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Brognara F, Castania JA, Ribeiro AB, Santos-Júnior NN, Salgado HC. The Bezold-Jarisch Reflex and The Inflammatory Response Modulation in Unanesthetized Endotoxemic Rats. Front Physiol 2021; 12:745285. [PMID: 34616312 PMCID: PMC8488195 DOI: 10.3389/fphys.2021.745285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Evidence indicates that the activation of the parasympathetic branch of the autonomic nervous system may be effective in treating inflammatory diseases. Previously, we have described that baroreflex activation displays anti-inflammatory properties. Analogous to the baroreflex, the Bezold-Jarisch reflex also promotes parasympathetic activation with simultaneous inhibition of the sympathetic system. Thus, the present study aimed to evaluate whether the activation of the Bezold-Jarisch reflex would also have the ability to reduce inflammation in unanesthetized rats. We used lipopolysaccharide (LPS) injection (5mg/kg, i.p.) to induce systemic inflammation in male Wistar Hannover rats and phenylbiguanide (PBG) administration (5μg/kg, i.v.) to activate the Bezold-Jarisch reflex. Spleen, heart, hypothalamus, and blood samples were collected to determine the levels of cytokines. Compared to baseline, PBG reduced the arterial pressure (115±2 vs. 88±5mmHg) and heart rate (380±7 vs. 114±26bpm), immediately after its administration, confirming the activation of the parasympathetic system and inhibition of the sympathetic system. From the immunological point of view, the activation of the Bezold-Jarisch reflex decreased the plasma levels of TNF (LPS: 775±209 vs. PBG + LPS: 248±30pg/ml) and IL-6 levels in the spleen (LPS: 39±6 vs. PBG + LPS: 24±4pg/mg of tissue). However, it did not change the other cytokines in the plasma or the other tissues evaluated. These findings confirm that the activation of the Bezold-Jarisch reflex can modulate inflammation and support the understanding that the cardiovascular reflexes regulate the immune system.
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Affiliation(s)
- Fernanda Brognara
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Jaci Airton Castania
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Aline Barbosa Ribeiro
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Helio Cesar Salgado
- Department of Physiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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Mendonça FT, Crepaldi Junior LC, Gersanti RC, de Araújo KC. Effect of ondansetron on spinal anesthesia-induced hypotension in non-obstetric surgeries: a randomised, double-blind and placebo-controlled trial. Braz J Anesthesiol 2021; 71:233-240. [PMID: 33766681 PMCID: PMC9373418 DOI: 10.1016/j.bjane.2020.12.028] [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] [Received: 06/17/2020] [Revised: 12/01/2020] [Accepted: 12/12/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Spinal anesthesia is an effective technique for many surgical procedures, but it is often associated with an increased risk of potentially deleterious hemodynamic disturbances. The benefits of prophylactic ondansetron for preventing spinal anesthesia-induced hypotension are still uncertain. Therefore, this study aimed to compare the effect of ondansetron and placebo before spinal block on the incidence of hypotension in patients having non-obstetric surgeries. METHODS Randomized, double-blind, parallel-group, superiority trial with a 1:1 allocation ratio. A total of 144 patients scheduled for non-obstetric surgeries with an indication for spinal anesthesia were randomized. Patients received intravenous ondansetron (8mg) or placebo before standard spinal anesthesia. The primary outcome was the rate of hypotension in the first 30 minutes after spinal anesthesia. RESULTS Hypotension occurred in 20 of 72 patients (27.8%) in the ondansetron group and in 36 of 72 patients (50%) in the placebo group (Odds Ratio-OR=0.38; 95% Confidence Interval-CI 0.19 to 0.77; p=0.007). Fewer patients in the ondansetron group required ephedrine compared to the placebo group (13.9% vs. 27.8%; OR=0.42; 95% CI 0.18 to 0.98; p=0.04). Exploratory analyses revealed that ondansetron may be more effective than placebo in patients aged 60 years or older (OR=0.12; 95% CI 0.03 to 0.48; p=0.03). No difference in heart rate variations was observed. CONCLUSION Our findings suggest that ondansetron can be a viable and effective strategy to reduce both the incidence of spinal anesthesia-induced hypotension and vasopressors usage in non-obstetric surgeries.
