Association of frequent intradialytic hypotension with the clinical outcomes of patients on hemodialysis: a prospective cohort study

Intradialytic hypotension (IDH) is a common complication of hemodialysis (HD), but there is no consensus on its definition. In 2015, Flythe proposed a definition of IDH (Definition 1 in this study): nadir systolic blood pressure (SBP) <90 mmHg during hemodialysis for patients with pre-dialysis SBP <159 mmHg, and nadir SBP <100 mmHg during hemodialysis for patients with pre-dialysis SBP ≥160 mmHg. This prospective observational cohort study investigated the association of frequent IDH based on Definition 1 with clinical outcomes and compared Definition 1 with a commonly used definition (nadir SBP <90 mmHg during hemodialysis, Definition 2). The incidence of IDH was observed over a 3-month exposure assessment period. Patients with IDH events ≥30% were classified as 'frequent IDH'; the others were 'infrequent IDH'. All-cause mortality, cardiovascular mortality, and all-cause hospitalization events were followed up for 36 months. This study enrolled 163 HD patients. The incidence of IDH was 11.1% according to Definition 1 and 10.5% according to Definition 2. The Kaplan-Meier curves showed that frequent IDH patients had higher risks of all-cause mortality (p = 0.009, Definition 1; p = 0.002, Definition 2) and cardiovascular mortality (p = 0.021, Definition 1). Multivariable Cox regression analysis indicated that frequent IDH was independently associated with a higher risk of all-cause mortality (Model 1: HR = 2.553, 95%CI 1.334-4.886, p = 0.005; Model 2: HR = 2.406, 95%CI 1.253-4.621, p = 0.008). In conclusion, HD patients classified as frequent IDH are at a greater risk of all-cause mortality. This highlights the significance of acknowledging and proactively managing frequent IDH within the HD patients.

External validation of the prediction model of intradialytic hypotension: a multicenter prospective cohort study

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.

The efficacy and safety of ivabradine hydrochloride in hemodialysis patients with chronic heart failure

INTRODUCTION

There is little evidence for ivabradine hydrochloride in patients undergoing hemodialysis.

METHODS

In this open-label prospective interventional trial of hemodialysis patients with chronic heart failure, during 12 weeks of treatment, changes in Heart rate (HR), frequency of dialysis-related hypotension were examined, and we investigated health-related quality of life (HR-QOL) and adverse effects.

RESULTS

18 patients from 6 facilities were enrolled in the study. HR significantly decreased over time, from 87 ± 12.61/min at baseline to 75.85 ± 8.91/min (p = 0.0003), and systolic blood pressure also increased significantly (p < 0.0001). The frequency of dialysis-related hypotension was markedly reduced (p = 0.0001). The HR-QOL survey showed significant improvements in Social Functioning among others (p = 0.0178). No specific adverse events occurred.

CONCLUSION

Ivabradine hydrochloride improved dialysis-related hypotension. Furthermore, the HR-QOL improvement effect were suggested. These results demonstrated the safety and effectiveness of ivabradine hydrochloride.

Adrenalectomy for the treatment of hypotension in a cat with phaeochromocytoma associated with caudal vena cava syndrome

An 11-year-old spayed female, Persian cat was referred to the Jeonbuk Animal Medical Center for evaluation of a 2-month history of lethargy and anorexia. Physical examination revealed tachycardia and hypotension. Abdominal imaging via sonography and CT identified a right adrenal gland mass causing severe deviation and compression of the caudal vena cava. After stabilising the blood pressure and heart rate through positive inotropes and fluid therapy, right adrenalectomy was performed. Surgery confirmed the adrenal gland mass was severely compressing the caudal vena cava. Histopathological examination revealed that the mass was a pheochromocytoma. After adrenalectomy, blood pressure and heart rate stabilised and remained unaffected 8 months postsurgery. This report describes a rare case of an adrenal pheochromocytoma leading to caudal vena cava compression in a cat presenting with hypotension.

Intraoperative Blood Pressure Management and Its Effects on Postoperative Delirium After Cardiac Surgery: A Single-Center Retrospective Cohort Study

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.

Effect of using hypotension prediction index versus conventional goal-directed haemodynamic management to reduce intraoperative hypotension in non-cardiac surgery: A randomised controlled trial

STUDY OBJECTIVE

It remains unclear whether it is the hypotension prediction index itself or goal-directed haemodynamic therapy that mitigates intraoperative hypotension.

DESIGN

A single centre randomised controlled trial.

SETTING

Sapporo Medical University Hospital.

PATIENTS

A total of 64 adults patients undergoing major non-cardiac surgery under general anaesthesia.

INTERVENTIONS

Patients were randomly assigned to either group receiving conventional goal-directed therapy (FloTrac group) or combination of the hypotension prediction index and conventional goal-directed therapy (HPI group). To investigate the independent utility of the index, the peak rates of arterial pressure and dynamic arterial elastance were not included in the treatment algorithm for the HPI group.

MEASUREMENTS

The primary outcome was the time-weighted average of the areas under the threshold. Secondary outcomes were area under the threshold, the number of hypotension events, total duration of hypotension events, mean mean arterial pressure during the hypotension period, number of hypotension events with mean arterial pressure < 50 mmHg, amounts of fluids, blood products, blood loss, and urine output, frequency and amount of vasoactive agents, concentration of haemoglobin during the monitoring period, and 30-day mortality.

MAIN RESULTS

The time-weighted average of the area below the threshold was lower in the HPI group than in the control group; 0.19 mmHg (interquartile range, 0.06-0.80 mmHg) vs. 0.66 mmHg (0.28-1.67 mmHg), with a median difference of -0.41 mmHg (95% confidence interval, -0.69 to -0.10 mmHg), p = 0.005. Norepinephrine was administered to 12 (40%) and 5 (17%) patients in the HPI and FloTrac groups, respectively (p = 0.045). No significant differences were observed in the volumes of fluid and blood products between the study groups.

CONCLUSIONS

The current randomised controlled trial results suggest that using the hypotension prediction index independently lowered the cumulative amount of intraoperative hypotension during major non-cardiac surgery.

Recovery and safety with prolonged high-frequency jet ventilation for catheter ablation of atrial fibrillation: A hospital registry study from a New England healthcare network

STUDY OBJECTIVE

To investigate post-procedural recovery as well as peri-procedural respiratory and hemodynamic safety parameters with prolonged use of high-frequency jet ventilation (HFJV) versus conventional ventilation in patients undergoing catheter ablation for atrial fibrillation.

DESIGN

Hospital registry study.

SETTING

Tertiary academic teaching hospital in New England.

PATIENTS

1822 patients aged 18 years and older undergoing catheter ablation between January 2013 and June 2020.

INTERVENTIONS

HFJV versus conventional mechanical ventilation.

MEASUREMENTS

The primary outcome was post-anesthesia care unit (PACU) length of stay. In secondary analyses we assessed the effect of HFJV on intra-procedural hypoxemia, defined as the occurrence of peripheral hemoglobin oxygen saturation (SpO2) <90%, post-procedural respiratory complications (PRC) as well as intra-procedural hypocarbia and hypotension. Multivariable negative binomial and logistic regression analyses, adjusted for patient and procedural characteristics, were applied.

MAIN RESULTS

1157 patients (63%) received HFJV for a median (interquartile range [IQR]) duration of 307 (253-360) minutes. The median (IQR) length of stay in the PACU was 244 (172-370) minutes in patients who underwent ablation with conventional mechanical ventilation and 226 (163-361) minutes in patients receiving HFJV. In adjusted analyses, patients undergoing HFJV had a longer PACU length of stay (adjusted absolute difference: 37.7 min; 95% confidence interval [CI] 9.7-65.8; p = 0.008). There was a higher risk of intra-procedural hypocarbia (adjusted odds ratio [ORadj] 5.90; 95%CI 2.63-13.23; p < 0.001) and hypotension (ORadj 1.88; 95%CI 1.31-2.72; p = 0.001) in patients undergoing HFJV. No association was found between the use of HFJV and intra-procedural hypoxemia or PRC (p = 0.51, and p = 0.97, respectively).

