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Xiang Y, Ma G, Yang Q, Cao M, Xu W, Li L, Yang Q. External validation of the prediction model of intradialytic hypotension: a multicenter prospective cohort study. Ren Fail 2024; 46:2322031. [PMID: 38466674 DOI: 10.1080/0886022x.2024.2322031] [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: 08/31/2023] [Accepted: 02/17/2024] [Indexed: 03/13/2024] Open
Abstract
OBJECTIVE Intradialytic hypotension (IDH) is a common and serious complication in patients with Maintenance Hemodialysis (MHD). The purpose of this study is to externally verify three IDH risk prediction models recently developed by Ma et al. and recalibrate, update and present the optimal model to improve the accuracy and applicability of the model in clinical environment. METHODS A multicenter prospective cohort study of patients from 11 hemodialysis centers in Sichuan Province, China, was conducted using convenience sampling from March 2022 to July 2022, with a follow-up period of 1 month. Model performance was assessed by: (1) Discrimination: Evaluated through the computation of the Area Under Curve (AUC) and its corresponding 95% confidence intervals. (2) Calibration: scrutinized through visual inspection of the calibration plot and utilization of the Brier score. (3) The incremental value of risk prediction and the utility of updating the model were gauged using NRI (Net Reclassification Improvement) and IDI (Integrated Discrimination Improvement). Decision Curve Analysis (DCA) was employed to evaluate the clinical benefit of updating the model. RESULTS The final cohort comprised 2235 individuals undergoing maintenance hemodialysis, exhibiting a 14.6% occurrence rate of IDH. The externally validated Area Under the Curve (AUC) values for the three original prediction models were 0.746 (95% CI: 0.718 to 0.775), 0.709 (95% CI: 0.679 to 0.739), and 0.735 (95% CI: 0.706 to 0.764) respectively. Conversely, the AUC value for the recalibrated and updated columnar plot model reached 0.817 (95% CI: 0.791 to 0.842), accompanied by a Brier score of 0.081. Furthermore, Decision Curve Analysis (DCA) exhibited a net benefit within the threshold probability range of 15.2% to 87.1%. CONCLUSION Externally validated, recalibrated, updated, and presented IDH prediction models may serve as a valuable instrument for evaluating IDH risk in clinical practice. Furthermore, they hold the potential to guide clinical providers in discerning individuals at risk and facilitating judicious clinical intervention decisions.
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Affiliation(s)
- Yuhe Xiang
- School of Nursing, Chengdu Medical College, Chengdu, China
| | - Guoting Ma
- Health Management Center, Sichuan Tai Kang Hospital, Chengdu, China
| | - Qin Yang
- School of Nursing, Chengdu Medical College, Chengdu, China
| | - Min Cao
- Department of Orthopedics, Sichuan second traditional Chinese medicine hospital, Chengdu, China
| | - Wenbin Xu
- School of Nursing, Chengdu Medical College, Chengdu, China
| | - Lin Li
- School of Nursing, Chengdu Medical College, Chengdu, China
| | - Qian Yang
- School of Nursing, Chengdu Medical College, Chengdu, China
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Crystal GJ, Pagel PS, Salem MR. Pleth variability index during preoxygenation did not reliably predict anesthesia-induced hypotension. J Clin Anesth 2024; 93:111370. [PMID: 38157662 DOI: 10.1016/j.jclinane.2023.111370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Affiliation(s)
- George J Crystal
- Department of Anesthesiology, the University of Illinois College of Medicine, Chicago, Illinois (GJC and MRS) and Anesthesia Service, the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, United States of America.
| | - Paul S Pagel
- Department of Anesthesiology, the University of Illinois College of Medicine, Chicago, Illinois (GJC and MRS) and Anesthesia Service, the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, United States of America
| | - M Ramez Salem
- Department of Anesthesiology, the University of Illinois College of Medicine, Chicago, Illinois (GJC and MRS) and Anesthesia Service, the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, United States of America
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Mohr NL, Krannich A, Jung H, Hulde N, von Dossow V. Intraoperative Blood Pressure Management and Its Effects on Postoperative Delirium After Cardiac Surgery: A Single-Center Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:1127-1134. [PMID: 38369449 DOI: 10.1053/j.jvca.2024.01.027] [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: 10/30/2023] [Revised: 01/17/2024] [Accepted: 01/23/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVES There is accumulating evidence that blood pressure management might be associated with end-organ dysfunction after cardiac surgery. This study aimed to investigate the impact of intraoperative hypotension (IOH) on adverse neurologic outcomes and mortality. DESIGN A single-center retrospective cohort study. SETTING The Heart and Diabetes Centre Bad Oeynhausen NRW, Ruhr-University Bochum. PARTICIPANTS This retrospective cohort study included 31,315 adult patients who underwent elective cardiac surgery at the authors' institution between January 2009 and December 2018. INTERVENTIONS All cardiac surgery procedures except assist device implantation, organ transplantation, and emergency surgery. MEASUREMENTS AND MAIN RESULTS Adverse neurologic outcomes were defined as postoperative delirium and stroke. IOH was defined as mean arterial pressure below 60 mmHg for >2 minutes. The frequency of IOH episodes and the cumulative IOH duration were recorded. The association between IOH and adverse neurologic outcomes was examined with unadjusted statistical analysis and multiple logistic regression analysis. Eight hundred forty-nine (2.9%) patients developed postoperative stroke, and 2,401 (7.7%) patients developed postoperative delirium. The frequency of IOH episodes was independently associated with postoperative delirium in the multiple logistic regression analysis (odds ratio 1.02, 95% CI 1.003-1.03, p < 0.001), whereas there was no association between it and stroke. CONCLUSION This large retrospective monocentric cohort study revealed that increased episodes of IOH were associated with the risk of developing postoperative delirium after cardiac surgery. This might have important clinical implications with respect to careful and precise hemodynamic monitoring and proactive treatment, especially in patients with increased risk for postoperative delirium.
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Affiliation(s)
- Niklas L Mohr
- Institute of Anesthesiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | | | - Hilke Jung
- Institute of Congenital heart diseases, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Nikolai Hulde
- Institute of Anesthesiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Vera von Dossow
- Institute of Anesthesiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-University Bochum, Bad Oeynhausen, Germany.
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Luo JC, Luo MH, Zhang YJ, Liu WJ, Ma GG, Hou JY, Su Y, Hao GW, Tu GW, Luo Z. Skin mottling score assesses peripheral tissue hypoperfusion in critically ill patients following cardiac surgery. BMC Anesthesiol 2024; 24:130. [PMID: 38580909 PMCID: PMC10996133 DOI: 10.1186/s12871-024-02474-0] [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: 11/13/2023] [Accepted: 02/27/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Skin mottling is a common manifestation of peripheral tissue hypoperfusion, and its severity can be described using the skin mottling score (SMS). This study aims to evaluate the value of the SMS in detecting peripheral tissue hypoperfusion in critically ill patients following cardiac surgery. METHODS Critically ill patients following cardiac surgery with risk factors for tissue hypoperfusion were enrolled (n = 373). Among these overall patients, we further defined a hypotension population (n = 178) and a shock population (n = 51). Hemodynamic and perfusion parameters were recorded. The primary outcome was peripheral hypoperfusion, defined as significant prolonged capillary refill time (CRT, > 3.0 s). The characteristics and hospital mortality of patients with and without skin mottling were compared. The area under receiver operating characteristic curves (AUROC) were used to assess the accuracy of SMS in detecting peripheral hypoperfusion. Besides, the relationships between SMS and conventional hemodynamic and perfusion parameters were investigated, and the factors most associated with the presence of skin mottling were identified. RESULTS Of the 373-case overall population, 13 (3.5%) patients exhibited skin mottling, with SMS ranging from 1 to 5 (5, 1, 2, 2, and 3 cases, respectively). Patients with mottling had lower mean arterial pressure, higher vasopressor dose, less urine output (UO), higher CRT, lactate levels and hospital mortality (84.6% vs. 12.2%, p < 0.001). The occurrences of skin mottling were higher in hypotension population and shock population, reaching 5.6% and 15.7%, respectively. The AUROC for SMS to identify peripheral hypoperfusion was 0.64, 0.68, and 0.81 in the overall, hypotension, and shock populations, respectively. The optimal SMS threshold was 1, which corresponded to specificities of 98, 97 and 91 and sensitivities of 29, 38 and 67 in the three populations (overall, hypotension and shock). The correlation of UO, lactate, CRT and vasopressor dose with SMS was significant, among them, UO and CRT were identified as two major factors associated with the presence of skin mottling. CONCLUSION In critically ill patients following cardiac surgery, SMS is a very specific yet less sensitive parameter for detecting peripheral tissue hypoperfusion.
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Affiliation(s)
- Jing-Chao Luo
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Geriatric Medical Center, Shanghai, 200032, China
| | - Ming-Hao Luo
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Yi-Jie Zhang
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Wen-Jun Liu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Guo-Guang Ma
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Jun-Yi Hou
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Ying Su
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Guang-Wei Hao
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Guo-Wei Tu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
| | - Zhe Luo
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
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Frassanito L, Vassalli F, Draisci G. The relationship between hypotension prediction index and mean arterial pressure: An analysis on real data. Eur J Anaesthesiol 2024; 41:314-316. [PMID: 38264965 DOI: 10.1097/eja.0000000000001957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Affiliation(s)
- Luciano Frassanito
- From the Department of Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, Rome (LF, GD), and the Department of Critical Care and Perinatal Medicine, IRCCS Istituto Giannina Gaslini, Genova, Italy (FV)
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Ripollés-Melchor J, Monge-García MI, Vincent JL. Dangers of misinterpreting intraoperative hypotension. Comments on Br J Anaesth 2023; 131: 823-31 and Br J Anaesth 2023; 131: 810-2. Br J Anaesth 2024; 132:802-803. [PMID: 38238197 DOI: 10.1016/j.bja.2023.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/04/2023] [Accepted: 12/23/2023] [Indexed: 03/05/2024] Open
Affiliation(s)
- Javier Ripollés-Melchor
- Department of Anesthesiology, Infanta Leonor University Hospital, Madrid, Spain; Fluid Therapy and Hemodynamic Monitoring Working Group of the Spanish Society of Anesthesiology and Critical Care, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain.
| | - Manuel I Monge-García
- Fluid Therapy and Hemodynamic Monitoring Working Group of the Spanish Society of Anesthesiology and Critical Care, Madrid, Spain; Jerez de La Frontera University Hospital, Jerez de la Frontera, Spain
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Gurunathan U, Roe A, Milligan C, Hay K, Ravichandran G, Chawla G. Preoperative Renin-Angiotensin System Antagonists Intake and Blood Pressure Responses During Ambulatory Surgical Procedures: A Prospective Cohort Study. Anesth Analg 2024; 138:763-774. [PMID: 38236756 DOI: 10.1213/ane.0000000000006728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND There is limited evidence to inform the association between the intake of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) and intraoperative blood pressure (BP) changes in an ambulatory surgery population. METHODS Adult patients who underwent ambulatory surgery and were discharged on the same day or within 24 hours of their procedure were enrolled in this prospective cohort study. The primary outcome of the study was early intraoperative hypotension (first 15 minutes of induction). Secondary outcomes included any hypotension, BP variability, and recovery. Hypotension was defined as a decrease in systolic BP of >30% from baseline for ≥5 minutes or a mean BP of <55 mm Hg. Four exposure groups were compared (no antihypertensives, ACEI/ARB intake <10 hours before surgery, ACEI/ARB intake ≥10 hours before surgery, and other antihypertensives). RESULTS Of the 537 participants, early hypotension was observed in 25% (n = 134), and any hypotension in 41.5% (n = 223). Early hypotension occurred in 30% (29 of 98) and 41% (17 of 41) with the intake of ACEI/ARBs <10 and ≥10 hours before surgery, respectively, compared to 30% (9 of 30) with other antihypertensives and 21% (79 of 368) with no antihypertensives ( P = .02). Those on antihypertensives also experienced any hypotension more frequently than those who were not on antihypertensives ( P < .001). After adjusting for age and baseline BP in a regression analysis, antihypertensive exposure groups were observed to be associated only with any intraoperative hypotension ( P = .012). In the ACEI/ARB subset, there was no evidence of an association between time since the last ACEI/ARB dose, and hypotension or minimum mean or systolic BP. Compared to normal baseline BP, BP ≥ 140/90 mm Hg increased the odds of early and any hypotension (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.1-7.1 and OR, 7.7; 95% CI, 3.7-14.9, respectively; P < .001). Intraoperative variability in systolic and diastolic BP demonstrated significant differences with age, baseline BP, and antihypertensive exposure group ( P < .001). CONCLUSIONS Early and any hypotension occurred more frequently in those on antihypertensives than those not on antihypertensives. Unadjusted associations between antihypertensive exposure and intraoperative hypotension were largely explained by baseline hypertension rather than the timing of ACEI/ARBs or type of antihypertensive exposure. Patients with hypertension and on treatment experience more intraoperative BP variability and should be monitored appropriately.