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Šklebar I, Bujas T, Habek D. SPINAL ANAESTHESIA-INDUCED HYPOTENSION IN OBSTETRICS: PREVENTION AND THERAPY. Acta Clin Croat 2019; 58:90-95. [PMID: 31741565 PMCID: PMC6813480 DOI: 10.20471/acc.2019.58.s1.13] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Regional centro-axial anaesthesia, primarily spinal block, is the preferred method of anaesthesia for elective caesarean section because it entails fewer risks for the mother and the foetus compared to general anaesthesia. The most common side effect associated with spinal block is hypotension due to sympatholysis, occurring in up to 75% of cases. Spinal block-induced sympatholysis leads to vasodilatation and consequently causes maternal hypotension, which may compromise uterine blood flow and foetal circulation, and thus cause foetal hypoxia, bradycardia and acidosis. The selection of the most efficient treatment strategy to achieve haemodynamic stability during spinal anaesthesia for caesarean section continues to be one of the main challenges in obstetric anaesthesiology. A number of measures for the prevention and treatment of spinal block-induced hypotension are used in clinical practice, such as preloading and coloading with crystalloid and/or colloid infusion, wrapping of lower limbs with compression stockings or bandages, administering an optimal dose of local anaesthetic and achieving an optimal spinal block level, left tilt positioning, and administering inotropes and vasopressors. Instead of administering vasopressors after a drop in blood pressure has already occurred, the latest algorithms recommend a prophylactic administration of vasopressor infusion. The preferred vasoconstrictor in this case is phenylephrine, which is associated with a lower incidence of foetal acidosis, and maternal nausea and vomiting compared to other vasoconstrictors.
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Affiliation(s)
| | - Tonka Bujas
- 1Clinic for Anaesthesiology, Reanimatology and Intensive Care, Sveti Duh" University Hospital Zagreb, Zagreb, Croatia; 2Catholic University of Croatia; 3Osijek Faculty of Medicine, Osijek, Croatia; 4Bjelovar University of Applied Sciences, Bjelovar, Croatia; 5Dr. Josip Benčević General Hospital, Department of Anaesthesiology, Reanimatology and Intensive Care, Slavonski Brod, Croatia; 6Sveti Duh University Hospital, Clinic for Gynaecology and Obstetrics, Zagreb, Croatia
| | - Dubravko Habek
- 1Clinic for Anaesthesiology, Reanimatology and Intensive Care, Sveti Duh" University Hospital Zagreb, Zagreb, Croatia; 2Catholic University of Croatia; 3Osijek Faculty of Medicine, Osijek, Croatia; 4Bjelovar University of Applied Sciences, Bjelovar, Croatia; 5Dr. Josip Benčević General Hospital, Department of Anaesthesiology, Reanimatology and Intensive Care, Slavonski Brod, Croatia; 6Sveti Duh University Hospital, Clinic for Gynaecology and Obstetrics, Zagreb, Croatia
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Left Atrial Appendage Closure and Systemic Homeostasis. J Am Coll Cardiol 2018; 71:135-144. [DOI: 10.1016/j.jacc.2017.10.092] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/23/2017] [Accepted: 10/30/2017] [Indexed: 11/20/2022]
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Raut MS, Maheshwari A, Dubey S. Sudden Hemodynamic Instability During Off-Pump Coronary Artery Bypass Grafting Surgery: Role of Bezold-Jarisch Reflex. J Cardiothorac Vasc Anesth 2017; 31:2139-2140. [PMID: 28774640 DOI: 10.1053/j.jvca.2017.03.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Monish S Raut
- Department of Cardiac Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India.