CONCLUSION

After confounder adjustment, HFJV for catheter ablation procedures for treatment of atrial fibrillation was associated with a longer length of stay in the PACU. It was further associated with an increased risk of intra-procedural abnormalities including abnormal carbon dioxide homeostasis, as well as intra-procedural arterial hypotension.

Profound hypoxemia and hypotension during posterior spinal fusion in a spinal muscular atrophy child with severe scoliosis: a case report

BACKGROUND

Anesthesia for spinal muscular atrophy (SMA) patients undergoing spinal deformity surgery is challenging. We report an unusual case of an SMA girl who developed severe intraoperative hypoxemia and hypotension during posterior spinal fusion related with surgical positioning.

CASE PRESENTATION

A 13-yr-old girl diagnosed with SMA type 2, severe kyphoscoliosis and thoracic deformity was scheduled for elective posterior spinal fusion. She developed severe hypoxemia and profound hypotension intraoperatively in the prone position with surgical table tilted 45° to the right. Though transesophageal echocardiography (TEE) could not be performed due to limited mouth opening, her preoperative computed tomography revealed a severely distorted thoracic cavity with much reduced volume of the right side. A reasonable explanation was when the surgeons performed surgical procedure with the tilted surgical table, the pressure was directly put on the shortest diameter of the significantly deformed thoracic cavity, causing severe compression of the pulmonary artery, resulting in both hypoxemia and hypotension. The patient stabilized when the surgical table was tilted back and successfully went through the surgery in the leveled prone position.

CONCLUSIONS

Spinal fusion surgery is beneficial for SMA patients in preventing scoliosis progression and improving ventilation. However, severe scoliosis and thoracic deformities put them at risk of both hemodynamic and respiratory instability during surgical positioning. When advanced monitoring like TEE is not practical intraoperatively, preoperative imaging may help with differential diagnosis, and guide the surgical positioning to minimize mechanical compression of the thoracic cavity, thereby helping the patient complete the surgery safely.

The effect of ascending- descending ultrafiltration and sodium profiles on blood pressure in hemodialysis patients: a randomized cross-over study

BACKGROUND

Considering no previous research into the utilization of ascending/descending ultrafiltration and linear sodium profiles in improving blood pressure among hemodialysis patients, the present study aimed to explore the effect of the A/D-UF along with linear sodium profiles on HD patients with hypotension.

METHODS

Applying a crossover design, this clinical trial was fulfilled between December 2022 and June 2023 on 20 patients undergoing HD, randomized into two groups, each one receiving two intervention protocols, viz., (a) an intervention protocol in which the liquid sodium in the dialysis solution was linear and the UF profiling was A/D, and (b) a routine protocol or HD, wherein both liquid sodium and UF in the dialysis solution remained constant. The HD patients' BP was then checked and recorded at six intervals, namely, before HD, one, two, three, and four hours after it, and following its completion, within each session. The data were further statistically analyzed using the IBM SPSS Statistics 20 and the related tests.

RESULTS

In total, 20 patients, including 12 men (60%) and 8 women (40%), with the mean age of 58.00 ± 14.54 on HD for an average of 54 months, were recruited in this study. No statistically significant difference was observed in the mean systolic and diastolic BP levels in the group receiving the A/D-UF profile all through the desired hours (p > 0.05), indicating that the patients did not face many changes in these two numbers during HD. Our cross-over clinical trial demonstrated a statistically significant reduction in symptomatic IDH episodes from 55 to 15% with the application of the A/D-UF profile (p < 0.05).

CONCLUSION

The study demonstrated that the A/D-UF profile could contribute to the stability of blood pressure levels among HD patients, with no significant fluctuations observed during treatment sessions.

TRIAL REGISTRATION

This study was registered in the Iranian Registry of Clinical Trials (no. IRCT20180429039463N5) on 07/01/2023.

Effect of subclavian vein diameter combined with perioperative fluid therapy on preventing post-induction hypotension in patients with ASA status I or II

BACKGROUND

Perioperative hypotension is frequently observed following the initiation of general anesthesia administration, often associated with adverse outcomes. This study assessed the effect of subclavian vein (SCV) diameter combined with perioperative fluid therapy on preventing post-induction hypotension (PIH) in patients with lower ASA status.

METHODS

This two-part study included patients aged 18 to 65 years, classified as ASA physical status I or II, and scheduled for elective surgery. The first part (Part I) included 146 adult patients, where maximum SCV diameter (dSCVmax), minimum SCV diameter (dSCVmin), SCV collapsibility index (SCVCI) and SCV variability (SCVvariability) assessed using ultrasound. PIH was determined by reduction in mean arterial pressure (MAP) exceeding 30% from baseline measurement or any instance of MAP < falling below 65 mmHg for ≥ a duration of at least 1 min during the period from induction to 10 min after intubation. Receiver Operating Characteristic (ROC) curve analysis was employed to determine the predictive values of subclavian vein diameter and other relevant parameters. The second part comprised 124 adult patients, where patients with SCV diameter above the optimal cutoff value, as determined in Part I study, received 6 ml/kg of colloid solution within 20 min before induction. The study evaluated the impact of subclavian vein diameter combined with perioperative fluid therapy by comparing the observed incidence of PIH after induction of anesthesia.

RESULTS

The areas under the curves (with 95% confidence intervals) for SCVCI and SCVvariability were both 0.819 (0.744-0.893). The optimal cutoff values were determined to be 45.4% and 14.7% (with sensitivity of 76.1% and specificity of 86.7%), respectively. Logistic regression analysis, after adjusting for confounding factors, demonstrated that both SCVCI and SCVvariability were significant predictors of PIH. A threshold of 45.4% for SCVCI was chosen as the grouping criterion. The incidence of PIH in patients receiving fluid therapy was significantly lower in the SCVCI ≥ 45.4% group compared to the SCVCI < 45.4% group.

CONCLUSIONS

Both SCVCI and SCVvariability are noninvasive parameters capable of predicting PIH, and their combination with perioperative fluid therapy can reduce the incidence of PIH.

Risk factors of more severe hypotension after spinal anesthesia for cesarean section

BACKGROUND

The aim of this study was to examine the risk factors associated with the use of vasopressors to prevent hypotension that occurs after spinal anesthesia during cesarean section. Although the prophylactic use of vasopressors is already suggested as routine care in many parts of the world, the occurrence of spinal anesthesia-induced hypotension (SAIH) is still common in parturients.

METHODS

This retrospective study included parturients receiving elective cesarean deliveries under spinal anesthesia from April 2016 to March 2020. Risk factors related to ephedrine dosage were analyzed using a hurdle model, and risk factors related to SAIH were further analyzed with logistic regression.

RESULTS

Five risk factors, namely maternal body mass index (BMI, p < 0.001), baseline systolic blood pressure (SBP, p < 0.001), baseline heart rate (HR, p = 0.047), multiparity ( p = 0.003), and large fetal weight ( p = 0.005) were significantly associated with the requirement for ephedrine. Furthermore, a higher ephedrine dosage was significantly associated with maternal BMI ( p < 0.001), baseline SBP ( p < 0.001), baseline HR ( p < 0.001), multiparity ( p = 0.027), large fetal weight ( p = 0.030), maternal age ( p = 0.009), and twin pregnancies ( p < 0.001). Logistic regression analysis also showed that the same five risk factors-maternal BMI ( p = 0.030), baseline SBP ( p < 0.001), baseline HR ( p < 0.001), multiparity ( p < 0.001), and large fetal weight ( p < 0.001)-were significantly associated with SAIH, even in cases where vasopressors were administered.

CONCLUSION

These findings can be useful for clinicians when deciding the dose of prophylactic ephedrine or phenylephrine to prevent SAIH.

Impact of Using Blood Warmer During Continuous Kidney Replacement Therapy in Patients With Acute Kidney Injury

PURPOSE

We investigated the impact of blood warmer use on hypotensive episodes in patients with acute kidney injury (AKI) receiving continuous kidney replacement therapy (CKRT).

