Haemodynamic assessment and management of hypotension in the preterm

The management of low blood flow states in premature neonates is fraught with many challenges. We remain over-reliant on regimented stepwise protocols that use mean blood pressure as a threshold for intervention to guide treatment, without giving due consideration to the underlying pathophysiology. The current available evidence does not reflect the need to concentrate on the unique pathophysiology of the preterm infant and thus leads to widespread misuse of vasoactive agents that often do not provide the desired clinical effect. Therefore, understanding the underlying pathophysiological underpinnings of haemodynamic compromise may better guide choice of agent and assess physiological response to the selected intervention.

Considerations and anesthetic management of a patient with giant right atrial myxoma: A case report and literature review

BACKGROUND

Myxoma is a common type of primary cardiac tumor. However, there are few researches to illustrate challenge of safely inducing anesthesia in a patient with a giant right atrial myxoma at moderate altitude.

PATIENT CONCERNS AND DIAGNOSES

A 54-year-old female patient lived in a city with an average altitude of 1932 m with scheduled surgical treatment for giant right atrial myxoma, prompting discussions on appropriate anesthesia modalities given her prolonged residence at moderate altitude.

METHODS AND RESULTS

Considering the potential impact of moderate altitude on perioperative management, this study emphasizes the necessity of adequate volume preload therapy and the utility of transthoracic echocardiography or transesophageal echocardiography to prevent hemodynamic compromise. Furthermore, it highlights the unique consideration that, post-tumor removal, hypotension may not necessarily lead to decreased oxygen saturation in these patients.

CONCLUSION

This case underscores the importance of avoiding hypotension, as pre-tumor resection blood pressure maintenance primarily determines blood oxygen concentration. Additionally, it sheds light on the intriguing observation that post-tumor removal hypotension may not result in decreased oxygen saturation. These findings have significant implications for the perioperative care of patients with giant right atrial myxoma at moderate altitudes.

Ultrasound-guided caudal anaesthesia combined with epidural anaesthesia for caesarean section: a randomized controlled clinical trial

BACKGROUND

Although epidural anaesthesia and spinal anaesthesia are currently the general choices for patients undergoing caesarean section, these two neuraxial anaesthesia methods still have drawbacks. Caudal anaesthesia has been considered to be more appropriate for gynaecological surgery. The purpose of this study was to compare epidural anaesthesia combined with caudal anaesthesia, spinal anaesthesia and single-space epidural anaesthesia for caesarean section with respect to postoperative comfort and intraoperative anaesthesia quality.

METHODS

In this clinical trial, 150 patients undergoing elective caesarean section were recruited and randomized into three groups according to a ratio of 1:1:1to receive epidural anaesthesia only, spinal anaesthesia only or epidural anaesthesia combined with caudal anaesthesia. The primary outcome was postoperative comfort in the three groups. Secondary outcomes included intraoperative anaesthesia quality and the incidences of nausea, vomiting, postdural puncture headache, maternal bradycardia, or hypotension.

RESULTS

More patients were satisfied with the intraoperative anaesthesia quality in the EAC group than in the EA group (P = 0.001). The obstetrician was more significantly satisfied with the intraoperative anaesthesia quality in the SA and EAC groups than in the EA group (P = 0.004 and 0.020, respectively). The parturients felt more comfortable after surgery in the EA and EAC groups (P = 0.007). The incidence of maternal hypotension during caesarean section was higher in the SA group than in the EA and EAC groups (P = 0.001 and 0.019, respectively).

CONCLUSIONS

Epidural anaesthesia combined with caudal anaesthesia may be a better choice for elective caesarean section. Compared with epidural anaesthesia and spinal anaesthesia, it has a higher quality of postoperative comfort and intraoperative anaesthesia.

Changes in the corrected carotid flow time can predict spinal anesthesia-induced hypotension in patients undergoing cesarean delivery: an observational study

PURPOSE

Spinal anesthesia is a standard technique for cesarean delivery; however, it possesses a risk of hypotension. We hypothesised that the changes in the corrected flow time induced by the Trendelenburg position could predict the incidence of hypotension after spinal anesthesia for cesarean delivery.