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Affiliation(s)
- Usha Gurunathan
- From the Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Adrian Roe
- Department of Urology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Caitlin Milligan
- From the Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Karen Hay
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Gowri Ravichandran
- Department of Anaesthesia, Caboolture Hospital, Caboolture, Queensland, Australia
| | - Gunjan Chawla
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia, Caboolture Hospital, Caboolture, Queensland, Australia
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Shan B, Li J, Shi Z, Han C, Zhang J, Zhao J, Hu R, Liu L, Ta S. Predictive value of estimated plasma volume for postoperative hypotension in percutaneous intramyocardial septal radiofrequency ablation treating for hypertrophic obstructive cardiomyopathy. BMC Cardiovasc Disord 2024; 24:177. [PMID: 38519968 PMCID: PMC10958927 DOI: 10.1186/s12872-024-03844-9] [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: 11/13/2023] [Accepted: 03/13/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Estimated plasma volume status (ePVS) estimated by the Duarte formula is associated with clinical outcomes in patients with heart failure. It remains unclear the predictive value of the ePVS to the postoperative hypotension (POH) in percutaneous intramyocardial septal radiofrequency ablation (PIMSRA) treating hypertrophic obstructive cardiomyopathy (HOCM). METHODS Data of HOCM patients who underwent PIMSRA were retrospectively collected. Preoperative ePVS was calculated using the Duarte formulas which derived from hemoglobin and hematocrit ratios. Clinical variables including physical assessment, biological and echocardiographic parameters were recorded. Patients were labeled with or without POH according to the medical record in the hospital. Univariable and multivariable logistic regression were performed to evaluate the association between ePVS and POH. Using different thresholds derived from quartiles and the best cutoff value of the receiver operating characteristic curve, the diagnostic performance of ePVS was quantified. RESULTS Among the 405 patients included in this study, 53 (13.1%) patients were observed with symptomatic POH. Median (IQR) of ePVS in overall patients was 3.77 (3.27~4.40) mL/g and in patients with POH were higher than those without POH. The ePVS was associated with POH, with the odds ratio of 1.669 (95% CI 1.299 ~ 2.144) per mL/g. After adjusted by potential confounders, ePVS remained independently associated with POH, with the approximate odds ratio in different models. CONCLUSION The preoperative ePVS derived from the Duarte formulas was independently associated with postoperative hypotension in HOCM patients who underwent PIMSRA and showed prognostic value to the risk stratification of postoperative management. TRIAL REGISTRATION NCT06003478 (22/08/2023).
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Affiliation(s)
- Bo Shan
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Jing Li
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Zhangwei Shi
- Department of Cardiology, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Chao Han
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Juan Zhang
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Jia Zhao
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Rui Hu
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Liwen Liu
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China.
| | - Shengjun Ta
- Department of Ultrasound, Hypertrophic Cardiomyopathy Center, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China.
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Mullaly R, El-Khuffash AF. Haemodynamic assessment and management of hypotension in the preterm. Arch Dis Child Fetal Neonatal Ed 2024; 109:120-127. [PMID: 37173119 DOI: 10.1136/archdischild-2022-324935] [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: 11/18/2022] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
The management of low blood flow states in premature neonates is fraught with many challenges. We remain over-reliant on regimented stepwise protocols that use mean blood pressure as a threshold for intervention to guide treatment, without giving due consideration to the underlying pathophysiology. The current available evidence does not reflect the need to concentrate on the unique pathophysiology of the preterm infant and thus leads to widespread misuse of vasoactive agents that often do not provide the desired clinical effect. Therefore, understanding the underlying pathophysiological underpinnings of haemodynamic compromise may better guide choice of agent and assess physiological response to the selected intervention.
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Affiliation(s)
- Rachel Mullaly
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
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Lerman TT, Greenberg N, Fishman B, Goldman A, Talmor-Barkan Y, Bauer M, Goldberg I, Goldberg E, Kornowski R, Krause I, Levi A, Cohen E. The real-world safety of sacubitril / valsartan among older adults (≥75): A pharmacovigilance study from the FDA data. Int J Cardiol 2024; 397:131613. [PMID: 38030039 DOI: 10.1016/j.ijcard.2023.131613] [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: 07/03/2023] [Revised: 11/12/2023] [Accepted: 11/23/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Heart failure is a major cause of morbidity and mortality among older adults. Sacubitril-Valsartan (Sac/Val) has been shown to improve patients' outcomes; however, its safety profile among older adults has not been adequately examined. We therefore aimed to examine its safety profile among this population. METHODS We conducted a retrospective pharmacovigilance study utilizing the FDA's database of safety reports (FAERS). We employed disproportionality analysis comparing Sac/Val to angiotensin receptor blockers (ARBs). We aim to evaluate the reporting of pre-defined adverse events associated with Sac/Val (hypotension, acute kidney injury (AKI), hyperkalemia and angioedema) in two age groups: adults (< 75 years) and older adults (≥ 75). For each subgroup, we calculated reporting odds ratio (ROR) and compared them by calculating P for interaction. RESULTS The FAERS database encompassed 18,432 unique reports of Sac/Val. Of them, 12,630 (68.5%) subjects were adults (< 75 years), and 5802 (31.5%) were older adults (≥ 75 years), with a median age (IQR) of 68 (59-77). When compared to ARBs, Sac/Val was associated with higher reporting of hypotension, lower reporting of acute kidney injury (AKI) and hyperkalemia, and similar reporting of angioedema. Notably, we did not observe a significant interaction between the age subgroups and the risk estimates (AKI: Pinteraction = 0.72, hyperkalemia: Pinteraction = 0.94, hypotension: Pinteraction = 0.31, and angioedema: Pinteraction = 0.61). CONCLUSIONS In this postmarking study, none of the prespecified adverse events was reported more frequently in older adults. These findings provide reassurance for safety use of Sac/Val in older adults.
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Affiliation(s)
- Tsahi T Lerman
- Department of Internal Medicine F-Recanati, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Noam Greenberg
- Department of Internal Medicine F-Recanati, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Fishman
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Leviev Heart Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Adam Goldman
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Leviev Heart Center, Sheba Medical Center, Ramat-Gan, Israel; Department of Internal Medicine F, Sheba Medical Center, Ramat-Gan, Israel
| | - Yeela Talmor-Barkan
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Menachem Bauer
- Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Idan Goldberg
- Department of Internal Medicine F-Recanati, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Elad Goldberg
- Department of Internal Medicine F-Recanati, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Krause
- Department of Internal Medicine F-Recanati, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amos Levi
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eytan Cohen
- Department of Internal Medicine F-Recanati, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Vistisen ST, Enevoldsen J. CON: The hypotension prediction index is not a validated predictor of hypotension. Eur J Anaesthesiol 2024; 41:118-121. [PMID: 38085015 DOI: 10.1097/eja.0000000000001939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
The Hypotension Prediction Index (HPI) algorithm is a commercial prediction algorithm developed to predict hypotension, a mean arterial pressure (MAP) below 65 mmHg. Although HPI has been investigated in several studies, recent concerns of have been raised regarding HPI's predictive abilities, which may have been overstated. A selection bias may have forced the HPI algorithm to learn almost exclusively from MAP. This CON position paper describes the selection bias further and summarises the scientific status of HPI's predictive abilities, including the meaning of a recent erratum retracting the primary conclusion of a published HPI validation study. We argue that the HPI algorithm needs re-validation or complete re-development to achieve a clinically relevant 'added value' in comparison with the predictive performance of a simple and costless MAP alarm threshold in the range of 70 to 75 mmHg.
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Affiliation(s)
- Simon Tilma Vistisen
- From the Institute of Clinical Medicine, Aarhus University (STV, JE) and Department of Anaesthesiology & Intensive Care, Aarhus University Hospital, Aarhus, Denmark (STV, JE)
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Longrois D, de Tymowski C. PRO: The hypotension prediction index is clinically relevant: A physiologic/pathophysiologic approach opposed to a purely computational debate. Eur J Anaesthesiol 2024; 41:115-117. [PMID: 38085023 DOI: 10.1097/eja.0000000000001927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Dan Longrois
- From the Department of Anaesthesia and Intensive Care, Bichat-Claude Bernard and Louis Mourier Hospitals, DMU PARABOL, Université Paris Cité, INSERM U1148, Paris, France (DL, CdT)
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Huang L, Li S, Xie X, Huang X, Xiao LD, Zou Y, Jiang W, Zhang F. Prevalence of postprandial hypotension in older adults: a systematic review and meta-analysis. Age Ageing 2024; 53:afae022. [PMID: 38411408 PMCID: PMC10898335 DOI: 10.1093/ageing/afae022] [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: 10/01/2023] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Older adults with postprandial hypotension (PPH) increase susceptibility to falls, syncope, stroke, acute cardiovascular diseases and even death. However, the prevalence of this condition varies significantly across studies. We aimed to determine the prevalence of PPH in older adults. METHODS Web of Science, PubMed, Cochrane Library, Embase and CINAHL were searched from their inception until February 2023. Search terms included 'postprandial period', 'hypotension' and 'postprandial hypotension'. Eligible studies were assessed using the Joanna Briggs Institute tool. Meta-analyses were performed among similar selected studies. RESULTS Thirteen eligible studies were included, and data from 3,021 participants were pooled. The meta-analysis revealed a PPH prevalence of 40.5% [95% confidence interval (CI): 0.290-0.519] in older adults, and this was prevalent in the community (32.8%, 95% CI: 0.078-0.647, n = 1,594), long-term healthcare facility (39.4%, 95% CI: 0.254-0.610, n = 1,062) and geriatrics department of hospitals (49.3%, 95% CI: 0.357-0.630, n = 365). The pooled results showed significant heterogeneity (I2 > 90%), partially related to the different ages, sex, pre-prandial systolic blood pressure levels of participants, or the different criteria and methodology used to diagnose PPH. CONCLUSIONS PPH is a prevalent condition in older adults. Further research is needed to confirm this result, and priority should be given to establishing international consensus on PPH diagnostic criteria and designing its diagnostic procedure.