MATERIALS AND METHODS

We included patients with AKI undergoing CKRT between January 1, 2012, and January 1, 2021, at a tertiary academic hospital. Hypotensive episodes were defined as mean arterial pressure (MAP) <60 mm Hg or a decrease in MAP by ≥10 mm Hg, systolic blood pressure (SBP) < 90 mm Hg or a decrease in SBP by ≥20 mm Hg, or increased vasopressor requirement. These were analyzed by Poisson regression with repeated-measures analysis of variance using generalized estimation equation.

RESULTS

There were 669 patients with AKI that required CKRT. Use of blood warmer on first day of CKRT was in 324 (48%) patients. Incidence rate ratio of hypotensive episodes during the first 24-h of CKRT in patients where a blood warmer was used was 1.06 (95% confidence interval [CI]: 0.98-1.13) compared to those where blood warmer was not used. This did not change in adjusted model. Overall, the within-subject effect of temperature on hypotensive episodes showed that higher temperature was associated with fewer episodes (0.94, 95% CI: 0.9-0.99 per 10 degrees increase, P = .007).

CONCLUSION

Blood rewarming was not associated with hypotensive episodes during CKRT.

Hypotension in the Emergency Department and Contrast Extravasation on Computerized Tomography Predict Blood Transfusion in Low-Energy Pelvic Fractures

INTRODUCTION

Although low-energy pelvic fractures seldom present with significant hemorrhage, early recognition of at-risk patients is essential. We aimed to identify predictors of transfusion requirements in this cohort.

METHODS

A 7-y retrospective chart review was performed. Low-energy mechanism was defined as falls of ≤5 feet. Fracture pattern was classified using the Orthopedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen system as A, B, or C. Primary outcome was transfusion of ≥2 units of packed red blood cells in the first 48 h. Univariable analysis and logistic regression analysis were performed. A P value ≤0.05 was considered significant.

RESULTS

Five hundred forty six patients were included with median (interquartile range) age of 86 (79-91) and median (interquartile range) Injury Severity Score of 5 (4-8). Five hundred forty one (99%) had type A fractures. Twenty six (5%) had the primary outcome and 17 (3%) died. Logistic regression found that systolic blood pressure <100 mmHg at any time in the Emergency Department, Injury Severity Score, and pelvic angiography were predictors of the primary outcome. Seventeen percent of those who had the primary outcome died compared with 2% who did not (P = 0.0004). Three hundred sixty four (67%) received intravenous contrast for computerized tomography scans and of these, 44 (12%) had contrast extravasation (CE). CE was associated with the primary outcome but not mortality.

CONCLUSIONS

Hypotension at any time in the Emergency Department and CE on computerized tomography predicted transfusion of ≥2 units packed red blood cells in the first 48 h in patients with low-energy pelvic fractures.

Incidence of intraoperative hypotension and its factors among adult traumatic head injury patients in comprehensive specialized hospitals, Northwest Ethiopia: a multicenter observational study

INTRODUCTION

Traumatic head injury (THI) poses a significant global public health burden, often contributing to mortality and disability. Intraoperative hypotension (IH) during emergency neurosurgery for THI can adversely affect perioperative outcomes, and understanding associated risk factors is essential for prevention.

METHOD

A multi-center observational study was conducted from February 10 to June 30, 2022. A simple random sampling technique was used to select the study participants. Patient data were analyzed using bivariate and multivariate logistic regression to identify significant factors associated with intraoperative hypotension (IH). Odds ratios with 95% confidence intervals were used to show the strength of association, and P value < 0.05 was considered as statistically significant.

RESULT

The incidence of intra-operative hypotension was 46.41% with 95%CI (39.2,53.6). The factors were duration of anesthesia ≥ 135 min with AOR: 4.25, 95% CI (1.004,17.98), severe GCS score with AOR: 7.23, 95% CI (1.098,47.67), intracranial hematoma size ≥ 15 mm with AOR: 7.69, 95% CI (1.18,50.05), and no pupillary abnormality with AOR: 0.061, 95% CI (0.005,0.732). CONCLUSION AND RECOMMENDATION: The incidence of intraoperative hypotension was considerably high. The duration of anesthesia, GCS score, hematoma size, and pupillary abnormalities were associated. The high incidence of IH underscores the need for careful preoperative neurological assessment, utilizing CT findings, vigilance for IH in patients at risk, and proactive management of IH during surgery. Further research should investigate specific mitigation strategies.

Clinical Predictors of Subacute Myocardial Dysfunction in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19

Multisystem Inflammatory Syndrome in Children (MIS-C) often involves a post-viral myocarditis and associated left ventricular dysfunction. We aimed to assess myocardial function by strain echocardiography after hospital discharge and to identify risk factors for subacute myocardial dysfunction. We conducted a retrospective single-center study of MIS-C patients admitted between 03/2020 and 03/2021. Global longitudinal strain (GLS), 4-chamber longitudinal strain (4C-LS), mid-ventricular circumferential strain (CS), and left atrial strain (LAS) were measured on echocardiograms performed 3-10 weeks after discharge and compared with controls. Among 60 MIS-C patients, hypotension (65%), ICU admission (57%), and vasopressor support (45%) were common, with no mortality. LVEF was abnormal (< 55%) in 29% during hospitalization but only 4% at follow-up. Follow-up strain abnormalities were prevalent (GLS abnormal in 13%, 4C-LS in 18%, CS in 16%, LAS in 5%). Hypotension, ICU admission, ICU and hospital length of stay, and any LVEF < 55% during hospitalization were factors associated with lower strain at follow-up. Higher peak C-reactive protein (CRP) was associated with hypotension, ICU admission, total ICU days, and with lower follow-up GLS (r = - 0.55; p = 0.01) and CS (r = 0.41; p = 0.02). Peak CRP < 18 mg/dL had negative predictive values of 100% and 88% for normal follow-up GLS and CS, respectively. A subset of MIS-C patients demonstrate subclinical systolic and diastolic function abnormalities at subacute follow-up. Peak CRP during hospitalization may be a useful marker for outpatient cardiac risk stratification. MIS-C patients with hypotension, ICU admission, any LVEF < 55% during hospitalization, or a peak CRP > 18 mg/dL may warrant closer monitoring than those without these risk factors.

Impact of clinicians' behavior, an educational intervention with mandated blood pressure and the hypotension prediction index software on intraoperative hypotension: a mixed methods study

PURPOSE

Intraoperative hypotension (IOH) is associated with adverse outcomes. We therefore explored beliefs regarding IOH and barriers to its treatment. Secondarily, we assessed if an educational intervention and mandated mean arterial pressure (MAP), or the implementation of the Hypotension Prediction Index-software (HPI) were associated with a reduction in IOH.

METHODS

Structured interviews (n = 27) and questionnaires (n = 84) were conducted to explore clinicians' beliefs and barriers to IOH treatment, in addition to usefulness of HPI questionnaires (n = 14). 150 elective major surgical patients who required invasive blood pressure monitoring were included in three cohorts to assess incidence and time-weighted average (TWA) of hypotension (MAP < 65 mmHg). Cohort one received standard care (baseline), the clinicians of cohort two had a training on hypotension and a mandated MAP > 65 mmHg, and patients of the third cohort received protocolized care using the HPI.

RESULTS

Clinicians felt challenged to manage IOH in some patients, yet they reported sufficient knowledge and skills. HPI-software was considered useful and beneficial. No difference was found in incidence of IOH between cohorts. TWA was comparable between baseline and education cohort (0.15 mmHg [0.05-0.41] vs. 0.11 mmHg [0.02-0.37]), but was significantly lower in the HPI cohort (0.04 mmHg [0.00 to 0.11], p < 0.05 compared to both).

CONCLUSIONS

Clinicians believed they had sufficient knowledge and skills, which could explain why no difference was found after the educational intervention. In the HPI cohort, IOH was significantly reduced compared to baseline, therefore HPI-software may help prevent IOH.

