1
|
Ishibashi H, Enomoto Y, Takaoka S, Aoki K, Nagai H, Yamagata K, Ishibashi-Kanno N, Uchida F, Fukuzawa S, Tabuchi K, Bukawa H, Suzuki Y, Yanagawa T. Analysis of predictors of fever after aortic valve replacement: Diabetic patients are less likely to develop fever after aortic valve replacement, a single-centre retrospective study. J Perioper Pract 2024:17504589241232503. [PMID: 38590001 DOI: 10.1177/17504589241232503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
BACKGROUND Postoperative temperature dysregulation affects the length of hospital stay and prognosis. This study evaluated the factors that influence the occurrence of fever in patients after aortic valve replacement surgery. METHODS Eighty-seven consecutive patients who underwent aortic valve replacement surgery were included. Patients' age, sex and body mass index; presence of diabetes mellitus; operation time; blood loss; blood transfusion volume; preoperative and postoperative laboratory findings; presence or absence of oral function management; and fever >38°C were retrospectively analysed through univariate and multiple logistic regression analyses. RESULTS Among the variables, only diabetes mellitus status was significantly associated with fever ⩾38°C. Postoperatively, patients with diabetes mellitus were significantly less likely to develop fever above 38°C and a fever rising to 38°C. CONCLUSIONS This study shows that the presence of comorbid diabetes mellitus decreases the frequency of developing fever >38°C after aortic valve replacement surgery.
Collapse
Affiliation(s)
- Hiroshi Ishibashi
- Doctoral program in Clinical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
- Department of Cardiology, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Yoshiharu Enomoto
- Department of Cardiovascular Surgery, Ibaraki Prefectural Central Hospital, Kasama, Japan
| | - Shohei Takaoka
- Department of Oral and Maxillofacial Surgery, University of Tsukuba Hospital, Tsukuba, Japan
| | - Kazuhiro Aoki
- Department of Cardiology, National Hospital Organization Tokyo National Hospital, Tokyo, Japan
| | - Hiroki Nagai
- Department of Oral and Maxillofacial Surgery, Ibaraki Prefectural Central Hospital, Kasama, Japan
| | - Kenji Yamagata
- Department of Oral and Maxillofacial Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Naomi Ishibashi-Kanno
- Department of Oral and Maxillofacial Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Fumihiko Uchida
- Department of Oral and Maxillofacial Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Satoshi Fukuzawa
- Department of Oral and Maxillofacial Surgery, University of Tsukuba Hospital, Tsukuba, Japan
| | - Katsuhiko Tabuchi
- Department of Molecular and Cellular Physiology, School of Medicine, Shinshu University, Matsumoto, Japan
| | - Hiroki Bukawa
- Department of Oral and Maxillofacial Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasuyuki Suzuki
- Department of Cardiovascular Surgery, Ibaraki Prefectural Central Hospital, Kasama, Japan
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Toru Yanagawa
- Department of Oral and Maxillofacial Surgery, Ibaraki Prefectural Central Hospital, Kasama, Japan
- Department of Oral and Maxillofacial Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| |
Collapse
|
2
|
Haas AV, Koefoed A, Easly RM, Celli J, Heydarpour M, Bonyhay I, Freeman R, Adler GK. Effect of hypoglycemia on baroreflex sensitivity in individuals with type 2 diabetes: implications for autonomic control of cardiovascular function in diabetes. Clin Auton Res 2023; 33:727-735. [PMID: 37733159 DOI: 10.1007/s10286-023-00983-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/07/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE Hypoglycemia is associated with increased mortality, though the mechanisms underlying this association are not established. Hypoglycemia impairs the counterregulatory hormonal and autonomic responses to subsequent hypoglycemia. It is unknown whether hypoglycemia elicits a generalized impairment in autonomic control of cardiovascular function in individuals with type 2 diabetes. We tested the hypothesis that in individuals with type 2 diabetes, hypoglycemia impairs a key measure of cardiovascular autonomic homeostasis, baroreflex sensitivity. METHODS Sixteen individuals with well-controlled type 2 diabetes and without known cardiovascular disease were exposed to two 90-min episodes of experimental hypoglycemia (2.8 mmol/L, 50 mg/dL) on the same day. All individuals experienced a hypoglycemic-hyperinsulinemic clamp in the morning (AM clamp) and again in the afternoon (PM clamp). Baroreflex sensitivity was assessed using the modified Oxford method before the initiation of each hypoglycemic-hyperinsulinemic clamp, during the last 30 min of hypoglycemia, and the following morning. A mixed effects model adjusting for sex, age, BMI, and insulin level, demonstrated a significant effect of hypoglycemia on baroreflex sensitivity. The study is registered at ClinicalTrials.gov (NCT03422471). RESULTS Baroreflex sensitivity during PM hypoglycemia was reduced compared to baseline, during AM hypoglycemia, and the next day. Insulin levels positively correlated with baroreflex sensitivity at baseline and during AM hypoglycemia. CONCLUSION Exposure to hypoglycemia impairs a key measure of autonomic control of cardiovascular function and, thus, may increase the risk of cardiac arrhythmias and blood pressure lability in individuals with type 2 diabetes. This effect is attenuated in part by increased insulin levels.