METHODS

Patients undergoing elective cesarean delivery under spinal anesthesia were enrolled. Before anesthesia induction, corrected flow time was measured in the supine and Trendelenburg positions (FTc-1 and FTc-2, respectively). Additionally, a percent change in corrected flow time induced by the Trendelenburg position was defined as ΔFTc. The primary endpoint was to investigate the ability of ΔFTc to predict the incidence of spinal anesthesia-induced hypotension until delivery. The receiver operating characteristics curves to assess the ability of FTc-1, FTc-2, and ΔFTc to predict the incidence of hypotension were generated.

RESULTS

Finally, 40 patients were included, and of those, 26 (65%) developed spinal anesthesia-induced hypotension. The areas under the curve for FTc-1, FTc-2, and ΔFTc were 0.591 (95% CI: 0.424 to 0.743) (P = 0.380), 0.742 (95% CI: 0.579 to 0.867) (P = 0.004), and 0.882 (95% CI: 0.740 to 0.962) (P < 0.001) respectively, indicating ΔFTc as the best predictor among these three parameters. The best threshold for ΔFTc was 6.4% (sensitivity: 80.8% (95% CI: 53.8 to 96.2), specificity: 85.7% (95% CI: 42.9 to 100.0)).

CONCLUSIONS

This study demonstrated that changes in the corrected carotid flow time induced by the Trendelenburg position could serve as a good predictor of spinal anesthesia-induced hypotension for cesarean delivery.

Hypotension and respiratory events related to electrical cardioversion for atrial fibrillation or atrial flutter in the emergency department

INTRODUCTION

Electrical cardioversion for atrial fibrillation/atrial flutter (AF/AFL) is common in the ED. Our previous work showed that hypotension and respiratory events were important adverse events that occurred in patients undergoing electrical cardioversion for AF/AFL. The purpose of this study was to examine if (1) beta-blockers or calcium channel blocker use prior to ECV were associated with hypotension and (2) medications used for procedural sedation were associated with respiratory events.

METHODS

This was a secondary analysis of pooled study data from four previous multicentred studies on AF/AFL. We conducted a multivariable logistic regression to examine predictors of hypotension and respiratory adverse events.

RESULTS

There were 1736 patients who received ECV. A hypotensive event occurred in 62 (3.6%) patients. There was no significant difference in the odds of a hypotensive event in patients who received a beta-blocker or calcium channel blocker in the ED compared to no rate control. Procedural sedation with fentanyl (OR 2.01 95% CI 1.15-3.51) and home beta-blocker use (OR 1.92, 95% CI 1.14-3.21) were significantly associated with hypotensive events. A respiratory event occurred in 179 (10.3%) patients. Older age (OR 2.02, 95% CI 1.30- 3.15) and receiving midazolam for procedural sedation were found to be significantly associated with respiratory events (OR 1.99, 95% CI 1.02-3.88).

CONCLUSION

Beta-blocker or calcium channel blocker use prior to ECV for AF/AFL was not associated with hypotension. However, sedation with fentanyl and home beta-blocker use was associated with hypotension. The use of midazolam for procedural sedation was significantly associated with respiratory events.

Postoperative hypotension following acute hip fracture surgery is a predictor of 30-day mortality

Aims

Hip fractures are some of the most common fractures encountered in orthopaedic practice. We aimed to identify whether perioperative hypotension is a predictor of 30-day mortality, and to stratify patient groups that would benefit from closer monitoring and early intervention. While there is literature on intraoperative blood pressure, there are limited studies examining pre- and postoperative blood pressure.

Methods

We conducted a prospective observational cohort study over a one-year period from December 2021 to December 2022. Patient demographic details, biochemical results, and haemodynamic observations were taken from electronic medical records. Statistical analysis was conducted with the Cox proportional hazards model, and the effects of independent variables estimated with the Wald statistic. Kaplan-Meier survival curves were estimated with the log-rank test.

