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Rice AD, Hu C, Spaite DW, Barnhart BJ, Chikani V, Gaither JB, Denninghoff KR, Bradley GH, Howard JT, Keim SM, Bobrow BJ. Correlation between prehospital and in-hospital hypotension and outcomes after traumatic brain injury. Am J Emerg Med 2023; 65:95-103. [PMID: 36599179 DOI: 10.1016/j.ajem.2022.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/06/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Hypotension has a powerful effect on patient outcome after traumatic brain injury (TBI). The relative impact of hypotension occurring in the field versus during early hospital resuscitation is unknown. We evaluated the association between hypotension and mortality and non-mortality outcomes in four cohorts defined by where the hypotension occurred [neither prehospital nor hospital, prehospital only, hospital only, both prehospital and hospital]. METHODS Subjects ≥10 years with major TBI were included. Standard statistics were used for unadjusted analyses. We used logistic regression, controlling for significant confounders, to determine the adjusted odds (aOR) for outcomes in each of the three cohorts. RESULTS Included were 12,582 subjects (69.8% male; median age 44 (IQR 26-61). Mortality by hypotension status: No hypotension: 9.2% (95%CI: 8.7-9.8%); EMS hypotension only: 27.8% (24.6-31.2%); hospital hypotension only: 45.6% (39.1-52.1%); combined EMS/hospital hypotension 57.6% (50.0-65.0%); (p < 0.0001). The aOR for death reflected the same progression: 1.0 (reference-no hypotension), 1.8 (1.39-2.33), 2.61 (1.73-3.94), and 4.36 (2.78-6.84), respectively. The proportion of subjects having hospital hypotension was 19.0% (16.5-21.7%) in those with EMS hypotension compared to 2.0% (1.8-2.3%) for those without (p < 0.0001). Additionally, the proportion of patients with TC hypotension was increased even with EMS "near hypotension" up to an SBP of 120 mmHg [(aOR 3.78 (2.97, 4.82)]. CONCLUSION While patients with hypotension in the field or on arrival at the trauma center had markedly increased risk of death compared to those with no hypotension, those with prehospital hypotension that was not resolved before hospital arrival had, by far, the highest odds of death. Furthermore, TBI patients who had prehospital hypotension were five times more likely to arrive hypotensive at the trauma center than those who did not. Finally, even "near-hypotension" in the field was strongly and independently associated the risk of a hypotensive hospital arrival (<90 mmHg). These findings are supportive of the prehospital guidelines that recommend aggressive prevention and treatment of hypotension in major TBI.
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Affiliation(s)
- Amber D Rice
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America.
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, United States of America
| | - Daniel W Spaite
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America
| | - Bruce J Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America
| | - Vatsal Chikani
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ, United States of America
| | - Joshua B Gaither
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America
| | - Kurt R Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America
| | - Gail H Bradley
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ, United States of America
| | - Jeffrey T Howard
- Department of Public Health, University of Texas at San Antonio, United States of America
| | - Samuel M Keim
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ, United States of America; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ, United States of America; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, United States of America
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, TX, United States of America
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Husarek K, Brunelli SM. Midodrine Is an Effective Therapy for Resistant Intradialytic Hypotension: CON. Kidney360 2023; 4:302-305. [PMID: 36996296 PMCID: PMC10103276 DOI: 10.34067/kid.0007422021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/10/2022] [Indexed: 11/27/2022]
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Schmitt CJ, Mattson AE, Brown CS, Mara KC, Cabrera D, Sandefur BJ, Wieruszewski ED. The incidence of cardiovascular instability in patients receiving various vasopressor strategies for peri-intubation hypotension. Am J Emerg Med 2023; 65:104-108. [PMID: 36603354 DOI: 10.1016/j.ajem.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/10/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Patients frequently experience hypotension in the peri-intubation period. This can be due to the underlying disease process, physiologic response to the intervention, or adverse effect from medications. With the heterogeneity in cause for hypotension, the duration can also be short or prolonged. Initiation of vasopressors for peri-intubation hypotension includes various strategies using continuous infusion norepinephrine (NE) or push-dose phenylephrine (PDPE) to obtain goal mean arterial pressure. There is a paucity of data describing cardiovascular stability outcomes in patients receiving vasopressors for peri-intubation hypotension. METHODS This is a retrospective cohort study including emergency department patients across three academic medical centers and smaller health system sites who received vasopressors for hypotension within 30 min of intubation. Patients were matched based on factors likely to influence vasopressor selection and were divided into groups if they received PDPE alone, continuous infusion NE alone, or PDPE followed by continuous infusion NE. The primary outcome was a composite of the incidence of hypotension (systolic blood pressure < 90 mmHg), bradycardia (HR < 60 beats per minute), and cardiac arrest within 2 h following initiation of vasopressors. RESULTS Screening occurred for 2518 patients, with 105 patients undergoing matching. Mean time to vasopressor initiation was 10 min following intubation. The composite primary outcome was not statistically different between groups and occurred 88.6%, 80.0%, and 88.6% in the NE, PDPE, and PDPE+NE groups, respectively. A subgroup analysis of patients with an ED diagnosis of sepsis or septic shock were more likely to receive PDPE before starting continuous infusion NE (41.3% vs. 27.1%, p = 0.075) and more frequently experienced the primary composite outcome (p = 0.045) but was not correlated with vasopressor strategy (p = 0.55). DISCUSSION Cardiovascular instability following vasopressor initiation for peri-intubation hypotension was no different depending on the selected vasopressor strategy. This held true in patients with a sepsis or septic shock diagnosis. Selection of vasopressors should continue to include patient specific factors and product availability.
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Affiliation(s)
- Cassandra J Schmitt
- Department of Pharmacy Services, Mayo Clinic Rochester, United States of America.
| | - Alicia E Mattson
- Department of Pharmacy Services, Mayo Clinic Rochester, United States of America.
| | - Caitlin S Brown
- Department of Pharmacy Services, Mayo Clinic Rochester, United States of America.
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic Rochester, United States of America.
| | - Daniel Cabrera
- Department of Emergency Medicine, Mayo Clinic Rochester, United States of America.
| | - Benjamin J Sandefur
- Department of Emergency Medicine, Mayo Clinic Rochester, United States of America.
| | - Erin D Wieruszewski
- Department of Pharmacy Services, Mayo Clinic Rochester, United States of America.
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154
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Kim JP, Chang TI. Midodrine Is an Effective Therapy for Resistant Intradialytic Hypotension: COMMENTARY. Kidney360 2023; 4:306-307. [PMID: 36996297 PMCID: PMC10103377 DOI: 10.34067/kid.0007442021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 04/25/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Jackson P Kim
- Stanford University Division of Nephrology, Stanford, California
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155
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Nissimov S, Joye S, Kharrat A, Zhu F, Ripstein G, Baczynski M, Choudhury J, Jasani B, Deshpande P, Ye XY, Weisz DE, Jain A. Dopamine or norepinephrine for sepsis-related hypotension in preterm infants: a retrospective cohort study. Eur J Pediatr 2023; 182:1029-1038. [PMID: 36544000 DOI: 10.1007/s00431-022-04758-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
The purpose of this study is to compare the clinical effectiveness of dopamine (DA) versus norepinephrine (NE) as first-line therapy for sepsis-related hypotension in preterm infants. This is a retrospective cohort study over 10 years at two tertiary neonatal units. Preterm infants born < 35 weeks post-menstrual age (PMA), who received DA or NE as primary therapy for hypotension during sepsis, defined as culture-positive or culture-negative infections or necrotizing enterocolitis (NEC), were included. Episode-related mortality (< 7 days from treatment), pre-discharge mortality, and major morbidities among survivors were compared between two groups. Analyses were adjusted using the inverse probability of treatment weighting estimated by propensity score (PS). A total of 156 infants were included, 113 received DA and 43 NE. The mean ± SD PMA at birth and at treatment for the DA and NE groups were 25.8 ± 2.3 vs. 25.2 ± 2.0 weeks and 27.7 ± 3.0 vs. 27.1 ± 2.6 weeks, respectively (p > 0.05). Pre-treatment, the NE group had higher mean airway pressure (14 ± 4 vs. 12 ± 4 cmH2O), heart rate (185 ± 17 vs. 175 ± 17 beats per minute), and median (IQR) fraction of inspired oxygen [0.67 (0.42, 1.0) vs. 0.52 (0.32, 0.82)] (p < 0.05 for all). After PS adjustment, NE was associated with lower episode-related mortality [adjusted odds ratio (95% CI) 0.55 (0.33, 0.92)], pre-discharge mortality [0.60 (0.37, 0.97)], post-illness new diagnosis of significant neurologic injury [0.32 (0.13, 0.82)], and subsequent occurrence of NEC/sepsis among the survivors [0.34, (0.18, 0.65)]. CONCLUSION NE may be more effective than DA for management of sepsis-related hypotension among preterm infants. These data provide a rationale for prospective evaluation of these commonly used agents. WHAT IS KNOWN •Dopamine is the commonest vasoactive agent used to support blood pressure among preterm infants. •For adult patients, norepinephrine is recommended as the preferred therapy over dopamine for septic shock. WHAT IS NEW •This is the first study examining the relative clinical effectiveness of dopamine and norepinephrine as first-line pharmacotherapy for sepsis-related hypotension among preterm infants. •Norepinephrine use may be associated with lower mortality and morbidity than dopamine in preterm infants with sepsis.
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Affiliation(s)
- Sagee Nissimov
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada
| | - Sébastien Joye
- Clinic of Neonatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Ashraf Kharrat
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Faith Zhu
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Michelle Baczynski
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - Julie Choudhury
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Bonny Jasani
- Division of Neonatology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Poorva Deshpande
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Xiang Y Ye
- Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Dany E Weisz
- Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada.
- Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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Elattaby GH, Kora MA, Emara MM, El-Khair NTA, Kasem HE. Nitric Oxide Levels as a Marker of Intradialytic Hypertension in End-Stage Renal Disease Patients. Saudi J Kidney Dis Transpl 2023; 34:134-141. [PMID: 38146722 DOI: 10.4103/1319-2442.391891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
Intradialytic hypertension (IDH) is an important emerging complication in hemodialysis patients. No study has examined the diagnostic markers of various risk factors for the occurrence of IDH in chronic hemodialysis patients. Therefore, our study aimed to assess the use of nitric oxide (NO) as a marker of IDH among end-stage renal disease patients. The patients were divided into two groups: Group I (40 patients) with IDH and Group II (40 patients) without IDH. For all participants, a full medical history was taken, followed by laboratory examinations to measure the level of NO and a clinical examination. The dose of erythropoietin per week, the level of intact parathyroid hormone, and platelet count were significantly higher in Group I than in Group II, whereas the mean level of NO (2.10 ± 1.23 pmol/L) was highly significantly lower in patients with IDH (P < 0.001). Multivariate analysis showed that hypertension (odds ratio: 1.824, 95% confidence interval: 1.273-2.982) and the level of NO (odds ratio: 1.68, 95% confidence interval: 1.13-2.97) were independent risk factors for IDH. The receiver operating characteristic curve showed that the cutoff point of NO was 2.52 μmol/L to differentiate between cases with and without IDH (area under the curve = 0.844). Our findings support previous research regarding the involvement of endothelial dysfunction and a higher sodium level in the pathogenesis of IDH. We also found that the NO level had a good diagnostic value for the occurrence of IDH at a cutoff of 2.52 μmol/L.
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Affiliation(s)
- Ghada H Elattaby
- Department of Internal Medicine, Faculty of Medicine, Menoufia, Egypt
| | - Mahmoud A Kora
- Nephrology Unit, Department of Internal Medicine, Menoufia, Egypt
| | - Mahmoud M Emara
- Nephrology Unit, Department of Internal Medicine, Menoufia, Egypt
| | - Noran T Abo El-Khair
- Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Heba E Kasem
- Nephrology Unit, Department of Internal Medicine, Menoufia, Egypt
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157
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House AA, McIntyre CW. Midodrine Is an Effective Therapy for Resistant Intradialytic Hypotension: PRO. Kidney360 2023; 4:299-301. [PMID: 36996295 PMCID: PMC10103263 DOI: 10.34067/kid.0007432021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/14/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Andrew A. House
- The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, Canada
- Division of Nephrology, Department of Medicine, London Health Sciences Centre and Schulich School of Medicine and Dentistry, London, Canada
- Lawson Health Research Institute, London, Canada
| | - Christopher W. McIntyre
- The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, Canada
- Division of Nephrology, Department of Medicine, London Health Sciences Centre and Schulich School of Medicine and Dentistry, London, Canada
- Lawson Health Research Institute, London, Canada
- Department of Medical Biophysics, Western University, London, Canada
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158
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Shapiro NI, Douglas IS, Brower RG, Brown SM, Exline MC, Ginde AA, Gong MN, Grissom CK, Hayden D, Hough CL, Huang W, Iwashyna TJ, Jones AE, Khan A, Lai P, Liu KD, Miller CD, Oldmixon K, Park PK, Rice TW, Ringwood N, Semler MW, Steingrub JS, Talmor D, Thompson BT, Yealy DM, Self WH. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. N Engl J Med 2023; 388:499-510. [PMID: 36688507 PMCID: PMC10685906 DOI: 10.1056/nejmoa2212663] [Citation(s) in RCA: 86] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intravenous fluids and vasopressor agents are commonly used in early resuscitation of patients with sepsis, but comparative data for prioritizing their delivery are limited. METHODS In an unblinded superiority trial conducted at 60 U.S. centers, we randomly assigned patients to either a restrictive fluid strategy (prioritizing vasopressors and lower intravenous fluid volumes) or a liberal fluid strategy (prioritizing higher volumes of intravenous fluids before vasopressor use) for a 24-hour period. Randomization occurred within 4 hours after a patient met the criteria for sepsis-induced hypotension refractory to initial treatment with 1 to 3 liters of intravenous fluid. We hypothesized that all-cause mortality before discharge home by day 90 (primary outcome) would be lower with a restrictive fluid strategy than with a liberal fluid strategy. Safety was also assessed. RESULTS A total of 1563 patients were enrolled, with 782 assigned to the restrictive fluid group and 781 to the liberal fluid group. Resuscitation therapies that were administered during the 24-hour protocol period differed between the two groups; less intravenous fluid was administered in the restrictive fluid group than in the liberal fluid group (difference of medians, -2134 ml; 95% confidence interval [CI], -2318 to -1949), whereas the restrictive fluid group had earlier, more prevalent, and longer duration of vasopressor use. Death from any cause before discharge home by day 90 occurred in 109 patients (14.0%) in the restrictive fluid group and in 116 patients (14.9%) in the liberal fluid group (estimated difference, -0.9 percentage points; 95% CI, -4.4 to 2.6; P = 0.61); 5 patients in the restrictive fluid group and 4 patients in the liberal fluid group had their data censored (lost to follow-up). The number of reported serious adverse events was similar in the two groups. CONCLUSIONS Among patients with sepsis-induced hypotension, the restrictive fluid strategy that was used in this trial did not result in significantly lower (or higher) mortality before discharge home by day 90 than the liberal fluid strategy. (Funded by the National Heart, Lung, and Blood Institute; CLOVERS ClinicalTrials.gov number, NCT03434028.).
