Safety of Low-Dose Oral Minoxidil in Patients With Hypertension and Arrhythmia: A Multicenter Study of 264 Patients. / [Artíulo traducido] Seguridad de minoxidil oral a dosis bajas en pacientes con hipertensión o arritmias: estudio multicéntrico de 264 pacientes.

BACKGROUND AND OBJECTIVE: Systemic adverse effects (AE) are a major concern of low-dose oral minoxidil (LDOM) treatment, especially in patients with arterial hypertension or arrhythmia. The objective of this study was to evaluate the safety of LDOM in patients with hypertension or arrhythmia. PATIENTS AND METHODS: Retrospective multicenter study of patients with hypertension or arrhythmia treated with LDOM for any type of alopecia. RESULTS: A total of 254 patients with hypertension [176 women (69.3%) and 78 men (30.7%)] with a mean age of 56.9 years (range 19-82) were included. From them, the dose of LDOM was titrated in 128 patients, allowing the analysis of 382 doses. Patients were receiving a mean of 1.45 (range 0-5) antihypertensive drugs. Systemic AE were detected in 26 cases (6.8%) and included lightheadedness (3.1%), fluid retention (2.6%), general malaise (0.8%), tachycardia (0.8%) and headache (0.5%), leading to LDOM discontinuation in 6 cases (1.5%). Prior treatment with doxazosin (P<0.001), or with three or more antihypertensive drugs (P=0.012) was associated with a higher risk of discontinuation of LDOM. CONCLUSIONS: LDOM treatment showed a favorable safety profile in patients with hypertension or arrhythmia, similar to general population.

Safety of Low-Dose Oral Minoxidil in Patients With Hypertension and Arrhythmia: A Multicenter Study of 264 Patients.

BACKGROUND AND OBJECTIVE: Systemic adverse effects (AE) are a major concern of low-dose oral minoxidil (LDOM) treatment, especially in patients with arterial hypertension or arrhythmia. The objective of this study was to evaluate the safety of LDOM in patients with hypertension or arrhythmia. PATIENTS AND METHODS: Retrospective multicenter study of patients with hypertension or arrhythmia treated with LDOM for any type of alopecia. RESULTS: A total of 254 patients with hypertension [176 women (69.3%) and 78 men (30.7%)] with a mean age of 56.9 years (range 19-82) were included. From them, the dose of LDOM was titrated in 128 patients, allowing the analysis of 382 doses. Patients were receiving a mean of 1.45 (range 0-5) antihypertensive drugs. Systemic AE were detected in 26 cases (6.8%) and included lightheadedness (3.1%), fluid retention (2.6%), general malaise (0.8%), tachycardia (0.8%) and headache (0.5%), leading to LDOM discontinuation in 6 cases (1.5%). Prior treatment with doxazosin (P<0.001), or with three or more antihypertensive drugs (P=0.012) was associated with a higher risk of discontinuation of LDOM. CONCLUSIONS: LDOM treatment showed a favorable safety profile in patients with hypertension or arrhythmia, similar to general population.

[Prevalence and relations of orthostatic hypotension in patients 80 years old and over from a primary care unit]. / Prevalencia y relaciones de la hipotensión ortostática en los pacientes de 80 o más años de edad de una unidad de atención primaria.

OBJECTIVE: To estimate the prevalence of orthostatic hypotension (OH) in patients 80 years old and over attending a primary care unit. To relate OH to the most prevalent pathologies and to the most used drugs. DESIGN: Transversal observational study. LOCATION: Primary care unit, Santiago de Compostela. PARTICIPANTS: Eighty one patients 80 years old or over representative of a primary care unit were recruited. Ten patients were excluded. MAIN MEASUREMENTS: Blood pressure was measured in decubitus and later in erect position first immediately after standing and then after 3 minutes. Diagnoses and active treatments were reviewed in the electronic clinical history and through an interview with the patient and caregiver. RESULTS: In 26.76% of patients the systolic blood pressure fell by 20mmHg or more and/or the diastolic blood pressure fell by 10mmHg in the instant following the postural shift. In 16.90% of patients the drop persisted after 3 minutes of standing from decubitus position. None of the patients was diagnosed with OH. The highest prevalence ratio was observed for diabetes mellitus (1.6; P=.412), not existing differences for arterial hypertension (P=.881). OH related in a statistically meaningful way to the use of renin angiotensin aldosterone system inhibitors (OR: 8.174, CI95%: 1.182-56.536); P=.033] and benzodiazepines (OR: 5.938, CI95%: 1.242-28.397; P=.026)]. CONCLUSION: OH had a prevalence of 16.90% among the elderly patients who had a consultation. Its connection with some drugs (renin angiotensin aldosterone system inhibitors and benzodiazepines) must be considered.

