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1.
Crit Care Resusc ; 22(1): 53-62, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32102643

RESUMO

OBJECTIVE: Postprandial hypotension occurs frequently in older survivors of critical illness at 3 months after discharge. We aimed to determine whether postprandial hypotension and its predictors - gastric dysmotility and cardiovascular autonomic dysfunction - persist or resolve as older survivors of critical illness recover, and whether postprandial hypotension after intensive care unit (ICU) discharge is associated with adverse outcomes at 12 months. DESIGN: Prospective observational study. SETTING: Tertiary medical-surgical ICU. PARTICIPANTS: Older adults (aged ≥ 65 years) who had been studied 3 months after ICU discharge and who returned for a follow-up study at 12 months after discharge. MAIN OUTCOME MEASURES: On both occasions after fasting overnight, participants consumed a 300 mL drink containing 75 g glucose, radiolabelled with 20 MBq 99mTcphytate. Blood pressure, heart rate, blood glucose concentration and gastric emptying rate were measured concurrently before and after ingestion of the drink. Falls, quality of life, hospitalisation and mortality rates were also quantified. RESULTS: Out of 35 older adults studied at 3 months, 22 returned for the follow-up study at 12 months. Postprandial hypotension was evident in 29% of participants (95% CI, 14-44%) at 3 months and 10% of participants (95% CI, 1-30%) at 12 months. Postprandial hypotension at 3 months was associated with a more than threefold increase in the risk of falls in the year after ICU discharge (relative risk, 3.7 [95% CI, 1.6-8.8]; P = 0.003). At 12 months, gastric emptying was normal (mean time taken for 50% of gastric contents to empty, 101.6 [SD, 33.3] min) and cardiovascular autonomic dysfunction prevalence was low (9% [95% CI, 1-29%]). CONCLUSIONS: In older adults who were evaluated 3 and 12 months after ICU discharge, postprandial hypotension at 3 months was associated with an increased risk of subsequent falls, but the prevalence of postprandial hypotension decreased with time.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Doenças do Sistema Nervoso Autônomo/fisiopatologia , Sistema Nervoso Autônomo/fisiologia , Estado Terminal , Hipotensão/complicações , Hipotensão/etiologia , Período Pós-Prandial , Idoso , Pressão Sanguínea , Feminino , Seguimentos , Humanos , Hipotensão/epidemiologia , Hipotensão/fisiopatologia , Masculino , Estudos Prospectivos , Qualidade de Vida
2.
Br J Anaesth ; 124(3): e108-e114, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31959386

RESUMO

BACKGROUND: Norepinephrine infusion has been suggested as an effective method for preventing hypotension during spinal anaesthesia for Caesarean delivery. However, optimal dosing regimens for norepinephrine have not been well established. This study aimed to determine the dose-response characteristics of a weight-adjusted fixed-rate infusion of norepinephrine to prevent hypotension during neuraxial anaesthesia for Caesarean delivery. METHODS: In a double-blind, randomised controlled trial, 80 parturients having elective Caesarean delivery received a prophylactic norepinephrine infusion at 0.025 µg kg-1 min-1 (Group N1), 0.05 µg kg-1 min-1 (Group N2), 0.075 µg kg-1 min-1 (Group N3), or 0.10 µg kg-1 min-1 (Group N4), starting immediately after induction of combined spinal-epidural anaesthesia. The primary outcome was non-occurrence of hypotension, defined as a decrease in systolic arterial pressure ≥20% below baseline value or to ≤90 mm Hg, before delivery. Values for 50% effective dose (ED50) and ED90 were calculated using probit regression. RESULTS: The incidence of hypotension was 11/20 (55%), 6/20 (30%), 2/20 (10%), and 1/20 (5%) in Groups N1, N2, N3, and N4, respectively (P<0.0001). The ED50 and ED90 (95% confidence interval) of norepinephrine infusions for preventing hypotension were 0.029 (-0.002 to 0.043) and 0.080 (0.065-0.116) µg kg-1 min-1, respectively. The incidence of reactive hypertension increased with increasing norepinephrine dose (P=0.002). Other adverse effects were similar among groups. CONCLUSIONS: Under the conditions of this study, an infusion of norepinephrine 0.08 µg kg-1 min-1 was effective for preventing hypotension in 90% of patients. This information should provide a guide for initiating norepinephrine infusions. CLINICAL TRIAL REGISTRATION: ChiCTR1900022322 at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/enindex.aspx).


Assuntos
Anestesia Epidural/efeitos adversos , Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Hipotensão/prevenção & controle , Norepinefrina/administração & dosagem , Adulto , Pressão Sanguínea/efeitos dos fármacos , Cesárea , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Humanos , Hipotensão/epidemiologia , Gravidez
3.
Expert Opin Drug Saf ; 19(1): 1-8, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31855607

RESUMO

Introduction: Hypoactive sexual desire disorder (HSDD) is the most prevalent sexual dysfunction in women, previously managed with off-label therapies. Indicated for premenopausal women, flibanserin is the first FDA-approved medication to treat HSDD.Areas covered: This review summarizes flibanserin's pharmacokinetics, proposed mechanism of action, and safety data in clinical trials with a focus on sedation- and hypotension-related adverse events, and drug interactions with alcohol and antidepressants. Sources included peer-reviewed publications and internal data from the manufacturer.Expert opinion: Flibanserin is a well-tolerated and effective treatment that decreases distress and restores sexual desire to a level that is normative for the individual patient with HSDD. Simplification of a risk mitigation program for flibanserin in the US is likely to increase the number of prescribing clinicians if accompanied with educational efforts to clarify flibanserin's risk-benefit profile. As flibanserin is dosed daily and may be used for a decade or more in the typical premenopausal patient, long-term pharmacovigilance data will be essential. Over time, HSDD will be treated by more nonspecialist health care professionals and flibanserin will likely become established as a significant treatment option along with other medications approved for this indication in the context of a holistic biopsychosocial treatment paradigm.


