Epidural ropivacaine versus bupivacaine for cesarean sections: a system review and meta-analysis

INTRODUCTION

It is still no consensus on the use of ropivacaine or bupivacaine in epidural anesthesia for cesarean section (CS), because their anesthetic potency and relative complications remains controversial. This system review and meta-analysis aimed to compare the efficacy of epidural ropivacaine and bupivacaine for elective CSs and investigate relative complications for parturients and neonates.

METHODS

We searched PubMed, MEDLINE, Embase, Cochrane Library, Science-Direct, and Google Scholar to June 30, 2023 for randomized controlled trials (RCTs), which compared epidural ropivacaine with bupivacaine for elective CSs. The success rate of epidural anesthesia (EA) was primary outcome. The secondary outcomes included onset times of sensory block, maternal side effects, neonatal Apgar scores and umbilical artery pH.

RESULTS

We analyzed 8 RCTs with 532 parturients. 0.75% ropivacaine is associated with a shorter onset time of sensory block than 0.5% bupivacaine (SMD = -0.43, 95% CI: -0.70 to -0.17; p = .001). 0.5% ropivacaine resulted in a reduced nausea than 0.5% bupivacaine (RR = 0.49, 95% CI: 0.28 to 0.83; p = .008). In addition, there were no significant difference between ropivacaine and bupivacaine groups in terms of success rate of epidural anesthesia, maternal side effects (hypotension, bradycardia, shivering), and neonatal Apgar scores and umbilical artery pH.

CONCLUSIONS

The findings suggest that there were no significant difference between epidural ropivacaine and bupivacaine for elective CSs in terms of the success rate (85.9% vs. 83.5), maternal side effects (hypotension, bradycardia, shivering), and neonatal Apgar scores and umbilical artery pH. But compared with 0.5% bupivacaine, epidural 0.75% ropivacaine was mildly effective for reducing onset time of sensory block and 0.5% ropivacaine reduced the incidence of maternal nausea.

Incidence, risk factors, and outcomes of the transition of HIPEC-induced acute kidney injury to acute kidney disease: a retrospective study

BACKGROUND

Acute kidney injury (AKI) is recognized as a common complication following cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Characterized by prolonged renal function impairment, acute kidney disease (AKD) is associated with a higher risk of chronic kidney disease (CKD) and mortality.

METHODS

From January 2018 to December 2021, 158 patients undergoing CRS-HIPEC were retrospectively reviewed. Patients were separated into non-AKI, AKI, and AKD cohorts. Laboratory parameters and perioperative features were gathered to evaluate risk factors for both HIPEC-induced AKI and AKD, with the 90-day prognosis of AKD patients.

RESULTS

AKI developed in 21.5% of patients undergoing CRS-HIPEC, while 13.3% progressed to AKD. The multivariate analysis identified that ascites, GRAN%, estimated glomerular filtration rate (eGFR), and intraoperative (IO) hypotension duration were associated with the development of HIPEC-induced AKI. Higher uric acid, lessened eGFR, and prolonged IO hypotension duration were more predominant in patients proceeding with AKD. The AKD cohort presented a higher risk of 30 days of in-hospital mortality (14.3%) and CKD progression (42.8%).

CONCLUSIONS

Our study reveals a high incidence of AKI and AKI-to-AKD transition. Early identification of risk factors for HIPEC-induced AKD would assist clinicians in taking measures to mitigate the incidence.

Comparison of remimazolam-based and propofol-based total intravenous anesthesia on hemodynamics during anesthesia induction in patients undergoing transcatheter aortic valve replacement: a randomized controlled trial

PURPOSE

This study aimed to compare the hemodynamic effects of remimazolam- and propofol-based total intravenous anesthesia in patients who underwent transcatheter aortic valve replacement.

METHODS

This was a single-center, single-blind, randomized controlled trial set at Nara Medical University, Kashihara, Japan. We included 36 patients aged ≥ 20 years scheduled to undergo elective transfemoral transcatheter aortic valve replacement (TAVR) under general anesthesia. The participants were randomly assigned to the remimazolam and propofol groups (n = 18 each). Remimazolam- or propofol-based total intravenous anesthesia was initiated at 12 mg/kg/min or 2.5 mcg/mL via target-controlled infusion, respectively, along with remifentanil. After confirming the loss of consciousness, the administration rate was adjusted using electroencephalographic monitoring. The primary outcome was the rate of arterial hypotension, defined as a mean arterial pressure < 60 mmHg, from anesthesia induction until the beginning of the surgical incision. The total doses of ephedrine and phenylephrine were also assessed.

RESULTS

During anesthesia induction, the arterial hypotension rates were 11.9% and 21.6% in the remimazolam and propofol groups, respectively (P = 0.01). The total dose of ephedrine was higher in the propofol group (14.4 mg) than in the remimazolam group (1.6 mg) (P < 0.001); however, the total dose of phenylephrine was not significantly different between the two groups (propofol 0.31 mg vs. remimazolam: 0.17 mg, P = 0.10).

CONCLUSION

Remimazolam-based total intravenous anesthesia resulted in a lower hypotension rate than propofol-based total intravenous anesthesia during induction in patients undergoing TAVR. Remimazolam-based total intravenous anesthesia can be used safely during anesthetic induction in patients with severe aortic stenosis.

Impact of "hypotension on arrival" on required surgical disciplines and usage of damage control protocols in severely injured patients

BACKGROUND

For trauma patients with subsequent immediate surgery, it is unclear which surgical disciplines are most commonly required for treatment, and whether and to what extend this might depend on or change with "hypotension on arrival". It is also not known how frequently damage control protocols are used in daily practice and whether this might also be related to "hypotension on arrival".

METHODS

A retrospective analysis of trauma patients from a German level 1 trauma centre and subsequent "immediate surgery" between 01/2017 and 09/2022 was performed. Patients with systolic blood pressure > 90 mmHg (group 1, no-shock) and < 90 mmHg (group 2, shock) on arrival were compared with regard to (a) most frequently required surgical disciplines, (b) usage of damage control protocols, and (c) outcome. A descriptive analysis was performed, and Fisher's exact test and the Mann‒Whitney U test were used to calculate differences between groups where appropriate.

RESULTS

In total, 98 trauma patients with "immediate surgery" were included in our study. Of these, 61 (62%; group 1) were normotensive, and 37 (38%, group 2) were hypotensive on arrival. Hypotension on arrival was associated with a significant increase in the need for abdominal surgery procedures (group 1: 37.1 vs. group 2: 54.5%; p = 0.009), more frequent usage of damage control protocols (group 1: 59.0 vs. group 2: 75.6%; p = 0.019) and higher mortality (group 1: 5.5 vs. group 2: 24.3%; p 0.027).