[Paradoxical transtentorial herniation, extreme trephined syndrome sign: A case report]. / Herniación paradójica transtentorial, manifestación extrema del síndrome del craniectomizado. Caso clínico.

The current increasing use of decompressive craniectomy carries the implicit appearance of complications due to alterations in both intracranial pressure and in the hydrostatic-hemodynamic equilibrium. Paradoxical transtentorial herniation represents a rare manifestation, included in "trephine syndrome", extremely critical but with relatively simple treatment. We present the case of a 56-year-old woman with no interesting medical history, who, after an olfactory groove meningioma surgery, presented a haemorrhage located in the surgical area with an important oedema. The patient required a second emergency surgery without any chance of conserving the cranial vault. During the post-operational period, great neurological deterioration in orthostatic position was noticed, which resolved spontaneously in decubitus. This deficit was resolved with bone replacement afterwards. We discuss possible predisposing factors and aetiologies of this pathology.

[Severe complications of orotracheal intubation in the Intensive Care Unit: An observational study and analysis of risk factors]. / Complicaciones graves en la intubación orotraqueal en cuidados intensivos: estudio observacional y análisis de factores de riesgo.

OBJECTIVE: A study is made to determine the characteristics of endotracheal intubation (ETI) procedures performed in an Intensive Care Unit, and to describe the associated severe complications and related risk factors. DESIGN: A prospective cohort study involving a 2-year period was carried out. SETTING: The combined clinical/surgical Intensive Care Unit in a secondary university hospital. PATIENTS: All ETIs carried out by intensivists were included. INTERVENTIONS: None. MAIN VARIABLES: We analyzed the data associated with the patient, the procedure and the postoperative complications after intubation. The study of risk factors was performed using multiple logistic regression analysis. RESULTS: Seventy-six percent of the ETIs were performed immediately. Most of them were carried out by Intensive Care Units residents (60%). A total of 34% of the procedures had severe complications, including respiratory (16%) or hemodynamic (5%) disorders, or both (10%). Three patients died (1%), and 2% of the subjects experienced cardiac arrest. Logistic regression analysis identified the following independent risk factors for complications: age (OR 1.1; 95% CI: 1.1-1.2), systolic blood pressure≤90mmHg (OR 3.0; 95% CI: 1.4-6.4) and SpO2≤90% (OR 4.4; 95% CI: 2.3-8.1) prior to intubation, the presence of secretions (OR 2.2; 95% CI: 1.1-4.6), and the need for more than one ETI attempt (OR 3.5; 95% CI: 1.4-8.7). CONCLUSIONS: ETI in Intensive Care Unit patients is associated with respiratory and hemodynamic complications. The independent risk factors associated with the development of complications were advanced age, hypotension and previous hypoxemia, the presence of secretions, and the need for more than one ETI attempt.

Bradycardia in frontotemporal dementia.

