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1.
Br J Anaesth ; 126(4): 808-817, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33558051

RESUMO

BACKGROUND: Intraoperative hypotension is associated with a risk of postoperative organ dysfunction. In this study, we aimed to present deep learning algorithms for real-time predictions 5, 10, and 15 min before a hypotensive event. METHODS: In this retrospective observational study, deep learning algorithms were developed and validated using biosignal waveforms acquired from patient monitoring of noncardiac surgery. The classification model was a binary classifier of a hypotensive event (MAP <65 mm Hg) or a non-hypotensive event by analysing biosignal waveforms. The regression model was developed to directly estimate the MAP. The primary outcome was area under the receiver operating characteristic (AUROC) curve and the mean absolute error (MAE). RESULTS: In total, 3301 patients were included. For invasive models, the multichannel model with an arterial pressure waveform, electrocardiography, photoplethysmography, and capnography showed greater AUROC than the arterial-pressure-only models (AUROC15-min, 0.897 [95% confidence interval {CI}: 0.894-0.900] vs 0.891 [95% CI: 0.888-0.894]) and lesser MAE (MAE15-min, 7.76 mm Hg [95% CI: 7.64-7.87 mm Hg] vs 8.12 mm Hg [95% CI: 8.02-8.21 mm Hg]). For the noninvasive models, the multichannel model showed greater AUROCs than that of the photoplethysmography-only models (AUROC15-min, 0.762 [95% CI: 0.756-0.767] vs 0.694 [95% CI: 0.686-0.702]) and lesser MAEs (MAE15-min, 11.68 mm Hg [95% CI: 11.57-11.80 mm Hg] vs 12.67 [95% CI: 12.56-12.79 mm Hg]). CONCLUSIONS: Deep learning models can predict hypotensive events based on biosignals acquired using invasive and noninvasive patient monitoring. In addition, the model shows better performance when using combined rather than single signals.


Assuntos
Aprendizado Profundo/tendências , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/tendências , Idoso , Humanos , Hipotensão/etiologia , Complicações Intraoperatórias/etiologia , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Valor Preditivo dos Testes , Estudos Retrospectivos
3.
Annu Int Conf IEEE Eng Med Biol Soc ; 2020: 5468-5471, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-33019217

RESUMO

Hypotension is common in critically ill patients. Early prediction of hypotensive events in the Intensive Care Units (ICUs) allows clinicians to pre-emptively treat the patient and avoid possible organ damage. In this study, we investigate the performance of various supervised machine-learning classification algorithms along with a real-time labeling technique to predict acute hypotensive events in the ICU. It is shown that logistic regression and SVM yield a better combination of specificity, sensitivity and positive predictive value (PPV). Logistic regression is able to predict 85% of events within 30 minutes of their onset with 81% PPV and 96% specificity, while SVM results in 96% specificity, 83% sensitivity and 82% PPV. To further reduce the false alarm rate, we propose a high-level decision-making algorithm that filters isolated false positives identified by the machine-learning algorithms. By implementing this technique, 24% of the false alarms are filtered. This saves 21 hours of medical staff time through 2,560 hours of monitoring and significantly reduces the disturbance caused by alarming monitors.


Assuntos
Hipotensão , Aprendizado de Máquina Supervisionado , Algoritmos , Humanos , Hipotensão/diagnóstico , Modelos Logísticos , Aprendizado de Máquina
4.
Anesth Analg ; 131(5): 1540-1550, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079877

RESUMO

BACKGROUND: Continuous blood pressure monitoring may facilitate early detection and prompt treatment of hypotension. We tested the hypothesis that area under the curve (AUC) mean arterial pressure (MAP) <65 mm Hg is reduced by continuous invasive arterial pressure monitoring. METHODS: Adults having noncardiac surgery were randomly assigned to continuous invasive arterial pressure or intermittent oscillometric blood pressure monitoring. Arterial catheter pressures were recorded at 1-minute intervals; oscillometric pressures were typically recorded at 5-minute intervals. We estimated the arterial catheter effect on AUC-MAP <65 mm Hg using a multivariable proportional odds model adjusting for imbalanced baseline variables and duration of surgery. Pressures <65 mm Hg were categorized as 0, 1-17, 18-91, and >91 mm Hg × minutes of AUC-MAP <65 mm Hg (ie, no hypotension and 3 equally sized groups of increasing hypotension). RESULTS: One hundred fifty-two patients were randomly assigned to arterial catheter use and 154 to oscillometric monitoring. For various clinical reasons, 143 patients received an arterial catheter, while 163 were monitored oscillometrically. There were a median [Q1, Q3] of 246 [187, 308] pressure measurements in patients with arterial catheters versus 55 (46, 75) measurements in patients monitored oscillometrically. In the primary intent-to-treat analysis, catheter-based monitoring increased detection of AUC-MAP <65 mm Hg, with an estimated proportional odds ratio (ie, odds of being in a worse hypotension category) of 1.78 (95% confidence interval [CI], 1.18-2.70; P = .006). The result was robust over an as-treated analysis and for sensitivity analyses with thresholds of 60 and 70 mm Hg. CONCLUSIONS: Intraoperative blood pressure monitoring with arterial catheters detected nearly twice as much hypotension as oscillometric measurements.