CONCLUSION

Our data from a German level 1 trauma centre proof that abdominal surgeons are most frequently required for the treatment of trauma patients with hypotension on arrival among all surgical disciplines (> thoracic surgery > vascular surgery > neurosurgery). Therefore, surgeons from these specialties must be available without delay to provide optimal trauma care.

Effects of Achieving Rapid, Intensive, and Sustained Blood Pressure Reduction in Intracerebral Hemorrhage Expansion and Functional Outcome

BACKGROUND AND OBJECTIVES

The time taken to achieve blood pressure (BP) control could be pivotal in the benefits of reducing BP in acute intracerebral hemorrhage (ICH). We aimed to assess the relationship between the rapid achievement and sustained maintenance of an intensive systolic BP (SBP) target with radiologic, clinical, and functional outcomes.

METHODS

Rapid, Intensive, and Sustained BP lowering in Acute ICH (RAINS) was a multicenter, prospective, observational cohort study of adult patients with ICH <6 hours and SBP ≥150 mm Hg at 4 Comprehensive Stroke Centers during a 4.5-year period. Patients underwent baseline and 24-hour CT scans and 24-hour noninvasive BP monitoring. BP was managed under a rapid (target achievement ≤60 minutes), intensive (target SBP <140 mm Hg), and sustained (target stability for 24 hours) BP protocol. SBP target achievement ≤60 minutes and 24-hour SBP variability were recorded. Outcomes included hematoma expansion (>6 mL or >33%) at 24 hours (primary outcome), early neurologic deterioration (END, 24-hour increase in NIH Stroke Scale score ≥4), and 90-day ordinal modified Rankin scale (mRS) score. Analyses were adjusted by age, sex, anticoagulation, onset-to-imaging time, ICH volume, and intraventricular extension.

RESULTS

We included 312 patients (mean age 70.2 ± 13.3 years, 202 [64.7%] male). Hematoma expansion occurred in 70/274 (25.6%) patients, END in 58/291 (19.9%), and the median 90-day mRS score was 4 (interquartile range, 2-5). SBP target achievement ≤60 minutes (178/312 [57.1%]) associated with a lower risk of hematoma expansion (adjusted odds ratio [aOR] 0.43, 95% confidence interval [CI] 0.23-0.77), lower END rate (aOR 0.43, 95% CI 0.23-0.80), and lower 90-day mRS scores (aOR 0.48, 95% CI 0.32-0.74). The mean 24-hour SBP variability was 21.0 ± 7.6 mm Hg. Higher 24-hour SBP variability was not related to expansion (aOR 0.99, 95% CI 0.95-1.04) but associated with higher END rate (aOR 1.15, 95% CI 1.09-1.21) and 90-day mRS scores (aOR 1.06, 95% CI 1.04-1.10).

DISCUSSION

Among patients with acute ICH, achieving an intensive SBP target within 60 minutes was associated with lower hematoma expansion risk. Rapid SBP reduction and stable sustention within 24 hours were related to improved clinical and functional outcomes. These findings warrant the design of randomized clinical trials examining the impact of effectively achieving rapid, intensive, and sustained BP control on hematoma expansion.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that in adults with spontaneous ICH and initial SBP ≥150 mm Hg, lowering SBP to <140 mm Hg within the first hour and maintaining this for 24 hours is associated with decreased hematoma expansion.

Point-of-Care Ultrasound in Critical Care Obstetrics: A Scoping Review of the Current Evidence

OBJECTIVES

To synthesize the current evidence of maternal point-of-care ultrasound (POCUS) in obstetrics. A scoping review was conducted using PubMed, Clinicaltrials.gov, and the Cochrane library from inception through October 2023.

METHODS

Studies were eligible for inclusion if they described the use of POCUS among obstetric or postpartum patients. Two authors independently screened all abstracts. Quantitative, qualitative, and mixed-methods studies were eligible for inclusion. Case reports of single cases, review articles, and expert opinion articles were excluded. Studies describing detailed maternal nonobstetric sonograms or maternal first trimester sonograms to confirm viability and rule out ectopic pregnancy were also excluded. Data were tabulated using Microsoft Excel and summarized using a narrative review and descriptive statistics.

RESULTS

A total of 689 publications were identified through the search strategy and 12 studies met the inclusion criteria. Nine studies evaluated the use of lung POCUS in obstetrics in different clinical scenarios. Lung ultrasound (LUS) findings in preeclampsia showed an excellent ability to detect pulmonary edema (area under the receiver operating characteristic 0.961) and findings were correlated with clinical evidence of respiratory distress (21 of 57 [37%] versus 14 of 109 [13%]; P = .001). Three studies evaluated abdominal POCUS, two of the inferior vena cava (IVC) to predict postspinal anesthesia hypotension (PSAH) and fluid receptivity and one to assess the rate of ascites in patients with preeclampsia. Patients with PSAH had higher IVC collapsibility (area under the curve = 0.950, P < .001) and, in patients with severe preeclampsia, there is a high rate of ascites (52%) associated with increased risk of adverse outcomes. There were no studies on the use of subjective cardiac POCUS.

CONCLUSION

POCUS use in the management of high-risk obstetrics has increased. LUS has been the most studied modality and appears to have a potential role in the setting of preeclampsia complicated by pulmonary edema. Cardiac and abdominal POCUS have not been well studied. Trials are needed to evaluate its clinical applicability, reliability, and technique standardization before widespread use.

Short anesthesia without intravenous fluid therapy in children: Results of a prospective non-interventional multicenter observational study

BACKGROUND

The German guidelines recommend that intravenous fluid therapy should not be mandatorily performed in children with short fasting times undergoing short anesthesia, but there is a lack of clinical studies including a large number of pediatric patients. Therefore, we performed a prospective non-interventional multicenter observational study to evaluate the perioperative hemodynamic and metabolic stability of children undergoing short anesthesia without intravenous fluid therapy.

AIMS

The primary aim was to assess the incidence of hypotension and the secondary aim was to assess the real preoperative fasting times, the incidence of hypoglycemia and the impact on ketone bodies and acid-base balance.

METHODS

Children aged 1 month-18 years undergoing short anesthesia (<1 h) without intravenous fluid therapy were enrolled. Patient demographics, the surgical or diagnostic procedure performed, anesthesia, hemodynamic, laboratory data, and adverse events were documented using a standardized case report form.