INTRODUCTION: Numerous regions of the brain, such as the medial frontal cortex, orbitofrontal cortex, insula, and amygdala, participate in the autonomic control of cardiovascular functions such as heart rate. The degenerative process in frontotemporal dementia (FTD) involves the listed anatomical structures and may therefore produce dysautonomic cardiovascular symptoms. AIM: To observe whether or not non-cardiogenic bradycardia was more frequent in a group of patients with FTD than in subjects with mild cognitive impairment or dementia of a different aetiology. PATIENTS AND METHOD: Once patients with primary cardiac arrhythmia were excluded, we registered the heart rates of 258 patients with cognitive symptoms (36 with FTD, 22 with Alzheimer disease, 23 with vascular dementia, 10 with other dementias, and 167 with non-dementia cognitive impairment). RESULTS: Bradycardia (<60 beats/minute) was significantly more frequent in patients with FTD. This difference remained significant after excluding subjects undergoing treatment with a potentially bradycardic effect. Bradycardia was more prevalent in behavioural FTD cases than in cases of the aphasic variant, and we detected a trend toward higher frequency among patients with more pronounced right hemisphere atrophy. Moreover, mean systolic blood pressure in FTD patients was lower than in other participants, and systolic hypotension (<120 and <100mm Hg) was more prevalent. CONCLUSION: Bradycardia was more frequent in the FTD sample than in other patients with cognitive symptoms. Further investigations will be necessary before we may consider bradycardia to be a sign supporting diagnosis of FTD or its behavioural variant.

Does intradialytic oral nutrition impact hemodialysis patients' quality of life, appetite, and safety? A pilot study of a crossover clinical trial.

Introduction: Introduction: due to the catabolic characteristics of hemodialysis (HD), patients should consume foods or supplements during this treatment to meet their energy requirements and maintain a neutral nitrogen balance; however, there are some outcomes in which the effect of intradialytic oral nutrition (ION) is scarcely known. Objectives: this study aims to evaluate the effect of two types of ION (liquid and solid) on Quality of Life (QoL), appetite, and safety in HD patients. Methods: a pilot randomized, crossover clinical trial was performed in 18 patients on chronic HD. One group received ION for 18 HD sessions, after the crossover continued for 18 more sessions in the control group, and vice versa. We recorded QoL, appetite, systolic blood pressure (SBP), and intradialytic hypotension (IH) events. Results: clinical improvement was observed for most QoL components. Regardless of the consistency of supplementation, SBP increased to 4.10 mmHg. Both study groups reported a "very good-to-good" appetite. Conclusion: favorable clinical changes were observed in QoL scores during the study. Five of six IH events were reported for patients in the ION group, and SBP increased within the safe range (≤ 10 mmHg); appetite remained stable in both groups. Therefore, we concluded that this strategy, regardless of implementation consistency, is safe to be used in stable patients.

Introducción: Introducción: debido a las características catabólicas de la hemodiálisis (HD), los pacientes deben consumir alimentos o suplementos durante este tratamiento para cubrir sus requerimientos energéticos y mantener un balance nitrogenado neutro; sin embargo, existen algunos desenlaces en los que el efecto de la nutrición oral intradialítica (NOID) es poco conocido. Objetivo: este estudio tiene como objetivo evaluar el efecto de dos tipos de NOID (líquido y sólido) sobre la calidad de vida, el apetito y la seguridad en pacientes en HD. Métodos: se realizó un estudio piloto en forma de ensayo clínico aleatorizado y cruzado con 18 pacientes en HD crónica. Un grupo recibió NOID durante 18 sesiones de HD, después del cruzamiento continuaron durante 18 sesiones más en el grupo de control, y viceversa. Se registraron la calidad de vida, el apetito, la presión arterial sistólica (PAS) y la hipotensión intradialítica (HI). Resultados: se observó mejoría clínica en la mayoría de los componentes de la calidad de vida. Independientemente de la consistencia de la suplementación, la PAS aumentó hasta 4,10 mmHg. Ambos grupos de estudio informaron de un apetito "muy bueno-bueno". Conclusiones: se observaron cambios clínicos favorables en las puntuaciones de calidad de vida durante el estudio. Cinco de seis eventos de HI se reportaron en pacientes del grupo de NOID y la PAS aumentó dentro del rango seguro (≤ 10 mmHg); el apetito se mantuvo estable en ambos grupos. Por lo tanto, se puede concluir que esta estrategia, independientemente de la consistencia implementada, es segura para ser utilizada en pacientes estables.

Semisitting position for cerebello-pontine angle surgery: Analysis of complications and how to avoid it.