Assuntos
Pressão Arterial , Cateteres , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/métodos , Idoso , Área Sob a Curva , Diagnóstico Precoce , Feminino , Humanos , Hipotensão/terapia , Complicações Intraoperatórias/terapia , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Oscilometria , Sensibilidade e Especificidade , Procedimentos Cirúrgicos Operatórios , Resultado do Tratamento
5.
PLoS One ; 15(8): e0236755, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32790681

RESUMO

BACKGROUND: Spinal anesthesia is a type of regional anesthesia that has been practicing for obstetric anesthesia since the beginning of the 20th century. Despite the simplicity and lower maternal mortality risk, compared to general anesthesia, spinal anesthesia is linked to different adverse effects, of which hypotension is the most common complication. The main aim of this study was to determine the incidence and associated factors of hypotension after spinal anesthesia during cesarean section. METHOD: Institution-based cross-sectional study was conducted with 410 clients. The study was conducted on cesarean section under spinal anesthesia from 5th January to 30th April 2019, at the Gandhi Memorial Hospital, Addis Ababa, Ethiopia. Both bivariable and multivariable logistic regression analysis were done on the associated factors. The level of statistical significance was represented at p<0.05. RESULTS: The incidence of hypotension among mothers who underwent a cesarean section after spinal anesthesia was 64%. Newborn weight ≥4kg (AOR = 5.373; 95%CI: (1.627-17.740)) showed an increase risk of association with hypotension. A baseline systolic blood pressure < 120mmHg (AOR = 6.293; (95%CI: 2.999-13.204)) was found to be associated with increased risk of hypotension. Sensory block height >T6 AOR = 2.230; 95%CI: (1.329-3.741), the time interval between spinal induction and skin incision > 6minutes AOR = 1.803; 95%CI: (1.044-3.114) and anesthetist experience AOR = 5.033(95%CI: 2.144-11.818) were also associated with hypotension. CONCLUSION: The identified risk factors for hypotension, after spinal anesthesia are sensory height block, weight of the baby, the time interval between spinal induction and skin incision, baseline systolic blood pressure, and anesthetist experience.


Assuntos
Raquianestesia/efeitos adversos , Hipotensão/diagnóstico , Adolescente , Adulto , Pressão Sanguínea , Cesárea , Etiópia/epidemiologia , Feminino , Hospitais , Humanos , Hipotensão/epidemiologia , Incidência , Razão de Chances , Gravidez , Fatores de Risco , Adulto Jovem
7.
Ann Vasc Surg ; 69: 182-189, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32502683

