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1.
BMJ Case Rep ; 14(1)2021 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-33509857

RESUMO

Takotsubo cardiomyopathy (TCM) associated with left ventricular outflow tract (LVOT) obstruction in the event of an ST-elevation myocardial infarction (STEMI) is a rare cause of hypotension during percutaneous coronary intervention (PCI). Herein, we describe a 57-year-old woman who presented with STEMI and underwent PCI. She developed hypotension which worsened during inotropic therapy. Echocardiography revealed evidence of LVOT obstruction in the setting of TCM. Therefore, inotropic support was promptly discontinued. Beta blockers and phenylephrine were rapidly administrated, resulting in improved blood pressure and stabilisation of the patient.


Assuntos
Hipotensão/etiologia , Complicações Intraoperatórias/etiologia , Intervenção Coronária Percutânea , Complicações Pós-Operatórias/etiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Cardiomiopatia de Takotsubo/complicações , Obstrução do Fluxo Ventricular Externo/complicações , Antagonistas Adrenérgicos beta/uso terapêutico , Cardiotônicos/efeitos adversos , Angiografia Coronária , Stents Farmacológicos , Ecocardiografia , Feminino , Ventrículos do Coração , Humanos , Hipotensão/tratamento farmacológico , Complicações Intraoperatórias/tratamento farmacológico , Pessoa de Meia-Idade , Fenilefrina/uso terapêutico , Complicações Pós-Operatórias/tratamento farmacológico , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Cardiomiopatia de Takotsubo/diagnóstico por imagem , Trombectomia , Trombose , Vasoconstritores/uso terapêutico , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem
2.
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
3.
Am J Obstet Gynecol ; 223(5): 747.e1-747.e13, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32791121

RESUMO

BACKGROUND: Maternal hypotension after spinal anesthesia, and time from anesthesia to delivery, are potentially modifiable risk factors for neonatal acidosis. OBJECTIVE: This study aimed to examine the relationship between the time from spinal anesthesia to delivery and spinal hypotension in planned cesarean deliveries and their effect on neonatal outcome, primarily neonatal acidosis. STUDY DESIGN: We performed a retrospective analysis of women with singleton pregnancy undergoing spinal anesthesia for planned cesarean delivery between 37 0/7 and 41 6/7 weeks' gestation using electronic medical records. The occurrence of spinal hypotension and anesthesia-to-incision and incision-to-delivery intervals (minutes) were the primarily studied variables. In addition, spinal hypotension index was developed to account for the duration and magnitude of maternal hypotension. The 90th percentile for the spinal hypotension index defined the sustained spinal hypotension group. The primary outcome was neonatal acidosis (pH of ≤7.1 or base deficit of ≥12.0). The odds ratios were calculated using univariate and multivariate logistic regression models. The multivariate analysis included sporadic spinal hypotension or sustained spinal hypotension, use of vasopressor treatment, and anesthesia-to-incision and incision-to-delivery intervals. RESULTS: We included 3150 women in the study. Notably, 43.4% experienced at least 1 event of spinal hypotension (sporadic) and 14.8% experienced sustained spinal hypotension. Neonatal acidosis occurred in 3.4% cases of sporadic spinal hypotension (odds ratio, 1.83; 95% confidence interval, 2.27-2.87) and in 5.8% cases of sustained hypotension (odds ratio, 3.00; 95% confidence interval, 1.87-4.80). Both anesthesia-to-incision and incision-to-delivery intervals were significantly associated with neonatal acidosis as follows: at 90th percentile cutoff, the odds ratios for neonatal acidosis were 3.82 (95% confidence interval, 2.03-7.19) and 2.94 (95% confidence interval, 1.70-5.10), respectively. The use of ephedrine (odds ratio, 2.42; 95% confidence interval, 1.35-4.32) but not phenylephrine (odds ratio, 0.76; 95% confidence interval, 0.34-1.72) treatment was also associated with more cases of neonatal acidosis. The woman's age, gestational age, neonatal birthweight, fetal presentation, and the number of previous cesarean deliveries were not associated with neonatal acidosis. In multivariate analysis, anesthesia-to-incision and incision-to-delivery intervals, use of vasopressor treatment, and sustained spinal hypotension were independently associated with neonatal acidosis. After adjustment, the risk for neonatal acidosis did not increase in women who experienced sporadic spinal hypotension only. Neither neonatal acidosis nor the primary research variables were associated with neonatal complications such as transient tachypnea of the newborn, respiratory distress, or admission to the neonatal unit. CONCLUSION: Neonatal acidosis in planned cesarean delivery was common. However, serious perinatal consequences were rare. The adverse effects of sustained spinal hypotension and prolonged anesthesia-to-incision and incision-to-delivery intervals on neonatal acid-base balance were additive. This supports the adoption of prevention strategies for spinal hypotension, which is widely evidenced based on the obstetrical anesthesia literature, but still not universally used. Whether the reduction in intraoperative time intervals would benefit the neonate should be determined by future prospective studies.