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Affiliation(s)
- Lei Huang
- West China School of Nursing/Nursing Key Laboratory of Sichuan Province/Innovation Center of Nursing Research/West China Hospital, Sichuan University, 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Xiaofeng Xie
- West China School of Nursing/Nursing Key Laboratory of Sichuan Province/Innovation Center of Nursing Research/West China Hospital, Sichuan University, 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
| | - Xiaoli Huang
- Center of Gerontology and Geriatrics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, China
| | - Lily Dongxia Xiao
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Ying Zou
- West China School of Nursing/Nursing Key Laboratory of Sichuan Province/Innovation Center of Nursing Research/West China Hospital, Sichuan University, 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
| | - Wenyi Jiang
- West China School of Nursing/Nursing Key Laboratory of Sichuan Province/Innovation Center of Nursing Research/West China Hospital, Sichuan University, 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
| | - Fengying Zhang
- West China School of Nursing/Nursing Key Laboratory of Sichuan Province/Innovation Center of Nursing Research/West China Hospital, Sichuan University, 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
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Dong Z, Chen X, Ritter J, Bai L, Huang J. American society of anesthesiologists physical status classification significantly affects the performances of machine learning models in intraoperative hypotension inference. J Clin Anesth 2024; 92:111309. [PMID: 37922642 PMCID: PMC10873053 DOI: 10.1016/j.jclinane.2023.111309] [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: 07/02/2023] [Revised: 09/24/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
STUDY OBJECTIVE To explore how American Society of Anesthesiologists (ASA) physical status classification affects different machine learning models in hypotension prediction and whether the prediction uncertainty could be quantified. DESIGN Observational Studies SETTING: UofL health hospital PATIENTS: This study involved 562 hysterectomy surgeries performed on patients (≥ 18 years) between June 2020 and July 2021. INTERVENTIONS None MEASUREMENTS: Preoperative and intraoperative data is collected. Three parametric machine learning models, including Bayesian generalized linear model (BGLM), Bayesian neural network (BNN), a newly proposed BNN with multivariate mixed responses (BNNMR), and one nonparametric model, Gaussian Process (GP), were explored to predict patients' diastolic and systolic blood pressures (continuous responses) and patients' hypotensive event (binary response) for the next five minutes. Data was separated into American Society of Anesthesiologists (ASA) physical status class 1- 4 before being read in by four machine learning models. Statistical analysis and models' constructions are performed in Python. Sensitivity, specificity, and the confidence/credible intervals were used to evaluate the prediction performance of each model for each ASA physical status class. MAIN RESULTS ASA physical status classes require distinct models to accurately predict intraoperative blood pressures and hypotensive events. Overall, high sensitivity (above 0.85) and low uncertainty can be achieved by all models for ASA class 4 patients. In contrast, models trained without controlling ASA classes yielded lower sensitivity (below 0.5) and larger uncertainty. Particularly, in terms of predicting binary hypotensive event, for ASA physical status class 1, BNNMR yields the highest sensitivity of 1. For classes 2 and 3, BNN has the highest sensitivity of 0.429 and 0.415, respectively. For class 4, BNNMR and GP are tied with the highest sensitivity of 0.857. On the other hand, the sensitivity is just 0.031, 0.429, 0.165 and 0.305 for BNNMR, BNN, GBLM and GP models respectively, when training data is not divided by ASA physical status classes. In terms of predicting systolic blood pressure, the GP regression yields the lowest root mean squared errors (RMSE) of 2.072, 7.539, 9.214 and 0.295 for ASA physical status classes 1, 2, 3 and 4, respectively, but a RMSE of 126.894 if model is trained without controlling the ASA physical status class. The RMSEs for other models are far higher. RMSEs are 2.175, 13.861, 17.560 and 22.426 for classes 1, 2, 3 and 4 respectively for the BGLM. In terms of predicting diastolic blood pressure, the GP regression yields the lowest RMSEs of 2.152, 6.573, 5.371 and 0.831 for ASA physical status classes 1, 2, 3 and 4, respectively; RMSE of 8.084 if model is trained without controlling the ASA physical status class. The RMSEs for other models are far higher. Finally, in terms of the width of the 95% confidence interval of the mean prediction for systolic and diastolic blood pressures, GP regression gives narrower confidence interval with much smaller margin of error across all four ASA physical status classes. CONCLUSIONS Different ASA physical status classes present different data distributions, and thus calls for distinct machine learning models to improve prediction accuracy and reduce predictive uncertainty. Uncertainty quantification enabled by Bayesian inference provides valuable information for clinicians as an additional metric to evaluate performance of machine learning models for medical decision making.
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Affiliation(s)
- Zehua Dong
- Department of Industrial and Systems Engineering, University at Buffalo, United States of America.
| | - Xiaoyu Chen
- Department of Industrial and Systems Engineering, University at Buffalo, United States of America.
| | - Jodie Ritter
- Department of Industrial Engineering, University of Louisville, United States of America.
| | - Lihui Bai
- Department of Industrial Engineering, University of Louisville, United States of America.
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, United States of America.
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Lessing JK, Kram SJ, Levy JH, Grecu LM, Katz JN. Droxidopa or Atomoxetine for Refractory Hypotension in Critically Ill Cardiothoracic Surgery Patients. J Cardiothorac Vasc Anesth 2024; 38:155-161. [PMID: 37838507 DOI: 10.1053/j.jvca.2023.09.023] [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: 07/28/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE To evaluate the effects of droxidopa or atomoxetine on intravenous (IV) vasoactive agent discontinuation in cardiothoracic intensive care unit (ICU) patients with hypotension refractory to midodrine. DESIGN Single-center, retrospective cohort study. SETTING Tertiary- and quaternary-care university teaching hospital. PARTICIPANTS Included patients who received at least 4 consecutive doses of droxidopa or atomoxetine and remained on concurrent midodrine. Patients were excluded if they received study medication before admission, had clinical deterioration after study medication initiation requiring additional vasoactives/escalation of IV vasoactive dosage for at least 12 hours, had a diagnosis of hepatorenal syndrome, were prisoners, or were pregnant. INTERVENTIONS Droxidopa, atomoxetine, or both. MEASUREMENTS AND MAIN RESULTS The primary endpoint was time to discontinuation of IV vasoactive agents after initiation of study medication, analyzed using a Kaplan-Meier estimate with the Wilcoxon method, censoring death within 24 hours of the last dose of study medication. No adjustment for repetitive analyses was made, as the analysis was hypothesis-generating. Of the 72 charts reviewed, 45 patients met inclusion criteria (18 atomoxetine, 17 droxidopa, and 10 both). There were no differences in median time to discontinuation of IV vasoactive agents (21.9 days v 8.0 days v 13.9 days, respectively; p = 0.259) or ICU or hospital length of stay between groups. A higher percentage of patients who survived to hospital discharge received both study medications or droxidopa alone (90% v 76.5%) than atomoxetine alone (44.4%, p = 0.028). CONCLUSIONS Droxidopa and atomoxetine are oral vasoactive agents with potential mechanisms to facilitate IV vasopressor weaning for patients in the ICU with hypotension refractory to midodrine, but further prospective research is needed.
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Affiliation(s)
- Julia K Lessing
- Duke University Hospital, Department of Pharmacy, Durham, NC.
| | - Shawn J Kram
- Duke University Hospital, Department of Pharmacy, Durham, NC
| | - Jerrold H Levy
- Duke University Hospital, Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham NC
| | - Loreta M Grecu
- Duke University Hospital, Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham NC
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, NC
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Calente TJN, Albino LB, Oliveira JG, Delfrate G, Sordi R, Santos FA, Fernandes D. EARLY BLOOD LACTATE AS A BIOMARKER FOR CARDIOVASCULAR COLLAPSE IN EXPERIMENTAL SEPSIS. Shock 2024; 61:142-149. [PMID: 38010082 DOI: 10.1097/shk.0000000000002265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
ABSTRACT Cecal ligation and puncture (CLP) is the gold standard model for studying septic shock, which is characterized by hypotension and hyporeactivity to vasoconstrictors. However, approximately 30% of CLP animals do not exhibit cardiovascular changes, requiring more replicates because of the high variability of the model. Therefore, biomarkers enabling the early prediction of cardiovascular collapse in sepsis would greatly benefit sepsis nonclinical studies, refining experimental models and improving clinical translation. Thus, this study aimed to test whether the early increase in lactate levels could predict hypotension and hyporesponsiveness to vasoconstrictors in a rat model of sepsis. Male and female Wistar rats were subjected to CLP or sham procedure. Tail blood lactate was measured 6, 12, and 24 h after surgery. Then, inflammatory, biochemical, and hemodynamic parameters were evaluated. Rats subjected to CLP developed hypotension, hyporesponsiveness to vasoconstrictors, an intense inflammatory process, and increased plasma markers of organ dysfunction. By using receiver operating characteristics curve analysis, we have established that a lactate value of 2.45 mmol/L can accurately discriminate between a rat exhibiting a normal vasoconstrictive response and a vasoplegic rat with 84% accuracy (area under the curve: 0.84; confidence interval [CI]: 0.67-1.00). The sensitivity, which is the ability to identify a diseased rat (true positive), was 75% (CI: 41-95), and the true negative rate was 81% (CI: 57-93). Therefore, early measurement of lactate levels in sepsis could serve as a valuable biomarker for distinguishing vasoplegic rats from those exhibiting normal vasoconstrictive responses.
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Affiliation(s)
| | - Lucas Braga Albino
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Junior Garcia Oliveira
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Gabrielle Delfrate
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Regina Sordi
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Fábio André Santos
- Department of Dentistry, Universidade Estadual de Ponta Grossa, Ponta Grossa, Brazil
| | - Daniel Fernandes
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
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Ehinmisan AO, Rosen R. Chest Pain and Hypotension in a Dialysis Patient. Kidney360 2024; 5:168-169. [PMID: 38271197 PMCID: PMC10917112 DOI: 10.34067/kid.0000000000000271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Affiliation(s)
| | - Raphael Rosen
- Division of Nephrology, Department of Medicine, Stamford Health Medical Group, Stamford, Connecticut
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Fathy MM, Wahdan RA, Salah AAA, Elnakera AM. Inferior vena cava collapsibility index as a predictor of hypotension after induction of general anesthesia in hypertensive patients. BMC Anesthesiol 2023; 23:420. [PMID: 38114949 PMCID: PMC10729554 DOI: 10.1186/s12871-023-02355-y] [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: 09/27/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Hypertensive patients are more susceptible to develop hypotension after the induction of general anesthesia (GA), most likely due to hypovolemia. An inferior vena cava collapsibility index (IVCCI) > 40-50% can predict hypotension after the induction of GA in the general population by variable accuracies. The current study aimed to investigate IVCCI% as a predictor of postinduction hypotension in hypertensive patients undergoing noncardiac surgery. METHODS Ultrasound IVCCI % was assessed for all controlled hypertensive patients immediately before induction of GA. After induction of GA, patients were diagnosed with postinduction hypotension if their systolic arterial pressure (SAP) dropped by ≥ 30% of the baseline value and/or mean arterial pressure (MAP) dropped to < 65 mmHg up to 15 min after intubation. The receiver operating characteristic (ROC) curve of IVCCI% was compared to patients' classification either developing hypotension after induction of GA or not as a gold standard. RESULTS Of the 153 patients who completed the study, 62 (40.5%) developed hypotension after the induction of GA, and 91 (59.5%) did not. An IVCCI > 39% predicted the occurrence of postinduction hypotension with high accuracy (84%) (AUC 0.908, P < 0.001). The area of uncertainty (by gray zone analysis) of IVCCI lies at values from 39 to 45%. This gray zone included 21 patients (13.7% of all patients). CONCLUSION An inferior vena cava collapsibility index > 39% before anesthetic induction can be a simple noninvasive reliable predictor of hypotension after the induction of GA for hypertensive patients not treated with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) and undergoing noncardiac surgery. TRIAL REGISTRATION This clinical trial was approved by the Institutional Review Board (IRB) at Zagazig University (ZUIRB #9424 dated 03/04/2022), and patients' informed consent for participation in the study was obtained during the period from May 2022 to May 2023. All study procedures were carried out in accordance with the ethical standards of the Helsinki Declaration of 2013.