RESUMO

BACKGROUND: Patients undergoing carotid endarterectomy (CEA) often experience postoperative hemodynamic changes that require intravenous medications for hypo- and hypertension. Prior studies have found these changes to be associated with increased risks of 30-day mortality, stroke, myocardial infarction (MI), and length of stay (LOS). Our aim is to investigate preoperative risk factors associated with the need for postoperative intravenous medications for blood pressure control. METHODS: A retrospective review of an internally maintained prospective database of patients undergoing carotid interventions between January 2014 and March 2019 was performed. Demographic data, clinical history, and perioperative data were recorded. Carotid artery stents and reinterventions were excluded. Our primary end points were the need to intervene with intravenous medication for either postoperative hypotension [systolic blood pressure (SBP) <100 mm Hg] or postoperative hypertension (SBP >160 mm Hg). RESULTS: A total of 221 patients were included in the study after excluding those with a prior ipsilateral CEA or carotid artery stent. The mean age was 72.3 (±8.9) years, 157 (71%) patients were male, and 78 (35.3%) were Caucasian. Following CEA, 151 (68.3%) patients were normotensive, while 33 (14.9%) and 37 (16.7%) required medication for hypotension and hypertension, respectively. A univariate logistic regression identified 5 variables as being associated with postoperative blood pressure including race, history of MI, prior percutaneous transluminal coronary angioplasty (PTCA), statin use, and angiotensin-converting enzyme-inhibitor/angiotensin-receptor blocker (ARB) use. A stepwise regression selection found race, prior MI, and statin use to be associated with our primary end points. The hypertensive group was more likely to have a history of MI compared to the hypotensive and normotensive groups (40.5% vs. 27.3% vs. 18.5%, P = 0.02), PTCA (43.2% vs. 39.4% vs. 23.8%, P = 0.03), and statin use (94.6% vs. 93.9% vs. 78.8%, P = 0.01). Mean LOS was also the highest for the hypertensive group, followed by hypotensive and normotensive patients [2.0 (±1.6) vs. 1.8 (±2.4) vs. 1.3 (±0.8), P = 0.002]. Multivariable logistic regression demonstrated that non-Caucasian patients [odds ratio (OR) 2.72, 95% confidence interval (CI) 1.26-5.86, P = 0.01] and those with a history of MI (OR 2.98, 95% CI 1.33-6.67) were more likely to have postoperative hypertension compared to patients who were Caucasian or had no history of MI. CONCLUSIONS: Postoperative hypertension is associated with non-Caucasian race and a history of MI. Given the potential implications for adverse perioperative outcomes including MI, mortality, and LOS, it is important to continue to elucidate potential risk factors in order to further tailor the perioperative management of patients undergoing CEA.


Assuntos
Pressão Sanguínea , Endarterectomia das Carótidas/efeitos adversos , Hipertensão/etiologia , Hipotensão/etiologia , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Bases de Dados Factuais , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Hipotensão/diagnóstico , Hipotensão/tratamento farmacológico , Hipotensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Vasoconstritores/uso terapêutico
8.
High Blood Press Cardiovasc Prev ; 27(4): 315-320, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32385789

RESUMO

INTRODUCTION: Previous observation identified both hypotension and arterial aging, indexed as Pulse Wave Velocity (PWV), as significant determinants of cognitive decline in older subjects. AIM: To investigate the role of PWV as a determinant of hypotension in older patients. METHODS: A cohort of 344 subjects came to our Outpatient Clinic, free of cancer, acute myocardial infarction or stroke, atrial fibrillation, renal, hepatic or cardiac failure, secondary hypertension, or thyroid disease. RESULTS: Hypotension occurred in 49% of participants. SBP levels (OR 0.79, 95% CI 0.67-0.84, p < 0.01), PWV (OR 0.86, 95% CI 0.77-0.94, p < 0.01), and use of beta-blockers (OR 2.42, 95% CI 1.09-5.36, p < 0.05), were independent determinants of the risk of hypotension. CONCLUSIONS: Hypotension is a quite common phenomenon in older subjects. Its prevention requires a more accurate management of hypertension aimed at better identifying which older subjects in whom intensive BP control may be harmful and those who may benefit from it.


Assuntos
Envelhecimento , Pressão Arterial , Hipotensão/etiologia , Rigidez Vascular , Antagonistas Adrenérgicos beta/efeitos adversos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hipotensão/diagnóstico , Hipotensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Análise de Onda de Pulso , Medição de Risco , Fatores de Risco
10.
Anesth Analg ; 130(5): 1157-1166, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32287123