RESULTS

Four hundred and twenty seven children that were investigated at three pediatric centers from July 2021 to June 2022 (mean age 83.4 ± 58.9 months, body weight 27.9 ± 19.8 kg) were included in the analysis. The real preoperative fasting times were 14.2 ± 3.6 h for solids, 7.2 ± 3.5 h for milk and 5 ± 4.8 h for clear fluids. During the course of anesthesia, hypotension (<2.5th percentile) was detected in 3 of 427 cases (0.7%), hypoglycemia (glucose <3.0 mmol L-1) in 1 of 355 cases (0.3%), and ketosis (ketone bodies ≥0.6 mmol L-1) in 51 of 233 cases (21.9%). The occurrence of ketosis was associated with lower body weight (p <.001) and longer fasting times for solids or milk (p =.021), but not for clear fluids (p =.69).

CONCLUSIONS

Our study supported the German guidelines recommendation that perioperative intravenous fluid therapy is not mandatory in children beyond the neonatal period with short pre- and postoperative fasting times undergoing short anesthesia (<1 h).

Mortality in hypotensive combat casualties who require emergent laparotomy in the forward deployed environment

INTRODUCTION

Mortality rates among hypotensive civilian patients requiring emergent laparotomy exceed 40%. Damage control (DCR) principles were incorporated into the military's Clinical Practice Guidelines (CPG) in 2008. We examined combat casualties requiring emergent laparotomy to characterize how mortality rates compare to hypotensive civilian trauma patients.

METHODS

The DoD Trauma Registry (2004-2020) was queried for adults who underwent combat laparotomy. Patients who were hypotensive were compared to normotensive patients. Mortality was the outcome of interest. Mortality rates before (2004-2007) and after (2009-2020) DCR CPG implementation were analyzed.

RESULTS

1051 patients were studied. Overall mortality was 6.5% for normotensive casualties and 28.7% for hypotensive casualties. Mortality decreased in normotensive patients but remained unchanged in hypotensive patients following the implementation of the DCR CPG.

CONCLUSION

Hypotensive combat casualties undergoing emergent laparotomy demonstrated a mortality rate of 29.5%. Despite many advances, mortality rates remain high in hypotensive patients requiring emergent laparotomy.

Salt sensitivity risk derived from nocturnal dipping and 24-h heart rate predicts long-term blood pressure reduction following renal denervation

BACKGROUND

Renal denervation (RDN) has been consistently shown in recent sham-controlled clinical trials to reduce blood pressure (BP). Salt sensitivity is a critical factor in hypertension pathogenesis, but cumbersome to assess by gold-standard methodology. Twenty-four-hour average heart rate (HR) and mean arterial pressure (MAP) dipping, taken by ambulatory blood pressure monitoring (ABPM), stratifies patients into high, moderate, and low salt sensitivity index (SSI) risk categories.

OBJECTIVES

We aimed to assess whether ABPM-derived SSI risk could predict the systolic blood pressure reduction at long-term follow-up in a real-world RDN patient cohort.

METHODS

Sixty participants had repeat ABPM as part of a renal denervation long-term follow-up. Average time since RDN was 8.9 ± 1.2 years. Based on baseline ABPM, participants were stratified into low (HR < 70 bpm and MAP dipping > 10%), moderate (HR ≥70 bpm or MAP dipping ≤ 10%), and high (HR ≥ 70 bpm and MAP dipping ≤ 10%) SSI risk groups, respectively.

RESULTS

One-way ANOVA indicated a significant treatment effect ( P  = 0.03) between low ( n  = 15), moderate ( n  = 35), and high ( n  = 10) SSI risk with systolic BP reduction of 9.6 ± 3.7 mmHg, 8.4 ± 3.5 mmHg, and 28.2 ± 9.6 mmHg, respectively. Baseline BP was not significantly different between SSI Risk groups ( P  = 0.18). High SSI risk independently correlated with systolic BP reduction ( P  = 0.02).

CONCLUSIONS

Our investigation indicates that SSI risk may be a simple and accessible measure for predicting the BP response to RDN. However, the influence of pharmacological therapy on these participants is an important extraneous variable requiring testing in prospective or drug naive RDN cohorts.

Central and peripheral mechanisms underlying postexercise hypotension: a scoping review

Blood pressure (BP) reduction occurs after a single bout of exercise, referred to as postexercise hypotension (PEH). The clinical importance of PEH has been advocated owing to its potential contribution to chronic BP lowering, and as a predictor of responders to exercise training as an antihypertensive therapy. However, the mechanisms underlying PEH have not been well defined. This study undertook a scoping review of research on PEH mechanisms, as disclosed in literature reviews. We searched the PubMed, Web of Science, Scopus, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Sport Discus databases until January 2023 to locate 21 reviews - 13 narrative, four systematic with 102 primary trials, and four meta-analyses with 75 primary trials involving 1566 participants. We classified PEH mechanisms according to major physiological systems, as central (autonomic nervous system, baroreflex, cardiac) or peripheral (vascular, hemodynamic, humoral, and renal). In general, PEH has been related to changes in autonomic control leading to reduced cardiac output and/or sustained vasodilation. However, the role of autonomic control in eliciting PEH has been challenged in favor of local vasodilator factors. The contribution of secondary physiological outcomes to changes in cardiac output and/or vascular resistance during PEH remains unclear, especially by exercise modality and population (normal vs. elevated BP, young vs. older adults). Further research adopting integrated approaches to investigate the potential mechanisms of PEH is warranted, particularly when the magnitude and duration of BP reductions are clinically relevant. (PROSPERO CRD42021256569).

ASGBI trauma committee position statement: a national audit of trauma laparotomy in the UK - an unmet need

Patients who undergo laparotomy for major trauma are amongst the most critically unwell patients, and they have high morbidity and mortality rates. Despite 20 yr of improvements in resuscitation practices, those who present with hypotension continue to have mortality rates of up to 50%. Currently there is no mechanism for capturing national audit data on these patients, leading to their exclusion from potential quality improvement initiatives. We argue that there is an unmet need for quality assurance in this patient cohort and outline possible mechanisms to address this.

Cardiovascular Risk in Patients With Treated Isolated Diastolic Hypertension and Isolated Low Diastolic Blood Pressure

BACKGROUND

The prognosis of high or markedly low diastolic blood pressure (DBP) with normalized on-treatment systolic blood pressure on major adverse cardiovascular events (MACEs) is uncertain. This study examined whether treated isolated diastolic hypertension (IDH) and treated isolated low DBP (ILDBP) were associated with MACEs in patients with hypertension.