TRIAL REGISTRATION

ISRCTN 17,085,700 on May 9th, 2019.

Use and Outcomes of Peripheral Vasopressors in Early Sepsis-Induced Hypotension Across Michigan Hospitals: A Retrospective Cohort Study

BACKGROUND

Vasopressors traditionally are administered via central access, but newer data suggest that peripheral administration may be safe and may avoid delays and complications associated with central line placement.

RESEARCH QUESTION

How commonly are vasopressors initiated through peripheral IV lines in routine practice? Is vasopressor initiation route associated with in-hospital mortality?

STUDY DESIGN AND METHODS

This retrospective cohort study included adults hospitalized with sepsis (November 2020-September 2022) at 29 hospitals in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. We assessed route of early vasopressor initiation, factors and outcomes associated with peripheral initiation, and timing of central line placement.

RESULTS

Five hundred ninety-four patients received vasopressors within 6 h of hospital arrival and were included in this study. Peripheral vasopressor initiation was common (400/594 [67.3%]). Patients with peripheral vs central initiation were similar; BMI was the only patient factor associated independently with initiation route (adjusted OR [aOR] of peripheral initiation [per 1-kg/m2 increase], 0.98; 95% CI, 0.97-1.00; P = .015). The specific hospital showed a large impact on initiation route (median OR, 2.19; 95% CI, 1.31-3.07). Compared with central initiation, peripheral initiation was faster (median, 2.5 h vs 2.7 h from hospital arrival; P = .002), but was associated with less initial norepinephrine use (84.3% vs 96.8%; P = .001). We found no independent association between initiation route and in-hospital mortality (32.3% vs 42.2%; aOR, 0.66; 95% CI, 0.39-1.12). No tissue injury from peripheral vasopressors was documented. Of patients with peripheral initiation, 135 of 400 patients (33.8%) never received a central line.

INTERPRETATION

Peripheral vasopressor initiation was common across Michigan hospitals and had practical benefits, including expedited vasopressor administration and avoidance of central line placement in one-third of patients. However, the findings of wide practice variation that was not explained by patient case mix and lower use of first-line norepinephrine with peripheral administration suggest that additional standardization may be needed.

Hypertension during transfer is associated with poor outcomes in unstable patients with ruptured abdominal aortic aneurysm

OBJECTIVE

Limited data exist for optimal blood pressure (BP) management during transfer of patients with ruptured abdominal aortic aneurysm (rAAA). This study evaluates the effects of hypertension and severe hypotension during interhospital transfers in a cohort of patients with rAAA in hemorrhagic shock.

METHODS

We performed a retrospective, single-institution review of patients with rAAA transferred via air ambulance to a quaternary referral center for repair (2003-2019). Vitals were recorded every 5 minutes in transit. Hypertension was defined as a systolic BP of ≥140 mm Hg. The primary cohort included patients with rAAA with hemorrhagic shock (≥1 episode of a systolic BP of <90 mm Hg) during transfer. The primary analysis compared those who experienced any hypertensive episode to those who did not. A secondary analysis evaluated those with either hypertension or severe hypotension <70 mm Hg. The primary outcome was 30-day mortality.

RESULTS

Detailed BP data were available for 271 patients, of which 125 (46.1%) had evidence of hemorrhagic shock. The mean age was 74.2 ± 9.1 years, 93 (74.4%) were male, and the median total transport time from helicopter dispatch to arrival at the treatment facility was 65 minutes (interquartile range, 46-79 minutes). Among the cohort with shock, 26.4% (n = 33) had at least one episode of hypertension. There were no significant differences in age, sex, comorbidities, AAA repair type, AAA anatomic location, fluid resuscitation volume, blood transfusion volume, or vasopressor administration between the hypertensive and nonhypertensive groups. Patients with hypertension more frequently received prehospital antihypertensives (15% vs 2%; P = .01) and pain medication (64% vs 24%; P < .001), and had longer transit times (36.3 minutes vs 26.0 minutes; P = .006). Episodes of hypertension were associated with significantly increased 30-day mortality on multivariable logistic regression (adjusted odds ratio [aOR], 4.71; 95% confidence interval [CI], 1.54-14.39; P = .007; 59.4% [n = 19] vs 40.2% [n = 37]; P = .01). Severe hypotension (46%; n = 57) was also associated with higher 30-day mortality (aOR, 2.82; 95% CI, 1.27-6.28; P = .01; 60% [n = 34] vs 32% [n = 22]; P = .01). Those with either hypertension or severe hypotension (54%; n = 66) also had an increased odds of mortality (aOR, 2.95; 95% CI, 1.08-8.11; P = .04; 58% [n = 38] vs 31% [n = 18]; P < .01). Level of hypertension, BP fluctuation, and timing of hypertension were not significantly associated with mortality.

CONCLUSIONS

Hypertensive and severely hypotensive episodes during interhospital transfer were independently associated with increased 30-day mortality in patients with rAAA with shock. Hypertension should be avoided in these patients, but permissive hypotension approaches should also maintain systolic BPs above 70 mm Hg whenever possible.

Effect of incremental PEEP titration on postoperative pulmonary complications in patients undergoing emergency laparotomy: a randomized controlled trial

Postoperative pulmonary complications (PPC) has a significant negative impact and are associated with increased length of hospital stay and cost of care. Emergency surgery is a well-established risk factor for PPC. Previous studies reported that personalized positive end-expiratory pressure (PEEP) might reduce postoperative atelectasis and postoperative pulmonary complications. N = 168 adult patients undergoing major emergency laparotomy under general anesthesia were recruited in this study. A minimum driving pressure based incremental PEEP titration was compared to a fixed PEEP of 5 cmH2O. The primary outcome was PPC up to postoperative day 7. The mean (standard deviation) of the recruited patients was 41.7(16.1)y, and 48.8% (82 of 168 patients) were female. The risk of PPC at postoperative day 7 was similar in both the study groups [Relative risk (RR) (95% Confidence interval, CI) 0.81 (0.58, 1.13); p = 0.25]. In addition, the incidence of intraoperative hypotension [p = 0.75], oxygen-free days at day 28 [p = 0.27], duration of postoperative hospital stay [p = 0.50], length of postoperative intensive care unit stay [p = 0.28], and in-hospital mortality [p = 0.38] were similar in two groups. Incidence of PPC was not reduced with the use of an individualized PEEP strategy based on lowest driving pressure. However, the incidence of hypotension and bradycardia was also not increased with titrated PEEP.Trial Registration: www.ctri.nic.in ; CTRI/2020/12/029765.

A bagging approach for improved predictive accuracy of intradialytic hypotension during hemodialysis treatment

The primary objective of this study is to enhance the prediction accuracy of intradialytic hypotension in patients undergoing hemodialysis. A significant challenge in this context arises from the nature of the data derived from the monitoring devices and exhibits an extreme class imbalance problem. Traditional predictive models often display a bias towards the majority class, compromising the accuracy of minority class predictions. Therefore, we introduce a method called UnderXGBoost. This novel methodology combines the under-sampling, bagging, and XGBoost techniques to balance the dataset and improve predictive accuracy for the minority class. This method is characterized by its straightforward implementation and training efficiency. Empirical validation in a real-world dataset confirms the superior performance of UnderXGBoost compared to existing models in predicting intradialytic hypotension. Furthermore, our approach demonstrates versatility, allowing XGBoost to be substituted with other classifiers and still producing promising results. Sensitivity analysis was performed to assess the model's robustness, reinforce its reliability, and indicate its applicability to a broader range of medical scenarios facing similar challenges of data imbalance. Our model aims to enable medical professionals to provide preemptive treatments more effectively, thereby improving patient care and prognosis. This study contributes a novel and effective solution to a critical issue in medical prediction, thus broadening the application spectrum of predictive modeling in the healthcare domain.

Predictive value of estimated plasma volume for postoperative hypotension in percutaneous intramyocardial septal radiofrequency ablation treating for hypertrophic obstructive cardiomyopathy

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).