RESUMO

BACKGROUND: Acute hypotensive episodes (AHE), defined as a drop in the mean arterial pressure (MAP) <65 mm Hg lasting at least 5 consecutive minutes, are among the most critical events in the intensive care unit (ICU). They are known to be associated with adverse outcome in critically ill patients. AHE prediction is of prime interest because it could allow for treatment adjustment to predict or shorten AHE. METHODS: The Super Learner (SL) algorithm is an ensemble machine-learning algorithm that we specifically trained to predict an AHE 10 minutes in advance. Potential predictors included age, sex, type of care unit, severity scores, and time-evolving characteristics such as mechanical ventilation, vasopressors, or sedation medication as well as features extracted from physiological signals: heart rate, pulse oximetry, and arterial blood pressure. The algorithm was trained on the Medical Information Mart for Intensive Care dataset (MIMIC II) database. Internal validation was based on the area under the receiver operating characteristic curve (AUROC) and the Brier score (BS). External validation was performed using an external dataset from Lariboisière hospital, Paris, France. RESULTS: Among 1151 patients included, 826 (72%) patients had at least 1 AHE during their ICU stay. Using 1 single random period per patient, the SL algorithm with Haar wavelets transform preprocessing was associated with an AUROC of 0.929 (95% confidence interval [CI], 0.899-0.958) and a BS of 0.08. Using all available periods for each patient, SL with Haar wavelets transform preprocessing was associated with an AUROC of 0.890 (95% CI, 0.886-0.895) and a BS of 0.11. In the external validation cohort, the AUROC reached 0.884 (95% CI, 0.775-0.993) with 1 random period per patient and 0.889 (0.768-1) with all available periods and BSs <0.1. CONCLUSIONS: The SL algorithm exhibits good performance for the prediction of an AHE 10 minutes ahead of time. It allows an efficient, robust, and rapid evaluation of the risk of hypotension that opens the way to routine use.


Assuntos
Algoritmos , Hospitalização/tendências , Hipotensão/diagnóstico , Unidades de Terapia Intensiva/tendências , Aprendizado de Máquina/tendências , Doença Aguda , Idoso , Estudos de Coortes , Feminino , Humanos , Hipotensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes
11.
Anesth Analg ; 130(5): 1201-1210, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32287127

RESUMO

BACKGROUND: Predictive analytics systems may improve perioperative care by enhancing preparation for, recognition of, and response to high-risk clinical events. Bradycardia is a fairly common and unpredictable clinical event with many causes; it may be benign or become associated with hypotension requiring aggressive treatment. Our aim was to build models to predict the occurrence of clinically significant intraoperative bradycardia at 3 time points during an operative course by utilizing available preoperative electronic medical record and intraoperative anesthesia information management system data. METHODS: The analyzed data include 62,182 scheduled noncardiac procedures performed at the University of Washington Medical Center between 2012 and 2017. The clinical event was defined as severe bradycardia (heart rate <50 beats per minute) followed by hypotension (mean arterial pressure <55 mm Hg) within a 10-minute window. We developed models to predict the presence of at least 1 event following 3 time points: induction of anesthesia (TP1), start of the procedure (TP2), and 30 minutes after the start of the procedure (TP3). Predictor variables were based on data available before each time point and included preoperative patient and procedure data (TP1), followed by intraoperative minute-to-minute patient monitor, ventilator, intravenous fluid, infusion, and bolus medication data (TP2 and TP3). Machine-learning and logistic regression models were developed, and their predictive abilities were evaluated using the area under the ROC curve (AUC). The contribution of the input variables to the models were evaluated. RESULTS: The number of events was 3498 (5.6%) after TP1, 2404 (3.9%) after TP2, and 1066 (1.7%) after TP3. Heart rate was the strongest predictor for events after TP1. Occurrence of a previous event, mean heart rate, and mean pulse rates before TP2 were the strongest predictor for events after TP2. Occurrence of a previous event, mean heart rate, mean pulse rates before TP2 (and their interaction), and 15-minute slopes in heart rate and blood pressure before TP2 were the strongest predictors for events after TP3. The best performing machine-learning models including all cases produced an AUC of 0.81 (TP1), 0.87 (TP2), and 0.89 (TP3) with positive predictive values of 0.30, 0.29, and 0.15 at 95% specificity, respectively. CONCLUSIONS: We developed models to predict unstable bradycardia leveraging preoperative and real-time intraoperative data. Our study demonstrates how predictive models may be utilized to predict clinical events across multiple time intervals, with a future goal of developing real-time, intraoperative, decision support.