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Affiliation(s)
- Nathan I Shapiro
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Ivor S Douglas
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Roy G Brower
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Samuel M Brown
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Matthew C Exline
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Adit A Ginde
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Michelle N Gong
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Colin K Grissom
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Douglas Hayden
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Catherine L Hough
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Weixing Huang
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Theodore J Iwashyna
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Alan E Jones
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Akram Khan
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Poying Lai
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Kathleen D Liu
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Chadwick D Miller
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Katherine Oldmixon
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Pauline K Park
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Todd W Rice
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Nancy Ringwood
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Matthew W Semler
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Jay S Steingrub
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Daniel Talmor
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - B Taylor Thompson
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Donald M Yealy
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Wesley H Self
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
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159
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Lee B, Lim BL, Lee WF. Woman With Fever and Hypotension. Ann Emerg Med 2023; 81:e11-e12. [PMID: 36681429 DOI: 10.1016/j.annemergmed.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 01/21/2023]
Affiliation(s)
- Berlin Lee
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | - Beng L Lim
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | - Wei F Lee
- Emergency Department, Ng Teng Fong General Hospital, Singapore
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160
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Batista JE, Diaz C, Aviles N, Moreno M, Akhter M. Elderly Woman With Fever and Hypotension. Ann Emerg Med 2023; 81:143-161. [PMID: 36681422 DOI: 10.1016/j.annemergmed.2022.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 01/21/2023]
Affiliation(s)
- José E Batista
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL
| | - Conley Diaz
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL
| | - Nicolle Aviles
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL
| | - Moises Moreno
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL
| | - Murtaza Akhter
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL; Department of Emergency Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ; Department of Emergency Medicine, Penn State Hershey Medical Center, Hershey, PA
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161
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Schnetz MP, Danks DJ, Mahajan A. Preoperative Identification of Patient-Dependent Blood Pressure Targets Associated With Low Risk of Intraoperative Hypotension During Noncardiac Surgery. Anesth Analg 2023; 136:194-203. [PMID: 36399417 PMCID: PMC9812417 DOI: 10.1213/ane.0000000000006238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intraoperative hypotension (IOH) is strongly linked to organ system injuries and postoperative death. Blood pressure itself is a powerful predictor of IOH; however, it is unclear which pressures carry the lowest risk and may be leveraged to prevent subsequent hypotension. Our objective was to develop a model that predicts, before surgery and according to a patient's unique characteristics, which intraoperative mean arterial pressures (MAPs) between 65 and 100 mm Hg have a low risk of IOH, defined as an MAP <65 mm Hg, and may serve as testable hemodynamic targets to prevent IOH. METHODS Adult, noncardiac surgeries under general anesthesia at 2 tertiary care hospitals of the University of Pittsburgh Medical Center were divided into training and validation cohorts, then assigned into smaller subgroups according to preoperative risk factors. Primary outcome was hypotension risk, defined for each intraoperative MAP value from 65 to 100 mm Hg as the proportion of a value's total measurements followed by at least 1 MAP <65 mm Hg within 5 or 10 minutes, and calculated for all values in each subgroup. Five models depicting MAP-associated IOH risk were compared according to best fit across subgroups with proportions whose confidence interval was <0.05. For the best fitting model, (1) performance was validated, (2) low-risk MAP targets were identified according to applied benchmarks, and (3) preoperative risk factors were evaluated as predictors of model parameters. RESULTS A total of 166,091 surgeries were included, with 121,032 and 45,059 surgeries containing 5.4 million and 1.9 million MAP measurements included in the training and validation sets, respectively. Thirty-six subgroups with at least 21 eligible proportions (confidence interval <0.05) were identified, representing 92% and 94% of available MAP measurements, respectively. The exponential with theta constant model demonstrated the best fit (weighted sum of squared error 0.0005), and the mean squared error of hypotension risk per MAP did not exceed 0.01% in validation testing. MAP targets ranged between 69 and 90 mm Hg depending on the subgroup and benchmark used. Increased age, higher American Society of Anesthesiologists physical status, and female sexindependently predicted ( P < .05) hypotension risk curves with less rapid decay and higher plateaus. CONCLUSIONS We demonstrate that IOH risk specific to a given MAP is patient-dependent, but predictable before surgery. Our model can identify intraoperative MAP targets before surgery predicted to reduce a patient's exposure to IOH, potentially allowing clinicians to develop more personalized approaches for managing hemodynamics.
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Affiliation(s)
- Michael P. Schnetz
- From the Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David J. Danks
- Departments of Philosophy and Psychology, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Aman Mahajan
- From the Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania
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162
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Cui Q, Che L, Zang H, Yu J, Xu L, Huang Y. Association between preoperative autonomic nervous system function and post-induction hypotension in elderly patients: a protocol for a cohort study. BMJ Open 2023; 13:e067400. [PMID: 36717143 PMCID: PMC9887722 DOI: 10.1136/bmjopen-2022-067400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Post-induction hypotension (PIH), which is prevalent among elderly patients, is associated with adverse perioperative outcomes. As a critical part of blood pressure regulation, baroreflex control is believed to be closely related to intraoperative blood pressure fluctuations. Spontaneous baroreflex sensitivity and heart rate variability measurement can aid evaluation of patients' autonomic function. This study aims to determine the association between preoperative decreased baroreflex function and PIH in elderly patients. METHODS AND ANALYSIS This prospective cohort study will enrol patients who are 65 years old and above, scheduled for elective non-cardiac surgery under general anaesthesia, and American Society of Anesthesiologists physical status I-III (n=180). Baseline assessment will include routine preoperative evaluations as well as symptoms and anamneses associated with baroreflex failure. Preoperative autonomic function monitoring will be performed through 20 min of continuous beat-to-beat heart rate and blood pressure monitoring using LiDCO rapid (Masimo Corporation, USA). The primary outcome will be PIH. Detailed use of anaesthetic agents during induction and maintenance will be documented for adjustment in multivariable analyses. ETHICS AND DISSEMINATION The Research Ethics Committee of Peking Union Medical College Hospital approved the study protocol (I-22PJ008). We aim to publish and disseminate our findings in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05425147.
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Affiliation(s)
- Quexuan Cui
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Lu Che
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Han Zang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiawen Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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163
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Niemczyk L, Romejko K, Szamotulska K, Schneditz D, Niemczyk S. Changes of Hemodynamic Parameters after Intradialytic Glucose Injection. Nutrients 2023; 15:nu15020437. [PMID: 36678308 PMCID: PMC9865591 DOI: 10.3390/nu15020437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/28/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Intradialytic hypotension (IDH) is a frequent complication of hemodialysis (HD). Current methods of IDH prevention are insufficient. METHODS We analyzed the intradialytic time course of systolic (SBP), diastolic (DBP), mean arterial (MAP), pulse pressure (PP), and heart rate (HR) in a group of chronic kidney disease (CKD) patients. First, 30 min into HD, a 40% glucose solution was injected into the venous line of the extracorporeal circulation at a dose of 0.5 g/kg of dry weight. Pressures and HR were measured in frequent intervals. Relative volume overload was determined by bioimpedance spectroscopy. RESULTS Thirty-five participants were studied. SBP increased after 5, 10, and 20 min of glucose infusion. DBP increased after 2 and 3 h and also at the end of HD. PP increased after 5, 10, and 20 min of glucose infusion and fell after the 2nd and 3rd hour and also at the end of HD. MAP increased after 2 and 3 h of glucose injection and at the end of HD. Significant interactions of the time course of SBP, DBP, MAP, with HR at baseline and of the time course of PP with fluid overload were observed. Symptomatic hypotensive episodes were absent. CONCLUSIONS Glucose infusions during HD prevent symptomatic IDH and do not cause severe hypertensive episodes.
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Affiliation(s)
- Longin Niemczyk
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, 1a Banacha Street, 02-097 Warsaw, Poland
| | - Katarzyna Romejko
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 128 Szaserów Street, 04-141 Warsaw, Poland
- Correspondence:
| | - Katarzyna Szamotulska
- Department of Epidemiology and Biostatistics, Institute of Mother and Child, 17 a Kasprzaka Street, 01-211 Warsaw, Poland
| | - Daniel Schneditz
- Otto Loewi Research Center, Division of Physiology, Medical University of Graz, Neue Stiftingtalstrasse 6/V, 8010 Graz, Austria
| | - Stanisław Niemczyk
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 128 Szaserów Street, 04-141 Warsaw, Poland
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McGuigan PJ, Giallongo E, Blackwood B, Doidge J, Harrison DA, Nichol AD, Rowan KM, Shankar-Hari M, Skrifvars MB, Thomas K, McAuley DF. The effect of blood pressure on mortality following out-of-hospital cardiac arrest: a retrospective cohort study of the United Kingdom Intensive Care National Audit and Research Centre database. Crit Care 2023; 27:4. [PMID: 36604745 PMCID: PMC9817239 DOI: 10.1186/s13054-022-04289-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/20/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Hypotension following out-of-hospital cardiac arrest (OHCA) may cause secondary brain injury and increase mortality rates. Current guidelines recommend avoiding hypotension. However, the optimal blood pressure following OHCA is unknown. We hypothesised that exposure to hypotension and hypertension in the first 24 h in ICU would be associated with mortality following OHCA. METHODS We conducted a retrospective analysis of OHCA patients included in the Intensive Care National Audit and Research Centre Case Mix Programme from 1 January 2010 to 31 December 2019. Restricted cubic splines were created following adjustment for important prognostic variables. We report the adjusted odds ratio for associations between lowest and highest mean arterial pressure (MAP) and systolic blood pressure (SBP) in the first 24 h of ICU care and hospital mortality. RESULTS A total of 32,349 patients were included in the analysis. Hospital mortality was 56.2%. The median lowest and highest MAP and SBP were similar in survivors and non-survivors. Both hypotension and hypertension were associated with increased mortality. Patients who had a lowest recorded MAP in the range 60-63 mmHg had the lowest associated mortality. Patients who had a highest recorded MAP in the range 95-104 mmHg had the lowest associated mortality. The association between SBP and mortality followed a similar pattern to MAP. CONCLUSIONS We found an association between hypotension and hypertension in the first 24 h in ICU and mortality following OHCA. The inability to distinguish between the median blood pressure of survivors and non-survivors indicates the need for research into individualised blood pressure targets for survivors following OHCA.
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Affiliation(s)
- Peter J McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK.
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK.
| | - Elisa Giallongo
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - James Doidge
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - David A Harrison
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Alistair D Nichol
- University College Dublin Clinical Research Centre, St Vincent's University Hospital, Dublin, Ireland
- The Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Manu Shankar-Hari
- Centre for Inflammation Research, Institute of Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki, Helsinki, Finland
- Helsinki University Hospital, Helsinki, Finland
| | - Karen Thomas
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Danny F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
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165
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Davis DP, Olvera D, Selde W, Wilmas J, Stuhlmiller D. Bolus Vasopressor Use for Air Medical Rapid Sequence Intubation: The Vasopressor Intravenous Push to Enhance Resuscitation Trial. Air Med J 2023; 42:36-41. [PMID: 36710033 DOI: 10.1016/j.amj.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 08/30/2022] [Accepted: 09/22/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Rapid sequence intubation (RSI) may compromise perfusion because of the use of sympatholytic medications as well as subsequent positive pressure ventilation. The use of bolus vasopressor agents may reverse hypotension and prevent arrest. METHODS This was a prospective, observational study enrolling air medical patients with critical peri-RSI hypotension (systolic blood pressure [SBP] < 90 mm Hg) to receive either arginine vasopressin (aVP), 2 U intravenously every 5 minutes, for trauma patients or phenylephrine (PE), 200 μg intravenously every 5 minutes, for nontrauma patients. The main outcome measures included an increase in SBP, a reversal of hypotension, and the occurrence of dysrhythmia or hypertension (SBP > 160 mm Hg) within 20 minutes of vasopressor administration. RESULTS A total of 523 patients (344 aVP and 179 PE) were enrolled over 2 years. An increase in SBP was observed in 326 aVP patients (95%), with reversal of hypotension in 272 patients (79%). An increase in SBP was observed in 171 PE patients (96%), with reversal of hypotension in 148 patients (83%). A low rate of rebound hypertension was observed for both aVP and PE patients. CONCLUSION Both aVP and PE appear to be safe and effective for treating critical hypotension in the peri-RSI period.