Results

A total of 528 patients were identified as suitable for inclusion. On multivariate analysis, postoperative hypotension of a systolic blood pressure (SBP) < 90 mmHg two to 24 hours after surgery showed an increased hazard ratio (HR) for 30-day mortality (HR 4.6 (95% confidence interval (CI) 2.3 to 8.9); p < 0.001) and was an independent risk factor accounting for sex (HR 2.7 (95% CI 1.4 to 5.2); p = 0.003), age (HR 1.1 (95% CI 1.0 to 1.1); p = 0.016), American Society of Anesthesiologists grade (HR 2.7 (95% CI 1.5 to 4.6); p < 0.001), time to theatre > 24 hours (HR 2.1 (95% CI 1.1 to 4.2); p = 0.025), and preoperative anaemia (HR 2.3 (95% CI 1.0 to 5.2); p = 0.043). A preoperative SBP of < 120 mmHg was close to achieving significance (HR 1.9 (95% CI 0.99 to 3.6); p = 0.052).

Conclusion

Our study is the first to demonstrate that postoperative hypotension within the first 24 hours is an independent risk factor for 30-day mortality after hip fracture surgery. Clinicians should recognize patients who have a SBP of < 90 mmHg in the early postoperative period, and be aware of the increased mortality risk in this specific cohort who may benefit from a closer level of monitoring and early intervention.

Effect of carotid corrected flow time combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients: a prospective cohort study

BACKGROUND

Hypotension often occurs following the induction of general anesthesia in elderly patients undergoing surgery and can lead to severe complications. This study assessed the effect of carotid corrected flow time (FTc) combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients.

MATERIALS AND METHODS

The prospective cohort study was divided into two parts. The first part (Part I) consisted of 112 elderly patients. Carotid FTc was measured using Color Doppler Ultrasound 5 min before anesthesia induction. Hypotension was defined as a decrease of greater than 30% in systolic blood pressure (SBP) or a decrease of greater than 20% in mean arterial pressure (MAP) from baseline, or an absolute SBP below 90 mmHg and MAP below 60 mmHg within 3 min after induction of general anesthesia. The predictive value of carotid FTc was determined using receiver operating characteristic (ROC) curve. The second part (Part II) consisted of 65 elderly patients. Based on the results in Part I, elderly patients with carotid FTc below the optimal cut-off value received perioperative fluid therapy at a volume of 8 ml/kg of balanced crystalloids (lactated Ringer's solution) in 30 min before induction. The effect of carotid FTc combined with perioperative fluid therapy was assessed by comparing observed incidence of hypotension after induction.

RESULTS

The area under the ROC for carotid FTc to predict hypotension after induction was 0.876 [95% confidence interval (CI) 0.800-0.952, P <0.001]. The optimal cut-off value was 334.95 ms (sensitivity of 87.20%; specificity of 82.20%). The logistic regression analysis revealed that carotid FTc is an independent predictor for post-induction hypotension in elderly patients. The incidence of post-induction hypotension was significantly lower ( P <0.001) in patients with carotid FTc less than 334.95 ms who received perioperative fluid therapy (35.71%) compared to those who did not (92.31%).

CONCLUSIONS

Carotid FTc combined with the perioperative fluid therapy could significantly reduce the incidence of hypotension after the induction of general anesthesia in elderly patients.

Hypotensive Levels on Endoscopic Sinus Surgery Visibility: A Randomized Non-Inferiority Trial

OBJECTIVE

Optimization of endoscopic sinus surgery (ESS) conditions is a common focus of interest for otolaryngologists and anesthesiologists. Relying on hypotension alone to achieve a bloodless field may not without risks. We sought to determine whether ESS is feasible in the context of moderate hypotension.