Assuntos
Bradicardia/diagnóstico , Hipotensão/diagnóstico , Aprendizado de Máquina/tendências , Monitorização Intraoperatória/tendências , Bradicardia/fisiopatologia , Previsões , Humanos , Hipotensão/fisiopatologia , Monitorização Intraoperatória/métodos , Valor Preditivo dos Testes , Estudos Retrospectivos
14.
JAMA ; 323(11): 1052-1060, 2020 03 17.
Artigo em Inglês | MEDLINE | ID: mdl-32065827

RESUMO

Importance: Intraoperative hypotension is associated with increased morbidity and mortality. A machine learning-derived early warning system to predict hypotension shortly before it occurs has been developed and validated. Objective: To test whether the clinical application of the early warning system in combination with a hemodynamic diagnostic guidance and treatment protocol reduces intraoperative hypotension. Design, Setting, and Participants: Preliminary unblinded randomized clinical trial performed in a tertiary center in Amsterdam, the Netherlands, among adult patients scheduled for elective noncardiac surgery under general anesthesia and an indication for continuous invasive blood pressure monitoring, who were enrolled between May 2018 and March 2019. Hypotension was defined as a mean arterial pressure (MAP) below 65 mm Hg for at least 1 minute. Interventions: Patients were randomly assigned to receive either the early warning system (n = 34) or standard care (n = 34), with a goal MAP of at least 65 mm Hg in both groups. Main Outcomes and Measures: The primary outcome was time-weighted average of hypotension during surgery, with a unit of measure of millimeters of mercury. This was calculated as the depth of hypotension below a MAP of 65 mm Hg (in millimeters of mercury) × time spent below a MAP of 65 mm Hg (in minutes) divided by total duration of operation (in minutes). Results: Among 68 randomized patients, 60 (88%) completed the trial (median age, 64 [interquartile range {IQR}, 57-70] years; 26 [43%] women). The median length of surgery was 256 minutes (IQR, 213-430 minutes). The median time-weighted average of hypotension was 0.10 mm Hg (IQR, 0.01-0.43 mm Hg) in the intervention group vs 0.44 mm Hg (IQR, 0.23-0.72 mm Hg) in the control group, for a median difference of 0.38 mm Hg (95% CI, 0.14-0.43 mm Hg; P = .001). The median time of hypotension per patient was 8.0 minutes (IQR, 1.33-26.00 minutes) in the intervention group vs 32.7 minutes (IQR, 11.5-59.7 minutes) in the control group, for a median difference of 16.7 minutes (95% CI, 7.7-31.0 minutes; P < .001). In the intervention group, 0 serious adverse events resulting in death occurred vs 2 (7%) in the control group. Conclusions and Relevance: In this single-center preliminary study of patients undergoing elective noncardiac surgery, the use of a machine learning-derived early warning system compared with standard care resulted in less intraoperative hypotension. Further research with larger study populations in diverse settings is needed to understand the effect on additional patient outcomes and to fully assess safety and generalizability. Trial Registration: ClinicalTrials.gov Identifier: NCT03376347.


Assuntos
Procedimentos Cirúrgicos Eletivos , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Aprendizado de Máquina , Idoso , Anestesia Geral , Determinação da Pressão Arterial/métodos , Feminino , Humanos , Hipotensão/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Centros de Atenção Terciária , Fatores de Tempo
15.
Anesthesiology ; 132(4): 723-737, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32022770

RESUMO

BACKGROUND: Physiologic data that is automatically collected during anesthesia is widely used for medical record keeping and clinical research. These data contain artifacts, which are not relevant in clinical care, but may influence research results. The aim of this study was to explore the effect of different methods of filtering and processing artifacts in anesthesiology data on study findings in order to demonstrate the importance of proper artifact filtering. METHODS: The authors performed a systematic literature search to identify artifact filtering methods. Subsequently, these methods were applied to the data of anesthesia procedures with invasive blood pressure monitoring. Different hypotension measures were calculated (i.e., presence, duration, maximum deviation below threshold, and area under threshold) across different definitions (i.e., thresholds for mean arterial pressure of 50, 60, 65, 70 mmHg). These were then used to estimate the association with postoperative myocardial injury. RESULTS: After screening 3,585 papers, the authors included 38 papers that reported artifact filtering methods. The authors applied eight of these methods to the data of 2,988 anesthesia procedures. The occurrence of hypotension (defined with a threshold of 50 mmHg) varied from 24% with a median filter of seven measurements to 55% without an artifact filtering method, and between 76 and 90% with a threshold of 65 mmHg. Standardized odds ratios for presence of hypotension ranged from 1.16 (95% CI, 1.07 to 1.26) to 1.24 (1.14 to 1.34) when hypotension was defined with a threshold of 50 mmHg. Similar variations in standardized odds ratios were found when applying methods to other hypotension measures and definitions. CONCLUSIONS: The method of artifact filtering can have substantial effects on estimates of hypotension prevalence. The effect on the association between intraoperative hypotension and postoperative myocardial injury was relatively small. Nevertheless, the authors recommend that researchers carefully consider artifacts handling and report the methodology used.