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Affiliation(s)
| | | | | | - John Wilmas
- Air Methods Corporation, Greenwood Village, CO
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166
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Clark CE. Hypertension and hypotension: getting the balance right. Br J Gen Pract 2023; 73:6-7. [PMID: 36543552 PMCID: PMC9799343 DOI: 10.3399/bjgp23x731493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Christopher E Clark
- Primary Care Research Group, Faculty of Health and Life Sciences, University of Exeter Medical School, Exeter
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Kompotiatis P, Shawwa K, Jentzer JC, Wiley BM, Kashani KB. Echocardiographic parameters and hemodynamic instability at the initiation of continuous kidney replacement therapy. J Nephrol 2023; 36:173-181. [PMID: 35849262 DOI: 10.1007/s40620-022-01400-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/06/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Investigate the association of echocardiographic parameters with hemodynamic instability after initiating continuous kidney replacement therapy (CKRT) in a cohort of intensive care unit (ICU) patients requiring CKRT. METHODS Historical cohort study of consecutive adults admitted to the ICU at a tertiary care hospital from December 2006 through November 2015 who underwent CKRT and had an echocardiogram done within seven days before CKRT initiation. The primary outcome was hypotension within one hour of CKRT initiation. RESULTS We included 980 patients, 804 (82%) with acute kidney injury (AKI) and 176 (18%) with end-stage kidney disease (ESKD). Median patient age was 63 (± 14) years, and median Sequential Organ Failure Assessment (SOFA) score on the day of CKRT initiation was 12 (IQR 10-14). Multivariable analysis showed that Left (OR 2.01, 95% CI 1.04-3.86), and Right (OR 1.5, 95% CI 1.04-2.25) moderate and severe ventricular enlargement, Vasoactive-Inotropic Score (VIS) one hour before CKRT initiation (OR 1.18 per 10 units increase, 95% CI 1.09-1.28) and high bicarbonate fluid replacement (OR 2.52, 95% CI 1.01-6.2) were associated with hypotension after CKRT initiation. CONCLUSION Right and left ventricular enlargement are risk factors associated with hypotension after CKRT initiation.
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Affiliation(s)
- Panagiotis Kompotiatis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Khaled Shawwa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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Chowdhury SR, Datta PK, Maitra S, Rawat D, Baidya DK, Roy A, Nath S. The use of preoperative inferior vena cava ultrasound to predict anaesthesia-induced hypotension: a systematic review. Anaesthesiol Intensive Ther 2023; 55:18-31. [PMID: 37306268 PMCID: PMC10156560 DOI: 10.5114/ait.2023.125310] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/09/2022] [Indexed: 09/20/2023] Open
Abstract
Preoperative ultrasound assessment of inferior vena cava (IVC) diameter and the collapsi-bility index might identify patients with intravascular volume depletion. The purpose of this review was to gather the existing evidence to find out whether preoperative IVC ultrasound (IVCUS) derived parameters can reliably predict hypotension after spinal or general anaesthesia. PubMed was searched to identify research articles that addressed the role of IVC ultrasound in predicting hypotension after spinal and general anaesthesia in adult patients. We included 4 randomized control trials and 17 observational studies in our final review. Among these, 15 studies involved spinal anaesthesia and 6 studies involved general anaesthesia. Heterogeneity with respect to the patient populations under evaluation, definitions used for hypotension after anaesthesia, IVCUS assessment methods, and cut-off values for IVCUS-derived parameters to predict hypotension precluded pooled meta-analysis. The maximum and minimum reported sensitivity of the IVC collapsibility index (IVCCI) for predicting post-spinal hypotension was 84.6% and 58.8% respectively, while the maximum and minimum specificities were 93.1% and 23.5% respectively. For the prediction of hypotension after general anaesthesia induction, the reported ranges of sensitivity and specificity of IVCCI were 86.67% to 45.5% and 94.29% to 77.27%, respectively. Current literature on the predictive role of IVCUS for hypotension after anaesthesia is heterogeneous both in methodology and in results. Standardization of the definition of hypotension under anaesthesia, method of IVCUS assessment, and the cut-offs for IVC diameter and the collapsibility index for prediction of hypotension after anaesthesia are necessary for drawing clinically relevant conclusions.
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Affiliation(s)
- Sumit Roy Chowdhury
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Priyankar Kumar Datta
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Souvik Maitra
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Dimple Rawat
- Clinical Epidemiology Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Dalim Kumar Baidya
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Avishek Roy
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Sayan Nath
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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169
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Lau C, Ho C. A 67-Year-Old Woman With Fluctuating Hypertension and Hypotension After Elective Surgery. Chest 2023; 163:e19-e22. [PMID: 36628680 DOI: 10.1016/j.chest.2022.08.2215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/17/2022] [Accepted: 08/16/2022] [Indexed: 01/11/2023] Open
Abstract
CASE PRESENTATION A 67-year-old woman with hypertension, type 2 diabetes mellitus, and hypothyroidism presented for an elective blepharoplasty. She underwent monitored anesthesia care with propofol and dexmedetomidine. No inhaled gases or neuromuscular blockade were administered during the procedure.
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Affiliation(s)
- Christopher Lau
- Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Cynthia Ho
- Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
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170
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Li W, Hu Z, Yuan Y, Liu J, Li K. Effect of hypotension prediction index in the prevention of intraoperative hypotension during noncardiac surgery: A systematic review. J Clin Anesth 2022; 83:110981. [PMID: 36242978 DOI: 10.1016/j.jclinane.2022.110981] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/01/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
Intraoperative hypotension (IOH) is common in noncardiac surgery and is associated with serious postoperative complications. Hypotension Prediction Index (HPI) has shown high sensitivity and specificity for predicting hypotension and may reduce IOH in noncardiac surgery. We conducted a systematic review of randomized controlled trials (RCTs) to evaluate the applications and effects of HPI in reducing hypotension during noncardiac surgery. We comprehensively searched the PubMed, Embase, Cochrane Library, Google Scholar, and http://ClinicalTrials.gov databases to identify RCTs conducted before May 2022. The primary outcome measures were the time-weighted average (TWA) of hypotension and the area under the hypotensive threshold (65 mmHg). Secondary outcomes were the incidence and duration of hypotension and the percentage of hypotensive time during surgery. The Cochrane Risk of Bias (RoB) tool was used to assess the quality of selected studies. We conducted data synthesis for median differences and assessed the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. We included five studies with a total of 461 patients. Limited evidence suggested that HPI-guided intraoperative hemodynamics management leads to lower a) TWA of hypotension (median of difference of medians [MDM], -0.27 mmHg; 95% confidence interval [CI], -0.38, -0.01), b) area under the hypotensive threshold (MDM, -60.28 mmHg*min; 95% CI, -74.00, -1.30), c) incidence of hypotension (MDM, -4.50; 95% CI, -5.00, -4.00), d) total duration of hypotension (MDM, -12.80 min; 95% CI, -16.11, -3.39), and e) percentage of hypotension (MDM, -5.80; 95% CI, -6.65, -4.82) than routine hemodynamic management during noncardiac surgery. However, only very low- to low-quality evidence on the benefit of intraoperative HPI-based hemodynamic management is available. Our review revealed that HPI has the potential to reduce the occurrence, duration, and severity of IOH during noncardiac surgery compared to standard intraoperative care with proper adherence to the protocol. Systematic review registration PROSPERO CRD42022333834.
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Affiliation(s)
- Wangyu Li
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Zhouting Hu
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Yuxin Yuan
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Jiayan Liu
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Kai Li
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun 130033, China.
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171
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Yoshimura M, Shiramoto H, Koga M, Morimoto Y. Preoperative echocardiography predictive analytics for postinduction hypotension prediction. PLoS One 2022; 17:e0278140. [PMID: 36441797 PMCID: PMC9704611 DOI: 10.1371/journal.pone.0278140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/09/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Hypotension is a risk factor for adverse perioperative outcomes. Preoperative transthoracic echocardiography has been extended for preoperative risk assessment before noncardiac surgery. This study aimed to develop a machine learning model to predict postinduction hypotension risk using preoperative echocardiographic data and compared it with conventional statistic models. We also aimed to identify preoperative echocardiographic factors that cause postinduction hypotension. METHODS In this retrospective observational study, we extracted data from electronic health records of patients aged >18 years who underwent general anesthesia at a single tertiary care center between April 2014 and September 2019. Multiple supervised machine learning classification techniques were used, with postinduction hypotension (mean arterial pressure <55 mmHg from intubation to the start of the procedure) as the primary outcome and 95 transthoracic echocardiography measurements as factors influencing the primary outcome. Based on the mean cross-validation performance, we used 10-fold cross-validation with the training set (70%) to select the optimal hyperparameters and architecture, assessed ten times using a separate test set (30%). RESULTS Of 1,956 patients, 670 (34%) had postinduction hypotension. The area under the receiver operating characteristic curve using the deep neural network was 0.72 (95% confidence interval (CI) = 0.67-0.76), gradient boosting machine was 0.54 (95% CI = 0.51-0.59), linear discriminant analysis was 0.56 (95% CI = 0.51-0.61), and logistic regression was 0.56 (95% CI = 0.51-0.61). Variables of high importance included the ascending aorta diameter, transmitral flow A wave, heart rate, pulmonary venous flow S wave, tricuspid regurgitation pressure gradient, inferior vena cava expiratory diameter, fractional shortening, left ventricular mass index, and end-systolic volume. CONCLUSION We have created developing models that can predict postinduction hypotension using preoperative echocardiographic data, thereby demonstrating the feasibility of using machine learning models of preoperative echocardiographic data for produce higher accuracy than the conventional model.
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Affiliation(s)
- Manabu Yoshimura
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Yamaguchi, Japan
- * E-mail:
| | - Hiroko Shiramoto
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Yamaguchi, Japan
| | - Mami Koga
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Yamaguchi, Japan
| | - Yasuhiro Morimoto
- Department of Anesthesiology, Ube Industries Central Hospital, Ube, Yamaguchi, Japan
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172
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Yang M, Kang C, Zhu S. Effects of epidural anesthesia in pheochromocytoma and paraganglioma surgeries: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e31768. [PMID: 36451496 PMCID: PMC9704962 DOI: 10.1097/md.0000000000031768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Anesthetic management is a great challenge during the surgical resection of pheochromocytomas and paragangliomas (PPGLs) due to potential hemodynamic fluctuations and/or postoperative complications. Although combined epidural-general anesthesia is commonly used in PPGLs surgeries, there is still no consensus whether combined epidural-general anesthesia was superior than general anesthesia alone for these populations. For the first time, we conducted this systematic review and meta-analysis to summarize the effects of combined epidural-general anesthesia versus general anesthesia alone on hemodynamic fluctuations as well as postoperative complications in patients undergone PPGLs surgeries. METHODS This systematic review and meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analyses statement. The primary outcome were hemodynamic fluctuations, including intraoperative hypotension, postoperative hypotension, and hypertensive crisis. Secondary outcome was the incidence of postoperative complications during hospital stay. RESULTS Finally, three retrospective cohort studies involving 347 patients met the inclusion criteria. A meta-analysis was not performed since outcomes from included studies were not available to be pooled. On the basis of the findings of non-randomized controlled trials (RCTs) literature, 2 studies suggested that combined epidural-general anesthesia was associated with intraoperative and postoperative hypotension, although one study reported that epidural anesthesia use reduced the incidence of postoperative complications in patients undergone surgical resection of PPGLs. CONCLUSIONS Currently, no published RCTs have yet assessed clinically relevant outcomes with respect to the application of epidural anesthesia during PPGLs surgeries. Well-designed RCTs should nonetheless be encouraged to properly assess the efficacy and safety of epidural anesthesia for PPGLs surgeries.
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Affiliation(s)
- Min Yang
- Department of Anesthesiology, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Chao Kang
- Department of Anesthesiology, Northwest Women’s and Children’s Hospital, Xi’an, China
| | - Shuai Zhu
- Department of Anesthesiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- * Correspondence: Shuai Zhu, Department of Anesthesiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, China (e-mail: )
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173
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Foster M, Self M, Gelber A, Kennis B, Lasoff DR, Hayden SR, Wardi G. Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation. Am J Emerg Med 2022; 61:131-136. [PMID: 36096015 PMCID: PMC10106101 DOI: 10.1016/j.ajem.2022.08.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/13/2022] [Accepted: 08/27/2022] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Emergency department (ED) patients undergoing emergent tracheal intubation often have multiple physiologic derangements putting them at risk for post-intubation hypotension. Prior work has shown that post-intubation hypotension is independently associated with increased morbidity and mortality. The choice of induction agent may be associated with post-intubation hypotension. Etomidate and ketamine are two of the most commonly used agents in the ED, however, there is controversy regarding whether either agent is superior in the setting of hemodynamic instability. The goal of this study is to determine whether there is a difference in the rate of post-intubation hypotension who received either ketamine or etomidate for induction. Additionally, we provide a subgroup analysis of patients at pre-existing risk of cardiovascular collapse (identified by pre-intubation shock index (SI) > 0.9) to determine if differences in rates of post-intubation hypotension exist as a function of sedative choice administered during tracheal intubation in these high-risk patients. We hypothesize that there is no difference in the incidence of post-intubation hypotension in patients who receive ketamine versus etomidate. METHODS A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016-6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension. RESULTS A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: -0.14 (95%, CI -0.2 to -0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: -10%, 95% CI -20.9% to -0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension. CONCLUSION In our cohort of patients undergoing emergent tracheal intubation, ketamine was used more often for patients with an elevated shock index. We did not identify an association between the incidence of post-intubation hypotension and induction agent between ketamine and etomidate. Patients with an elevated shock index were at higher risk of cardiovascular collapse regardless of the choice of ketamine or etomidate.
