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Rationalising the dose threshold for severe carbamazepine toxicity: a retrospective series.

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.

Shock Simulation Day: Medical Decision-Making and Communication Skills for Managing a Hypotensive Adult in a Rapid Response.

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.

ALM Resuscitation With Brain and Multiorgan Protection for Far-Forward Operations: Survival at Hypotensive Pressures.

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.

Predictive ability of hypotension prediction index and machine learning methods in intraoperative hypotension: a systematic review and meta-analysis.

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.

A Real-world Study Evaluating the Clinical Factors Associated with the Initial SGLT2 Inhibitor Prescription.

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.

Association of postoperative delirium with hypotension in critically ill patients after cardiac surgery: a prospective observational study.

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.

Fascia Iliaca Block Combined with Low-dose Spinal Anesthesia for Hip Fracture Surgery in the Elderly: Effects on Severe Hypotension and Analgesia. A Randomized Controlled Trial.

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.

Up-and-Down Determination of Different Crystalloid Coload Volumes on the ED 90 of Prophylactic Norepinephrine Infusion for Preventing Postspinal Anesthesia Hypotension During Cesarean Section.

Background: Fluid loading improves hemodynamic stability and reduces the incidence rate of post-spinal anesthesia hypotension when prophylactic vasopressors are administered. We investigated the impact of different crystalloid coload volumes on the 90% effective dose (ED) of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension in non-hypertensive patients undergoing cesarean section. Methods: Patients were randomly allocated to receive one of the different crystalloid coload volumes (0mL/kg [0mL/kg Group], 5mL kg [5mL/kg Group], and 10mL kg [10mL/kg Group]) in combination with prophylactic norepinephrine infusion immediately after the induction of spinal anesthesia. The prophylactic norepinephrine infusion doses were determined using the up-and-down sequential allocation methodology, with an initial dose of 0.025 µg/kg/min and a gradient of 0.005 µg/kg/min. The primary endpoint was the effective dose at which 90% (ED 90) of patients responded to prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension. Results: The estimated effective dose of norepinephrine infusion, at which 90% (ED 90) of patients responded, was found to be 0.084 (95% CI, 0.070 to 0.86), 0.074 (95% CI, 0.059 to 0.077), and 0.063 (95% CI, 0.053 to 0.064) µg/kg/min in the three groups, respectively. Conclusion: A crystalloid coload of 5 mL/kg or 10 mL/kg, as opposed to the groups receiving 0 mL/kg crystalloid coloads, resulted in a reduction of approximately 11.9% and 25.0%, respectively, in the ED90 of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension during cesarean section.

Effect of haemodialysis practice guideline on dialysis indicators and haemodynamic complications among patients undergoing haemodialysis.

To assess the effect of haemodialysis practice guidelines on dialysis indicators and haemodynamic complications, the comparative study was conducted at the dialysis unit of Sheikh Zayed Hospital, Lahore, Pakistan, and comprised patients undergoing haemodialysis who were divided into intervention group A in which updated haemodialysis practice guidelines were used, and control group B in which routine base dialysis was given. Data was collected using a self-structured tool. Data was analysed using McNemar test and Mann-Whitney U-test with p<0.05. Compared to baseline, there was a significant improvement in post-intervention ratio of effective removal of clearance (K) resulting from the treatment characterised by time (t) in the patient with a specific volume of distribution (V), or Kt/V, median & IQR 0.83(0.355) vs 1.21(0.11) and percentage of urea reduction ratio with median & IQR 49(12) vs. 66.5(18.65) (p<0.05). Intradialytic hypotension was found in 17(56.6%) subjects in group B and in 4(13.4%) in group A (p=0.002). Intradialytic hypertension was found in 8(25.6%) patients in group B and 1(3.4%) in group A (p=0.039). It is recommended that dialysis be performed in accordance with the most recent clinical guidelines in order to improve practices and to increase haemodialysis effectiveness.

The impact of intraoperative hypotension on postoperative acute kidney injury, mortality and length of stay following off-pump coronary artery bypass grafting surgery: a single-center retrospective cohort study.

