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Saha P, Konwar C, Pandey A, Bharali P. Comparison of the effect of intravenous phenylephrine and norepinephrine boluses for post-spinal hypotension on neonatal outcome in elective caesarean section: A randomised controlled trial. Indian J Anaesth 2024; 68:348-353. [PMID: 38586272 PMCID: PMC10993945 DOI: 10.4103/ija.ija_920_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 04/09/2024] Open
Abstract
Background and Aims There is limited data on the effects of norepinephrine on neonatal outcomes and maternal complications relative to other vasopressors. The study aimed to compare neonatal outcomes and maternal complications after bolus intravenous doses of phenylephrine and norepinephrine for post-spinal hypotension in elective caesarean section women. Methods This randomised study was done on 100 elective caesarean section women under spinal anaesthesia. Block randomisation divided women into two groups to receive intravenous phenylephrine 50 μg bolus (Group A) or norepinephrine 5 μg bolus (Group B) following post-spinal hypotension. Groups were evaluated and compared for umbilical arterial blood gas analysis, birth weight, APGAR (appearance, pulse, grimace, activity, and respiration) score, maternal haemodynamics, and complications. Kolmogorov-Smirnov and Shapiro-Wilk tests were used to verify data normality. Independent samples t-test or Mann-Whitney U test was employed to compare continuous variables based on data normality, and the Chi-square test was used to determine categorical variable associations. Results Demographic characteristics of women were found to be comparable between groups. Umbilical arterial potential of hydrogen, partial pressure of oxygen, partial pressure of carbon dioxide, base excess, bicarbonate, birth weight, and APGAR scores were comparable across groups, showing no significant differences (P > 0.05). Groups had similar maternal haemodynamic characteristics and episodes of nausea, vomiting, and chest pain across groups without statistical significance (P > 0.05). Conclusion No notable distinction was found between neonatal outcomes and maternal complications between phenylephrine and norepinephrine bolus regimens. Norepinephrine can be used as an alternative to phenylephrine post-spinal hypotension in women undergoing elective caesarean section.
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Affiliation(s)
- Prerona Saha
- Department of Anaesthesiology, Dhubri Medical College and Hospital, Dhubri, Assam, India
| | - Chandita Konwar
- Department of Anaesthesiology, Dhubri Medical College and Hospital, Dhubri, Assam, India
| | - Aditya Pandey
- Department of Community Medicine, MLB Medical College, Jhansi, UP, India
| | - Prabal Bharali
- Department of Anaesthesiology, Nagaon Medical College, Nagaon, Assam, India
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Wu W, Zheng Q, Zhou J, Li X, Zhou H. Norepinephrine versus phenylephrine on cerebral tissue oxygen saturation during prophylactic infusion to prevent spinal hypotension for Caesarean birth. Medicine (Baltimore) 2024; 103:e37454. [PMID: 38457564 PMCID: PMC10919502 DOI: 10.1097/md.0000000000037454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/08/2024] [Accepted: 02/09/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Phenylephrine may cause a reduction in maternal cerebral tissue oxygen saturation (SctO2) during Caesarean birth to prevent spinal hypotension; however, the effect of norepinephrine has not been assessed. We hypothesized that norepinephrine was more effective than phenylephrine in maintaining SctO2 when preventing spinal hypotension during Caesarean birth. METHODS We conducted a randomized, double-blind, controlled study. Sixty patients were randomly assigned to prophylactic norepinephrine or phenylephrine to maintain blood pressure during spinal anesthesia for Caesarean birth. SctO2, systolic blood pressure, and heart rate were recorded. The primary outcome was the incidence of a 10% reduction of intraoperative SctO2 from baseline or more during Caesarean birth. RESULTS The norepinephrine group had a lower incidence of more than 10% reduction of intraoperative SctO2 from baseline than that of the phenylephrine group (13.3% vs 40.0%, P = .02). The change in SctO2 after 5 minutes of norepinephrine infusion was higher than that after phenylephrine infusion (-3.4 ± 4.7 vs -6.2 ± 5.6, P = .04). The change in SctO2 after 10 minutes of norepinephrine infusion was higher than that after phenylephrine infusion (-2.5 ± 4.4 vs -5.4 ± 4.6, P = .006). The norepinephrine group showed greater left- and right-SctO2 values than the phenylephrine group at 5 to 10 minutes. However, the change in systolic blood pressure was comparable between the 2 groups. CONCLUSION Norepinephrine was more effective than phenylephrine in maintaining SctO2 when preventing spinal hypotension during Caesarean birth. However, the changes in clinical outcomes caused by differences in SctO2 between the 2 medications warrant further studies.
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Affiliation(s)
- Weiguo Wu
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
| | - Qiang Zheng
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
| | - Jinfeng Zhou
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
| | - Xiujuan Li
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
| | - Haipeng Zhou
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
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3
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Pan ZB, Sheng ZM, Zhu M, Mei Z, Shen YP, Liu JP, Qian XW. Randomized Double-Blinded Comparison of Intermittent Boluses Phenylephrine and Norepinephrine for the Treatment of Postspinal Hypotension in Patients with Severe Pre-Eclampsia During Cesarean Section. Drug Des Devel Ther 2024; 18:639-650. [PMID: 38476203 PMCID: PMC10927372 DOI: 10.2147/dddt.s446657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/08/2024] [Indexed: 03/14/2024] Open
Abstract
Background Norepinephrine has fewer negative effects on heart rate (HR) and cardiac output (CO) for treating postspinal hypotension (PSH) compared with phenylephrine during cesarean section. However, it remains unclear whether fetuses from patients with severe pre-eclampsia could benefit from the superiority of CO. The objective of this study was to compare the safety and efficacy of intermittent intravenous boluses of phenylephrine and norepinephrine used in equipotent doses for treating postspinal hypotension in patients with severe pre-eclampsia during cesarean section. Methods A total of 80 patients with severe pre-eclampsia who developed PSH predelivery during cesarean section were included. Eligible patients were randomized at a 1:1 ratio to receive either phenylephrine or norepinephrine for treating PSH. The primary outcome was umbilical arterial pH. Secondary outcomes included other umbilical cord blood gas values, Apgar scores at 1 and 5 min, changes in hemodynamic parameters including CO, mean arterial pressure (MAP), HR, stroke volume (SV), and systemic vascular resistance (SVR), the number of vasopressor boluses required, and the incidence of bradycardia, hypertension, nausea, vomiting, and dizziness. Results No significant difference was observed in umbilical arterial pH between the phenylephrine and norepinephrine groups (7.303±0.38 vs 7.303±0.44, respectively; P=0.978). Compared with the phenylephrine group, the overall CO (P=0.009) and HR (P=0.015) were greater in the norepinephrine group. The median [IQR] total number of vasopressor boluses required was comparable between the two groups (2 [1 to 3] and 2 [1 to 3], respectively; P=0.942). No significant difference was found in Apgar scores or the incidence of maternal complications between groups. Conclusion A 60 µg bolus of phenylephrine and a 4.5 µg bolus of norepinephrine showed similar neonatal outcomes assessed by umbilical arterial pH and were equally effective when treating PSH during cesarean section in patients with severe pre-eclampsia. Norepinephrine provided a higher maternal CO and a lower incidence of bradycardia.
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Affiliation(s)
- Zheng-Bin Pan
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Department of Anesthesiology, Shaoxing Maternity and Child Health Care Hospital, Shaoxing, People’s Republic of China
| | - Zhi-Min Sheng
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Miao Zhu
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Zhong Mei
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Yan-Ping Shen
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Jin-Ping Liu
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Xiao-Wei Qian
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
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Yella SST, Krishna Sasanka KSBS, Singh H, Meena B. A Routine over the Counter Phenylephrine Causing Rarer Drug Eruption as Adverse Drug Reaction - A Case Report. Curr Drug Saf 2024; 19:291-294. [PMID: 37264618 DOI: 10.2174/1574886318666230601162144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 04/18/2023] [Accepted: 05/01/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Phenylephrine is a sympathomimetic, which means it acts analogous to adrenaline. Phenylephrine can be taken orally to treat nasal congestion symptoms. It is also frequently mixed with other medicines in products meant to relieve cough and cold symptoms. Given the widespread usage of phenylephrine, related drug eruptions appear to be uncommon. CASE PRESENTATION Here we discuss a case of a 19-year-old female patient who reported to our hospital with blebs on the skin throughout her legs and torso. The drug eruption or adverse drug response was linked with itching, had a slow beginning, and progressed. Her medical history indicated that she had been taking phenylephrine 10 mg orally twice a day. On the sixth day, she experienced an adverse medication response caused by the medicine phenylephrine. Phenylephrine was stopped immediately and the other medications, such as levocetirizine, montelukast, and nasal spray, were continued. The patient was told not to use phenylephrine, either alone or in combination with FDCs. There are no other complaints. As a result, the patient was diagnosed with phenylephrine- induced eruption. CONCLUSION We present this case to highlight the importance of inspiring a pharmacovigilance mindset among all clinicians providing care as a routine alert drug, phenylephrine-induced drug eruption.
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Affiliation(s)
| | | | - Harminder Singh
- Department of Pharmacology, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
| | - Bhumika Meena
- All India Institute of Medical Sciences, Deoghar, Jharkhand, India
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Meng L, Sun Y, Zhao X, Meng DM, Liu Z, Adams DC, McDonagh DL, Rasmussen M. Effects of phenylephrine on systemic and cerebral circulations in humans: a systematic review with mechanistic explanations. Anaesthesia 2024; 79:71-85. [PMID: 37948131 DOI: 10.1111/anae.16172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 11/12/2023]
Abstract
We conducted a systematic review of the literature reporting phenylephrine-induced changes in blood pressure, cardiac output, cerebral blood flow and cerebral tissue oxygen saturation as measured by near-infrared spectroscopy in humans. We used the proportion change of the group mean values reported by the original studies in our analysis. Phenylephrine elevates blood pressure whilst concurrently inducing a reduction in cardiac output. Furthermore, despite increasing cerebral blood flow, it decreases cerebral tissue oxygen saturation. The extent of phenylephrine's influence on cardiac output (r = -0.54 and p = 0.09 in awake humans; r = -0.55 and p = 0.007 in anaesthetised humans), cerebral blood flow (r = 0.65 and p = 0.002 in awake humans; r = 0.80 and p = 0.003 in anaesthetised humans) and cerebral tissue oxygen saturation (r = -0.72 and p = 0.03 in awake humans; r = -0.24 and p = 0.48 in anaesthetised humans) appears closely linked to the magnitude of phenylephrine-induced blood pressure changes. When comparing the effects of phenylephrine in awake and anaesthetised humans, we found no evidence of a significant difference in cardiac output, cerebral blood flow or cerebral tissue oxygen saturation. There was also no evidence of a significant difference in effect on systemic and cerebral circulations whether phenylephrine was given by bolus or infusion. We explore the underlying mechanisms driving the phenylephrine-induced cardiac output reduction, cerebral blood flow increase and cerebral tissue oxygen saturation decrease. Individualised treatment approaches, close monitoring and consideration of potential risks and benefits remain vital to the safe and effective use of phenylephrine in acute care.
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Affiliation(s)
- L Meng
- Department of Anesthesia, Indiana University School of Medicine, IA, Indianapolis, USA
| | - Y Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - X Zhao
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - D M Meng
- Choate Rosemary Hall School, CT, Wallingford, USA
| | - Z Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, IA, Indianapolis, USA
| | - D C Adams
- Department of Anesthesia, Indiana University School of Medicine, IA, Indianapolis, USA
| | - D L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, Neurology and Neurotherapeutics, UT Southwestern Medical Center, TX, Dallas, USA
| | - M Rasmussen
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
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Looft-Wilson RC, Stechmann JK, Milenski KG, Shah VM, Kulkarni PG, Arif AB, Guiot T, Beinlich NMC, Dos Santos CA, Rice SK. Myoendothelial feedback in mouse mesenteric resistance arteries is similar between the sexes, dependent on nitric oxide synthase, and independent of TPRV4. Am J Physiol Heart Circ Physiol 2024; 326:H190-H202. [PMID: 37921665 DOI: 10.1152/ajpheart.00170.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 10/17/2023] [Accepted: 10/30/2023] [Indexed: 11/04/2023]
Abstract
Myoendothelial feedback (MEF), the endothelium-dependent vasodilation following sympathetic vasoconstriction (mediated by smooth muscle to endothelium gap junction communication), has been well studied in resistance arteries of males, but not females. We hypothesized that MEF responses would be similar between the sexes, but different in the relative contribution of the underlying nitric oxide and hyperpolarization mechanisms, given that these mechanisms differ between the sexes in agonist-induced endothelium-dependent dilation. We measured MEF responses (diameter changes) of male and female first- to second-order mouse mesenteric arteries to phenylephrine (10 µM) over 30 min using isolated pressure myography ± blinded inhibition of nitric oxide synthase (NOS) using Nω-nitro-l-arginine methyl ester (l-NAME; 0.1-1.0 mM), hyperpolarization using 35 mM KCl, or transient receptor potential vanilloid 4 (TRPV4) channels using GSK219 (0.1-1.0 µM) or RN-1734 (30 µM). MEF was similar [%dilation (means ± SE): males = 26.7 ± 2.0 and females = 26.1 ± 1.9 at 15 min] and significantly inhibited by l-NAME (1.0 mM) at 15 min [%dilation (means ± SE): males = 8.2 ± 3.3, P < 0.01; females = 6.8 ± 1.9, P < 0.001] and over time (P < 0.01) in both sexes. l-NAME (0.1 mM) + 35 mM KCl nearly eliminated MEF in both sexes (P < 0.001-0.0001). Activation of TRPV4 with GSK101 (0.1-10 µM) induced similar dilation between the sexes. Inhibition of TRPV4, which is reportedly involved in the hyperpolarization mechanism, did not inhibit MEF in either sex. Similar expression of eNOS was found between the sexes with Western blot. Thus, MEF is prominent and similar in murine first- and second-order mesenteric resistance arteries of both sexes, and reliant primarily on NOS and secondarily on hyperpolarization, but not TRPV4.NEW & NOTEWORTHY We found that female mesenteric resistance arteries have similar postconstriction dilatory responses (i.e., myoendothelial feedback) to a sympathetic neurotransmitter analog as male arteries. Both sexes use nitric oxide synthase (NOS) and hyperpolarization, but not TRPV4, in this response. Moreover, the key protein involved in this pathway (eNOS) is similarly expressed in these arteries between the sexes. These similarities are surprising given that agonist-induced endothelium-dependent dilatory mechanisms differ in these arteries between the sexes.
