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1.
Medicine (Baltimore) ; 99(40): e21533, 2020 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-33019383

RESUMO

RATIONALE: Midodrine is widely used in the treatment of hypotensive states, there have been no reports of myoclonus associated with midodrine use in hypotension with chronic kidney disease. PATIENT CONCERNS: We report a 58-year-old female patient with chronic kidney disease (CKD) presenting with involuntary tremor 2 h after taking midodrine, which became more frequent after 6 h. Brain CT and neurological examination did not yield findings of note. Blood chemistry showed serum albumin of 3.1 g/L, ALT of 19 U/L, AST of 22 U/L, SCr of 273.9 µmol/L, K of 2.94 mmol/L, Ca of 1.63 mmol/L, and Mg of 0.46 mmol/L. Her BP was maintained at 83-110/56-75 mmHg. Her urine volume was 600-1000 mL/d, and her heart rate was within a range of 90-100 beats/min. DIAGNOSIS: Chronic kidney disease (CKD), hypotension, metabolic acidosis, hypocalcemia, hypokalemia, and hypomagnesemia. INTERVENTIONS: Midodrine treatment was stopped and the patient was treated with intravascular rehydration and furosemide. Myoclonus ceased one day after midodrine withdrawal. LESSONS: Oral midodrine is widely used in the treatment of orthostatic hypotension, recurrent reflex syncope and dialysis-associated hypotension and the adverse effects are mostly mild. However, clinicians should be alert for midodrine-induced myoclonus, especially in patients with CKD.


Assuntos
Agonistas de Receptores Adrenérgicos alfa 1/efeitos adversos , Hipotensão/tratamento farmacológico , Midodrina/efeitos adversos , Mioclonia/induzido quimicamente , Administração Oral , Agonistas de Receptores Adrenérgicos alfa 1/administração & dosagem , Feminino , Humanos , Hipotensão/etiologia , Pessoa de Meia-Idade , Midodrina/administração & dosagem , Insuficiência Renal Crônica/complicações
2.
PLoS One ; 15(8): e0233852, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32866219

RESUMO

OBJECTIVE: Hypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation. METHODS: A multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure <65 mmHg; 2) systolic blood pressure <80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation. RESULTS: Post-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure <65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients' pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients' risk of hypotension. CONCLUSIONS: A novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients. STUDY REGISTRATION: Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.


Assuntos
Hipotensão/etiologia , Intubação Intratraqueal/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Estado Terminal , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Modelos Biológicos , Estudos Prospectivos
4.
Curr Opin Anaesthesiol ; 33(5): 646-650, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32769747

RESUMO

PURPOSE OF REVIEW: Intraoperative hypotension (IOH) may render patients at a risk of cerebral hypoperfusion with decreasing cerebral blood flow (CBF), and lead to postoperative neurological injury. On the basis of the literature in recent years, this review attempts to refine the definition of IOH and evaluate its impact on neurological outcomes. RECENT FINDINGS: Although both absolute and relative blood pressure (BP) thresholds, with or without a cumulative period, have been used in collective clinical studies, no definitive threshold of IOH has been established for neurological complications, including perioperative stroke, postoperative cognitive disorder and delirium. The CBF is jointly modulated by multiple pressure processes (i.e. cerebral pressure autoregulation) and nonpressure processes, including patient, surgical and anaesthesia-related confounding factors. The confounding factors and variability in cerebral pressure autoregulation might impede evaluating the effect of IOH on the neurological outcomes. Furthermore, the majority of the evidence presented in this review are cohort studies, which are weak in demonstrating a cause--effect relationship between IOH and neurological complications. The maintenance of target BP based on the monitoring of regional cerebral oxygen saturation (rScO2) or cerebral pressure autoregulation seems to be associated with the decreased incidence of postoperative neurological complications. SUMMARY: Despite the lack of a known threshold value, IOH is a modifiable risk factor targeted to improve neurological outcomes. Ideal BP management is recommended in order to maintain target BP based on the monitoring of rScO2 or cerebral pressure autoregulation.


