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1.
Anaesthesia ; 75(1): 109-121, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31531852

RESUMO

Spinal anaesthesia for caesarean section commonly causes maternal hypotension. This systematic review and network meta-analysis compared methods to prevent hypotension in women receiving spinal anaesthesia for caesarean section. We selected randomised controlled trials that compared an intervention to prevent hypotension with another intervention or inactive control by searching MEDLINE and Embase, Web of Science to December 2018. There was no language restriction. Two reviewers extracted data on trial characteristics, methods and outcomes. We assessed risk of bias for individual trials (Cochrane tool) and quality of evidence (GRADE checklist). We assessed 109 trials (8561 women) and 12 different methods that resulted in 30 direct comparisons. Methods ranked by OR (95%CI) from most effective to least effective were: metaraminol 0.11 (0.04-0.26); norepinephrine 0.13 (0.06-0.28); phenylephrine 0.18 (0.11-0.29); leg compression 0.25 (0.14-0.43); ephedrine 0.28 (0.18-0.43); colloid given before induction of anaesthesia 0.38 (0.24-0.61); angiotensin 2, 0.12 (0.02-0.75); colloid given after induction of anaesthesia 0.52 (0.30-0.90); mephentermine 0.09 (0.01-1.30); crystalloid given after induction of anaesthesia 0.78 (0.46-1.31); and crystalloid given before induction of anaesthesia 1.16 (0.76-1.79). Phenylephrine caused maternal bradycardia compared with control, OR (95%CI) 0.23 (0.07-0.79). Ephedrine lowered umbilical artery pH more than phenylephrine, standardised mean difference (95%CI) 0.78 (0.47-1.49). We conclude that vasopressors should be given to healthy women to prevent hypotension during caesarean section with spinal anaesthesia.


Assuntos
Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Cesárea , Hipotensão/prevenção & controle , Vasoconstritores/uso terapêutico , Adulto , Feminino , Humanos , Hipotensão/tratamento farmacológico , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto
2.
Molecules ; 24(15)2019 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-31370142

RESUMO

Hypertension is considered a major public health issue due to its high prevalence and subsequent risk of cardiovascular and kidney diseases. Thus, the search for new antihypertensive compounds remains of great interest. Snake venoms provide an abundant source of lead molecules that affect the cardiovascular system, which makes them prominent from a pharmaceutical perspective. Such snake venom components include bradykinin potentiating peptides (proline-rich oligopeptides), natriuretic peptides, phospholipases A2, serine-proteases and vascular endothelial growth factors. Some heparin binding hypotensive factors, three-finger toxins and 5' nucleotidases can also exert blood pressure lowering activity. Great advances have been made during the last decade regarding the understanding of the mechanism of action of these hypotensive proteins. Bradykinin potentiating peptides exert their action primarily by inhibiting the angiotensin-converting enzyme and increasing the effect of endogenous bradykinin. Snake venom phospholipases A2 are capable of reducing blood pressure through the production of arachidonic acid, a precursor of cyclooxygenase metabolites (prostaglandins or prostacyclin). Other snake venom proteins mimic the effects of endogenous kallikrein, natriuretic peptides or vascular endothelial growth factors. The aim of this work was to review the current state of knowledge regarding snake venom components with potential antihypertensive activity and their mechanisms of action.


Assuntos
Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Hipotensão/tratamento farmacológico , Inibidores da Enzima Conversora de Angiotensina/química , Animais , Anti-Hipertensivos/química , Bradicinina/química , Bradicinina/uso terapêutico , Humanos , Peptídeos/química , Peptídeos/uso terapêutico , Venenos de Serpentes/química
3.
R I Med J (2013) ; 102(6): 44-46, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31398969

RESUMO

We describe a case of disulfiram-ethanol reaction in a patient presenting with altered mental status. The patient was found to be profoundly hypotensive, requiring multiple vasopressor agents. As the symptoms associated with disulfiram reaction are non-specific, it is important to maintain a high level of suspicion for drug reaction when caring for the undifferentiated altered and hypotensive patient.