| | - Arun Maheshwari
- Department of Cardiac Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Sumir Dubey
- Department of Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India
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Salman IM, Hildreth CM, Phillips JK. Chronic kidney disease impairs renal nerve and haemodynamic reflex responses to vagal afferent input through a central mechanism. Auton Neurosci 2016; 204:65-73. [PMID: 27776979 DOI: 10.1016/j.autneu.2016.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 09/20/2016] [Accepted: 10/08/2016] [Indexed: 11/25/2022]
Abstract
We investigated age- and sex-related changes in reflex renal sympathetic nerve activity (RSNA) and haemodynamic responses to vagal afferent stimulation in a rodent model of chronic kidney disease (CKD). Using anaesthetised juvenile (7-8weeks) and adult (12-13weeks) Lewis Polycystic Kidney (LPK) and Lewis control rats of either sex (n=63 total), reflex changes in RSNA, heart rate (HR) and mean arterial pressure (MAP) to vagal afferent stimulation (5-s train, 4.0V, 2.0-ms pulses, 1-16Hz) were measured. In all groups, stimulation of the vagal afferents below 16Hz produced frequency-dependent reductions in RSNA, HR and MAP, while a 16Hz stimulus produced an initial sympathoinhibition followed by sympathoexcitation. In juvenile LPK versus age-matched Lewis, sympathoinhibition was reduced when responses were expressed as % baseline (P<0.05), but not as microvolts, while bradycardic responses were greater. Reflex depressor responses were greater (P=0.015) only in juvenile female LPK. In adult LPK, reflex sympathoinhibition (%) was blunted (P<0.05), and an age-related decline apparent (when expressed as microvolts). Reflex reductions in HR and MAP were only diminished (P<0.05) in adult female LPK versus age-matched Lewis. Peak reflex sympathoexcitation at 16Hz did not differ between groups; however, area under the curve values were greater in the LPK versus Lewis (overall, 9±1 versus 19±3μVs, P<0.05) irrespective of age, suggestive of enhanced sympathoexcitatory drive in the LPK. Our data demonstrates a progressive deficit in the central processing of vagal afferent input and a differential sex influence on reflex regulation of autonomic function and blood pressure homeostasis in CKD.
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Affiliation(s)
- Ibrahim M Salman
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia.
| | - Cara M Hildreth
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Jacqueline K Phillips
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
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Salman IM. Current Approaches to Quantifying Tonic and Reflex Autonomic Outflows Controlling Cardiovascular Function in Humans and Experimental Animals. Curr Hypertens Rep 2016; 17:84. [PMID: 26363932 DOI: 10.1007/s11906-015-0597-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The role of the autonomic nervous system in the pathophysiology of human and experimental models of cardiovascular disease is well established. In the recent years, there have been some rapid developments in the diagnostic approaches used to assess and monitor autonomic functions. Although most of these methods are devoted for research purposes in laboratory animals, many have still found their way to routine clinical practice. To name a few, direct long-term telemetry recording of sympathetic nerve activity (SNA) in rodents, single-unit SNA recording using microneurography in human subjects and spectral analysis of blood pressure and heart rate in both humans and animals have recently received an overwhelming attention. In this article, we therefore provide an overview of the methods and techniques used to assess tonic and reflex autonomic functions in humans and experimental animals, highlighting current advances available and procedure description, limitations and usefulness for diagnostic purposes.
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Affiliation(s)
- Ibrahim M Salman
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia.
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Major Autonomic Neuroregulatory Pathways Underlying Short- and Long-Term Control of Cardiovascular Function. Curr Hypertens Rep 2016; 18:18. [DOI: 10.1007/s11906-016-0625-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Silva FC, de Menezes RC, Chianca DA. The implication of protein malnutrition on cardiovascular control systems in rats. Front Physiol 2015; 6:246. [PMID: 26388783 PMCID: PMC4557349 DOI: 10.3389/fphys.2015.00246] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 08/17/2015] [Indexed: 01/01/2023] Open
Abstract
The malnutrition in early life is associated with metabolic changes and cardiovascular impairment in adulthood. Deficient protein intake-mediated hypertension has been observed in clinical and experimental studies. In rats, protein malnutrition also increases the blood pressure and enhances heart rate and sympathetic activity. In this review, we discuss the effects of post-weaning protein malnutrition on the resting mean arterial pressure and heart rate and their variabilities, cardiovascular reflexes sensitivity, cardiac autonomic balance, sympathetic and renin-angiotensin activities and neural plasticity during adult life. These insights reveal an interesting prospect on the autonomic modulation underlying the cardiovascular imbalance and provide relevant information on preventing cardiovascular diseases.