Assuntos
Artefatos , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/métodos , Humanos , Hipotensão/etiologia , Hipotensão/fisiopatologia , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/fisiopatologia , Monitorização Intraoperatória/normas , Prevalência , Resultado do Tratamento
16.
Eur J Vasc Endovasc Surg ; 59(4): 526-534, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32033871

RESUMO

OBJECTIVE: Intra-operative haemodynamic instability during carotid endarterectomy (CEA) has been associated with an increased risk of procedural stroke. Diffusion weighted imaging (DWI) lesions have been proposed as a surrogate marker for peri-operative silent cerebral ischaemia. This study aimed to investigate the relationship between peri-operative blood pressure (BP) and presence of post-operative DWI lesions in patients undergoing CEA. METHODS: A retrospective analysis was performed based on patients with symptomatic CEA included in the MRI substudy of the International Carotid Stenting Study. Relative intra-operative hypotension was defined as a decrease of intra-operative systolic BP ≥ 20% compared with pre-operative ('baseline') BP, absolute hypotension was defined as a drop in systolic BP < 80  mmHg. The primary endpoint was the presence of any new DWI lesions on post-operative MRI (DWI positive). The occurrence and duration of intra-operative hypotension was compared between DWI positive and DWI negative patients as was the magnitude of the difference between pre- and intra-operative BP. RESULTS: Fifty-five patients with symptomatic CEA were included, of whom eight were DWI positive. DWI positive patients had a significantly higher baseline systolic (186 ± 31 vs. 158 ± 27 mmHg, p = .011) and diastolic BP (95 ± 15 vs. 84 ± 13 mmHg, p = .046) compared with DWI negative patients. Other pre-operative characteristics did not differ. Relative intra-operative hypotension compared with baseline occurred in 53/55 patients (median duration 34 min; range 0-174). Duration of hypotension did not differ significantly between the groups (p = .088). Mean systolic intra-operative BP compared with baseline revealed a larger drop in BP (-37 ± 29 mmHg) in DWI positive compared with DWI negative patients (-14 ± 26 mmHg, p = .024). Absolute intra-operative systolic BP values did not differ between the groups. CONCLUSION: In this exploratory study, high pre-operative BP and a larger drop of intra-operative BP were associated with peri-procedural cerebral ischaemia as documented with DWI. These results call for confirmation in an adequately sized prospective study, as they suggest important consequences for peri-operative haemodynamic management in carotid revascularisation.


Assuntos
Infarto Encefálico/epidemiologia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Hipertensão/diagnóstico , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Idoso , Doenças Assintomáticas/epidemiologia , Determinação da Pressão Arterial/estatística & dados numéricos , Encéfalo/irrigação sanguínea , Encéfalo/diagnóstico por imagem , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/etiologia , Estenose das Carótidas/complicações , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Hipertensão/complicações , Hipotensão/etiologia , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
17.
BMJ Case Rep ; 13(1)2020 Feb 02.
Artigo em Inglês | MEDLINE | ID: mdl-32014989

RESUMO

We present a case of a young Asian female with rheumatoid arthritis who received latent tuberculosis infection (LTBI) treatment prior to treatment with a biologic agent, and developed shock with resistant hypotension on re-exposure to rifampicin. We discuss the epidemiology, pathophysiology and management of rifampicin induced shock, concluding that clinicians should be aware of this rare, but potential adverse effect, and be aware that adverse reactions to rifampicin are more frequent during re-exposure or longer dosing interval regimes. The evidence for desensitisation following such a reaction is lacking and this approach is not currently recommended. We would suggest close collaboration between specialties prescribing immunosuppression and the tuberculosis team when LTBI treatment is required after a reaction, with patient involvement to discuss the risks and benefits of treatment options.