BACKGROUND: Off-pump coronary artery bypass grafting (OPCABG) presents distinct hemodynamic characteristics, yet the relationship between intraoperative hypotension and short-term adverse outcomes remains clear. Our study aims to investigate association between intraoperative hypotension and postoperative acute kidney injury (AKI), mortality and length of stay in OPCABG patients. METHODS: Retrospective data of 494 patients underwent OPCABG from January 2016 to July 2023 were collected. We analyzed the relationship between intraoperative various hypotension absolute values (MAP > 75, 65 < MAP ≤ 75, 55 < MAP ≤ 65, MAP ≤ 55 mmHg) and postoperative AKI, mortality and length of stay. Logistic regression assessed the impacts of exposure variable on AKI and postoperative mortality. Linear regression was used to analyze risk factors on the length of intensive care unit stay (ICU) and hospital stay. RESULTS: The incidence of AKI was 31.8%, with in-hospital and 30-day mortality at 2.8% and 3.5%, respectively. Maintaining a MAP greater than or equal 65 mmHg [odds ratio (OR) 0.408; p = 0.008] and 75 mmHg (OR 0.479; p = 0.024) was significantly associated with a decrease risk of AKI compared to MAP less than 55 mmHg for at least 10 min. Prolonged hospital stays were linked to low MAP, while in-hospital mortality and 30-day mortality were not linked to IOH but exhibited correlation with a history of myocardial infarction. AKI showed correlation with length of ICU stay. CONCLUSIONS: MAP > 65 mmHg emerges as a significant independent protective factor for AKI in OPCABG and IOH is related to length of hospital stay. Proactive intervention targeting intraoperative hypotension may provide a potential opportunity to reduce postoperative renal injury and hospital stay. TRIAL REGISTRATION: ChiCTR2400082518. Registered 31 March 2024. https://www.chictr.org.cn/bin/project/edit?pid=225349 .

Development and validation of a predictive model for PACU hypotension in elderly patients undergoing sedated gastrointestinal endoscopy.

BACKGROUND: Hypotension, characterized by abnormally low blood pressure, is a frequently observed adverse event in sedated gastrointestinal endoscopy procedures. Although the examination time is typically short, hypotension during and after gastroscopy procedures is frequently overlooked or remains undetected. This study aimed to construct a risk nomogram for post-anesthesia care unit (PACU) hypotension in elderly patients undergoing sedated gastrointestinal endoscopy. METHODS: This study involved 2919 elderly patients who underwent sedated gastrointestinal endoscopy. A preoperative questionnaire was used to collect data on patient characteristics; intraoperative medication use and adverse events were also recorded. The primary objective of the study was to evaluate the risk of PACU hypotension in these patients. To achieve this, the least absolute shrinkage and selection operator (LASSO) regression analysis method was used to optimize variable selection, involving cyclic coordinate descent with tenfold cross-validation. Subsequently, multivariable logistic regression analysis was applied to build a predictive model using the selected predictors from the LASSO regression. A nomogram was visually developed based on these variables. To validate the model, a calibration plot, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) were used. Additionally, external validation was conducted to further assess the model's performance. RESULTS: The LASSO regression analysis identified predictors associated with an increased risk of adverse events during surgery: age, duration of preoperative water abstinence, intraoperative mean arterial pressure (MAP) <65 mmHg, decreased systolic blood pressure (SBP), and use of norepinephrine (NE). The constructed model based on these predictors demonstrated moderate predictive ability, with an area under the ROC curve of 0.710 in the training set and 0.778 in the validation set. The DCA indicated that the nomogram had clinical applicability when the risk threshold ranged between 20 and 82%, which was subsequently confirmed in the external validation with a range of 18-92%. CONCLUSION: Incorporating factors such as age, duration of preoperative water abstinence, intraoperative MAP <65 mmHg, decreased SBP, and use of NE in the risk nomogram increased its usefulness for predicting PACU hypotension risk in elderly patient undergoing sedated gastrointestinal endoscopy.

Accuracy of oscillometric noninvasive blood pressure at the ankle in the lateral position during general anesthesia.

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.

A patient with AL amyloidosis presenting with refractory tuberculosis, chest tightness and hypotension: case report.

INTRODUCTION: Immunoglobulin light chain (AL) amyloidosis presents a clinical spectrum characterized by diverse manifestations and involvement of multiple organs, posing a significant diagnostic challenge for physicians. METHODS AND RESULTS: We present a case of a patient admitted to our hospital due to recurrent cough and sputum, which was initially diagnosed as refractory tuberculosis. Throughout his hospitalization, the patient experienced distressing symptoms, including uncontrollable chest tightness, hypotension, and fever. Noteworthy observations included a persistent elevation in cardiac biomarkers, indicative of cardiac damage. Bronchoalveolar lavage revealed the presence of various pathogenic microorganisms, while bone marrow flow cytometry demonstrated the existence of clonal plasma cells. Additionally, the urine free light chain assay detected the presence of M protein, and the positive congo red staining of the abdominal wall fat biopsy confirmed amyloid deposition in the tissues. Taking into account the patient's clinical presentation and the examination findings, we reached a conclusive diagnosis of immunoglobulin light chain (AL) amyloidosis. CONCLUSION: This case serves as a reminder for physicians to consider rare diseases like AL amyloidosis when patients present with symptoms involving multiple organ systems such as heart, lung and kidney that are unresponsive to conventional treatment options.