Assuntos
Acidose/epidemiologia , Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Cesárea/métodos , Hipotensão/etiologia , Doenças do Recém-Nascido/epidemiologia , Vasoconstritores/uso terapêutico , Adulto , Índice de Apgar , Apresentação Pélvica , Recesariana/métodos , Efedrina/uso terapêutico , Feminino , Macrossomia Fetal , Humanos , Hipotensão/tratamento farmacológico , Recém-Nascido , Terapia Intensiva Neonatal/estatística & dados numéricos , Análise Multivariada , Fenilefrina/uso terapêutico , Gravidez , Síndrome do Desconforto Respiratório do Recém-Nascido/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Taquipneia Transitória do Recém-Nascido/epidemiologia
4.
Ann Vasc Surg ; 69: 182-189, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32502683

RESUMO

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


Assuntos
Pressão Sanguínea , Endarterectomia das Carótidas/efeitos adversos , Hipertensão/etiologia , Hipotensão/etiologia , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Bases de Dados Factuais , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Hipotensão/diagnóstico , Hipotensão/tratamento farmacológico , Hipotensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Vasoconstritores/uso terapêutico
6.
PLoS One ; 15(5): e0232830, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32407353

RESUMO

During general anesthesia (GA), direct analysis of arterial pressure or aortic flow waveforms may be inconclusive in complex situations. Patient-specific biomechanical models, based on data obtained during GA and capable to perform fast simulations of cardiac cycles, have the potential to augment hemodynamic monitoring. Such models allow to simulate Pressure-Volume (PV) loops and estimate functional indicators of cardiovascular (CV) system, e.g. ventricular-arterial coupling (Vva), cardiac efficiency (CE) or myocardial contractility, evolving throughout GA. In this prospective observational study, we created patient-specific biomechanical models of heart and vasculature of a reduced geometric complexity for n = 45 patients undergoing GA, while using transthoracic echocardiography and aortic pressure and flow signals acquired in the beginning of GA (baseline condition). If intraoperative hypotension (IOH) appeared, diluted norepinephrine (NOR) was administered and the model readjusted according to the measured aortic pressure and flow signals. Such patients were a posteriori assigned into a so-called hypotensive group. The accuracy of simulated mean aortic pressure (MAP) and stroke volume (SV) at baseline were in accordance with the guidelines for the validation of new devices or reference measurement methods in all patients. After NOR administration in the hypotensive group, the percentage of concordance with 10% exclusion zone between measurement and simulation was >95% for both MAP and SV. The modeling results showed a decreased Vva (0.64±0.37 vs 0.88±0.43; p = 0.039) and an increased CE (0.8±0.1 vs 0.73±0.11; p = 0.042) in hypotensive vs normotensive patients. Furthermore, Vva increased by 92±101%, CE decreased by 13±11% (p < 0.001 for both) and contractility increased by 14±11% (p = 0.002) in the hypotensive group post-NOR administration. In this work we demonstrated the application of fast-running patient-specific biophysical models to estimate PV loops and functional indicators of CV system using clinical data available during GA. The work paves the way for model-augmented hemodynamic monitoring at operating theatres or intensive care units to enhance the information on patient-specific physiology.