METHODS

This randomized non-inferiority trial enrolled 96 adult patients who were to undergo ESS. The patients were divided into two groups: Controlled hypotension group (n = 48, MAP reduction to 55-65 mmHg, minimum of 60% of baseline blood pressure) or Individualized hypotension group (n = 48, MAP reduction to 75-80% of baseline blood pressure). All participants were placed in 10° reverse Trendelenburg position during ESS, and cottonoid patties dammed with epinephrine was recommended to clear the operative field of bleeding. The two groups were compared according to Boezaart grading scale (BS) score, estimated blood loss, blood loss rate, arterial lactate level and postoperative recovery.

RESULTS

Both levels of intraoperative hypotension (62.2 ± 2.3 mmHg vs. 74.0 ± 2.8 mmHg) provided acceptable surgical conditions with no difference in mean BS scores [2.00 (1.88-2.33) vs. 2.00 (1.85-2.45), p = 0.926]. The 95% CI for median value differences in mean BS scores is lower than the preset non-inferiority margin. There were no differences in blood loss rate and estimated blood loss between two groups (p > 0.05) Postoperative arterial lactate and Ramsay sedation scores were significantly different between the two groups (p < 0.05).

CONCLUSIONS

In ESS, both levels of intraoperative hypotension, combined with position adjustment and low-concentration adrenaline to constrict nasal mucosal blood vessels, provided acceptable surgical conditions.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:569-576, 2024.

Myeloid ACE2 protects against septic hypotension and vascular dysfunction through Ang-(1-7)-Mas-mediated macrophage polarization

Angiotensin converting enzyme 2 (ACE2) is a new identified member of the renin-angiotensin-aldosterone system (RAAS) that cleaves angiotensin II (Ang II) to Ang (1-7), which exerts anti-inflammatory and antioxidative activities via binding with Mas receptor (MasR). However, the functional role of ACE2 in sepsis-related hypotension remains unknown. Our results indicated that sepsis significantly reduced blood pressure and led to disruption between ACE-Ang II and ACE2-Ang (1-7) balance. ACE2 knock-in mice exhibited improved sepsis-induced mortality, hypotension and vascular dysfunction, while ACE2 knockout mice exhibited the opposite effects. Bone marrow transplantation and in vitro experiments confirmed that myeloid ACE2 exerted a protective role by suppressing oxidative stress, NO production and macrophage polarization via the Ang (1-7)-MasR-NF-κB and STAT1 pathways. Thus, ACE2 on myeloid cells could protect against sepsis-mediated hypotension and vascular dysfunction, and upregulating ACE2 may represent a promising therapeutic option for septic patients with hypotension.

American society of anesthesiologists physical status classification significantly affects the performances of machine learning models in intraoperative hypotension inference

STUDY OBJECTIVE

To explore how American Society of Anesthesiologists (ASA) physical status classification affects different machine learning models in hypotension prediction and whether the prediction uncertainty could be quantified.

DESIGN

Observational Studies SETTING: UofL health hospital PATIENTS: This study involved 562 hysterectomy surgeries performed on patients (≥ 18 years) between June 2020 and July 2021.

INTERVENTIONS

None MEASUREMENTS: Preoperative and intraoperative data is collected. Three parametric machine learning models, including Bayesian generalized linear model (BGLM), Bayesian neural network (BNN), a newly proposed BNN with multivariate mixed responses (BNNMR), and one nonparametric model, Gaussian Process (GP), were explored to predict patients' diastolic and systolic blood pressures (continuous responses) and patients' hypotensive event (binary response) for the next five minutes. Data was separated into American Society of Anesthesiologists (ASA) physical status class 1- 4 before being read in by four machine learning models. Statistical analysis and models' constructions are performed in Python. Sensitivity, specificity, and the confidence/credible intervals were used to evaluate the prediction performance of each model for each ASA physical status class.