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Affiliation(s)
- Robin C Looft-Wilson
- Department of Kinesiology, William and Mary, Williamsburg, Virginia, United States
| | - Jacob K Stechmann
- Department of Kinesiology, William and Mary, Williamsburg, Virginia, United States
| | - Katherine G Milenski
- Department of Kinesiology, William and Mary, Williamsburg, Virginia, United States
| | - Vishakha M Shah
- Department of Kinesiology, William and Mary, Williamsburg, Virginia, United States
| | - Preetika G Kulkarni
- Department of Kinesiology, William and Mary, Williamsburg, Virginia, United States
| | - Arusha B Arif
- Department of Kinesiology, William and Mary, Williamsburg, Virginia, United States
| | - Tanner Guiot
- Department of Kinesiology, William and Mary, Williamsburg, Virginia, United States
| | | | | | - Spencer K Rice
- Department of Kinesiology, William and Mary, Williamsburg, Virginia, United States
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Boyes NG, Mannozzi J, Rapin N, Alvarez A, Al-Hassan MH, Lessanework B, Lahti DS, Olver TD, O'Leary DS, Tomczak CR. Augmented sympathoexcitation slows postexercise heart rate recovery. J Appl Physiol (1985) 2023; 135:1300-1311. [PMID: 37883101 DOI: 10.1152/japplphysiol.00549.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/13/2023] [Accepted: 10/23/2023] [Indexed: 10/27/2023] Open
Abstract
Slow heart rate recovery following exercise may be influenced by persistent sympathoexcitation. This study examined 1) the effect of muscle metaboreflex activation (MMA) on heart rate recovery following dynamic exercise; and 2) whether the effect of MMA on heart rate recovery is reversible by reducing sympathoexcitation [baroreflex activation via phenylephrine (PE)] in canines. Twenty-two young adults completed control and MMA protocols during cycle ergometry at 110% ventilatory threshold with 5 min recovery. Heart rate recovery kinetics [tau (τ), amplitude, end-exercise, and end-recovery heart rate] and root mean square of successive differences (RMSSD) were measured. Five chronically instrumented canines completed control, MMA (50%-60% imposed reduction in hindlimb blood flow), and MMA with end-exercise PE infusion (MMA + PE) protocols during moderate exercise (6.4 km·h-1) and 3 min recovery. Heart rate recovery kinetics and MAP were measured. MAP increased during MMA versus control in canines (P < 0.001). Heart rate recovery τ was slower during MMA versus control in humans (17% slower; P = 0.011) and canines (150% slower; P = 0.002). Heart rate recovery τ was faster during MMA + PE versus MMA (40% faster; P = 0.034) and was similar to control in canines (P = 0.426). Amplitude, end-exercise, and end-recovery heart rate were similar between conditions in humans (all P ≥ 0.122) and in canines (all P ≥ 0.084). MMA decreased RMSSD in early recovery (P = 0.004). MMA-induced sympathoexcitation slows heart rate recovery and this effect is markedly attenuated with PE. Therefore, elevated sympathoexcitation via MMA impairs heart rate recovery and inhibition of this stimulus normalizes, in part, heart rate recovery.NEW & NOTEWORTHY Augmented sympathoexcitation, via muscle metaboreflex activation, functionally slows heart rate recovery in both young healthy adults and chronically instrumented canines. Furthermore, elevated sympathoexcitation corresponded with lower parasympathetic activity, as assessed by heart rate variability, during the first 3 min of recovery. Finally, sympathoinhibition, via phenylephrine infusion, normalizes heart rate recovery during muscle metaboreflex activation.
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Affiliation(s)
- Natasha G Boyes
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Joseph Mannozzi
- Department of Physiology, School of Medicine, Wayne State University, Detroit, Michigan, United States
| | - Nicole Rapin
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Alberto Alvarez
- Department of Physiology, School of Medicine, Wayne State University, Detroit, Michigan, United States
| | - Mohamed-Hussein Al-Hassan
- Department of Physiology, School of Medicine, Wayne State University, Detroit, Michigan, United States
| | - Beruk Lessanework
- Department of Physiology, School of Medicine, Wayne State University, Detroit, Michigan, United States
| | - Dana S Lahti
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - T Dylan Olver
- Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Donal S O'Leary
- Department of Physiology, School of Medicine, Wayne State University, Detroit, Michigan, United States
| | - Corey R Tomczak
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Wolfskeil M, Bafort V, Besard M, Moerman A, De Hert S, Vanpeteghem C. Continuous Noninvasive Blood Pressure Measurement With "ClearSight" Compared to Standard Intermittent Blood Pressure Measurement in Patients With Peripheral Arterial Disease. Are Potential Differences Influenced by Phenylephrine or Dobutamine? J Cardiothorac Vasc Anesth 2023; 37:2470-2474. [PMID: 37657998 DOI: 10.1053/j.jvca.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 08/06/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVES To investigate the agreement between continuous noninvasive blood pressure measurement with the ClearSight system (cNIBP-CS) and standard intermittent noninvasive blood pressure measurement (iNIBP) in patients with peripheral arterial disease (PAD). Additionally, the influence of vasoactive medication on potential measurement differences was assessed. DESIGN A secondary analysis of a randomized controlled trial. SETTING At a university hospital. PARTICIPANTS Thirty-four patients with PAD undergoing percutaneous transluminal angioplasty of the lower limbs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Continuous noninvasive blood pressures were measured with the "ClearSight" system and compared to standard iNIBPs. Bland-Altman analysis revealed a mean bias of 13 mmHg (±15) between cNIBP-CS and iNIBP, with 95% limits of agreement (LOA) ranging from -17 to 42 mmHg. When comparing both medication groups, a similar mean bias was found for phenylephrine and dobutamine (12 mmHg [±13] and 13 mmHg [±13], respectively). CONCLUSION In this study, in patients with PAD, cNIBP-CS showed an underestimation of blood pressure compared to iNIBP in phenylephrine- and dobutamine-treated patients. Compared to previous studies, a larger bias and wider 95% LOA were found.
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Affiliation(s)
- Martha Wolfskeil
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium.
| | - Vincent Bafort
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Milan Besard
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Anneliese Moerman
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Stefan De Hert
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
| | - Caroline Vanpeteghem
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent, Belgium
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Livier Castillo J, Flores Valdés JR, Maney Orellana M, Satish S, Ijioma CE, Benjamin J, Ramirez Alvarez E, Martinez Ramirez M, Arruarana VS, Calderon Martinez E. The Use and Efficacy of Oral Phenylephrine Versus Placebo Treating Nasal Congestion Over the Years on Adults: A Systematic Review. Cureus 2023; 15:e49074. [PMID: 38125218 PMCID: PMC10730950 DOI: 10.7759/cureus.49074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 12/23/2023] Open
Abstract
Nasal congestion is a common issue stemming from various factors such as allergies and anatomical variations. Allergic rhinitis frequently leads to nasal congestion. The pathophysiology involves inflammation, swelling, and mucus production in the nasal mucosa. Multiple treatments are available, including oral phenylephrine, an over-the-counter or prescription option. However, the effectiveness and safety of phenylephrine have been subjects of debate. This systematic review aims to provide an updated perspective on the efficacy of oral phenylephrine versus placebo in addressing nasal congestion in adults. We conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, a systematic review involving searches on PubMed, Cochrane, and Scopus databases. Inclusion/exclusion criteria were defined to identify high-quality studies. The focus was on randomized controlled trials (RCTs) and case-control studies published in English between 1998 and 2023, involving adult populations. The interventions compared oral phenylephrine with placebo or standard care, with outcomes centering on changes in nasal congestion symptoms and nasal airway resistance. We identified four articles that met the criteria. These studies exhibited varied designs and populations. The findings consistently indicated that phenylephrine was not more effective than a placebo in relieving nasal congestion. This systematic review demonstrates that oral phenylephrine did not offer substantial relief from nasal congestion compared to a placebo in adults. The studies featured diverse designs, yet the prevailing conclusion was that phenylephrine's efficacy was limited. Safety assessments showed no life-threatening adverse events, with common side effects including headaches and mild discomfort. In summary, this systematic review indicates that oral phenylephrine is not significantly more effective than a placebo in alleviating nasal congestion in adults. Clinicians should explore alternative treatment options, considering the review's limitations. Additional research may be needed to clarify the role of oral phenylephrine in managing nasal congestion.
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Affiliation(s)
| | | | | | - Sruthi Satish
- Internal Medicine, Kasturba Medical College, Manipal, Manipal, IND
| | - Chimaobi E Ijioma
- Medicine and Surgery, Abia State University Faculty of Medicine, Uturu, Umuahia, NGA
| | - Janet Benjamin
- Internal Medicine, Ross University School of Medicine, Miramar, USA
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10
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Cannarozzo CJ, Araos J, Martin-Flores M. Phenylephrine and norepinephrine increase blood pressure through opposing physiologic mechanisms in isoflurane-anesthetized dogs receiving acepromazine. Am J Vet Res 2023; 84:ajvr.23.06.0147. [PMID: 37657733 DOI: 10.2460/ajvr.23.06.0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/16/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE To elucidate the cardiovascular effects of escalating doses of phenylephrine and norepinephrine in dogs receiving acepromazine and isoflurane. ANIMALS 8 beagles aged 1 to 2 years (7.4 to 11.2 kg). METHODS All dogs received acepromazine 0.01 mg/kg, propofol 4 to 5 mg/kg, and isoflurane and were mechanically ventilated. Mean arterial pressure (MAP) from a femoral artery catheter and continuous electrocardiogram were recorded. Cardiac output (CO) was measured with transpulmonary thermodilution. Systemic vascular resistance (SVR), global end-diastolic volume (GEDV), and global ejection fraction (GEF) were subsequently calculated. Phenylephrine and norepinephrine were infused in random order at 0.07, 0.3, 0.7, and 1.0 μg/kg/min. All variables were measured after 15 minutes of each infusion rate. The effects of dose, agent, and their interaction on the change of each variable were evaluated with mixed-effect models. A P < .05 was used for significance. RESULTS Atrial premature complexes occurred in 3 dogs during norepinephrine infusion at doses of 0.3, 0.7, and 1 μg/kg/min; no dysrhythmias were seen with phenylephrine administration. MAP increased during dose escalation (P < .0001) within each agent and did not differ between agents (P = .6). The decrease in HR was greater for phenylephrine (P < .0001). Phenylephrine decreased CO and GEF and increased GEDV and SVR (all P < .03). Norepinephrine decreased the SVR and increased CO, GEDV, and GEF (all P < .03). CLINICAL RELEVANCE Our results confirm that phenylephrine increases arterial pressures mainly through vasoconstriction in acepromazine-premedicated dogs while norepinephrine, historically considered a vasopressor, does so primarily through an increase in inotropism.
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Affiliation(s)
- Cheyenne J Cannarozzo
- Cornell University Hospital for Animals, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - Joaquin Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
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11
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Ivanova GT. [Functional state of the mesenteric arteries with higt fat intake in rats with streptozotocin-induced diabetes]. Vopr Pitan 2023; 92:64-72. [PMID: 38198420 DOI: 10.33029/0042-8833-2023-92-6-64-72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/30/2023] [Indexed: 01/12/2024]
Abstract
An increase in the incidence of diabetes mellitus (DM) is associated with excessive consumption of fats and carbohydrates, while DM leads to the development of cardiovascular diseases. The aim of the research was to evaluate the effect of a high-fat diet (HFD) on the functional state of the mesenteric arteries in vivo in Wistar rats with DM. Material and methods. The study was conducted on 45 male Wistar rats with an initial body weight of 220-240 g, which were divided into 3 equal groups. Animals of the control group received a standard diet for 3 months. Rats of the second group (STZ) were fed a standard diet, after 8 weeks the animals were intraperitoneally injected with streptozotocin (STZ, 35 mg/kg body weight). Animals in the STZ+HFD group received HFD (50% beef tallow), and an injection of STZ (35 mg/kg). We assessed the effect of HFD on endothelium-dependent and endothelium-free reactions of phenylephrine (PE) precontracted mesenteric arteries under the action of agonists in the absence and use of blockers of NO-synthase (L-NAME), cyclooxygenase (indomethacin), and K+-channels (tetraethylammonium), using microphoto- and videorecording of vessel diameter in vivo. Results. DM in rats led to an increase in the constrictor reaction to FE; in animals of the STZ+HFD group, the diameter of the vessel decreased by 63.7±4.7%; in the STZ group, by 60.4±3.8%; and in the control group, by 48.9±4.1%. HFD and DM induction had no effect on the amount of relaxation under the action of sodium nitroprusside. The amplitude of acetylcholine-induced relaxation of the mesenteric arteries of rats with DM in the absence of blockers was significantly lower (by 27.1% on average in the STZ+HFD group, by 14.6% in the STZ group) compared with control animals. After NO synthase inhibition, the relaxation amplitude decreased in the STZ+HFD group by 48.6±3.2%, in the STZ group by 56.1±2.8%, and in control animals by 58.3±3.1% compared with the dilatation amplitude without the use of a blocker. Acetylcholine-induced vascular dilatation under conditions of simultaneous use of a complex of three blockers - L-NAME, indomethacin and tetraethylammonium was reduced in rats with DM treated with HFD by an average of 18.9% and in animals of the STZ group by 22.1% compared with control animals. Conclusion. Thus, excessive fat intake in rats with STZ-induced DM enhances the impairment of the functional state of the mesenteric arteries compared to animals with DM that received a standard diet. In HFD in rats with DM, a decrease in endotheliumdependent vasodilation was mediated as a failure of NO-dependent relaxation mechanisms and a decrease in the efficiency of the mechanism of endothelial hyperpolarization, whereas in rats with DM fed a standard diet, it was predominantly a disturbance in the mechanism of endothelial hyperpolarization.