Assuntos
Benzimidazóis/administração & dosagem , Pré-Menopausa , Disfunções Sexuais Psicogênicas/tratamento farmacológico , Benzimidazóis/efeitos adversos , Interações de Medicamentos , Humanos , Hipotensão/induzido quimicamente , Hipotensão/epidemiologia
4.
J Surg Res ; 245: 492-499, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31446191

RESUMO

BACKGROUND: Older adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidence-based guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care. MATERIALS AND METHODS: We analyzed patients ≥50 y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs. RESULTS: Among 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry <1 L (OR 4.72, 95% CI 2.14-10.45); use of a walker (OR 2.86, 95% CI 1.29-6.34); increased chest Abbreviated Injury Scale score (AIS 3 OR 5.83, 95% CI 2.34-14.50); age ≥72 y (OR 2.68, 95% CI 1.48-4.86); and active smoking (OR 2.11, 95% CI 1.06-4.20). CONCLUSIONS: Routine ICU admission is not necessary for most older adults with isolated rib fractures. The predictors we identified warrant prospective evaluation for development of a clinical decision rule to preclude unnecessary ICU admissions.


Assuntos
Hipotensão/epidemiologia , Unidades de Terapia Intensiva/normas , Admissão do Paciente/normas , Fraturas das Costelas/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/normas , Cuidados Críticos/estatística & dados numéricos , Feminino , Humanos , Hipotensão/etiologia , Hipotensão/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Fraturas das Costelas/complicações , Medição de Risco , Centros de Traumatologia/normas , Centros de Traumatologia/estatística & dados numéricos
5.
Wei Sheng Yan Jiu ; 48(6): 869-875, 2019 Nov.
Artigo em Chinês | MEDLINE | ID: mdl-31875807

RESUMO

OBJECTIVE: To analyze the prevalence and variation of hypotension in Chinese adults residents in 2002 and 2010-2012. METHODS: Data of the blood pressure measurements from 2002 and 2010-2012 China National Nutrition and Health Survey(CNNHS), a multistage stratified cluster random sampling survey was conducted in 2002, and the sample size was 147 488, 64 869 males, 82 619 females, 50 123 urban residents, 97 365 rural residents, 71 078 northern residents and 76 410 southern residents. A multi-stage stratified and population-proportional cluster random sampling method was used in 2010-2012, and the sample size of was 120 427, 52 499 males, 67 928 females, 60 214 urban residents, 60 213 rural residents, 53 863 northern residents and 66 564 southern residents. The population data published by the National Bureau of Statistics in 2009 was used as a standard population of the data result for 2002 and 2010-2012. Complex sampling weighting method was adopted in data analyses. The prevalence of hypotension and 95%CI in different populations were calculated. Chi-square test was used to compare the rates, multi-factor analysis was conducted by using SURVEYLOGISTIC model regression. RESULTS: In 2002, the prevalence rate of hypotension in Chinese adults was 3. 0%, 1. 9% in males, 4. 1% in females, 2. 7% in urban residents, 3. 3% in rural residents, 2. 8% in northern residents and 3. 2% in southern residents. The prevalence rate of hypotension was the highest in 18-44 age group(4. 3%). Among people with different body mass index(BMI), the prevalence of hypotension was higher in low weight group(7. 0%). From 2010 to 2012, the prevalence rate of hypotension in Chinese adults was 2. 1%, 1. 1% in males, 3. 2% in females, 1. 9% in urban residents, 2. 2% in rural residents, 1. 8% in northern residents and 2. 3%in southern residents. The prevalence rate of hypotension was the highest in 18-44 age group(3. 1%). Among people with different BMI, the prevalence of hypotension was higher in low weight group(7. 4%). The total prevalence of hypotension in adult residents in China from 2010 to 2012 was lower than that in 2002, and the difference was statistically significant(χ~2= 624. 3, P <0. 0001). In 2002 and 2010-2012, the prevalence of hypotension in adult residents of China decreased with the increase of age, and the prevalence of hypotension in men and women also decreased with the increase of age. Women were higher than men, the lower age group was higher than the higher age group, and the lower weight group was higher than the normal population. The differences were statistically significant. Multivariate Logistic regression analysis also showed that lower age group, women and people with low weight were more prone to develop hypotension. CONCLUSION: In 2002 and 2010-2012, the total prevalence of hypotension in adult residents of China, and that of hypotension in both men and women decreased with the increase of age. Women were higher than men, the lower age group was higher than the higher age group, and the lower weight group was higher than the normal population. 18-44 age group, women and low weight group are more likely to have low blood pressure. Compared with 2002, the total prevalence of hypotension in Chinese adult residents showed a decreasing trend from 2010 to 2012.