Collapse
Affiliation(s)
- Andrea V Haas
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA.
| | - Andrew Koefoed
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Rebecca M Easly
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Johanna Celli
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Mahyar Heydarpour
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Istvan Bonyhay
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gail K Adler
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| |
Collapse
|
3
|
Maroun W, Abi Shadid C, Fayed M, Foz C, Beresian J, Oseili A. Perioperative Autonomic Dysfunction in a Patient With Charcot-Marie-Tooth Disease: A Case Report. A A Pract 2023; 17:e01722. [PMID: 37703136 DOI: 10.1213/xaa.0000000000001722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Autonomic dysfunction can lead to unexpected hemodynamic instability during surgery, and best practices for the perioperative care of patients with this condition are not well-defined. We report the case of a 63-year-old woman with Charcot-Marie-Tooth disease who experienced perioperative autonomic dysfunction characterized by severe fluctuations in blood pressure while under spinal anesthesia. However, <1 month later, a second hip surgery performed under general anesthesia with special precautions resulted in an uncomplicated perioperative course, with only mild fluctuations in blood pressure.
Collapse
Affiliation(s)
- Wissam Maroun
- From the Department of Anesthesiology and Pain Medicine at the American University of Beirut, Beirut, Lebanon
| | - Carol Abi Shadid
- From the Department of Anesthesiology and Pain Medicine at the American University of Beirut, Beirut, Lebanon
| | - Mohamed Fayed
- Department of Anesthesiology and Pain Medicine, Henry Ford Health, Detroit, Michigan
| | - Carine Foz
- From the Department of Anesthesiology and Pain Medicine at the American University of Beirut, Beirut, Lebanon
| | - Jean Beresian
- From the Department of Anesthesiology and Pain Medicine at the American University of Beirut, Beirut, Lebanon
| | - Ahmad Oseili
- From the Department of Anesthesiology and Pain Medicine at the American University of Beirut, Beirut, Lebanon
| |
Collapse
|
4
|
Chiew A, Mathew D, Kumar CM, Seet E, Imani F, Khademi SH. Anesthetic Considerations for Cataract Surgery in Patients with Parkinson's Disease: A Narrative Review. Anesth Pain Med 2023; 13:e136093. [PMID: 38021330 PMCID: PMC10664173 DOI: 10.5812/aapm-136093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 12/01/2023] Open
Abstract
Parkinson's disease (PD) is a chronic neurological degenerative disease affecting the central nervous system, which is responsible for progressive disorders such as slow movements, tremors, rigidity, and cognitive disorders. There are no specific recommendations and guidelines for anesthetic management of patients with PD undergoing ophthalmic procedures. This narrative review aims to summarise the anesthetic considerations in patients with PD presenting for cataract surgery.
Collapse
Affiliation(s)
- Alyssa Chiew
- Department of Anaesthesia, Khoo Teck Puat Hospital, Yishun, Singapore
| | - David Mathew
- Department of Anaesthesia, Khoo Teck Puat Hospital, Yishun, Singapore
| | - Chandra M. Kumar
- Department of Anaesthesia, Khoo Teck Puat Hospital, Yishun, Singapore
| | - Edwin Seet
- Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed-Hossein Khademi
- Department of Anesthesiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| |
Collapse
|
5
|
Takri T, Mathew RR, Sivadasan A, Raju K, Karuppusami R, Mariappan R. The Utility of COMPASS-31 Questionnaire to Predict Autonomic Dysfunction in Patients With Cervical/Upper Thoracic Compressive Myelopathy. J Neurosurg Anesthesiol 2023; 35:243-247. [PMID: 34873138 DOI: 10.1097/ana.0000000000000824] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 11/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with cervical/upper thoracic compressive myelopathy may have autonomic dysfunction. The composite autonomic severity score (CASS) is the gold standard test to detect autonomic dysfunction, and the self-rated composite autonomic system scale (COMPASS-31) questionnaire is a screening tool to diagnose autonomic dysfunction. This study compared the COMPASS-31 and modified CASS scores for the detection of autonomic dysfunction in patients with compressive myelopathy. METHODS Patients with cervical/upper thoracic compressive myelopathy scheduled for decompressive surgery completed a COMPASS-31 questionnaire and underwent autonomic function tests to calculate the modified CASS score before surgery. RESULTS Forty-two patients were included in the study; 19 (45.2%) had mild autonomic dysfunction, 5 (11.9%) had moderate autonomic dysfunction, and 18 (42.9%) had severe autonomic dysfunction. Median (interquartile range) of modified CASS and COMPASS-31 scores were 19 (6.33) and 3 (2.5), respectively. There was a positive correlation between modified CASS and COMPASS-31 scores ( r =0.43; P =0.004). Receiver operating characteristic curve analysis confirmed that COMPASS-31 had fair accuracy for prediction of moderate to severe autonomic dysfunction (area under the curve, 0.74; 95% confidence interval, 0.64-0.82; P =0.009). A cut-off of 30 for total COMPASS-31 score had a sensitivity of 52.2% and specificity of 89.5% to detect moderate to severe autonomic dysfunction, with positive and negative predictive values of 85.7% and 60.7%, respectively. CONCLUSION Patients with cervical/upper thoracic compressive myelopathy had varying degrees of autonomic dysfunction based on the modified CASS. There was a positive correlation between the modified CASS and COMPASS-31 questionnaire. A COMPASS-31 score of >30 30 could be utilized to predict moderate to severe autonomic dysfunction in patients with compressive myelopathy.