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Affiliation(s)
- Mitchell Foster
- University of California San Diego School of Medicine, California, United States; Department of Emergency Medicine, NYU Langone Health and NYC Health + Hospitals/Bellevue, New York, United States.
| | - Michael Self
- Department of Emergency Medicine, UC San Diego Health, California, United States; Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, UC San Diego Health, California, United States.
| | - Alon Gelber
- University of California San Diego School of Medicine, California, United States; Department of Bioengineering, University of California at San Diego, California, United States.
| | - Brent Kennis
- University of California San Diego School of Medicine, California, United States.
| | - Daniel R Lasoff
- Department of Emergency Medicine, UC San Diego Health, California, United States; Division of Medical Toxicology, UC San Diego Health, California, United States.
| | - Stephen R Hayden
- Department of Emergency Medicine, UC San Diego Health, California, United States.
| | - Gabriel Wardi
- Department of Emergency Medicine, UC San Diego Health, California, United States; Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego Health, California, United States.
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174
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Xiang Z, Lin X, Wang J, Yu G. The clinical efficacy of Shenmai injection in the prophylaxis and treatment of intradialytic hypotension: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e30949. [PMID: 36254066 PMCID: PMC9575838 DOI: 10.1097/md.0000000000030949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Intradialytic hypotension (IDH) is a common complication in hemodialysis. IDH can induce vomiting, chest tightness and syncope, and hemodialysis shall be discontinued in patients with severe IDH. As is revealed in related studies, Shenmai injection (SMI) can be used in the prophylaxis and treatment of IDH. However, there is still a lack of consensus about the efficacy among reported studies, which cannot provide compelling evidence. Therefore, a meta-analysis was conducted in this study to further investigate the efficacy and safety of SMI in the prophylaxis and treatment of IDH. METHODS PubMed, Web of Science, Scopus, Cochrane Library, Embase, China Scientific Journal Database, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang Data were systematically retrieved from their establishment to June 2022. Subsequently, literature screening, data extraction, quality evaluation and cross-checking of results were performed according to the Cochrane Handbook. Besides, a meta-analysis was performed with the assistance of Revman 5.3 software. RESULTS This study will evaluate whether SMI is effective in the prophylaxis and treatment of IDH. CONCLUSIONS The latest evidence for the efficacy and safety of SMI in the prevention and treatment of IDH can be provided through this study.
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Affiliation(s)
- Zhen Xiang
- Department of Nephropathy Rheumatism, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, Hubei Province, China
| | - Xin Lin
- Department of Nephropathy Rheumatism, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, Hubei Province, China
| | - Jun Wang
- Department of Nephropathy Rheumatism, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, Hubei Province, China
| | - Guodan Yu
- Department of Nephropathy Rheumatism, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, Hubei Province, China
- *Correspondence: Guodan Yu, Department of Nephropathy Rheumatism, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, Hubei Province, China (e-mail: )
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Priyanka P, Chang CCH, Chawla LS, Kellum JA, Clermont G, Murugan R. VASOPRESSOR-RESISTANT HYPOTENSION, COMBINATION VASOPRESSOR THERAPY, AND SHOCK PHENOTYPES IN CRITICALLY ILL ADULTS WITH VASODILATORY SHOCK. Shock 2022; 58:260-268. [PMID: 36018286 PMCID: PMC9584039 DOI: 10.1097/shk.0000000000001980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/09/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Objective: To examine the risk factors, resource utilization, and 1-year mortality associated with vasopressor-resistant hypotension (VRH) compared with vasopressor-sensitive hypotension (VSH) among critically ill adults with vasodilatory shock. We also examined whether combination vasopressor therapy and patient phenotype were associated with mortality. Design: Retrospective cohort study. Setting: Eight medical-surgical intensive care units at the University of Pittsburgh Medical Center, Pittsburgh, PA. Patients : Critically ill patients with vasodilatory shock admitted between July 2000 and October 2008. Interventions : None. Measurements and Main Results: Vasopressor-resistant hypotension was defined as those requiring greater than 0.2 μg/kg per minute of norepinephrine equivalent dose of vasopressor consecutively for more than 6 h, and VSH was defined as patients requiring ≤0.2 μg/kg per minute to maintain MAP between 55 and 70 mm Hg after adequate fluid resuscitation. Of 5,313 patients with vasodilatory shock, 1,291 patients (24.3%) developed VRH. Compared with VSH, VRH was associated with increased risk of acute kidney injury (72.7% vs. 65.0%; P < 0.001), use of kidney replacement therapy (26.0% vs. 11.0%; P < 0.001), longer median (interquartile range [IQR]) intensive care unit length of stay (10 [IQR, 4.0-20.0] vs. 6 [IQR, 3.0-13.0] days; P < 0.001), and increased 1-year mortality (64.7% vs. 34.8%; P < 0.001). Vasopressor-resistant hypotension was associated with increased odds of risk-adjusted mortality (adjusted odds ratio [aOR], 2.93; 95% confidence interval [CI], 2.52-3.40; P < 0.001). When compared with monotherapy, combination vasopressor therapy with two (aOR, 0.91; 95% CI, 0.78-1.06) and three or more vasopressors was not associated with lower mortality (aOR, 0.93; 95% CI, 0.68-1.27). Using a finite mixture model, we identified four unique phenotypes of patient clusters that differed with respect to demographics, severity of illness, processes of care, vasopressor use, and outcomes. Conclusions: Among critically ill patients with vasodilatory shock, VRH compared with VSH is associated with increased resource utilization and long-term risk of death. However, combination vasopressor therapy was not associated with lower risk of death. We identified four unique phenotypes of patient clusters that require further validation.
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Affiliation(s)
- Priyanka Priyanka
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Biostatistics and Data Management Core, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Chung-Chou H. Chang
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Biostatistics and Data Management Core, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lakhmir S. Chawla
- Department of Veterans Affairs Medical Center, San Diego, California
| | - John A. Kellum
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gilles Clermont
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Raghavan Murugan
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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176
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Gülaşti F, Gülaşti S, Sari S. Tricuspid annular plane systolic excursion to predict arterial hypotension caused by general anesthesia induction. Minerva Anestesiol 2022; 89:265-272. [PMID: 36282227 DOI: 10.23736/s0375-9393.22.16711-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hypotension, which may develop after anesthesia induction, may cause ischemic stroke, myocardial damage, acute kidney injury, and postoperative mortality. Various assessments can be used to predict hypotension. We aimed to test the relationship of tricuspid annular plane systolic movement (TAPSE) with hypotension. METHODS A total of 47 patients aged 18-65 years, who were scheduled for general anesthesia for elective surgery, had ASA I-II, and had no known cardiovascular disease, were included in the study. TAPSE was calculated in an apical four-chamber view by placing an M-mode cursor along the tricuspid annulus, and measuring the longitudinal movement amount in the peak systole. TAPSE was measured 30 minutes before the surgery. The primary objective of the present study was to test the relationship between TAPSE and hypotension because of general anesthesia induction. We accepted hypotension as a decrease of 30% or more from baseline in systolic blood pressure (SBP) in the first 10 minutes following induction or a decrease in mean arterial pressure (MAP) below 60 mmHg. RESULTS Statistically significant differences were detected in TAPSE values compared to the hypotension status after general anesthesia induction (P<0.001). The value of TAPSE had an optimal cut-off value of ≤2.48cm for the diagnostic yield of the development of hypotension after the general anesthesia induction. This cut-off value had a sensitivity and specificity of 90.00% and 95.83%. CONCLUSIONS TAPSE predicted the development of hypotension after general anesthesia induction. Further studies are required to prove the diagnostic accuracy of TAPSE as a predictor of hypotension after general anesthesia induction.
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Affiliation(s)
- Ferdi Gülaşti
- Department of Anesthesiology and Reanimation, Aydin Gynecology and Children's Hospital, Aydin, Türkiye -
| | - Sevil Gülaşti
- Department of Cardiology, Faculty of Medicine, Adnan Menderes University, Aydin, Türkiye
| | - Sinem Sari
- Department of Anesthesiology, Faculty of Medicine, Adnan Menderes University, Aydin, Türkiye
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Mambelli E, Rigotti A. A novel double parameters based biofeedback system to prevent intradialytic hypotension in clinical practice: Case report. Int J Artif Organs 2022; 45:966-970. [PMID: 36151712 DOI: 10.1177/03913988221124620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intradialytic hypotension (IDH) still represents the main complication during dialysis treatment. Patient's discomfort, reduced dialysis efficiency, reduced treatment time are only some of the main problems that could derive from the need to stop or temporarily interrupt the treatment because of IDH. Up to now, different types of treatment (HDF, HF, or AFB) have been considered to prevent IDH as well as the use of biofeedback systems (Blood Volume Monitoring, Temperature control, Sodium profiling, Blood Pressure monitoring). Recently a new biofeedback system (Biologic Fusion®) controlling simultaneously blood pressure (BP) and relative blood volume changes (RBV) has been developed to prevent IDH. This system runs according to fuzzy logic. We describe how this system works and to a better understanding, we report a clinical case of a patient with frequent IDH treated with the use of this system.
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Affiliation(s)
- Emanuele Mambelli
- U.O. Nefrologia e Dialisi, Ospedale Infermi-Rimini-AUSL della Romagna, Italy
| | - Angelo Rigotti
- U.O. Nefrologia e Dialisi, Ospedale Infermi-Rimini-AUSL della Romagna, Italy
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178
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Thadani S, Fogarty T, Mottes T, Price JF, Srivaths P, Bell C, Akcan-Arikan A. Hemodynamic instability during connection to continuous kidney replacement therapy in critically ill pediatric patients. Pediatr Nephrol 2022; 37:2167-2177. [PMID: 35118547 DOI: 10.1007/s00467-022-05424-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/23/2021] [Accepted: 12/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emerging data suggest evidence of organ hypoperfusion during continuous kidney replacement therapy (CKRT). To facilitate kidney and global recovery, we must understand the hemodynamic risks associated with CKRT. We aimed to investigate frequency of hemodynamic instability and association with patient outcomes in pediatric CKRT. METHODS In a single-center study of CKRT patients between September 2016 and October 2018, we collected hemodynamic data using archived high-resolution physiologic data before and after connection. Primary outcome was hypotension defined as ≥ 20% decrease in baseline mean arterial pressure (MAP) for ≥ 2 consecutive minutes in the 60 min following connection. Secondary outcomes were tachycardia (≥ 20% increase in heart rate (HR)) and hemodynamic interventions. RESULTS Seventy-one patients median age 54 months (IQR 7-144), weight 16.7 kg (IQR 8-41), on hemodiafiltration had 304 filter connections, 4 (IQR 1-7) filters per patient; the median duration of CKRT was 9 days (IQR 3-20). The most common CKRT indication was AKI with fluid overload (48/71, 69%). There were 78 (27%) hypotension and 42 (14%) tachycardia events; cumulative duration of hypotension was 14 min IQR (3-31.75). Teams provided intervention in 17/304 (6%) of connections. Pediatric Logistic Organ Dysfunction 2 was the only independent predictor of hypotension (aOR 2.12 (CI 1.02-4.41)). CONCLUSIONS One in four and one in six pediatric CKRT filter connections were complicated by hypotension and tachycardia, respectively. Higher illness severity at CKRT initiation was independently associated with hypotension. Impact of CKRT-associated hemodynamic instability on global patient outcomes requires further targeted study. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Sameer Thadani
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Thomas Fogarty
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Theresa Mottes
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jack F Price
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Poyyapakkam Srivaths
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Cynthia Bell
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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179
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银 海, 万 里, 黄 瀚. [Effective Dose of Prophylactic Norepinephrine for Preventing Hypotension under Combined Spinal and Epidural Anesthesia during Cesarean Section in Singleton Versus Twin Pregnancies]. Sichuan Da Xue Xue Bao Yi Xue Ban 2022; 53:880-889. [PMID: 36224692 PMCID: PMC10408785 DOI: 10.12182/20220960204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Indexed: 06/16/2023]
Abstract
Objective To determine and compare the 90% effective dose (ED 90) of prophylactic infusion of norepinephrine for preventing hypotension during combined spinal-epidural anesthesia for cesarean section in singleton versus twin pregnancies. Methods A randomized controlled trial was conducted, enrolling 200 pregnant women, 100 of which were of singleton pregnancies while the other 100 were of twin pregnancies, at West China Second University Hospital, Sichuan University between November 3, 2020 and June 2, 2021. All 200 subjects were to have Cesarean section under combined spinal-epidural anesthesia. By using a random number table, they were randomly assigned to five groups, receiving norepinephrine at the infusion dosage of 0.025, 0.050, 0.075, 0.100, and 0.125 μg/(kg·min), with 20 subjects of singleton pregnancy and 20 subjects of twin pregnancy in each group. Norepinephrine infusion started when the anesthesiologist initiated the spinal anesthetic injection and lasted until the delivery of the fetus. The primary outcome measure was the incidence of maternal hypotension during combined spinal-epidural anesthesia, up until the delivery of the fetus. Survival analysis, with survival being defined as not having hypotension, of the incidence of hypotension among the subjects was conducted. Probit regression was used to determine the ED 90 of norepinephrine, as well as the corresponding 95% confidence interval ( CI), for preventing hypotension during cesarean delivery under combined spinal-epidural anesthesia in women with singleton and twin pregnancies. Results There was no significant difference in the baseline data or the anesthesia and operation data between pregnant women of singleton pregnancy and those of twin pregnancy ( P>0.05). In singleton pregnant women receiving 0.025, 0.05, 0.075, 0.1 and 0.125 μg/(kg·min) of norepinephrine, the incidence of hypotension was 50% (10/20), 35% (7/20), 20% (4/20), 10% (2/20) and 5% (1/20), respectively. The estimated ED 90 of prophylactic norepinephrine for preventing hypotension during anesthesia was 0.100 (95% CI, 0.082-0.130) μg/(kg·min). In twin pregnant women receiving 0.025, 0.05, 0.075, 0.1 and 0.125 μg/(kg·min) of norepinephrine, the corresponding incidence of hypotension was 60% (12/20), 20% (4/20), 20% (4/20), 10% (2/20) and 5% (1/20). The estimated ED 90 of norepinephrine for preventing hypotension during anesthesia was 0.098 (95% CI, 0.080-0.127) μg/(kg·min). Survival analysis showed significant difference in the incidence of hypotension among the five groups receiving different infusion doses in singleton pregnancy subjects, and the same is true of the twin pregnancy subjects ( P<0.05). The incidence of reactive hypertension increased with increasing dosage of norepinephrine in both singleton pregnancy subjects and twin pregnancy subjects ( P<0.05). There was no significant difference in the incidence of other maternal adverse reaction or in neonatal outcomes in singleton and twin pregnancy subjects receiving different dosage of norepinephrine ( P>0.05). The gestational weeks, weight, and BMI were significantly different ( P<0.05), while the other characteristics, including age and height, were comparable ( P>0.05) between singleton and twin pregnancy subjects receiving norepinephrine at the same dosage. There was no significant difference in the incidence of hypotension, reactive hypertension, bradycardia, nausea and vomiting, and dizziness between singleton and twin pregnancy subjects receiving the same dose ( P>0.05). Survival analysis displayed no significant difference in the incidence of hypotension between singleton and twin pregnancy subjects receiving norepinephrine at the same dosage ( P>0.05). There was no significant difference in the ED 90 of norepinephrine between women with singleton pregnancies and those with twin pregnancies ( P>0.05). Conclusion There was no significant difference in the ED 90 of norepinephrine for preventing hypotension during combined spinal-epidural anesthesia between women with singleton pregnancy and those with twin pregnancy. Interference of other factors, including gestational age, body mass, and BMI should be considered in clinical practice.