Assuntos
Hipotensão , População Rural , Adulto , Grupo com Ancestrais do Continente Asiático , China/epidemiologia , Feminino , Humanos , Hipotensão/epidemiologia , Masculino , Prevalência
6.
Pan Afr Med J ; 33: 91, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31489069

RESUMO

Introduction: Haemodialysis (HD) which is a form of renal replacement therapy commonly prescribed for patients with chronic kidney disease (CKD). However, it is not without deleterious haemodynamic responses which may occur either during or immediately after the termination of the procedure. These may include hypotension or hypertension. Methods: This was a retrospective study that reviewed chronic kidney disease (CKD) patients on maintenance haemodialysis at the renal unit of University of Calabar Teaching Hospital, Calabar, Nigeria. In all, 71 patients were reviewed but only 64 patients had complete data for analysis. Socio-demographic, clinical and biochemical data were obtained from the records in the dialysis unit. Results: There were more males 38 (59.4%) than females 26 (40.6%) in the study. The mean age was 51.71±15.43 years and 43.04±14.03years for males and females respectively. The prevalence of intradialysis hypertension 29 (45.3%) was higher than that of intradialysis hypotension 20 (31.3%) and the commonest cause of CKD requiring haemodialysis was diabetic nephropathy. The factors associated with intradialysis hypotension were lower post-dialysis systolic blood pressure (PDSBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and less number of antihypertensive medications; while the factors associated with intradialysis hypertension were higher post-dialysis systolic blood pressure (SBP), MAP, greater number of antihypertensive medications and longer duration of haemodialysis. Conclusion: Our study shows that there are several modifiable factors associated with blood pressure fluctuations among CKD patients on maintenance haemodialysis in the renal unit of the University of Calabar Teaching Hospital, Calabar.


Assuntos
Hipertensão/epidemiologia , Hipotensão/epidemiologia , Diálise Renal/métodos , Insuficiência Renal Crônica/terapia , Adolescente , Adulto , Idoso , Anti-Hipertensivos/administração & dosagem , Pressão Sanguínea , Feminino , Hospitais de Ensino , Humanos , Hipertensão/etiologia , Hipotensão/etiologia , Masculino , Pessoa de Meia-Idade , Nigéria , Prevalência , Estudos Retrospectivos , Fatores de Risco , Centros de Atenção Terciária , Fatores de Tempo , Adulto Jovem
7.
World Neurosurg ; 131: e425-e432, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31376552

RESUMO

BACKGROUND: Near-infrared spectroscopy (NIRS) is an alternative monitoring method during carotid artery stenting (CAS). NIRS has been reported to be effective in emergency care; however, it is unknown whether it can predict intraoperative ischemic intolerance and cerebral hyperperfusion during CAS. Perioperative ischemic intolerance and cerebral hyperperfusion are potential events during CAS for carotid artery stenosis. We evaluated whether perioperative monitoring of the tissue oxygenation index (TOI) using NIRS with the NIRO system can predict the occurrence of ischemic intolerance and cerebral hyperperfusion. METHODS: The TOI of 27 patients was measured during CAS. The relationship between the TOI and ischemic intolerance or cerebral hyperperfusion was analyzed, and the cutoff TOI was calculated to predict their occurrence. RESULTS: Ischemic intolerance occurred in 5 patients during balloon protection. The TOI in the presence of ischemic intolerance was significantly lower than that without ischemic intolerance. The cutoff TOI to detect ischemic intolerance was 50% and that of the TOI change rate before and after balloon protection was 80%. The ischemic symptoms in all patients had resolved immediately after balloon deflation. The cerebral hyperperfusion phenomenon was detected using single-photon emission computed tomography in 4 patients. These patients showed a transient increase in the TOI immediately after CAS; however, none of these patients showed symptomatic cerebral hyperperfusion phenomenon. The cutoff TOI to detect cerebral hyperperfusion was 109% compared with the TOI before CAS. CONCLUSION: Monitoring of the TOI using the NIRO system could be useful for the detection of ischemic intolerance and cerebral hyperperfusion during CAS and to prevent perioperative adverse events.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Estenose das Carótidas/terapia , Complicações Intraoperatórias/diagnóstico por imagem , Monitorização Intraoperatória/métodos , Complicações Pós-Operatórias/diagnóstico por imagem , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/métodos , Circulação Cerebrovascular , Feminino , Humanos , Hipotensão/epidemiologia , Complicações Intraoperatórias/epidemiologia , Masculino , Complicações Pós-Operatórias/epidemiologia , Stents , Tomografia Computadorizada de Emissão de Fóton Único
8.
Postgrad Med ; 131(7): 415-422, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31424301

RESUMO

Alzheimer's disease (AD) is the most common form of dementia manifesting as alterations in cognitive abilities, behavior, and deterioration in memory which is progressive, leading to gradual worsening of symptoms. Major pathological features of AD are accumulations of neuronal amyloid plaques and neurofibrillary tangles, with early lesions appearing primarily in the hippocampus, the area of the brain involved in memory and learning. Cardiovascular-related risk factors are believed to play a crucial role in disease development and the acceleration of cognitive deterioration by worsening cerebral perfusion, promoting disturbances in amyloid clearance. Current evidence supports hypertension, hypotension, heart failure, stroke and coronary artery diseases as potential factors playing a role in cognitive decline in patients with Alzheimer's dementia. Although dementia due to cardiovascular deficits is more strongly linked to the development of vascular dementia, a stepwise decline in cognition, recent researches have also discovered its deleterious influence on AD development.