Determination of ED90s of Phenylephrine and Norepinephrine Infusion for Prevention of Spinal Anesthesia-Induced Hypotension in Patients with Preeclampsia During Cesarean Delivery.

Background: Vasopressors remain an important strategy for managing spinal anesthesia-induced hypotension in women with preeclampsia. The aim of this study was to investigate the ED90s and efficacy ratio of phenylephrine and norepinephrine in managing spinal anesthesia-induced hypotension in women with preeclampsia during cesarean delivery. Methods: 60 women with preeclampsia, who underwent cesarean delivery, were randomly assigned to receive either a continuous intravenous infusion of phenylephrine or norepinephrine following spinal anesthesia. The initial dosage of phenylephrine or norepinephrine for the first women was 0.5 or 0.05 µg/kg/min, respectively, and subsequent infusion dosages were adjusted based on their efficacy in preventing spinal anesthesia-induced hypotension (defined as a systolic blood pressure less than 80% of the baseline level). The incremental or decremental doses of phenylephrine or norepinephrine were set at 0.1 or 0.01 µg/kg/min. The primary outcomes were the ED90s and efficacy ratio of phenylephrine and norepinephrine infusions for preventing spinal anesthesia-induced hypotension prior to delivery. Results: The results obtained from isotonic regression analysis revealed that the ED90 values of the phenylephrine and norepinephrine group for preventing spinal anesthesia-induced hypotension were 0.597 (95% CI: 0.582-0.628) and 0.054 (95% CI: 0.053-0.056) µg/kg/min, respectively, with an efficacy ratio of 11.1:1. The results of Probit regression analysis revealed that the ED90 values were determined to be 0.665 (95% CI: 0.576-1.226) and 0.055 (95% CI: 0.047-0.109) µg/kg/min, respectively, with an efficacy ratio of 12.1:1. Conclusion: The administration of 0.6 µg/kg/min phenylephrine and 0.05 µg/kg/min norepinephrine has been found to effectively manage a 90% incidence of spinal anesthesia-induced hypotension in women with preeclampsia.

Effect of low blood pressure on prognosis of acute heart failure.

Low blood pressure (BP) is associated with poor outcomes in patients with heart failure (HF). We investigated the influence of initial BP on the prognosis of HF patients at admission, and prescribing patterns of HF medications, such as angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), and beta-blockers (BB). Data were sourced from a multicentre cohort of patients admitted for acute HF. Patients were grouped into heart failure reduced ejection fraction (HFrEF) and HF mildly reduced/preserved ejection fraction (HFmrEF/HFpEF) groups. Initial systolic and diastolic BPs were categorized into specific ranges. Among 2778 patients, those with HFrEF were prescribed ACEi, ARB, or BB at discharge, regardless of their initial BP. However, medication use in HFmrEF/HFpEF patients tended to decrease as BP decreased. Lower initial BP in HFrEF patients correlated with an increased incidence of all-cause death and composite clinical events, including HF readmission or all-cause death. However, no significant differences in clinical outcomes were observed in HFmrEF/HFpEF patients according to BP. Initial systolic (< 120 mmHg) and diastolic (< 80 mmHg) BPs were independently associated with a 1.81-fold (odds ratio [OR] 1.81, 95% confidence interval [CI] 1.349-2.417, p < 0.001) and 2.24-fold (OR 2.24, 95% CI 1.645-3.053, p < 0.001) increased risk of long-term mortality in HFrEF patients, respectively. In conclusion, low initial BP in HFrEF patients correlated with adverse clinical outcomes, and BP < 120/80 mmHg independently increased mortality. However, this relationship was not observed in HFmrEF/HFpEF patients.

Association between intraoperative hypotension and postoperative nausea and vomiting: a retrospective cohort study.