METHODS AND RESULTS

A total of 7582 patients with on-treatment systolic blood pressure <130 mm Hg from SPRINT (Systolic Blood Pressure Intervention Trial) were categorized on the basis of average DBP: <60 mm Hg (n=1031; treated ILDBP), 60 to 79 mm Hg (n=5432), ≥80 mm Hg (n=1119; treated IDH). MACE risk was estimated using Cox proportional-hazards models. Among the SPRINT participants, median age was 67.0 years and 64.9% were men. Over a median follow-up of 3.4 years, 512 patients developed a MACE. The incidence of MACEs was 3.9 cases per 100 person-years for treated ILDBP, 1.9 cases for DBP 60 to 79 mm Hg, and 1.8 cases for treated IDH. Comparing with DBP 60 to 79 mm Hg, treated ILDBP was associated with an 1.32-fold MACE risk (hazard ratio [HR], 1.32, 95% CI, 1.05-1.66), whereas treated IDH was not (HR, 1.18 [95% CI, 0.87-1.59]). There was no effect modification by age, sex, atherosclerotic cardiovascular disease risk, or cardiovascular disease history (all P values for interaction >0.05).

CONCLUSIONS

In this secondary analysis of SPRINT, among treated patients with normalized systolic blood pressure, excessively low DBP was associated with an increased MACE risk, while treated IDH was not. Further research is required for treated ILDBP management.

Teaching Medical Students Rapid Ultrasound for shock and hypotension (RUSH): learning outcomes and clinical performance in a proof-of-concept study

BACKGROUND

Point-of-care ultrasound (POCUS) is a critical diagnostic tool in various medical settings, yet its instruction in medical education is inconsistent. The Rapid Ultrasound for Shock and Hypotension (RUSH) protocol is a comprehensive diagnostic tool, but its complexity poses challenges for teaching and learning. This study evaluates the effectiveness of a single-day training in RUSH for medical students by assessing their performance in clinical scenarios.

METHODS

In this prospective single-center observational proof-of-concept study, 16 medical students from Saarland University Medical Center underwent a single-day training in RUSH, followed by evaluations in clinical settings and on a high-fidelity simulator. Performance was assessed using a standardized scoring tool and time to complete the RUSH exam. Knowledge gain was measured with pre- and post-training written exams, and diagnostic performance was evaluated with an objective structured clinical examination (OSCE).

RESULTS

Students demonstrated high performance in RUSH exam views across patients (median performance: 85-87%) and improved scanning times, although not statistically significant. They performed better on simulators than on live patients. Written exam scores significantly improved post-training, suggesting a gain in theoretical knowledge. However, more than a third of students could not complete the RUSH exam within five minutes on live patients.

CONCLUSIONS

Single-day RUSH training improved medical students' theoretical knowledge and simulator performance but translating these skills to clinical settings proved challenging. The findings suggest that while short-term training can be beneficial, it may not suffice for clinical proficiency. This study underscores the need for structured and possibly longitudinal training programs to ensure skill retention and clinical applicability.

Association of relative hand grip strength with myocardial infarction and angina pectoris in the Korean population: a large-scale cross-sectional study

BACKGROUND

Low hand grip strength (HGS) is associated with the risk of cardiovascular diseases, but the association between HGS and myocardial infarction/angina pectoris (MIAP) is unclear. Furthermore, there have been no studies examining the associations of MIAP with anthropometric indices, absolute HGS indices, and relative HGS indices calculated by dividing absolute HGS values by body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), or weight values. Therefore, the objective of this study was to examine the associations of MIAP with absolute and relative HGS combined with several anthropometric indices.

METHODS

In this large-scale cross-sectional study, a total of 12,963 subjects from the National Health and Nutrition Examination Survey were included. Odds ratios and 95% confidence intervals for the associations of MIAP with anthropometric indices, absolute HGS indices, and relative HGS indices were computed from binary logistic regression models. We built 3 models: a crude model, a model that was adjusted for age (Model 1), and a model that was adjusted for other relevant covariates (Model 2).

RESULTS

For men, the average age was 61.55 ± 0.16 years in the MIAP group and 66.49 ± 0.61 years in the non-MIAP group. For women, the average age was 61.99 ± 0.14 years in the MIAP group and 70.48 ± 0.61 years in the non-MIAP group. For both sexes, the MIAP group had lower diastolic blood pressure, shorter stature, greater WC, and a greater WHtR than did the non-MIAP group, and women tended to have greater systolic blood pressure, weight, and BMI than in men. HGS was strongly associated with the risk of MIAP in the Korean population. In men, relative HGS indices combined with WC and the WHtR had greater associations with MIAP than did the anthropometric indices and absolute HGS indices. However, in women, anthropometric indices, including weight, BMI, WC, and WHtR, were more strongly associated with MIAP than were absolute and relative HGS indices, unlike in men. When comparing absolute and relative HGS indices in women, relative HGS indices combined with BMI and weight was more strongly related to MIAP than was absolute HGS indices.

CONCLUSIONS

MIAP might be better identified by relative HGS than absolute HGS in both sexes. The overall magnitudes of the associations of MIAP with absolute and relative HGS are greater in men than in women.

Analyses of the onset mechanisms of cardio-stimulatory action by aciclovir

Cardio-stimulatory actions of aciclovir have been considered to primarily depend on the sympathetically-mediated reflex resulting from its hypotensive effect. To further clarify onset mechanisms of the cardio-stimulatory actions, we initially studied them using isoflurane-anesthetized dogs under thorough β1-adrenoceptor blockade with atenolol (1 mg/kg, i.v.) (n = 4). Aciclovir (20 mg/kg/10 min, i.v.) decreased mean arterial blood pressure by 10 mmHg, whereas it increased heart rate by 10 bpm and maximum upstroke velocity of ventricular pressure by 928 mmHg/s, and shortened AH interval by 2 ms, indicating that cardio-stimulatory actions were not totally abolished by β1-adrenoceptor blockade. Then, unknown mechanisms of cardio-stimulatory action were explored. Since aciclovir has a similar chemical structure to theophylline, in silico molecular docking simulation was performed, indicating aciclovir as well as theophylline possesses strong likelihood of interactions with phosphodiesterase 1A, 1C and 3A. Indeed, aciclovir inhibited phosphodiesterase 1A derived from the bovine heart (n = 4), moreover it exerted positive chronotropic action on the atrial tissue preparation of rats along with an increase of tissue cyclic AMP concentration (n = 4). These results indicate that cardio-stimulatory actions of aciclovir could result from not only hypotension-induced, reflex-mediated increase of sympathetic tone but also its inhibitory effects on phosphodiesterase in the heart.