Collapse
|
6
|
Kim DD, DeSnyder SM, Dougherty PM, Cata JP. Effect of neoadjuvant chemotherapy on intraoperative core temperature in patients with breast cancer: a retrospective cohort study. BJA OPEN 2023; 5:100119. [PMID: 37587989 PMCID: PMC10430839 DOI: 10.1016/j.bjao.2022.100119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 08/18/2023]
Abstract
Background Clinical evidence suggests that chemotherapeutic agents are associated with neuropathy and peripheral autonomic dysfunction. However, the possible effects of neoadjuvant chemotherapy on intraoperative temperature remain poorly characterised. Methods We evaluated patients who underwent a mastectomy for breast cancer between April 2016 and July 2020. Propensity scores were used to match patients who received neoadjuvant chemotherapy with those who did not, and intraoperative core temperature patterns were analysed in the matched cohort. The independent associations between vasopressor use and heart rate during general anaesthesia in the matched cohort were also analysed. Results Data from 1764 patients were analysed (882 patients in each group). Both groups presented a similar pattern of heat redistribution and subsequent rewarming; however, the neoadjuvant chemotherapy group did not reach the same intraoperative plateau temperature as the group that did not receive prior chemotherapy, with differences of up to 0.4°C (95% confidence interval: 0.11-0.63°C; P=0.005). In a subgroup analysis, neuropathy in patients who received neoadjuvant chemotherapy was associated with increased use of vasopressors and higher heart rate. Conclusions In patients with breast cancer, neoadjuvant chemotherapy is associated with lower plateau core temperatures, increased vasopressor use, and higher heart rates during general anaesthesia, which is more severe in the presence of neuropathy.
Collapse
Affiliation(s)
- Daniel D. Kim
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Sarah M. DeSnyder
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick M. Dougherty
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| |
Collapse
|
7
|
Itamura K, Kupferman S, Lee J, Mallen-St. Clair J. Jaw-in-a-Riley-Day: Mandibular Free Flap Reconstruction With Virtual Surgical Planning in a Patient With Familial Dysautonomia. Cureus 2022; 14:e26336. [PMID: 35911292 PMCID: PMC9315436 DOI: 10.7759/cureus.26336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2022] [Indexed: 11/27/2022] Open
Abstract
We present a unique case of mandibular reconstruction using virtual surgical planning (VSP) of a post-traumatic mandibular non-union defect for a patient with familial dysautonomia (FD), also known as Riley-Day Syndrome. In this case, the complexity related to perioperative and surgical challenges illustrates the utility of VSP and the importance of multi-disciplinary collaboration in jaw-free flap reconstructive surgery. We highlight our experience with the “Jaw-In-A-Day” approach in conjunction with tailored preoperative planning and perioperative care resulting in successful mandibular free flap reconstruction.