Transcatheter aortic valve replacement in patients with severe aortic stenosis reduced the frequency of intradialytic hypotension

Intradialytic hypotension (IDH) is a common complication during hemodialysis that increases cardiovascular morbidity and mortality. Aortic stenosis (AS) is a cause of IDH. Transcatheter aortic valve replacement (TAVR) has become an established treatment for patients with severe AS. However, whether TAVR reduce the frequency of IDH has not been investigated. This study aims to verify the efficacy of TAVR for reduction of the frequency of IDH. Consecutive hemodialysis patients who underwent TAVR at Sendai Kosei Hospital from February 2021 to November 2021 with available records 1 month before and 3 months after TAVR were included in the study. IDH was defined as a decrease in systolic blood pressure by 20 mmHg or a decrease in the mean blood pressure by 10 mmHg associated with hypotensive symptoms or requiring intervention. Patients with ≥ 3 episodes of IDH in ten hemodialysis sessions comprised the IDH group. Overall, 18/41 (43.9%) patients were classified into the IDH group. In ten hemodialysis sessions, IDH events were observed 2.1, 4.3, and 0.4 times in the overall cohort, IDH group, and non-IDH group, respectively. After TAVR, the incidence of IDH decreased from 43.2 to 10.3% (p < 0.0001) and IDH improved significantly in 15 patients in the IDH group. The result suggested that severe AS was the major cause of IDH in this cohort, and TAVR may be an effective treatment option for reduction of the frequency of IDH in patients with severe AS.

Effect of different targets of goal-directed fluid therapy on intraoperative hypotension and fluid infusion in robot-assisted laparoscopic gynecological surgery: a randomized non-inferiority trial

Carotid corrected flow time (FTc) and tidal volume challenge pulse pressure variation (VtPPV) are useful clinical parameters for assessing volume status and fluid responsiveness in robot-assisted surgery, but their usefulness as goal-directed fluid therapy (GDFT) targets is unclear. We investigated whether FTc or VtPPV as targets are inferior to PPV in GDFT. This single-center, prospective, randomized, non-inferiority study included 133 women undergoing robot-assisted laparoscopic gynecological surgery in the modified head-down lithotomy position. Patients were equally divided into three groups, and the GDFT protocol was guided by FTc, VtPPV, or PPV during surgery. Primary outcomes were non-inferiority of the time-weighted average of hypotension, intraoperative fluid volume, and urine output. Secondary outcomes were optic nerve sheath diameter (ONSD) pre- and post-operatively and creatinine and blood urea nitrogen preoperatively and on day 1 post-operatively. No significant differences were observed in intraoperative hypotension index, infusion and urine volumes, and ONSD post-operatively between the FTc and VtPPV groups and the PPV group. No differences in serum creatinine and urea nitrogen levels were identified between the FTc and VtPPV groups preoperatively, but on day 1 post-operatively, the urea nitrogen level in the FTc group was higher than that in the PPV group (4.09 ± 1.28 vs. 3.0 ± 1.1 mmol/L, 1.08 [0.59, 1.58], p < 0.0001), and the difference from the preoperative value was smaller than that in the PPV group (- 2 [- 2.97, 1.43] vs. - 1.34 [- 1.9, - 0.67], p = 0.004). FTc- or VtPPV-guided protocols are not inferior to that of PPV in GDFT during robot-assisted laparoscopic surgery in the modified head-down lithotomy position.Trial registration: Chinese Clinical Trial Registry (ChiCTR2200064419).

Derivation of the Difficult Airway Physiological Score (DAPS) in adults undergoing endotracheal intubation in the emergency department

BACKGROUND

Prediction of serious outcomes among patients with physiological instability is crucial in airway management. In this study, we aim to develop a score to predict serious outcomes following intubation in critically ill adults with physiological instability by using clinical and laboratory parameters collected prior to intubation.

METHOD

This single-center analytical cross-sectional study was conducted in the Emergency Department from 2016 to 2020. The airway score was derived using the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) methodology. To gauge model's performance, the train-test split technique was utilized. The discrete random number generation approach was used to divide the dataset into two groups: development (training) and validation (testing). The validation dataset's instances were used to calculate the final score, and its validity was measured using ROC analysis and area under the curve (AUC). By computing the Youden's J statistic using the metrics sensitivity, specificity, positive predictive value, and negative predictive value, the discriminating factor of the additive score was determined.

RESULTS

The mean age of the 1021 patients who needed endotracheal intubations was 52.2 years (± 17.5), and 632 (62%) of them were male. In the development dataset, there were 527 (64.9%) physiologically difficult airways, 298 (36.7%) post-intubation hypotension, 124 (12%) cardiac arrest, 347 (42.7%) shock index > 0.9, and 456 [56.2%] instances of pH < 7.3. On the contrary, in the validation dataset, there were 143 (68.4%) physiologically difficult airways, 33 (15.8%) post-intubation hypotension, 41 (19.6%) cardiac arrest, 87 (41.6%) shock index > 0.9, and 121 (57.9%) had pH < 7.3, respectively. There were 12 variables in the difficult airway physiological score (DAPS), and a DAPS of 9 had an area under the curve of 0.857. The accuracy of DAPS was 77%, the sensitivity was 74%, the specificity was 83.3%, and the positive predictive value was 91%.

CONCLUSION

DAPS demonstrated strong discriminating ability for anticipating physiologically challenging airways. The proposed model may be helpful in the clinical setting for screening patients who are at high risk of deterioration.

Norepinephrine versus phenylephrine on cerebral tissue oxygen saturation during prophylactic infusion to prevent spinal hypotension for Caesarean birth

BACKGROUND

Phenylephrine may cause a reduction in maternal cerebral tissue oxygen saturation (SctO2) during Caesarean birth to prevent spinal hypotension; however, the effect of norepinephrine has not been assessed. We hypothesized that norepinephrine was more effective than phenylephrine in maintaining SctO2 when preventing spinal hypotension during Caesarean birth.

METHODS

We conducted a randomized, double-blind, controlled study. Sixty patients were randomly assigned to prophylactic norepinephrine or phenylephrine to maintain blood pressure during spinal anesthesia for Caesarean birth. SctO2, systolic blood pressure, and heart rate were recorded. The primary outcome was the incidence of a 10% reduction of intraoperative SctO2 from baseline or more during Caesarean birth.

RESULTS

The norepinephrine group had a lower incidence of more than 10% reduction of intraoperative SctO2 from baseline than that of the phenylephrine group (13.3% vs 40.0%, P = .02). The change in SctO2 after 5 minutes of norepinephrine infusion was higher than that after phenylephrine infusion (-3.4 ± 4.7 vs -6.2 ± 5.6, P = .04). The change in SctO2 after 10 minutes of norepinephrine infusion was higher than that after phenylephrine infusion (-2.5 ± 4.4 vs -5.4 ± 4.6, P = .006). The norepinephrine group showed greater left- and right-SctO2 values than the phenylephrine group at 5 to 10 minutes. However, the change in systolic blood pressure was comparable between the 2 groups.

CONCLUSION

Norepinephrine was more effective than phenylephrine in maintaining SctO2 when preventing spinal hypotension during Caesarean birth. However, the changes in clinical outcomes caused by differences in SctO2 between the 2 medications warrant further studies.

Incidence and predictors of intraoperative hypotension during transurethral bladder tumor resection with oral 5-aminolevulinic acid

OBJECTIVES

To analyze the incidence and risk factors of intraoperative hypotension related to photodynamic diagnosis-assisted transurethral resection of bladder tumor (PDD-TURBT) with oral 5-aminolevulinic acid (5-ALA).

METHODS

We retrospectively analyzed 487 patients with bladder tumors who underwent PDD-TURBT (n = 184) or conventional TURBT (conv-TURBT) (n = 303) between 2018 and 2021. Intraoperative hypotension was defined as hypotension requiring vasopressors during TURBT, and its incidence was compared between the two groups. Potential risk factors of intraoperative hypotension, including preoperative change in mean arterial pressure (MAP), were further investigated in patients receiving PDD-TURBT.