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Affiliation(s)
- Mohamed Metwaly Fathy
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Rehab A Wahdan
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
| | - Amal Abdul Azeem Salah
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Abeer M Elnakera
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Srica N, Strunk CI. Evaluation and management of hypotensive patients in the emergency department. Emerg Med Pract 2023; 25:1-28. [PMID: 37976547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Hypotension can be a sign of significant underlying pathology, and if it is not rapidly identified and addressed, it can contribute to organ injury. Treatment of hypotension is best targeted at the underlying etiology, although this can be difficult to discern early in a patient's disease course. Expedited bedside evaluation with rapid initiation of treatment based on the most likely underlying etiology is paramount, followed by serial reassessment of the patient's condition. This review synthesizes the key aspects of the presentation and evaluation of a patient with hypotension, including salient historical features, physical examination findings, and diagnostic tests that can help guide treatment.
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Affiliation(s)
- Nickolas Srica
- Faculty Physician and Education Faculty, Department of Emergency Medicine, Yale School of Medicine; Yale New Haven Hospital, New Haven, CT
| | - Clark I Strunk
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
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20
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Jiang JG, Moore HB, Moore EE, Pieracci F, Sauaia A. Tissue plasminogen activator challenge thrombelastography is the most accurate assay in predicting the need for massive transfusion in hypotensive trauma patients. Am J Surg 2023; 226:778-783. [PMID: 37301646 DOI: 10.1016/j.amjsurg.2023.05.033] [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: 03/31/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Tissue plasminogen activator (tPA) added to thrombelastography (TEG) detects hyperfibrinolysis by measuring clot lysis at 30 min (tPA-challenge-TEG). We hypothesize that tPA-challenge-TEG is a better predictor of massive transfusion (MT) than existing strategies in trauma patients with hypotension. METHODS Trauma activation patients (TAP, 2014-2020) with 1) systolic blood pressure <90 mmHg (early) or 2) those who arrived normotensive but developed hypotension within 1H postinjury (delayed) were analyzed. MT was defined as >10 RBC U/6H postinjury or death within 6H after ≥1 RBC unit. Area under the receiver operating characteristics curves were used to compare predictive performance. Youden index determined optimal cutoffs. RESULTS tPA-challenge-TEG was the best predictor of MT in the early hypotension subgroup (N = 212) with positive (PPV) and negative predictive values (NPV) of 75.0%, and 77.6%, respectively. tPA-challenge-TEG was a better predictor of MT than all but TASH (PPV = 65.0%, NPV = 93.3%) in the delayed hypotension group (N = 125). CONCLUSIONS The tPA-challenge-TEG is the most accurate predictor of MT in trauma patients arriving hypotensive and offers early recognition of MT in patients with delayed hypotension.
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Affiliation(s)
- Jessie G Jiang
- University of Colorado School of Medicine, CU Anschutz Fitzsimons Building, 13001 East 17th Place, C290, Aurora, CO, 80045, USA
| | - Hunter B Moore
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA.
| | - Ernest E Moore
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Ernest E Moore Shock Trauma Center at Denver Health, Department of Surgery, 777 Bannock St, Denver, CO, 80204, USA
| | - Fredric Pieracci
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Ernest E Moore Shock Trauma Center at Denver Health, Department of Surgery, 777 Bannock St, Denver, CO, 80204, USA
| | - Angela Sauaia
- University of Colorado Denver School of Public Health, Department of Health Systems, Management and Policy, Fitzsimons Building, 3rd Floor, 13001 E. 17th Place, Mail Stop B119, Aurora, CO, 80045, USA
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Dai A, Zhou Z, Jiang F, Guo Y, Asante DO, Feng Y, Huang K, Chen C, Shi H, Si Y, Zou J. Incorporating intraoperative blood pressure time-series variables to assist in prediction of acute kidney injury after type a acute aortic dissection repair: an interpretable machine learning model. Ann Med 2023; 55:2266458. [PMID: 37813109 PMCID: PMC10563625 DOI: 10.1080/07853890.2023.2266458] [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: 06/19/2023] [Accepted: 09/24/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and serious complication after the repair of Type A acute aortic dissection (TA-AAD). However, previous models have failed to account for the impact of blood pressure fluctuations on predictive performance. This study aims to develop machine learning (ML) models combined with intraoperative medicine and blood pressure time-series data to improve the accuracy of early prediction for postoperative AKI risk. METHODS Indicators reflecting the duration and depth of hypotension were obtained by analyzing continuous mean arterial pressure (MAP) monitored intraoperatively with multiple thresholds (<65, 60, 55, 50) set in the study. The predictive features were selected by logistic regression and the least absolute shrinkage and selection operator (LASSO), and 4 ML models were built based on the above features. The performance of the models was evaluated by area under receiver operating characteristic curve (AUROC), calibration curve and decision curve analysis (DCA). Shapley additive interpretation (SHAP) was used to explain the prediction models. RESULTS Among the indicators reflecting intraoperative hypotension, 65 mmHg showed a statistically superior difference to other thresholds in patients with or without AKI (p < .001). Among 4 models, the extreme gradient boosting (XGBoost) model demonstrated the highest AUROC: 0.800 (95% 0.683-0.917) and sensitivity: 0.717 in the testing set and was verified the best-performing model. The SHAP summary plot indicated that intraoperative urine output, cumulative time of mean arterial pressure lower than 65 mmHg outside cardiopulmonary bypass (OUT_CPB_MAP_65 time), autologous blood transfusion, and smoking were the top 4 features that contributed to the prediction model. CONCLUSION With the introduction of intraoperative blood pressure time-series variables, we have developed an interpretable XGBoost model that successfully achieve high accuracy in predicting the risk of AKI after TA-AAD repair, which might aid in the perioperative management of high-risk patients, particularly for intraoperative hemodynamic regulation.
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Affiliation(s)
- Anran Dai
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhou Zhou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Fan Jiang
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yaoyi Guo
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Dorothy O. Asante
- Department of Preventive Medicine and Public Health Laboratory Science, School of Medicine, Jiangsu University, Zhenjiang, China
| | - Yue Feng
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Kaizong Huang
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chen Chen
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Hongwei Shi
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yanna Si
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jianjun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Aghi S, Ganesan R, Singh A. Toward a Better Understanding of a Model Identifying Blood Pressure Targets Associated With Low Risk of Intraoperative Hypotension. Anesth Analg 2023; 137:e37-e38. [PMID: 37712481 DOI: 10.1213/ane.0000000000006630] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Affiliation(s)
- Shweta Aghi
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India,
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Smith A, Turoczi Z. Con: Hypotension Prediction Index-A New Tool to Predict Hypotension in Cardiac Surgery? J Cardiothorac Vasc Anesth 2023; 37:2137-2140. [PMID: 37385883 DOI: 10.1053/j.jvca.2023.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/25/2023] [Accepted: 05/30/2023] [Indexed: 07/01/2023]
Affiliation(s)
- Alexander Smith
- Kings College Hospital National Health Services Foundation Trust, London, United Kingdom
| | - Zsolt Turoczi
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary.
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Wang L, Xiao L, Hu L, Chen X, Wang X. Development and validation of a nomogram for predicting intraoperative hypotension in cardiac valve replacement. Biomark Med 2023; 17:849-858. [PMID: 38214145 DOI: 10.2217/bmm-2023-0548] [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: 01/13/2024] Open
Abstract
Background: Cardiac valve replacement risks include intraoperative hypotension, endangering organ perfusion. Our nomogram predicted hypotension risk in valve surgery, guiding early intervention. Methods: Analyzing 561 patients from July to November 2022, we developed a nomogram to predict hypotension in valve replacement patients, validated using data from December 2022 to January 2023 on 241 patients, with robust statistical confirmation. Results: Our study identified age, hypertension, left ventricular ejection fraction and serum creatinine as hypotension predictors. The resulting nomogram, validated with high concordance index and area under the curve scores, provided a clinically useful tool for managing intraoperative risk. Conclusion: For valve replacement patients, factors like age, hypertension, low left ventricular ejection fraction and high serum creatinine predicted hypotension risk. Our nomogram enabled clinicians to quantify this risk and proactively manage it.
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Affiliation(s)
- Lei Wang
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Liqiong Xiao
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Lanyue Hu
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xin Chen
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaoliang Wang
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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25
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Müller-Wirtz LM, Ruetzler K, Rössler J. Intraoperative hypotension and delirium. J Clin Anesth 2023; 89:111153. [PMID: 37245475 DOI: 10.1016/j.jclinane.2023.111153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 05/17/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Lukas M Müller-Wirtz
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
| | - Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Parsons H, Zilahi G. Pro: Hypotension Prediction Index-A New Tool to Predict Hypotension in Cardiac Surgery? J Cardiothorac Vasc Anesth 2023; 37:2133-2136. [PMID: 37301700 DOI: 10.1053/j.jvca.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/02/2023] [Accepted: 05/12/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Harvey Parsons
- St. Bartholomew's Hospital, Department of Perioperative Medicine, London, United Kingdom
| | - Gabor Zilahi
- St. James's University Hospitals, Dublin, Ireland.
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27
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Gamal RM, Mostafa M, Hasanin AM, Khedr SA, Abdelgalil AS, Elshal MM. Evaluation of the accuracy of oscillometric non-invasive blood pressure measurement at the ankle in children during general anesthesia. J Clin Monit Comput 2023; 37:1239-1245. [PMID: 37166693 PMCID: PMC10520206 DOI: 10.1007/s10877-023-01025-1] [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: 10/03/2022] [Accepted: 04/24/2023] [Indexed: 05/12/2023]
Abstract
This study aimed to evaluate the accuracy of oscillometric blood pressure measurement at the ankle in children using invasive blood pressure as reference standard. This prospective observational study included children undergoing noncardiac surgery. Paired radial invasive and ankle non-invasive blood pressure measurements were obtained. Delta blood pressure was calculated as the difference between two consecutive readings. The primary outcome was the mean bias and agreement between the two methods using the Bland-Altman analysis. The ISO standard was fulfilled if the mean bias between the two methods was ≤ 5 ± 8 mmHg. Other outcomes included the trending ability of ankle blood pressure using the four-quadrant plot and the accuracy of ankle measurement to detect hypotension using area under receiver operating characteristic curve (AUC) analysis. We analyzed 683 paired readings from 86 children. The mean bias between the two methods for systolic, diastolic, and mean blood pressure (SBP, DBP, MAP) was - 7.2 ± 10.7, 4.5 ± 12.8, and - 1.8 ± 8.2 mmHg, respectively. The concordance rate of ankle blood pressure was 72%, 71%, and 77% for delta SBP, DBP and MAP, respectively. The AUC (95% confidence interval) for ankle MAP ability to detect hypotension was 0.91 (0.89-0.93) with negative predictive value of 100% at cut-off value ≤ 70 mmHg, We concluded that in pediatric population undergoing noncardiac surgery, ankle blood pressure was not interchangeable with the corresponding invasive readings with the ankle MAP having the least bias compared to SBP and DBP. An ankle MAP > 70 mmHg can exclude hypotension with negative predictive value of 100%.