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Affiliation(s)
- 海英 银
- 四川大学华西第二医院 麻醉科 (成都 610041)Departmentof Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- 出生缺陷与相关妇儿疾病教育部重点实验室(四川大学) (成都 610041)Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, Sichuan University, Chengdu 610041, China
| | - 里 万
- 四川大学华西第二医院 麻醉科 (成都 610041)Departmentof Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- 出生缺陷与相关妇儿疾病教育部重点实验室(四川大学) (成都 610041)Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, Sichuan University, Chengdu 610041, China
| | - 瀚 黄
- 四川大学华西第二医院 麻醉科 (成都 610041)Departmentof Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- 出生缺陷与相关妇儿疾病教育部重点实验室(四川大学) (成都 610041)Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, Sichuan University, Chengdu 610041, China
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180
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Bae TW, Kim MS, Park JW, Kwon KK, Kim KH. Multilayer Perceptron-Based Real-Time Intradialytic Hypotension Prediction Using Patient Baseline Information and Heart-Rate Variation. Int J Environ Res Public Health 2022; 19:10373. [PMID: 36012006 PMCID: PMC9408052 DOI: 10.3390/ijerph191610373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
Intradialytic hypotension (IDH) is a common side effect that occurs during hemodialysis and poses a great risk for dialysis patients. Many studies have been conducted so far to predict IDH, but most of these could not be applied in real-time because they used only underlying patient information or static patient disease information. In this study, we propose a multilayer perceptron (MP)-based IDH prediction model using heart rate (HR) information corresponding to time-series information and static data of patients. This study aimed to validate whether HR differences and HR slope information affect real-time IDH prediction in patients undergoing hemodialysis. Clinical data were collected from 80 hemodialysis patients from 9 September to 17 October 2020, in the artificial kidney room at Yeungnam University Medical Center (YUMC), Daegu, South Korea. The patients typically underwent hemodialysis 12 times during this period, 1 to 2 h per session. Therefore, the HR difference and HR slope information within up to 1 h before IDH occurrence were used as time-series input data for the MP model. Among the MP models using the number and data length of different hidden layers, the model using 60 min of data before the occurrence of two layers and IDH showed maximum performance, with an accuracy of 81.5%, a true positive rate of 73.8%, and positive predictive value of 87.3%. This study aimed to predict IDH in real-time by continuously supplying HR information to MP models along with static data such as age, diabetes, hypertension, and ultrafiltration. The current MP model was implemented using relatively limited parameters; however, its performance may be further improved by adding additional parameters in the future, further enabling real-time IDH prediction to play a supporting role for medical staff.
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Affiliation(s)
- Tae Wuk Bae
- Daegu-Gyeongbuk Research Center, Electronics and Telecommunications Research Institute, Daegu 42994, Korea
| | - Min Seong Kim
- Daegu-Gyeongbuk Research Center, Electronics and Telecommunications Research Institute, Daegu 42994, Korea
| | - Jong Won Park
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Korea
| | - Kee Koo Kwon
- Daegu-Gyeongbuk Research Center, Electronics and Telecommunications Research Institute, Daegu 42994, Korea
| | - Kyu Hyung Kim
- Daegu-Gyeongbuk Research Center, Electronics and Telecommunications Research Institute, Daegu 42994, Korea
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181
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Cummings LC, Liang C, Mascha EJ, Saager L, Smith ZL, Bhavani S, Vargo JJ, Cummings KC. Incidence of sedation-related adverse events during ERCP with anesthesia assistance: a multicenter observational study. Gastrointest Endosc 2022; 96:269-281.e1. [PMID: 35381231 DOI: 10.1016/j.gie.2022.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/25/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Anesthesia assistance is commonly used for ERCP. General anesthesia (GA) may provide greater airway protection but may lead to hypotension. We aimed to compare GA versus sedation without planned intubation (SWPI) on the incidence of hypoxemia and hypotension. We also explored risk factors for conversion from SWPI to GA. METHODS This observational study used data from the Multicenter Perioperative Outcomes Group. Adults with American Society of Anesthesiologists physical status class I to IV undergoing ERCP between 2006 and 2019 were included. We compared GA and SWPI on incidence of hypoxemia (oxygen saturation <90% for ≥3 minutes) and hypotension (mean arterial pressure <65 mm Hg for ≥5 minutes) using joint hypothesis testing. The association between anesthetic approach and outcomes was assessed using logistic regression. The noninferiority delta for hypoxemia and hypotension was an odds ratio of 1.20. One approach was deemed better if it was noninferior on both outcomes and superior on at least 1 outcome. To explore risk factors associated with conversion from SWPI to GA, we constructed a logistic regression model. RESULTS Among 61,735 cases from 42 institutions, 38,830 (63%) received GA and 22,905 (37%) received SWPI. The GA group had 1.27 times (97.5% confidence interval, 1.19-1.35) higher odds of hypotension but .71 times (97.5% confidence interval, .63-.80) lower odds of hypoxemia. Neither group was noninferior to the other on both outcomes. Conversion from SWPI to GA occurred in 6.5% of cases and was associated with baseline comorbidities and higher institutional procedure volume. CONCLUSIONS GA for ERCP was associated with less hypoxemia, whereas SWPI was associated with less hypotension. Neither approach was better on the combined incidence of hypotension and hypoxemia.
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Affiliation(s)
- Linda C Cummings
- Division of Gastroenterology and Liver Disease, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Department of Medicine, Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Chen Liang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward J Mascha
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Leif Saager
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany; Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sekar Bhavani
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John J Vargo
- Department of Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kenneth C Cummings
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Anesthesiology, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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Thapaliya P, Ahmad T, Sikander N, Mazcuri M, Abid A. Saved by the Clot in Superior Vena Cava Injury. J Coll Physicians Surg Pak 2022; 32:1083-1085. [PMID: 35932141 DOI: 10.29271/jcpsp.2022.08.1083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/27/2020] [Indexed: 06/15/2023]
Abstract
Penetrating neck injuries (PNIs) can cause injuries to great vessels. Superior vena cava (SVC) injury from a stab to the neck is rare and when it occurs, poses a significant risk of exsanguinating hemorrhage. We report a case of a 17-year female who survived a delayed presentation of five hours after sustaining stab injury to zone 1 of the neck. Her external wound was just above the medial 1/3rd of the clavicle which resulted in SVC laceration. Mechanism and site of injury along with clinical presentation with right hemothorax was highly suspicious for a vascular injury. Exsanguinating hemorrhage was halted by a soft clot in this hypotensive patient. Furthermore, permissive hypotension with judicious resuscitation stabilised the patient enough to undergo a contrast venogram to identify the level of SVC injury. The patient underwent successful surgical repair of SVC. This case illustrates the point that control of bleeding by soft clots does not rule out major vascular injury. Additionally, it demonstrates how permissive hypotension can be helpful as a damage control stepping stone in the management of these critical patients. Key Words: Penetrating neck injury, Permissive hypotension, SVC laceration, Venorrhaphy.
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Affiliation(s)
- Pratikshya Thapaliya
- Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Tanveer Ahmad
- Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Nazish Sikander
- Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Misauq Mazcuri
- Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Ambreen Abid
- Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
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Alirezaei T, Jebreil Moosavi MJ, Irilouzadian R, Taziki E. Elevated Cardiac Troponin I following Asymptomatic Intradialytic Hypotension: A Pilot Study with a 2-Year Follow-Up. Int J Clin Pract 2022; 2022:4214429. [PMID: 35966145 PMCID: PMC9359825 DOI: 10.1155/2022/4214429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/25/2022] [Accepted: 07/12/2022] [Indexed: 11/18/2022] Open
Abstract
Background Intradialytic hypotension (IDH) has been recognized as a serious and frequent complication during hemodialysis (HD) of end-stage renal disease (ESRD) patients, but the effect of asymptomatic IDH on cardiac troponin I (cTnI) levels is not definitively elucidated. Methods 70 asymptomatic HD patients with negative predialysis cTnI were included. They were on maintenance HD thrice weekly. All patients were monitored during the HD session for hemodynamic changes and symptoms related to IDH. Patients were followed for two years, and their outcomes are noted as an acute coronary syndrome (ACS), cardiac death, no ACS, noncardiac death, and kidney transplant. Results Compared with the baseline blood pressure values, there was a drop in systolic blood pressure for all subjects, but according to the 2007 European Best Practice Guidelines on hemodynamic instability, asymptomatic IDH was defined in 27 (38.6%) patients. The results demonstrated a significant correlation (r = 0.492) (p < 0.05) between asymptomatic IDH and elevated postdialysis levels of cTnI. In 2-year follow-up of patients, ACS and cardiac death happened more in patients with elevated cTnI. Conclusion The results of our study suggest that asymptomatic IDH affects cTnI levels. Given that cTnI is a marker of myocardial damage and a predictor of cardiovascular mortality in ESRD patients, these findings recommend that considering the asymptomatic decrease in blood pressure levels during HD is very important and critical.
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Affiliation(s)
- Toktam Alirezaei
- Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mir Jafar Jebreil Moosavi
- Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rana Irilouzadian
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elahe Taziki
- Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Ko WH, Cho YH, Jang W, Kim SH, Lee HS, Ko HC, Kwon JH. Hemodynamic protective effects of epinephrine containing saline irrigation in biportal endoscopic lumbar surgery. Medicine (Baltimore) 2022; 101:e29311. [PMID: 35905267 PMCID: PMC9333511 DOI: 10.1097/md.0000000000029311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
During endoscopic orthopedic surgery, epinephrine mixed with irrigation saline is frequently used to improve visualization. By monitoring hemodynamic parameters throughout the procedure, we intended to discover the hemodynamic effect of epinephrine between the normal saline irrigation fluid without epinephrine group (NS) and normal saline irrigation fluid with epinephrine group (EPI). Patients who underwent 1-level lumbar decompression or discectomy surgery without fusion between August 2019 and July 2020 were reviewed retrospectively. The hemodynamic parameters were compared between the NS group and EPI group. As a second endpoint, the incidence of hypotension and hypertension events, expected blood loss, postoperative nausea and vomiting and postoperative epidural hematoma were compared between the 2 groups. The 2 groups were homogeneous in terms of age, sex, weight, height, body mass index (BMI), ASA physical status (ASA PS), and diagnosis. The incidence of hypotension events (67.2 % in the NS group, 45.7 % in the EPI group, P =.015) and severe hypotension events (51.7 % in the NS group, 28.6 % in the EPI group, P = .015) were less frequent in the EPI group. Only epinephrine had a significant protective effect through a multivariable analysis (P = .027, OR = 2.361) and in severe hypotension events, only epinephrine had a significant protective effect through a multivariable analysis (P = .011, OR = 2.818), and EBL was the risk factor through a multivariable analysis (P = .016, OR = 1.002) We believe that the addition of epinephrine to irrigation saline has hemodynamic protective effects in patients who underwent endoscopic lumbar surgery.