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Affiliation(s)
- G T Ivanova
- Pavlov Institute of Physiology, Russian Academy of Sciences, 199034, Saint Petersburg, Russian Federation
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12
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Gioia M, De Bernardo M, Pagliarulo S, Cione F, Mottola FF, La Marca A, De Pascale I, Albano G, Rosa N. Evaluation of Tropicamide- Phenylephrine Mydriatic Eye Drop Instillation on Choroidal Thickness. J Clin Med 2023; 12:6355. [PMID: 37834998 PMCID: PMC10573589 DOI: 10.3390/jcm12196355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
The purpose of this study is to evaluate choroidal thickness (ChT) at the subfoveal and peripheral level after the instillation of 0.5% tropicamide + 10% phenylephrine 9 hydrochloride eye drops by using OCT scans in enhanced depth image (EDI) mode. In total, 53 patients (30 males and 23 females) were involved, and the mean age was 25.62 ± 2.41 (age range: 23-36). The dominant eye was treated with tropicamide + phenylephrine (Visumidriatic Fenil 100 mg/mL + 5 mg/mL, Visufarma) while the nondominant eye was used as the control. An OCT analysis was performed on both eyes before and 30 min after the instillation of a drop of mydriatic in the dominant eye. The ChT was measured by using the OCT software measurement tool (Spectralis; Heidelberg Engineering; Heidelberg, Germany, version 6.0). The results showed a statistically significant ChT decrease (p = 0.009) in the temporal sector after the treatment with tropicamide + phenylephrine. In the subfoveal and nasal sectors, no statistically significant ChT changes were detected (p = 0.94; p = 0.85) following the administration of the mydriatic eye drops. The ChT thinning in the temporal sector following the instillation of the tropicamide + phenylephrine eye drops suggests that in the case of ChT studies, mydriatic administration should be avoided.
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Affiliation(s)
| | | | | | - Ferdinando Cione
- Eye Unit, Department of Medicine Surgery and Dentistry, “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (M.G.); (M.D.B.); (N.R.)
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13
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Li J, Wang C, Xiao W, Chen Y, Tu J, Wan F, Deng K, Li H. TRAF Family Member 4 Promotes Cardiac Hypertrophy Through the Activation of the AKT Pathway. J Am Heart Assoc 2023; 12:e028185. [PMID: 37642020 PMCID: PMC10547335 DOI: 10.1161/jaha.122.028185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 05/03/2023] [Indexed: 08/31/2023]
Abstract
Background Pathological cardiac hypertrophy is a major cause of heart failure morbidity. The complex mechanism of intermolecular interactions underlying the pathogenesis of cardiac hypertrophy has led to a lack of development and application of therapeutic methods. Methods and Results Our study provides the first evidence that TRAF4, a member of the tumor necrosis factor receptor-associated factor (TRAF) family, acts as a promoter of cardiac hypertrophy. Here, Western blotting assays demonstrated that TRAF4 is upregulated in cardiac hypertrophy. Additionally, TRAF4 deletion inhibits the development of cardiac hypertrophy in a mouse model after transverse aortic constriction surgery, whereas its overexpression promotes phenylephrine stimulation-induced cardiomyocyte hypertrophy in primary neonatal rat cardiomyocytes. Mechanistically, RNA-seq analysis revealed that TRAF4 promoted the activation of the protein kinase B pathway during cardiac hypertrophy. Moreover, we found that inhibition of protein kinase B phosphorylation rescued the aggravated cardiomyocyte hypertrophic phenotypes caused by TRAF4 overexpression in phenylephrine-treated neonatal rat cardiomyocytes, suggesting that TRAF4 may regulate cardiac hypertrophy in a protein kinase B-dependent manner. Conclusions Our results revealed the regulatory function of TRAF4 in cardiac hypertrophy, which may provide new insights into developing therapeutic and preventive targets for this disease.
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Affiliation(s)
- Jian Li
- Department of Thoracic and Cardiovascular SurgeryHuanggang Central Hospital of Yangtze UniversityHuanggangChina
| | - Chang‐Quan Wang
- Department of NeurologyHuanggang Central Hospital of Yangtze UniversityHuanggangChina
| | - Wen‐Chang Xiao
- Department of Cardiovascular SurgeryHuanggang Central Hospital of Yangtze UniversityHuanggangChina
- Huanggang Institute of Translational MedicineHuanggangChina
| | - Yun Chen
- Clinical Trial CentersHuanggang Central Hospital of Yangtze UniversityHuanggangChina
| | - Jun Tu
- Huanggang Institute of Translational MedicineHuanggangChina
| | - Feng Wan
- Department of NeurologyHuanggang Central Hospital of Yangtze UniversityHuanggangChina
- Huanggang Institute of Translational MedicineHuanggangChina
| | - Ke‐Qiong Deng
- Huanggang Institute of Translational MedicineHuanggangChina
- Department of CardiologyZhongnan Hospital of Wuhan UniversityWuhanChina
| | - Huo‐Ping Li
- Department of CardiologyHuanggang Central Hospital of Yangtze UniversityHuanggangChina
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14
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Kovacheva VP, Armero W, Zhou G, Bishop D, Dyer R, Carvalho B. Investigation of the Optimum Baseline Blood Pressure for Spinal Anesthesia to Guide Vasopressor Management for Elective Cesarean Delivery: A Case-Control Design. Cureus 2023; 15:e45380. [PMID: 37854732 PMCID: PMC10579048 DOI: 10.7759/cureus.45380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Current guidelines recommend prophylactic vasopressor administration during spinal anesthesia for cesarean delivery to maintain intraoperative blood pressure above 90% of the baseline value. We sought to determine the optimum baseline mean arterial pressure (MAP) reading to guide the management of spinal hypotension. METHODS We performed a secondary analysis of data collected from normotensive patients presenting for elective cesarean delivery in a tertiary care institution from October 2018 to August 2020. We compared the magnitude of hypotension in patients who reported nausea versus those who did not, using a case-control design. Baseline MAPs at last office visit, morning of surgery, or operating room (pre-spinal) were determined. We calculated the duration and degree of hypotension using the area under the curve (AUC) when the MAP of the respective patient was below 90% of each baseline. RESULTS The patients who experienced nausea (n=45) had longer and more profound periods of hypotension than those who did not develop nausea (n=240). A comparison of AUC using MAP baseline at the last office visit or on the morning of surgery showed a statistically significant between-group difference, P=0.02, and P=0.005, respectively, and no significant between-group difference when 90% of the MAP baseline in the operating room was used. CONCLUSIONS Patients had the highest preoperative MAP in the operating room and the AUC was similar for those with and without nausea when the pre-spinal MAP baseline was used. Therefore, maintaining higher intraoperative blood pressure using individual pre-spinal MAP as baseline should reduce intraoperative maternal nausea.
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Affiliation(s)
- Vesela P Kovacheva
- Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - William Armero
- Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, USA
| | - Guohai Zhou
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, USA
| | - David Bishop
- Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Scottsville, ZAF
| | - Robert Dyer
- Anaesthesia and Perioperative Medicine, Groote Schuur Hospital Observatory, University of Cape Town, Cape Town, ZAF
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15
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Jiménez González R, Posporis C. Bilateral miosis and third eyelid protrusion in a Golden Retriever with lateralizing forebrain signs. J Am Vet Med Assoc 2023; 261:1396-1399. [PMID: 37315938 DOI: 10.2460/javma.23.04.0196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/26/2023] [Indexed: 06/16/2023]
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16
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Schreier B, Stern C, Rabe S, Mildenberger S, Gekle M. Assessment of the Role of Endothelial and Vascular Smooth Muscle EGFR for Acute Blood Pressure Effects of Angiotensin II and Adrenergic Stimulation in Obese Mice. Biomedicines 2023; 11:2241. [PMID: 37626737 PMCID: PMC10452314 DOI: 10.3390/biomedicines11082241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
(1) Background: Obesity is associated with hypertension because of endocrine dysregulation of the adrenergic and the renin-angiotensin-aldosterone systems. The epidermal growth factor receptor (EGFR) is an important signaling hub in the cardiovascular system. In this study, we investigate the role of smooth muscle cell (VSMC) and endothelial cell (EC) EGFRs for blood pressure homeostasis and acute vascular reactivity in vivo. (2) Methods: Mice with deletion of the EGFR in the respective cell type received either a high-fat (HFD) or standard-fat diet (SFD) for 18 weeks. Intravascular blood pressure was measured via a Millar catheter in anesthetized animals upon vehicle load, angiotensin II (AII) and phenylephrine (PE) stimulation. (3) Results: We confirmed that deletion of the EGFR in VSMCs leads to reduced blood pressure and a most probably compensatory heart rate increase. EC-EGFR and VSMC-EGFR had only a minor impact on volume-load-induced blood pressure changes in lean as well as in obese wild-type animals. Regarding vasoactive substances, EC-EGFR seems to have no importance for angiotensin II action and counteracting HFD-induced prolonged blood pressure increase upon PE stimulation. VSMC-EGFR supports the blood pressure response to adrenergic and angiotensin II stimulation in lean animals. The responsiveness to AII and alpha-adrenergic stimulation was similar in lean and obese animals despite the known enhanced activity of the RAAS and the sympathetic nervous system under a high-fat diet. (4) Conclusions: We demonstrate that EGFRs in VSMCs and to a lesser extent in ECs modulate short-term vascular reactivity to AII, catecholamines and volume load in lean and obese animals.
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Affiliation(s)
- Barbara Schreier
- Julius-Bernstein-Institute of Physiology, Martin-Luther-University Halle-Wittenberg, 06112 Halle, Germany
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17
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Paranjape VV, Garcia-Pereira FL, Menciotti G, Saksena S, Henao-Guerrero N, Ricco-Pereira CH. Evaluation of Electrical Cardiometry for Measuring Cardiac Output and Derived Hemodynamic Variables in Comparison with Lithium Dilution in Anesthetized Dogs. Animals (Basel) 2023; 13:2362. [PMID: 37508139 PMCID: PMC10376001 DOI: 10.3390/ani13142362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Numerous cardiac output (CO) technologies were developed to replace the 'gold standard' pulmonary artery thermodilution due to its invasiveness and the risks associated with it. Minimally invasive lithium dilution (LiD) shows excellent agreement with thermodilution and can be used as a reference standard in animals. This study evaluated CO via noninvasive electrical cardiometry (EC) and acquired hemodynamic variables against CO measured using LiD in six healthy, anesthetized dogs administered different treatments (dobutamine, esmolol, phenylephrine, and high-dose isoflurane) impacting CO values. These treatments were chosen to cause drastic variations in CO, so that fair comparisons between EC and LiD across a wide range of CO values (low, intermediate, and high) could be made. Statistical analysis included linear regression, Bland-Altman plots, Lin's concordance correlation coefficient (ρc), and polar plots. Values of p < 0.05 represented significance. Good agreement was observed between EC and LiD, but consistent underestimation was noted when the CO values were high. The good trending ability, ρc of 0.88, and low percentage error of ±31% signified EC's favorable performance. Other EC-acquired variables successfully tracked changes in CO measured using LiD. EC may be a pivotal hemodynamic tool for continuously monitoring circulatory changes, as well as guiding and treating cardiovascular anesthetic complications in clinical settings.
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Affiliation(s)
- Vaidehi V Paranjape
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA 24061, USA
| | | | - Giulio Menciotti
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA 24061, USA
| | - Siddharth Saksena
- Department of Civil and Environmental Engineering, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA
| | - Natalia Henao-Guerrero
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA 24061, USA
| | - Carolina H Ricco-Pereira
- Department of Veterinary Clinical Sciences, The Ohio State University-College of Veterinary Medicine, Columbus, OH 43210, USA
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Paranjape VV, Pereira FLG, Menciotti G, Saksena S, Guerrero NH, Pereira CHR. Agreement of cardiac output measurements by esophageal Doppler and transesophageal echocardiography with intermittent pulmonary artery thermodilution during pharmacologic manipulation of hemodynamics in anesthetized dogs. Am J Vet Res 2023:1-11. [PMID: 37385599 DOI: 10.2460/ajvr.23.05.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/12/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To compare cardiac output (CO) measurements by transesophageal echocardiography (TEECO) and esophageal Doppler monitor (EDMCO) with pulmonary artery thermodilution (PATDCO) in anesthetized dogs subjected to pharmacological interventions. The effect of treatments on EDM-derived indexes was also investigated. ANIMALS 6 healthy male dogs (10.8 ± 0.7 kg). METHODS Dogs were anesthetized with propofol and isoflurane, mechanically ventilated, and monitored with invasive mean arterial pressure (MAP), end-tidal isoflurane concentration (ETISO), PATDCO, TEECO, EDMCO, and EDM-derived indexes. Four treatments were administered to all dogs by randomization. Baseline data were collected before each treatment: (1) dobutamine infusion; (2) esmolol infusion; (3) phenylephrine infusion; and (4) ETISO > 3%. Data were collected after 10-minute stabilization and after 30 minutes of washout between treatments. Statistical tests were pairwise t test, Bland-Altman analysis, Lin's concordance correlation (ρc), and polar plot analysis with P < .05 set as significance. RESULTS The mean ± SD relative bias (limits of agreement) for TEECO was 0.35 ± 25.2% (-49.1% to 49.8%) and for EDMCO was -27.2 ± 22.5% (-71.4% to 17%) versus PATDCO. The percent error for TEECO and EDMCO was 27.6% and 44.1%, respectively. The ρc value was 0.82 for TEECO and 0.66 for EDMCO. TEECO and EDMCO showed good trending ability. EDM-derived indexes displayed significant changes specific to the drug administered (P < .001). CLINICAL RELEVANCE For minimally invasive CO monitoring, TEE may provide more favorable performance than EDM in clinical settings; however, EDM-derived indexes yield valuable hemodynamic information that reliably follows trends in CO, thus supporting critical decision-making in canine patients.