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Affiliation(s)
- Reham M Gamal
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute, Cairo University, Cairo, Egypt
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, 01 Elsarayah street, Elmanyal, Cairo 11559 Egypt
| | - Ahmed M Hasanin
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Suzan Adlan Khedr
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ahmed Salah Abdelgalil
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mamdouh Mahmoud Elshal
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute, Cairo University, Cairo, Egypt
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Beringer R, Keith A, Jones E, Murphy T, White P. A prospective comparison of invasive and non-invasive blood pressure in children undergoing cardiac catheterization. Paediatr Anaesth 2023; 33:816-822. [PMID: 37391941 DOI: 10.1111/pan.14723] [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: 04/13/2023] [Revised: 06/08/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Blood pressure measurement is a standard of monitoring during general anesthesia. Invasive measurement is considered the gold standard but is less commonly used than non-invasive. Automated oscillometric blood pressure devices measure the mean arterial pressure (MAP) and use an algorithm to determine the systolic and diastolic pressures. Few devices have been validated in children, particularly during anesthesia. Few studies have assessed the agreement between invasive and non-invasive blood pressure measurements in children. METHODS This was a multi-center prospective observational study of children under 16 years undergoing cardiac catheterization with general anesthesia. Paired invasive and non-invasive blood pressure measurements were recorded for each patient during stable periods of the procedure. Correlation within and between sites was assessed with Pearson's correlation coefficient, and agreement was examined using Bland-Altman methodology to determine bias. Agreement during episodes of hypotension and for age and weight was also determined. Bias greater than 5 mmHg and standard deviation greater than 8 mmHg was considered clinically significant. The primary end point was agreement of MAP measurements. RESULTS A total of 683 paired blood pressure values were collected from 254 children in three pediatric hospitals. Median [IQR] age and weight were 3 [1-7] years and 13.9 [8-23] Kg. The overall bias (SD) for mean arterial pressure values was 7.2 (11.4) mmHg. During hypotension (190 readings), the bias (SD) was 15 (11.0) mmHg. The non-invasive MAP was frequently higher than invasive MAP during infancy, and lower in older children. CONCLUSION Automated oscillometric blood pressure measurement is unreliable in anesthetized children during cardiac catheterization. Invasive pressure measurement should be considered for high-risk cases.
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Affiliation(s)
| | | | - Elin Jones
- Birmingham Children's Hospital, Birmingham, UK
| | - Tim Murphy
- Bristol Royal Hospital for Children, Bristol, UK
| | - Paul White
- University of the West of England, Bristol, UK
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29
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Lee H, Moon SJ, Kim SW, Min JW, Park HS, Yoon HE, Kim YS, Kim HW, Yang CW, Chung S, Koh ES, Chung BH. Prediction of intradialytic hypotension using pre-dialysis features-a deep learning-based artificial intelligence model. Nephrol Dial Transplant 2023; 38:2310-2320. [PMID: 37019834 DOI: 10.1093/ndt/gfad064] [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: 01/11/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Intradialytic hypotension (IDH) is a serious complication of hemodialysis (HD) that is associated with increased risks of cardiovascular morbidity and mortality. However, its accurate prediction remains a clinical challenge. The aim of this study was to develop a deep learning-based artificial intelligence (AI) model to predict IDH using pre-dialysis features. METHODS Data from 2007 patients with 943 220 HD sessions at seven university hospitals were used. The performance of the deep learning model was compared with three machine learning models (logistic regression, random forest and XGBoost). RESULTS IDH occurred in 5.39% of all studied HD sessions. A lower pre-dialysis blood pressure (BP), and a higher ultrafiltration (UF) target rate and interdialytic weight gain in IDH sessions compared with non-IDH sessions, and the occurrence of IDH in previous sessions was more frequent among IDH sessions compared with non-IDH sessions. Matthews correlation coefficient and macro-averaged F1 score were used to evaluate both positive and negative prediction performances. Both values were similar in logistic regression, random forest, XGBoost and deep learning models, developed with data from a single session. When combining data from the previous three sessions, the prediction performance of the deep learning model improved and became superior to that of other models. The common top-ranked features for IDH prediction were mean systolic BP (SBP) during the previous session, UF target rate, pre-dialysis SBP, and IDH experience during the previous session. CONCLUSIONS Our AI model predicts IDH accurately, suggesting it as a reliable tool for HD treatment.
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Affiliation(s)
- Hanbi Lee
- Transplantation Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | | | | | - Ji Won Min
- Department of Internal Medicine, Bucheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea
| | - Hoon Suk Park
- Department of Internal Medicine, Eunpyeong St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye Eun Yoon
- Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea
| | - Young Soo Kim
- Department of Internal Medicine, Uijeongbu St Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Republic of Korea
| | - Hyung Wook Kim
- Department of Internal Medicine, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Chul Woo Yang
- Transplantation Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungjin Chung
- Division of Nephrology, Department of Internal Medicine, Yeouido St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Sil Koh
- Division of Nephrology, Department of Internal Medicine, Yeouido St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung Ha Chung
- Transplantation Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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30
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Kouz K, Weidemann F, Naebian A, Lohr A, Bergholz A, Thomsen KK, Krause L, Petzoldt M, Moll-Khosrawi P, Sessler DI, Flick M, Saugel B. Continuous Finger-cuff versus Intermittent Oscillometric Arterial Pressure Monitoring and Hypotension during Induction of Anesthesia and Noncardiac Surgery: The DETECT Randomized Trial. Anesthesiology 2023; 139:298-308. [PMID: 37265355 DOI: 10.1097/aln.0000000000004629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Finger-cuff methods allow noninvasive continuous arterial pressure monitoring. This study aimed to determine whether continuous finger-cuff arterial pressure monitoring helps clinicians reduce hypotension within 15 min after starting induction of anesthesia and during noncardiac surgery. Specifically, this study tested the hypotheses that continuous finger-cuff-compared to intermittent oscillometric-arterial pressure monitoring helps clinicians reduce the area under a mean arterial pressure of 65 mmHg within 15 min after starting induction of anesthesia and the time-weighted average mean arterial pressure less than 65 mmHg during noncardiac surgery. METHODS In this single-center trial, 242 noncardiac surgery patients were randomized to unblinded continuous finger-cuff arterial pressure monitoring or to intermittent oscillometric arterial pressure monitoring (with blinded continuous finger-cuff arterial pressure monitoring). The first of two hierarchical primary endpoints was the area under a mean arterial pressure of 65 mmHg within 15 min after starting induction of anesthesia; the second primary endpoint was the time-weighted average mean arterial pressure less than 65 mmHg during surgery. RESULTS Within 15 min after starting induction of anesthesia, the median (interquartile range) area under a mean arterial pressure of 65 mmHg was 7 (0, 24) mmHg × min in 109 patients assigned to continuous finger-cuff monitoring versus 19 (0.3, 60) mmHg × min in 113 patients assigned to intermittent oscillometric monitoring (P = 0.004; estimated location shift: -6 [95% CI: -15 to -0.3] mmHg × min). During surgery, the median (interquartile range) time-weighted average mean arterial pressure less than 65 mmHg was 0.04 (0, 0.27) mmHg in 112 patients assigned to continuous finger-cuff monitoring and 0.40 (0.03, 1.74) mmHg in 115 patients assigned to intermittent oscillometric monitoring (P < 0.001; estimated location shift: -0.17 [95% CI: -0.41 to -0.05] mmHg). CONCLUSIONS Continuous finger-cuff arterial pressure monitoring helps clinicians reduce hypotension within 15 min after starting induction of anesthesia and during noncardiac surgery compared to intermittent oscillometric arterial pressure monitoring. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Weidemann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ashkan Naebian
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anneke Lohr
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Parisa Moll-Khosrawi
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; and Outcomes Research Consortium, Cleveland, Ohio
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and Outcomes Research Consortium, Cleveland, Ohio
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Melendo-Viu M, Dobarro D, Marchán López Á, Domínguez LM, Raposeiras-Roubín S, Abu-Assi E, Cardero-González C, Pérez-Expósito L, Cespón Fernández M, Parada Barcia JA, Barreiro Pérez M, García E, Íñiguez Romo A. Hypotension at heart failure discharge: Should it be a limiting factor for drug titration? Int J Cardiol 2023; 386:59-64. [PMID: 37169152 DOI: 10.1016/j.ijcard.2023.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/29/2023] [Accepted: 05/05/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Medical treatment in Heart Failure (HF) with reduced ejection fraction (HFrEF; LVEF ≤40%) has shifted towards quadruple therapy. Maximum tolerated dose is the goal, yet no hypotension's cut-off point has been specified. In this work, we analyze the impact of intensive drug titration in clinical events, focusing on low blood pressure (BP) patients at hospital discharge. METHODS AND RESULTS Retrospective analysis of 713 patients with HFrEF discharged after an acute HF event (mean LVEF 30 ± 5%). Mean SBP was 112.4 ± 16.5 mmHg and 50.6% were discharged on triple therapy. We considered hypotension as a Systolic blood pressure (SBP) <100 mmHg (21.7% of patients, mean SBP was 112.4 ± 16.5 mmHg) and codified the intensity of drug therapy in 5 stages from untreated to very high therapy intensity. The impact of the intensity of treatment was analysed with a propensity score and increasing the intensity was associated in the whole cohort with a reduction of the composite outcome of all-cause mortality and HF readmission, (HR 0.69; CI95% 0.57-0.85, p < 0.001) and benefit in mortality was maintained for SBP < 100 mmHg (HR 0.42; CI95% 0.22-0.82; p = 0.011). Moreover, therapy intensity was clearly associated with lower risk of HF-hospitalization and death after the additional regression, considering SBP as a covariate, in the whole cohort (HR 0.70; CI95% 0.57-0.85; p < 0.001). CONCLUSIONS In this retrospective cohort analysis, patients with HFrEF and an acute-HF admission, intensive drug dose titration was related to better outcomes, even in patients with low blood pressure at hospital discharge. Therefore, hypotension is not a contraindication for NHB uptitration.