Assuntos
Dissuasores de Álcool/efeitos adversos , Dissulfiram/efeitos adversos , Etanol/efeitos adversos , Hipotensão/induzido quimicamente , Dissuasores de Álcool/administração & dosagem , Dissulfiram/administração & dosagem , Etanol/administração & dosagem , Feminino , Humanos , Hipotensão/tratamento farmacológico , Pessoa de Meia-Idade , Norepinefrina/uso terapêutico , Vasoconstritores/uso terapêutico , Vasopressinas/uso terapêutico
4.
Am J Health Syst Pharm ; 76(1): 13-16, 2019 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31381098

RESUMO

PURPOSE: Use of the vasodilator midodrine for the treatment of treprostinil-induced hypotension is reported. SUMMARY: Intradialytic hypotension is a common complication of dialysis that increases patient mortality due to suboptimal ultrafiltration and interruption of hemodialysis. Midodrine is an α1 vasoconstrictor commonly used for the treatment of pulmonary arterial hypertension (PAH) and intradialytic hypotension. The safety of midodrine dosing at greater than 30 mg daily has not been established to date. A 49-year-old African-American man with a history of PAH and end-stage renal disease (ESRD) was receiving hemodialysis (HD) 3 times weekly. Subcutaneous treprostinil infusions were initiated for PAH, subsequently causing hypotension, with predialysis blood pressure values as low as 60/50 mm Hg. During a 6-month follow-up period, 38 of 62 dialysis sessions were interrupted or discontinued due to severe intradialytic hypotension. Counteraction of treprostinil effects was achieved by increasing the total daily midodrine dose from 30 mg to 90 mg over 6 months, with no remarkable adverse effects. In previously reported cases, maximum midodrine daily doses of 30 mg in nondialysis patients and 25 mg in patients with ESRD receiving hemodialysis were reported. The patient described here received a total daily dose of 90 mg, including 60 mg administered in divided doses for daily maintenance and 30-mg intradialytic doses; this was the highest daily midodrine dose reported to date. CONCLUSION: A 49-year-old patient tolerated 60-mg daily doses of midodrine along with 30-mg intradialytic doses for the management of treprostinil-induced hypotension and prevention of HD interruption, without adverse effects.


Assuntos
Anti-Hipertensivos/efeitos adversos , Epoprostenol/análogos & derivados , Hipotensão/tratamento farmacológico , Midodrina/administração & dosagem , Diálise Renal/efeitos adversos , Relação Dose-Resposta a Droga , Epoprostenol/efeitos adversos , Humanos , Hipotensão/etiologia , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , /tratamento farmacológico
5.
Medicine (Baltimore) ; 98(33): e16872, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31415426

RESUMO

Patients undergoing surgery and taking angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) are susceptible to complications related to intraoperative hypotension. Perioperative continuation of such medications in patients undergoing colorectal surgery may be associated with more harm than benefit, as these patients are often exposed to other risk factors which may contribute to intraoperative hypotension. Our objectives were to assess the incidence and severity of postinduction hypotension as well as the rates of acute kidney injury (AKI), 30-day all-cause mortality, 30-day readmission, and hospital length of stay in adult patients undergoing colorectal surgery who take ACEi/ARB.We performed a retrospective chart review of patients undergoing colorectal surgery of ≥4 hour duration at a tertiary care academic medical center between January 2011 and November 2016. The preoperative and intraoperative characteristics as well as postoperative outcomes were compared between patients taking ACEi/ARB and patients not taking these medications.Of the 1020 patients meeting inclusion criteria, 174 (17%) were taking either ACEi or ARB before surgery. Patients taking these medications were more likely to receive both postinduction and intraoperative phenylephrine and ephedrine. The incidences of postoperative AKI (P = .35), 30-day all-cause mortality (P = .36), 30-day hospital readmission (P = .45), and hospital length of stay (P = .25), were not significantly different between the 2 groups.Our results support the current recommendation that ACEi/ARB use is probably safe within the colorectal surgery population during the perioperative period. Intraoperative hypotension should be expected and treated with vasopressors.


Assuntos
Antagonistas de Receptores de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Cirurgia Colorretal/efeitos adversos , Hipotensão/induzido quimicamente , Assistência Perioperatória/métodos , Lesão Renal Aguda/induzido quimicamente , Adulto , Estudos de Casos e Controles , Cirurgia Colorretal/mortalidade , Feminino , Humanos , Hipotensão/tratamento farmacológico , Masculino , Estudos Retrospectivos , Vasoconstritores/uso terapêutico
6.
J Pept Sci ; 25(8): e3197, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31264321