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Affiliation(s)
- Fernanda C Silva
- Laboratory of Cardiovascular Physiology, Department of Biological Sciences, Institute of Biological Sciences, Federal University of Ouro Preto Ouro Preto, Brazil ; Graduate Program in Biological Sciences - CBIOL/NUPEB, Federal University of Ouro Preto Ouro Preto, Brazil
| | - Rodrigo C de Menezes
- Laboratory of Cardiovascular Physiology, Department of Biological Sciences, Institute of Biological Sciences, Federal University of Ouro Preto Ouro Preto, Brazil ; Graduate Program in Biological Sciences - CBIOL/NUPEB, Federal University of Ouro Preto Ouro Preto, Brazil
| | - Deoclécio A Chianca
- Laboratory of Cardiovascular Physiology, Department of Biological Sciences, Institute of Biological Sciences, Federal University of Ouro Preto Ouro Preto, Brazil ; Graduate Program in Biological Sciences - CBIOL/NUPEB, Federal University of Ouro Preto Ouro Preto, Brazil
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Marx JO, Jensen JA, Seelye S, Walton RM, Hankenson FC. The Effects of Acute Blood Loss for Diagnostic Bloodwork and Fluid Replacement in Clinically Ill Mice. Comp Med 2015; 65:202-216. [PMID: 26141445 PMCID: PMC4485629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 01/03/2015] [Accepted: 01/25/2015] [Indexed: 06/04/2023]
Abstract
Despite the great value of diagnostic bloodwork for identifying disease in animals, the volume of blood required for these analyses limits its use in laboratory mice, particularly when they are clinically ill. We sought to determine the effects of acute blood loss (ABL) following blood collection for diagnostic bloodwork in healthy mice compared with streptozotocin-induced diabetic and dextran sulfate sodium (DSS)-treated dehydrated mice. ABL caused several mild changes in the control mice, with significant decreases in body weight, temperature, and activity in both experimental groups; increased dehydration and azotemia in the DSS-treated mice; and a significant drop in the blood pressure of the diabetic mice. To determine whether these negative outcomes could be ameliorated, we treated mice with intraperitoneal lactated Ringers solution either immediately after or 30 min before ABL. Notably, preABL administration of fluids helped prevent the worsening of the dehydration and azotemia in the DSS-treated mice and the changes in blood pressure in the diabetic mice. However, fluid administration provided no benefit in control of blood pressure when administered after ABL in the diabetic mice. Furthermore, fluid therapy did not prevent ABL-induced drops in body weight and activity. Although one mouse not receiving fluid therapy became moribund at the 24-h time point, no animals died during the 24-h study. This investigation demonstrates that blood for diagnostic bloodwork can be collected safely from clinically ill mice and that preemptive fluid therapy mitigates some of the negative changes associated with this blood loss.
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Affiliation(s)
- James O Marx
- University Laboratory Animal Resources, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - JanLee A Jensen
- Division of Laboratory Animal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Stacie Seelye
- Comparative Medicine Program, Texas A&M, College Station, Texas, USA
| | - Raquel M Walton
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - F Claire Hankenson
- Campus Animal Resources and College of Veterinary Medicine, Michigan State University, East Lansing, Michigan, USA
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Patel RAG. State of the art in carotid artery stenting: trial data, technical aspects, and limitations. J Cardiovasc Transl Res 2014; 7:446-57. [PMID: 24771314 DOI: 10.1007/s12265-014-9567-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 04/13/2014] [Indexed: 10/25/2022]
Abstract
The volume of carotid artery stenting (CAS) safety and efficacy data has grown exponentially over the last decade. Recent comparative data with carotid endarterectomy, the utility of embolic protection devices, peri-procedural medications, basic technical aspects of CAS, developments in carotid stent design, potential complications of CAS, and complication risk factors are discussed in this review.