Assuntos
Doença de Alzheimer/fisiopatologia , Doenças Cardiovasculares/fisiopatologia , Doença de Alzheimer/epidemiologia , Doença de Alzheimer/metabolismo , Peptídeos beta-Amiloides/metabolismo , Doenças Cardiovasculares/epidemiologia , Circulação Cerebrovascular , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/fisiopatologia , Progressão da Doença , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Hipotensão/epidemiologia , Hipotensão/fisiopatologia , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/fisiopatologia
9.
S Afr Med J ; 109(7): 535-540, 2019 Jun 28.
Artigo em Inglês | MEDLINE | ID: mdl-31266582

RESUMO

BACKGROUND: Frailty is a state characterised by diminished physiological reserve that leaves an individual vulnerable to external stressors and delays recovery. Frailty assessments are proving to be more valuable in predicting poor perioperative outcomes than other well-known perioperative risk assessment tools. Very few studies using validated frailty assessment tools have been done to assess the prevalence of frailty in South Africa (SA), and none have assessed the intraoperative implications of frailty in a surgical population. OBJECTIVES: To determine the demographics and frailty levels of patients presenting for surgery at three academic hospitals in Johannesburg, compare intraoperative complications between the frail and non-frail patients, and compare the association between frailty scores and American Society of Anesthesiologists Physical Status (ASA-PS) scores. METHODS: We prospectively enrolled 299 patients aged 18 - 90 years undergoing various types of elective surgery between mid-November 2016 and mid-March 2017 in three SA academic hospitals. Frailty was assessed using the nine-point Clinical Frailty Scale (CFS) and defined as a score of ≥5. The CFS and demographic and clinical data were documented by the anaesthetists assigned to the respective elective lists. The primary outcome measure was intraoperative complications (hypotension, desaturation, and need for vasopressors and blood transfusion). We also compared associations between the patients' comorbidities and frailty and those between the CFS and ASA-PS scores. RESULTS: Of a total of 299 patients included in the study (mean age (standard deviation) 50.6 (15.8) years), 156 (52%) were women and 67 (22%) were classified as frail. Compared with patients who were not classified as frail, the frail group had significantly higher incidences of hypotension (odds ratio (OR) 1.87, 95% confidence interval (CI) 1.083 - 3.259; p=0.02) and desaturation (OR 3.79, 95% CI 1.367 - 10.54; p=0.01), and were more likely to need vasopressors (OR 2.81, 95% CI 1.607 - 4.912; p=0.00) and blood transfusion (OR 3.26, 95% CI 1.138 - 9.368; p=0.02). On multivariable logistic regression analysis, adjusting for factors related to frailty such as age, gender and comorbidities, desaturation was significantly associated with frailty (adjusted OR (aOR) 4.21, 95% CI 1.31 - 13.53; p=0.01), and the frail were more likely to require blood transfusion (aOR 5.36, 95% CI 1.50 - 19.16; p=0.01) and were older and had more comorbidities. Higher ASA-PS scores were also strongly associated with frailty. CONCLUSIONS: The prevalence of frailty was high among surgical patients. Consistent with other studies, frailty was associated with older age and multiple comorbidities. The association between frailty and intraoperative complications found in this study may indicate and help inform areas of further research.


Assuntos
Procedimentos Cirúrgicos Eletivos , Fragilidade/diagnóstico , Fragilidade/epidemiologia , Centros Médicos Acadêmicos , Adolescente , Adulto , Fatores Etários , Idoso , Transfusão de Sangue/estatística & dados numéricos , Comorbidade , Uso de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Hipotensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Prevalência , Estudos Prospectivos , África do Sul/epidemiologia , Vasoconstritores/uso terapêutico , Adulto Jovem
10.
Environ Int ; 131: 104941, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31288180

RESUMO

BACKGROUND: Although blood pressure decreases in response to high ambient temperature, little is known about whether the ambient temperature can induce clinical hypotension events. Therefore, we conducted a time-series analysis to evaluate the association between hypotension hospital visits and ambient temperature in seven metropolitan cities of Korea. METHODS: We used the National Health Insurance Database, which contains the complete hospital visit data of the entire Korean population. We collected hospital visit data of seven metropolitan cities and linked the number of daily hypotension hospital visits to city-level ambient temperature, relative humidity, and air pollution levels from 2011 to 2015. Time-series analysis using the Poisson generalized additive model was conducted for each metropolitan city and we meta-analyzed the time-series results using the random effect model. RESULTS: There were 132,097 hospital visits for hypotension during our study period. A 1 degree Celsius (°C) increase in ambient temperature was associated with 1.1% increase in hospital visits for hypotension on lag day 0. Effects of ambient temperature lasted for 7 days, showing greater effects in shorter lag days. Subgroup analysis by sex and income groups showed similar results, but effects of ambient temperature on hypotension hospital visits was higher in the younger age group compared to older age group (aged over 65 years old). The results were unchanged when we applied cumulative lags, different case definitions, degrees of freedom per year, and multi-pollutant model adjusting for air pollutants. CONCLUSIONS: Hospital visits for hypotension were positively associated with ambient temperature. Increased hypotension events in response to increased ambient temperature might explain the high cardiovascular mortality on hot days.