RESUMO

Platelet-activating factor (PAF) is known as an important mediator of anaphylaxis and, therefore, may possibly serve as a direct target for anti-anaphylactic drugs. We recently reported that a synthetic N-terminally biotinylated peptide, BP21, alleviates hypothermia and vascular hyperpermeability during anaphylactic reactions in a mouse model of anaphylaxis via the direct binding of a Tyr-Lys-Asp-Gly sequence in the peptide to PAF. In this study, we investigated the effect of BP21 on in vivo anaphylactic hypotension. Results showed that BP21 significantly inhibited anaphylactic hypotension in a dose-dependent manner, with peak severity being reached within 20 minutes. Adrenaline, which is the recommended first line treatment for anaphylactic patients, did not inhibit anaphylactic hypothermia. The combined administration of BP21 with adrenaline inhibited both hypotension and hypothermia, even at both low doses, more effectively compared with solo administration of BP21 or adrenaline. These results suggested that BP21 could potentially be a novel anti-anaphylactic agent for targeting PAF in vivo.


Assuntos
Anafilaxia/tratamento farmacológico , Biotina/análogos & derivados , Proteínas Hemolisinas/uso terapêutico , Hipotensão/tratamento farmacológico , Fragmentos de Peptídeos/uso terapêutico , Animais , Biotina/química , Biotina/metabolismo , Biotina/uso terapêutico , Biotinilação , Proteínas Hemolisinas/química , Proteínas Hemolisinas/metabolismo , Masculino , Camundongos , Camundongos Endogâmicos BALB C , Camundongos Transgênicos , Estrutura Molecular , Fragmentos de Peptídeos/química , Fragmentos de Peptídeos/metabolismo
7.
Am J Health Syst Pharm ; 76(2): 101-107, 2019 Jan 16.
Artigo em Inglês | MEDLINE | ID: mdl-31361800

RESUMO

OBJECTIVE: Clinical data and gaps in knowledge regarding angiotensin II (AT2), which was approved by the Food and Drug Administration in December 2017 via priority review for treatment of septic and other vasodilatory shock, is discussed. SUMMARY: AT2 is an endogenous peptide that raises blood pressure via vasoconstriction and increased aldosterone release. It was previously available but withdrawn from the US market; previous low-quality research describes increases in mean arterial pressure (MAP). The recent approval of AT2 was based on data from a Phase III randomized trial comparing i.v. AT2 (n = 163) with placebo use (n = 158) in patients with vasodilatory shock receiving high doses of other vasopressors. AT2 significantly increased achievement of the primary endpoint, MAP response at 3 hours after the start of infusion, relative to placebo use (69.9% [n = 114] versus 23.4% [n = 37], p < 0.0001). Serious adverse events occurred in 60.7% (n = 99) and 67.1% (n = 106) of patients treated with AT2 and placebo recipients, respectively, including venous and arterial thromboembolic events (12.9% [n = 21] and 5.1% [n = 8], respectively). No significant effects of AT2 on 7- or 28-day mortality were seen among all patients in the ATHOS-3 trial. However, post hoc analyses suggested that AT2 may reduce mortality in patients with low baseline AT2 levels, exaggerated response to AT2, and acute kidney injury receiving concomitant renal replacement therapy. Overall, due to shortcomings of the ATHOS-3 trial data and the absence of confirmatory studies, the optimal place in therapy of AT2 for vasodilatory shock cannot be determined with confidence. CONCLUSION: Intravenous AT2 represents a novel treatment strategy for refractory septic or other vasodilatory shock, although findings of safety and efficacy have not been replicated and the drug's optimal place in therapy is uncertain.


Assuntos
Angiotensina II/administração & dosagem , Hipotensão/tratamento farmacológico , Choque Séptico/tratamento farmacológico , Vasoconstritores/administração & dosagem , Administração Intravenosa , Angiotensina II/efeitos adversos , Pressão Sanguínea/efeitos dos fármacos , Humanos , Hipotensão/mortalidade , Hipotensão/fisiopatologia , Fluxo Sanguíneo Regional/efeitos dos fármacos , Fluxo Sanguíneo Regional/fisiologia , Choque Séptico/mortalidade , Choque Séptico/fisiopatologia , Resultado do Tratamento , Vasoconstritores/efeitos adversos
8.
Phytomedicine ; 63: 152984, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31255877