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Affiliation(s)
- Rajan A G Patel
- John Ochsner Heart & Vascular Institute, Ochsner Medical Center, 1514 Jefferson Hwy., New Orleans, LA, 70121, USA,
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Dadu RT, McPherson CA. The ventriculophasic response: relationship to sinus arrhythmia and the duration of interposed QRS complexes. Ann Noninvasive Electrocardiol 2013; 18:336-43. [PMID: 23879273 DOI: 10.1111/anec.12038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The ventriculophasic response (VR) refers to shortening of sinus cycle length during heart block when a QRS complex is interposed between 2 P waves. Our purpose was to analyze its relationship to respiratory sinus arrhythmia (SA) and to compare VR in relation to paced versus intrinsic QRS complexes. METHODS Patients with advanced heart block had their pacer devices temporarily programmed to ventricular inhibited mode at 30 ppm. In 35 subjects, we analyzed VR and SA before, during and after 3 cycles of deep breathing. In 16 other patients we compared VR in the presence of paced versus narrower intrinsic QRS complexes. RESULTS The magnitude of P-P interval shortening surrounding QRS complexes during inspiration correlated with SA (r = 0.36, P = 0.03). The prevalence of VR increased from 37% at baseline to 77% of subjects during deep breathing (P = 0.02). The mean P-P interval shortening was greater surrounding intrinsic QRS complexes than paced QRS complexes (3.6 ± 3.6% vs. 1.4 ± 1.1%, P = 0.02). The prevalence of VR increased from 25% during paced rhythm to 56% when intrinsic complexes were present. CONCLUSION VR, like SA, increases with deep breathing and likely reflects intact parasympathetic nervous system function. Its increase in the presence of narrower beats suggests it may reflect ventricular synchrony.
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Affiliation(s)
- Razvan T Dadu
- Bridgeport Hospital/Yale University, Clinical Yale University School of Medicine
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The treatment with pyridostigmine improves the cardiocirculatory function in rats with chronic heart failure. Auton Neurosci 2013; 173:58-64. [DOI: 10.1016/j.autneu.2012.11.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 10/26/2012] [Accepted: 11/12/2012] [Indexed: 11/24/2022]
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Goodman SM, Krauser D, Mackenzie CR, Memtsoudis S. Cardiac Arrest during Total Hip Arthroplasty in a Patient on an Angiotensin Receptor Antagonist. HSS J 2012; 8:175-83. [PMID: 23874260 PMCID: PMC3715635 DOI: 10.1007/s11420-011-9225-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 10/13/2011] [Indexed: 02/07/2023]
Abstract
Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor antagonists (ARA) are effective and well-tolerated first-line drugs in the therapy of hypertension and, therefore, are frequently encountered in the perioperative setting. Hemodynamic compensation for volume depletion seen in the perioperative period is normally mediated by the renin-angiotensin system, which is blocked by ACEI/ARA. These drugs may contribute to severe hypotension during anesthesia induction and may have contributed to the cardiac arrest seen in this patient. Additional factors such as increased intra-abdominal pressures and respiratory obstructive episodes leading to diminished venous return, as well diuretic use and the fasting state, common in the perioperative orthopedic patient, are likely to have contributed as well. Medication use may be an easily modifiable risk factor for severe hypotension and possible cardiac arrest in the perioperative setting.
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Affiliation(s)
- Susan M. Goodman
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- />Weill Cornell Medical College, New York, NY USA
| | - Daniel Krauser
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- />Weill Cornell Medical College, New York, NY USA
| | - C. Ronald Mackenzie
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- />Weill Cornell Medical College, New York, NY USA
| | - Stavros Memtsoudis
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- />Weill Cornell Medical College, New York, NY USA
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