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Morgan K, Smith A, Blitshteyn S. POTS and Pregnancy: A Review of Literature and Recommendations for Evaluation and Treatment. Int J Womens Health 2022; 14:1831-1847. [PMID: 36590760 PMCID: PMC9795856 DOI: 10.2147/ijwh.s366667] [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: 08/01/2022] [Accepted: 12/06/2022] [Indexed: 12/25/2022] Open
Abstract
Postural Orthostatic Tachycardia Syndrome (POTS) is a disorder of the autonomic nervous system most commonly affecting women of reproductive age. Studies on POTS and pregnancy are limited, and there is a lack of clinical guidelines regarding assessment and management of pregnant women with POTS. The purpose of this review is to summarize data from the available studies on the topic of pregnancy in POTS and common comorbid conditions and to provide the clinical recommendations regarding evaluation and treatment of POTS in pregnant women, based on the available studies and clinical experience. We conclude that pregnancy appears to be safe for women with POTS and is best managed by a multi-disciplinary team with knowledge of POTS and its various comorbidities. Importantly, large, prospective studies are needed to better delineate the course and outcomes of pregnancy, as well as possible pregnancy-related complications in women with POTS. Clinicians should be aware of the clinical presentation, diagnostic criteria, and treatment options in pregnant women with POTS to optimize outcomes and improve medical care during pregnancy and post-partum period.
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Affiliation(s)
- Kate Morgan
- School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Angela Smith
- HNE Health Libraries, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Svetlana Blitshteyn
- Department of Neurology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA,Dysautonomia Clinic, Williamsville, NY, USA,Correspondence: Svetlana Blitshteyn, 300 International Drive, Suite 100, Williamsville, NY, 14221, USA, Tel +1-716-531-4598, Fax +1-716-478-6917, Email
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2
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Costa-Pinto R, Jones DA, Udy AA, Warrillow SJ, Bellomo R. Midodrine use in critically ill patients: a narrative review. CRIT CARE RESUSC 2022; 24:298-308. [PMID: 38047013 PMCID: PMC10692611 DOI: 10.51893/2022.4.r] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Midodrine is a peripherally acting, oral α-agonist that is increasingly used in intensive care units despite conflicting evidence for its effectiveness. It has pharmacological effects on blood vessels as well as pupillary, cardiac, renal, gastrointestinal, genitourinary, lymphatic and skin tissue. It has approval for use as a treatment for orthostatic hypotension, but a surge in interest over the past decade has prompted its use for a growing number of off-label indications. In critically ill patients, midodrine has been used as either an adjunctive oral therapy to wean vasoplegic patients off low dose intravenous vasopressor infusions, or as an oral vasopressor agent to prevent or minimise the need for intravenous infusion. Clinical trials have mostly focused on midodrine as an intravenous vasopressor weaning agent. Early retrospective studies supported its use for this indication, but more recent randomised controlled trials have largely refuted this practice. Key questions remain on its role in managing critically ill patients before intensive care admission, during intensive care stay, and following discharge. This narrative review presents a comprehensive overview of midodrine use for the critical care physician and highlights why lingering questions around ideal patient selection, dosing, timing of initiation, and efficacy of midodrine for critically ill patients remain unanswered.
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Affiliation(s)
- Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Daryl A. Jones
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew A. Udy
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Stephen J. Warrillow
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
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3
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Harding F, Hyndman N, Burns R. Anaesthetic management of postural orthostatic tachycardia syndrome presenting during pregnancy. Int J Obstet Anesth 2019; 39:132-134. [PMID: 30837098 DOI: 10.1016/j.ijoa.2019.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 12/19/2018] [Accepted: 02/02/2019] [Indexed: 11/29/2022]
Affiliation(s)
- F Harding
- Anaesthetic Department, Royal Infirmary of Edinburgh, Edinburgh, UK.