RESUMO

BACKGROUND: A fixed combination of hawthorn and camphor (Korodin Herz-Kreislauf-Tropfen®) has been used in the therapy of hypotension for decades. Although its efficacy was evaluated in clinical trials, these studies have not been critically assessed in meta-analyses. PURPOSE: To systematically evaluate the efficacy of a fix combination of camphor and hawthorn extract (Korodin®) on blood pressure and cognition compared to placebo, in a meta-analysis based on randomized controlled trials (RCTs). STUDY DESIGN: The meta-analysis was carried out following the PRISMA guidelines, using the PICO format, and it was registered in the PROSPERO register. METHODS: The Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web of Science databases were searched for relevant studies. Placebo-controlled clinical studies involving adult patients receiving a fix combination of hawthorn extract and camphor were included. No language or publication year restrictions were applied. RESULTS: Four randomized trials including a total of 221 patients were pooled for statistical analysis. According to the present meta-analysis, the fixed combination of hawthorn and camphor significantly increases systolic and diastolic blood pressure compared to placebo (p-values: 0.017 and 0.049, respectively) and had a beneficial, but not statistically significant effect on the cognitive performance in the connect-the-numbers test (p-value: 0.071). CONCLUSION: Korodin® is an effective and presumably safe complementary therapy for the treatment of hypotension. Its blood pressure increasing effect is confirmed; however, the evidence supporting its use is very limited. The optimum dose and duration of treatment is still unclear. The comprehensive evaluation of efficacy and safety is required in further, high-quality clinical studies, involving larger patient populations and comparable endpoints.


Assuntos
Pressão Sanguínea/efeitos dos fármacos , Cânfora/farmacologia , Crataegus/química , Extratos Vegetais/farmacologia , Adulto , Cognição/efeitos dos fármacos , Humanos , Hipotensão/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
10.
Anaesthesia ; 74(7): 850-855, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31044424

RESUMO

Phenylephrine is currently the vasopressor of choice during elective caesarean section, but it can cause reflex bradycardia. Noradrenaline, a potent α-agonist and weak ß-agonist, may be associated with a lower incidence of bradycardia. However, comparative information is limited. This double-blind randomised controlled trial compared the effects of 100 µg phenylephrine and 5 µg noradrenaline administered as boluses for the treatment of postspinal hypotension during elective caesarean section in women with an uncomplicated singleton pregnancy. Hypotension was defined as a decrease of ≥ 20% from baseline systolic arterial pressure, or an absolute value < 100 mmHg. Ninety women were included in the study. The primary outcome was the incidence of maternal bradycardia < 60 beats.min-1 . There was no difference in the incidence of bradycardia (37.8% with phenylephrine vs. 22.2% with noradrenaline; p = 0.167), number of hypotensive episodes, number of boluses required to treat the first hypotensive episode or reactive hypertension. The total number of boluses used was higher in the phenylephrine group (p = 0.01). Maternal heart rate at 1 min after vasopressor administration was non-significantly lower using phenylephrine vs. noradrenaline (p = 0.034, considering p < 0.01 as statistically significant). The umbilical artery pH was higher using phenylephrine than with noradrenaline (p = 0.034). In conclusion, both vasopressors reversed postspinal hypotension without a statistically significant difference in maternal bradycardia. However, in view of the lower umbilical artery pH when using noradrenaline, further research is warranted to study its placental transfer and fetal metabolic effects.


Assuntos
Raquianestesia/efeitos adversos , Cesárea , Hipotensão/tratamento farmacológico , Norepinefrina/uso terapêutico , Fenilefrina/uso terapêutico , Vasoconstritores/uso terapêutico , Adulto , Anestesia Obstétrica/efeitos adversos , Método Duplo-Cego , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Hipotensão/etiologia , Infusões Intravenosas , Norepinefrina/administração & dosagem , Fenilefrina/administração & dosagem , Gravidez , Resultado do Tratamento , Vasoconstritores/administração & dosagem
11.
Clin Perinatol ; 46(2): 273-290, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31010560

RESUMO

There is a distinct lack of age-appropriate cardiotonic drugs, and adult derived formulations continue to be administered, without evidence-based knowledge on their dosing, safety, efficacy, and long-term effects. Dopamine remains the most commonly studied and prescribed cardiotonic drug in the neonatal intensive care unit (NICU), but evidence of its effect on endorgan perfusion still remains. Unlike adult and pediatric critical care, there are significant gaps in our knowledge on the use of various cardiotonic drugs in various forms of circulatory failure in the NICU.