MAIN RESULTS

ASA physical status classes require distinct models to accurately predict intraoperative blood pressures and hypotensive events. Overall, high sensitivity (above 0.85) and low uncertainty can be achieved by all models for ASA class 4 patients. In contrast, models trained without controlling ASA classes yielded lower sensitivity (below 0.5) and larger uncertainty. Particularly, in terms of predicting binary hypotensive event, for ASA physical status class 1, BNNMR yields the highest sensitivity of 1. For classes 2 and 3, BNN has the highest sensitivity of 0.429 and 0.415, respectively. For class 4, BNNMR and GP are tied with the highest sensitivity of 0.857. On the other hand, the sensitivity is just 0.031, 0.429, 0.165 and 0.305 for BNNMR, BNN, GBLM and GP models respectively, when training data is not divided by ASA physical status classes. In terms of predicting systolic blood pressure, the GP regression yields the lowest root mean squared errors (RMSE) of 2.072, 7.539, 9.214 and 0.295 for ASA physical status classes 1, 2, 3 and 4, respectively, but a RMSE of 126.894 if model is trained without controlling the ASA physical status class. The RMSEs for other models are far higher. RMSEs are 2.175, 13.861, 17.560 and 22.426 for classes 1, 2, 3 and 4 respectively for the BGLM. In terms of predicting diastolic blood pressure, the GP regression yields the lowest RMSEs of 2.152, 6.573, 5.371 and 0.831 for ASA physical status classes 1, 2, 3 and 4, respectively; RMSE of 8.084 if model is trained without controlling the ASA physical status class. The RMSEs for other models are far higher. Finally, in terms of the width of the 95% confidence interval of the mean prediction for systolic and diastolic blood pressures, GP regression gives narrower confidence interval with much smaller margin of error across all four ASA physical status classes.

CONCLUSIONS

Different ASA physical status classes present different data distributions, and thus calls for distinct machine learning models to improve prediction accuracy and reduce predictive uncertainty. Uncertainty quantification enabled by Bayesian inference provides valuable information for clinicians as an additional metric to evaluate performance of machine learning models for medical decision making.

Carotid sinus baroafferent signals contribute to cerebral blood flow regulation during acute hypotension in young males: A randomized crossover study

Cerebral autoregulation is an important factor in prevention of cerebral ischemic events. We tested a traditional but unproven hypothesis that carotid sinus baroafferent signals contribute to dynamic cerebral autoregulation. Middle cerebral artery mean blood velocity (MCA Vmean ) responses to thigh-cuff deflation-induced acute hypotension were compared between conditions using neck suction soon after cuff deflation, without or with a cushion wrapped around the upper neck, in nine healthy males (aged 25 ± 5 years). Neck suction was applied close to the hypotension. The MCA Vmean response was expected to differ between conditions because the cushion was presumed to prevent the carotid sinus distension by neck suction. The cushion hindered bradycardia and depressor responses during sole neck suction. Thigh-cuff deflation decreased mean arterial blood pressure (MAP) and MCA Vmean (Ps < 0.05) with an almost unchanged respiratory rate under both conditions. However, in the neck suction + cushion condition, subsequent MCA Vmean restoration was faster and greater (Ps ≤ 0.0131), despite similar changes in MAP in both conditions. Thus, carotid sinus baroafferent signals would accelerate dynamic cerebral autoregulation during rapid hypotension in healthy young males. Elucidating the mechanism underlying cerebral neural autoregulation could provide a new target for preventing cerebral ischemic events.

Predicting fluid responsiveness in spontaneously breathing parturients undergoing caesarean section via carotid artery blood flow and velocity time integral measured by carotid ultrasound: a prospective cohort study

BACKGROUND

Present evidence suggests that the Doppler ultrasonographic indices, such as carotid artery blood flow (CABF) and velocity time integral (VTI), had the ability to predict fluid responsiveness in non-obstetric patients. The purpose of this study was to assess their capacity to predict fluid responsiveness in spontaneous breathing parturients undergoing caesarean section and to determine the effect of detecting and management of hypovolemia (fluid responsiveness) on the incidence of hypotension after anaesthesia.