Assuntos
Antituberculosos/efeitos adversos , Hipotensão/induzido quimicamente , Tuberculose Latente/tratamento farmacológico , Rifampina/efeitos adversos , Choque Séptico/induzido quimicamente , Adulto , Feminino , Hidratação , Humanos , Hipotensão/diagnóstico , Hipotensão/terapia , Retratamento , Choque Séptico/diagnóstico , Choque Séptico/tratamento farmacológico
18.
J Korean Med Sci ; 35(1): e8, 2020 Jan 06.
Artigo em Inglês | MEDLINE | ID: mdl-31898435

RESUMO

BACKGROUND: There has been no consensus regarding the discontinuation order of vasopressors in patients recovering from septic shock treated with concomitant norepinephrine (NE) and arginine vasopressin (AVP). The aim of this study was to compare the incidence of hypotension within 24 hours based on whether NE or AVP was discontinued first in order to determine the optimal sequence for discontinuation of vasopressors. METHODS: A systematic literature search was conducted in MEDLINE, Embase, and the Cochrane Central Register. The primary end-point was incidence of hypotension within 24 hours after discontinuation of the first vasopressor. RESULTS: We identified five studies comprising 930 patients, of whom 631 (67.8%) discontinued NE first and 299 (32.2%) discontinued AVP first. In pooled estimates, a random-effect model showed that discontinuation of NE first was associated with a significant reduction of the incidence of hypotension compared to discontinuing AVP first (31.8% vs. 54.8%; risk ratios, 0.35; 95% confidence interval, 0.16 to 0.76; P = 0.008; I² = 90.7%). Although a substantial degree of heterogeneity existed among the trials, we could not identify the significant source of bias. In addition, there were no significant differences in intensive care unit (ICU) mortality, in-hospital mortality, 28-day mortality, or ICU length of stay between the groups. CONCLUSION: Discontinuing NE prior to AVP was associated with a lower incidence of hypotension in patients recovering from septic shock. However, our results should be interpreted with caution, due to the considerable between-study heterogeneity.


Assuntos
Arginina Vasopressina/uso terapêutico , Hipotensão/diagnóstico , Norepinefrina/uso terapêutico , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico , Humanos , Hipotensão/epidemiologia , Incidência , Adesão à Medicação , Razão de Chances , Choque Séptico/patologia
20.
Sci Rep ; 10(1): 822, 2020 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-31964979

RESUMO

Increased concentrations of the vasodilator histamine have been observed in patients undergoing abdominal surgery. The role of histamine during orthotopic liver transplantation (OLT) has only been studied in animals. The aim of this study was to measure plasma concentrations of histamine and its degrading enzyme diamine oxidase (DAO) in patients undergoing orthotopic liver transplantation, and assess whether histamine or DAO correlate with intraoperative noradrenaline requirements. Histamine and DAO concentrations were measured in 22 adults undergoing liver transplantation and 22 healthy adults. Furthermore, norepinephrine requirements during liver transplantation were recorded. Baseline concentrations of histamine and DAO were greater in patients, who underwent liver transplantation, than in healthy individuals (Histamine: 6.4 nM, IQR[2.9-11.7] versus 4.3 nM, IQR[3.7-7.1], p = 0.029; DAO: 2.0 ng/mL, IQR[1.5-4.1] versus <0,5 ng/mL, IQR[<0.5-1.1], p < 0.001). During liver transplantation, histamine concentrations decreased to 1.8 nM, IQR[0.5-4.9] in the anhepatic phase (p < 0.0001 versus baseline), and to 1.5 nM, IQR[0.5-2.9] after reperfusion (p < 0.0001 versus baseline). In contrast, DAO concentrations increased to 35.5 ng/ml, IQR[20-50] in the anhepatic phase (p = 0.001 versus baseline) and to 39.5 ng/ml, IQR[23-64] after reperfusion (p = 0.001 versus baseline), correlating inversely with histamine. Norepinephrine requirements during human liver transplantation correlated significantly with DAO concentrations in the anhepatic phase (r = 0.58, p = 0.011) and after reperfusion (r = 0.56; p = 0.022). In patients undergoing orthotopic liver transplantation, histamine concentrations decrease whereas DAO concentrations increase manifold. Diamine oxidase correlates with intraoperative norepinephrine requirements in patients undergoing OLT.


Assuntos
Amina Oxidase (contendo Cobre)/sangue , Doença Hepática Terminal/cirurgia , Histamina/sangue , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Transplante de Fígado/efeitos adversos , Transplante de Fígado/métodos , Idoso , Biomarcadores/sangue , Doença Hepática Terminal/sangue , Doença Hepática Terminal/fisiopatologia , Feminino , Hemodinâmica , Humanos , Hipotensão/diagnóstico por imagem , Hipotensão/etiologia , Cuidados Intraoperatórios , Complicações Intraoperatórias/tratamento farmacológico , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem
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