OBJECTIVE: To analyze the primary complications related to semisitting position in patients undergoing cerebelo-pontine angle surgery. METHODS: Retrospective data analysis from patients undergoing elective tumoral cerebelo-pontine angle surgery in a semisitting position. The incidence, severity, occurrence moment, treatment, duration, and outcomes of venous air embolism (VAE), pneumocephalus, postural hypotension, and other complications were recorded. Neurointensive care unit (NICU), length of stay (LOS), hospital LOS, and modified Rankin scale scores were calculated six months after surgery. RESULTS: Fifty patients were operated on. Eleven (22%) presented VAE (mean duration 8±4.5min): five (10%) during tumor resection, and four (8%) during dural opening. Ten (20%) were resolved by covering the surgical bed, air bubbles aspiration, jugular compression, and one (2%) tilted to a steep Trendelenburg position. One (2%) had intraoperative hemodynamic instability. The only variable associated with VAE was meningioma at histopathology OR=4.58, p=0.001. NICU was higher in patients with VAE (5.5±1.06 vs. 1.9±0.20 days, p=0.01). There were no differences in the Rankin scale. All patients presented postoperative pneumocephalus with a good level of consciousness, except one (2%) who required evacuation. Seven patients (14%) showed postural hypotension, three (6%) after positioning, and one (2%) after developing a VAE; all were reversed with usual vasoactive drugs. No other position-related complications or mortality were registered in this series. CONCLUSIONS: The semisitting position is a safe option with the knowledge, prevention, detection, and early solution of all the possible complications. The development of VAE rarely implies hemodynamic instability or greater disability after surgery. Postoperative pneumocephalus is very common and rarely requires evacuation. Excellent cooperation between anesthesia, nursing, neurophysiology, and neurosurgery teams is essential to manage complications.

Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group.

Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.

Refractory hypotension secondary to chronic treatment with high doses of quetiapine.

Quetiapine is an atypical antipsychotic used in the treatment of depressive, schizophrenic, or bipolar disorders. It acts on dopamine D1 and D2, histamine, and 5HT1A and 5HT2 receptors. However, it also acts as an antagonist for α1 receptors causing cardiovascular side effects, including hypotension. We present the case of a patient chronically medicated with Quetiapine who developed hypotension refractory to vasoconstrictors and intraoperative fluid therapy. Noradrenalin has a strong α1 effect with lower affinity for ß2 receptors unlike adrenalin. This translates into peripheral vasoconstriction and an improved clinical picture. Therefore, it should be considered the vasoactive drug of choice in patients on high doses of Quetiapine.

Postoperative arterial hypotension: the unnoticed enemy.

Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.

Inferior vena cava ultrasonography before general anesthesia cannot predict arterial hypotension in patients undergoing vascular surgery.

INTRODUCTION: Intraoperative hypotension (IH) is an independent predictor of mortality. Some experts have suggested that ultrasound measurement of the inferior vena cava (IVC) in spontaneous ventilation can predict IH. OBJECTIVE: To evaluate the capacity of ultrasound measures of IVC in spontaneous ventilation to predict episodes of IH after anaesthesia induction. PATIENTS AND METHODS: We studied 55 high-risk cardiac patients undergoing vascular surgery. The maximum (dIVCmax) and minimum (dIVCmin) diameter of the IVC were measured and the collapsibility index CI = (dIVCmax-dIVCmin)/dIVCmax was calculated prior to anaesthesia induction. Three definitions of IH were used: systolic blood pressure (SBP) less than 100 mmHg, mean arterial pressure (MAP) less than 60 mmHg, and a decrease in MAP greater than or equal to 30% compared to baseline. RESULTS: There were no significant differences in dIVCmax or in CI between patients presenting IH after anaesthesia induction and those who did not. ROC curves for dIVCmax showed an area under the curve of 0.55 (0.39-0.70), 0.69 (0.48-0.90), and 0.57 (0.42-0.73) and ROC curves for the CI were 0.62 (0.47-0.78), 0.60 (0.41-0.78) and 0.62 (0.47-0.78) for the 3 definitions of IH (<100 mmHg, MAP < 60 mmHg, and MAP ≥30% baseline), respectively. CONCLUSIONS: Ultrasound measurements of IVC in spontaneous ventilation are not good predictors of IH after anaesthesia induction in these patients. The optimal cut-off points show low specificity and moderate sensitivity for predicting IH.