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Affiliation(s)
- Maria Melendo-Viu
- Cardiology Department, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain; Faculty of Medicine, University Complutense of Madrid, Spain.
| | - David Dobarro
- Cardiology Department, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain
| | | | | | - Sergio Raposeiras-Roubín
- Cardiology Department, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain
| | - Emad Abu-Assi
- Cardiology Department, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain
| | | | | | | | | | | | - Enrique García
- Cardiology Department, University Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Andrés Íñiguez Romo
- Cardiology Department, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain
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Ability of an Arterial Waveform Analysis-Derived Hypotension Prediction Index to Predict Future Hypotensive Events in Surgical Patients: Erratum. Anesth Analg 2023; 137:e33. [PMID: 37590816 DOI: 10.1213/ANE.0000000000006674] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
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Gervasoni F, Bellocchio F, Rosenberger J, Arkossy O, Ion Titapiccolo J, Kovarova V, Larkin J, Nikam M, Stuard S, Tripepi GL, Usvyat LA, Winter A, Neri L, Zoccali C. Development and validation of AI-based triage support algorithms for prevention of intradialytic hypotension. J Nephrol 2023; 36:2001-2011. [PMID: 37707692 DOI: 10.1007/s40620-023-01741-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/19/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Intradialytic hypotension remains one of the most recurrent complications of dialysis sessions. Inadequate management can lead to adverse outcomes, highlighting the need to develop personalized approaches for the prevention of intradialytic hypotension. Here, we sought to develop and validate two AI-based risk models predicting the occurrence of symptomatic intradialytic hypotension at different time points. METHODS The models were built using the XGBoost algorithm and they predict the occurrence of intradialytic hypotension in the next dialysis session and in the next month. The initial dataset, obtained from routinely collected data in the EuCliD® Database, was split to perform model derivation, training and validation. Model performance was evaluated by concordance statistic and calibration charts; the importance of features was assessed with the Shapley Additive Explanation (SHAP) methodology. RESULTS The final dataset included 1,249,813 dialysis sessions, and the incidence rate of intradialytic hypotension was 10.07% (95% CI 10.02-10.13). Our models retained good discrimination (AUC around 0.8) and a suitable calibration yielding to the selection of three classification thresholds identifying four distinct risk groups. Variables providing the most significant impact on risk estimates were blood pressure dynamics and other metrics mirroring hemodynamic instability over time. CONCLUSIONS Recurrent symptomatic intradialytic hypotension could be reliably and accurately predicted using routinely collected data during dialysis treatment and standard clinical care. Clinical application of these prediction models would allow for personalized risk-based interventions for preventing and managing intradialytic hypotension.
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Affiliation(s)
| | | | - Jaroslav Rosenberger
- FMC-Dialysis Services Slovakia, Kosice, Slovakia
- Medical Faculty, University of PJ Safarik, Kosice, Slovakia
| | - Otto Arkossy
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | | | | | - Milind Nikam
- Fresenius Medical Care, Singapore, 307684, Singapore
| | - Stefano Stuard
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | | | - Anke Winter
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Luca Neri
- Fresenius Medical Care Italia SpA, Palazzo Pignano, Italy.
| | - Carmine Zoccali
- Renal Research Institute, New York, USA
- Associazione Ipertensione Nefrologia e Trapianto Renale (IPNET) c/o Nefrologia e CNR, Grande Ospedale Metropolitano, Reggio Calabria, Italy
- Biologia E Genetica Molecolare (BIOGEM) Research Center, Ariano Irpino, Avellino, Italy
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Vaid A, Takkavatakarn K, Divers J, Charytan DM, Chan L, Nadkarni GN. Deep Learning on Electrocardiograms for Prediction of In-hospital Intradialytic Hypotension in Patients with ESKD. Kidney360 2023; 4:e1293-e1296. [PMID: 37418626 PMCID: PMC10547223 DOI: 10.34067/kid.0000000000000208] [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] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/29/2023] [Indexed: 07/09/2023]
Abstract
Intradialytic hypotension is common in patients who are on hemodialysis. We applied deep learning techniques to ECGs to predict patients at risk of IDH. The performance of the model was good with an AUC of 0.763 and AUPRC of 0.35.
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Affiliation(s)
- Akhil Vaid
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jasmin Divers
- Division of Health Services, Department of Medicine, NYU (New York University) Long Island School of Medicine, Mineola, New York
| | - David M. Charytan
- Division of Nephrology, Department of Medicine, NYU (New York University) Grossman School of Medicine and NYU Langone Medical Center, New York, New York
| | - Lili Chan
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Girish N. Nadkarni
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Michard F, Futier E. Predicting intraoperative hypotension: from hope to hype and back to reality. Br J Anaesth 2023; 131:199-201. [PMID: 36997473 DOI: 10.1016/j.bja.2023.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/30/2023] Open
Abstract
The analysis of arterial pressure waveforms with machine learning algorithms has been proposed to predict intraoperative hypotension. The ability to forecast arterial hypotension 5-15 min ahead of the fall in blood pressure allows clinicians to be pro-active instead of reactive, and could potentially decrease postoperative morbidity. However, the predictive value of machine learning algorithms has been overestimated due to selection bias in several clinical studies, and they might not be superior to mere observation of arterial pressure. Continuous blood pressure monitoring enables immediate detection of hypotension, and giving fluid, vasopressors or inotropes to patients who are not yet (and might never become) hypotensive based on an algorithm is questionable. Finally, recent prospective interventional studies suggest that reducing intraoperative hypotension does not improve postoperative outcomes.
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Affiliation(s)
| | - Emmanuel Futier
- Department of Anesthesia and Critical Care, Université Clermont Auvergne, Hopital d'Estaing, Clermont-Ferrand, France
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36
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Conroy TB, Araos J, Kan EC. Systolic Time Interval Extraction in Hypertensive and Hypotensive Pig Models Using Wearable Near-Field Radio-Frequency Sensors. Annu Int Conf IEEE Eng Med Biol Soc 2023; 2023:1-6. [PMID: 38082805 DOI: 10.1109/embc40787.2023.10340193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Screening and monitoring for cardiovascular diseases (CVDs) can be enabled by analyzing systolic time intervals (STIs). As CVDs have a strong causal correlation with hypertension, it is important to validate STI sensor accuracy in hypertensive hearts to ensure consistent performance in this prevalent cardiac disease state. This work presents STI extraction using a non-invasive near-field radio-frequency (RF) sensor during normotension, hypertension, and hypotension in a pig model. Waveform features of semilunar and atrioventricular valve dynamics during systole were extracted to derive isovolumic contraction time (ICT) and left ventricular ejection time (LVET), benchmarked by a phonocardiogram and aortic catheterization. Study-wide mean relative ICT and LVET errors were -4.4ms and -3.6ms, respectively, demonstrating high accuracy during both normal and abnormal systemic pressures.Clinical relevance- This work demonstrates accurate STI extraction with relative error less than 5 ms from a non-invasive near-field RF sensor during normotensive, hypotensive, and hypertensive systemic pressures, validating the sensor's accuracy as a screening tool during this disease state.
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Kondo Y, Mihara T, Nakamura E, Noma H, Shimizu S, Goto T. Predictive ability of pulse oximetry-derived indices for hypotension after spinal anaesthesia for caesarean section: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e069309. [PMID: 37355260 PMCID: PMC10314498 DOI: 10.1136/bmjopen-2022-069309] [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: 10/18/2022] [Accepted: 06/09/2023] [Indexed: 06/26/2023] Open
Abstract
INTRODUCTION In general, caesarean sections are performed under spinal anaesthesia. Hypotension after spinal anaesthesia adversely affects both the mother and fetus. Although several studies have used pulse oximetry-derived indices, such as pulse perfusion index (PI) and Pleth variability index (PVI), to predict hypotension after spinal anaesthesia, the predictive ability of the PI and PVI remain controversial. METHODS AND ANALYSIS We prepared this protocol following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We will conduct searches of MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Clinicaltrial.gov, European Union Clinical Trials Register (EU-CTR), WHO International Clinical Trials Registry Platform (ICTRP) and University Hospital Medical Information Network Clinical Trials Registry (UMIN) from inception until 8 October 2022. We will include retrospective and prospective observational studies and randomised controlled trials that evaluated the predictive ability of PI and PVI for hypotension after spinal anaesthesia for caesarean section, published in any language. We will exclude case reports, case series and animal studies. Two authors will independently scan and select eligible studies and perform data extraction and assessment of risk of bias. We will estimate predictive ability of PI and PVI as indices of hypotension after spinal anaesthesia for caesarean section using the Reitsma-type bivariate random-effects synthesis model and the hierarchical summary receiver operating characteristic curve. We will assess the quality of evidence using the Grading of Recommendation Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION Ethics approval is not required as the systematic review will use existing published data. The results will be submitted for publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42022362596.
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Affiliation(s)
- Yuriko Kondo
- Department of Health Data Science, Yokohama City University, Yokohama, Japan
| | - Takahiro Mihara
- Department of Health Data Science, Yokohama City University, Yokohama, Japan
| | - Eishin Nakamura
- Department of Health Data Science, Yokohama City University, Yokohama, Japan
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tchikawa, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Yokohama City University, Yokohama, Japan
| | - Takahisa Goto
- Anaesthesiology and Critical Care Medicine, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Japan
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Turan A, Rivas E, Devereaux PJ, Pu X, Rodriguez-Patarroyo FA, Yalcin EK, Nault R, Maheshwari K, Ruetzler K, Sessler DI. Relative contributions of anaemia and hypotension to myocardial infarction and renal injury: Post hoc analysis of the POISE-2 trial. Eur J Anaesthesiol 2023; 40:365-371. [PMID: 36891761 DOI: 10.1097/eja.0000000000001816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
BACKGROUND Hypotension and postoperative anaemia are associated with myocardial and renal injury after noncardiac surgery, but the interaction between them remains unknown. OBJECTIVES To test the hypothesis that a double-hit of postoperative anaemia and hypotension synergistically worsens a 30-day composite of myocardial infarction (MI) and mortality and acute kidney injury (AKI). Characterising the interaction when hypotension and anaemia occur at same time on myocardial infarction and acute kidney injury. DESIGN Post hoc analysis of the POISE-2 trial. SETTING Patients were enrolled between July 2010 and December 2013 at 135 hospitals in 23 countries. PATIENTS Adults at least 45 years old with known or suspected cardiovascular disease. We excluded patients without available postoperative haemoglobin measurements or hypotension duration records. Exposures were the lowest haemoglobin concentration and the average daily duration of SBP less than 90 mmHg within the first four postoperative days. MAIN OUTCOME MEASURES The primary outcome was a collapsed composite of nonfatal MI and all-cause mortality during the initial 30 postoperative days; our secondary outcome was AKI. RESULTS We included 7940 patients. The mean ± SD lowest postoperative haemoglobin was 10 ± 2 g dl -1 , and 24% of the patients had SBP less than 90 mmHg with daily duration ranging from 0 to 15 h. Four hundred and nine (5.2%) patients had an infarction or died within 30 postoperative days, and 417 (6.4%) patients developed AKI. Lowest haemoglobin concentrations less than 11 g dl -1 , and duration of SBP less than 90 mmHg was associated with greater hazard of composite outcome of nonfatal MI and all-cause mortality, as well as with AKI. However, we did not find significant multiplicative interactions between haemoglobin splines and hypotension duration on the primary composite or on AKI. CONCLUSION Postoperative anaemia and hypotension were meaningfully associated with both our primary composite and AKI. However, lack of significant interaction suggests that the effects of hypotension and anaemia are additive rather than multiplicative. TRIAL REGISTRATION Clinicaltrials.gov: NCT01082874.