Assuntos
Hospitalização/estatística & dados numéricos , Temperatura Alta/efeitos adversos , Hipotensão/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Cidades , Feminino , Humanos , Hipotensão/etiologia , Masculino , Pessoa de Meia-Idade , República da Coreia/epidemiologia , Adulto Jovem
11.
Hypertension ; 74(3): 645-651, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31327266

RESUMO

Alpha-blockers (ABs) are commonly prescribed as part of a multidrug regimen in the management of hypertension. We set out to assess the risk of hypotension and related adverse events with AB use compared with other blood pressure (BP) lowering drugs using a population-based, retrospective cohort study of women (≥66 years) between 1995 and 2015 in Ontario, Canada. Cox proportional hazards examined the association of AB use and hypotension and related events (syncope, fall, and fracture) compared with other BP lowering drugs matched via a high dimensional propensity score. The primary outcome was a composite of hospitalizations for hypotension and related events (syncope, fractures, and falls) within 1 year. From 734 907 eligible women, 14 106 were dispensed an AB (mean age, 75.7; standard deviation 6.9 years, median follow-up 1 year) and matched to 14 106 dispensed other BP lowering agents. The crude incidence rate of hypotension and related events was 95.7 (95% CI [confidence interval], 90.4-101.1, events 1214 [8.6%]) with AB and 79.8 (95% CI, 74.9-84.7 per 1000 person-years, events 1025 [7.3%]) with other BP lowering medications (incident rate ratio, 1.20; 95% CI, 1.10-1.30). The risk was higher for hypotension (hazard ratio, 1.71; 95% CI, 1.33-2.20) and syncope (hazard ratio, 1.44; 95% CI, 1.18-1.75) with no difference in falls, fractures, adverse cardiac events, or all-cause mortality. Treatment of hypertension in women with ABs is associated with a higher risk of hypotension and hypotension-related events compared with other BP lowering agents. Our findings suggest that ABs should be used with caution, even as add on therapy for hypertension.


Assuntos
Antagonistas Adrenérgicos alfa/efeitos adversos , Hipertensão/tratamento farmacológico , Hipotensão/induzido quimicamente , Hipotensão/epidemiologia , Acidentes por Quedas/estatística & dados numéricos , Antagonistas Adrenérgicos alfa/uso terapêutico , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/uso terapêutico , Canadá , Estudos de Coortes , Relação Dose-Resposta a Droga , Esquema de Medicação , Feminino , Fraturas Ósseas/diagnóstico , Fraturas Ósseas/epidemiologia , Avaliação Geriátrica/métodos , Humanos , Hipertensão/diagnóstico , Hipotensão/fisiopatologia , Incidência , Prognóstico , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Síncope/diagnóstico , Síncope/epidemiologia , Resultado do Tratamento
12.
Geriatr Gerontol Int ; 19(9): 874-878, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31359614

RESUMO

AIM: The aim of the present study was to evaluate the incidence, risk factors, clinical characteristics and outcomes of acute kidney injury (AKI) in octogenarians admitted to the emergency room, and to compare these parameters with those in a younger group of patients admitted in the same period. METHODS: This is a prospective, observational, single-center study that enrolled adult patients admitted to the emergency room of Shaare Zedek Medical Center, Jerusalem, Israel. Patients were stratified by age (≥80 years or <80 years) and followed up prospectively until discharge. The incidence of AKI, in-hospital mortality and duration of hospital stay were recorded. RESULTS: Of 319 patients, 128 were octogenarians (mean age 86.7 years, range 80-105 years) and 191 were younger (mean age 60.6 years, range 18-79 years). The incidence of AKI and in-hospital mortality was significantly higher in octogenarians (16.4% vs 12.6%, P = 0.039 and 15.6% vs 3.1%, P = 0.001, respectively). In multivariate analysis, only low systolic blood pressure at admission in octogenarians (P = 0.002), and a history of chronic kidney disease (P < 0.001) and hypoalbuminemia (P = 0.001) in the younger patients were independent risk factors for AKI. CONCLUSION: The present results confirm the observation that AKI is common in octogenarians. We identified systolic blood pressure as the only independent variable associated with AKI in octogenarians. However, the role of therapeutic strategies aimed to increase systolic blood pressure and diminish complications in octogenarians remains to be elucidated. Geriatr Gerontol Int 2019; 19: 874-878.


Assuntos
Lesão Renal Aguda , Emergências/epidemiologia , Hipotensão , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/mortalidade , Fatores Etários , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Hipotensão/diagnóstico , Hipotensão/epidemiologia , Hipotensão/fisiopatologia , Incidência , Israel/epidemiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco
13.
Drug Discov Ther ; 13(2): 101-107, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31080200

RESUMO

Acute febrile illness (AFI) is one of the commonest indications for hospitalization and can present with varying severity including single or multiple organ dysfunction syndrome (MODS). During monsoon season, there is a spurt of AFI often caused by vector borne diseases leading to substantial morbidity and mortality. Our aim was to determine distribution of etiological causes, differential organ involvement and predictors of mortality in critically ill patients with AFI. It was a hospital based observational study which included patients with AFI with dysfunction of at least one organ system. The study was conducted over 4 months during monsoon season. Admitted patients were included who had been subjected to a standard battery of tests and managed with standard hospital based management protocol. 145 patients were included and etiology of fever was ascertained in 81.4% of patients with the most common single infection being chikungunya (20.7%) followed by dengue (20%) fever. Thrombocytopenia and deranged liver biochemistry each were seen in nearly 75% of the patients. Renal (50.3%) and nervous system (46.2%) dysfunction were the predominant organ failures. 49 patients died (33.8%) which correlated with predicted mortality by APACHE (acute physiological assessment and chronic health evaluation) II score. Independent predictors for mortality were older age (> 55 years) (p = 0.01), acidemia (p = 0.01), altered sensorium (p = 0.02) and coagulopathy (p = 0.048). Sub-group analysis revealed that amongst patients with MODS, hypotension could help differentiate between bacterial and non-bacterial causes (p = 0.01). Critically ill patients with AFI suffer from significant morbidity and mortality. Features like the presence of hypotension in MODS may differentiate between a bacterial cause vis-à-vis viral or protozoal etiology.