Reducing Time to Postintubation Sedation in a Pediatric Emergency Department

BACKGROUND AND OBJECTIVE

Inadequate postintubation sedation (PIS) can lead to unplanned extubations, conscious paralysis, and overall unsafe care of patients. From 2018 to 2020, we realized at our hospital that ∼25% of children received sedation in an adequate time frame in the pediatric emergency department, with 2 unplanned dislodgements of the endotracheal tube. Our objective was to reduce time to initiating PIS from a mean of 39 minutes to less than 15 minutes in our pediatric emergency department by September 2021.

METHODS

A multidisciplinary team was formed in March 2020 to develop a key driver diagram and a protocol to standardize PIS. Baseline data were obtained from December 2017 through March 2020. The primary measure was time from intubation to administration of first sedation medication. Plan-do-study-act cycles informed interventions for protocol development, awareness, education, order set development, and PIS checklist. The secondary measure was unplanned extubations and the balancing measure was PIS-related hypotension requiring pressors. An X-bar and S chart were used to analyze data.

RESULTS

Protocol implementation was associated with decrease in mean time to PIS from 39 minutes to 21 minutes. Following educational interventions, order set implementation, and the addition of PIS plan to the intubation checklist, there was a decrease in mean time to PIS to 13 minutes, which was sustained for 9 months without any observed episodes of PIS-related hypotension or unplanned extubations.

CONCLUSIONS

Quality improvement methodology led to a sustained reduction in time to initiation of PIS in a pediatric emergency department.

Apnea Testing Practice to Increase Baseline PaCO2 and Frequency of Blood Gas Analyses

OBJECTIVE

To study the influence of the initial partial pressure of carbon dioxide (PaCO2) and frequency of blood gas analyses on the positivity rate and safety of apnea testing (AT).

DESIGN

A prospective multicenter cohort study.

SETTING

Seven teaching hospitals.

PARTICIPANTS

A total of 55 patients who underwent AT.

INTERVENTIONS

Patients were divided into 2 groups according to their initial PaCO2-the experimental group (≥40 mmHg, 27 patients) and the control group (<40 mmHg, 28 patients). Blood gas analysis was performed at 3, 5, and 8 minutes, and vital signs were taken. AT results and complications were compared between the groups.

RESULTS

The initial PaCO2 of the experimental group was 42.8 ± 2.2 mmHg v 36.4 ± 2.9 mmHg in the controls. The AT positivity rate was 100%. The experimental group needed less time to reach the target PaCO2 than the control group (4.07 ± 1.27 minutes v 5.68 ± 2.06 minutes; p = 0.001). Twenty-six patients (96.3%) in the experimental group reached the target PaCO2 in 5 minutes v 17 in the control group (60.7%) (p = 0.001). Seven patients (12.7%) were unable to complete 8-minute disconnection due to hypotension. The experimental group had a slightly lower incidence of hypotension than the control group, but there was no statistical difference (7.4% v 17.9%, p = 0.245).

CONCLUSION

Increasing the baseline PaCO2 and doing more blood gas analyses can significantly shorten the time needed for AT and improve the AT positivity rate.

The Effect of Propofol on Peri-Induction Hemodynamics and Resuscitation in Operative Penetrating Trauma

BACKGROUND

Hemorrhaging trauma patients may be disproportionately affected by choice of induction agent during rapid sequence intubation (RSI). Etomidate, ketamine, and propofol are safe in the trauma population-at-large but have not been assessed in patients with ongoing hemorrhage. We hypothesize that in hemorrhaging patients with penetrating injury, propofol deleteriously affects peri-induction hypotension compared to etomidate and ketamine.

METHODS

Retrospective cohort study. Primary outcome was the effect of induction agent on peri-induction systolic blood pressure. Secondary outcomes were the incidence of peri-induction vasopressor use and quantity of peri-induction blood transfusion requirements. Linear multivariate regression modeling assessed the effect of induction agent on the variables of interest.

RESULTS

169 patients were included, 146 received propofol and 23 received etomidate or ketamine. Univariate analysis revealed no difference in peri-induction systolic blood pressure (P = .53), peri-induction vasopressor administration (P = .62), or transfusion requirements within the first hour after induction (PRBC P = .24, FFP P = .19, PLT P = .29). Choice of RSI agent did not independently predict peri-induction systolic blood pressure or blood product administration. Rather, only presenting shock index independently predicted peri-induction hypotension.

CONCLUSIONS

This is the first study to directly assess the peri-induction effects of anesthetic induction agent choice in penetrating trauma patients undergoing emergent hemorrhage control surgery. Propofol does not appear to worsen peri-induction hypotension regardless of dose. Patient physiology is most predictive of peri-induction hypotension.

Accuracy and clinical utility of heart rate variability derived from a wearable heart rate monitor in patients undergoing major abdominal surgery

Low heart rate variability (HRV) can potentially identify patients at risk of intraoperative hypotension. However, it is unclear whether cheaper, readily accessible consumer heart rate (HR) monitors can provide similar utility to clinical Holter electrocardiograph (ECG) monitors. The objectives of this study were (1) to assess the validity of using the Polar H10 HR monitor as an alternative to a clinical Holter ECG and (2) to test total power (TP) as a predictor of intraoperative hypotension. The primary outcome was the level of agreement between Polar H10 and Holter ECG. Twenty-three patients undergoing major abdominal surgery with general anesthesia had 5-minute HR recordings taken concurrently with both devices during a pre-anesthetic consultation. Agreement between Polar H10 and Holter ECG was compared via Bland-Altman analysis and Lin's Concordance Correlation Coefficient. Patients were divided into groups based on TP <  500 m s 2 and TP >  500 m s 2 . Intraoperative hypotension was defined as MAP < 60 mmHg, systolic blood pressure < 80 mmHg, or 35% decrease in MAP from baseline. There was substantial agreement between Polar H10 and Holter ECG for average R-R interval, TP and other HRV indices. Reduced TP (< 500 ms 2 ) had a high sensitivity (80%) and specificity (100%) in predicting intraoperative hypotension. Patients with reduced TP were significantly more likely to require vasoactive drugs to maintain blood pressure.The substantial agreement between Polar H10 and Holter ECG may justify its use clinically. The use of preoperative recordings of HRV has the potential to become part of routine preoperative assessment as a useful screening tool to predict hemodynamic instability in patients undergoing general anesthesia.