RESULTS

The median age was 72 years, 392 patients (81%) were male, and 203 (42%) had hypertension. TURBT was performed under general and spinal anesthesia in 76 (16%) and 411 (84%) patients, respectively. The incidence of intraoperative hypotension was significantly higher in PDD-TURBT compared to conv-TURBT (43% vs. 17%, respectively). The median change in MAP until the induction of anesthesia was +6.5 mmHg (range: -29.0 to +46.3) in the PDD-TURBT group and +14.7 mmHg (range: -35.3 to +67.7) in the conv-TURBT group, showing a significantly smaller increase in the PDD-TURBT group (p < 0.001). In the multivariable analysis for PDD-TURBT patients, advanced age, general anesthesia, and lower MAP change (<+6.5 mmHg) until anesthesia induction were significantly associated with intraoperative hypotension (p = 0.0104, <0.001, and <0.001, respectively).

CONCLUSIONS

Intraoperative hypotension occurred more frequently in patients who underwent PDD-TURBT than in those who underwent conv-TURBT. Using oral 5-ALA decreases preoperative blood pressure elevation and may be responsible for intraoperative hypotension.

Haemodynamic assessment and management of hypotension in the preterm

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.

Considerations and anesthetic management of a patient with giant right atrial myxoma: A case report and literature review

BACKGROUND

Myxoma is a common type of primary cardiac tumor. However, there are few researches to illustrate challenge of safely inducing anesthesia in a patient with a giant right atrial myxoma at moderate altitude.

PATIENT CONCERNS AND DIAGNOSES

A 54-year-old female patient lived in a city with an average altitude of 1932 m with scheduled surgical treatment for giant right atrial myxoma, prompting discussions on appropriate anesthesia modalities given her prolonged residence at moderate altitude.

METHODS AND RESULTS

Considering the potential impact of moderate altitude on perioperative management, this study emphasizes the necessity of adequate volume preload therapy and the utility of transthoracic echocardiography or transesophageal echocardiography to prevent hemodynamic compromise. Furthermore, it highlights the unique consideration that, post-tumor removal, hypotension may not necessarily lead to decreased oxygen saturation in these patients.

CONCLUSION

This case underscores the importance of avoiding hypotension, as pre-tumor resection blood pressure maintenance primarily determines blood oxygen concentration. Additionally, it sheds light on the intriguing observation that post-tumor removal hypotension may not result in decreased oxygen saturation. These findings have significant implications for the perioperative care of patients with giant right atrial myxoma at moderate altitudes.

Ultrasound-guided caudal anaesthesia combined with epidural anaesthesia for caesarean section: a randomized controlled clinical trial

BACKGROUND

Although epidural anaesthesia and spinal anaesthesia are currently the general choices for patients undergoing caesarean section, these two neuraxial anaesthesia methods still have drawbacks. Caudal anaesthesia has been considered to be more appropriate for gynaecological surgery. The purpose of this study was to compare epidural anaesthesia combined with caudal anaesthesia, spinal anaesthesia and single-space epidural anaesthesia for caesarean section with respect to postoperative comfort and intraoperative anaesthesia quality.

METHODS

In this clinical trial, 150 patients undergoing elective caesarean section were recruited and randomized into three groups according to a ratio of 1:1:1to receive epidural anaesthesia only, spinal anaesthesia only or epidural anaesthesia combined with caudal anaesthesia. The primary outcome was postoperative comfort in the three groups. Secondary outcomes included intraoperative anaesthesia quality and the incidences of nausea, vomiting, postdural puncture headache, maternal bradycardia, or hypotension.

RESULTS

More patients were satisfied with the intraoperative anaesthesia quality in the EAC group than in the EA group (P = 0.001). The obstetrician was more significantly satisfied with the intraoperative anaesthesia quality in the SA and EAC groups than in the EA group (P = 0.004 and 0.020, respectively). The parturients felt more comfortable after surgery in the EA and EAC groups (P = 0.007). The incidence of maternal hypotension during caesarean section was higher in the SA group than in the EA and EAC groups (P = 0.001 and 0.019, respectively).

CONCLUSIONS

Epidural anaesthesia combined with caudal anaesthesia may be a better choice for elective caesarean section. Compared with epidural anaesthesia and spinal anaesthesia, it has a higher quality of postoperative comfort and intraoperative anaesthesia.

Hypotension and respiratory events related to electrical cardioversion for atrial fibrillation or atrial flutter in the emergency department

INTRODUCTION

Electrical cardioversion for atrial fibrillation/atrial flutter (AF/AFL) is common in the ED. Our previous work showed that hypotension and respiratory events were important adverse events that occurred in patients undergoing electrical cardioversion for AF/AFL. The purpose of this study was to examine if (1) beta-blockers or calcium channel blocker use prior to ECV were associated with hypotension and (2) medications used for procedural sedation were associated with respiratory events.

METHODS

This was a secondary analysis of pooled study data from four previous multicentred studies on AF/AFL. We conducted a multivariable logistic regression to examine predictors of hypotension and respiratory adverse events.

RESULTS

There were 1736 patients who received ECV. A hypotensive event occurred in 62 (3.6%) patients. There was no significant difference in the odds of a hypotensive event in patients who received a beta-blocker or calcium channel blocker in the ED compared to no rate control. Procedural sedation with fentanyl (OR 2.01 95% CI 1.15-3.51) and home beta-blocker use (OR 1.92, 95% CI 1.14-3.21) were significantly associated with hypotensive events. A respiratory event occurred in 179 (10.3%) patients. Older age (OR 2.02, 95% CI 1.30- 3.15) and receiving midazolam for procedural sedation were found to be significantly associated with respiratory events (OR 1.99, 95% CI 1.02-3.88).

CONCLUSION

Beta-blocker or calcium channel blocker use prior to ECV for AF/AFL was not associated with hypotension. However, sedation with fentanyl and home beta-blocker use was associated with hypotension. The use of midazolam for procedural sedation was significantly associated with respiratory events.

Changes in the corrected carotid flow time can predict spinal anesthesia-induced hypotension in patients undergoing cesarean delivery: an observational study

PURPOSE

Spinal anesthesia is a standard technique for cesarean delivery; however, it possesses a risk of hypotension. We hypothesised that the changes in the corrected flow time induced by the Trendelenburg position could predict the incidence of hypotension after spinal anesthesia for cesarean delivery.

METHODS

Patients undergoing elective cesarean delivery under spinal anesthesia were enrolled. Before anesthesia induction, corrected flow time was measured in the supine and Trendelenburg positions (FTc-1 and FTc-2, respectively). Additionally, a percent change in corrected flow time induced by the Trendelenburg position was defined as ΔFTc. The primary endpoint was to investigate the ability of ΔFTc to predict the incidence of spinal anesthesia-induced hypotension until delivery. The receiver operating characteristics curves to assess the ability of FTc-1, FTc-2, and ΔFTc to predict the incidence of hypotension were generated.

RESULTS

Finally, 40 patients were included, and of those, 26 (65%) developed spinal anesthesia-induced hypotension. The areas under the curve for FTc-1, FTc-2, and ΔFTc were 0.591 (95% CI: 0.424 to 0.743) (P = 0.380), 0.742 (95% CI: 0.579 to 0.867) (P = 0.004), and 0.882 (95% CI: 0.740 to 0.962) (P < 0.001) respectively, indicating ΔFTc as the best predictor among these three parameters. The best threshold for ΔFTc was 6.4% (sensitivity: 80.8% (95% CI: 53.8 to 96.2), specificity: 85.7% (95% CI: 42.9 to 100.0)).

CONCLUSIONS

This study demonstrated that changes in the corrected carotid flow time induced by the Trendelenburg position could serve as a good predictor of spinal anesthesia-induced hypotension for cesarean delivery.