A systematic review and meta-analysis of the hemodynamic effects of etomidate versus other sedatives in patients undergoing rapid sequence intubation.

INTRODUCTION: Rapid sequence intubation is an airway rescue and protection technique in which different sedatives are used to perform orotracheal intubation. Etomidate, due to its pharmacokinetic and pharmacodynamic qualities, particularly hemodynamic stability, is the most widely used sedative in this scenario. However, its superiority over other sedatives is controversial. MATERIALS AND METHODS: We performed a meta-analysis using a pre-designed protocol and PRISMA guidelines to evaluate the mean difference between systolic blood pressure before and after administration of the sedative. We also analyzed the relative risks of hypotension. RESULTS: Ten studies were included. The incidence of hypotension in patients receiving etomidate ranged from 6.4% to 75.2%, and between 24.0% and 65.9% in patients receiving other sedatives. No significant differences were found in the mean difference in systolic blood pressure during pre-intubation 0.01 mm Hg (95% CI: -0.90; 0.92) or in post-intubation 0.98 mmHg (95% CI: -0.24; 2.20). The relative risk analysis showed that the risk of hypotension is equal to an RR of 1.19 (95% CI: 0.92-1.54) between those who received etomidate and those who received the other sedatives. CONCLUSIONS: The risk of hypotension after rapid intubation sequence with etomidate does not differ significantly compared to other sedatives. However, the studies included in this review were heterogeneous.

Cerebrospinal fluid hypotension following fall in a child: Case report.

CSF hypotension arises in the context of a leak of CSF which causes negative intracranial pressure. Sacral fractures result from high-energy trauma which are frequently underdiagnosed. A ten-year-old boy presented with hip pain, after a fall. He mobilized both lower limbs, reported no leg pain, irradiation nor lack of sphincter control. The neurological examination was normal. When asked to stand, he began biparietal headache, nausea and vomiting, which improved laying down. CT scan showed an occult intrasacral meningocele; the MRI revealed collections of CSF along the spine, a S3 fracture with potential laceration of the meningocele and opening of a CSF fistula. Our diagnosis was the CSF hypotension, secondary to the fistula opening. The diagnosis was challenging. The child first presented with symptoms of CSF hypotension without evident cause. The discovery of the meningocele led us to hypothesize the opening of a fistula, a rare diagnosis, later confirmed by MRI.

Epidural anesthesia for cesarean section with 0.125% versus 0.25% bupivacaine: An Ecuadorian prospective cohort.