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Affiliation(s)
- Woo-Hyeong Ko
- Department of Anesthesiology and Pain Medicine, Seoul Sungsim General Hospital, Seoul, Korea
- *Correspondence: Woo-Hyeong Ko, Department of Anesthesiology and Pain Medicine, Seoul Sungsim General Hospital, 259 Wangsan-ro, Dongdaemun-gu, Seoul 02488, Korea (e-mail: )
| | - Yong-Hyun Cho
- Department of Anesthesiology and Pain Medicine, Seoul Sungsim General Hospital, Seoul, Korea
| | - Won Jang
- Department of Anesthesiology and Pain Medicine, Seoul Sungsim General Hospital, Seoul, Korea
| | - Sun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul Sungsim General Hospital, Seoul, Korea
| | - Hyun-Seok Lee
- Department of Anesthesiology and Pain Medicine, Seoul Sungsim General Hospital, Seoul, Korea
| | - Hyun-Cheol Ko
- Department of Anesthesiology and Pain Medicine, Seoul Sungsim General Hospital, Seoul, Korea
| | - Jae-Hyun Kwon
- Department of Anesthesiology and Pain Medicine, Seoul Sungsim General Hospital, Seoul, Korea
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Russell DW, Casey JD, Gibbs KW, Ghamande S, Dargin JM, Vonderhaar DJ, Joffe AM, Khan A, Prekker ME, Brewer JM, Dutta S, Landsperger JS, White HD, Robison SW, Wozniak JM, Stempek S, Barnes CR, Krol OF, Arroliga AC, Lat T, Gandotra S, Gulati S, Bentov I, Walters AM, Dischert KM, Nonas S, Driver BE, Wang L, Lindsell CJ, Self WH, Rice TW, Janz DR, Semler MW. Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA 2022; 328:270-279. [PMID: 35707974 PMCID: PMC9204618 DOI: 10.1001/jama.2022.9792] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/25/2022] [Indexed: 12/12/2022]
Abstract
Importance Hypotension is common during tracheal intubation of critically ill adults and increases the risk of cardiac arrest and death. Whether administering an intravenous fluid bolus to critically ill adults undergoing tracheal intubation prevents severe hypotension, cardiac arrest, or death remains uncertain. Objective To determine the effect of fluid bolus administration on the incidence of severe hypotension, cardiac arrest, and death. Design, Setting, and Participants This randomized clinical trial enrolled 1067 critically ill adults undergoing tracheal intubation with sedation and positive pressure ventilation at 11 intensive care units in the US between February 1, 2019, and May 24, 2021. The date of final follow-up was June 21, 2021. Interventions Patients were randomly assigned to receive either a 500-mL intravenous fluid bolus (n = 538) or no fluid bolus (n = 527). Main Outcomes and Measures The primary outcome was cardiovascular collapse (defined as new or increased receipt of vasopressors or a systolic blood pressure <65 mm Hg between induction of anesthesia and 2 minutes after tracheal intubation, or cardiac arrest or death between induction of anesthesia and 1 hour after tracheal intubation). The secondary outcome was the incidence of death prior to day 28, which was censored at hospital discharge. Results Among 1067 patients randomized, 1065 (99.8%) completed the trial and were included in the primary analysis (median age, 62 years [IQR, 51-70 years]; 42.1% were women). Cardiovascular collapse occurred in 113 patients (21.0%) in the fluid bolus group and in 96 patients (18.2%) in the no fluid bolus group (absolute difference, 2.8% [95% CI, -2.2% to 7.7%]; P = .25). New or increased receipt of vasopressors occurred in 20.6% of patients in the fluid bolus group compared with 17.6% of patients in the no fluid bolus group, a systolic blood pressure of less than 65 mm Hg occurred in 3.9% vs 4.2%, respectively, cardiac arrest occurred in 1.7% vs 1.5%, and death occurred in 0.7% vs 0.6%. Death prior to day 28 (censored at hospital discharge) occurred in 218 patients (40.5%) in the fluid bolus group compared with 223 patients (42.3%) in the no fluid bolus group (absolute difference, -1.8% [95% CI, -7.9% to 4.3%]; P = .55). Conclusions and Relevance Among critically ill adults undergoing tracheal intubation, administration of an intravenous fluid bolus compared with no fluid bolus did not significantly decrease the incidence of cardiovascular collapse. Trial Registration ClinicalTrials.gov Identifier: NCT03787732.
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Affiliation(s)
- Derek W. Russell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
- Pulmonary Section, Birmingham Veteran’s Affairs Medical Center, Birmingham, Alabama
| | - Jonathan D. Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kevin W. Gibbs
- Section of Pulmonary, Critical Care, Allergy, and Immunologic Disease, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Shekhar Ghamande
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
| | - James M. Dargin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Derek J. Vonderhaar
- Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, Louisiana
| | - Aaron M. Joffe
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Akram Khan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland
| | - Matthew E. Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Joseph M. Brewer
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Simanta Dutta
- Section of Pulmonary, Critical Care, Allergy, and Immunologic Disease, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Janna S. Landsperger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Heath D. White
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
| | - Sarah W. Robison
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
| | - Joanne M. Wozniak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Susan Stempek
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | | | - Olivia F. Krol
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland
| | - Alejandro C. Arroliga
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
| | - Tasnim Lat
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
| | - Sheetal Gandotra
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
| | - Swati Gulati
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
| | - Itay Bentov
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Andrew M. Walters
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Kevin M. Dischert
- Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, Louisiana
| | - Stephanie Nonas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland
| | - Brian E. Driver
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Li Wang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David R. Janz
- University Medical Center New Orleans, New Orleans, Louisiana
- Section of Pulmonary/Critical Care and Allergy/Immunology, Department of Medicine, Louisiana State University School of Medicine, New Orleans
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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Chewcharat A, Chewcharat P, Liu W, Cellini J, Phipps EA, Melendez Young JA, Nigwekar SU. The effect of levocarnitine supplementation on dialysis-related hypotension: A systematic review, meta-analysis, and trial sequential analysis. PLoS One 2022; 17:e0271307. [PMID: 35834513 PMCID: PMC9282471 DOI: 10.1371/journal.pone.0271307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/27/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Dialysis patients have been shown to have low serum carnitine due to poor nutrition, deprivation of endogenous synthesis from kidneys, and removal by hemodialysis. Carnitine deficiency leads to impaired cardiac function and dialysis-related hypotension which are associated with increased mortality. Supplementing with levocarnitine among hemodialysis patients may diminish incidence of intradialytic hypotension. Data on this topic, however, lacks consensus. METHODS We conducted electronic searches in PubMed, Embase and Cochrane Central Register of Controlled Trials from January 1960 to 19th November 2021 to identify randomized controlled studies (RCTs), which examined the effects of oral or intravenous levocarnitine (L-carnitine) on dialysis-related hypotension among hemodialysis patients. The secondary outcome was muscle cramps. Study results were pooled and analyzed utilizing the random-effects model. Trial sequential analysis (TSA) was performed to assess the strength of current evidence. RESULTS Eight trials with 224 participants were included in our meta-analysis. Compared to control group, L-carnitine reduced the incidence of dialysis-related hypotension among hemodialysis patients (pooled OR = 0.26, 95% CI [0.10-0.72], p = 0.01, I2 = 76.0%). TSA demonstrated that the evidence was sufficient to conclude the finding. Five studies with 147 participants showed a reduction in the incidence of muscle cramps with L-carnitine group (pooled OR = 0.22, 95% CI [0.06-0.81], p = 0.02, I2 = 74.7%). However, TSA suggested that further high-quality studies were required. Subgroup analysis on the route of supplementation revealed that only oral but not intravenous L-carnitine significantly reduced dialysis-related hypotension. Regarding dose and duration of L-carnitine supplementation, the dose > 4,200 mg/week and duration of at least 12 weeks appeared to prevent dialysis-related hypotension. CONCLUSION Supplementing oral L-carnitine for at least three months above 4,200 mg/week helps prevent dialysis-related hypotension. L-carnitine supplementation may ameliorate muscle cramps. Further well-powered studies are required to conclude this benefit.
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Affiliation(s)
- Api Chewcharat
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, United States of America
| | - Pol Chewcharat
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Weitao Liu
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, United States of America
| | - Jacqueline Cellini
- Countway Library, Harvard Medical School, Boston, MA, United States of America
| | - Elizabeth A. Phipps
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, United States of America
| | - Jill A. Melendez Young
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, United States of America
| | - Sagar U. Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
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187
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Wijeysundera DN, Duncan D, Moreno Garijo J, Jerath A, Meineri M, Parotto M, Wąsowicz M, McCluskey SA. A randomised controlled feasibility trial of a clinical protocol to manage hypotension during major non-cardiac surgery. Anaesthesia 2022; 77:795-807. [PMID: 37937943 DOI: 10.1111/anae.15715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/15/2022] [Accepted: 02/28/2022] [Indexed: 11/09/2023]
Abstract
Intra-operative hypotension is a risk factor for postoperative morbidity and mortality. Minimally invasive monitors that derive other haemodynamic parameters, such as stroke volume, may better inform the management of hypotension. As a prelude to a multicentre randomised controlled trial, we conducted a single-centre feasibility trial of a protocol to treat hypotension as informed by minimally invasive haemodynamic monitoring during non-cardiac surgery. We recruited adults aged ≥40 years with cardiovascular risk factors who underwent non-cardiac surgery requiring invasive arterial pressure monitoring. Participants were randomly allocated to usual care, or a clinical protocol informed by an arterial waveform contour analysis monitor. Participants, outcome assessors, clinicians outside operating theatres and analysts were blinded to treatment allocation. Feasibility was evaluated based on: consent rate; recruitment rate; structured feedback from anaesthesia providers; and between-group differences in blood pressure, processes-of-care and outcomes. The consent rate among eligible patients was 33%, with 30 participants randomly allocated to the protocol and 30 to usual care. Anaesthesia providers rated the protocol to be feasible and acceptable. The protocol was associated with reduced fluid balance and hypotension exposure in the peri-operative setting. Postoperative complications included: acute myocardial injury in 18 (30%); acute kidney injury in 17 (28%); and surgical site infection in 7 (12%). The severity of complications was rated as moderate or severe in 25 (42%) participants. In summary, this single-centre study confirmed the feasibility of a multicentre trial to assess the efficacy and safety of a physiologically guided treatment protocol for intra-operative hypotension based on minimally invasive haemodynamic monitors.
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Affiliation(s)
- D N Wijeysundera
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - D Duncan
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - J Moreno Garijo
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - A Jerath
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - M Meineri
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
- Department of Anaesthesia and Intensive Care, Heart Centre Leipzig, Germany
| | - M Parotto
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - M Wąsowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - S A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
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188
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Causland FRM, Ravi KS, Curtis KA, Kibbelaar ZA, Short SAP, Singh AT, Correa S, Waikar SS. A randomized controlled trial of two dialysate sodium concentrations in hospitalized hemodialysis patients. Nephrol Dial Transplant 2022; 37:1340-1347. [PMID: 34792161 PMCID: PMC9217525 DOI: 10.1093/ndt/gfab329] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Several large dialysis organizations have lowered the dialysate sodium concentration (DNa) in an effort to ameliorate hypervolemia. The implications of lower DNa on intra-dialytic hypotension (IDH) during hospitalizations of hemodialysis (HD) patients is unclear. METHODS In this double-blind, single center, randomized controlled trial (RCT), hospitalized maintenance HD patients were randomized to receive higher (142 mmol/L) or lower (138 mmol/L) DNa for up to six sessions. Blood pressure (BP) was measured in a standardized fashion pre-HD, post-HD and every 15 min during HD. The endpoints were: (i) the average decline in systolic BP (pre-HD minus lowest intra-HD, primary endpoint) and (ii) the proportion of total sessions complicated by IDH (drop of ≥20 mmHg from the pre-HD systolic BP, secondary endpoint). RESULTS A total of 139 patients completed the trial, contributing 311 study visits. There were no significant differences in the average systolic blood pressure (SBP) decline between the higher and lower DNa groups (23 ± 16 versus 26 ± 16 mmHg; P = 0.57). The proportion of total sessions complicated by IDH was similar in the higher DNa group, compared with the lower DNa group [54% versus 59%; odds ratio 0.72; 95% confidence interval (95% CI) 0.36-1.44; P = 0.35]. In post hoc analyses adjusting for imbalances in baseline characteristics, higher DNa was associated with 8 mmHg (95% CI 2-13 mmHg) less decline in SBP, compared with lower DNa. Patient symptoms and adverse events were similar between the groups. CONCLUSIONS In this RCT for hospitalized maintenance of HD patients, we found no difference in the absolute SBP decline between those who received higher versus lower DNa in intention-to-treat analyses. Post hoc adjusted analyses suggested a lower risk of IDH with higher DNa; thus, larger, multi-center studies to confirm these findings are warranted.
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Affiliation(s)
- Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Katherine Scovner Ravi
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Katherine A Curtis
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Zoé A Kibbelaar
- Renal Section, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Samuel A P Short
- Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Anika T Singh
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Simon Correa
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sushrut S Waikar
- Renal Section, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
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Pyun AJ, Potter HA, Magee GA, Manzur MF, Weaver FA, Ziegler KR, Paige JK, Han SM. Comparative Early Results of In-Situ Fenestrated Endovascular Aortic Repair and Other Emergent Complex Endovascular Aortic Repair Techniques for Ruptured Suprarenal and Thoracoabdominal Aortic Aneurysms at a Regional Aortic Center. J Vasc Surg 2022; 76:875-883. [PMID: 35697311 DOI: 10.1016/j.jvs.2022.04.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/25/2022] [Accepted: 04/09/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Emergent endovascular repair of suprarenal (SRAAA) and thoracoabdominal aortic aneurysms (TAAA) poses a significant challenge due to the need for branch vessel incorporation, time constraints, and lack of dedicated devices. Techniques to incorporate branch vessels have included parallel grafting (PG), physician modified endografts (PMEG), double-barrel/reversed iliac branch device (DB/rIBE), and in situ fenestration (ISF). This study describes a single-center experience and the associated outcomes when using these techniques for ruptured SRAAA and TAAA. METHODS A retrospective review of patients who underwent endovascular repair of ruptured SRAAA and TAAAs from July 2014 - March 2021 with branch vessel incorporation was performed. Clinical presentation, intraoperative details, and postoperative outcomes of those who underwent ISF were compared to those who underwent repair using non-ISF techniques. The primary outcome of interest was in-hospital mortality. Secondary outcomes were major adverse events including myocardial infarction, respiratory failure, renal dysfunction, new onset dialysis, bowel ischemia, stroke, and spinal cord ischemia. RESULTS Forty-two patients underwent endovascular repair for ruptured SRAAA and TAAA, 18 of whom underwent ISF repair. Seventy-two percent of ISF patients were hypotensive prior to surgery, compared to 46% of the patients who underwent repair using non-ISF techniques (PMEG, PG, or DB/rIBE). The total procedural and fluoroscopy times were similar between the two groups despite a greater mean number of branch vessels incorporated with the ISF technique (3.1 vs. 2.2 per patient, P = .015). In-hospital mortality was 19% for all ruptures, and 25% for ruptures with hypotension. Compared to the non-ISF group, in-hospital mortality trended lower in the ISF group (11% vs. 25%, P = .233), reaching statistical significance when comparing patients who presented with hypotension (8% vs 45%, P =.048). The rate of major adverse events was 57% across all techniques and did not significantly differ between the ISF and non-ISF groups, with postoperative renal dysfunction being the most frequent complication (48%). Overall, ISF became the most commonly utilized technqiue later in the study period. CONCLUSIONS While emergent endovascular repair of ruptured SRAAA/TAAA remains a challenge, a number of techniques are available for expeditious treatment. In this series, ISF was associated improve survival, including a 5-fold reduction in mortality in patients presenting with hypotension, and has now become the dominant technique at our center. Despite these advantages, postoperative complications and reinterventions are common. Further experience and longer-term follow-up is needed to validate these initial results and assess durability.