Postoperative hypotension following acute hip fracture surgery is a predictor of 30-day mortality

Aims

Hip fractures are some of the most common fractures encountered in orthopaedic practice. We aimed to identify whether perioperative hypotension is a predictor of 30-day mortality, and to stratify patient groups that would benefit from closer monitoring and early intervention. While there is literature on intraoperative blood pressure, there are limited studies examining pre- and postoperative blood pressure.

Methods

We conducted a prospective observational cohort study over a one-year period from December 2021 to December 2022. Patient demographic details, biochemical results, and haemodynamic observations were taken from electronic medical records. Statistical analysis was conducted with the Cox proportional hazards model, and the effects of independent variables estimated with the Wald statistic. Kaplan-Meier survival curves were estimated with the log-rank test.

Results

A total of 528 patients were identified as suitable for inclusion. On multivariate analysis, postoperative hypotension of a systolic blood pressure (SBP) < 90 mmHg two to 24 hours after surgery showed an increased hazard ratio (HR) for 30-day mortality (HR 4.6 (95% confidence interval (CI) 2.3 to 8.9); p < 0.001) and was an independent risk factor accounting for sex (HR 2.7 (95% CI 1.4 to 5.2); p = 0.003), age (HR 1.1 (95% CI 1.0 to 1.1); p = 0.016), American Society of Anesthesiologists grade (HR 2.7 (95% CI 1.5 to 4.6); p < 0.001), time to theatre > 24 hours (HR 2.1 (95% CI 1.1 to 4.2); p = 0.025), and preoperative anaemia (HR 2.3 (95% CI 1.0 to 5.2); p = 0.043). A preoperative SBP of < 120 mmHg was close to achieving significance (HR 1.9 (95% CI 0.99 to 3.6); p = 0.052).

Conclusion

Our study is the first to demonstrate that postoperative hypotension within the first 24 hours is an independent risk factor for 30-day mortality after hip fracture surgery. Clinicians should recognize patients who have a SBP of < 90 mmHg in the early postoperative period, and be aware of the increased mortality risk in this specific cohort who may benefit from a closer level of monitoring and early intervention.

Effect of carotid corrected flow time combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients: a prospective cohort study

BACKGROUND

Hypotension often occurs following the induction of general anesthesia in elderly patients undergoing surgery and can lead to severe complications. This study assessed the effect of carotid corrected flow time (FTc) combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients.

MATERIALS AND METHODS

The prospective cohort study was divided into two parts. The first part (Part I) consisted of 112 elderly patients. Carotid FTc was measured using Color Doppler Ultrasound 5 min before anesthesia induction. Hypotension was defined as a decrease of greater than 30% in systolic blood pressure (SBP) or a decrease of greater than 20% in mean arterial pressure (MAP) from baseline, or an absolute SBP below 90 mmHg and MAP below 60 mmHg within 3 min after induction of general anesthesia. The predictive value of carotid FTc was determined using receiver operating characteristic (ROC) curve. The second part (Part II) consisted of 65 elderly patients. Based on the results in Part I, elderly patients with carotid FTc below the optimal cut-off value received perioperative fluid therapy at a volume of 8 ml/kg of balanced crystalloids (lactated Ringer's solution) in 30 min before induction. The effect of carotid FTc combined with perioperative fluid therapy was assessed by comparing observed incidence of hypotension after induction.

RESULTS

The area under the ROC for carotid FTc to predict hypotension after induction was 0.876 [95% confidence interval (CI) 0.800-0.952, P <0.001]. The optimal cut-off value was 334.95 ms (sensitivity of 87.20%; specificity of 82.20%). The logistic regression analysis revealed that carotid FTc is an independent predictor for post-induction hypotension in elderly patients. The incidence of post-induction hypotension was significantly lower ( P <0.001) in patients with carotid FTc less than 334.95 ms who received perioperative fluid therapy (35.71%) compared to those who did not (92.31%).

CONCLUSIONS

Carotid FTc combined with the perioperative fluid therapy could significantly reduce the incidence of hypotension after the induction of general anesthesia in elderly patients.

Hypotensive Levels on Endoscopic Sinus Surgery Visibility: A Randomized Non-Inferiority Trial

OBJECTIVE

Optimization of endoscopic sinus surgery (ESS) conditions is a common focus of interest for otolaryngologists and anesthesiologists. Relying on hypotension alone to achieve a bloodless field may not without risks. We sought to determine whether ESS is feasible in the context of moderate hypotension.

METHODS

This randomized non-inferiority trial enrolled 96 adult patients who were to undergo ESS. The patients were divided into two groups: Controlled hypotension group (n = 48, MAP reduction to 55-65 mmHg, minimum of 60% of baseline blood pressure) or Individualized hypotension group (n = 48, MAP reduction to 75-80% of baseline blood pressure). All participants were placed in 10° reverse Trendelenburg position during ESS, and cottonoid patties dammed with epinephrine was recommended to clear the operative field of bleeding. The two groups were compared according to Boezaart grading scale (BS) score, estimated blood loss, blood loss rate, arterial lactate level and postoperative recovery.

RESULTS

Both levels of intraoperative hypotension (62.2 ± 2.3 mmHg vs. 74.0 ± 2.8 mmHg) provided acceptable surgical conditions with no difference in mean BS scores [2.00 (1.88-2.33) vs. 2.00 (1.85-2.45), p = 0.926]. The 95% CI for median value differences in mean BS scores is lower than the preset non-inferiority margin. There were no differences in blood loss rate and estimated blood loss between two groups (p > 0.05) Postoperative arterial lactate and Ramsay sedation scores were significantly different between the two groups (p < 0.05).

CONCLUSIONS

In ESS, both levels of intraoperative hypotension, combined with position adjustment and low-concentration adrenaline to constrict nasal mucosal blood vessels, provided acceptable surgical conditions.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:569-576, 2024.

Myeloid ACE2 protects against septic hypotension and vascular dysfunction through Ang-(1-7)-Mas-mediated macrophage polarization

Angiotensin converting enzyme 2 (ACE2) is a new identified member of the renin-angiotensin-aldosterone system (RAAS) that cleaves angiotensin II (Ang II) to Ang (1-7), which exerts anti-inflammatory and antioxidative activities via binding with Mas receptor (MasR). However, the functional role of ACE2 in sepsis-related hypotension remains unknown. Our results indicated that sepsis significantly reduced blood pressure and led to disruption between ACE-Ang II and ACE2-Ang (1-7) balance. ACE2 knock-in mice exhibited improved sepsis-induced mortality, hypotension and vascular dysfunction, while ACE2 knockout mice exhibited the opposite effects. Bone marrow transplantation and in vitro experiments confirmed that myeloid ACE2 exerted a protective role by suppressing oxidative stress, NO production and macrophage polarization via the Ang (1-7)-MasR-NF-κB and STAT1 pathways. Thus, ACE2 on myeloid cells could protect against sepsis-mediated hypotension and vascular dysfunction, and upregulating ACE2 may represent a promising therapeutic option for septic patients with hypotension.

American society of anesthesiologists physical status classification significantly affects the performances of machine learning models in intraoperative hypotension inference

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.

Carotid sinus baroafferent signals contribute to cerebral blood flow regulation during acute hypotension in young males: A randomized crossover study

Cerebral autoregulation is an important factor in prevention of cerebral ischemic events. We tested a traditional but unproven hypothesis that carotid sinus baroafferent signals contribute to dynamic cerebral autoregulation. Middle cerebral artery mean blood velocity (MCA Vmean ) responses to thigh-cuff deflation-induced acute hypotension were compared between conditions using neck suction soon after cuff deflation, without or with a cushion wrapped around the upper neck, in nine healthy males (aged 25 ± 5 years). Neck suction was applied close to the hypotension. The MCA Vmean response was expected to differ between conditions because the cushion was presumed to prevent the carotid sinus distension by neck suction. The cushion hindered bradycardia and depressor responses during sole neck suction. Thigh-cuff deflation decreased mean arterial blood pressure (MAP) and MCA Vmean (Ps < 0.05) with an almost unchanged respiratory rate under both conditions. However, in the neck suction + cushion condition, subsequent MCA Vmean restoration was faster and greater (Ps ≤ 0.0131), despite similar changes in MAP in both conditions. Thus, carotid sinus baroafferent signals would accelerate dynamic cerebral autoregulation during rapid hypotension in healthy young males. Elucidating the mechanism underlying cerebral neural autoregulation could provide a new target for preventing cerebral ischemic events.