Hypotension during intensive care stay and mortality and morbidity: a systematic review and meta-analysis

PURPOSE

The aim of this study is to provide a summary of the existing literature on the association between hypotension during intensive care unit (ICU) stay and mortality and morbidity, and to assess whether there is an exposure-severity relationship between hypotension exposure and patient outcomes.

METHODS

CENTRAL, Embase, and PubMed were searched up to October 2022 for articles that reported an association between hypotension during ICU stay and at least one of the 11 predefined outcomes. Two independent reviewers extracted the data and assessed the risk of bias. Results were gathered in a summary table and studies designed to investigate the hypotension-outcome relationship were included in the meta-analyses.

RESULTS

A total of 122 studies (176,329 patients) were included, with the number of studies varying per outcome between 0 and 82. The majority of articles reported associations in favor of 'no hypotension' for the outcomes mortality and acute kidney injury (AKI), and the strength of the association was related to the severity of hypotension in the majority of studies. Using meta-analysis, a significant association was found between hypotension and mortality (odds ratio: 1.45; 95% confidence interval (CI) 1.12-1.88; based on 13 studies and 34,829 patients), but not for AKI.

CONCLUSION

Exposure to hypotension during ICU stay was associated with increased mortality and AKI in the majority of included studies, and associations for both outcomes increased with increasing hypotension severity. The meta-analysis reinforced the descriptive findings regarding mortality but did not yield similar support for AKI.

Dietary approach for the treatment of arterial hypertension in patients with diabetes mellitus

The association of hypertension and diabetes mellitus is extremely common, increasing the mortality risk of patients, mainly by cardiovascular causes. Regarding the blood pressure (BP) targets to be achieved, most guidelines suggest levels of 130 mmHg for SBP and of 80 mmHg for DBP. Dietary modifications are quite effective, and many studies suggest that decreasing sodium intake and increasing potassium ingestion are both valuable practices for reducing BP. This can be achieved by stimulating the ingestion of lacteous products, vegetables, and nuts. As for the ideal pharmacologic treatment for hypertension, either calcium channel blockers, diuretics or angiotensin-system blockers can be the first class of drug to be used. In this review, we summarize the evaluation of patients with diabetes mellitus and hypertension, and discuss the available therapeutic approaches, with emphasis on evidence-based dietary recommendations.

Effectiveness of a 3-year community-based intervention for blood pressure reduction among adults: a repeated cross-sectional study with a comparison area

Raised blood pressure is the leading risk factor for cardiovascular diseases. We aimed to demonstrate the effectiveness of a 3-year community-based healthy lifestyle promotion intervention at a neighbourhood level for blood pressure reduction among adults in the context of a political transition. We conducted repeated cross-sectional surveys including 1880 (940 from each area) participants at baseline and 1977 (1001 in the intervention area; 976 comparison area) participants at follow-up. Data collection was conducted through home visits. Multiple linear regression models were used to identify the intervention effect and factors associated with blood pressure change in each area. The prevalence of hypertension was 4.4% lower (35.8% vs. 31.4%) in the intervention area after 3 years (p = 0.044). The mean systolic and diastolic blood pressures changed significantly in the intervention area, from 132.4 ± 19.2 mmHg at baseline to 130.6 ± 17.7 mmHg at follow-up (p = 0.035) and from 78.7 ± 11.8 mmHg to 76.9 ± 11.1 mmHg (p < 10-3), respectively. In the control group, the mean systolic blood pressure increased from 129.4 ± 17.8 mmHg to 130.4 ± 17.9 mmHg (p = 0.38). A significant protective effect of the intervention on systolic (β = -0.4; 95% CI: -0.76; -0.06) and diastolic blood pressures (β = -0.22; 95% CI: -0.38; -0.07) was found in the intervention area. In the control area, the effect was not significant for systolic blood pressure. Lifestyle intervention at the neighbourhood level, in the context of a sociopolitical transition, was found to be effective for reducing blood pressure in Sousse, Tunisia. This approach could be scaled up and applied in other similar settings. Future research also needs to focus on designing, implementing, and evaluating multisectoral action plans and legislative measures.

The contribution of sodium reduction and potassium increase to the blood pressure lowering observed in the Salt Substitute and Stroke Study

The Salt Substitute and Stroke Study (SSaSS) demonstrated significant reductions in systolic blood pressure (SBP), and the risk of stroke, major cardiovascular events and total mortality with the use of potassium-enriched salt. The contribution of sodium reduction versus potassium increase to these effects is unknown. We identified four different data sources describing the association between sodium reduction, potassium supplementation and change in SBP. We then fitted a series of models to estimate the SBP reductions expected for the differences in sodium and potassium intake in SSaSS, derived from 24-h urine collections. The proportions of the SBP reduction separately attributable to sodium reduction and potassium supplementation were calculated. The observed SBP reduction in SSaSS was -3.3 mmHg with a corresponding mean 15.2 mmol reduction in 24-h sodium excretion and a mean 20.6 mmol increase in 24-h potassium excretion. Assuming 90% of dietary sodium intake and 70% of dietary potassium intake were excreted through urine, the models projected falls in SBP of between -1.67 (95% confidence interval: -4.06 to +0.73) mmHg and -5.33 (95% confidence interval: -8.58 to -2.08) mmHg. The estimated proportional contribution of sodium reduction to the SBP fall ranged between 12 and 39% for the different models fitted. Sensitivity analyses assuming different proportional urinary excretion of dietary sodium and potassium intake showed similar results. In every model, the majority of the SBP lowering effect in SSaSS was estimated to be attributable to the increase in dietary potassium rather than the fall in dietary sodium.

Greater use of antihypertensive medications explains lower blood pressures and better control in statin-treated than statin-eligible untreated adults

OBJECTIVE

Statins appear to have greater antihypertensive effects in observational studies than in randomized controlled trials. This study assessed whether more frequent treatment of hypertension contributed to better blood pressure (BP, mmHg) control in statin-treated than statin-eligible untreated adults in observational studies.

METHODS

National Health and Nutrition Examination Surveys 2009-2020 data were analyzed for adults 21-75 years ( N  = 3814) with hypertension (BP ≥140/≥90 or treatment). The 2013 American College of Cardiology/American Heart Association Cholesterol Guideline defined statin eligibility. The main analysis compared BP values and hypertension awareness, treatment, and control in statin-treated and statin-eligible but untreated adults. Multivariable logistic regression was used to assess the association of statin therapy to hypertension control and the contribution of antihypertensive therapy to that relationship.