Assuntos
Circulação Cerebrovascular/fisiologia , Hipotensão/etiologia , Complicações Intraoperatórias , Complicações Pós-Operatórias , Pressão Sanguínea/fisiologia , Estudos de Coortes , Humanos , Oximetria/métodos , Oxigênio/metabolismo , Procedimentos Cirúrgicos Operatórios
5.
Am Surg ; 86(8): 937-943, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32762468

RESUMO

INTRODUCTION: There is disagreement in the trauma community concerning the extent to which emergency medical services (EMS) should perform on-scene interventions. Additionally, in recent years the "ABC" algorithm has been questioned in hypotensive patients. The objective of this study was to quantify the delay introduced by different on-scene interventions. METHODS: A retrospective analysis of hypotensive trauma patients brought to an urban level 1 trauma center by EMS from 2007 to 2018 was performed, and patients were stratified by mechanism of injury and new injury severity score (NISS). Independent samples median tests were used to compare median on-scene times. RESULTS: Among 982 trauma patients, median on-scene time was 5 minutes (interquartile range 3-8). In penetrating trauma patients (n = 488) with NISS of 16-25, intubation significantly increased scene time from 4 to 6 minutes (P < .05). In penetrating trauma patients with NISS of 10-15, wound care significantly increased scene time from 3 to 6 minutes (P < .05). Tourniquet use, interosseous (IO) access, intravenous (IV) access, and needle decompression did not significantly increase scene time. CONCLUSION: Understanding that intubation increases scene time in penetrating trauma, while IV and IO access do not, alterations to the traditional "ABC" algorithm may be warranted. Further investigation of prehospital interventions is needed to determine which are appropriate on-scene.


Assuntos
Algoritmos , Tomada de Decisão Clínica/métodos , Serviços Médicos de Emergência/métodos , Hipotensão/terapia , Tempo para o Tratamento/estatística & dados numéricos , Ferimentos e Lesões/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos Clínicos , Feminino , Mortalidade Hospitalar , Humanos , Hipotensão/etiologia , Hipotensão/mortalidade , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Transporte de Pacientes , Centros de Traumatologia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidade
6.
Medicine (Baltimore) ; 99(28): e20946, 2020 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-32664094

RESUMO

BACKGROUND: The beach chair position (BCP), used during shoulder surgery, is associated with hypotension, bradycardia, and risk of cerebral hypoperfusion. Phenylephrine is commonly used as a first treatment of choice of intraoperative hypotension during surgery. We evaluated the hemodynamic effects of 2 doses of intravenous phenylephrine infusion administered before being placed in BCP for arthroscopic shoulder surgery. The primary endpoint was the incidence of hypotension after positional change. METHODS: Sixty-six patients were randomized to receive either intravenous normal saline (group NS) or intravenous phenylephrine infusion (0.5 µg/kg/min, group LP or 1.0 µg/kg/min, group HP) for 5 minutes before being placed in the BCP. Mean arterial pressure(MAP), heart rate, stroke volume variation, and cardiac index were measured before and after positional change. RESULTS: The total incidence of hypotension after the BCP was 93.65%, but was not significantly different among the 3 groups. However, there was a significant difference in trends between the groups for MAP for 5 minutes after BCP (P = .028). Comparison of changes in MAP at 1 minute compared to post-induction MAP was significantly different between group HP and group NS (P = .014). CONCLUSION: Infusion of 0.5 and 1.0 µg/kg/min of phenylephrine for 5 minutes before the BCP has no preventive effect for incidence of hypotension. However, this study showed that 1.0 µg/kg/min of phenylephrine infusion for 5 minutes can attenuate the severity of hypotension.