Collapse
|
8
|
Sasaki H, Miyakawa H, Watanabe A, Tamura K, Shiga K, Lyu Y, Ichikawa N, Fu Y, Hayashi K, Imamura M, Shibata S. Evening rather than morning increased physical activity alters the microbiota in mice and is associated with increased body temperature and sympathetic nervous system activation. Biochim Biophys Acta Mol Basis Dis 2022; 1868:166373. [DOI: 10.1016/j.bbadis.2022.166373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/21/2022] [Accepted: 02/28/2022] [Indexed: 12/30/2022]
|
9
|
Ackerman RS, Muncey AR, Aldawoodi NN, Kotha R, Getting REG. Cancer Immunotherapies: What the Perioperative Physician Needs to Know. Curr Oncol Rep 2022; 24:399-414. [PMID: 35141856 PMCID: PMC9056594 DOI: 10.1007/s11912-022-01202-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/26/2022]
Abstract
Purpose of Review For patients with cancer, treatment may include combination therapy, including surgery and immunotherapy. Here, we review perioperative considerations for the patient prescribed immunotherapeutic agents. Recent Findings The perioperative period is a poignant moment in the journey of a patient with cancer, potentially deemed most influential compared to other moments in the care continuum. Several immunotherapeutic medications have been employed near the time of surgery to potentially increase effectiveness. Of the various drug classes, including immune checkpoint inhibitors, cytokines, toll-like receptor agonists, and oncolytic viruses, among others, several notable immune-related adverse effects were noted. They range from minor effects to more serious ones, such as renal failure, myocarditis, and tumor growth. Summary Surgery and immunotherapy are often employed in combination for primary treatment and prevention of cancer recurrence. Careful review and consideration of the pharmacokinetics, pharmacodynamics, and toxicities of immunotherapy benefit the perioperative physician and their patients.
Collapse
Affiliation(s)
- Robert S Ackerman
- Department of Anesthesiology, Duke University Medical Center, 134 Research Drive, Durham, NC, 27710, USA.
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Aaron R Muncey
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Nasrin N Aldawoodi
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Rohini Kotha
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | |
Collapse
|
10
|
Lubnin AY. [Sitting position in neurosurgery: realizing the risks]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:99-108. [PMID: 35758085 DOI: 10.17116/neiro20228603199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The author discusses potential intraoperative complications following neurosurgical interventions in sitting position: venous air embolism and paradoxical air embolism, postural hypotension, pneumocephalus, cervical flexion neuropathy, positional damage to peripheral nerves and others. Naturally, prevention of these complications is also considered, and the most effective approach is surgery in lying position.
Collapse
Affiliation(s)
- A Yu Lubnin
- Burdenko Neurosurgical Center, Moscow, Russia
| |
Collapse
|
11
|
Anaesthesia techniques and advanced monitoring in CANVAS patients - Implications for postoperative morbidity and patient recovery: A case report. Int J Surg Case Rep 2021; 83:106058. [PMID: 34098187 PMCID: PMC8187836 DOI: 10.1016/j.ijscr.2021.106058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Cerebellar ataxia, neuropathy and vestibular areflexia syndrome (CANVAS) is a rare multisystem neurodegenerative disorder. We describe our perioperative evaluation and care of a patient with CANVAS undergoing a pancreaticoduodenectomy for an ampullary adenocarcinoma, with a focus on perioperative risk stratification and optimisation, intraoperative advanced haemodynamic monitoring and the postoperative care. Case presentation A 69-year-old female with CANVAS presented with asymptomatic obstructive jaundice, icterus and abdominal pain. She had limited mobility and deconditioning due to severe generalised neuropathy. Computed tomography confirmed a resectable periampullary tumour. Her Duke Activity Status Index was 8.25 points and Edmonton Frailty Scale score was 11, confirming moderate frailty. However, the Charlson Comorbidity Index was five, indicative of a 21% estimated 10-year survival. Further risk stratification including respiratory function testing, echocardiography and cardiopulmonary exercise testing was conducted. The patient proceeded with surgery after multidisciplinary discussions with her treating medical teams. Discussion CANVAS is a rare and challenging condition requiring careful perioperative planning and management. There is no effective treatment for CANVAS. The management approach focuses on mitigating symptoms and improving quality of life. Given that no specific guidelines for managing these patients in the perioperative period have been provided, this report highlights several critical medical issues and implications that should be considered for the successful management of these patients. We demonstrate the role of specific anaesthesia techniques and advanced haemodynamic monitoring in both preventing postoperative morbidity and optimising patient recovery. Conclusion CANVAS is a rare and challenging condition in anaesthesia requiring careful perioperative planning and management. CANVAS is a rare multisystem neurological disorder There is no effective treatment for CANVAS Perioperative management for patients with CANVAS is complex Perioperative risk stratification requires multidisciplinary involvement CANVAS patients can present with unique anaesthesia challenges
Collapse
|
12
|
Idiaquez JF, Idiaquez J, Casar JC, Biaggioni I. Neurogenic Orthostatic Hypotension. Lessons From Synucleinopathies. Am J Hypertens 2021; 34:125-133. [PMID: 33705537 DOI: 10.1093/ajh/hpaa131] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/04/2020] [Accepted: 08/12/2020] [Indexed: 12/15/2022] Open
Abstract
Maintenance of upright blood pressure critically depends on the autonomic nervous system and its failure leads to neurogenic orthostatic hypotension (NOH). The most severe cases are seen in neurodegenerative disorders caused by abnormal α-synuclein deposits: multiple system atrophy (MSA), Parkinson's disease, Lewy body dementia, and pure autonomic failure (PAF). The development of novel treatments for NOH derives from research in these disorders. We provide a brief review of their underlying pathophysiology relevant to understand the rationale behind treatment options for NOH. The goal of treatment is not to normalize blood pressure but rather to improve quality of life and prevent syncope and falls by reducing symptoms of cerebral hypoperfusion. Patients not able to recognize NOH symptoms are at a higher risk for falls. The first step in the management of NOH is to educate patients on how to avoid high-risk situations and providers to identify medications that trigger or worsen NOH. Conservative countermeasures, including diet and compression garments, should always precede pharmacologic therapies. Volume expanders (fludrocortisone and desmopressin) should be used with caution. Drugs that enhance residual sympathetic tone (pyridostigmine and atomoxetine) are more effective in patients with mild disease and in MSA patients with spared postganglionic fibers. Norepinephrine replacement therapy (midodrine and droxidopa) is more effective in patients with neurodegeneration of peripheral noradrenergic fibers like PAF. NOH is often associated with other cardiovascular diseases, most notably supine hypertension, and treatment should be adapted to their presence.