Assuntos
Cardiotônicos/uso terapêutico , Hipotensão/tratamento farmacológico , Choque/tratamento farmacológico , Vasoconstritores/uso terapêutico , Corticosteroides/uso terapêutico , Asfixia Neonatal/complicações , Dobutamina/uso terapêutico , Dopamina/uso terapêutico , Cardiopatias Congênitas/complicações , Humanos , Hipotensão/etiologia , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Milrinona/uso terapêutico , Sepse Neonatal/complicações , Norepinefrina/uso terapêutico , Síndrome da Persistência do Padrão de Circulação Fetal/complicações , Choque/etiologia , Simendana/uso terapêutico , Vasopressinas/uso terapêutico
14.
Am J Emerg Med ; 37(6): 1217.e1-1217.e2, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30952604

RESUMO

We report here the case of a patient with perindopril intoxication inducing severe bradycardia together with a profound hypotension. Initiation of a naloxone infusion completely resolved those symptoms. As a consequence, we could recommend as a first step the use of naloxone in order to prevent the use of more invasive therapeutic tools.


Assuntos
Inibidores da Enzima Conversora de Angiotensina/envenenamento , Bradicardia/tratamento farmacológico , Hipotensão/tratamento farmacológico , Naloxona/uso terapêutico , Perindopril/envenenamento , Pressão Sanguínea/efeitos dos fármacos , Bradicardia/induzido quimicamente , Humanos , Hipotensão/induzido quimicamente , Masculino , Pessoa de Meia-Idade
15.
Crit Care ; 23(1): 118, 2019 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-30987647

RESUMO

BACKGROUND: We hypothesized that the cardiovascular responses to Surviving Sepsis Guidelines (SSG)-defined resuscitation are predictable based on the cardiovascular state. METHODS: Fifty-five septic patients treated by SSG were studied before and after volume expansion (VE), and if needed norepinephrine (NE) and dobutamine. We measured mean arterial pressure (MAP), cardiac index (CI), and right atrial pressure (Pra) and calculated pulse pressure and stroke volume variation (PPV and SVV), dynamic arterial elastance (Eadyn), arterial elastance (Ea) and left ventricular (LV) end-systolic elastance (Ees), Ees/Ea (VAC), LV ejection efficiency (LVeff), mean systemic pressure analogue (Pmsa), venous return pressure gradient (Pvr), and cardiac performance (Eh), using standard formulae. RESULTS: All patients were hypotensive (MAP 56.8 ± 3.1 mmHg) and tachycardic (113.1 ± 7.5 beat min-1), with increased lactate levels (lactate = 5.0 ± 4.2 mmol L-1) with a worsened VAC. CI was variable but > 2 L min-1 M-2 in 74%. Twenty-eight-day mortality was 48% and associated with admission lactate, blood urea nitrogen (BUN), and creatinine levels but not cardiovascular state. In all patients, both MAP and CI improved following VE, as well as cardiac contractility (Ees). Fluid administration improved Pra, Pmsa, and Pvr in all patients, whereas both HR and Ea decreased after VE, thus normalizing VAC. CI increases were proportional to baseline PPV and SVV. CI increases proportionally decreased PPV and SVV. VE increased MAP > 65 mmHg in 35/55 patients. MAP responders had higher PPV, SVV, and Eadyn than non-responders. NE was given to 20/55 patients in septic shock, but increased MAP > 65 mmHg in only 12. NE increased Ea, Eadyn, Pra, Pmsa, and VAC while decreasing HR, PPV, SVV, and LVeff. MAP responders had higher pre-NE Ees and lower VAC. Dobutamine was given to 6/8 patients who remained hypotensive following NE. It increased Ees, MAP, CI, and LVeff, while decreasing HR, Pra, and VAC. At all times and all steps of the protocol, CI changes were proportional to Pvr changes independent of treatment. CONCLUSIONS: The cardiovascular response to SSG-based resuscitation is highly heterogeneous but predictable from pre-treatment measures of cardiovascular state.