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Affiliation(s)
- Vaidehi V Paranjape
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA
| | | | - Giulio Menciotti
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA
| | - Siddharth Saksena
- Department of Civil and Environmental Engineering, Virginia Polytechnic Institute and State University, Blacksburg, VA
| | - Natalia Henao Guerrero
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA
| | - Carolina H Ricco Pereira
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH
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Benevides ML, Andrade BWB, Zambardino HMD, Benevides MAM. A Prospective Single-Center Brazilian Study Investigating the Efficacy and Safety of Prophylactic Phenylephrine Infusion for the Management of Hypotension During Cesarean Section Under Spinal Anesthesia. Cureus 2023; 15:e42156. [PMID: 37602045 PMCID: PMC10438977 DOI: 10.7759/cureus.42156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
Background Maternal hypotension occurs in up to 80% of parturients during cesarean section (CS) under spinal anesthesia. Phenylephrine, a direct-acting α-1 agonist, has been widely recommended for the prevention of hypotension. We evaluated the efficacy and safety of phenylephrine infusion to prevent hypotension in obese and non-obese patients during cesarean section. Methods One hundred forty-one patients were included in this single-arm study. Patients received prophylactic phenylephrine infusion at a rate of 50 μg/min-1 immediately after spinal local anesthetic injection until delivery. Hypotension was defined as a systolic blood pressure <100 mmHg or <20% of baseline. The primary outcome was the incidence of hypotension. Results The incidence of hypotension was 17%. The median and interquartile range (IQR) of the number of hypotensive episodes was 0 (0-0). It was observed that 79.1% of the patients had hypotension in the first six minutes. Reactive hypertension and bradycardia occurred in 20.5 and 12.7% of the patients, respectively. In addition, there was a higher incidence of bradycardia in pregnant women with a body index mass of < 30 kg/m-2. Patients with baseline systolic blood pressure <120 mmHg had a threefold increased risk of hypotension. The incidence of nausea and vomiting was 13.4 and 2.8%, respectively. The incidence of an Apgar score <7 at the first minute was 2.8%, and no neonates presented an Apgar score <7 at the fifth minute. A pH of <7.2 occurred in 6.3% of the neonates. All neonates had no sequelae and were discharged together with their mothers. Conclusion The prophylactic infusion of phenylephrine 50 μg/min-1 is safe and demonstrates efficacy in reducing maternal hypotension providing adequate maternal hemodynamic stability during CS under spinal anesthesia.
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Affiliation(s)
- Marcio L Benevides
- Department of Anesthesiology, Hospital Geral e Maternidade de Cuiabá, Cuiaba, BRA
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Pauline A, Arthi K, Parameswari A, Vakamudi M, Manickam A. Prophylactic Fixed-Rate Phenylephrine Versus Norepinephrine Infusion in the Prevention of Post-spinal Anesthesia Hypotension During Cesarean Delivery. Cureus 2023; 15:e41251. [PMID: 37529826 PMCID: PMC10389118 DOI: 10.7759/cureus.41251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2023] [Indexed: 08/03/2023] Open
Abstract
Background Maternal hypotension following spinal anesthesia can be actively countered by the use of vasopressors. Prophylactic infusion of vasopressors with a rescue bolus dosing was observed to be more effective for hemodynamic stability when compared to administering a bolus dose alone. Although phenylephrine is the recommended drug to treat spinal hypotension, many recent studies have focussed on the role of norepinephrine infusions during cesarean section. In this study, we compared prophylactic fixed-rate intravenous infusions of phenylephrine and norepinephrine during cesarean delivery under spinal anesthesia and the requirement of intraoperative provider-administered rescue bolus of phenylephrine needed to overcome post-spinal anesthesia hypotension. Methodology A total of 208 patients undergoing elective cesarean section under spinal anesthesia were randomly assigned to two groups (group P and group N). Group N included 104 patients who received norepinephrine infusion at a rate of 2.5 μg/minute (0.04 μg/kg/minute), and group P included 104 patients who received phenylephrine infusion at a rate of 50 μg/minute (0.8 μg/kg/minute) to treat spinal hypotension. The primary outcome of our study was to compare the reduction in the number and total dose of intraoperative provider-administered rescue bolus of phenylephrine needed to maintain systolic blood pressure. The secondary outcome of our study was to compare the neonatal outcome using umbilical venous blood gas sampling and Apgar score at one and five minutes. Results The total number of phenylephrine rescue bolus required to treat hypotension was significantly lower in group N (p = 0.0005) compared to group P. The neonatal outcome was similar between the two groups. Conclusions Prophylactic norepinephrine infusion when compared to prophylactic phenylephrine infusion is associated with a lesser requirement of rescue phenylephrine boluses.
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Affiliation(s)
- Anisha Pauline
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - K Arthi
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Aruna Parameswari
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Mahesh Vakamudi
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Akilandeswari Manickam
- Anesthesiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
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Salhotra R, Tyagi A, Rautela RS, Chauhan J, Dolma L, Sharma A, Batra P, Srivastava H. Efficacy of fixed-dose phenylephrine bolus for treating post-spinal hypotension: Comparison between pre-eclamptics and normotensives. J Anaesthesiol Clin Pharmacol 2023; 39:451-457. [PMID: 38025583 PMCID: PMC10661643 DOI: 10.4103/joacp.joacp_518_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/31/2022] [Indexed: 12/01/2023] Open
Abstract
Background and Aims Pre-eclamptic parturients may have an exaggerated response to vasopressors. This study compares the efficacy of a 50 μg fixed bolus of phenylephrine for treatment of post-spinal hypotension in pre-eclamptic versus normotensive parturients. Material and Methods After written informed consent and ethics committee approval, 30 normotensive and 30 pre-eclamptic parturients between 18 and 40 years with singleton term pregnancy about to undergo cesarean section (CS) under spinal anesthesia were included. Post-spinal hypotension was treated with a 50 μg fixed bolus of phenylephrine. The cumulative dose of phenylephrine, the number of boluses, and the median dose required to treat the first hypotensive episode, total number of hypotensive episodes, maternal side effects, neonatal appearance, pulse, grimace, activity, and respiration (APGAR) scores, and umbilical arterial cord blood pH were noted. Statistical analysis was done using Student's t-test, Mann-Whitney U-test, Chi-square test/Fisher's exact test as appropriate. A P <0.05 was considered significant. Results The cumulative dose and number of boluses of phenylephrine required to treat post-spinal hypotension were comparable. The median dose required to treat the first episode of post-spinal hypotension was also similar (p = 0.792). The time to develop the first hypotensive episode was significantly earlier for group N (p = 0.002). The efficacy of a single fixed bolus of 50 μg phenylephrine was similar in both groups (p = 1.000). Neonatal median APGAR scores at 1 min after birth were significantly higher for group N (p = 0.016). Conclusion A fixed-dose bolus of 50 μg phenylephrine is safe and effective in treating post-spinal hypotension in pre-eclampsia. The efficacy of phenylephrine is comparable in pre-eclamptic and normotensive parturients.
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Affiliation(s)
- Rashmi Salhotra
- Department of Anesthesiology and Critical Care, UCMS and GTB Hospital, Delhi, India
| | - Asha Tyagi
- Department of Anesthesiology and Critical Care, UCMS and GTB Hospital, Delhi, India
| | - Rajesh Singh Rautela
- Department of Anesthesiology and Critical Care, UCMS and GTB Hospital, Delhi, India
| | - Jainendra Chauhan
- Department of Anesthesiology and Critical Care, UCMS and GTB Hospital, Delhi, India
| | - Lhamo Dolma
- Department of Anesthesiology and Critical Care, Sikkim Manipal Institute of Medical Sciences, Central Referral Hospital, Gangtok, Sikkim, India
| | - Ankit Sharma
- Department of Anesthesiology and Critical Care, Department of Onco-Anesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Prerna Batra
- Department of Pediatrics, UCMS and GTB Hospital, Delhi, India
| | - Himsweta Srivastava
- Department of Obstetrics and Gynecology, UCMS and GTB Hospital, Delhi, India
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Ravichandrane B, Subramaniam R, Muthiah T, Talawar P, Ramadurai R. Comparison of Prophylactic Infusion of Phenylephrine Versus Norepinephrine for the Prevention of Post Spinal Hypotension in Parturients Undergoing Elective Caesarean Section-a Randomized, Double-Blinded, Non-Inferiority Trial. Turk J Anaesthesiol Reanim 2023; 51:213-2018. [PMID: 37455439 DOI: 10.4274/tjar.2022.22909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Objective Postspinal hypotension occurs in nearly 50% of women undergoing cesarean section (CS). Although phenylephrine (PE) is currently the vasopressor of choice, severe maternal bradycardia may adversely affect the fetal status due to the reduction in the maternal cardiac output. Norepinephrine (NE) is not associated with bradycardia and is now being evaluated for the treatment of post-spinal hypotension in obstetric patients. The hypothesis of this study was that the prophylactic NE infusion was non-inferior to PE infusion when used for the prevention of postspinal hypotension. Methods This was a randomized, double-blinded controlled study conducted in 130 parturients scheduled for CS. The participants received either prophylactic NE (5 μg min-1) or PE (25 μg min-1) infusion beginning at the time of spinal injection. The primary outcome was the incidence of hypotension in both groups. Maternal bradycardia, reactive hypertension, nausea and vomiting, requirement of rescue boluses of vasopressor and/or atropine, and neonatal acid base status were also recorded. Results The incidence of hypotension was 33.80% (22 of 65) in Group PE and 26.10% (17 of 65) in Group NE (P=0.85). The absolute risk difference [90% confidence interval (CI)] in the incidence of hypotension between the groups was -7.7% (-20.9, 5.4). The upper limit of the CI was less than the non-inferiority margin of 20%, indicating that the NE infusion was non-inferior to PE. Conclusion Prophylactic infusion of NE is not inferior to prophylactic PE infusion in the prevention of postspinal hypotension in patients undergoing CS.
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Affiliation(s)
- Banupriya Ravichandrane
- Department of Anaesthesiology, All India Institute of Medical Sciences, Pain Medicine and Critical Care, New Delhi, India
| | - Rajeshwari Subramaniam
- Department of Anaesthesiology, All India Institute of Medical Sciences, Pain Medicine and Critical Care, New Delhi, India
| | - Thilaka Muthiah
- Department of Anaesthesiology, All India Institute of Medical Sciences, Pain Medicine and Critical Care, New Delhi, India
| | - Praveen Talawar
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, India
| | - Rajasekar Ramadurai
- Department of Anaesthesiology & Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
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Guo L, Xu X, Qin R, Shi Y, Xue W, He L, Ma S, Chen Y. Prophylactic Norepinephrine and Phenylephrine Boluses to Prevent Postspinal Anesthesia Hypotension During Cesarean Section: A Randomized Sequential Allocation Dose-Finding Study. Drug Des Devel Ther 2023; 17:1547-1555. [PMID: 37249928 PMCID: PMC10224683 DOI: 10.2147/dddt.s406671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/16/2023] [Indexed: 05/31/2023] Open
Abstract
Background Norepinephrine and phenylephrine are widely used for obstetric anesthesia. Our central objective was to determine the ED (effective dose) 90 and potency ratio of prophylactic norepinephrine and phenylephrine boluses for preventing postspinal anesthesia hypotension during cesarean section. Methods Patients scheduled for elective cesarean section (n = 80) were randomly allocated to receive prophylactic norepinephrine (NE) or phenylephrine (PE) boluses immediately after induction of spinal anesthesia. An initial dose of NE (3 μg) and PE (37.5 μg) was given to the first patient, and an up-and-down sequential allocation method was used to determine the next dose level according to the responses (the effectiveness for preventing postspinal anesthesia hypotension [defined as SBP < 80% of baseline value]). Primary outcomes were ED90 and the potency ratio of prophylactic norepinephrine and phenylephrine boluses. Secondary outcomes were the incidence of postspinal anesthesia hypotension, severe postspinal anesthesia hypotension, nausea, vomiting, bradycardia, hypertension, umbilical artery blood gas values, and Apgar scores. Results The ED90 values for prophylactic norepinephrine and phenylephrine boluses were 8.0 μg (95% CI 7.1-11.0 μg) and 90.9 μg (95% CI 82.0-123.9 μg), respectively. The estimated relative potency ratio was 11.4:1. The incidence of bradycardia was lower in the NE group (2.5% vs 20%, P = 0.034). Other outcomes were comparable between the two groups. Conclusion An 8-μg prophylactic bolus of norepinephrine and a 90-μg prophylactic bolus of phenylephrine can effectively prevent postspinal anesthesia hypotension in patients during cesarean section.