METHODS

A total of 72 full term singleton parturients undergoing elective caesarean section were enrolled in this study. CABF, VTI, and hemodynamic parameters were recorded before and after fluid challenge and assessed by carotid artery ultrasonography. Fluid responsiveness was defined as an increase in stroke volume index (SVI) of 15% or more after the fluid challenge.

RESULTS

Thirty-one (43%) patients were fluid responders. The area under the ROC curve to predict fluid responsiveness for CABF and VTI were 0.803 (95% CI, 0.701-0.905) and 0.821 (95% CI, 0.720-0.922). The optimal cut-off values of CABF and VTI for fluid responsiveness was 175.9 ml/min (sensitivity of 74.0%; specificity of 78.0%) and 8.7 cm/s (sensitivity of 67.0%; specificity of 90.0%). The grey zone for CABF and VTI were 114.2-175.9 ml/min and 6.8-8.7 cm/s. The incidence of hypotension after the combined spinal-epidural anaesthesia (CSEA) was significantly higher in the Responders group 25.8% (8/31) than in the Non-Responders group 17.1(7/41) (P < 0.001). The total incidence of hypotension after CSEA of the two groups was 20.8% (15/72).

CONCLUSIONS

Ultrasound evaluation of CABF and VTI seem to be the feasible parameters to predict fluid responsiveness in parturients undergoing elective caesarean section and detecting and management of hypovolemia (fluid responsiveness) could significantly decrease incidence of hypotension after anaesthesia.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Registry (ChiCTR) ( www.chictr.org ), registration number was ChiCTR1900022327 (The website link: https://www.chictr.org.cn/showproj.html?proj=37271 ) and the date of trial registration was in April 5, 2019. This study was performed in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of Women's Hospital, Zhejiang University School of Medicine (20,180,120).

Use total portosystemic shunt to rescue an emergency PNF with intractable hypotension: A case report

RATIONALE

Living donor allogeneic liver transplantation is a surgical treatment for patients with end-stage liver disease, wherein a healthy liver is implanted in the patient, facilitating the recovery of the liver function in patients with end-stage liver disease. However, primary nonfunction (PNF) may occur as a result of this procedure.

PATIENT CONCERNS

A case of an 65-year-old Asian male with a medical history of cirrhosis and hepatocellular carcinoma is described. Intractable hypotension occurred after open hepatic portal anastomosis, and large doses of vasoactive substances did not improve the condition.

DIAGNOSIS

PNF was diagnosed during surgery and it caused intractable hypotension.

INTERVENTIONS

we promptly used the total portosystemic shunt to achieve a successful rescue.

OUTCOMES

The strengthening of perioperative management and active treatment allowed second liver transplantation and anhepatic phase of up to 10 hours, following which the patient was rescued.

LESSONS

The lesson we have learned is that total portosystemic shunt composited with careful anesthesia management can rescue the event of PNF with intractable hypotension in liver transplantation surgery. At the same time, we give attention to blood pressure, electrocardiogram, albumin, calcium, potassium, acidosis, coagulopathy, anti-infection, and protection of vital organs is essential for successful retransplant outcomes.

Effectiveness of general anaesthesia with remimazolam tosilate on intraoperative haemodynamics and postoperative recovery: study protocol for a randomised, positive-controlled, pragmatic clinical trial (GARTH trial)

INTRODUCTION

It is encouraged to estimate the effectiveness of components within the enhanced recovery after surgery (ERAS) protocol through patient-reported outcomes, alongside doctor-reported outcomes and length of hospital stay. At present, studies on the contributions of optimal anaesthetic drugs within the ERAS protocol to patient-reported and doctor-reported outcomes are limited. Therefore, this study aims to pragmatically evaluate the effectiveness and safety of general anaesthesia (GA) with remimazolam tosilate within the ERAS protocol on intraoperative haemodynamics and postoperative recovery in adults undergoing elective surgeries, compared with propofol.