ANTECEDENTES: En una cesárea se puede emplear analgesia epidural con bupivacaína 0.125% and lidocaína 1.5% ó bupivacaína 0.25% and lidocaína 1.0%. Una concentración mayor de bupivacaína alcanza mayor analgesia con más eventos adversos. OBJETIVO: evaluar la analgesia y seguridad de bupivacaína 0.125% and lidocaína 1.5% ó bupivacaína 0.25% and lidocaína 1.0%. MATERIALES Y MÉTODOS: Cohorte prospectivo estratificado según ambas concentraciones de bupivacaína. RESULTADOS: Se recuperó cien gestantes a término (cincuenta por cohorte). A los 20 y 30 minutos tras la administración epidural hubo más casos con mayor bloqueo motor en quienes se empleó bupivacaína 0.125% and lidocaína 1.5% (p = 0.0229 y p = 0.0006, respectivamente). No hubo diferencia significativa respecto al bloqueo sensitivo. Bupivacaína 0.25% and lidocaína 1.5% mostró una tencencia a la hipotensión (p < 0.001) y a la bradicardia (p = 0.4100). De la cohorte de bupivacaína 0.125% and lidocaína 1.5%, 25 casos (50%) presentaron cuando menos un evento adverso, en contraste con 44/50 (88%) de la cohorte de bupivacaína 0.25% and lidocaína 1.0% (p < 0.001). CONCLUSIÓN: En la analgesia epidural durante cesárea, bupivacaína 0.125% and lidocaína 1.5% está asociado con un efecto analgésico similar a bupivacaína 0.25% and lidocaína 1.0%. Sin embargo, mayores concentraciones están significativamente relacionadas con mayor tasa de eventos adversos (especialmente hipotensión). BACKGROUND: In a cesarean section, epidural analgesia with 0.125% bupivacaine and 1.5% lidocaine or 0.25% bupivacaine with 1.0% lidocaine concentrations can be used. A higher concentration of bupivacaine reaches better analgesia but with a higher rate of drug-related adverse events. AIM: The aim of the study was to assess analgesia and safety of 0.125% bupivacaine and 1.5% lidocaine or 0.25% bupivacaine with 1.0% lidocaine during cesarean. MATERIALS AND METHODS: Prospective cohort stratified following both bupivacaine concentrations. RESULTS: One hundred women with full-term pregnancies were selected (fifty per cohort). At 20 and 30 min after epidural administration, there was a higher proportion of motor blockade cases from the 0.125% bupivacaine and 1.5% lidocaine cohort (p = 0.0229 and p = 0.0006, respectively). There was no significant difference among sensitive blockage. A 0.25% bupivacaine and 1.0% lidocaine concentration showed a tendency to hypotension (p < 0.001) and bradycardia (p = 0.4100). From 0.125% bupivacaine and 1.5% lidocaine cohort, 25 cases (50%) presented at least one adverse event; in contrast with 44/50 (88%) from 0.25% bupivacaine and 1.0% lidocaine cohort (p < 0.001). CONCLUSION: In epidural analgesia during cesarean, using 0.125% bupivacaine and 1.5% lidocaine presented similar analgesia than 0.25% bupivacaine and 1.0% lidocaine. However, a higher bupivacaine concentration is significantly related to more frequent drug-related adverse events (especially hypotension).

[Hypertension in the elderly: What we need to know]. / Hipertensión del anciano: qué debemos conocer.

More than two thirds of people over 65 are hypertensive. Along with the high prevalence, hypertension is associated by comorbidities that originates a heterogeneous elderly population in relation to their autonomy and functional capacity. At this age, hypertension has special characteristics that make its management difficult, highlighting by isolated systolic hypertension due to the vascular stiffness typical of aging. Although decision-making is based on the clinical measurement of blood pressure, it is known that in the elderly pressure is subject to numerous influences: temporal (absence of night dipping), of the environment (exacerbation of the white coat phenomenon) and of the position (orthostatic hypotension). These circumstances must be taken into account when evaluating and deciding on therapy. At this age, there is sufficient evidence that treatment reduces both cardiovascular morbimortality and all-cause mortality.

Cerebrospinal fluid hypotension following fall in a child: Case report.

CSF hypotension arises in the context of a leak of CSF which causes negative intracranial pressure. Sacral fractures result from high-energy trauma which are frequently underdiagnosed. A ten-year-old boy presented with hip pain, after a fall. He mobilized both lower limbs, reported no leg pain, irradiation nor lack of sphincter control. The neurological examination was normal. When asked to stand, he began biparietal headache, nausea and vomiting, which improved laying down. CT scan showed an occult intrasacral meningocele; the MRI revealed collections of CSF along the spine, a S3 fracture with potential laceration of the meningocele and opening of a CSF fistula. Our diagnosis was the CSF hypotension, secondary to the fistula opening. The diagnosis was challenging. The child first presented with symptoms of CSF hypotension without evident cause. The discovery of the meningocele led us to hypothesize the opening of a fistula, a rare diagnosis, later confirmed by MRI.

The value of hypotensive prediction index and dP/dtmax to predict and treat hypotension in a patient with a dilated cardiomyopathy. / Valor del índice de predicción de la hipotensión y el dP/dtmax para predecir y tratar la hipotensión en un paciente con miocardiopatía dilatada.