Assuntos
Anestesia Geral/métodos , Pressão Arterial/fisiologia , Débito Cardíaco/fisiologia , Monitorização Hemodinâmica/métodos , Hipotensão/fisiopatologia , Modelos Cardiovasculares , Volume Sistólico/fisiologia , Algoritmos , Fenômenos Biomecânicos , Pressão Sanguínea , Feminino , Humanos , Hipotensão/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem , Estudo de Prova de Conceito , Estudos Prospectivos , Vasoconstritores/administração & dosagem
8.
PLoS One ; 15(1): e0227410, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31914454

RESUMO

BACKGROUND: Effectiveness of controlled hypotension has been proven in alleviating intraoperative bleeding. Many recent studies emphasized the efficacy of dexmedetomidine and magnesium in providing controlled hypotension during various surgeries. The present meta-analysis of randomized controlled trials (RCTs) was performed to evaluate comprehensively the effects and safety of these two medications. METHODS: Literature search was performed in four databases from inception to April 2019. All RCTs that used dexmedetomidine and magnesium as hypotensive agents were enrolled. The outcomes contained bleeding condition of surgical site, hemodynamic parameters, duration of surgeries, number of patients requiring opioid/analgesia administration, recovery period, and adverse events emerged during surgeries. RESULTS: Ten studies with 663 patients met with our inclusion criteria. The results indicated that both bleeding score and values of mean arterial pressure (MAP) and heart rate (HR) were significantly lower in patients receiving dexmedetomidine (SMD 1.65 with 95% CI [0.90,2.41], P<0.00001) compared to the patients receiving magnesium. The effect in decreasing the necessity of using opioid/analgesia was affirmative in dexmedetomidine group (29.13% with magnesium vs 10.78% with dexmedetomidine), and the condition was more favorable in magnesium group in reducing recovery period (SMD -1.98 with 95% CI [-4.27,0.30], P = 0.09). Compared with magnesium, using of dexmedetomidine was associated with higher incidence of bradycardia but lower incidence of nausea and vomiting. CONCLUSION: Compared with magnesium, dexmedetomidine is more effective to provide promising surgical field condition, favorable controlled hypotension, and less necessity of opioid or analgesia administration. But long recovery period and high-probability bradycardia should be deliberated.


Assuntos
Bases de Dados Factuais , Dexmedetomidina/uso terapêutico , Hipotensão/tratamento farmacológico , Sulfato de Magnésio/uso terapêutico , Procedimentos Cirúrgicos Operatórios , Dexmedetomidina/efeitos adversos , Humanos , Hipotensão/fisiopatologia , Sulfato de Magnésio/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto
9.
Ann Pharmacother ; 54(7): 706-714, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31958982

RESUMO

Objective: To summarize literature evaluating vasopressin use, focusing on clinical controversies regarding initiation, dosing, and discontinuation and interaction of vasopressin with other therapies in septic shock patients. Data Sources: A PubMed English-language literature search (January 2008 to December 2019) was performed using these terms: arginine vasopressin, septic, shock, and sepsis. Citations, including controlled trials, observational studies, review articles, guidelines, and consensus statements, were reviewed. Study Selection and Data Extraction: Relevant clinical data focusing on specific controversial questions regarding the utility of vasopressin in patients with septic shock were narratively summarized. Data Synthesis: Current literature does not strongly support the use of vasopressin as a first-line initial therapy for septic shock. Additionally, there are conflicting data for weight-based dosing of vasopressin in overweight patients. Evidence for vasopressin renal protection and interaction with corticosteroids is minimal. However, vasopressin has the ability to reduce catecholamine requirements in septic shock patients and may provide a mortality benefit in specific subgroups. Discontinuation of vasopressin last, not second to last, in resolving septic shock may reduce hypotension development. Relevance to Patient Care and Clinical Practice: This review addresses specific clinical controversies that drive vasopressin use in septic shock patients in real-world practice. Conclusion: Vasopressin should remain second-line adjunct to norepinephrine to augment mean arterial pressures. Dosing should be initiated at 0.03 U/min, and higher doses offer minimal benefit. There are conflicting data on the impact of weight on vasopressin response. Studies have failed to show renal benefit with vasopressin use or an interaction with corticosteroid therapy.