Assuntos
Fenômenos Fisiológicos Cardiovasculares , Ressuscitação/normas , Sepse/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Débito Cardíaco/fisiologia , Cardiotônicos/uso terapêutico , Dobutamina/uso terapêutico , Feminino , Frequência Cardíaca/efeitos dos fármacos , Hemodinâmica/efeitos dos fármacos , Humanos , Hipotensão/tratamento farmacológico , Hipotensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Norepinefrina/uso terapêutico , Ressuscitação/métodos , Ressuscitação/estatística & dados numéricos , Sepse/tratamento farmacológico , Choque Séptico/tratamento farmacológico , Choque Séptico/fisiopatologia , Estatísticas não Paramétricas , Volume Sistólico/fisiologia , Vasoconstritores/uso terapêutico
16.
Br J Anaesth ; 122(5): 605-612, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30916032

RESUMO

BACKGROUND: During general anaesthesia, intraoperative hypotension (IOH), defined as a mean arterial pressure (MAP) reduction of > 20%, is frequent and may lead to complications. Pulse oximetry is mandatory in the operating room, making the photoplethysmographic signal and parameters, such as relative dicrotic notch height (Dicpleth) or perfusion index (PI), readily available. The purpose of this study was to investigate whether relative variations of Dicpleth and PI could detect IOH during anaesthesia induction, and to follow their variations during vasopressor boluses. METHODS: MAP, Dicpleth, and PI were monitored at 1-min intervals during target control induction of anaesthesia with propofol and remifentanil in 61 subjects. Vasopressor infusion (norepinephrine or phenylephrine) was performed when hypotension occurred according to the decision of the physician. RESULTS: The delta in Dicpleth and PI accurately detected IOH, with areas under the receiver operating characteristic curves (AUC) of 0.86 and 0.83, respectively. The optimal thresholds were -19% (sensitivity 79%; specificity 84%) and 51% (sensitivity 82%; specificity 74%) for ΔDicpleth and ΔPI, respectively. There was no difference between the ROC of ΔDicpleth and ΔPI (P=0.22). Combining both ΔDicpleth and ΔPI further improved the hypotension detection power (AUC=0.91) with a sensitivity and specificity of 84%. MAP variations were correlated with ΔDicpleth and ΔPI during vasopressor infusion (r=0.73 and -0.62, respectively; P<0.001). CONCLUSIONS: The relative variation in Dicpleth and PI derived from the photoplethysmographic signal can be used as a non invasive, continuous, and simple tool to detect intraoperative hypotension, and to track the vascular response to vasoconstrictor drugs during induction of general anaesthesia. CLINICAL TRIAL REGISTRATION: NCT03756935.


Assuntos
Anestesia Geral/efeitos adversos , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/métodos , Adulto , Pressão Sanguínea/efeitos dos fármacos , Determinação da Pressão Arterial/métodos , Feminino , Humanos , Hipotensão/induzido quimicamente , Hipotensão/tratamento farmacológico , Hipotensão/fisiopatologia , Cuidados Intraoperatórios/métodos , Complicações Intraoperatórias/induzido quimicamente , Complicações Intraoperatórias/tratamento farmacológico , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Fotopletismografia/métodos , Estudo de Prova de Conceito , Estudos Prospectivos , Sensibilidade e Especificidade , Vasoconstritores/farmacologia , Vasoconstritores/uso terapêutico
17.
J Med Econ ; 22(7): 645-651, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30838899

RESUMO

Objective: Recent studies indicate intraoperative hypotension, common in non-cardiac surgical patients, is associated with myocardial injury, acute kidney injury, and mortality. This study extends on these findings by quantifying the association between intraoperative hypotension and hospital expenditures in the US. Methods: Monte Carlo simulations (10,000 trial per simulation) based on current epidemiological and cost outcomes literature were developed for both acute kidney injury (AKI) and myocardial injury in non-cardiac surgery (MINS). For AKI, three models with different epidemiological assumptions (two models based on observational studies and one model based on a randomized control trial [RCT]) estimate the marginal probability of AKI conditional on intraoperative hypotension status. Similar models are also developed for MINS (except for the RCT case). Marginal probabilities of AKI and MINS sequelae (myocardial infarction, congestive heart failure, stroke, cardiac catheterization, and percutaneous coronary intervention) are multiplied by marginal cost estimates for each outcome to evaluate costs associated with intraoperative hypotension. Results: The unadjusted (adjusted) model found hypotension control lowers the absolute probability of AKI by 2.2% (0.7%). Multiplying these probabilities by the marginal cost of AKI, the unadjusted (adjusted) AKI model estimated a cost reduction of $272 [95% CI = $223-$321] ($86 [95% CI = $47-$127]) per patient. The AKI model based on relative risks from the RCT had a mean cost reduction estimate of $281 (95% CI = -$346-$750). The unadjusted (adjusted) MINS model yielded a cost reduction of $186 [95% CI = $73-$393] ($33 [95% CI = $10-$77]) per patient. Conclusions: The model results suggest improved intraoperative hypotension control in a hospital with an annual volume of 10,000 non-cardiac surgical patients is associated with mean cost reductions ranging from $1.2-$4.6 million per year. Since the magnitude of the RCT mean estimate is similar to the unadjusted observational model, the institutional costs are likely at the upper end of this range.