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Affiliation(s)
- Lei Guo
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Xiangzhao Xu
- Department of Anesthesiology, The People’s Hospital of Nanchuan, Chongqing, People’s Republic of China
| | - Rui Qin
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Yongqiang Shi
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Wei Xue
- Department of Obstetrics, General Hospital of Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Ling He
- Department of Obstetrics, General Hospital of Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Shuqin Ma
- Department of Obstetrics, General Hospital of Ningxia Medical University, Yinchuan, People’s Republic of China
| | - Yi Chen
- Department of Anesthesiology and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, People’s Republic of China
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Chayet A, Ramirez A, Scott B, Whitcomb J, Lam P, Ianchulev T. Pupil dilation evaluation of two mydriatic dosing profiles delivered by the Optejet ®. Ther Deliv 2023; 14:93-103. [PMID: 37158245 DOI: 10.4155/tde-2022-0061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Aim: To compare pupil dilation achieved by a single microdose versus two microdoses of tropicamide-phenylephrine fixed combination (TR-PH FC) delivered by the Optejet®. Patients & methods: In this assessor-masked, crossover, noninferiority study, 60 volunteers underwent two treatment visits and received either one (∼8 μl) or two sprays (∼16 μl) of TR-PH FC to both eyes in randomly assigned order. Results: At 35 min postdose, mean change in pupil diameter was 4.6 mm and 4.9 mm following one or two sprays, respectively. The estimated treatment group difference was -0.249 mm (standard error: 0.036; 95% CI: -0.320, -0.177). No adverse events were reported. Conclusion: A single microdose was noninferior to two microdoses of TR-PH FC and achieved clinically significant mydriasis in a timely manner. Clinical Trial Registration: NCT04907474 (ClinicalTrials.gov).
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Affiliation(s)
| | | | | | | | - Peter Lam
- Eyenovia, Inc., New York, NY 10017, USA
| | - Tsontcho Ianchulev
- Eyenovia, Inc., New York, NY 10017, USA
- New York Eye & Ear Infirmary of Mount Sinai, New York, NY 10003, USA
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25
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Juhl-Olsen P, Berg-Hansen K, Nørskov J, Enevoldsen J, Hermansen JL. The haemodynamic effects of phenylephrine after cardiac surgery. Acta Anaesthesiol Scand 2023. [PMID: 37186094 DOI: 10.1111/aas.14256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/24/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Phenylephrine increases systemic- and pulmonary resistances and therefore may increase blood pressures at the expense of blood flow. Cardio-pulmonary bypass alters vasoreactivity and many patients exhibit chronotropic insufficiency after cardiac surgery. We aimed to describe the haemodynamic effects of phenylephrine infusion after cardiac surgery. METHODS Patients in steady state after low-risk cardiac surgery received incremental infusion rates of phenylephrine up to 1.0 μg/kg/min with the aim of increasing systemic mean arterial blood pressure 20 mmHg. Invasive haemodynamic parameters, including pulmonary wedge pressures, were captured along with echocardiographic measures of biventricular function before, during phenylephrine infusion at target systemic blood pressure, and 20 min after phenylephrine discontinuation. RESULTS Thirty patients were included. Phenylephrine increased mean arterial pressure increased from 78 (±9) mmHg to 98 (±10) mmHg with phenylephrine infusion. Also, pulmonary blood pressure as well as systemic- and pulmonary resistances increased. The ratio between systemic- and pulmonary artery resistances did not change statistically significantly (p = .59). Median cardiac output was 4.35 (interquartile range [IQR] 3.6-5.4) L/min at baseline and increased significantly with phenylephrine infusion (median Δcardiac output was 0.25 [IQR 0.1-0.6] L/min) (p = .012). Pulmonary artery wedge pressure increased from 10.2 (±3.0) mmHg to 11.9 (±3.4) mmHg (p < .001). This was accompanied by significant increases in central venous pressure. Phenylephrine infusion increased left ventricular end-diastolic volume from 105 (±46) mL to 119 (±44) mL (p < .001). All results of phenylephrine infusion were reversed with discontinuation. CONCLUSION In haemodynamically stable patients after cardiac surgery, phenylephrine increased PVR and SVR, but did not change the PVR/SVR ratio. Phenylephrine increased biventricular filling pressures and left ventricular end-diastolic area. Consequently, CO increased as ejection fraction was maintained. These findings do not discourage the use of phenylephrine after low-risk cardiac surgery. REGISTRATION clinicaltrial.gov (identifier NCT04419662).
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Affiliation(s)
- Peter Juhl-Olsen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kristoffer Berg-Hansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper Nørskov
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
| | - Johannes Enevoldsen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Johan Lyngklip Hermansen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Legrand M, Kothari R, Fong N, Palaniappa N, Boldt D, Chen LL, Kurien P, Gabel E, Sturgess-DaPrato J, Harhay MO, Pirracchio R, Bokoch MP. Norepinephrine versus phenylephrine for treating hypotension during general anaesthesia in adult patients undergoing major noncardiac surgery: a multicentre, open-label, cluster-randomised, crossover, feasibility, and pilot trial. Br J Anaesth 2023; 130:519-527. [PMID: 36925330 DOI: 10.1016/j.bja.2023.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Intraoperative hypotension is associated with postoperative complications. The use of vasopressors is often required to correct hypotension but the best vasopressor is unknown. METHODS A multicentre, cluster-randomised, crossover, feasibility and pilot trial was conducted across five hospitals in California. Phenylephrine (PE) vs norepinephrine (NE) infusion as the first-line vasopressor in patients under general anaesthesia alternated monthly at each hospital for 6 months. The primary endpoint was first-line vasopressor administration compliance of 80% or higher. Secondary endpoints were acute kidney injury (AKI), 30-day mortality, myocardial injury after noncardiac surgery (MINS), hospital length of stay, and rehospitalisation within 30 days. RESULTS A total of 3626 patients were enrolled over 6 months; 1809 patients were randomised in the NE group, 1817 in the PE group. Overall, 88.2% received the assigned first-line vasopressor. No drug infiltrations requiring treatment were reported in either group. Patients were median 63 yr old, 50% female, and 58% white. Randomisation in the NE group vs PE group did not reduce readmission within 30 days (adjusted odds ratio=0.92; 95% confidence interval, 0.6-1.39), 30-day mortality (1.01; 0.48-2.09), AKI (1.1; 0.92-1.31), or MINS (1.63; 0.84-3.16). CONCLUSIONS A large and diverse population undergoing major surgery under general anaesthesia was successfully enrolled and randomised to receive NE or PE infusion. This pilot and feasibility trial was not powered for adverse postoperative outcomes and a follow-up multicentre effectiveness trial is planned. CLINICAL TRIAL REGISTRATION NCT04789330 (ClinicalTrials.gov).
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA; INI-CRCT Network, Nancy, France.
| | - Rishi Kothari
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA; Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas Fong
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA; School of Medicine, University of California, San Francisco, CA, USA
| | - Nandini Palaniappa
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - David Boldt
- Department of Anesthesia and Perioperative Care, University of California, Los Angeles, USA
| | - Lee-Lynn Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Philip Kurien
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Eilon Gabel
- Department of Anesthesia and Perioperative Care, University of California, Los Angeles, USA
| | - Jillene Sturgess-DaPrato
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Michael O Harhay
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Romain Pirracchio
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Michael P Bokoch
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
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McPherson C. Eyesight to the Blind-Pharmacotherapy for Retinopathy of Prematurity. Neonatal Netw 2023; 42:88-95. [PMID: 36868806 DOI: 10.1891/nn.2022-0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 03/05/2023]
Abstract
Retinopathy of prematurity (ROP) places preterm infants at significant risk for blindness. Angiogenesis of retinal blood vessels relies on vascular endothelial growth factor (VEGF) released in response to physiologic in utero hypoxia. Relative hyperoxia and disruption in the supply of growth factors after preterm birth lead to cessation of normal vascular growth. Recovery of VEGF production after 32 weeks' postmenstrual age results in aberrant vascular growth, including the formation of fibrous scars with the potential to detach the retina. Ablation of aberrant vessels by mechanical or pharmacologic methods relies on timely diagnosis in the early stages of ROP. Mydriatic medications dilate the pupil to allow examination of the retina. Mydriasis is typically accomplished using a combination of topical phenylephrine, a potent alpha-receptor agonist, and cyclopentolate, an anticholinergic. Systemic absorption of these agents results in a high incidence of cardiovascular, gastrointestinal, and respiratory adverse effects. Procedural analgesia should include the topical anesthetic proparacaine, oral sucrose, and nonpharmacologic interventions like non-nutritive sucking. Analgesia is often incomplete, leading to investigation of systemic agents like oral acetaminophen. If ROP threatens retinal detachment, laser photocoagulation is utilized to arrest vascular growth. More recently, the VEGF-antagonists, bevacizumab and ranibizumab, have emerged as treatment options. Systemic absorption of intraocular bevacizumab and the profound consequences of diffuse disruption of VEGF in the setting of rapid, neonatal organogenesis require dose optimization and careful evaluation of long-term outcomes in clinical trials. Intraocular ranibizumab is likely a safer alternative; however, outstanding questions remain regarding efficacy. Optimal patient outcomes rely on a combination of risk management throughout neonatal intensive care, timely diagnosis through careful ophthalmologic examinations, and treatment when indicated with laser therapy and/or anti-VEGF intravitreal injection.
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Schmitt CJ, Mattson AE, Brown CS, Mara KC, Cabrera D, Sandefur BJ, Wieruszewski ED. The incidence of cardiovascular instability in patients receiving various vasopressor strategies for peri-intubation hypotension. Am J Emerg Med 2023; 65:104-108. [PMID: 36603354 DOI: 10.1016/j.ajem.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/10/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Patients frequently experience hypotension in the peri-intubation period. This can be due to the underlying disease process, physiologic response to the intervention, or adverse effect from medications. With the heterogeneity in cause for hypotension, the duration can also be short or prolonged. Initiation of vasopressors for peri-intubation hypotension includes various strategies using continuous infusion norepinephrine (NE) or push-dose phenylephrine (PDPE) to obtain goal mean arterial pressure. There is a paucity of data describing cardiovascular stability outcomes in patients receiving vasopressors for peri-intubation hypotension. METHODS This is a retrospective cohort study including emergency department patients across three academic medical centers and smaller health system sites who received vasopressors for hypotension within 30 min of intubation. Patients were matched based on factors likely to influence vasopressor selection and were divided into groups if they received PDPE alone, continuous infusion NE alone, or PDPE followed by continuous infusion NE. The primary outcome was a composite of the incidence of hypotension (systolic blood pressure < 90 mmHg), bradycardia (HR < 60 beats per minute), and cardiac arrest within 2 h following initiation of vasopressors. RESULTS Screening occurred for 2518 patients, with 105 patients undergoing matching. Mean time to vasopressor initiation was 10 min following intubation. The composite primary outcome was not statistically different between groups and occurred 88.6%, 80.0%, and 88.6% in the NE, PDPE, and PDPE+NE groups, respectively. A subgroup analysis of patients with an ED diagnosis of sepsis or septic shock were more likely to receive PDPE before starting continuous infusion NE (41.3% vs. 27.1%, p = 0.075) and more frequently experienced the primary composite outcome (p = 0.045) but was not correlated with vasopressor strategy (p = 0.55). DISCUSSION Cardiovascular instability following vasopressor initiation for peri-intubation hypotension was no different depending on the selected vasopressor strategy. This held true in patients with a sepsis or septic shock diagnosis. Selection of vasopressors should continue to include patient specific factors and product availability.
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Affiliation(s)
- Cassandra J Schmitt
- Department of Pharmacy Services, Mayo Clinic Rochester, United States of America.
| | - Alicia E Mattson
- Department of Pharmacy Services, Mayo Clinic Rochester, United States of America.
| | - Caitlin S Brown
- Department of Pharmacy Services, Mayo Clinic Rochester, United States of America.
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic Rochester, United States of America.
| | - Daniel Cabrera
- Department of Emergency Medicine, Mayo Clinic Rochester, United States of America.
| | - Benjamin J Sandefur
- Department of Emergency Medicine, Mayo Clinic Rochester, United States of America.
| | - Erin D Wieruszewski
- Department of Pharmacy Services, Mayo Clinic Rochester, United States of America.
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Kęcik D, Grabska-Liberek I, Jurowski P, Mrukwa-Kominek E, Omulecki W, Romanowska-Dixon B, Szaflik JP, Romaniuk W, Szaflik J, Kopacz D, Mianowska K. Pupil diameter during cataract surgery after intracameral injection of the first ready-to-use combination of mydriatics and anaesthetic at the beginning of surgery in patients with a preoperative pupil diameter <6 mm. Acta Ophthalmol 2023; 101:e81-e87. [PMID: 35974455 PMCID: PMC10087216 DOI: 10.1111/aos.15218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 06/07/2022] [Accepted: 07/19/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE We evaluated, in a real-life setting, the effect of Mydrane® (ready-to-use combination of tropicamide, phenylephrine hydrochloride and lidocaine, injected into the anterior chamber at the beginning of cataract surgery to induce mydriasis and intraocular anaesthesia) on the pupil diameter during cataract surgery in patients with a preoperative pupil diameter <6 mm after the use of topical mydriatics. METHODS We collected and analysed the data of 59 consecutive patients whose pupils dilated to a diameter <6 mm after the administration of mydriatic eye drops during the preoperative visit and who received Mydrane® during cataract surgery. RESULTS In the group of 59 patients with a preoperative pupil diameter <6 mm after topical mydriatics, cataract surgery was performed in 36 patients (61.0%) using only Mydrane® to obtain mydriasis, with no additional drug or medical device. The mean pupil diameters in this group (36 of 59) during the preoperative assessment after topical mydriatics and just before capsulorhexis when Mydrane® was injected during surgery were 5.1 ± 0.74 and 6.15 ± 1.14 mm. Additional drugs were used in 23 patients (39%). In this group, the mean pupil diameters after topical mydriatics and just before capsulorhexis using Mydrane® were 4.58 ± 1.06 and 5.6 ± 1.26 mm, respectively. CONCLUSION In a real-life setting, the mean pupil diameter achieved during cataract surgery after the intracameral injection of Mydrane® in patients with a preoperative pupil diameter <6 mm was over 1 mm larger than the mean pupil diameter after topical mydriatics, despite the trauma caused by the operation.