Assuntos
Febre de Chikungunya/epidemiologia , Estado Terminal/mortalidade , Dengue/epidemiologia , Hipotensão/epidemiologia , Insuficiência de Múltiplos Órgãos/etiologia , APACHE , Adolescente , Adulto , Febre de Chikungunya/complicações , Febre de Chikungunya/transmissão , Criança , Dengue/complicações , Dengue/transmissão , Feminino , Humanos , Índia , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/classificação , Insuficiência de Múltiplos Órgãos/mortalidade , Estudos Prospectivos , Fatores de Risco , Estações do Ano , Centros de Atenção Terciária , Adulto Jovem
14.
PLoS One ; 14(5): e0215061, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31042724

RESUMO

INTRODUCTION: The early identification of patients at risk of severe dengue infection (DI) is critical to guide clinical management. There is currently no validated laboratory test which can predict severe complications of DI. The Atypical lymphocyte count (ALC) is a research parameter generated at no extra cost when an automated Full Blood Count (FBC) is performed. The purpose of this study was to assess the association of ALC with the severity of DI. METHODS: We prospectively collected data on patients admitted to Nawaloka Hospital Sri Lanka (NH) with DI between December 2016 and November 2017. DI was diagnosed based on a positive Non-structural antigen 1 (NS1) or dengue IgM antibody. ALC (absolute ALC and percentage) data were extracted from the Sysmex XS500i automated full blood count (FBC) analyzer (Sysmex Corporation Kobe, Japan). Clinical data was recorded from medical records and the computerized data base maintained by NH. RESULTS: 530 patients were enrolled. Patients with clinical manifestations of severe dengue have a significantly higher AL % compared to dengue without warning signs. Patients who presented with respiratory compromise had statistically significantly higher AL% compared to those without. (AL%; 8.65±12.09 vs 2.17±4.25 [p = 0.01]). Similarly, patients who developed hypotension had higher AL% compared to those who did not suffered from shock (AL%; 8.40±1.26 vs 2.18±4.25 [p = 0.001]). The AL% of dengue patients presenting with bleeding, at 4.07%, is also higher than those without bleeding complications, at 2.15%. There was a significant negative association between platelet count and AL% (p = 0.04). CONCLUSIONS: Clinical manifestations of severe dengue have a significantly higher AL % compared to dengue without warning signs. AL % at presentation may be predictive of severe DI and future larger prospective longitudinal studies should be done to determine if AL % on admission is predictive of the complications of DI.


Assuntos
Hipotensão/epidemiologia , Dengue Grave/imunologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hipotensão/etiologia , Contagem de Linfócitos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Dengue Grave/complicações , Índice de Gravidade de Doença , Adulto Jovem
15.
Pharmacol Res Perspect ; 7(2): e00463, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30873284

RESUMO

Cinaciguat, a soluble guanylate cyclase (sGC) activator, was under clinical development for use in acute decompensated heart failure (ADHF), but was discontinued due to occurrence of hypotension. We hypothesized that short-term activation of sGC in ADHF patients would exert a vasodilative effect without hypotension irrespective of disease state, using a novel short-acting sGC activator, TY-55002. The objective of this study was to investigate the vasodilation and hemodynamic effects of TY-55002 in comparison with those of cinaciguat. TY-55002 and cinaciguat activated both normal and heme-oxidized sGC in a dose-dependent manner and caused rapid relaxation of phenylephrine-contracted rat aorta. However, TY-55002 had a milder effect than cinaciguat in enhancing the dose-activity response between normal and oxidized sGC. Therefore, we suggest that the pharmacological effect of TY-55002 is less subject than cinaciguat to oxidative stress associated with complications such as cardiovascular disease or diabetes. In normal dogs, the effects of intravenous TY-55002 or cinaciguat on blood pressure were evaluated in conjunction with the plasma concentrations of the compounds, and pharmacokinetic (PK)-pharmacodynamic (PD) analyses were carried out. The plasma-to-effect-site transfer rate constant (Ke0) for TY-55002 was three times greater than for cinaciguat. On the other hand, there was a small difference in blood half-life (T1/2) between the compounds. It is possible that the rapid fall in blood pressure after the initial administration of TY-55002 and the quick recovery after cessation were due to the pharmacodynamic property of the compound. In heart failure-model dogs, TY-55002 and cinaciguat improved the condition to the same degree, and the short-term action of TY-55002 was replicated. In conclusion, TY-55002 is a novel short-acting sGC activator, which offers the possibility of easy dose management without excessive hypotension. It therefore holds potential to serve as an innovative drug in the pharmacotherapy of ADHF.


Assuntos
Insuficiência Cardíaca/tratamento farmacológico , Hemodinâmica/efeitos dos fármacos , Hipotensão/epidemiologia , Vasodilatação/efeitos dos fármacos , Vasodilatadores/farmacologia , Animais , Benzoatos/farmacologia , Benzoatos/uso terapêutico , Modelos Animais de Doenças , Cães , Relação Dose-Resposta a Droga , Feminino , Meia-Vida , Insuficiência Cardíaca/etiologia , Humanos , Hipotensão/induzido quimicamente , Masculino , Modelos Biológicos , Ratos , Ratos Sprague-Dawley , Guanilil Ciclase Solúvel/metabolismo , Fatores de Tempo , Resultado do Tratamento , Vasodilatadores/uso terapêutico
16.
Pregnancy Hypertens ; 15: 134-140, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30713829

