Association Between Pituitary-Adrenal Axis Dominance Over the Renin-Angiotensin-Aldosterone System and Hypertension.

CONTEXT: The hypothalamus-pituitary-adrenal (HPA) axis and the renin-angiotensin aldosterone system (RAAS) are well known to be associated with hypertension. However, the extent of the effects is not yet well elucidated in general conditions. OBJECTIVE: To separately determine the effect of the HPA axis and the RAAS on hypertension in a general population. DESIGN, SETTING, AND PARTICIPANTS: A population-based study of 859 Japanese individuals enrolled in the 2014 Iwaki study and without hypertension or steroid treatment (age, 50.2 ± 14.7 years). MAIN OUTCOME MEASURES: Hypertension prevalence, plasma concentration of aldosterone, ACTH, cortisol, and plasma renin activity. RESULTS: Principal component (PC) analysis using these four hormones identified two PCs (PC1 and PC2), which represent levels of these hormones as a whole, and dominance between the HPA axis (ACTH and cortisol) and the RAAS (plasma renin activity and plasma concentration of aldosterone), respectively. Association between these PCs and hypertension was significant (PC1, high vs low, odds ratio [OR], 1.48; 95% confidence interval [CI], 1.09-2.02; and PC2, HPA axis vs RAAS dominancy, OR, 2.08; and 95% CI, 1.51-2.85). However, association between the hormone levels as a whole and hypertension became insignificant after adjustment for multiple factors including these PCs together. However, association between the HPA axis dominance and hypertension remained significant even after the adjustment (the HPA axis vs the RAAS, OR, 1.73; 95% CI, 1.20-2.48). CONCLUSIONS: The HPA axis dominance over the RAAS is significantly associated with hypertension in a Japanese population.

[Use of argatroban as a substitute for heparin in a patient with suspected HIT type II undergoing carotid endarterectomy].

Heparin-induced thrombocytopenia (HIT) type II is characterized by a decrease in platelet count and thrombosis following heparin administration. We anesthetized a 67-year-old woman with suspected HIT type II undergoing carotid endarterectomy (CEA). Preoperatively, the patient had received anticoagulation therapy with heparin for cerebral infarction due to thrombosis and she developed thrombocytopenia with deterioration of cerebral infarction. Platelet level recovered by discontinuation of heparin and platelet infusion. During the surgical procedure, a substitution for heparin as an anticoagulant was necessary and we used argatroban, a direct thrombin inhibitor, with monitoring activated coagulation time (ACT). The ACT values were maintained above 200 sec during endoarterectomy and the operation was successfully carried out. We believe that argatroban is one of the choices for anticoagulants in a patient with HIT type II.

Continuous monitoring of gastric intraluminal carbon dioxide pressure, cardiac output, and end-tidal carbon dioxide pressure in the perioperative period in patients receiving cardiovascular surgery using cardiopulmonary bypass.

OBJECTIVE: To verify the hypothesis that the gastric intraluminal PCO2 (PgCO2) changes independently of the change in cardiac output (CO) during and after cardiovascular surgery using cardiopulmonary bypass (CPB), and that the elevation of PgCO2 affects the patients' morbidity. DESIGN: Prospective, noninterventional study. SETTING: Medical/surgical intensive care unit and operating theater of a university hospital. PATIENTS: Sixteen adults patients receiving elective cardiovascular surgery using CPB. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After induction of anesthesia, the patients were fitted with a gastric tube equipped at the tip with a CO2 sensor (ion-selective field effect transistor) that can continuously measure real-time PgCO2, and a pulmonary artery catheter capable of monitoring continuous CO (CCO) and end-tidal CO2. Data from the devices was uploaded to a personal computer every 2 mins until the catheter was pulled off based on clinical judgment (PgCO2 values were blinded to everyone except the investigator). One patient expired as a result of multiple organ failure subsequent to sepsis, and postoperative morbidity assessed by the peak SOFA (sequential organ failure assessment) score (mean +/- SD 6.9 +/- 3.5; range, 2-13) was correlated with the peak PgCO2 during intensive care unit stay (mean +/- SD 74.1 +/- 30.7 mm Hg; range, 45-169 mm Hg) (p < .01, by regression analysis). The peak PgCO2 during surgery (mean +/- SD 71.1 +/- 18.1 mm Hg; range, 44-115 mm Hg) had no correlation with the postoperative morbidity. From analysis of CCO before, during, and after returning from the above 60 mm Hg of PgCO2, PgCO2 changed independently of CCO. CONCLUSIONS: PgCO2 changed independently of CCO, and its postoperative elevation was related to morbidity, even in the group of patients with a good outcome. Continuous monitoring of PgCO2 is useful for the detection of morbidity and can be expected to help elucidate the pathophysiology of change of PgCO2.