The Hypotension Prediction Index (HPi) is a new parameter, recently developed to predict the risk of a patient developing a hypotensive event, defined as a fall in mean arterial pressure below 65 mmHg. The calculated HPi value is displayed on a monitor as a number ranging from 1 to 100; where the first warning for the appearance of such event occurs when HPi values exceed 85. A secondary screen shows the stroke volume variation value; the dP/dt max; and the dynamic arterial elastance. We described a patient with a mild to moderately dilated cardiomyopathy that presented several episodes of hypotension after induction of anaesthesia and how by using HPi technology, these were successfully solved. We recommend the use of a HPi value >85 as a warning of intervention, and to use the secondary screen to determine the cause and the treatment. We consider that HPi technology may be a valid alternative for the anaesthetic management of patients with a dilated cardiomyopathy.

Intradialytic hypotension definitions with mortality prediction capacity in a cohort of haemodialysis patients. / Definiciones de hipotensión intradiálisis con poder predictivo de mortalidad en una cohorte de hemodiálisis.

INTRODUCTION: Intradialytic hypotension (IDH) is a common complication and is associated with higher morbidity and mortality in patients on haemodialysis. However, there is a lack of uniformity in definitions of IDH. The main objective of this study is to analyse clinical and dialysis related factors with several IDH definitions, and its relationship with morbidity and mortality in a cohort of haemodialysis patients. METHODOLOGY: Observational study with a 30-month follow-up period that includes 68 prevalent patients on haemodialysis with at least six months of treatment. We analysed 18 non-consecutive dialysis sessions (first three of each month of a six-month period), and different definitions of IDH were recorded. A positive event of IDH was defined if any definition occurred in more than 25% of the sessions studied. Using survival analysis, we analysed the prediction capacity of each IDH definition (Nadir90, Nadir100, Fall20, Fall30, Fall20Nadir90, Fall30Nadir90, KDOQI, HEMO). The relationship with non-fatal cardiovascular disease and global mortality was estimated using different Cox proportional models. RESULTS: We found IDH definitions that occurred significantly more frequently (Nadir100: 339.8/1,000 sessions, Nadir90: 172.3/1,000 sessions) than others (KDOQI: 98/1,000 sessions, HEMO 129.9/1,000 sessions). We registered 13 fatal events with a mean follow-up of 27.12±6.84 months. A greater number of sessions with IDH according to the Nadir90 definition was a predictive factor of mortality (Log rank 5.02, p=0.025), independent according to adjusted models (HR: 3.23 [95% CI: 1.08-9.6], p=0.035). The definitions Nadir100 (HR: 4.54 [95% CI: 1.25-16.4], p=0.02) and Fall30Nadir90 (HR: 3.08 [95% CI: 1.07-8.8], p=0.03) were independent predictors of non-fatal cardiovascular disease in adjusted models. CONCLUSIONS: Intradialytic hypotension, even asymptomatic, is a predictor of mortality and non-fatal cardiovascular disease in prevalent patients on haemodialysis.

Intracranial hypotension secondary to spontaneous spinal cerebrospinal fluid fistula: Three case reports. / Hipotensión intracraneal secundaria a fístula espinal espontánea de líquido cefalorraquídeo: Presentación de tres casos.

Spontaneous intracranial hypotension syndrome (SIH) is a rare condition. The main symptom is orthostatic headache, although other symptoms such as vegetative symptoms, meningism, or focal neurological deficits may appear. The most common cause is a cerebrospinal fluid leak, usually traumatic. Spontaneous cerebrospinal fluid leaks are rare and associated with the presence of meningeal cysts / diverticula or in the setting of connective tissue diseases. The diagnosis is based on imaging tests, both to detect intracranial complications and bilateral subdural hematomas and to locate the leak point at the intracranial or spinal level. The treatment of SIH is usually conservative: bed rest, caffeine and analgesics. Epidural blood patch is a good option when symptoms persist. Surgery is indicated in refractory cases or when there is an evident and accessible anatomic defect. This article describes three clinical cases with intracranial hypotension syndrome secondary to a spontaneous spinal cerebrospinal fluid leak.