METHODS AND ANALYSIS

This study is a single-centre, randomised, blinded, positive-controlled, pragmatic clinical trial. A total of 900 patients, aged ≥18 years old, scheduled for an elective surgical procedure under GA will be included. Patients will be randomised in a 1:1 ratio to the remimazolam group (the GA with remimazolam tosilate within the ERAS protocol group) or propofol group (the GA with propofol within the ERAS protocol group), stratified by general surgery, thoracic surgery and other surgeries (including urological surgery and otolaryngology surgery). The primary outcomes include the 24-hour postoperative quality of recovery-40 score and the rate of intraoperative hypotension. Secondary endpoints include the rate of sedative hypotension requiring treatment, the haemodynamic profiles, the 72-hour postoperative quality of recovery-40 score, the functional anaesthetic capability, adverse events and complications, quality of life within 3 months as well as economic health outcomes.

ETHICS AND DISSEMINATION

This study protocol has been approved by the ethics committee of Guangdong Provincial People's Hospital (KY-H-2022-005-03-08). Dissemination plans will be presented at scientific meetings and in scientific publications.

TRIAL REGISTRATION NUMBER

ChiCTR2200062520.

Carotid blood flow changes following a simulated end-inspiratory occlusion maneuver measured by ultrasound can predict hypotension after the induction of general anesthesia: an observational study

BACKGROUND

The primary purpose of this study was to investigate the predictive value of alterations in cervical artery hemodynamic parameters induced by a simulated end-inspiratory occlusion test (sEIOT) measured by ultrasound for predicting postinduction hypotension (PIH) during general anesthesia.

METHODS

Patients undergoing gastrointestinal tumor resection under general anesthesia were selected for this study. Ultrasound has been utilized to assess hemodynamic parameters in carotid artery blood flow before induction, specifically focusing on variations in corrected flow time (ΔFTc) and peak blood flow velocity (ΔCDPV), both before and after sEIOT. Anesthesia was induced by midazolam, sufentanil, propofol, and rocuronium, and blood pressure (BP) and heart rate (HR) were recorded within the first 10 min following endotracheal intubation. PIH was defined as fall in systolic blood pressure (SBP) or mean arterial pressure (MAP) by > 30% of baseline or MAP to < 60 mm Hg.

RESULTS

The area under the receiver operating characteristic curves (AUC) for carotid artery ΔFTc was 0.88 (95%CI, 0.81 to 0.96; P < 0.001), and the optimal cutoff value was -16.57%, with a sensitivity of 91.4% and specificity of 77.60%. The gray zone for carotid artery ΔFTc was -16.34% to -15.36% and included 14% of the patients. The AUC for ΔCDPV was 0.54, with an optimal cutoff value of -1.47%. The sensitivity and specificity were calculated as 55.20% and 57.10%, respectively.

CONCLUSION

The corrected blood flow time changes in the carotid artery induced by sEIOT can predict hypotension following general anesthesia-induced hypotension, wherein ΔFTc less than 16.57% is the threshold.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( www.chictr.org.cn ; 20/06/2023; ChiCTR2300072632).

Spectrum of Pneumonia in Renal Transplant Recipients: An Indian Experience

OBJECTIVES

Respiratory tract infections are life-threatening infections in solid-organ transplant recipients that pose risk to the graft and to the patient. This study was undertaken to examine the clinical and microbiological spectrum of pneumonia in renal transplant recipients.

MATERIALS AND METHODS

Of 400 consecutive renal transplant recipients, 87 recipients (21.8%) were hospitalized between November 2014 and October 2016 with pneumonia. We examined demographic profiles and clinical investigations.