RESULTS

Among adults with hypertension in 2009-2020, 30.3% were not statin-eligible, 36.9% were on statins, and 32.8% were statin-eligible but not on statins. Statin-treated adults were more likely to be aware of (93.4 vs. 80.6%) and treated (91.4 vs. 70.7%) for hypertension than statin-eligible adults not on statins. The statin-treated group had 8.3 mmHg lower SBP (130.3 vs. 138.6), and 22.8% greater control (<140/<90: 69.0 vs. 46.2%; all P values <0.001). The association between statin therapy and hypertension control [odds ratio 1.94 (95% confidence interval 1.53-2.47)] in multivariable logistic regression was not significant after also controlling for antihypertensive therapy [1.29 (0.96-1.73)].

CONCLUSION

Among adults with hypertension, statin-treated adults have lower BP and better control than statin-eligible untreated adults, which largely reflects differences in antihypertensive therapy.

Treatment for Resistant Hypertension Under the Guidance of Pharmacogenomics: A Randomised Controlled Open-Label Trial

OBJECTIVE

To evaluate the efficacy and safety of pharmacogenomics (PGx)-guided treatment in individuals with resistant hypertension (RH).

STUDY DESIGN

Randomised controlled open-label study. Place and Duration of the Study: Department of Cardiology, The First Hospital of China Medical University, Shenyang, Liaoning Province, China, from June 2019 to November 2021.

METHODOLOGY

The study assigned RH patients to two groups. The intervention group (IG) received 12 weeks of PGx-guided treatment, while the control group (CG) followed a consensus-based approach. Examining 10 genes and their alleles with 31 antihypertensive drugs in the IG, the study provided specific medication advice. The primary outcome measured the difference in office systolic blood pressure (SBP) change from baseline at 12 weeks. Secondary outcomes included changes in diastolic blood pressure (DBP), hepatic and renal function, and major adverse cardiovascular events.

RESULTS

Fifty-nine patients from the First Hospital of China Medical University participated, with 29 in the IG and 30 in the CG. Significant differences were noted in SBP reduction (IG: 31.26 ± 18.64 mmHg; CG: 14.61 ± 17.74 mmHg; p=0.001) and DBP reduction (IG: 19.61 ± 17.32 mmHg; CG: 7.81 ± 11.23 mmHg; p = 0.003) after 12 weeks. One IG patient had a heart attack, and one CG subject developed heart failure. At week 12, hepatic insufficiency was observed in one IG patient and six CG patients, while renal insufficiency occurred in five patients of both groups.

CONCLUSION

Treatment guided by PGx demonstrated significant reductions in both SBP and DBP compared to consensus-based treatment.

KEY WORDS

Resistant hypertension, Treatment, Pharmacogenomics, Clinical study.

Vasorelaxant effects of ellagitannins isolated from Cuphea carthagenensis

Cuphea carthagenensis (Jacq.) J. F. Macbr. is a popular plant in Brazilian folk medicine owing to its hypotensive and central nervous system depressant effects. This study aimed to validate the hypotensive effect of the plant's aqueous extract (AE) in rats and examine the vascular actions of three hydrolyzable tannins, oenothein B, woodfordin C, and eucalbanin B, isolated from AE. Systolic blood pressure in unanesthetized rats was determined using the non-invasive tail-cuff method. Oral treatment of normotensive rats with 0.5 and 1.0 g/kg/day AE induced a dose-related hypotensive effect after 1 week. In rat aortic rings pre-contracted with noradrenaline, all ellagitannins (20 - 180 µM) induced a concentration-related vasorelaxation. This effect was blocked by either removing the endothelium or pre-incubating with NG-nitro-l-arginine methyl ester (10 µM), an inhibitor of nitric oxide (NO) synthase. In KCl-depolarized rat portal vein preparations, the investigated compounds did not affect significantly the maximal contractile responses and pD2 values of the concentration-response curves to CaCl2. Our results demonstrated the hypotensive effect of C. carthagenensis AE in unanesthetized rats. All isolated ellagitannins induced vasorelaxation in vitro via activating NO synthesis/NO release from endothelial cells, without altering the Ca2+ influx in vascular smooth muscle preparations. Considering the low oral bioavailability of ellagitannins, the determined in vitro actions of these compounds are unlikely to account for the hypotensive effect of AE in vivo. It remains to be determined the role of the bioactive ellagitannin-derived metabolites in the hypotensive effect observed after oral treatment of unanesthetized rats with the plant extract.

Incidence and Risk Factors for Postoperative Visual Loss after Cardiac Surgical Procedures: A Systematic Review

ABSTRACT

Postoperative visual loss (POVL) is an infrequent yet consequential complication that can follow cardiac surgical interventions. This systematic review aims to provide a comprehensive analysis of the incidence of POVL after cardiac surgery and to delineate the associated risk factors. A comprehensive search was conducted in major medical databases for relevant studies published up to September 2022. Eligible studies reporting on the incidence of POVL and identifying risk factors in patients undergoing cardiac surgery were included. Data extraction was performed independently by two reviewers. The pooled incidence rates and the identified risk factors were synthesized qualitatively. POVL after cardiac surgery has an overall incidence of 0.015%, that is, 15 cases per 100,000 cardiac surgical procedures. Risk factors for POVL include patient characteristics (advanced age, diabetes, hypertension, and preexisting ocular conditions), procedural factors (prolonged surgery duration, cardiopulmonary bypass time, and aortic cross-clamping), anesthetic considerations (hypotension, blood pressure fluctuations, and specific techniques), and postoperative complications (stroke, hypotension, and systemic hypoperfusion). Ischemic optic neuropathy (ION) is an uncommon complication, associated with factors like prolonged cardiopulmonary bypass, low hematocrit levels, excessive body weight gain, specific medications, hypothermia, anemia, raised intraocular pressure, and micro-embolization. Diabetic patients with severe postoperative anemia are at increased risk for anterior ischemic optic neuropathy (AION). Posterior ischemic optic neuropathy (PION) can occur with factors like hypertension, postoperative edema, prolonged mechanical ventilation, micro-embolization, inflammation, hemodilution, and hypothermia.While the overall incidence of POVL postcardiac surgery remains modest, its potential impact is substantial, necessitating meticulous consideration of modifiable risk factors. Notably, prolonged surgical duration, intraoperative hypotension, anemia, and reduced hematocrit levels remain salient contributors. Vigilance is indispensable to promptly detect this infrequent yet visually debilitating phenomenon in the context of postcardiac surgical care.