RESUMO

Objectives: To investigate whether age at menarche is related to maternal blood pressure in pregnancy and, if so, whether obesity and insulin resistance can modify the associations. Study Design: Analysis of data collected from 438 pregnant women from the longitudinal and prospective Cambridge Baby Growth Study. Main Outcome: Testing associations between questionnaire-derived age at menarche and blood pressure measurements in pregnancy collected from hospital notes, and investigating whether any associations were altered by maternal pre-pregnancy body mass index (BMI) and insulin resistance. Measures: Mean arterial blood pressure at four time points across pregnancy, age at menarche, (Homeostasis Model Assessment) insulin resistance around week 28 of pregnancy. Results: For each increased year in age at menarche there was a drop in mean arterial blood pressure (mmHg) of 0.6 at 11.9 weeks, 0.9 at 31.4 and 37.0 weeks, and 0.4 at 38.8 weeks (a maximal difference of over 7 mmHg across extremes of AAM). Each association was attenuated by both maternal pre-pregnancy BMI and insulin resistance. Conclusions: Age at menarche is negatively associated with future blood pressure in pregnancy, so those with the earliest age at menarche have the highest blood pressures. Either these associations may be mediated by links between age at menarche and obesity/insulin resistance, or there may be a confounder (e.g. systemic inflammation) that links age at menarche to each of them.


Assuntos
Pressão Arterial , Hipertensão Induzida pela Gravidez/epidemiologia , Hipotensão/epidemiologia , Resistência à Insulina/fisiologia , Menarca , Obesidade/fisiopatologia , Adolescente , Adulto , Fatores Etários , Índice de Massa Corporal , Criança , Feminino , Idade Gestacional , Humanos , Hipertensão Induzida pela Gravidez/fisiopatologia , Hipotensão/fisiopatologia , Gravidez
17.
J Clin Nurs ; 28(11-12): 2245-2252, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30790377

RESUMO

AIMS AND OBJECTIVES: To investigate the associations between nurse staffing and the incidence and severity of hypoxaemia, arterial hypotension and bradycardia of postoperative patients during their postanaesthesia care unit stay. BACKGROUND: Nurse understaffing has been associated with adverse patient outcomes in a variety of hospital settings. In the postanaesthesia care unit, nursing shortage is common and can be related to compromised prevention, detection and treatment of adverse events. DESIGN: Observational, single-centre, prospective study that adhered to Strengthening the Reporting of Observational studies in Epidemiology checklist (see Supporting information Appendix S1); 2,207 patients admitted to the postanaesthesia care unit of a tertiary care hospital over a 5-month period were enrolled. METHODS: Incidence of hypoxaemia (arterial oxygen saturation <95%), arterial hypotension (systolic blood pressure <90 mmHg) and bradycardia (heart rate <50 beats per minute), along with episode severity, was recorded. Patients were classified into three groups as follows: sufficient staffing, low and high understaffing. Risk for hypoxaemia, arterial hypotension and bradycardia was adjusted according to patient, anaesthesia and operation characteristics. RESULTS: The incidence of hypoxaemia was significantly higher in the high understaffing group patients, while the incidence of arterial hypotension was significantly higher in both low and high understaffing group patients, compared to sufficient staffing group ones. In the high understaffing group patients, hypoxaemia and arterial hypotension episodes were of significantly higher severity. CONCLUSIONS: These associations between hypoxaemia and arterial hypotension and postanaesthesia care unit understaffing indicate that care quality and patient safety can be compromised in case patient acuity is not matched with sufficient nursing resources. RELEVANCE TO CLINICAL PRACTICE: Higher incidence of hypoxaemia and arterial hypotension advocates for the prevention of imbalances between patient number and care demands and the number of available nurses.


Assuntos
Período de Recuperação da Anestesia , Recursos Humanos de Enfermagem no Hospital/provisão & distribução , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Adulto , Bradicardia/epidemiologia , Feminino , Humanos , Hipotensão/epidemiologia , Hipóxia/epidemiologia , Incidência , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Período Pós-Operatório , Estudos Prospectivos , Qualidade da Assistência à Saúde
18.
Curr Opin Anaesthesiol ; 32(3): 268-270, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30747727

RESUMO

PURPOSE OF REVIEW: Low-dose combined spinal epidural (CSE) anesthesia is a common technique to anesthetize women for cesarean section. It is used to reduce the incidence of hypotension while providing excellent anesthetic conditions. RECENT FINDINGS: Low spinal doses produce effective anesthesia but of limited duration. Therefore, an epidural catheter (and thus CSE) is required to guarantee pain-free surgery. Recent work confirmed that lower spinal doses can reduce significantly hypotension. SUMMARY: Low-dose CSE is a valuable strategy to anesthetize pregnant women for cesarean section but requires attention and training.


Assuntos
Anestesia Epidural/métodos , Anestesia Obstétrica/métodos , Bupivacaína/administração & dosagem , Cesárea/efeitos adversos , Hipotensão/prevenção & controle , Anestesia Epidural/efeitos adversos , Anestesia Epidural/instrumentação , Anestesia Obstétrica/efeitos adversos , Anestesia Obstétrica/instrumentação , Anestésicos Locais , Bupivacaína/efeitos adversos , Cateteres , Relação Dose-Resposta a Droga , Feminino , Humanos , Hipotensão/induzido quimicamente , Hipotensão/epidemiologia , Incidência , Gravidez , Fatores de Tempo
19.
Am J Obstet Gynecol ; 220(4): 389.e1-389.e9, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30633919