RESULTS

The median age of patients was 38 years (range, 19-72 y). The mean time of presentation after renal transplant was 18 months (range, 1-174 mo). Most patients (80.5%) were on maintenance immunosuppression with tacrolimus, mycophenolate mofetil, and steroids; 34% of patients had an induction agent. Chronic hepatitis C and hepatitis B infections were found in 12.6% and 2.2% of patients, respectively, and new-onset diabetes in 19.5% of patients. Fever (88%), cough (87%), shortness of breath (68%), and hypotension (33%) were common presenting symptoms. Diarrhea was the most frequent accompanying symptom, found in 9.2% of patients. Cytopenia and graft dysfunction were present in 38.7% and 80.4% of patients. Among infections, fungal infections were the most frequent (30%) followed by mixed infections (20.7%), tuberculosis (12.6%), bacterial (12.6%), and viral (3.5%) infections. Etiology could not be found in 27.6% patients. Mortality rate was 24.1%, with the highest rates for fungal infections (44%), followed by bacterial (25%) and mixed infections (18%). Presence of hypoxia and hypotension at presentation was associated with increased risk of death, whereas use of induction agents, new-onset diabetes posttransplant, diabetes mellitus, and acute kidney injury were not correlated with death or increased duration of hospital stay.

CONCLUSIONS

Pneumonia carries high risk of mortality in renal transplant recipients. Fungal and bacterial infections carry high risk of mortality. Despite invasive investigations, a substantial number of patients had unidentified etiology.

Modality-specific outcomes of patients undergoing carotid revascularization in the setting of recent myocardial infarction

OBJECTIVE

Recent myocardial infarction (MI) represents a real challenge in patients requiring any vascular procedure. There is currently a lack of data on the effect of preoperative MI on the outcomes of carotid revascularization methodology (carotid enterectomy [CEA], transfemoral carotid artery stenting [TFCAS], or transcarotid artery revascularization [TCAR]). This study looks to identify modality-specific outcomes for patients with recent MI undergoing carotid revascularization.

METHODS

Data was collected from the Vascular Quality Initiative (2016-2022) for patients with carotid stenosis in the United States and Canada with recent MI (<6 months) undergoing CEA, TFCAS, or TCAR. In-hospital outcomes after TFCAS vs CEA and TCAR vs CEA were compared. TCAR vs TFCAS were compared in a secondary analysis. We used logistic regression models to compare the outcomes of these three procedures in patients with recent MI, adjusting for potential confounders. Primary outcomes included 30-day in-hospital rates of stroke, death, and MI. Secondary outcomes included stroke/death, stroke/death/MI, postoperative hypertension, postoperative hypotension, prolonged length of stay (>2 days), and 30-day mortality.

RESULTS

The final cohort included 1217 CEA (54.2%), 445 TFCAS (19.8%), and 584 TCAR (26.0%) cases. Patients undergoing CEA were more likely to have prior coronary artery bypass graft/percutaneous coronary intervention and to use anticoagulant. Patients undergoing TFCAS were more likely to be symptomatic, have prior congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and undergo urgent operations. Patients undergoing TCAR were more likely to have higher rates of American Society of Anesthesiologists class IV to V, P2Y12 inhibitor, and protamine use. In the univariate analysis, CEA was associated with a lower rate of ipsilateral stroke (P = .079), death (P = .002), and 30-day mortality (P = .007). After adjusting for confounders, TFCAS was associated with increased risk of stroke/death (adjusted odds ratio [aOR], 2.69; 95% confidence interval [CI], 1.36-5.35; P = .005) and stroke/death/MI (aOR, 1.67; 95% CI, 1.07-2.60; P = .025) compared with CEA. However, TCAR had similar outcomes compared with CEA. Both TFCAS and TCAR were associated with increased risk of postoperative hypotension (aOR, 1.62; 95% CI, 1.18-2.23; P = .003 and aOR, 1.74; 95% CI, 1.31-2.32; P ≤ .001, respectively) and decreased risk of postoperative hypertension (aOR, 0.59; 95% CI, 0.36-0.95; P = .029 and aOR, 0.50; 95% CI, 0.36-0.71; P ≤ .001, respectively) compared with CEA.

CONCLUSIONS

Although recent MI has been established as a high-risk criterion for CEA and an approved indication for TFCAS, this study showed that CEA is safer in this population with lower risk of stroke/death and stroke/death/MI compared with TFCAS. TCAR had similar stroke/death/MI outcomes in comparison to CEA in patients with recent MI. Further prospective studies are needed to confirm our findings.