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Affiliation(s)
- Alparslan Turan
- From the Department of Outcomes Research (AT, ER, XP, FAR-P, EKY, KM, KR, DIS), Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA (AT, KM, KR), Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Spain (ER), Population Health Research Institute, Hamilton Health Sciences and McMaster University, and the Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, Hamilton, Ontario, Canada (PJD), Department of Quantitative Health Sciences (XP) and Learner Medical School, Cleveland Clinic, Cleveland, Ohio, USA (RN)
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Sveen WN, Antommaria AHM, Gilene SJ, Stalets EL. Adverse Events During Apnea Testing for the Determination of Death by Neurologic Criteria: A Single-Center, Retrospective Pediatric Cohort. Pediatr Crit Care Med 2023; 24:399-405. [PMID: 36815829 DOI: 10.1097/pcc.0000000000003198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVES To report the prevalence of adverse events in children undergoing apnea testing as part of the determination of death by neurologic criteria (DNC). DESIGN Single-center, retrospective study. SETTING Academic children's hospital that is a Level I Trauma Center. PATIENTS All children who underwent apnea testing to determine DNC from July 2013 to June 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We abstracted the medical history, blood gases, ventilator settings, blood pressures, vasoactive infusions, intracranial pressures, chest radiographs, and echocardiograms for all apnea tests as well as any ancillary test. Adverse events were defined as hypotension, hypoxia, pneumothorax, arrhythmia, intracranial hypertension, and cardiac arrest. Fifty-eight patients had 105 apnea tests. Adverse events occurred in 21 of 105 apnea tests (20%), the most common being hypotension (15/105 [14%]) and hypoxia (4/105 [4%]). Five of 21 apnea tests (24%) with adverse events were terminated prematurely (three for hypoxia, one for hypotension, and one for both hypoxia and hypotension) but the patients did not require persistent escalation in care. In the other 16 of 21 apnea tests (76%) with adverse events, clinical changes were transient and managed by titrating vasoactive infusions or completing the apnea test. CONCLUSIONS In our center, 20% of all apnea tests were associated with adverse events. Only 5% of all apnea tests required premature termination and the remaining 15% were completed and the adverse events resolved with medical care.
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Affiliation(s)
- William N Sveen
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Armand H Matheny Antommaria
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Stephen J Gilene
- Division of Hematology and Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Erika L Stalets
- Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
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Feld SI, Hippe DS, Miljacic L, Polissar NL, Newman SF, Nair BG, Vavilala MS. A Machine Learning Approach for Predicting Real-time Risk of Intraoperative Hypotension in Traumatic Brain Injury. J Neurosurg Anesthesiol 2023; 35:215-223. [PMID: 34759236 PMCID: PMC9091057 DOI: 10.1097/ana.0000000000000819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 10/08/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of death and disability. Episodes of hypotension are associated with worse TBI outcomes. Our aim was to model the real-time risk of intraoperative hypotension in TBI patients, compare machine learning and traditional modeling techniques, and identify key contributory features from the patient monitor and medical record for the prediction of intraoperative hypotension. METHODS The data included neurosurgical procedures in 1005 TBI patients at an academic level 1 trauma center. The clinical event was intraoperative hypotension, defined as mean arterial pressure <65 mm Hg for 5 or more consecutive minutes. Two types of models were developed: one based on preoperative patient-level predictors and one based on intraoperative predictors measured per minute. For each of these models, we took 2 approaches to predict the occurrence of a hypotensive event: a logistic regression model and a gradient boosting tree model. RESULTS The area under the receiver operating characteristic curve for the intraoperative logistic regression model was 0.80 (95% confidence interval [CI]: 0.78-0.83), and for the gradient boosting model was 0.83 (95% CI: 0.81-0.85). The area under the precision-recall curve for the intraoperative logistic regression model was 0.16 (95% CI: 0.12-0.20), and for the gradient boosting model was 0.19 (95% CI: 0.14-0.24). Model performance based on preoperative predictors was poor. Features derived from the recent trend of mean arterial pressure emerged as dominantly predictive in both intraoperative models. CONCLUSIONS This study developed a model for real-time prediction of intraoperative hypotension in TBI patients, which can use computationally efficient machine learning techniques and a streamlined feature-set derived from patient monitor data.
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Affiliation(s)
- Shara I Feld
- Anesthesiology and Pain Medicine, University of Washington
| | - Daniel S Hippe
- The Mountain-Whisper-Light: Statistics & Data Science, Seattle, WA
| | | | - Nayak L Polissar
- The Mountain-Whisper-Light: Statistics & Data Science, Seattle, WA
| | | | - Bala G Nair
- Anesthesiology and Pain Medicine, University of Washington
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Khan MN, Soomro NA, Naseeb K, Bhatti UH, Rauf R, Balouch IJ, Moazzam A, Bashir S, Ashraf T, Karim M. Safety and tolerability of Sacubitril/Valsartan in heart failure patient with reduced ejection fraction. BMC Cardiovasc Disord 2023; 23:133. [PMID: 36915075 PMCID: PMC10012729 DOI: 10.1186/s12872-023-03070-9] [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: 05/26/2022] [Accepted: 01/13/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Angiotensin receptor blocker and a neprilysin inhibitor (ARNI) has emerged as an innovative therapy for patients of heart failure with reduced ejection fraction (HFrEF). The purpose of this study was to assess the safety and tolerability of Sacubitril/Valsartan in patient with HFrEF in Pakistani population. METHODS This proof-of-concept, open label non-randomized clinical trial was conducted at a tertiary care cardiac center of Karachi, Pakistan. Patients with HFrEF were prescribed with Sacubitril/Valsartan and followed for 12 weeks for the assessment of safety and tolerability. Safety measures included incidence of hypotension, renal dysfunction, hyperkalemia, and angioedema. RESULTS Among the 120 HFrEF patients, majority were male (79.2%) with means age of 52.73 ± 12.23 years. At the end of 12 weeks, four (3.3%) patients died and eight (6.7%) dropped out of the study. In the remaining 108 patients, 80.6% (87) of the patients were tolerant to the prescribed dose. Functional class improved gradually with 75.0% (81) in class I and 24.1% (26) in class II, and only one (0.9%) patient in class III at the end of 12 weeks. Hyperkalemia remains the main safety concern with incidence rate of 21.3% (23) followed by hypotension in 19.4% (21), and renal dysfunction in 3.7% (4) of the patients. CONCLUSIONS Sacubitril/Valsartan therapy in HFrEF patients is safe and moderately tolerated among the Pakistani population. It can be used as first line of treatment for these patients. TRIAL REGISTRATION NCT05387967. Registered 24 May 2022-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05387967.
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Affiliation(s)
| | | | - Khalid Naseeb
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Usman Hanif Bhatti
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Rubina Rauf
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Iram Jehan Balouch
- National Institute of Cardiovascular Diseases (NICVD), Hyderabad, Pakistan
| | - Ali Moazzam
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Sonia Bashir
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Tariq Ashraf
- Karachi Institute of Heart Diseases (KIHD), Karachi, Pakistan
| | - Musa Karim
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
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Batista JE, Diaz C, Aviles N, Moreno M, Akhter M. Elderly Woman With Fever and Hypotension. Ann Emerg Med 2023; 81:143-161. [PMID: 36681422 DOI: 10.1016/j.annemergmed.2022.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 01/21/2023]
Affiliation(s)
- José E Batista
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL
| | - Conley Diaz
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL
| | - Nicolle Aviles
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL
| | - Moises Moreno
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL
| | - Murtaza Akhter
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL; Department of Emergency Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ; Department of Emergency Medicine, Penn State Hershey Medical Center, Hershey, PA
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Schnetz MP, Danks DJ, Mahajan A. Preoperative Identification of Patient-Dependent Blood Pressure Targets Associated With Low Risk of Intraoperative Hypotension During Noncardiac Surgery. Anesth Analg 2023; 136:194-203. [PMID: 36399417 PMCID: PMC9812417 DOI: 10.1213/ane.0000000000006238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intraoperative hypotension (IOH) is strongly linked to organ system injuries and postoperative death. Blood pressure itself is a powerful predictor of IOH; however, it is unclear which pressures carry the lowest risk and may be leveraged to prevent subsequent hypotension. Our objective was to develop a model that predicts, before surgery and according to a patient's unique characteristics, which intraoperative mean arterial pressures (MAPs) between 65 and 100 mm Hg have a low risk of IOH, defined as an MAP <65 mm Hg, and may serve as testable hemodynamic targets to prevent IOH. METHODS Adult, noncardiac surgeries under general anesthesia at 2 tertiary care hospitals of the University of Pittsburgh Medical Center were divided into training and validation cohorts, then assigned into smaller subgroups according to preoperative risk factors. Primary outcome was hypotension risk, defined for each intraoperative MAP value from 65 to 100 mm Hg as the proportion of a value's total measurements followed by at least 1 MAP <65 mm Hg within 5 or 10 minutes, and calculated for all values in each subgroup. Five models depicting MAP-associated IOH risk were compared according to best fit across subgroups with proportions whose confidence interval was <0.05. For the best fitting model, (1) performance was validated, (2) low-risk MAP targets were identified according to applied benchmarks, and (3) preoperative risk factors were evaluated as predictors of model parameters. RESULTS A total of 166,091 surgeries were included, with 121,032 and 45,059 surgeries containing 5.4 million and 1.9 million MAP measurements included in the training and validation sets, respectively. Thirty-six subgroups with at least 21 eligible proportions (confidence interval <0.05) were identified, representing 92% and 94% of available MAP measurements, respectively. The exponential with theta constant model demonstrated the best fit (weighted sum of squared error 0.0005), and the mean squared error of hypotension risk per MAP did not exceed 0.01% in validation testing. MAP targets ranged between 69 and 90 mm Hg depending on the subgroup and benchmark used. Increased age, higher American Society of Anesthesiologists physical status, and female sexindependently predicted ( P < .05) hypotension risk curves with less rapid decay and higher plateaus. CONCLUSIONS We demonstrate that IOH risk specific to a given MAP is patient-dependent, but predictable before surgery. Our model can identify intraoperative MAP targets before surgery predicted to reduce a patient's exposure to IOH, potentially allowing clinicians to develop more personalized approaches for managing hemodynamics.
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Affiliation(s)
- Michael P. Schnetz
- From the Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David J. Danks
- Departments of Philosophy and Psychology, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Aman Mahajan
- From the Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania
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Hsieh WH, Ku CCY, Hwang HPC, Tsai MJ, Chen ZZ. Model for Predicting Complications of Hemodialysis Patients Using Data From the Internet of Medical Things and Electronic Medical Records. IEEE J Transl Eng Health Med 2023; 11:375-383. [PMID: 37435541 PMCID: PMC10332468 DOI: 10.1109/jtehm.2023.3234207] [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] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 10/24/2022] [Accepted: 12/28/2022] [Indexed: 09/30/2023]
Abstract
Intelligent models for predicting hemodialysis-related complications, i.e., hypotension and the deterioration of the quality or obstruction of the AV fistula, based on machine learning (ML) methods were established to offer early warnings to medical staff and give them enough time to provide pre-emptive treatment. A novel integration platform collected data from the Internet of Medical Things (IoMT) at a dialysis center and inspection results from electronic medical records (EMR) to train ML algorithms and build models. The selection of the feature parameters was implemented using Pearson's correlation method. Then, the eXtreme Gradient Boost (XGBoost) algorithm was chosen to create the predictive models and optimize the feature choice. 75% of collected data are used as a training dataset and the other 25% are used as a testing dataset. We adopted the prediction precision and recall rate of hypotension and AV fistula obstruction to measure the effectiveness of the predictive models. These rates were sufficiently high at approximately 71%-90%. In the context of hemodialysis, hypotension and the deterioration of the quality or obstruction of the arteriovenous (AV) fistula affect treatment quality and patient safety and may lead to a poor prognosis. Our prediction models with high accuracies can provide excellent references and signals for clinical healthcare service providers. Clinical and Translational Impact Statement-With the integrated dataset collected from IoMT and EMR, the superior predictive results of our models for complications of hemodialysis patients are demonstrated. We believe, after enough clinical tests are implemented as planned, these models can assist the healthcare team in making appropriate preparations in advance or adjusting the medical procedures to avoid these adverseevents.