RESUMO

BACKGROUND: Neuraxial block-related hypotension and maternal obesity contribute to uterine hypoperfusion and decreased umbilical arterial pH at cesarean delivery. Between the time of anesthesia placement and delivery, the fetus may be exposed to a hypoperfused uterine environment without surgeon awareness of fetal compromise. OBJECTIVE: We sought to evaluate neonatal umbilical arterial pH according to predelivery time intervals at scheduled term cesarean. STUDY DESIGN: We performed a retrospective cohort study of cesarean deliveries between September 2014 and February 2017. Singleton gestations undergoing scheduled cesarean delivery under spinal anesthesia between 37 and 41 weeks with a reassuring preoperative nonstress test were included. Time intervals between operative room entry, spinal anesthesia placement, skin incision, uterine incision, and delivery were calculated. The primary outcome was umbilical arterial pH. Demographic data, maternal blood pressures, predelivery time intervals, and delivery outcomes were analyzed according to umbilical arterial pH intervals of <7.0, 7.01-7.10, 7.11-7.20, 7.21-7.30, and >7.30. Umbilical cord gas analytes and neonatal outcomes were analyzed by spinal to delivery time. Stepwise linear regression was performed to identify predictors of decreasing umbilical arterial pH. Receiver-operator characteristic curves were calculated for spinal to delivery time and umbilical arterial pH <7.0 and 7.1. RESULTS: Among 527 included participants, median umbilical arterial pH was 7.27 [interquartile range, 7.23-7.29] and body mass index was 35 kg/m2 [interquartile range, 30-41]. Both maternal body mass index and hypotensive episodes increased with decreasing umbilical arterial pH (P <.001, P ≤ .02). All predelivery time intervals (operative room to delivery, spinal to skin, spinal to delivery, and uterine incision to delivery) increased as umbilical arterial pH interval decreased (P < .05 for all). In a stepwise linear regression, maternal body mass index, noncephalic presentation, spinal start to delivery interval, uterine incision to delivery interval, and maximum reduction in blood pressure from baseline were predictive of decreasing umbilical arterial pH after controlling for confounding variables (F [5,442] = 17.7, P = .0001], adjusted R2 of 0.157. When evaluated by spinal to delivery time, both umbilical arterial and venous pH and partial pressure of carbon dioxide decreased (P < .001 for all), but base deficit and neonatal outcomes were similar (P ≥ .7 for all). There were 2 cases of hypoxic-ischemic encephalopathy (0.38%). A receiver-operating characteristic curve demonstrated that a spinal start to delivery time greater than 27 minutes was associated with an umbilical arterial pH <7.1 (area under the curve, 0.74, 100% sensitivity, 21% specificity), and an interval greater than 30 minutes was associated with an umbilical arterial pH <7.0 (area under the curve, 0.80, 100% sensitivity, 33% specificity). CONCLUSION: Longer spinal-to-delivery and uterine incision-to-delivery time intervals were associated with decreasing umbilical arterial pH at scheduled term cesarean delivery. Efforts to minimize predelivery time following spinal placement could reduce the frequency of unanticipated neonatal acidemia.


Assuntos
Acidose/epidemiologia , Raquianestesia/estatística & dados numéricos , Cesárea/estatística & dados numéricos , Hipotensão/epidemiologia , Doenças do Recém-Nascido/epidemiologia , /epidemiologia , Adulto , Anestesia Obstétrica , Gasometria , Índice de Massa Corporal , Procedimentos Cirúrgicos Eletivos , Feminino , Sangue Fetal , Humanos , Concentração de Íons de Hidrogênio , Recém-Nascido , Modelos Lineares , Gravidez , Estudos Retrospectivos , Fatores de Tempo , Artérias Umbilicais , Adulto Jovem
20.
J Clin Anesth ; 55: 146-150, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30660093

RESUMO

STUDY OBJECTIVE: To evaluate the intraoperative hemodynamics and medication requirements of cocaine-positive patients compared to matched cocaine-negative controls. DESIGN: Retrospective cohort study. SETTING: Public county hospital. PATIENTS: 821 patients undergoing general anesthesia. MEASUREMENTS: Incidence of hemodynamic events, defined by a mean arterial pressure of <65 mmHg or >105 mmHg or a heart rate of <50 beats per minute or >100 beats per minute. MAIN RESULTS: Cocaine-positive patients did not experience a higher incidence of hemodynamic events when compared with matched cocaine-negative patients. Cocaine-positive patients were not more likely to be administered vasopressors intraoperatively but did receive more anti-hypertensive agents. The minimum alveolar concentration of anesthetics used was similar between the two groups. Anesthesia duration, length of stay, and in-hospital mortality did not significantly differ between the two cohorts. CONCLUSIONS: Cocaine-positive patients did not demonstrate more intraoperative hemodynamic events or adverse short-term outcomes as compared to matched cocaine-negative controls.


Assuntos
Anestesia Geral/efeitos adversos , Cocaína/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Hipertensão/epidemiologia , Hipotensão/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adulto , Anti-Hipertensivos/administração & dosagem , Pressão Arterial/efeitos dos fármacos , Pressão Arterial/fisiologia , Estudos de Casos e Controles , Cocaína/administração & dosagem , Feminino , Frequência Cardíaca/efeitos dos fármacos , Frequência Cardíaca/fisiologia , Mortalidade Hospitalar , Humanos , Hipertensão/etiologia , Hipertensão/fisiopatologia , Hipertensão/prevenção & controle , Hipotensão/etiologia , Hipotensão/fisiopatologia , Hipotensão/prevenção & controle , Incidência , Cuidados Intraoperatórios/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Vasoconstritores/administração & dosagem
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