Collapse
Affiliation(s)
- Juan Francisco Idiaquez
- Hospital Padre Hurtado, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago de Chile, Chile
| | - Juan Idiaquez
- Departamento de Neurologia, Pontificia Universidad Catolica de Chile, Santiago de Chile, Chile
| | - Juan Carlos Casar
- Departamento de Neurologia, Pontificia Universidad Catolica de Chile, Santiago de Chile, Chile
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
13
|
Abstract
Patients with Parkinson's disease (PD) may undergo several elective and emergency surgeries. Motor fluctuations, the presence of a wide range of non-motor symptoms (NMS), and the use of several medications, often not limited to dopaminergic agents, make the perioperative management of PD challenging. However, the literature on perioperative management of PD is sparse. In this descriptive review article, we comprehensively discuss the issues in the pre-, intra-, and postoperative phases which may negatively affect the PD patients and discuss the approach to their prevention and management. The major preoperative challenges include accurate medication reconciliation and administration of the dopaminergic medications during the nil per os (NPO) state. While the former can be addressed with staff education and PD-specific admission protocols, knowledge of non-oral formulations of dopaminergic agents (apomorphine, inhalational levodopa, and rotigotine transdermal patch) is the key to the management of the Parkinsonian symptoms in NPO state. Deep brain stimulation (DBS) devices should be turned off to avert potential electromagnetic interference with surgical appliances. Choosing the appropriate anesthesia and avoiding and managing respiratory issues and dysautonomia are the major intraoperative challenges. Timely reinitiation of dopaminergic medications, adequate management of pain, nausea, and vomiting, and prevention of postoperative infections and delirium are the postoperative challenges. Overall, a multidisciplinary approach is pivotal to prevent and manage the perioperative complications in PD. Administration of anti-Parkinson medications during NPO state, prevention of anesthesia-related complications, and timely rehabilitation remain the key to healthy surgical outcomes.
Collapse
|
14
|
Kumar CM, Seet E, Singh RK, Joshi GP. Anesthesia in Patients With Multiple-System Atrophy: A Narrative Review and Practice Guidance. A A Pract 2019; 12:176-179. [DOI: 10.1213/xaa.0000000000000939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
15
|
Balaji RM, Nagaraja PS, Singh NG, Prabhakar V, Manjunatha N. ANSiscope™: Can it be the crystal ball of cardiac anesthesia? Ann Card Anaesth 2019; 22:101-106. [PMID: 30648692 PMCID: PMC6350435 DOI: 10.4103/aca.aca_9_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background : Autonomic dysfunction (AD) is infrequently evaluated preoperatively despite having profound perioperative implications. The ANSiscope™ is a monitoring device that quantifies AD. This study aims to determine the potential of the device to predict hypotension following anesthetic induction, occurrence of arrhythmias, and inotrope requirement for patients undergoing off-pump coronary artery bypass surgery (OPCAB). Study Design : Prospective observational double-blinded study. Materials and Methodology Seventy-five patients undergoing OPCAB had their autonomic function assessed by ANSiscope™. They were classified into four groups based on their AD and compared to perioperative adverse events. Results Patients with diabetes had a higher ANSindex (P = 0.0263). They had a greater decrease in systolic blood pressure (P = 0.001) and mean arterial pressure (P = 0.004) postinduction, had an increased incidence of arrhythmias (P = 0.009), required higher inotropic support immediately (P = 0.010) and at 24 h after surgery (P = 0.018), and longer duration of postoperative ventilation (P < 0.001). They also had a higher incidence of emergency conversion of OPCAB to on-pump surgery (P = 0.009). Conclusions An increased association between AD as quantified by the ANSiscope™ and perioperative adverse outcomes was observed. An increased rate of emergency conversion of OPCAB to on-pump surgery with higher dysfunction was noted. The authors opine that the threshold for conversion must be lower in patients deemed to be at a higher risk. Proper evaluation of the autonomic nervous system empowers the anesthesiologist to anticipate and adequately prepare for complications.