| | - N Hyndman
- Anaesthetic Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - R Burns
- Anaesthetic Department, Royal Infirmary of Edinburgh, Edinburgh, UK
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4
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Morgan K, Chojenta C, Tavener M, Smith A, Loxton D. Postural Orthostatic Tachycardia Syndrome during pregnancy: A systematic review of the literature. Auton Neurosci 2018; 215:106-118. [DOI: 10.1016/j.autneu.2018.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/27/2018] [Accepted: 05/07/2018] [Indexed: 01/25/2023]
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5
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Overview of the management of postural tachycardia syndrome in pregnant patients. Auton Neurosci 2018; 215:102-105. [DOI: 10.1016/j.autneu.2018.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/14/2018] [Accepted: 02/14/2018] [Indexed: 11/23/2022]
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6
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Pezaro S, Pearce G, Reinhold E. Hypermobile Ehlers-Danlos Syndrome during pregnancy, birth and beyond. ACTA ACUST UNITED AC 2018. [DOI: 10.12968/bjom.2018.26.4.217] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sally Pezaro
- Midwife, researcher and lecturer, Faculty of Health & Life Sciences, Coventry University
| | - Gemma Pearce
- Senior research assistant, Centre for Advances in Behavioural Science, Coventry University
| | - Emma Reinhold
- Portfolio GP; Clinical Champion for the Ehlers Danlos Syndromes, Royal College of GPs; Primary Care Advisor, EDS UK
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7
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Abstract
Purpose Postural orthostatic tachycardia syndrome (POTS) is a form of orthostatic intolerance characterized by an increased heart rate upon transition from supine to standing, and head-up tilt without orthostatic hypotension. Its etiology is multifactorial, and no clear cause has been identified. Common symptoms include light-headedness, blurred vision, weakness, cognitive difficulties, and fatigue and are often accompanied by palpitations, shortness of breath, syncope, or gastrointestinal symptoms. Management includes volume expansion, physical counter maneuvers, and pharmacological agents such as fludrocortisone, midodrine, propranolol, and pyridostigmine. The course of POTS in pregnancy is variable and POTS has not been directly implicated in any adverse outcomes for the mother or fetus. Methods Two cases of POTS in pregnancy are presented, along with a review of the literature for reports of POTS in pregnancy. Results Along with our 2 cases, 10 other case reports were identified and included. Conclusion The course of POTS in pregnancy is variable, and not directly linked to increase perinatal morbidity or mortality. Women can safely undergo regional anesthesia, and vaginal delivery with close monitoring of hemodynamic changes.
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Affiliation(s)
- Brianna Lide
- Texas A and M University College of Medicine, Temple, Texas
| | - Sina Haeri
- St. David's North Austin Medical Center, Austin, Texas ; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
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Pramya N, Puliyathinkal S, Sagili H, Jayalaksmi D, Reddi Rani P. Postural orthostatic tachycardia syndrome complicating pregnancy: a case report with review of literature. Obstet Med 2012; 5:83-5. [PMID: 27579141 DOI: 10.1258/om.2011.110012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2011] [Indexed: 11/18/2022] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) affects women of child-bearing age. There are little reported data on the outcomes of pregnancy in women with POTS. The most common mode of delivery reported in the literature is the caesarean section. Here we describe a woman with POTS who delivered vaginally without any complications and present a comprehensive review of the literature on pregnancy in POTS.