Assuntos
Simulação por Computador , Custos Hospitalares , Hipotensão/economia , Complicações Intraoperatórias/economia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/economia , Lesão Renal Aguda/terapia , Idoso , Feminino , Humanos , Hipotensão/diagnóstico , Hipotensão/tratamento farmacológico , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/terapia , Masculino , Pessoa de Meia-Idade , Método de Monte Carlo , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/economia , Infarto do Miocárdio/terapia , Medição de Risco , Procedimentos Cirúrgicos Operatórios/economia , Procedimentos Cirúrgicos Operatórios/métodos , Estados Unidos
18.
Med Sci Monit ; 25: 1093-1101, 2019 Feb 09.
Artigo em Inglês | MEDLINE | ID: mdl-30738019

RESUMO

BACKGROUND This study aimed to compare the efficacy and safety of bolus norepinephrine, phenylephrine, and ephedrine in parturient with preeclampsia who had hypotension during cesarean delivery under spinal anesthesia. MATERIAL AND METHODS One hundred and sixty-six parturient women with preeclampsia who had a baseline systolic blood pressure (SBP) <80% during spinal anesthesia for cesarean section were divided into three treatment groups; bolus norepinephrine 4 µg (group N) (n=56), phenylephrine 50 µg (group P) (n=55), and ephedrine 4 mg (group E) (n=55). Primary outcomes included overall SBP and heart rate (HR) until delivery. Secondary outcomes included the incidence of tachycardia (HR >120 bpm), bradycardia (HR <60 bpm), hypertension (SBP >120% baseline), number of boluses of vasopressor required and episodes of hypotension, maternal side effects, and neonatal outcome. RESULTS Overall HR in group N was significantly increased compared with group P (80.5±12 vs. 76.6±6.9 bpm; P=0.04), and significantly lower compared with group E (80.5±12 vs. 84.9±7.1 bpm; P=0.02). Parturients in group N had fewer episodes of bradycardia compared with group P (3.6% vs. 21.8%; RR=0.26l; 95% CI, 0.07-0.73; P=0.004) and fewer episodes of tachycardia compared with group E (16.1% vs. 36.4%; RR 0.54; 95% CI, 0.29-0.90; P=0.02). CONCLUSIONS A bolus dose of norepinephrine showed similar efficacy to phenylephrine but improved maternal and neonatal safety in parturients with preeclampsia with hypotension during cesarean section under spinal anesthesia.


Assuntos
Hipotensão/tratamento farmacológico , Vasoconstritores/uso terapêutico , Adulto , Raquianestesia , Pressão Sanguínea , Cesárea , China , Efedrina/administração & dosagem , Efedrina/uso terapêutico , Feminino , Frequência Cardíaca , Humanos , Norepinefrina/administração & dosagem , Norepinefrina/uso terapêutico , Parto , Fenilefrina/administração & dosagem , Fenilefrina/uso terapêutico , Pré-Eclâmpsia/tratamento farmacológico , Gravidez , Complicações na Gravidez/tratamento farmacológico , Resultado do Tratamento
19.
Am J Respir Crit Care Med ; 199(9): 1097-1105, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30704260

RESUMO

Rationale: Recent retrospective evidence suggests the efficacy of early norepinephrine administration during resuscitation; however, prospective data to support this assertion are scarce. Objectives: To conduct a phase II trial evaluating the hypothesis that early low-dose norepinephrine in adults with sepsis with hypotension increases shock control by 6 hours compared with standard care. Methods: This single-center, randomized, double-blind, placebo-controlled clinical trial was conducted at Siriraj Hospital, Bangkok, Thailand. The study enrolled 310 adults diagnosed with sepsis with hypotension. The patients were randomly divided into two groups: early norepinephrine (n = 155) and standard treatment (n = 155). The primary outcome was shock control rate (defined as achievement of mean arterial blood pressure ≥65 mm Hg, with urine flow ≥0.5 ml/kg/h for 2 consecutive hours, or decreased serum lactate ≥10% from baseline) by 6 hours after diagnosis. Measurements and Main Results: The patients in both groups were well matched in background characteristics and disease severity. Median time from emergency room arrival to norepinephrine administration was significantly shorter in the early norepinephrine group (93 vs. 192 min; P < 0.001). Shock control rate by 6 hours was significantly higher in the early norepinephrine group (118/155 [76.1%] vs. 75/155 [48.4%]; P < 0.001). The 28-day mortality was not different between groups: 24/155 (15.5%) in the early norepinephrine group versus 34/155 (21.9%) in the standard treatment group (P = 0.15). The early norepinephrine group was associated with lower incidences of cardiogenic pulmonary edema (22/155 [14.4%] vs. 43/155 [27.7%]; P = 0.004) and new-onset arrhythmia (17/155 [11%] vs. 31/155 [20%]; P = 0.03). Conclusions: Early norepinephrine was significantly associated with increased shock control by 6 hours. Further studies are needed before this approach is introduced in clinical resuscitation practice. Clinical trial registered with www.clinicaltrials.gov (NCT01945983) (CENSER trial).