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Affiliation(s)
- Dariusz Kęcik
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
| | - Iwona Grabska-Liberek
- Department of Ophthalmology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Piotr Jurowski
- Department of Eye Diseases, Medical University of Lodz, Lodz, Poland
| | - Ewa Mrukwa-Kominek
- Department of Ophthalmology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Wojciech Omulecki
- Department of Ophthalmology, Medical University of Lodz, University Hospital No 1, Lodz, Poland
| | - Bożena Romanowska-Dixon
- Department of Ophthalmology and Ocular Oncology, Jagiellonian University Medical College, Cracow, Poland
| | - Jacek P Szaflik
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
| | - Wanda Romaniuk
- Department of Ophthalmology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Jerzy Szaflik
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Kopacz
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
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Abstract
BACKGROUND Phenylephrine is a selective α1-receptor agonist used to manage shock. Current guidelines for septic shock recommend limited utilization of phenylephrine due to the lack of evidence available. This deviates from previous guidelines, which had recommendations of when utilization may be appropriate. OBJECTIVE The primary objective of this study was to evaluate mortality in patients receiving phenylephrine for the management of septic shock. METHODS This was a retrospective chart review from September 2015 to September 2017 evaluating all adult patients admitted to an intensive care unit (ICU) on vasopressors for management of septic shock. Patients were divided into 2 groups, those treated with phenylephrine and those treated without phenylephrine. The primary outcome was mortality. Secondary objectives included days on vasopressors and ICU length of stay. Two subgroup analyses were performed: 1 for phenylephrine as first-line therapy and 1 for patients with tachycardia at initiation of vasopressors. Patients started on phenylephrine for salvage therapy were excluded from this study. RESULTS 499 patients enrolled in the study. 148 (32%) were enrolled in the phenylephrine group. Phenylephrine was associated with an increase in mortality (56% vs 41%; p = 0.003). There was no difference in the days on vasopressors or ICU length of stay. Patients who had ongoing tachycardia were associated with increased mortality with phenylephrine (54% vs 36%, p = 0.02). There was no difference in mortality when phenylephrine was started as the initial vasopressor. CONCLUSION Utilization of phenylephrine in septic shock patients, especially those with ongoing tachycardia, was associated with an increased rate of mortality.
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Affiliation(s)
- Vishal V Patel
- 518097Idaho College of Osteopathic Medical School, Meridian, ID, USA.,Community Medical Center, Toms River, NJ, USA
| | - Jesse B Sullivan
- 7856Fairleigh Dickinson University School of Pharmacy & Health Sciences, Florham Park, NJ, USA
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Ghanian S, Wambier SP, Procianoy F, Wambier CG. About the pathways to deliver brimonidine to the Muller's muscle. JAAD Case Rep 2023; 33:7-8. [PMID: 36785538 PMCID: PMC9918388 DOI: 10.1016/j.jdcr.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Soha Ghanian
- Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Fernando Procianoy
- Department of Ophthalmology and Otorhinolaryngology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Carlos G. Wambier
- Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island,Correspondence to: Carlos G. Wambier, MD, PhD Department of Dermatology, Rhode Island Hospital, 593 Eddy Street, APC building, 10th Floor, Providence, RI 02903. @WambierMD
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32
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Vikman PS, Zhuravleva AS, Strelova OY, Grebenyuk AN. [Ways to solve the problem of cross-reactions during immunochromatographic examination of biological objects]. Sud Med Ekspert 2023; 66:43-49. [PMID: 36719313 DOI: 10.17116/sudmed20236601143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The purpose of this review is to study the causes of cross-reactions of a number of drugs (mebeverine, phenibut, tropicamide, ramipril, metoprolol, phenylephrine, sertraline, chloropyramine and diphenhydramine) during the preliminary stage of laboratory diagnostics by immunochromatographic method and to propose a possible algorithm for solving this problem. Conducting a hair study in order to identify the fact of the use of psychoactive substances will increase the reliability of analytical diagnostics and reduce the likelihood of false positive results of the analysis. The use of a validated method of enzymatic hydrolysis of hair will eliminate unreliable results of the analysis due to the detection of the native molecule of the toxicant, increase the efficiency and accuracy of the diagnostic procedure.
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Affiliation(s)
- P S Vikman
- Saint Petersburg State Chemical and Pharmaceutical University, Saint Petersburg, Russia
| | - A S Zhuravleva
- Saint Petersburg State Chemical and Pharmaceutical University, Saint Petersburg, Russia
| | - O Yu Strelova
- Saint Petersburg State Chemical and Pharmaceutical University, Saint Petersburg, Russia
| | - A N Grebenyuk
- Saint Petersburg State Chemical and Pharmaceutical University, Saint Petersburg, Russia
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Pedersen SS, Meyhoff CS, Olsen MH, Stisen ZR, Lund A, Møller K, Skjøth-Rasmussen J, Moltke FB, Sørensen MK. Impact of hyperoxia and phenylephrine on cerebral oxygenation: An experimental clinical study. Acta Anaesthesiol Scand 2023; 67:57-65. [PMID: 36112064 PMCID: PMC10092244 DOI: 10.1111/aas.14149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/16/2022] [Accepted: 08/21/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Oxygen supply to the brain is of special importance during intracranial surgery because it may be compromised by intracranial pathology. A high arterial blood pressure (mean arterial pressure above 80 mmHg) and a high arterial oxygen tension (PaO2 above 12 kPa) is therefore often targeted in these patients, when for example intracranial pressure is increased or when a mass effect on brain tissue from a tumour is present, and it is pursued by administering vasopressors such as phenylephrine and by increasing inspiratory oxygen fraction (FiO2 ). However, whether these interventions increase cerebral oxygenation remains uncertain. We aimed to investigate the effect of hyperoxia and phenylephrine on brain tissue oxygen tension (PbtO2 ) in patients undergoing craniotomy. METHODS In this experimental study, we included 17 adult patients scheduled for elective craniotomy. After securing a stable baseline of the oxygen probe, PbtO2 was measured in white matter peripherally in the surgical field during general anaesthesia. Primary comparisons were PbtO2 before versus after an increase in FiO2 from 0.30 to 0.80 as well as before versus after a bolus dose of phenylephrine (0.1-0.2 mg depending on patient haemodynamics). Data were analysed with the Wilcoxon signed rank test. RESULTS We obtained complete data sets in 11 patients undergoing the FiO2 increase and six patients receiving the phenylephrine bolus. PbtO2 was 22 (median; 5%-95% range, 4.6-54) mmHg during 30% oxygen, 68 (8.4-99) mmHg during 80% oxygen (p = .004 compared to 30% oxygen), 21 (4.5-81) mmHg before phenylephrine, and 19 (4.2-56) mmHg after phenylephrine (p = .56 compared to before phenylephrine). CONCLUSION In patients undergoing craniotomy under general anaesthesia, brain tissue oxygen tension increased with a high inspiratory oxygen fraction but remained unchanged after a bolus dose of phenylephrine.
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Affiliation(s)
- Sofie S Pedersen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark.,Copenhagen Center for Translational Research, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark.,Copenhagen Center for Translational Research, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Zara R Stisen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark.,Copenhagen Center for Translational Research, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Anton Lund
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jane Skjøth-Rasmussen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Finn B Moltke
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Martin Kryspin Sørensen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Ikeda Y, Sugiyama T, Shiko Y, Nagai A, Noguchi S, Kawasaki Y, Mazda Y. Association between maternal cardiac output and fetal acidaemia in Caesarean delivery under spinal anaesthesia with norepinephrine infusion: a retrospective cohort study. Br J Anaesth 2023; 130:e4-e7. [PMID: 36411131 DOI: 10.1016/j.bja.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/10/2022] [Accepted: 10/10/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Yusuke Ikeda
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Takayasu Sugiyama
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Yuki Shiko
- Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan; Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Azusa Nagai
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Shohei Noguchi
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba University, Chiba, Japan; Faculty of Nursing, Japanese Red Cross College of Nursing, Tokyo, Japan
| | - Yusuke Mazda
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical University, Kawagoe, Saitama, Japan.
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Bansal V, Saxena KN, Wadhwa B. Refractory hypertension after phenylephrine infusion in cesarean section under subarachnoid block. Saudi J Anaesth 2023; 17:107-109. [PMID: 37032673 PMCID: PMC10077792 DOI: 10.4103/sja.sja_461_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/28/2022] [Indexed: 12/24/2022] Open
Abstract
A 21-year-old female was scheduled to undergo elective cesarean section for breech presentation under the subarachnoid block (SAB). The pre-operative examination was unremarkable and baseline vitals were normal. Under all aseptic precautions and American society of anesthesiologists standard monitoring, SAB was administered with 2.2 ml of 0.5% hyperbaric bupivacaine. Soon after administration of SAB, prophylactic infusion of phenylephrine was started at the rate of 50 μg/min; after pre-treatment with 0.2 mg glycopyrrolate intravenous immediately after the start of the infusion, the patient complained of severe headache. Blood pressure (BP) recorded at that time was 191/102 mm of Hg. Phenylephrine infusion was stopped immediately but the BP remained high and came to within 20% of baseline value only after 9 min of discontinuing the infusion. We report this case of refractory hypertension following phenylephrine infusion in a healthy parturient undergoing elective cesarean section under SAB.
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Affiliation(s)
- Vikash Bansal
- Department of Anaesthesiology and Critical Care, Maulana Azad Medical College, New Delhi, India
| | - Kirti N Saxena
- Department of Anaesthesiology and Critical Care, Maulana Azad Medical College, New Delhi, India
| | - Bharti Wadhwa
- Department of Anaesthesiology and Critical Care, Maulana Azad Medical College, New Delhi, India
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Abstract
In recent years, inflammatory diseases of the nose and paranasal sinuses have been on the rise. In addition to infectious diseases, in the modern world a large percentage of the population suffers from allergic diseases. The approach to therapy and the choice of a drug should take into account the pathogenesis of the inflammatory reaction in the nasal cavity and paranasal sinuses. By exerting its effect, the drug should reduce hyperemia and swelling of the nasal mucosa, reduce the level of mucus secretion, improve the drainage of the paranasal sinuses, i.e. possess vasoconstrictive and anti-allergic properties. As such a drug, you can use the combined intranasal spray Frinozol, which basically contains cetirizine and phenylephrine. The use of Frinozol in the complex treatment of inflammation of the mucous membrane of the nasal cavity and paranasal sinuses contributes to the rapid and pronounced weakening of the symptoms of the disease, and is also the key to successful therapy.
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Affiliation(s)
- A V Gurov
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Muzhichkova
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M A Yushkina
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
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37
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Muacevic A, Adler JR, Ramani S, Balasubramanian N. A Randomized Controlled Trial Comparing the Effect of Phenylephrine by Intramuscular Route With Intravenous Infusion in Maintaining Haemodynamic Stability During Elective Lower Segment Caesarean Section Under Spinal Anaesthesia. Cureus 2023; 15:e34118. [PMID: 36843684 PMCID: PMC9949751 DOI: 10.7759/cureus.34118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 01/25/2023] Open
Abstract
Background Hypotension is a commonly encountered side effect in patients undergoing spinal anaesthesia, particularly in patients undergoing caesarean section. Phenylephrine is a widely used drug to treat spinal-induced hypotension and to maintain hemodynamic stability. Our aim is to evaluate the effectiveness of phenylephrine given through two different routes prophylactically in prevention of post-spinal hypotension in patients undergoing caesarean section. Methods A total of 150 healthy pregnant women undergoing elective caesarean section were randomly allocated into three groups: Group M (prophylactic intramuscular use of 2 mg phenylephrine), group V (prophylactic intravenous infusion of 30 mcg phenylephrine per minute), and group P (no prophylaxis), rescue phenylephrine 30 mcg IV and atropine 0.6 mg IV were used intraoperatively to treat bradycardia and hypotension in all three groups. The primary outcome was maternal hemodynamic changes. Results There was an insignificant difference in demographic data between the groups. Maternal systolic and diastolic blood pressure were more stable in group M compared to group V and group P. Heart rate was significantly lower only in group V. We did not observe any statistical difference between the groups in the APGAR score or the fetal arterial blood gas values. The incidence of nausea and vomiting was more in group P. Conclusion Preventive intramuscular phenylephrine exhibited a more stable maternal hemodynamics when compared with the prophylactic intravenous infusion of phenylephrine and placebo in elective caesarean under spinal anaesthesia.