Predicting fluid responsiveness in spontaneously breathing parturients undergoing caesarean section via carotid artery blood flow and velocity time integral measured by carotid ultrasound: a prospective cohort study

BACKGROUND

Present evidence suggests that the Doppler ultrasonographic indices, such as carotid artery blood flow (CABF) and velocity time integral (VTI), had the ability to predict fluid responsiveness in non-obstetric patients. The purpose of this study was to assess their capacity to predict fluid responsiveness in spontaneous breathing parturients undergoing caesarean section and to determine the effect of detecting and management of hypovolemia (fluid responsiveness) on the incidence of hypotension after anaesthesia.

METHODS

A total of 72 full term singleton parturients undergoing elective caesarean section were enrolled in this study. CABF, VTI, and hemodynamic parameters were recorded before and after fluid challenge and assessed by carotid artery ultrasonography. Fluid responsiveness was defined as an increase in stroke volume index (SVI) of 15% or more after the fluid challenge.

RESULTS

Thirty-one (43%) patients were fluid responders. The area under the ROC curve to predict fluid responsiveness for CABF and VTI were 0.803 (95% CI, 0.701-0.905) and 0.821 (95% CI, 0.720-0.922). The optimal cut-off values of CABF and VTI for fluid responsiveness was 175.9 ml/min (sensitivity of 74.0%; specificity of 78.0%) and 8.7 cm/s (sensitivity of 67.0%; specificity of 90.0%). The grey zone for CABF and VTI were 114.2-175.9 ml/min and 6.8-8.7 cm/s. The incidence of hypotension after the combined spinal-epidural anaesthesia (CSEA) was significantly higher in the Responders group 25.8% (8/31) than in the Non-Responders group 17.1(7/41) (P < 0.001). The total incidence of hypotension after CSEA of the two groups was 20.8% (15/72).

CONCLUSIONS

Ultrasound evaluation of CABF and VTI seem to be the feasible parameters to predict fluid responsiveness in parturients undergoing elective caesarean section and detecting and management of hypovolemia (fluid responsiveness) could significantly decrease incidence of hypotension after anaesthesia.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Registry (ChiCTR) ( www.chictr.org ), registration number was ChiCTR1900022327 (The website link: https://www.chictr.org.cn/showproj.html?proj=37271 ) and the date of trial registration was in April 5, 2019. This study was performed in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of Women's Hospital, Zhejiang University School of Medicine (20,180,120).

Use total portosystemic shunt to rescue an emergency PNF with intractable hypotension: A case report

RATIONALE

Living donor allogeneic liver transplantation is a surgical treatment for patients with end-stage liver disease, wherein a healthy liver is implanted in the patient, facilitating the recovery of the liver function in patients with end-stage liver disease. However, primary nonfunction (PNF) may occur as a result of this procedure.

PATIENT CONCERNS

A case of an 65-year-old Asian male with a medical history of cirrhosis and hepatocellular carcinoma is described. Intractable hypotension occurred after open hepatic portal anastomosis, and large doses of vasoactive substances did not improve the condition.

DIAGNOSIS

PNF was diagnosed during surgery and it caused intractable hypotension.

INTERVENTIONS

we promptly used the total portosystemic shunt to achieve a successful rescue.

OUTCOMES

The strengthening of perioperative management and active treatment allowed second liver transplantation and anhepatic phase of up to 10 hours, following which the patient was rescued.

LESSONS

The lesson we have learned is that total portosystemic shunt composited with careful anesthesia management can rescue the event of PNF with intractable hypotension in liver transplantation surgery. At the same time, we give attention to blood pressure, electrocardiogram, albumin, calcium, potassium, acidosis, coagulopathy, anti-infection, and protection of vital organs is essential for successful retransplant outcomes.

Effectiveness of general anaesthesia with remimazolam tosilate on intraoperative haemodynamics and postoperative recovery: study protocol for a randomised, positive-controlled, pragmatic clinical trial (GARTH trial)

INTRODUCTION

It is encouraged to estimate the effectiveness of components within the enhanced recovery after surgery (ERAS) protocol through patient-reported outcomes, alongside doctor-reported outcomes and length of hospital stay. At present, studies on the contributions of optimal anaesthetic drugs within the ERAS protocol to patient-reported and doctor-reported outcomes are limited. Therefore, this study aims to pragmatically evaluate the effectiveness and safety of general anaesthesia (GA) with remimazolam tosilate within the ERAS protocol on intraoperative haemodynamics and postoperative recovery in adults undergoing elective surgeries, compared with propofol.

METHODS AND ANALYSIS

This study is a single-centre, randomised, blinded, positive-controlled, pragmatic clinical trial. A total of 900 patients, aged ≥18 years old, scheduled for an elective surgical procedure under GA will be included. Patients will be randomised in a 1:1 ratio to the remimazolam group (the GA with remimazolam tosilate within the ERAS protocol group) or propofol group (the GA with propofol within the ERAS protocol group), stratified by general surgery, thoracic surgery and other surgeries (including urological surgery and otolaryngology surgery). The primary outcomes include the 24-hour postoperative quality of recovery-40 score and the rate of intraoperative hypotension. Secondary endpoints include the rate of sedative hypotension requiring treatment, the haemodynamic profiles, the 72-hour postoperative quality of recovery-40 score, the functional anaesthetic capability, adverse events and complications, quality of life within 3 months as well as economic health outcomes.

ETHICS AND DISSEMINATION

This study protocol has been approved by the ethics committee of Guangdong Provincial People's Hospital (KY-H-2022-005-03-08). Dissemination plans will be presented at scientific meetings and in scientific publications.

TRIAL REGISTRATION NUMBER

ChiCTR2200062520.

Carotid blood flow changes following a simulated end-inspiratory occlusion maneuver measured by ultrasound can predict hypotension after the induction of general anesthesia: an observational study

BACKGROUND

The primary purpose of this study was to investigate the predictive value of alterations in cervical artery hemodynamic parameters induced by a simulated end-inspiratory occlusion test (sEIOT) measured by ultrasound for predicting postinduction hypotension (PIH) during general anesthesia.

METHODS

Patients undergoing gastrointestinal tumor resection under general anesthesia were selected for this study. Ultrasound has been utilized to assess hemodynamic parameters in carotid artery blood flow before induction, specifically focusing on variations in corrected flow time (ΔFTc) and peak blood flow velocity (ΔCDPV), both before and after sEIOT. Anesthesia was induced by midazolam, sufentanil, propofol, and rocuronium, and blood pressure (BP) and heart rate (HR) were recorded within the first 10 min following endotracheal intubation. PIH was defined as fall in systolic blood pressure (SBP) or mean arterial pressure (MAP) by > 30% of baseline or MAP to < 60 mm Hg.

RESULTS

The area under the receiver operating characteristic curves (AUC) for carotid artery ΔFTc was 0.88 (95%CI, 0.81 to 0.96; P < 0.001), and the optimal cutoff value was -16.57%, with a sensitivity of 91.4% and specificity of 77.60%. The gray zone for carotid artery ΔFTc was -16.34% to -15.36% and included 14% of the patients. The AUC for ΔCDPV was 0.54, with an optimal cutoff value of -1.47%. The sensitivity and specificity were calculated as 55.20% and 57.10%, respectively.

CONCLUSION

The corrected blood flow time changes in the carotid artery induced by sEIOT can predict hypotension following general anesthesia-induced hypotension, wherein ΔFTc less than 16.57% is the threshold.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( www.chictr.org.cn ; 20/06/2023; ChiCTR2300072632).