Collapse
Affiliation(s)
- Rohini Mayur Balaji
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - P S Nagaraja
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Naveen G Singh
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - V Prabhakar
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - N Manjunatha
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| |
Collapse
|
16
|
Anker A, Prantl L, Strauss C, Brébant V, Heine N, Lamby P, Geis S, Schenkhoff F, Pawlik M, Klein S. Vasopressor support vs. liberal fluid administration in deep inferior epigastric perforator (DIEP) free flap breast reconstruction – a randomized controlled trial. Clin Hemorheol Microcirc 2018; 69:37-44. [DOI: 10.3233/ch-189129] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- A.M. Anker
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - L. Prantl
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - C. Strauss
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - V. Brébant
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - N. Heine
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - P. Lamby
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - S. Geis
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - F. Schenkhoff
- Department of Anaesthesiology, Caritas Hospital St. Josef, Regensburg, Germany
| | - M. Pawlik
- Department of Anaesthesiology, Caritas Hospital St. Josef, Regensburg, Germany
| | - S.M. Klein
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| |
Collapse
|
17
|
Reimer P, Máca J, Szturz P, Jor O, Kula R, Ševčík P, Burda M, Adamus M. Role of heart-rate variability in preoperative assessment of physiological reserves in patients undergoing major abdominal surgery. Ther Clin Risk Manag 2017; 13:1223-1231. [PMID: 29033572 PMCID: PMC5614745 DOI: 10.2147/tcrm.s143809] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Major abdominal surgery (MAS) is associated with increased morbidity and mortality. The main objective of our study was to evaluate the predictive value of heart-rate variability (HRV) concerning development of postoperative complications in patients undergoing MAS. The secondary objectives were to identify the relationship of HRV and use of vasoactive drugs during anesthesia, intensive care unit length of stay (ICU-LOS), and hospital length of stay (H-LOS). Patients and methods Sixty-five patients scheduled for elective MAS were enrolled in a prospective, single-center, observational study. HRV was measured by spectral analysis (SA) preoperatively during orthostatic load. Patients were divided according to cardiac autonomic reactivity (CAR; n=23) and non-cardiac autonomic reactivity (NCAR; n=30). Results The final analysis included 53 patients. No significant difference was observed between the two groups regarding type of surgery, use of minimally invasive techniques or epidural catheter, duration of surgery and anesthesia, or the amount of fluid administered intraoperatively. The NCAR group had significantly greater intraoperative blood loss than the CAR group (541.7±541.9 mL vs 269.6±174.3 mL, p<0.05). In the NCAR group, vasoactive drugs were used during anesthesia more frequently (n=21 vs n=4; p<0.001), and more patients had at least one postoperative complication compared to the CAR group (n=19 vs n=4; p<0.01). Furthermore, the NCAR group had more serious complications (Clavien–Dindo ≥ Grade III n=6 vs n=0; p<0.05) and a greater number of complications than the CAR group (n=57 vs n=5; p<0.001). Significant differences were found for two specific subgroups of complications: hypotension requiring vasoactive drugs (NCAR: n=10 vs CAR: n=0; p<0.01) and ileus (NCAR: n=11 vs CAR: n=2; p<0.05). Moreover, significant differences were found in the ICU-LOS (NCAR: 5.7±3.5 days vs CAR: 2.6±0.7 days; p<0.0001) and H-LOS (NCAR: 12.2±5.6 days vs CAR: 7.2±1.7 days; p<0.0001). Conclusion Preoperative HRV assessment during orthostatic load is objective and useful for identifying patients with low autonomic physiological reserves and high risk of poor post-operative course.