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Affiliation(s)
- N Pramya
- Department of Obstetrics and Gynaecology , Jipmer, Puducherry 605005 , India
| | | | - Haritha Sagili
- Department of Obstetrics and Gynaecology , Jipmer, Puducherry 605005 , India
| | - D Jayalaksmi
- Department of Obstetrics and Gynaecology , Jipmer, Puducherry 605005 , India
| | - P Reddi Rani
- Department of Obstetrics and Gynaecology , Jipmer, Puducherry 605005 , India
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Blitshteyn S, Poya H, Bett GCL. Pregnancy in postural tachycardia syndrome: clinical course and maternal and fetal outcomes. J Matern Fetal Neonatal Med 2012; 25:1631-4. [PMID: 22185354 DOI: 10.3109/14767058.2011.648671] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Postural tachycardia syndrome (POTS), a disorder of the autonomic nervous system, predominantly occurs in women of child-bearing age. We set out to determine the clinical course and maternal and fetal outcomes in pregnant women with pre-existing POTS. METHODS Participants were asked to complete a detailed questionnaire assessing the clinical course of POTS before, during and after pregnancy, as well as complications of pregnancy, labor and delivery and fetal outcomes. RESULTS Among 10 women with pre-existing POTS (pregnancy age 28 ± 7 years, range 16-39), with a total of 17 live births, two were complicated by pre-eclampsia, 14 were normal vaginal deliveries and three were C-sections. The rate of severe vomiting or hyperemesis gravidarum in the first trimester was 59%. There were no stillbirths or congenital abnormalities. The average birth weight was 3076 ± 733 grams, with two infants born premature. During pregnancy, POTS symptoms were either improved or stable in six of 10 women, and four of these six women utilized medications for POTS. Six months after delivery, POTS symptoms were improved in three, stable in two and worsened in five women compared to before pregnancy. CONCLUSIONS POTS may have a variable clinical course in pregnancy, with 60% of women reporting either improved or stable symptoms during pregnancy, and 50% of women reporting either improved or stable symptoms 6 months after delivery. There may be a higher rate of severe vomiting in the first trimester in women with POTS than in general population.
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Affiliation(s)
- Svetlana Blitshteyn
- Department of Neurology, State University of New York At Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY 14203, USA.
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Rabbitts JA, Groenewald CB, Jacob AK, Low PA, Curry TB. Postural orthostatic tachycardia syndrome and general anesthesia: a series of 13 cases. J Clin Anesth 2011; 23:384-92. [PMID: 21802629 DOI: 10.1016/j.jclinane.2010.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 11/02/2010] [Accepted: 12/08/2010] [Indexed: 10/17/2022]
Abstract
STUDY OBJECTIVE To investigate whether patients with postural orthostatic tachycardia syndrome (POTS) developed unexpected perioperative complications. DESIGN Retrospective case series. SETTING Academic medical center. MEASUREMENTS The records of 13 patients with POTS, who underwent surgical procedures during general anesthesia, were studied. Details of disease management, anesthetic induction, hemodynamic response to induction and intubation, intraoperative course, and immediate postoperative management were analyzed. MAIN RESULTS Three patients developed prolonged intraoperative hypotension, which was not associated with induction of anesthesia. All 13 patients were successfully treated and they recovered without complications. There were no unplanned hospital or intensive care admissions. CONCLUSIONS Intraoperative hypotension, but not tachycardia, was observed in three of 13 patients with POTS who received general anesthesia for a variety of surgical procedures using multiple medications and techniques.
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11
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Salmon JR. Severe autonomic dysfunction complicated by hyperemesis gravidarum causing unstable blood pressure in pregnancy. Aust N Z J Obstet Gynaecol 2010; 49:699-700. [PMID: 20070729 DOI: 10.1111/j.1479-828x.2009.01079.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Powless CA, Harms RW, Watson WJ. Postural tachycardia syndrome complicating pregnancy. J Matern Fetal Neonatal Med 2010; 23:850-3. [DOI: 10.3109/14767050903265089] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Outcomes of pregnancy in patients with preexisting postural tachycardia syndrome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:1000-3. [PMID: 19659618 DOI: 10.1111/j.1540-8159.2009.02430.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postural orthostatic tachycardia syndrome (POTS) occurs more commonly in women than in men and often affects women of childbearing age. Many of these women wish to have children, yet there are little reported data on the outcomes of pregnancy in patients with POTS. To date there has been one report of two patients with POTS who successfully completed pregnancy. We report the outcomes of 22 women with preexisting POTS who became pregnant. OBJECTIVE To assess the outcome of pregnancy in patients with preexisting POTS. METHODS AND RESULTS Twenty-two patients, age 30 +/- 7 years, with POTS became pregnant. Migraine was the common comorbidity found in 40% of patients. Medications used were beta-blockers (18%), midiodrine (31%), selective serotonin reuptake inhibitors (31%), fludrocortisone (13%), combination (40%), and none (18%). During pregnancy, symptoms of POTS remained unchanged in three (13%), improved in 12 (55%), and worsened in seven (31%) patients. One patient who had recurrent episodes of syncope without aura was found to have complete heart block and received a cardiac pacemaker. All patients completed pregnancy successfully. There were no stillbirths. One patient developed hyperemesis. Eighteen patients had vaginal delivery and four patients delivered by cesarian section. No other complications of pregnancy were encountered. Congenital abnormalities were encountered in the form of one atrial septal defect, one ventricular septal defect, and one Down's syndrome. Postpartum symptoms of POTS remained stable in 15 (69%) patients and worsened in seven (31%) patients. CONCLUSION Based on our observation, patients with POTS can safely complete pregnancy if they desire to do so. POTS should not be considered a contraindication to pregnancy per se.