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Affiliation(s)
- Alexander Muacevic
- Anaesthesiology, SRM Medical College Hospital and Research Centre (MCHRC), Chennai, IND
| | - John R Adler
- Anaesthesiology, SRM Medical College Hospital and Research Centre (MCHRC), Chennai, IND
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Muacevic A, Adler JR. Acute Pulmonary Edema During a Cesarean Delivery After an Adverse Drug Event. Cureus 2022; 14:e32876. [PMID: 36694485 PMCID: PMC9867893 DOI: 10.7759/cureus.32876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 12/25/2022] Open
Abstract
Acute pulmonary edema (APEd) is rare in pregnancy and in the postpartum period. An intermediate type of APEd characterized as a transudate with a protein concentration between that of cardiogenic and noncardiogenic APEd has been described in the literature. This transudate might actually be the result of capillary pressure having increased to a point of high-permeability edema and/or alveolar hemorrhage. Clinically, the presentation would be a dramatic form of APEd - flash pulmonary edema - characterized by a rapid accumulation of fluid within the lung's interstitial and alveolar spaces as a result of suddenly elevated cardiac filling pressures. Here, we present a case of a healthy pregnant woman who underwent cesarean delivery and developed a constellation of signs and symptoms, suggestive of an APEd, after a supratherapeutic bolus of phenylephrine. During the diagnostic excursion, bilateral parenchymal infiltrations suggestive of hemorrhage were observed on a computed tomography scan. This case highlights the high morbidity associated with adverse drug events and the imperative to prevent them. It also underscores the critical need for careful management of volume shifts and hemodynamics in full-term pregnancies.
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Zhang Y, Jin L, Liu H, Meng X, Ji F. Ephedrine vs. phenylephrine effect on sublingual microcirculation in elderly patients undergoing laparoscopic rectal cancer surgery. Front Med (Lausanne) 2022; 9:969654. [PMID: 36275828 PMCID: PMC9581143 DOI: 10.3389/fmed.2022.969654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background The effects of anesthesia administration on sublingual microcirculation are unknown. It is unclear how sublingual microcirculation responds to ephedrine or phenylephrine administration. We hypothesized that microvascular perfusion is impaired under anesthesia. Materials and methods We randomly divided 100 elderly patients undergoing laparoscopic rectal cancer surgery into phenylephrine and ephedrine groups in a 1:1 ratio. Ephedrine or phenylephrine was administered when MAP was < 80% for > 1 min. The heart rate (HR) and mean arterial pressure (MAP) were recorded every 5 min. Lactic acid was tested both pre- and postoperatively. The sublingual microcirculation characteristics of the microvascular flow index, the percentage of perfused vessels, the density of perfused vessels, and the heterogeneity index were monitored using a sidestream dark field imaging device. Results Their MAP showed an evident decrease of > 20%. At this point, the HR, microvascular flow index, perfused vessel density, and proportion of perfused vessels decreased similarly in ephedrine and phenylephrine groups. Conversely, the heterogeneity index increased in both groups. After phenylephrine and ephedrine administration, ephedrine treatment significantly increased the proportion of perfused vessels, microvascular flow index, and HR compared with phenylephrine treatment. Conclusion General anesthesia was associated with reduced MAP, HR, and sublingual microcirculation in elderly patients undergoing laparoscopic rectal cancer surgery. The results of ephedrine treatment were better than those of phenylephrine treatment in terms of HR, increased the proportion of perfused vessels, and microvascular flow index of sublingual microcirculation. Clinical trial registration [www.ClinicalTrials.gov], identifier [ChiCTR-2000035959].
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Simons C. The Safety and Efficacy of Peripherally Administered Norepinephrine during the Perioperative Period. AANA J 2022; 90:387-395. [PMID: 36173798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Intraoperative hypotension (IOH) is a highly prevalent adverse event associated with the induction and maintenance of general anesthesia. While the etiology of IOH is complex and multifactorial, hypotension most often occurs because anesthetic agents decrease vascular smooth muscle tone, impair myocardial contractility, and decrease levels of circulating catecholamines. The vasopressor drugs phenylephrine, norepinephrine (NE), and ephedrine have been traditionally used to counteract anesthesia-induced hypotension, with the sympathomimetic agent phenylephrine historically viewed as the first-line agent. However, NE may have a more advantageous clinical profile for treating hypotension by maintaining or increasing cardiac output and restoring decreased concentrations of circulating catecholamines. Yet despite these advantages, concerns of the safety of peripherally administered NE have limited its use to specific clinical settings such as central line in situ. Recent bench and clinical research examining the efficacy and safety profile of peripherally administered NE indicates that this stigma bears reexamination. Data from human and animal studies suggest that the peripheral administration of NE for the treatment of IOH may not only be acceptable, but in many cases, may be the best option.
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Affiliation(s)
- Christopher Simons
- is a staff CRNA at Virginia Commonwealth University Health System in Richmond, Virginia. E-mail:
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Xu T, Ji B, Li L, Lei J, Zhao M, Sun M, Xu Z, Gao Q. Antenatal Dexamethasone Exposure Impairs Vascular Contractile Functions via Upregulating IP3 Receptor 1 and Cav1.2 in Adult Male Offspring. Hypertension 2022; 79:1997-2007. [PMID: 35762340 DOI: 10.1161/hypertensionaha.122.19040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Administration of antenatal glucocorticoids remains common practice for treating preterm delivery. Antenatal glucocorticoid exposure increased the risk of developing vascular diseases in later life, but the precise mechanisms remain unclear. This study aimed to explore the effects and mechanisms of antenatal exposure to clinically relevant doses of dexamethasone (synthetic glucocorticoids) on vascular functions in adult male offspring. METHODS Pregnant Sprague-Dawley rats received dexamethasone or vehicle during the last week of pregnancy. Male offspring were killed at gestational day 21 (Fetus) or postnatal day 120 (adult offspring). Mesenteric arteries were collected for vascular function, electrophysiology, target gene expression, and promotor methylation studies. RESULTS Antenatal dexamethasone exposure increased phenylephrine-mediated vascular contractility in offspring, which was resulted by the activated inositol 1,4,5-trisphosphate (IP3) receptor and L-type Ca2+ channels. Specifically, increases of IP3R1 (IP3 receptor 1) and Cav1.2 (L-type Ca2+ channels subunit alpha1 C) were responsible for an activated IP3-Ca2+ pathway in the vasculature, and eventually predisposed the antenatal dexamethasone offspring to vascular hypercontractility. In addition, IP3R1 and Cav1.2 was upregulated through transcriptional mechanism; the overall changes in promotor histone modifications were consistent with the corresponding changes in transcriptional levels of the 2 genes, suggesting that antenatal dexamethasone exposure activated the transcription of IP3R1 and Cav1.2 via altering promotor histone modifications. CONCLUSIONS Taken together, this study demonstrated that antenatal dexamethasone exposure resulted in vascular adverse outcomes in male offspring that is linked to the increases of IP3R1 and Cav1.2 mediated by epigenetic modifications in the vasculature.
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Affiliation(s)
- Ting Xu
- Institute for Fetology, The First Affiliated Hospital of Soochow University, Suzhou, China (T.X., B.J., L.L., J.L., M.Z., M.S., Z.X., Q.G.)
| | - Bingyu Ji
- Institute for Fetology, The First Affiliated Hospital of Soochow University, Suzhou, China (T.X., B.J., L.L., J.L., M.Z., M.S., Z.X., Q.G.)
| | - Lingjun Li
- Institute for Fetology, The First Affiliated Hospital of Soochow University, Suzhou, China (T.X., B.J., L.L., J.L., M.Z., M.S., Z.X., Q.G.)
| | - Jiahui Lei
- Institute for Fetology, The First Affiliated Hospital of Soochow University, Suzhou, China (T.X., B.J., L.L., J.L., M.Z., M.S., Z.X., Q.G.)
| | - Meng Zhao
- Institute for Fetology, The First Affiliated Hospital of Soochow University, Suzhou, China (T.X., B.J., L.L., J.L., M.Z., M.S., Z.X., Q.G.)
| | - Miao Sun
- Institute for Fetology, The First Affiliated Hospital of Soochow University, Suzhou, China (T.X., B.J., L.L., J.L., M.Z., M.S., Z.X., Q.G.)
| | - Zhice Xu
- Institute for Fetology, The First Affiliated Hospital of Soochow University, Suzhou, China (T.X., B.J., L.L., J.L., M.Z., M.S., Z.X., Q.G.)
| | - Qinqin Gao
- Institute for Fetology, The First Affiliated Hospital of Soochow University, Suzhou, China (T.X., B.J., L.L., J.L., M.Z., M.S., Z.X., Q.G.)
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Scarberry K, Deebel NA, Dutta R, Matz E, Terlecki RP. Safety and efficacy of Phenylephrine administration for the treatment of ischemic priapism: An opportunity for quality improvement in periprocedural safety assessment. Urology 2022:S0090-4295(22)00709-9. [PMID: 36007685 DOI: 10.1016/j.urology.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/24/2022] [Accepted: 08/03/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To determine the safety and efficacy of hourly, high dose phenylephrine (>1000 μg) for acute ischemic priapism (AIP) through monitoring adverse hemodynamic events amongst risk profiles. METHODS An IRB-approved retrospective review of patients with AIP from 2010-2020. Patients were stratified to a low or high dose phenylephrine group based on cumulative, hourly dose of ≤1000 μg and > 1000 μg respectively and examined for successful resolution of their AIP. The safety profile of phenylephrine for patients at risk for adverse hemodynamic events was examined. RESULTS A total of 123 patients were identified with a median age of 40 (range: 7-76) years with median time from AIP onset to presentation of 11 (2-168) hours. 97 men received phenylephrine (78.9%) and detumescence was achieved nonoperatively in 62 of these men (63.9%) with a mean priapism duration of 8.7 hours. Those resolving with phenylephrine administration had a mean duration of 8.8 ± 5.6 versus 57.3 ± 37.1 hours without resolution p < 0.001. Among low and high dose phenylephrine groups (500 and 2000 μg respectively), the median duration of AIP was 10 and 12 hours respectively without a difference in AIP resolution (p > 0.05). Twenty-one patients (17.1%) were deemed at risk for phenylephrine complication of which 4 (4.1%) had phenylephrine discontinued due to hemodynamic changes. CONCLUSIONS Nonoperative resolution of AIP with phenylephrine does not appear to be dose-dependent and hemodynamic changes secondary to phenylephrine administration may be underreported. Future work should utilize standardized risk assessment and periprocedural monitoring for hemodynamic change.
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Graham BA, Wael A, Jack C, Rohan MA, Wayne HJG. An overview of emergency pharmacotherapy for priapism. Expert Opin Pharmacother 2022; 23:1371-1380. [PMID: 35815373 DOI: 10.1080/14656566.2022.2099271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Priapism is a compartment syndrome, defined as an unwanted penile erection lasting longer than four hours, unrelated to sexual stimulation, and persistent even after ejaculation/orgasm. Ischemic priapism is considered a urologic emergency requiring time-sensitive management. Studies have documented that untreated priapism is associated with progressive ischemic histological changes in the corpora cavernosa, such as widespread smooth muscle necrosis, blood vessel and nerve attrition, and trabecular fibrosis. Treatment options include conservative management, corporal irrigation, pharmacologic therapy, and surgery. We herein provide an overview of the emergency pharmacology for priapism. AREAS COVERED The American Urological Association (AUA) and the European Association of Urology (EAU) both recommend penile aspiration in conjunction with intracavernosal injection of sympathomimetics as the initial management of ischemic priapism. We have performed a retrospective review of the literature from 1914 to 2022 by using PubMed and a review of the treatment guidelines from the AUA and the EAU to discuss the various therapies for ischemic priapism in the emergent setting. EXPERT OPINION After a thorough overview of the literature regarding the treatment of ischemic priapism in the emergent setting, we conclude that intracavernosal phenylephrine is superior to other agents due to its demonstrated efficacy and limited systemic side effects.
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Affiliation(s)
- Bobo A Graham
- Department of Urology, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Almajed Wael
- Department of Urology, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Conlon Jack
- Department of Urology, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Morenas A Rohan
- Department of Urology, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Hellstrom J G Wayne
- Department of Urology, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
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Benken J, Lichvar A, Benedetti E, Behnam J, Kaur A, Rahman S, Nishioka H, Hubbard C, Benken ST. Perioperative Vasopressors are Associated with Delayed Graft Function in Kidney Transplant Recipients in a Primarily Black and Hispanic Cohort. Prog Transplant 2022; 32:15269248221087433. [PMID: 35477338 DOI: 10.1177/15269248221087433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Negative outcome studies of vasopressors in kidney transplant have not focused on patient populations that are predominantly Black or Hispanic. Project Aims: The evaluation sought to investigate the independent impact of perioperative vasopressors on postoperative renal allograft function in a sample drawn from a primarily Black and Hispanic population. Design: Retrospective, observational, single-center evaluation of patients > 18 years old who underwent kidney transplantation comparing outcomes based on vasopressor exposure. Results: The study included 150 patients of which 60 received vasopressors. The primary outcome differed between groups with delayed graft function occurring in 17(28%) versus 11(12.2%) occurring more often in those that received perioperative vasopressors (P = 0.02). The serum creatinine at postoperative day 7 was higher (2.69 vs1.52 mg/dL, P = 0.004), postoperative day 7 eGFR was worse (27.3 vs 52.9 mL/min/1.73m2, P = 0.002) in patients who received vasopressors. Patients who received perioperative vasopressors experienced more postoperative arrhythmias (15% vs 8%, P = 0.007), insulin infusion therapy (26.7% vs 13.3%, P = 0.04), and increased hospital length of stay (6 days vs 5 days, P = 0.006). Using IPWRA, patients receiving vasopressors were more likely to experience delayed function, relative risk difference of 22% (95% CI:0.08-0.35;P = 0.002) and in multivariate logistic regression modeling, an increased odds ratio of 3.2 (95% CI:1.1-8.62;P = 0.022). Conclusions: The use of perioperative vasopressors was independently associated with worsened early renal allograft function including delayed graft function, increased adverse events such as postoperative arrhythmias, and longer ICU length of stay. Further investigation is needed surrounding vasopressor use in this population.