Collapse
Affiliation(s)
- Petr Reimer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Jan Máca
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Pavel Szturz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Ondřej Jor
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Roman Kula
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Pavel Ševčík
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Michal Burda
- Institute for Research and Applications of Fuzzy Modeling, Centre of Excellence IT4Innovations, University of Ostrava, Ostrava
| | - Milan Adamus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Olomouc, Olomouc, Czech Republic
| |
Collapse
|
18
|
Agarwal S, Aggarwal R. Anesthetic considerations in a patient with multiple system atrophy-cerebellar for lower limb surgery. Saudi J Anaesth 2017; 11:365-366. [PMID: 28757850 PMCID: PMC5516512 DOI: 10.4103/sja.sja_57_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sandhya Agarwal
- Department of Anaesthesiology and Critical Care, Deen Dayal Upadhyay Hospital, New Delhi, India
| | - Ritu Aggarwal
- Department of Anaesthesiology and Critical Care, Deen Dayal Upadhyay Hospital, New Delhi, India
| |
Collapse
|
19
|
Kim HJ, Lee HJ, Lee DW, Kim JY, Kwon JY, Kim HK, Kim WS, Hwang BY. Anesthetic experience of frontotemporal dementia patient with severe autonomic dysfunction: a case report. Korean J Anesthesiol 2017; 70:356-360. [PMID: 28580089 PMCID: PMC5453900 DOI: 10.4097/kjae.2017.70.3.356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/15/2016] [Accepted: 12/16/2016] [Indexed: 11/10/2022] Open
Abstract
Anesthetic experience in frontotemporal dementia (FTD) with severe hypotension associated autonomic dysfunction has not yet been reported. Here in case, we report on the case of treatment with vasopressin to refractory hypotension in FTD patient. A 54-year-old male presented with a ten-year history of FTD with frequent syncope. The patient was scheduled to undergo subtotal gastrectomy for resection of stomach cancer. During the operation, sudden hypotension occurred and it was refractory to fluid and 1 unit of blood resuscitation and did not respond to catecholamine. Transesophageal echocardiography showed normal heart with adequate volume state. After intravenous administration of arginine vasopressin, the patient's vital signs returned to baseline values. Arginine vasopressin might be considered as a valuable alternative for treatment of severe refractory hypotension in autonomic dysfunction patients with FTD.
Collapse
Affiliation(s)
- Hyae-Jin Kim
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Hyeon Jeong Lee
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Do Won Lee
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Jae Yeon Kim
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Jae Young Kwon
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Hae-Kyu Kim
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Won-Sung Kim
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Boo-Young Hwang
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea
| |
Collapse
|
20
|
Abstract
PURPOSE OF REVIEW The autonomic nervous system functions to control heart rate, blood pressure, respiratory rate, gastrointestinal motility, hormone release, and body temperature on a second-to-second basis. Here we summarize some of the latest literature on autonomic dysfunction, focusing primarily on the perioperative implications. RECENT FINDINGS The variety of autonomic dysfunction now extends to a large number of clinical conditions in which the cause or effect of the autonomic component is blurred. Methods for detecting dysautonomia can be as simple as performing a history and physical examination that includes orthostatic vital signs measured in both recumbent and vertical positions; however, specialized laboratories are required for definitive diagnosis. Heart rate variability monitoring is becoming more commonplace in the assessment and understanding of autonomic instability. Degenerative diseases of the autonomic nervous system include Parkinson's disease and multiple system atrophy, with the most serious manifestations being postural hypotension and paradoxical supine hypertension. Other conditions occur in which the autonomic dysfunction is only part of a larger disease process, such as diabetic autonomic neuropathy, traumatic brain injury, and spinal cord injury. SUMMARY Patients with dysautonomia often have unpredictable and paradoxical physiological responses to various perioperative stimuli. Knowledge of the underlying pathophysiology of their condition is required in order to reduce symptom exacerbation and limit morbidity and mortality during the perioperative period.
Collapse
|
21
|
De Wandele I, Rombaut L, Leybaert L, Van de Borne P, De Backer T, Malfait F, De Paepe A, Calders P. Dysautonomia and its underlying mechanisms in the hypermobility type of Ehlers–Danlos syndrome. Semin Arthritis Rheum 2014; 44:93-100. [DOI: 10.1016/j.semarthrit.2013.12.006] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/20/2013] [Accepted: 12/24/2013] [Indexed: 11/26/2022]
|
22
|
A retrospective review of autonomic screening tests conducted at a Tertiary General Hospital. Auton Neurosci 2014; 181:69-73. [DOI: 10.1016/j.autneu.2013.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 09/26/2013] [Accepted: 11/29/2013] [Indexed: 10/25/2022]
|
23
|
Abstract
Abstract
Background:
Early mobilization is important for postoperative recovery but is limited by orthostatic intolerance (OI) with a prevalence of 50% 6 h after major surgery. The pathophysiology of postoperative OI is assumed to include hypovolemia besides dysregulation of vasomotor tone. Stroke volume–guided fluid therapy, so-called goal-directed therapy (GDT), corrects functional hypovolemia, and the authors hypothesized that GDT reduces the prevalence of OI after major surgery and assessed this in a prospective, double-blinded trial.