Assuntos
Hipotensão/etiologia , Hipotensão/prevenção & controle , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/prevenção & controle , Posicionamento do Paciente/efeitos adversos , Fenilefrina/administração & dosagem , Idoso , Feminino , Humanos , Hipotensão/epidemiologia , Incidência , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Método Simples-Cego
7.
Pol Merkur Lekarski ; 48(285): 215-220, 2020 Jun 17.
Artigo em Polonês | MEDLINE | ID: mdl-32564050

RESUMO

Demographic data clearly show the progressive aging of societies. Problems and specificity of anaesthesia in the elderly becomes a particularly important issue in this context. Spinal anesthesia is a method often used to anesthetize elderly patients, and hypotension is one of its most common early complications. Untreated or improperly treated hypotension increases the risk of perioperative complications such as myocardial infarction, ischemic stroke or acute renal failure. The prevention of hypotension consists of intravenous fluid therapy and pre-emptive use of vasoconstrictor drugs. Among vasoconstrictors, ephedrine and phenylephrine are commonly used to treat hypotension due to spinal anaesthesia. Both drugs are available in Poland. Issues related to their use in the treatment of hypotension caused by spinal anaesthesia in the elderly, including the features of both drugs, their method of administration and dosage based on the literature and own experience are the subject of this study. It should be noted, however, that most studies in the use of ephedrine and phenylephrine as a targeted treatment for hypotension concern the obstetric patient population while the elderly population is underrepresented and the results are inconclusive.


Assuntos
Anestesia , Hipotensão , Idoso , Anestesia/efeitos adversos , Anestesia Obstétrica/efeitos adversos , Cesárea , Feminino , Humanos , Hipotensão/etiologia , Fenilefrina , Polônia , Gravidez
8.
Am J Emerg Med ; 38(7): 1549.e1-1549.e2, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32425320

RESUMO

A patient presented to the emergency department with altered mental status and lower extremity weakness in the setting of nitrous oxide inhalant abuse and Coronavirus Disease-2019 (COVID-19) infection. He subsequently developed hypotension and severe hypoxia, found to have a saddle pulmonary embolus (PE) with right heart strain requiring alteplase (tPA).


Assuntos
Infecções por Coronavirus/diagnóstico , Abuso de Inalantes/complicações , Óxido Nitroso , Pneumonia Viral/diagnóstico , Embolia Pulmonar/diagnóstico por imagem , Betacoronavirus , Infecções por Coronavirus/fisiopatologia , Fibrinolíticos/uso terapêutico , Humanos , Hipotensão/etiologia , Hipóxia/etiologia , Masculino , Pandemias , Pneumonia Viral/fisiopatologia , Embolia Pulmonar/terapia , Ativador de Plasminogênio Tecidual/uso terapêutico , Tomografia Computadorizada por Raios X , Adulto Jovem
10.
Anesthesiology ; 133(3): 523-533, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32433278

RESUMO

BACKGROUND: Children are required to fast before elective general anesthesia. This study hypothesized that prolonged fasting causes volume depletion that manifests as low blood pressure. This study aimed to assess the association between fluid fasting duration and postinduction low blood pressure. METHODS: A retrospective cohort study was performed of 15,543 anesthetized children without preinduction venous access who underwent elective surgery from 2016 to 2017 at Children's Hospital of Philadelphia. Low blood pressure was defined as systolic blood pressure lower than 2 standard deviations below the mean (approximately the 2.5th percentile) for sex- and age-specific reference values. Two epochs were assessed: epoch 1 was from induction to completion of anesthesia preparation, and epoch 2 was during surgical preparation. RESULTS: In epoch 1, the incidence of low systolic blood pressure was 5.2% (697 of 13,497), and no association was observed with the fluid fasting time groups: less than 4 h (4.6%, 141 of 3,081), 4 to 8 h (6.0%, 219 of 3,652), 8 to 12 h (4.9%, 124 of 2,526), and more than 12 h (5.0%, 213 of 4,238). In epoch 2, the incidence of low systolic blood pressure was 6.9% (889 of 12,917) and varied across the fasting groups: less than 4 h (5.6%, 162 of 2,918), 4 to 8 h (8.1%, 285 of 3,531), 8 to 12 h (5.9%, 143 of 2,423), and more than 12 h (7.4%, 299 of 4,045); after adjusting for confounders, fasting 4 to 8 h (adjusted odds ratio, 1.33; 95% CI, 1.07 to 1.64; P = 0.009) and greater than 12 h (adjusted odds ratio, 1.28; 95% CI, 1.04 to 1.57; P = 0.018) were associated with significantly higher odds of low systolic blood pressure compared with the group who fasted less than 4 h, whereas the increased odds of low systolic blood pressure associated with fasting 8 to 12 h (adjusted odds ratio, 1.11; 95% CI, 0.87 to 1.42; P = 0.391) was nonsignificant. CONCLUSIONS: Longer durations of clear fluid fasting in anesthetized children were associated with increased risk of postinduction low blood pressure during surgical preparation, although this association appeared nonlinear.