Assuntos
Norepinefrina/uso terapêutico , Ressuscitação/métodos , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico , Idoso , Método Duplo-Cego , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Hipotensão/tratamento farmacológico , Hipotensão/etiologia , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem , Choque Séptico/complicações , Choque Séptico/terapia , Vasoconstritores/administração & dosagem
20.
JAMA ; 321(5): 473-483, 2019 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-30721296

RESUMO

Importance: Intraoperative electroencephalogram (EEG) waveform suppression, often suggesting excessive general anesthesia, has been associated with postoperative delirium. Objective: To assess whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium. Design, Setting, and Participants: Randomized clinical trial of 1232 adults aged 60 years and older undergoing major surgery and receiving general anesthesia at Barnes-Jewish Hospital in St Louis. Recruitment was from January 2015 to May 2018, with follow-up until July 2018. Interventions: Patients were randomized 1:1 (stratified by cardiac vs noncardiac surgery and positive vs negative recent fall history) to receive EEG-guided anesthetic administration (n = 614) or usual anesthetic care (n = 618). Main Outcomes and Measures: The primary outcome was incident delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration, EEG suppression, and hypotension. Adverse events included undesirable intraoperative movement, intraoperative awareness with recall, postoperative nausea and vomiting, medical complications, and death. Results: Of the 1232 randomized patients (median age, 69 years [range, 60 to 95]; 563 women [45.7%]), 1213 (98.5%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 157 of 604 patients (26.0%) in the guided group and 140 of 609 patients (23.0%) in the usual care group (difference, 3.0% [95% CI, -2.0% to 8.0%]; P = .22). Median end-tidal volatile anesthetic concentration was significantly lower in the guided group than the usual care group (0.69 vs 0.80 minimum alveolar concentration; difference, -0.11 [95% CI, -0.13 to -0.10), and median cumulative time with EEG suppression was significantly less (7 vs 13 minutes; difference, -6.0 [95% CI, -9.9 to -2.1]). There was no significant difference between groups in the median cumulative time with mean arterial pressure below 60 mm Hg (7 vs 7 minutes; difference, 0.0 [95% CI, -1.7 to 1.7]). Undesirable movement occurred in 137 patients (22.3%) in the guided and 95 (15.4%) in the usual care group. No patients reported intraoperative awareness. Postoperative nausea and vomiting was reported in 48 patients (7.8%) in the guided and 55 patients (8.9%) in the usual care group. Serious adverse events were reported in 124 patients (20.2%) in the guided and 130 (21.0%) in the usual care group. Within 30 days of surgery, 4 patients (0.65%) in the guided group and 19 (3.07%) in the usual care group died. Conclusions and Relevance: Among older adults undergoing major surgery, EEG-guided anesthetic administration, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support the use of EEG-guided anesthetic administration for this indication. Trial Registration: ClinicalTrials.gov Identifier: NCT02241655.


Assuntos
Anestésicos Gerais/administração & dosagem , Eletroencefalografia , Delírio do Despertar/prevenção & controle , Monitorização Intraoperatória/métodos , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Anestesia Geral/efeitos adversos , Anestésicos Gerais/efeitos adversos , Cardiotônicos/uso terapêutico , Delírio do Despertar/epidemiologia , Feminino , Humanos , Hipotensão/induzido quimicamente , Hipotensão/tratamento farmacológico , Incidência , Complicações Intraoperatórias/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Fenilefrina/uso terapêutico , Náusea e Vômito Pós-Operatórios , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/mortalidade
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