Methods:
Forty-two patients scheduled for open radical prostatectomy were randomized into standard fluid therapy (control group) or GDT groups. Both groups received a fixed-volume crystalloid regimen supplemented with 1:1 replacement of blood loss with colloid, and in addition, the GDT group received colloid to obtain a maximal stroke volume (esophageal Doppler). The primary outcome was the prevalence of OI assessed with a standardized mobilization protocol before and 6 h after surgery. Hemodynamic and hormonal orthostatic responses were evaluated.
Results:
Twelve (57%) versus 15 (71%) patients in the control and GDT groups (P = 0.33), respectively, demonstrated OI after surgery, group difference 14% (CI, −18 to 45%). Patients in the GDT group received more colloid during surgery (1,758 vs. 1,057 ml; P = 0.001) and reached a higher stroke volume (102 vs. 89 ml; P = 0.04). OI patients had an increased length of hospital stay (3 vs. 2 days; P = 0.02) and impaired hemodynamic and norepinephrine responses on mobilization.
Conclusion:
GDT did not reduce the prevalence of OI, and patients with OI demonstrated impaired cardiovascular and hormonal responses to mobilization.
Collapse
|
24
|
Guerri-Guttenberg RA, Siaba-Serrate F, Cacheiro FJ. [Clinical relevance of cardiopulmonary reflexes in anesthesiology]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:448-456. [PMID: 23121709 DOI: 10.1016/j.redar.2012.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 08/31/2012] [Accepted: 09/08/2012] [Indexed: 06/01/2023]
Abstract
The baroreflex, chemoreflex, pulmonary reflexes, Bezold-Jarisch and Bainbridge reflexes and their interaction with local mechanisms, are a demonstration of the richness of cardiovascular responses that occur in human beings. As well as these, the anesthesiologist must contend with other variables that interact by attenuating or accentuating cardiopulmonary reflexes such as, anesthetic drugs, surgical manipulation, and patient positioning. In the present article we review these reflexes and their clinical relevance in anesthesiology.
Collapse
Affiliation(s)
- R A Guerri-Guttenberg
- Departamento de Anestesiología, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | | | | |
Collapse
|
25
|
Cardiac Autonomic Dysfunction in the Early Phase after Left Ventricular Assist Device Implant: Implications for Surgery and Follow-Up? Int J Artif Organs 2013; 36:410-8. [DOI: 10.5301/ijao.5000210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2013] [Indexed: 11/20/2022]
Abstract
Purpose In congestive heart failure (CHF) patients, a profound cardiac autonomic derangement, clinically expressed by reduced heart rate variability (HRV), is present and is related to the degree of ventricular dysfunction. Implantation of a left ventricular assist device (LVAD) can progressively improve HRV, associated with an increased circulatory output. Data from patients studied at different times after LVAD implantation are controversial. The aims of this study were to assess cardiac autonomic function in the early phases after axial-flow LVAD implantation, and to estimate the potential relevance of recent major surgical stress on the autonomic balance. Methods HRV (time-domain; 24-h Holter) was evaluated in 14 patients, 44.8 ± 25.8 days after beginning of Jarvik-2000 LVAD support; 47 advanced stage CHF, 24 cardiac surgery (CS) patients and 30 healthy subjects served as control groups. Inclusion criteria: sinus rhythm, stable clinical conditions, no diabetes or other known causes of HRV alteration. Results HRV was considerably reduced in LVAD patients in the early phases after device implantation in comparison to all control groups. A downgrading of HRV parameters was also present in CS controls. Circadian oscillations were highly depressed in LVAD and CHF patients, and slightly reduced in CS patients. Conclusions In CHF patients supported by a continuous-flow LVAD, a profound cardiac dysautonomia is still evident in the first two months from the beginning of circulatory support; the degree of cardiac autonomic imbalance is even greater in comparison to advanced CHF patients. The recent surgical stress could be partly linked to these abnormalities.
Collapse
|
26
|
Chandrakantan A, Poulton TJ. Anesthetic considerations for rapid-onset obesity, hypoventilation, hypothalamic dysfunction, and autonomic dysfunction (ROHHAD) syndrome in children. Paediatr Anaesth 2013; 23:28-32. [PMID: 22862685 DOI: 10.1111/j.1460-9592.2012.03924.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Rapid-onset obesity, hypoventilation, hypothalamic dysfunction, and autonomic dysfunction is an increasingly common diagnosis in patients who are being seen at tertiary care children's hospitals. We present two cases of anesthetics from the authors' own experience in addition to a comprehensive review of the disorder and anesthetic implications.
Collapse
Affiliation(s)
- Arvind Chandrakantan
- Department of Anesthesiology & Pediatrics, Stony Brook University Medical Center, Stony Brook Children's Hospital, Stony Brook, NY, USA.
| | | |
Collapse
|
27
|
Current world literature. Curr Opin Nephrol Hypertens 2012; 21:557-66. [PMID: 22874470 DOI: 10.1097/mnh.0b013e3283574c3b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|