Assuntos
Arginina Vasopressina/uso terapêutico , Hipotensão/tratamento farmacológico , Norepinefrina/uso terapêutico , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico , Arginina Vasopressina/administração & dosagem , Arginina Vasopressina/efeitos adversos , Pressão Arterial/efeitos dos fármacos , Peso Corporal , Humanos , Norepinefrina/administração & dosagem , Norepinefrina/efeitos adversos , Guias de Prática Clínica como Assunto , Vasoconstritores/administração & dosagem , Vasoconstritores/efeitos adversos
10.
Am J Emerg Med ; 38(5): 1046.e5-1046.e7, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31952869

RESUMO

BACKGROUND: Local anesthetic systemic toxicity characteristically occurs after inadvertent intravascular injection of local anesthetics; however, it is unclear if similar symptoms arise after intrathecal adminstration. Intrathecal use of local anesthetics for chronic pain is increasing and carries a potential risk of toxicity. Experience with the presenting symptoms and appropriate treatment for intrathecal local anesthetic toxicity is limited. CASE STUDY: A 74-year-old woman with an intrathecal bupivacaine/morphine pump developed lower extremity sensory neuropathy followed by obtundation, hypotension, and lower extremity flaccidity after an intrathecal pump refill. Her condition evolved to status epilepticus (SE) refractory to standard treatment. Intravenous fat emulsion (IFE) was administered, but was not immediately effective thus necessitating phenobarbital loading and propofol infusion. Despite significant bupivacaine neurotoxicity, no cardiotoxicity developed. DISCUSSION: The patient developed intrathecal local anesthetic and opioid toxicity after a malfunction of her intrathecal pump during a refill. We hypothesize that no cardiotoxicity developed secondary to sequestration of bupivacaine within the central nervous system. Likewise, poor CNS penetration of intravenous lipid emulsion may have negated or delayed any antidotal effect. CONCLUSION: We present a case of intrathecal toxicity leading to prolonged spinal anesthesia, progressive encephalopathy, and SE refractory to intravenous lipid emulsion. Management of SE with benzodiazepines and barbiturates may be more effective than lipids in cases of toxicity from intrathecal administration of bupivacaine.


Assuntos
Bupivacaína/efeitos adversos , Hipotensão/induzido quimicamente , Morfina/efeitos adversos , Estado Epiléptico/induzido quimicamente , Idoso , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Raquianestesia/efeitos adversos , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Barbitúricos/uso terapêutico , Benzodiazepinas/uso terapêutico , Bupivacaína/administração & dosagem , Emulsões Gordurosas Intravenosas , Feminino , Humanos , Hipotensão/tratamento farmacológico , Injeções Espinhais , Morfina/administração & dosagem , Estado Epiléptico/tratamento farmacológico
11.
A A Pract ; 14(1): 12-14, 2020 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31703007

RESUMO

A 72-year-old man with end-stage renal disease (ESRD) undergoing transurethral resection of a bladder tumor experienced severe and prolonged hypotension after receiving oral 5-aminolevulinic acid (5-ALA). Continuous infusions of norepinephrine and vasopressin ultimately resolved the hypotension over the course of 26 hours. It is uncertain whether 5-ALA is causative or is a contributing factor that influences other factors, such as hypovolemia after hemodialysis and autonomic nerve dysfunction associated with ESRD. Our findings suggest that anesthesiologists should be aware of the possible occurrence of hypotension after administration of 5-ALA, and urologists should consider intravesical 5-ALA administration in patients with ESRD.


Assuntos
Ácido Aminolevulínico/efeitos adversos , Hipotensão/induzido quimicamente , Falência Renal Crônica/fisiopatologia , Neoplasias da Bexiga Urinária/cirurgia , Administração Oral , Idoso , Ácido Aminolevulínico/administração & dosagem , Humanos , Hipotensão/tratamento farmacológico , Norepinefrina/administração & dosagem , Norepinefrina/uso terapêutico , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos , Vasopressinas/administração & dosagem , Vasopressinas/uso terapêutico
12.
Br J Anaesth ; 124(3): e95-e107, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31810562