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Affiliation(s)
- Wen-Huai Hsieh
- Department of SurgeryChang-Hua HospitalMinistry of Health and WelfareChanghua513007Taiwan
| | - Cooper Cheng-Yuan Ku
- Institute of Information Management, National Yang Ming Chiao Tung UniversityHsinchu300093Taiwan
| | - Humble Po-Ching Hwang
- Institute of Information Management, National Yang Ming Chiao Tung UniversityHsinchu300093Taiwan
| | - Min-Juei Tsai
- Department of NephrologyChang-Hua HospitalMinistry of Health and WelfareChanghua513007Taiwan
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Clark CE. Hypertension and hypotension: getting the balance right. Br J Gen Pract 2023; 73:6-7. [PMID: 36543552 PMCID: PMC9799343 DOI: 10.3399/bjgp23x731493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Christopher E Clark
- Primary Care Research Group, Faculty of Health and Life Sciences, University of Exeter Medical School, Exeter
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Lau C, Ho C. A 67-Year-Old Woman With Fluctuating Hypertension and Hypotension After Elective Surgery. Chest 2023; 163:e19-e22. [PMID: 36628680 DOI: 10.1016/j.chest.2022.08.2215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/17/2022] [Accepted: 08/16/2022] [Indexed: 01/11/2023] Open
Abstract
CASE PRESENTATION A 67-year-old woman with hypertension, type 2 diabetes mellitus, and hypothyroidism presented for an elective blepharoplasty. She underwent monitored anesthesia care with propofol and dexmedetomidine. No inhaled gases or neuromuscular blockade were administered during the procedure.
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Affiliation(s)
- Christopher Lau
- Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Cynthia Ho
- Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
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Simonin M, Delsuc C, Meuret P, Caruso L, Deleat-Besson R, Lamblin A, Huriaux L, Abraham P, Bidon C, Giai J, Riche B, Rimmelé T. Hypobaric Unilateral Spinal Anesthesia Versus General Anesthesia for Hip Fracture Surgery in the Elderly: A Randomized Controlled Trial. Anesth Analg 2022; 135:1262-1270. [PMID: 36135347 DOI: 10.1213/ane.0000000000006208] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Hypotension during surgery is frequent in the elderly population and is associated with acute kidney and myocardial injury, which are, themselves, associated with increased 30-day mortality. The present study compared the hemodynamic effects of hypobaric unilateral spinal anesthesia (HUSA) to general anesthesia (GA) in patients ≥70 years of age undergoing hip fracture surgery. METHODS We conducted a single-center, prospective, randomized study. In the HUSA group, patients were positioned with the operated hip above, and the hypobaric anesthetic solution was composed of 9 mg ropivacaine, 5 µg sufentanil, and 1 mL of sterile water. Anesthesia was adjusted for the GA group. Mean arterial pressure (MAP) was measured with a noninvasive blood pressure upper arm cuff every 3 minutes. Hypotension was treated with a bolus of ephedrine and then a continuous intravenous of norepinephrine to obtain a MAP ≥65 mm Hg. Primary outcome was the occurrence of severe hypotension, defined as a MAP <65 mm Hg for >12 consecutive minutes. RESULTS A total of 154 patients were included. Severe hypotension was more frequent in the GA group compared to the HUSA group (odds ratio, 5.6; 95% confidence interval, 2.7-11.7; P < .001). There was no significant difference regarding the short-term outcomes between the HUSA and GA groups: acute kidney injury (respectively, 5.1% vs 11.3%; P = .22), myocardial injury (18.0% vs 14.0%; P = .63), and 30-day mortality (2.4% vs 4.7%; P = .65). CONCLUSIONS HUSA leads to fewer episodes of severe intraoperative hypotension compared to GA in an elderly population undergoing hip fracture surgery.
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Affiliation(s)
- Marine Simonin
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Claire Delsuc
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Pascal Meuret
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Liana Caruso
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Robert Deleat-Besson
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Antoine Lamblin
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Laetitia Huriaux
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Paul Abraham
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Cyril Bidon
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Joris Giai
- Université de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Villeurbanne, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France
- Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France
| | - Benjamin Riche
- Université de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Villeurbanne, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France
- Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France
| | - Thomas Rimmelé
- From the Département d'Anesthésie-Réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
- Hospices Civils de Lyon-Biomérieux-Université Claude Bernard Lyon 1, Hôpital Édouard Herriot, Lyon, France
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Foster M, Self M, Gelber A, Kennis B, Lasoff DR, Hayden SR, Wardi G. Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation. Am J Emerg Med 2022; 61:131-136. [PMID: 36096015 PMCID: PMC10106101 DOI: 10.1016/j.ajem.2022.08.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/13/2022] [Accepted: 08/27/2022] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Emergency department (ED) patients undergoing emergent tracheal intubation often have multiple physiologic derangements putting them at risk for post-intubation hypotension. Prior work has shown that post-intubation hypotension is independently associated with increased morbidity and mortality. The choice of induction agent may be associated with post-intubation hypotension. Etomidate and ketamine are two of the most commonly used agents in the ED, however, there is controversy regarding whether either agent is superior in the setting of hemodynamic instability. The goal of this study is to determine whether there is a difference in the rate of post-intubation hypotension who received either ketamine or etomidate for induction. Additionally, we provide a subgroup analysis of patients at pre-existing risk of cardiovascular collapse (identified by pre-intubation shock index (SI) > 0.9) to determine if differences in rates of post-intubation hypotension exist as a function of sedative choice administered during tracheal intubation in these high-risk patients. We hypothesize that there is no difference in the incidence of post-intubation hypotension in patients who receive ketamine versus etomidate. METHODS A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016-6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension. RESULTS A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: -0.14 (95%, CI -0.2 to -0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: -10%, 95% CI -20.9% to -0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension. CONCLUSION In our cohort of patients undergoing emergent tracheal intubation, ketamine was used more often for patients with an elevated shock index. We did not identify an association between the incidence of post-intubation hypotension and induction agent between ketamine and etomidate. Patients with an elevated shock index were at higher risk of cardiovascular collapse regardless of the choice of ketamine or etomidate.
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Affiliation(s)
- Mitchell Foster
- University of California San Diego School of Medicine, California, United States; Department of Emergency Medicine, NYU Langone Health and NYC Health + Hospitals/Bellevue, New York, United States.
| | - Michael Self
- Department of Emergency Medicine, UC San Diego Health, California, United States; Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, UC San Diego Health, California, United States.
| | - Alon Gelber
- University of California San Diego School of Medicine, California, United States; Department of Bioengineering, University of California at San Diego, California, United States.
| | - Brent Kennis
- University of California San Diego School of Medicine, California, United States.
| | - Daniel R Lasoff
- Department of Emergency Medicine, UC San Diego Health, California, United States; Division of Medical Toxicology, UC San Diego Health, California, United States.
| | - Stephen R Hayden
- Department of Emergency Medicine, UC San Diego Health, California, United States.
| | - Gabriel Wardi
- Department of Emergency Medicine, UC San Diego Health, California, United States; Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego Health, California, United States.
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Jo YY, Jang JH, Kwon JM, Lee HC, Jung CW, Byun S, Jeong H. Predicting intraoperative hypotension using deep learning with waveforms of arterial blood pressure, electroencephalogram, and electrocardiogram: Retrospective study. PLoS One 2022; 17:e0272055. [PMID: 35944013 PMCID: PMC9362925 DOI: 10.1371/journal.pone.0272055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/13/2022] [Indexed: 11/18/2022] Open
Abstract
To develop deep learning models for predicting Interoperative hypotension (IOH) using waveforms from arterial blood pressure (ABP), electrocardiogram (ECG), and electroencephalogram (EEG), and to determine whether combination ABP with EEG or CG improves model performance. Data were retrieved from VitalDB, a public data repository of vital signs taken during surgeries in 10 operating rooms at Seoul National University Hospital from January 6, 2005, to March 1, 2014. Retrospective data from 14,140 adult patients undergoing non-cardiac surgery with general anaesthesia were used. The predictive performances of models trained with different combinations of waveforms were evaluated and compared at time points at 3, 5, 10, 15 minutes before the event. The performance was calculated by area under the receiver operating characteristic (AUROC), area under the precision-recall curve (AUPRC), sensitivity and specificity. The model performance was better in the model using both ABP and EEG waveforms than in all other models at all time points (3, 5, 10, and 15 minutes before an event) Using high-fidelity ABP and EEG waveforms, the model predicted IOH with a AUROC and AUPRC of 0.935 [0.932 to 0.938] and 0.882 [0.876 to 0.887] at 5 minutes before an IOH event. The output of both ABP and EEG was more calibrated than that using other combinations or ABP alone. The results demonstrate that a predictive deep neural network can be trained using ABP, ECG, and EEG waveforms, and the combination of ABP and EEG improves model performance and calibration.
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Affiliation(s)
- Yong-Yeon Jo
- AI Research Team, Medical AI, Co. Ltd., Seoul, Republic of Korea
| | - Jong-Hwan Jang
- AI Research Team, Medical AI, Co. Ltd., Seoul, Republic of Korea
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
| | - Joon-myoung Kwon
- AI Research Team, Medical AI, Co. Ltd., Seoul, Republic of Korea
- Department of Emergency Medicine, Mediplex Sejong Hospital, Incheon, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seonjeong Byun
- Department of Psychiatry, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Gyeonggi-do, Republic of Korea
- * E-mail: (SB); (HGJ)
| | - Han‐Gil Jeong
- Division of Neurocritical Care, Department of Neurosurgery and Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
- Center for Artificial Intelligence in Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- * E-mail: (SB); (HGJ)
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Connor JPG, Pepino JA, Kwon BK, Horiguchi D, Hahn JO, Reisner AT. Predicting Hypertensive Events with Time-Series Analysis of Mean Arterial Pressure. Annu Int Conf IEEE Eng Med Biol Soc 2022; 2022:1406-1409. [PMID: 36085671 DOI: 10.1109/embc48229.2022.9871929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
We investigated whether a statistical model used previously to predict hypotension from mean arterial pressure (MAP) time series analysis could predict hypertension. We performed a retrospective analysis of minute-by-minute MAP records from two cohorts of intensive care unit (ICU) patients. The first cohort was comprised of surgical and medical ICUs while the second cohort was comprised of acute spinal cord injury (ASCI) patients in a neurological ICU. At each time point with physiological MAP, time series analysis was used to predict the median MAP for the subsequent 20 min. This method was used to predict hypertensive episodes, i.e., intervals of 20 or more minutes where at least half of the MAP measurements were > 105 mmHg. Advance prediction of hypertensive episodes was similar in the two cohorts (69.15% vs. 82.61%, respectively), as was positive predictive value of the hypertension predictions (67.42% vs. 71.57%). The results suggest that the methodology may be useable for predicting hypertension from time-series analysis of MAP. Patients requiring continuous vasopressor infusion are at risk of hypertension and excessive vasoconstriction. We found evidence that time-series analysis previously validated for predicting hypotension may also be usable for predicting hypertension.
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