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Affiliation(s)
- Jamie Benken
- Department of Pharmacy Practice, 15508University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | - Alicia Lichvar
- Department of Pharmacy Practice, 15508University of Illinois at Chicago College of Pharmacy, Chicago, IL
- UC San Diego Health, Center for Transplantation, San Diego, CA
| | - Enrico Benedetti
- Department of Surgery, Division of Transplantation, 12247University of Illinois at Chicago College of Medicine, Chicago, IL
| | - Jessica Behnam
- Department of Pharmacy Practice, 15508University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | - Arashpreet Kaur
- Department of Pharmacy Practice, 15508University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | - Syeda Rahman
- Department of Pharmacy Practice, 15508University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | - Hokuto Nishioka
- Department of Medicine, Division of Clinical Anesthesiology, 12247University of Illinois at Chicago College of Medicine, Chicago, IL
| | - Colin Hubbard
- Department of Pharmacy Practice, 15508University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | - Scott T Benken
- Department of Pharmacy Practice, 15508University of Illinois at Chicago College of Pharmacy, Chicago, IL
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McPherson KL, Kovacic Scherrer NL, Hays WB, Greco AR, Garavaglia JM. A Review of Push-Dose Vasopressors in the Peri-operative and Critical Care Setting. J Pharm Pract 2022:8971900221096967. [PMID: 35459405 DOI: 10.1177/08971900221096967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
During hospitalization, the risk of hypotension and associated sequelae remain important considerations for patient outcomes. The use of push-dose vasopressors (PDP) outside of the operating room has increased in recent years to combat the negative effects of hypotension. This narrative review evaluates the utility of PDP in its traditional perioperative setting as well as in areas of increasing use such as the emergency department and intensive care unit. Articles evaluating PDP highlight successful increases in blood pressure with all agents but differ in rates of adverse events and most lack direct comparison of PDP agents in regard to safety and efficacy. Agents utilized as PDP, including epinephrine, phenylephrine, norepinephrine, vasopressin, and ephedrine vary in mechanism of action, onset of action, and duration of action. These variations in pharmacology along with published literature may lead to differences in the preferred PDP for various clinical scenarios. Many adverse events associated with PDP have been due to dosing errors highlighting the importance of education surrounding the use of these agents. Additional research is necessary to further elucidate the risks and benefits of PDP in clinical practice, and to determine which PDP is truly preferred. Careful consideration should be given when determining the appropriateness of this administration method of vasopressors in various clinical scenarios.
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Affiliation(s)
- Kaitlyn L McPherson
- Emergency Medicine Pharmacist, Department of Pharmacy, 20205Charleston Area Medical Center General Hospital, Charleston, WV, USA
| | | | - William B Hays
- Emergency Medicine Pharmacist, Department of Pharmacy, Indiana University Health West Hospital, Avon, IN, USA
| | - Alexandra R Greco
- Critical Care Pharmacist, Department of Pharmacy, WVU Medicine, Morgantown, WV, USA
| | - Jeffrey M Garavaglia
- Neurology Intensive Care Pharmacist, Department of Pharmacy, WVU Medicine, Morgantown, WV, USA
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Zhou Y, Yu Y, Chu M, Zhang Y, Yu X, Chen G. Comparison of Metaraminol, Phenylephrine, and Norepinephrine Infusion for Prevention of Hypotension During Combined Spinal-Epidural Anaesthesia for Elective Caesarean Section: A Three-Arm, Randomized, Double-Blind, Non-Inferiority Trial. Drug Des Devel Ther 2022; 16:117-127. [PMID: 35027821 PMCID: PMC8752065 DOI: 10.2147/dddt.s331177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/15/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND A direct comparison of phenylephrine, metaraminol, and norepinephrine in preventing hypotension during spinal anaesthesia for elective caesarean section has never been made. PATIENTS AND METHODS Seventy-five parturients scheduled for elective caesarean section were randomly assigned into the three groups. After spinal anaesthesia induction, patients received a bonus dose of vasopressor (norepinephrine 4ug, phenylephrine 50ug, or metaraminol 250ug) combined with continuous infusion (norepinephrine 8ug/mL, phenylephrine 100ug/mL, or metaraminol 500ug/mL) at a rate of 30 mL/h to prevent hypotension. The primary outcome was umbilical arterial (UA) pH and other intraoperative data were also recorded. RESULTS The UA pH was 7.32±0.03 for metaraminol, 7.31±0.03 for phenylephrine, and 7.31±0.03 for norepinephrine. The 95% CI of MD was -0.011 to 0.026 comparing metaraminol with norepinephrine and 0.0181 to 0.0182 comparing phenylephrine with norepinephrine. Both lower bounds of the 95% CI of MD were above the predetermined lower boundary of clinical non-inferiority of -0.03, indicating both metaraminol and phenylephrine were non-inferior to norepinephrine. Moreover, the incidence of hypotension was lower in metaraminol compared with norepinephrine (P = 0.01). However, the incidence of hypertension was significantly lower in both phenylephrine and metaraminol compared with norepinephrine. CONCLUSION Both metaraminol and phenylephrine were non-inferior to norepinephrine with respect to neonatal UA pH when used as a bolus and continuous infusion to prevent hypotension during combined spinal-epidural anaesthesia for elective caesarean section.
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Affiliation(s)
- Youfa Zhou
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yunyun Yu
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Department of Anesthesiology, Lishui Central Hospital, Lishui, Zhejiang, People's Republic of China
| | - Miaofei Chu
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Department of Anesthesiology, Zhejiang Greentown Cardiovascular Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - Yanting Zhang
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Xin Yu
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Gang Chen
- Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
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Hatton RC, Hendeles L. Why Is Oral Phenylephrine on the Market After Compelling Evidence of Its Ineffectiveness as a Decongestant? Ann Pharmacother 2022; 56:10600280221081526. [PMID: 35337187 DOI: 10.1177/10600280221081526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Ineffective over-the-counter (OTC) drugs should be removed from the US market. Despite solid research showing that oral phenylephrine is ineffective as a decongestant, the US Food and Drug Administration has failed to respond to a 2015 citizen's petition to remove it from the OTC nasal decongestant monograph. Other examples of scientifically proven ineffective OTC medications include guaifenesin as an expectorant, dextromethorphan as a cough suppressant, and chlorpheniramine for cold symptoms.
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Affiliation(s)
- Randy C Hatton
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Fernandina Beach, FL, USA
| | - Leslie Hendeles
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Pediatric Pulmonary Division, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, USA
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48
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Singh J, Singh J, Mitra S, Anand LK, Goel B, Kaur M. Comparison of prophylactic phenylephrine and norepinephrine infusion on umbilical arterial pH and maternal blood pressure during spinal anaesthesia for caesarean delivery. Indian J Anaesth 2022; 66:S115-S121. [PMID: 35601041 PMCID: PMC9116634 DOI: 10.4103/ija.ija_345_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 03/13/2022] [Accepted: 03/14/2022] [Indexed: 11/25/2022] Open
Abstract
Background and Aims Spinal anaesthesia induced maternal hypotension in parturients undergoing caesarean delivery may lead to neonatal acidosis and fall in umbilical artery pH. The aim of this study was to compare low dose norepinephrine infusion with phenylephrine to see the effect on umbilical arterial pH and maternal blood pressure during spinal anaesthesia for caesarean delivery. Methods In a randomised, double-blind study, 60 parturients belonging to American Society of Anesthesiologists grade II, age 18-35 years with singleton term pregnancy were divided into the phenylephrine group and norepinephrine group. Participants received prophylactic phenylephrine and norepinephrine infusion after spinal anaesthesia till the delivery of the baby at a fixed rate of 50 μg/min and 2.5 μg/min, respectively. The primary outcome was umbilical artery pH. Neonatal Apgar score, incidence of bradycardia and hypotension, number of boluses of vasopressor required and reactive hypertension were also compared. Results The umbilical arterial pH was comparable between the groups (p = 0.38). Apgar scores were comparable (p = 0.17). Incidence of bradycardia was higher in phenylephrine group without reaching statistical significance (43.3% vs. 20%, P = 0.052). Incidence of hypotension was more but not significant in norepinephrine group compared to phenylephrine group (16.7% vs. 10%, P = 0.44). Number of vasopressor boluses and reactive hypertension episodes were comparable between both groups (p = 0.09). Conclusion Low dose (2.5 μg/min) intravenous infusion of norepinephrine is a suitable alternative to phenylephrine in the maintenance of umbilical arterial pH and maternal blood pressure.
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Affiliation(s)
- Jasveer Singh
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Jaskaran Singh
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Sukanya Mitra
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Lakesh K. Anand
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Bharti Goel
- Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Chandigarh, India
| | - Manjeet Kaur
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
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Li XX, Zhang P, Yang Y, Wang JJ, Zheng YJ, Tan JL, Liu SY, Yan YM, Zhang YY, Cheng YX, Yang HT. Small molecule QF84139 ameliorates cardiac hypertrophy via activating the AMPK signaling pathway. Acta Pharmacol Sin 2022; 43:588-601. [PMID: 33967278 DOI: 10.1038/s41401-021-00678-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/02/2021] [Indexed: 02/06/2023] Open
Abstract
Cardiac hypertrophy is a common adaptive response to a variety of stimuli, but prolonged hypertrophy leads to heart failure. Hence, discovery of agents treating cardiac hypertrophy is urgently needed. In the present study, we investigated the effects of QF84139, a newly synthesized pyrazine derivative, on cardiac hypertrophy and the underlying mechanisms. In neonatal rat cardiomyocytes (NRCMs), pretreatment with QF84139 (1-10 μM) concentration-dependently inhibited phenylephrine-induced hypertrophic responses characterized by fetal genes reactivation, increased ANP protein level and enlarged cardiomyocytes. In adult male mice, administration of QF84139 (5-90 mg·kg-1·d-1, i.p., for 2 weeks) dose-dependently reversed transverse aortic constriction (TAC)-induced cardiac hypertrophy displayed by cardiomyocyte size, left ventricular mass, heart weights, and reactivation of fetal genes. We further revealed that QF84139 selectively activated the AMPK signaling pathway without affecting the phosphorylation of CaMKIIδ, ERK1/2, AKT, PKCε, and P38 kinases in phenylephrine-treated NRCMs and in the hearts of TAC-treated mice. In NRCMs, QF84139 did not show additive effects with metformin on the AMPK activation, whereas the anti-hypertrophic effect of QF84139 was abolished by an AMPK inhibitor Compound C or knockdown of AMPKα2. In AMPKα2-deficient mice, the anti-hypertrophic effect of QF84139 was also vanished. These results demonstrate that QF84139 attenuates the PE- and TAC-induced cardiac hypertrophy via activating the AMPK signaling. This structurally novel compound would be a promising lead compound for developing effective agents for the treatment of cardiac hypertrophy.
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50
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Yang C, Meng Q, Cheng Y, Huang S, Yu X. Effect of maternal body mass index on the prophylactic dose of phenylephrine for preventing hypotension in parturients after spinal anaesthesia. Anaesth Crit Care Pain Med 2022; 41:101035. [PMID: 35181530 DOI: 10.1016/j.accpm.2022.101035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND To compare the median effective dose (ED50) of phenylephrine for prophylactic continuous infusion in parturients with different body mass indices (BMIs) during combined spinal-epidural anaesthesia for caesarean section and to investigate the impact of maternal BMI on the prophylactic dose of phenylephrine. METHODS Parturients receiving combined spinal-epidural anaesthesia for elective caesarean section were divided into a standard group (Group S, BMI < 30 kg/m2) and an obesity group (Group O, BMI > 30 kg/m2), each with 30 patients. A sequential allocation design was used to administer the prophylactic infusion of phenylephrine after the completion of a spinal anaesthetic injection to prevent hypotension (defined as a reduction of systolic blood pressure ≥ 20% of the baseline value or systolic blood pressure < 90 mmHg), with an initial infusion rate of 50 μg/min for the first parturient subsequent adjusted up or down by 10 μg/min depending on whether the previous parturient developed hypotension or not during the study period. The Dixon and Massey method and the isotonic regression method were used to calculate and compare the ED50 and 95% confidence interval (CI) of phenylephrine between the two groups. RESULTS The results were 21.92 μg/min (95% CI, 14.90-28.94 μg/min) for Group S and 42.14 μg/min (95% CI, 24.58-59.70 μg/min) for Group O. The ratio of relative potency of Group O to Group S is 1.92 (95% CI 1.09 - 3.14), P = 0.034. CONCLUSIONS The dose of phenylephrine for the prevention of hypotension after spinal anaesthesia for caesarean section is dependent on maternal BMI. Therefore, a weight-based phenylephrine dose is reasonable.
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Affiliation(s)
- Chen Yang
- Department of Anaesthesia, Obstetrics & Gynaecology Hospital, Fudan University, Shanghai, China
| | - Qiuyu Meng
- Department of Anaesthesia, Obstetrics & Gynaecology Hospital, Fudan University, Shanghai, China
| | - Yan Cheng
- Department of Anaesthesia, Obstetrics & Gynaecology Hospital, Fudan University, Shanghai, China
| | - Shaoqiang Huang
- Department of Anaesthesia, Obstetrics & Gynaecology Hospital, Fudan University, Shanghai, China.
| | - Xinhua Yu
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, USA
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