RESUMO

BACKGROUND: The optimal choice of vasopressor drugs for managing hypotension during neuraxial anaesthesia for Caesarean delivery is unclear. Although phenylephrine was recently recommended as a consensus choice, direct comparison of phenylephrine with vasopressors used in other healthcare settings is largely lacking. Therefore, we assessed this indirectly by collating data from relevant studies in this comprehensive network meta-analysis. Here, we provide the possible rank orders for these vasopressor agents in relation to clinically important fetal and maternal outcomes. METHODS: RCTs were independently searched in MEDLINE, Web of Science, Embase, The Cochrane Central Register of Controlled Trials, and clinicaltrials.gov (updated January 31, 2019). The primary outcome assessed was umbilical arterial base excess. Secondary fetal outcomes were umbilical arterial pH and Pco2. Maternal outcomes were incidences of nausea, vomiting, and bradycardia. RESULTS: We included 52 RCTs with a total of 4126 patients. Our Bayesian network meta-analysis showed the likelihood that norepinephrine, metaraminol, and mephentermine had the lowest probability of adversely affecting the fetal acid-base status as assessed by their effect on umbilical arterial base excess (probability rank order: norepinephrine > mephentermine > metaraminol > phenylephrine > ephedrine). This rank order largely held true for umbilical arterial pH and Pco2. With the exception of maternal bradycardia, ephedrine had the highest probability of being the worst agent for all assessed outcomes. Because of the inherent imprecision when collating direct/indirect comparisons, the rank orders suggested are possibilities rather than absolute ranks. CONCLUSION: Our analysis suggests the possibility that norepinephrine and metaraminol are less likely than phenylephrine to be associated with adverse fetal acid-base status during Caesarean delivery. Our results, therefore, lay the scientific foundation for focused trials to enable direct comparisons between these agents and phenylephrine.


Assuntos
Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Teorema de Bayes , Hipotensão/prevenção & controle , Metanálise em Rede , Vasoconstritores/uso terapêutico , Cesárea , Feminino , Humanos , Hipotensão/tratamento farmacológico , Norepinefrina/uso terapêutico , Fenilefrina/uso terapêutico , Gravidez
13.
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
14.
Prehosp Emerg Care ; 24(2): 188-195, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-30808241

RESUMO

Introduction: Hypotension is a critical event during the transport of critically ill patients. Push dose vasopressor use, though widely adopted by anesthesiologists, has only recently found use in the field of emergency medicine and may have utility in the management of out-of-hospital hypotension. This study aimed to characterize the hemodynamic effects and adverse events that occur following push dose epinephrine (PDE) administration by critical care transport (CCT) providers to correct documented hypotension. Methods: We performed a retrospective observational study of patients transported by a regional critical care transport service and who received PDE during transport to correct documented hypotension. Per protocol, 10-20 µg of 1:100,000 epinephrine was given intravenously every 2 min until: (1) the systolic blood pressure (SBP) was at least 90 mmHg, or (2) the mean arterial pressure (MAP) was 65 mmHg or greater. All patients were over 18 years of age and were transported between January 1, 2015 and December 31, 2016. Primary outcomes of interest were the primary diagnoses associated with PDE use, hemodynamic outcomes of the intervention, and adverse events. Results: During the study period 100 doses of push dose epinephrine were given during the transport of 58 patients. Of these, 94 (94.0%) were found to be appropriately dosed and indicated per protocol. The most common diagnoses associated with PDE use were: post-cardiac arrest (n = 24), sepsis (n = 9), altered mental status (n = 7), and cardiogenic shock (n = 3). The median increase in MAP across all doses was 13.0 (5.0-34.0) mmHg, and the heart rate increase was 2.0 (-1.0-9.3) beats per minute. Hypotension was resolved in 55 of 94 instances (58.5%). A single episode of transient extreme hypertension occurred after one PDE dose and did not result in patient harm. Conclusions: Push dose epinephrine may be an effective method of temporarily resolving hypotension during the CCT of critically ill patients. In the cases where PDE was administered, there was close adherence to the established protocol and adverse events were found to be rare directly following PDE administration. Further research is needed to validate these findings, establish optimal dosing, and evaluate use in non-CCT prehospital settings.