OBJECTIVE: Postoperative nausea and vomiting (PONV) occurs in up to 30% of patients and its pathophysiology and mechanisms have not been completely described. Hypotension and a decrease in cardiac output are suspected to induce nausea. The hypothesis that intraoperative hypotension might influence the incidence of PONV was investigated. MATERIAL AND METHODS: The study was conducted as a retrospective large single center cohort study. The incidence of PONV was investigated until discharge from post anesthesia care unit (PACU). Surgical patients with general anesthesia during a 2-year period between 2018 and 2019 at a university hospital in Germany were included. Groups were defined based on the lowest documented mean arterial pressure (MAP) with group H50: MAP <50mmHg; group H60: MAP <60mmHg; group H70: MAP <70mmHg, and group H0: no MAP <70mmHg. Decreases of MAP in the different groups were related to PONV. Propensity-score matching was carried out to control for overlapping risk factors. RESULTS: In the 2-year period 18.674 patients fit the inclusion criteria. The overall incidence of PONV was 11%. Patients with hypotension had a significantly increased incidence of PONV (H0 vs. H50: 11.0% vs.17.4%, Risk Ratio (RR): 1.285 (99%CI: 1.102-1.498), p < 0.001; H0 vs. H60: 10.4% vs. 13.5%, RR: 1.1852 (99%CI: 1.0665-1.3172), p < 0.001; H0 vs. H70: 9.4% vs. 11.2%, RR: 1.1236 (99%CI: 1.013 - 1.2454); p = 0.0027). CONCLUSION: The study demonstrates an association between intraoperative hypotension and early PONV. A more severe decrease of MAP had a pronounced effect.

Personalized prediction of intradialytic hypotension in clinical practice: Development and evaluation of a novel AI dashboard incorporating risk factors from previous and current dialysis sessions.

BACKGROUND: Intradialytic hypotension (IDH) is one of the most common and critical complications of hemodialysis. Despite many proven factors associated with IDH, accurately predicting it before it occurs for individual patients during dialysis sessions remains a challenge. PURPOSE: To establish artificial intelligence (AI) predictive models for IDH, which consider risk factors from previous and ongoing dialysis to optimize model performance. We then implement a novel digital dashboard with the best model for continuous monitoring of patients' status undergoing hemodialysis. The AI dashboard can display the real-time probability of IDH for each patient in the hemodialysis center providing an objective reference for care members for monitoring IDH and treating it in advance. METHODS: Eight machine learning (ML) algorithms, including Logistic Regression (LR), Random Forest (RF), Support Vector Machine (SVM), K Nearest Neighbor (KNN), Light Gradient Boosting Machine (LightGBM), Multilayer Perception (MLP), eXtreme Gradient Boosting (XGBoost), and NaiveBayes, were used to establish the predictive model of IDH to determine if the patient will acquire IDH within 60 min. In addition to real-time features, we incorporated several features sourced from previous dialysis sessions to improve the model's performance. The electronic medical records of patients who had undergone hemodialysis at Chi Mei Medical Center between September 1, 2020 and December 31, 2020 were included in this research. Impact evaluation of AI assistance was conducted by IDH rate. RESULTS: The results showed that the XGBoost model had the best performance (accuracy: 0.858, sensitivity: 0.858, specificity: 0.858, area under the curve: 0.936) and was chosen for AI dashboard implementation. The care members were delighted with the dashboard providing real-time scientific probabilities for IDH risk and historic predictive records in a graphic style. Other valuable functions were appended in the dashboard as well. Impact evaluation indicated a significant decrease in IDH rate after the application of AI assistance. CONCLUSION: This AI dashboard provides high-quality results in IDH risk prediction during hemodialysis. High-risk patients for IDH will be recognized 60 min earlier, promoting individualized preventive interventions as part of the treatment plan. Our approachis believed to promise an excellent way for IDH management.

Ion Channels Remodeling in the Regulation of Vascular Hyporesponsiveness During Shock.

Shock is characterized with vascular hyporesponsiveness to vasoconstrictors, thereby to cause refractory hypotension, insufficient tissue perfusion, and multiple organ dysfunction. The vascular hyporeactivity persisted even though norepinephrine and fluid resuscitation were administrated, it is of critical importance to find new potential target. Ion channels are crucial in the regulation of cell membrane potential and affect vasoconstriction and vasodilation. It has been demonstrated that many types of ion channels including K+ channels, Ca2+ permeable channels, and Na+ channels exist in vascular smooth muscle cells and endothelial cells, contributing to the regulation of vascular homeostasis and vasomotor function. An increasing number of studies suggested that the structural and functional alterations of ion channels located in arteries contribute to vascular hyporesponsiveness during shock, but the underlying mechanisms remained to be fully clarified. Therefore, the expression and functional changes in ion channels in arteries associated with shock are reviewed, to pave the way for further exploring the potential of ion channel-targeted compounds in treating refractory hypotension in shock.