Assuntos
Jejum/efeitos adversos , Hipotensão/etiologia , Hipotensão/fisiopatologia , Cuidados Pré-Operatórios/métodos , Pressão Sanguínea , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Masculino , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Tempo
11.
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
16.
PLoS One ; 15(4): e0231172, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32298292

RESUMO

Arterial hypotension during the early phase of anesthesia can lead to adverse outcomes such as a prolonged postoperative stay or even death. Predicting hypotension during anesthesia induction is complicated by its diverse causes. We investigated the feasibility of developing a machine-learning model to predict postinduction hypotension. Naïve Bayes, logistic regression, random forest, and artificial neural network models were trained to predict postinduction hypotension, occurring between tracheal intubation and incision, using data for the period from between the start of anesthesia induction and immediately before tracheal intubation obtained from an anesthesia monitor, a drug administration infusion pump, an anesthesia machine, and from patients' demographics, together with preexisting disease information from electronic health records. Among 222 patients, 126 developed postinduction hypotension. The random-forest model showed the best performance, with an area under the receiver operating characteristic curve of 0.842 (95% confidence interval [CI]: 0.736-0.948). This was higher than that for the Naïve Bayes (0.778; 95% CI: 0.65-0.898), logistic regression (0.756; 95% CI: 0.630-0.881), and artificial-neural-network (0.760; 95% CI: 0.640-0.880) models. The most important features affecting the accuracy of machine-learning prediction were a patient's lowest systolic blood pressure, lowest mean blood pressure, and mean systolic blood pressure before tracheal intubation. We found that machine-learning models using data obtained from various anesthesia machines between the start of anesthesia induction and immediately before tracheal intubation can predict hypotension occurring during the period between tracheal intubation and incision.


Assuntos
Anestesia Geral/efeitos adversos , Anestésicos/efeitos adversos , Hipotensão/epidemiologia , Aprendizado de Máquina , Modelos Cardiovasculares , Adulto , Idoso , Anestesia Geral/instrumentação , Anestésicos/administração & dosagem , Pressão Arterial/efeitos dos fármacos , Teorema de Bayes , Colecistectomia Laparoscópica/efeitos adversos , Sistemas de Liberação de Medicamentos/estatística & dados numéricos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Hipotensão/etiologia , Intubação Intratraqueal/efeitos adversos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/estatística & dados numéricos , Redes Neurais de Computação , Curva ROC , Estudos Retrospectivos , Medição de Risco/métodos
17.
Br J Anaesth ; 125(1): e28-e37, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32312571

RESUMO

Tracheal intubation in coronavirus disease 2019 (COVID-19) patients creates a risk to physiologically compromised patients and to attending healthcare providers. Clinical information on airway management and expert recommendations in these patients are urgently needed. By analysing a two-centre retrospective observational case series from Wuhan, China, a panel of international airway management experts discussed the results and formulated consensus recommendations for the management of tracheal intubation in COVID-19 patients. Of 202 COVID-19 patients undergoing emergency tracheal intubation, most were males (n=136; 67.3%) and aged 65 yr or more (n=128; 63.4%). Most patients (n=152; 75.2%) were hypoxaemic (Sao2 <90%) before intubation. Personal protective equipment was worn by all intubating healthcare workers. Rapid sequence induction (RSI) or modified RSI was used with an intubation success rate of 89.1% on the first attempt and 100% overall. Hypoxaemia (Sao2 <90%) was common during intubation (n=148; 73.3%). Hypotension (arterial pressure <90/60 mm Hg) occurred in 36 (17.8%) patients during and 45 (22.3%) after intubation with cardiac arrest in four (2.0%). Pneumothorax occurred in 12 (5.9%) patients and death within 24 h in 21 (10.4%). Up to 14 days post-procedure, there was no evidence of cross infection in the anaesthesiologists who intubated the COVID-19 patients. Based on clinical information and expert recommendation, we propose detailed planning, strategy, and methods for tracheal intubation in COVID-19 patients.


Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Intubação Intratraqueal/métodos , Equipamento de Proteção Individual , Pneumonia Viral/terapia , Idoso , China , Infecções por Coronavirus/complicações , Infecções por Coronavirus/prevenção & controle , Feminino , Humanos , Hipotensão/etiologia , Hipóxia/etiologia , Masculino , Pandemias/prevenção & controle , Pneumonia Viral/complicações , Pneumonia Viral/prevenção & controle , Pneumotórax/etiologia , Guias de Prática Clínica como Assunto , Estudos Retrospectivos
18.
Am J Kidney Dis ; 76(3): 331-339, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32331831

RESUMO

BACKGROUND: Most patients receiving maintenance hemodialysis (HD) experience adverse symptoms, which are associated with decreased quality of life. Despite decades of experience, our understanding of causes of HD symptoms remains limited. We aimed to identify modifiable patient- and HD-related predictors of intradialytic symptoms. STUDY DESIGN: Prospective cohort. SETTING & PARTICIPANTS: We leveraged patient-level (n=1,838) and HD session-level (n=64,797) data from the Hemodialysis Trial. EXPOSURE: Pre-HD serum urea nitrogen (SUN) level, pre-HD systolic blood pressure (SBP), intradialytic SBP decline, and ultrafiltration rate (UFR). OUTCOMES: Intra-HD symptoms, including cramps, nausea, chest pain, headache, and lightheadedness. ANALYTICAL APPROACH: Random-effects logistic regression models. RESULTS: Overall, symptoms occurred in 10.7% of HD sessions. Higher pre-HD SUN level (per 10 mg/dL) was associated with higher adjusted odds of muscle cramping and lightheadedness (adjusted ORs [aORs] of 1.20 [95% CI, 1.17-1.22] and 1.13 [95% CI, 1.08-1.18], respectively). SBP decline (from the predialysis value to the dialysis session nadir, per each 10-mm Hg decrease) was associated with greater risk for muscle cramping, headache, chest pain, vomiting, and lightheadedness (the largest aORs were for the 2 latter symptoms: 1.24 [95% CI, 1.20-1.28] and 1.37 [95% CI, 1.33-1.42], respectively). Higher UFR (per 1 mL/kg/h) was associated with greater odds of cramping (aOR, 1.03; 95% CI, 1.02-1.03). Conversely, higher pre-HD SBP (per 10 mm Hg) was associated with reduced risk for vomiting (aOR, 0.88; 95% CI, 0.85-0.92) and lightheadedness (aOR, 0.82; 95% CI, 0.80-0.85). LIMITATIONS: Measured osmolality, dialysate prescription data, and time stamps for symptom occurrence were not available. Clinical trial data may not be broadly generalizable. CONCLUSIONS: Higher pre-HD SUN level, UFR, pre-HD SBP, and SBP decline are independently associated with different patterns of adverse intradialytic symptoms. Recognition that different symptoms may have variable causes may allow tailoring of personalized treatments in future interventional studies.


Assuntos
Diálise Renal/efeitos adversos , Adulto , Idoso , Pressão Sanguínea , Nitrogênio da Ureia Sanguínea , Tontura/epidemiologia , Tontura/etiologia , Feminino , Cefaleia/epidemiologia , Cefaleia/etiologia , Humanos , Hipotensão/epidemiologia , Hipotensão/etiologia , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto/estatística & dados numéricos , Cãibra Muscular/epidemiologia , Cãibra Muscular/etiologia , Náusea/epidemiologia , Náusea/etiologia , Estudos Prospectivos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos
20.
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
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