Assuntos
Cuidados Críticos , Epinefrina/administração & dosagem , Hipotensão/tratamento farmacológico , Transporte de Pacientes , Vasoconstritores/administração & dosagem , Idoso , Pressão Sanguínea , Feminino , Humanos , Hipotensão/diagnóstico , Hipotensão/etiologia , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Retrospectivos
15.
Arch Dis Child ; 105(4): 390-394, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31471281

RESUMO

OBJECTIVE: To evaluate whether changing dopamine infusions every 12 hours and preparing these infusions 30 min before administration reduces blood pressure fluctuations in preterm and term neonates. DESIGN: This was a retrospective study using data from live patients on the neonatal unit and prospective study exploring stability of infusions in a laboratory-based neonatal ward simulation. SETTING: Single-centre study in a tertiary neonatal surgical unit in a university teaching hospital. PATIENTS: Neonates who received more than one subsequent dopamine infusion and had invasive arterial blood pressure monitoring, during their admission in the neonatal unit, were included. INTERVENTIONS: As part of the Quality Improvement project, the standard operating procedure (SOP) was changed, and dopamine infusions were prepared by nursing staff and left to rest for 30 min before administering to the neonate. Additionally, infusions were replaced every 12 hours. MAIN OUTCOME MEASURES: The percentage change in mean arterial pressure (MAP) and the percentage loss in the drug concentration during infusion during changeover. RESULTS: Our findings indicate that up to 15% of the initial dopamine concentration is lost after 24 hours. This results in a sharp variation in the dopamine concentration during infusion changeover that correlates with observed rapid fluctuations in MAP. In changing the SOP, no significant difference in the concentration of dopamine and MAP were observed over 12 hours. CONCLUSIONS: Delaying administration of dopamine infusions by 30 min after preparation combined with changing infusions 12 hourly has reduced MAP fluctuations. Therefore, the risks associated with MAP fluctuations, including intraventricular haemorrhages, are reduced.


Assuntos
Pressão Arterial/efeitos dos fármacos , Pressão Sanguínea/efeitos dos fármacos , Dopamina/administração & dosagem , Hipotensão/tratamento farmacológico , Terapia Intensiva Neonatal , Dopamina/farmacologia , Feminino , Hemodinâmica , Humanos , Hipotensão/fisiopatologia , Recém-Nascido , Infusões Intravenosas , Masculino , Estudos Prospectivos , Estudos Retrospectivos
18.
Pacing Clin Electrophysiol ; 42(12): 1552-1557, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31702059

RESUMO

BACKGROUND: The perioperative anesthesia care during subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation is still evolving. OBJECTIVE: To assess the feasibility and safety of S-ICD implantation with monitored anesthesia care (MAC) versus general anesthesia (GA) in a tertiary care center. METHODS: This is a single-center retrospective study of patients undergoing S-ICD implantation between October 2012 and May 2019. Patients were categorized into MAC and GA group based on the mode of anesthesia. Procedural success without escalation to GA was the primary endpoint of the study, whereas intraprocedural hemodynamics, need of pharmacological support for hypotension and bradycardia, length of the procedure, stay in the post-anesthesia care unit, and postoperative pain were assessed as secondary endpoints. RESULTS: The study comprises 287 patients with MAC in 111 and GA in 176 patients. Compared to MAC, patients in GA group were younger and had a higher body mass index. All patients had successful S-ICD implantation. Only one patient (0.9%) in the MAC group was converted to GA. Despite a similar baseline heart rate (HR) and mean arterial blood pressure (MAP) in both groups, patients with GA had significantly lower HR and MAP during the procedure and more frequently required pharmacological hemodynamic support. Length of the procedure, stay in the postanesthesia care unit, and postoperative pain was similar in both groups. CONCLUSION: This retrospective experience suggests that implantation of S-ICD is feasible and safe with MAC. Use of GA is associated with more frequent administration of hemodynamic drugs during S-ICD implantation.


Assuntos
Anestesia/métodos , Desfibriladores Implantáveis , Implantação de Prótese/métodos , Anestesia Geral , Anestesia Local , Bradicardia/tratamento farmacológico , Estudos de Viabilidade , Feminino , Hemodinâmica , Humanos , Hipotensão/tratamento farmacológico , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Medição da Dor , Dor Pós-Operatória/prevenção & controle , Estudos Retrospectivos
19.
Blood Purif ; 48 Suppl 1: 27-32, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31752008