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Affiliation(s)
- Khalil Kanjwal
- Pacing and Electrophysiology section, Division of Cardiology, Department of Medicine, University of Toledo Medical Center, Toledo, Ohio 43614, USA
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Kodakkattil S, Das S. Pregnancy in woman with postural orthostatic tachycardia syndrome (POTS). J OBSTET GYNAECOL 2009; 29:764-5. [DOI: 10.3109/01443610903165529] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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16
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Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Postpartum postural orthostatic tachycardia syndrome in a patient with the joint hypermobility syndrome. Cardiol Res Pract 2009; 2009:187543. [PMID: 19946638 PMCID: PMC2778448 DOI: 10.4061/2009/187543] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Revised: 09/08/2009] [Accepted: 09/10/2009] [Indexed: 11/20/2022] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) commonly affects women of childbearing age. We report on a 37-year-old woman who developed symptoms of recurrent syncope in the postpartum period. Her head up tilt test and clinical presentation was consistent with POTS.
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Affiliation(s)
- Khalil Kanjwal
- Division of Cardiology, Department of Medicine, The University of Toledo Medical Center, Health Sciences Campus, Mail Stop 1118, 3000 Arlington Avenue, Toledo, OH 43614, USA
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Jones T, Ng C. Anaesthesia for caesarean section in a patient with Ehlers-Danlos syndrome associated with postural orthostatic tachycardia syndrome. Int J Obstet Anesth 2008; 17:365-9. [DOI: 10.1016/j.ijoa.2008.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2008] [Indexed: 11/30/2022]
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McEvoy MD, Low PA, Hebbar L. Postural orthostatic tachycardia syndrome: anesthetic implications in the obstetric patient. Anesth Analg 2007; 104:166-7. [PMID: 17179264 DOI: 10.1213/01.ane.0000246815.39197.2b] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
We report the anesthetic management of a parturient with postural orthostatic tachycardia syndrome. This syndrome is associated with hemodynamic instability, which can be worsened by the physiology of labor and delivery. We discuss anesthetic concerns with this disease in the parturient and suggest approaches for management of this disease.
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Affiliation(s)
- Matthew D McEvoy
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Corbett WL, Reiter CM, Schultz JR, Kanter RJ, Habib AS. Anaesthetic management of a parturient with the postural orthostatic tachycardia syndrome: a case report. Br J Anaesth 2006; 97:196-9. [PMID: 16698864 DOI: 10.1093/bja/ael105] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Postural orthostatic tachycardia syndrome encompasses a group of disorders characterized by orthostatic intolerance. We describe the anaesthetic management of analgesia for labour and of Caesarean section in a parturient suffering from this disorder. Worsening of her symptoms during pregnancy was managed with an increase in the dose of beta-blockers taken by the patient. Epidural analgesia was instigated early to attenuate the stress of labour and avoid consequent triggering of a tachycardic response. Slow titration of epidural analgesia and anaesthesia after an adequate fluid preload was undertaken to minimize hypotension and subsequent tachycardia. Neuraxial opioid, combined with non-steroidal anti-inflammatory drugs and bilateral iliohypogastric and ilioinguinal nerve blocks were used to optimize postoperative analgesia.
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Affiliation(s)
- W L Corbett
- Department of Anaesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710, USA
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