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Affiliation(s)
- Alyssa J Pyun
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Helen A Potter
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Gregory A Magee
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Miguel F Manzur
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Kenneth R Ziegler
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Jacquelyn K Paige
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Sukgu M Han
- Comprehensive Aortic Center, Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA.
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190
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Lorente JV, Jimenez I, Ripollés-Melchor J, Becerra A, Wesselink W, Reguant F, Mojarro I, Fuentes MDLA, Abad-Motos A, Agudelo E, Herrero-Machancoses F, Callejo P, Bosch J, Monge MI. Intraoperative haemodynamic optimisation using the Hypotension Prediction Index and its impact on tissular perfusion: a protocol for a randomised controlled trial. BMJ Open 2022; 12:e051728. [PMID: 35654467 PMCID: PMC9163532 DOI: 10.1136/bmjopen-2021-051728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Intraoperative arterial hypotension is associated with poor postoperative outcomes. The Hypotension Prediction Index (HPI) developed using machine learning techniques, allows the prediction of arterial hypotension analysing the arterial pressure waveform. The use of this index may reduce the duration and severity of intraoperative hypotension in adults undergoing non-cardiac surgery. This study aims to determine whether a treatment protocol based on the prevention of arterial hypotension using the HPI algorithm reduces the duration and severity of intraoperative hypotension compared with the recommended goal-directed fluid therapy strategy and may improve tissue oxygenation and organ perfusion. METHODS AND ANALYSIS We will conduct a multicentre, randomised, controlled trial (N=80) in high-risk surgical patients scheduled for elective major abdominal surgery. All participants will be randomly assigned to a control or intervention group. Haemodynamic management in the control group will be based on standard haemodynamic parameters. Haemodynamic management of patients in the intervention group will be based on functional haemodynamic parameters provided by the HemoSphere platform (Edwards Lifesciences), including dynamic arterial elastance, dP/dtmax and the HPI. Tissue oxygen saturation will be recorded non-invasively and continuously by using near-infrared spectroscopy technology. Biomarkers of acute kidney stress (cTIMP2 and IGFBP7) will be obtained before and after surgery. The primary outcome will be the intraoperative time-weighted average of a mean arterial pressure <65 mm Hg. ETHICS AND DISSEMINATION Ethics committee approval was obtained from the Ethics Committee of Hospital Gregorio Marañón (Meeting of 27 July 2020, minutes 18/2020, Madrid, Spain). Findings will be widely disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT04301102.
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Affiliation(s)
- Juan Victor Lorente
- Anesthesia and Critical Care, Hospital Juan Ramon Jimenez, Huelva, Spain
- School of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Ignacio Jimenez
- Anesthesia and Critical Care, Virgen del Rocio University Hospital, Sevilla, Spain
| | | | - Alejandra Becerra
- Anesthesia and Critical Care, Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain
| | | | - Francesca Reguant
- School of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
- Anesthesia, Fundacio Althaia de Manresa, Manresa, Spain
| | - Irene Mojarro
- Anesthesia and Critical Care, Hospital Juan Ramon Jimenez, Huelva, Spain
| | | | - Ane Abad-Motos
- Anesthesia and Critical Care, Infanta Leonor University Hospital, Madrid, Spain
| | - Elizabeth Agudelo
- Anesthesia and Critical Care, Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain
| | | | | | - Joan Bosch
- School of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Manuel Ignacio Monge
- Intensive Care Unit, Hospital Universitario de Jerez de la Frontera, Jerez de la Frontera, Spain
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191
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Agarwal S, Kumar M, Gupta A, Rautela RS, Jain N. Effect of Intravenous Calcium Gluconate on Prevention of Post Spinal Hypotension during Spinal Anaesthesia for Caesarean Section: A Randomized Double-Blind Controlled Study. J Nepal Health Res Counc 2022; 20:89-95. [PMID: 35945859 DOI: 10.33314/jnhrc.v20i01.3882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 06/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Calcium, a physiological ion, causes vasoconstriction and has a positive ionotropic action on heart. Its use to prevent post-spinal hypotension has been suggested but never formally evaluated for patients undergoing caesarean section. This study investigated the hemodynamic effects of calcium administration in parturients with the primary aim of comparing the incidence of post-spinal hypotension. METHODS Sixty healthy full-term pregnant patients scheduled for caesarean section were randomly allocated to two equal groups to receive either calcium gluconate or normal Saline bolus over 20min by syringe infusion pump under electrocardiography monitoring immediately after the patient was turned supine following spinal anaesthesia. Blood pressure and heart rate were recorded at baseline, and at regular intervals following spinal. Maternal calcium levels were estimated before and after infusion. Neonatal blood gas analysis and calcium level were analyzed. Total mephentermine requirement was recorded in both groups. RESULTS The heart rate values remained comparable to baseline value in group calcium gluconate while in group normal Saline, it decreased significantly at 8,12 and 16min. Blood pressure decreased significantly as compared to the baseline value from 4min onwards in both the groups. However, it was comparable in the two groups at all time points(0.622). Nineteen patients(63.33%) required mephentermine infusion in group calcium gluconate as compared to 23 patients(76.6%) in group normal Saline for maintenance of systolic blood pressure.(p=0.791) Umbilical venous pH (p=0.038) and partial pressure of carbon dioxide(p=0.038) were significantly better in group calcium gluconate. CONCLUSIONS Calcium used for prophylaxis of hypotension in healthy parturients undergoing caesarean section reduced the vasopressor requirements and total mephenteramine dose, but the difference did not attain statistical significance.
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Affiliation(s)
- Shilpa Agarwal
- UCMS and associated GTB Hospital, Shahdara, Delhi, India
| | - Mahender Kumar
- UCMS and associated GTB Hospital, Shahdara, Delhi, India
| | - Anju Gupta
- Department of Anaesthesiology, Pain and critical care, AIIMS, Delhi, India. New Delhi, India
| | - R S Rautela
- UCMS and associated GTB Hospital, Shahdara, Delhi, India
| | - Nidhi Jain
- UCMS and associated GTB Hospital, Shahdara, Delhi, India
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192
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Saengrung S, Kaewborisutsakul A, Tunthanathip T, Phuenpathom N, Taweesomboonyat C. Risk Factors for Intraoperative Hypotension During Decompressive Craniectomy in traumatic Brain Injury Patients. World Neurosurg 2022; 162:e652-e658. [PMID: 35358728 DOI: 10.1016/j.wneu.2022.03.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Decompressive craniectomy (DC) is an important therapy for treating intracranial pressure elevation following traumatic brain injury (TBI). During this procedure, about one-third of patients become complicated with intraoperative hypotension (IH), which is associated with abruptly decreasing sympathetic activity resulting from brain decompression. This study aimed to identify factors associated with IH during DC procedures and the mortality rate in these patients. METHODS The records of adult TBI patients aged 18 years and older who underwent DC at Songklanagarind Hospital between January 2014 and January 2021 were retrospectively reviewed. Using logistic regression analysis, various factors were analyzed for their associations with IH during the DC procedures. RESULTS This study included 83 patients. The incidence of IH was 54%. Multivariate analysis showed that Glasgow Coma Scale motor response (GCS-M) 1-3 (vs. 4-6), higher preoperative heart rate (PHR), and larger amount of intraoperative blood loss were significantly associated with IH (P = 0.013, P < 0.001, and P < 0.001, respectively). Patients with GCS-M 1-3 and PHR ≥ 75 bpm had the highest chance of IH (77%), while patients with neither of these risk factors had the lowest chance (29%). The in-hospital mortality rate in the IH and non-IH groups was 44% and 26%, respectively (P = 0.138). CONCLUSIONS GCS-M 1-3, higher PHR, and larger amount of intraoperative blood loss were the risk factors associated with IH during DC procedure in TBI patients. Patients who have these risk factors should be closely monitored and the attending physician be ready to apply prompt resuscitation and treatment for IH.
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Affiliation(s)
- Suchada Saengrung
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Anukoon Kaewborisutsakul
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thara Tunthanathip
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Nakornchai Phuenpathom
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Chin Taweesomboonyat
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
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Rocchi M, Fresiello L, Jacobs S, Dauwe D, Droogne W, Meyns B. Potential of Medical Management to Mitigate Suction Events in Ventricular Assist Device Patients. ASAIO J 2022; 68:814-821. [PMID: 34524148 DOI: 10.1097/mat.0000000000001573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Ventricular suction is a common adverse event in ventricular assist device (VAD) patients and can be due to multiple underlying causes. The aim of this study is to analyze the potential of different therapeutic interventions to mitigate suction events induced by different pathophysiological conditions. To do so, a suction module was embedded in a cardiovascular hybrid (hydraulic-computational) simulator reproducing the entire cardiovascular system. An HVAD system (Medtronic) was connected between a compliant ventricular apex and a simulated aorta. Starting from a patient profile with severe dilated cardiomyopathy, four different pathophysiological conditions leading to suction were simulated: hypovolemia (blood volume: -900 ml), right ventricular failure (contractility -70%), hypotension (systemic vascular resistance: 8.3 Wood Units), and tachycardia (heart rate:185 bpm). Different therapeutic interventions such as volume infusion, ventricular contractility increase, vasoconstriction, heart rate increase, and pump speed reduction were simulated. Their effects were compared in terms of general hemodynamics and suction mitigation. Each intervention elicited a different effect on the hemodynamics for every pathophysiological condition. Pump speed reduction mitigated suction but did not ameliorate the hemodynamics. Administering volume and inducing a systemic vasoconstriction were the most efficient interventions in both improving the hemodynamics and mitigating suction. When simulating volume infusion, the cardiac powers increased, respectively, by 38%, 25%, 42%, and 43% in the case of hypovolemia, right ventricular failure, hypotension, and tachycardia. Finally, a management algorithm is proposed to identify a therapeutic intervention suited for the underlying physiologic condition causing suction.
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Affiliation(s)
- Maria Rocchi
- From the Department of Cardiovascular Sciences, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Libera Fresiello
- From the Department of Cardiovascular Sciences, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Steven Jacobs
- From the Department of Cardiovascular Sciences, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Dieter Dauwe
- From the Department of Cardiovascular Sciences, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Walter Droogne
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- From the Department of Cardiovascular Sciences, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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194
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Correa S, Guerra-Torres XE, Ravi KS, Mothi SS, Waikar SS, Mc Causland FR. Risk of Intradialytic Hypotension by Day of the Week in Maintenance Hemodialysis. ASAIO J 2022; 68:865-873. [PMID: 34494985 PMCID: PMC10157838 DOI: 10.1097/mat.0000000000001576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Intradialytic hypotension (IDH) is a common complication of hemodialysis (HD) and is associated with a higher risk of cardiovascular (CV) events and mortality. CV events are more common on the days of HD, especially following the longer interdialytic interval. We investigated the risk of IDH according to day of HD in adults undergoing in-center, thrice-weekly HD in the Hemodialysis (HEMO) Study (N = 1,837 patients; n = 64,474 sessions), and the DaVita Clinical Research biorepository [BioReG]) (N = 952 patients; n = 61,197 sessions). Random effects logistic regression models assessed the risk of IDH (defined as nadir intra-HD systolic blood pressure [SBP] <90 mm Hg if pre-HD SBP <160 mm Hg, or <100 mm Hg if pre-HD SBP ≥160 mm Hg [Nadir90/100 definition]) according to HD day (Mon/Tue [HD1]; Wed/Thu [HD2]; Fri/Sat [HD3]). Alternative definitions of IDH were explored. Nadir90/100 occurred in 14% of HEMO and 18% of BioReG sessions. A monotonic increase in the risk of IDH was observed for HD2 and HD3, compared with HD1, for all IDH definitions in both cohorts. Compared with HD1, HD2 was associated with a 10% higher risk of Nadir90/100 (adjusted odds ratio, 1.10; 95% CI, 1.03-1.17) and HD3 was associated with a 31% higher risk (adjusted odds ratio, 1.31; 95% CI, 1.19-1.45) in HEMO, with consistent results in BioReG. We observed a monotonic increased risk of IDH with later days of the dialytic week in two separate cohorts. Further research to determine the underlying mechanisms is necessary to guide strategies for IDH prevention.