RESUMO

BACKGROUND: Intermittent infusion hemodiafiltration is a recently developed convective method of renal replacement therapy using cyclic back-filtration infusion. Quick and regular infusion prevents intradialytic hypotension. However, the optimal dose of bolus dialysate infusion required to stabilize blood pressure has not been reported. Here, we investigated the relationship between the dose of bolus dialysate infusion and blood pressure. SUMMARY: A total of 77 patients on maintenance hemodialysis were enrolled in this study. Dialysate was infused rapidly by backward filtration at a rate of 150 mL/min at 30-min intervals using an automated dialysis machine. The effects with two bolus infusion volumes (100 and 200 mL) were compared, each for an observation period of 2 weeks. Systolic blood pressure (SBP) was measured at the start and at the end of each dialysis session, and the highest SBP and lowest SBP measurements were also recorded. Patients were divided according to dry weight into a <52 kg group and a ≥52 kg group, and various parameters were compared between the 100 and 200 mL bolus infusion volumes in each group. Among patients in the <52 kg group, SBP did not vary at any of the time points. However, for patients in the ≥52 kg group, SBP at the end of treatment was significantly lower in the 100-mL group than in the 200-mL group (141 ± 20 vs. 144 ± 21 mm Hg, p = 0.041), and the minimum SBP was also lower in the 100-mL group than in the 200-mL group (127 ± 17 vs. 131 ± 18 mm Hg, p = 0.010). Key Messages: Among patients with a dry weight of ≥52 kg, blood pressure was more stable when a bolus fluid volume of 200 mL was used, compared with a volume of 100 mL. However, for patients with a dry weight of <52 kg, the significance of the difference in bolus fluid volumes disappeared. Thus, the replacement fluid volume might be better determined based on the patient's dry weight. TRIAL REGISTRATION: UMIN 000028145, Registered July 10, 2017.


Assuntos
Pressão Sanguínea/efeitos dos fármacos , Soluções para Diálise/administração & dosagem , Hipotensão , Idoso , Feminino , Hemodiafiltração , Humanos , Hipotensão/sangue , Hipotensão/tratamento farmacológico , Hipotensão/etiologia , Hipotensão/fisiopatologia , Masculino , Pessoa de Meia-Idade
20.
Pflugers Arch ; 471(11-12): 1441-1453, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31728701

RESUMO

Butyric acid (BA) is a short-chain fatty acid (SCFA) produced by gut bacteria in the colon. We hypothesized that colon-derived BA may affect hemodynamics. Arterial blood pressure (BP) and heart rate (HR) were recorded in anesthetized, male, 14-week-old Wistar rats. A vehicle, BA, or 3-hydroxybutyrate, an antagonist of SCFA receptors GPR41/43 (ANT) were administered intravenously (IV) or into the colon (IC). Reactivity of mesenteric (MA) and gracilis muscle (GMA) arteries was tested ex vivo. The concentration of BA in stools, urine, portal, and systemic blood was measured with liquid chromatography coupled with mass spectrometry. BA administered IV decreased BP with no significant effect on HR. The ANT reduced, whereas L-NAME, a nitric oxide synthase inhibitor, did not affect the hypotensive effect of BA. In comparison to BA administered intravenously, BA administered into the colon produced a significantly longer decrease in BP and a decrease in HR, which was associated with a 2-3-fold increase in BA colon content. Subphrenic vagotomy and IC pretreatment with the ANT significantly reduced the hypotensive effect. Ex vivo, BA dilated MA and GMA. In conclusion, an increase in the concentration of BA in the colon produces a significant hypotensive effect which depends on the afferent colonic vagus nerve signaling and GPR41/43 receptors. BA seems to be one of mediators between gut microbiota and the circulatory system.


Assuntos
Pressão Arterial/efeitos dos fármacos , Ácido Butírico/farmacologia , Colo/efeitos dos fármacos , Microbioma Gastrointestinal/fisiologia , Receptores Acoplados a Proteínas-G/metabolismo , Nervo Vago/efeitos dos fármacos , Animais , Artérias/efeitos dos fármacos , Artérias/metabolismo , Colo/metabolismo , Ácidos Graxos Voláteis/farmacologia , Frequência Cardíaca/efeitos dos fármacos , Hipotensão/tratamento farmacológico , Hipotensão/metabolismo , Masculino , NG-Nitroarginina Metil Éster/farmacologia , Ratos , Ratos Wistar , Transdução de Sinais/efeitos dos fármacos , Nervo Vago/metabolismo
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