%ΔLV + dP/dt max) with 3P-MPP syn (15.6%, 95% CI: 8.8%-22.5%) was neither statistically significantly different to 3P-MPP seq (11.8%, 95% CI: 7.6-16.0%) nor to SPP basal (11.5%, 95% CI:7.1-15.9%) or SPP mid (12.2%, 95% CI:7.9-16.5%), but higher than SPP apical (10.6%, 95% CI:5.3-15.9%, p = 0.03). AHR (defined as a %ΔLV + dP/dt max ≥ 10%) varied between pacing configurations: 36% (9/25) for SPP apical, 44% (11/25) for SPP basal, 54% (13/24) for SPP mid, 56% (14/25) for 3P-MPP syn and 48% (11/23) for 3P-MPP seq.Fifteen patients (15/25, 60%) had an AHR in at least one pacing configuration. AHR was observed in 10/13 (77%) patients with a LBBB but only in 5/12 (42%) patients with a non-LBBB (p = 0.11). To conclude, simultaneous or sequential multipoint pacing compared to single point pacing did not improve the acute hemodynamic effect in a suboptimal CRT response population. Clinical Trial Registration: ClinicalTrials.gov, identifier: NCT02914457.

Fluid-Structure Interaction Analysis on the Influence of the Aortic Valve Stent Leaflet Structure in Hemodynamics.

Transcatheter aortic valve replacement (TAVR) is a minimally invasive surgical treatment for heart valve disease. At present, personalized TAVR valves are not available for some patients. This study adopts the fluid-structure interaction (FSI) model of the research object that has a three-disc leaflet form and structural design in the valve leaflet area. The valve opening shape, orifice area, stress-strain, and distribution of hemodynamic flow and pressure were compared under the condition of equal contact area between valve and blood. The FSI method was used to simulate the complex three dimensional characteristics of the flow field more accurately around the valve after TAVR stent implantation. Three personalized stent systems were established to study the performance of the leaflet design based on computational fluid dynamics. By comparing the different leaflet geometries, the maximum stress on leaflets and stents of model B was relatively reduced, which effectively improved the reliability of the stent design. Such valve design also causes the opening area of the valve leaflet to increase and the low-velocity area of the flow field to decrease during the working process of the valve, thus reducing the possibility of thrombosis. These findings can underpin breakthroughs in product design, and provide important theoretical support and technical guidance for clinical research.

Hemodynamic performance of a compact centrifugal left ventricular assist device with fully magnetic levitation under pulsatile operation: An in vitro study.

Long-term using continuous flow ventricular assist devices could trigger complications associated with diminished pulsatility, such as valve insufficiency and gastrointestinal bleeding. One feasible solution is to produce pulsatile flow assist with speed regulation in continuous flow ventricular assist devices. A third-generation blood pump with pulsatile operation control algorithm was first characterized alone under pulsatile mode at various speeds, amplitudes, and waveforms. The pump was then incorporated in a Mock circulation system to evaluate in vitro hemodynamic effects when using continuous and different pulsatile operations. Pulsatility was evaluated by surplus hemodynamic energy. Results showed that pulsatile operations provided sufficient hemodynamic assistance and increased pulsatility of the circulatory system (53% increment), the mean aortic pressure (65% increment), and cardiac output (27% increment). The pulsatility of the system under pulsatile operation support was increased 147% compared with continuous operation support. The hemodynamic performance of pulsatile operations is susceptible to phase shifts, which could be a tacking angle for physiological control optimization. This study found third-generation blood pumps using different pulsatile operations for ventricular assistance promising.

The optimization of iloprost inhalation under moderate flow of oxygen therapy in severe pulmonary arterial hypertension.

Inhaled iloprost efficiently improves pulmonary hemodynamics, exercise capacity, and quality of life in patients with pulmonary arterial hypertension (PAH). However, the process of inhalation is laborious for patients suffering from resting dyspnea. We describe a 75-year-old man with idiopathic PAH and a low gas transfer. Investigations excluded significant parenchymal lung disease and airflow obstruction (presuming FEV1/FVC ration > 70%). The patient struggled to complete iloprost inhalation due to severe dyspnea and hypoxemia. As such, we optimized the methods of oxygen supply from the nasal cannula to the trans-inhalator during the inhalation. We successfully shortened the inhalation duration that effectively reduced the laborious efforts required of patients. We also recorded pulmonary hemodynamics during inhalation of nebulized iloprost. This revealed significant hemodynamic improvement immediately following inhalation but hemodynamics returned to baseline within 2 hours. We hope that this optimization will enable patients with severe PAH to undergo iloprost inhalation.

Hemodynamic significance of collateral blood flow in chronic venous obstruction.

INTRODUCTION: Complaints related to the post-thrombotic syndrome do not always correlate well with the extent of post-thrombotic changes on diagnostic imaging. One explanation might be a difference in development of collateral blood flow. The aim of this study is to investigate the hemodynamic effect of collateralisation in deep venous obstruction. METHODOLOGY: Resting intravenous pressure of the common femoral vein was measured bilaterally in the supine position of patients with unilateral iliofemoral post-thrombotic obstruction. In addition, pressure in control limbs was also measured in the common femoral vein after sudden balloon occlusion in the external iliac vein. RESULTS: Fourteen patients (median age 42 years, 12 female) were tested. In eleven limbs post-thrombotic disease extended below the femoral confluence. Median common femoral vein pressure was 17.0 mmHg in diseased limbs compared to 12.8 mmHg in controls (p = 0.001) and 23.5 mmHg in controls after sudden balloon occlusion (p = 0.009). Results remained significant after correcting for non-occlusive post-thrombotic disease. CONCLUSION: This study shows that common femoral vein pressure is increased in post-thrombotic iliofemoral deep venous obstruction, though not as much as after sudden balloon occlusion. The latter difference could explain the importance of collateralisation in deep venous obstructive disease and the discrepancy between complaints and anatomical changes; notwithstanding, the presence of collaterals does not eliminate the need for treatment.

Pressors and inotropes.

To effectively treat an aging and increasingly complex patient population, emergency physicians and other acute-care providers must be comfortable with the use of vasopressors, inotropes, and chronotropes. These medicines are used to augment the cardiovascular function of critically ill patients. Each class of medication produces a different hemodynamic effect. Some agents produce only one of these actions, whereas others have multiple effects. For the emergency physician, these agents are used with the explicit goal of preserving vital organ perfusion during acute and severe illness. This article reviews the physiologic receptors targeted by such drugs, common agents used, and specific clinical indications for their use.