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Affiliation(s)
- Simon Correa
- From the Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale New Haven Hospital, New Haven, Connecticut
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Xavier E Guerra-Torres
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Katherine Scovner Ravi
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Suraj S Mothi
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sushrut S Waikar
- Nephrology Section, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Finnian R Mc Causland
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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195
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Tartaglione M, Carenzo L, Gamberini L, Lupi C, Giugni A, Mazzoli CA, Chiarini V, Cavagna S, Allegri D, Holcomb JB, Lockey D, Sbrana G, Gordini G, Coniglio C. Multicentre observational study on practice of prehospital management of hypotensive trauma patients: the SPITFIRE study protocol. BMJ Open 2022; 12:e062097. [PMID: 35636792 PMCID: PMC9152935 DOI: 10.1136/bmjopen-2022-062097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Major haemorrhage after injury is the leading cause of preventable death for trauma patients. Recent advancements in trauma care suggest damage control resuscitation (DCR) should start in the prehospital phase following major trauma. In Italy, Helicopter Emergency Medical Services (HEMS) assist the most complex injuries and deliver the most advanced interventions including DCR. The effect size of DCR delivered prehospitally on survival remains however unclear. METHODS AND ANALYSIS This is an investigator-initiated, large, national, prospective, observational cohort study aiming to recruit >500 patients in haemorrhagic shock after major trauma. We aim at describing the current practice of hypotensive trauma management as well as propose the creation of a national registry of patients with haemorrhagic shock. PRIMARY OBJECTIVE the exploration of the effect size of the variation in clinical practice on the mortality of hypotensive trauma patients. The primary outcome measure will be 24 hours, 7-day and 30-day mortality. Secondary outcomes include: association of prehospital factors and survival from injury to hospital admission, hospital length of stay, prehospital and in-hospital complications, hospital outcomes; use of prehospital ultrasound; association of prehospital factors and volume of first 24-hours blood product administration and evaluation of the prevalence of use, appropriateness, haemodynamic, metabolic and effects on mortality of prehospital blood transfusions. INCLUSION CRITERIA age >18 years, traumatic injury attended by a HEMS team including a physician, a systolic blood pressure <90 mm Hg or weak/absent radial pulse and a confirmed or clinically likely diagnosis of major haemorrhage. Prehospital and in-hospital variables will be collected to include key times, clinical findings, examinations and interventions. Patients will be followed-up until day 30 from admission. The Glasgow Outcome Scale Extended will be collected at 30 days from admission. ETHICS AND DISSEMINATION The study has been approved by the Ethics committee 'Comitato Etico di Area Vasta Emilia Centro'. Data will be disseminated to the scientific community by abstracts submitted to international conferences and by original articles submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04760977.
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Affiliation(s)
- Marco Tartaglione
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Cristian Lupi
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Aimone Giugni
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Alberto Mazzoli
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Valentina Chiarini
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Silvia Cavagna
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Davide Allegri
- Department of Clinical Governance and Quality, Azienda Unità Sanitaria Locale di Bologna, Bologna, Italy
| | - John B Holcomb
- Center for Injury Science, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David Lockey
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Giovanni Sbrana
- UOS 118 Gestione Territorio Area Provinciale Aretina and Grosseto HEMS, Azienda USL Toscana Sud Est, Grosseto, Italy
| | - Giovanni Gordini
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Coniglio
- Department of Anesthesia, Intensive Care and Prehospital Emergency Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
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Putowski Z, Krzych Ł, Czajka S. High intraoperative pulse pressure is a risk factor for postoperative acute kidney injury in a cohort of abdominal surgery patients: An exploratory study. ADV CLIN EXP MED 2022; 31:511-517. [PMID: 35166075 DOI: 10.17219/acem/145946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Both intraoperative hypotension and hypertension have been reported to increase the occurrence of acute kidney injury (AKI). However, the impact of the intraoperative pulse pressure (PP) on the latter complications remains relatively unknown. OBJECTIVES To explore whether high intraoperative PP values are associated with postoperative AKI. MATERIAL AND METHODS The data for this study come from a prospective cohort study in which patients who underwent abdominal surgery between October 1, 2018 and July 15, 2019 in university hospital in Katowice, Poland were included in the analysis. Preand intraoperative data, including blood pressure measurements, were acquired from medical charts. Several PP thresholds were applied: >50, >55, >60, >65, >70, >75, >80, >85, and >90 mm Hg. Additionally, by analyzing the maximal PP during the procedures, the cutoff point for the occurrence of outcomes was estimated. Postoperative AKI was considered as the outcome of the study. Univariable and multivariable analyses were performed to assess PP relationship with AKI. RESULTS Four hundred and ninety-four patients were included in the analysis. The AKI was present in 32 (6.5%) cases. The receiver operating characteristic (ROC) curve analysis estimated a cutoff point of >84 mm Hg of maximal PP to be associated with the outcome. The PP values above 80 mm Hg and onward were successfully included in the multivariable statistical models. A model in which PP > 90 mm Hg (odds ratio (OR) = 4.03; 95% confidence interval (95% CI): [1.53; 10.62]) was included, had the best predicting value in predicting hypoperfusion injury (area under the receiver operating characteristics (AUROC) = 0.88). Apart from PP, intraoperative hypotension, presence of chronic arterial hypertension, chronic kidney disease, and procedure duration were independently associated with AKI. CONCLUSIONS High intraoperative PP may be associated with the occurrence of postoperative AKI. However, the effect of high PP should be confirmed in other noncardiac populations to prove the generalizability of our results.
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Affiliation(s)
- Zbigniew Putowski
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Łukasz Krzych
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Szymon Czajka
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
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197
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Aissaoui Y, Jozwiak M, Bahi M, Belhadj A, Alaoui H, Qamous Y, Serghini I, Seddiki R. Prediction of post-induction hypotension by point-of-care echocardiography: A prospective observational study. Anaesth Crit Care Pain Med 2022; 41:101090. [PMID: 35508291 DOI: 10.1016/j.accpm.2022.101090] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/23/2022] [Accepted: 03/03/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Post-induction hypotension (PIH) is a common side effect of general anaesthesia and is associated with poor perioperative outcomes. We assessed the ability of two point-of-care echocardiographic variables to predict the occurrence of PIH: the passive leg raising-induced changes in the velocity-time integral of the left ventricular outflow tract (ΔVTI-PLR) and the inferior vena cava collapsibility index (IVC-CI). METHODS We studied 64 patients > 50 years scheduled for elective abdominal surgery. ΔVTI-PLR and IVC-CI were prospectively obtained before general anaesthesia induction. PIH was defined by a systolic arterial pressure < 90 mmHg or a mean arterial pressure < 65 mmHg or by a decrease in systolic or mean arterial pressure > 30% from pre-induction level. Intraclass correlation coefficients (ICCs) were calculated to assess the reproducibility of echocardiographic measurements. Receiver operating characteristic (ROC) curves with 95% confidence intervals (CIs) were generated to test the ability of ΔVTI-PLR and IVC-CI to predict the occurrence of PIH. RESULTS PIH occurred in 33 (51%) patients. The ICCs for VTI and IVC measurements showed excellent reproducibility. The occurrence of PIH was accurately predicted by ΔVTI-PLR with an area under the ROC curve (AUROC) of 0.89 (95% CI: 0.80-0.97), a threshold value of 18% with a sensitivity of 88% (95% CI: 71-97%) and a specificity of 84% (95% CI: 66-94%). The occurrence of PIH was poorly predicted by IVC-CI with an AUROC of 0.68 (95% CI: 0.54-0.80) and a threshold value of 42%. CONCLUSIONS ΔVTI-PLR, unlike IVC-CI, could reliably predict the occurrence of PIH. The use of ΔVTI-PLR could help individualise anaesthesia management to prevent PIH.
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Affiliation(s)
- Younes Aissaoui
- Pôle Anesthésie Réanimation, Hôpital Militaire Avicenne, 1 Avenue Al Mouqaouama, 40015, Marrakesh, Morocco; Laboratoire Biosciences et Santé, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40000, Marrakesh, Morocco.
| | - Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nice, Hôpital l'Archet 1, 151 route saint Antoine de Ginestière, 06200, Nice, France; UR2CA, Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Mohammed Bahi
- Pôle Anesthésie Réanimation, Hôpital Militaire Avicenne, 1 Avenue Al Mouqaouama, 40015, Marrakesh, Morocco
| | - Ayoub Belhadj
- Pôle Anesthésie Réanimation, Hôpital Militaire Avicenne, 1 Avenue Al Mouqaouama, 40015, Marrakesh, Morocco; Laboratoire Biosciences et Santé, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40000, Marrakesh, Morocco
| | - Hassan Alaoui
- Pôle Anesthésie Réanimation, Hôpital Militaire Avicenne, 1 Avenue Al Mouqaouama, 40015, Marrakesh, Morocco; Laboratoire Biosciences et Santé, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40000, Marrakesh, Morocco
| | - Youssef Qamous
- Pôle Anesthésie Réanimation, Hôpital Militaire Avicenne, 1 Avenue Al Mouqaouama, 40015, Marrakesh, Morocco; Laboratoire Biosciences et Santé, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40000, Marrakesh, Morocco
| | - Issam Serghini
- Pôle Anesthésie Réanimation, Hôpital Militaire Avicenne, 1 Avenue Al Mouqaouama, 40015, Marrakesh, Morocco; Laboratoire Biosciences et Santé, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40000, Marrakesh, Morocco
| | - Rachid Seddiki
- Pôle Anesthésie Réanimation, Hôpital Militaire Avicenne, 1 Avenue Al Mouqaouama, 40015, Marrakesh, Morocco; Laboratoire Biosciences et Santé, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40000, Marrakesh, Morocco
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198
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Sheikh AR, Mantoo S, Shah S, Hamid Wani RU, Wani SN. Predictors of Prolonged Hospital Stay in Patients with Acute Pulmonary Thromboembolism- A Hospital Based Cohort Study. J Assoc Physicians India 2022; 70:11-12. [PMID: 35598131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
AIMS AND OBJECTIVES Patients with pulmonary thromboembolism (PTE) are commonly admitted to hospital and generally have a prolonged hospital stay in this part of the world. We aimed to determine different clinical and laboratory parameters that are associated with prolonged hospital stay in our set-up and to analyse effectiveness of Pulmonary Embolism Severity Index (PESI) score as a predictor of prolonged hospital stay in patients with PTE. MATERIALS AND METHODS It was a hospital based observational prospective study. Confirmed cases of PTE defined as patients with evidence of thrombus on CT pulmonary angiogram (CTPA) were included in this study. Depending on the length of hospital stay, patients were divided into two cohorts: Shorter Hospital stay (less than mean i.e., < 10 Days) and Prolonged Hospital stay (longer than mean i.e., ≥ 10 Days). Logistic regression analysis was done to identify predictors of prolonged hospital stay. RESULTS 150 patients were included in the study with 67 patients (44.67%) having shorter hospital stay (<10 days) and 83 patients (55.33%) having prolonged hospital stay (≥10 days). On multivariate regression analysis, parameters that were found to be statistically significant were hypotension at presentation, decreased level of consciousness, pco2 < 30 mmHg, presence of S1Q3T3 pattern on electrocardiogram (ECG) and high risk PESI (class III-V). CONCLUSION PESI class can be effectively used to predict prolonged hospital stay in patients with pulmonary embolism. Patients with hypotension at presentation, decreased level of consciousness, pco2 less than 30 mmHg, and S1Q3T3 on ECG are more likely to have prolonged hospital stay in our healthcare setup.
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Affiliation(s)
- Arif Rehman Sheikh
- Senior Resident, SKIMS, Srinagar, Jammu and Kashmir; Corresponding Author
| | - Suhail Mantoo
- Assistant professor, SKIMS, Srinagar, Jammu and Kashmir
| | - Sanaullah Shah
- Professor, 4Resident, SKIMS, Srinagar, Jammu and Kashmir
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199
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Peterson DM, Damsky WE, Vesely MD. Fever, Hypotension, and a Worsening Necrotic Wound. JAMA 2022; 327:1496-1497. [PMID: 35311923 DOI: 10.1001/jama.2022.2806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - William E Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Matthew D Vesely
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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200
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Feng Y, Li W, Liu H, Chen X. Low dose sacubitril/valsartan is effective and safe in hemodialysis patient with decompensated heart failure and hypotension: A case report. Medicine (Baltimore) 2022; 101:e29186. [PMID: 35475805 PMCID: PMC9276171 DOI: 10.1097/md.0000000000029186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/09/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Severe heart failure in chronic hemodialysis (HD) patients is a great treatment challenge. Here we reported a chronic HD patient with the lowest ejection fraction reported so far and hypotension who well tolerated and benefited from angiotensin-receptor neprilysin inhibitor (ARNI) treatment. PATIENT CONCERNS This case was a 67 year old lady with decompensated heart failure and hypotension who was on regular HD. Intensified hemofiltration failed to improve her heart failure symptoms and was also retarded by hypotension. DIAGNOSIS Chronic HD with decompensated heart failure. INTERVENTIONS In addition to regular HD, low does sacubitril/valsartan was initiated and titrated from 12/13 mg to 24/26 mg twice daily. OUTCOMES Sacubitril/valsartan treatment was well tolerated and did not affect ultrafiltration during HD treatment. Transthoracic echocardiology at 3 months after initiation of ARNI treatment indicated significant improvement of both systolic and diastolic cardiac function. The patient has improved from New York Heart Association class 4 to class 2. LESSONS Low does ARNI treatment could effectively improve cardiac function in HD patients with heart failure and hypotension. It was also safe and well tolerated.
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Affiliation(s)
- Yunlin Feng
- Nephrology Department, Sichuan Provincial People's Hospital, Chengdu, China
- Medical School of University of Electronic Science and Technology of China, Chengdu, China
| | - Wenhua Li
- Medical School of University of Electronic Science and Technology of China, Chengdu, China
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, Chengdu, China
| | - Hongjun Liu
- Nephrology Department, Anyue County People's Hospital, Ziyang, China
| | - Xiuling Chen
- Nephrology Department, Sichuan Provincial People's Hospital, Chengdu, China
- Medical School of University of Electronic Science and Technology of China, Chengdu, China
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