Mechanism-based therapy of non-cardiac syncope: a practical guide

The term non-cardiac syncope includes all forms of syncope, in which primary intrinsic cardiac mechanism and non-syncopal transient loss of consciousness can be ruled out. Reflex syncope and orthostatic hypotension are the most frequent aetiologies of non-cardiac syncope. As no specific therapy is effective for all types of non-cardiac syncope, identifying the underlying haemodynamic mechanism is the essential prerequisite for an effective personalized therapy and prevention of syncope recurrences. Indeed, choice of appropriate therapy and its efficacy are largely determined by the syncope mechanism rather than its aetiology and clinical presentation. The two main haemodynamic phenomena leading to non-cardiac syncope include either profound hypotension or extrinsic asystole/pronounced bradycardia, corresponding to two different haemodynamic syncope phenotypes, the hypotensive and bradycardic phenotypes. The choice of therapy-aimed at counteracting hypotension or bradycardia-depends on the given phenotype. Discontinuation of blood pressure-lowering drugs, elastic garments, and blood pressure-elevating agents such as fludrocortisone and midodrine are the most effective therapies in patients with hypotensive phenotype. Cardiac pacing, cardioneuroablation, and drugs preventing bradycardia such as theophylline are the most effective therapies in patients with bradycardic phenotype of extrinsic cause.

Preoperative routine measurement of NT-proBNP predicts postoperative morbidity after non-cardiac surgery with intermediate or high surgical risk: an observational study

BACKGROUND

Chronic heart failure (HF) is a common clinical condition associated with adverse outcomes in elderly patients undergoing non-cardiac surgery. This study aimed to estimate a clinically applicable NT-proBNP cut-off that predicts postoperative 30-day morbidity in a non-cardiac surgical cohort.

METHODS

One hundred ninety-nine consecutive patients older than 65 years undergoing elective non-cardiac surgery with intermediate or high surgical risk were analysed. Preoperative NT-proBNP was measured, and clinical events were assessed up to postoperative day 30. The primary endpoint was the composite morbidity endpoint (CME) consisting of rehospitalisation, acute decompensated heart failure (ADHF), acute kidney injury (AKI), and infection at postoperative day 30. Secondary endpoints included perioperative fluid balance and incidence, duration, and severity of perioperative hypotension.

RESULTS

NT-proBNP of 443 pg/ml had the highest accuracy in predicting the composite endpoint; a clinical cut-off of 450 pg/ml was implemented to compare clinical endpoints. Although 35.2% of patients had NT-proBNP above the threshold, only 10.6% had a known history of HF. The primary endpoint was the composite morbidity endpoint (CME) consisting of rehospitalisation, acute decompensated heart failure (ADHF), acute kidney injury (AKI), and infection. Event rates were significantly increased in patients with NT-proBNP > 450 pg/ml (70.7% vs. 32.4%, p < 0.001), which was due to the incidence of cardiac rehospitalisation (4.4% vs. 0%, p = 0.018), ADHF (20.1% vs. 4.0%, p < 0.001), AKI (39.8% vs. 8.3%, p < 0.001), and infection (46.3% vs. 24.4%, p < 0.01). Perioperative fluid balance and perioperative hypotension were comparable between groups. Preoperative NT-proBNP > 450 pg/ml was an independent predictor of the CME in a multivariable Cox regression model (hazard ratio 2.92 [1.72-4.94]).

CONCLUSIONS

Patients with NT-proBNP > 450 pg/ml exhibited profoundly increased postoperative morbidity. Further studies should focus on interdisciplinary approaches to improve outcomes through integrated interventions in the perioperative period.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00027871, 17/01/2022.

Intensive Blood Pressure Lowering in Individuals With Low Diastolic Blood Pressure and Elevated Troponin Levels in SPRINT

BACKGROUND

Among individuals with hypertension and low diastolic blood pressure (DBP), the optimal BP target remains controversial due to concerns that BP lowering may reduce coronary perfusion. We determined the impact of intensive BP control among individuals with elevated systolic BP who have low DBP and elevated hs-cTnT (high-sensitivity cardiac troponin T) levels.

METHODS AND RESULTS

A total of 8828 participants in SPRINT (Systolic Blood Pressure Intervention Trial) were stratified by baseline DBP. Those with low DBP (<70 mm Hg) were further stratified by elevated hs-cTnT (≥14 ng/L) at baseline. The effects of intensive versus standard BP lowering on a cardiovascular disease composite end point, all-cause death, and 1-year change in hs-cTnT were determined. The combination of low DBP/high hs-cTnT was independently associated with a higher risk for cardiovascular disease and all-cause death, as well as greater 1-year increases in hs-cTnT, compared with DBP ≥70 mm Hg. However, randomization to intensive versus standard BP lowering led to similar reductions in cardiovascular disease risk among individuals with low DBP/high hs-cTnT (hazard ratio [HR], 0.82 [95% CI, 0.57-1.19]), low DBP/low hs-cTnT (HR, 0.48 [95% CI, 0.29-0.79]), and DBP ≥70 mm Hg (HR, 0.73 [95% CI, 0.60-0.89]; P for interaction=0.20). Intensive BP lowering also led to a reduction in all-cause death that was similar across groups (P for interaction=0.57).

CONCLUSIONS

In this nonprespecified subgroup analysis of SPRINT, individuals with low DBP and elevated hs-cTnT, low DBP and nonelevated hs-cTnT, and DBP ≥70 mm Hg derived similar cardiovascular disease and mortality benefits from intensive BP lowering. These findings warrant confirmation in other studies.

High dose cholecalciferol supplementation causing morning blood pressure reduction in patients with type 1 diabetes mellitus and cardiovascular autonomic neuropathy

We evaluated the association of cardiovascular autonomic neuropathy (CAN), blood pressure (BP) and Vitamin D (VD) levels before and after high-dose cholecalciferol supplementation (4000/10,000) UI/day) for 12 weeks in patients (N = 67) with type 1 diabetes mellitus (T1DM). Based on this prospective controlled pilot study, patients were divided into group 1 (N = 23 with CAN) and group 2 (N = 44 without CAN). At baseline, group 1 had higher systolic BP (SBP) during sleep (115 ± 14 vs. 107 ± 12 mmHg, p = 0.04) and lower nocturnal dipping (3 ± 5 vs. 8 ± 6%, p = 0.009). Among those with loss of nocturnal dipping, 45.4% (20/44) had CAN, while in normal nocturnal dipping group it occurred only in 13% (3/23) (p = 0.007). Non-dipper group had worse CAN parameters when compared to dipper group [Very low frequency (VLF) (2.5 ± 0.5vs.2.8 ± 0.4 s, p = 0.01), total power (TP) (2.9 ± 0.6 vs. 3.3 ± 0.4 s, p = 0.01), Valsalva coefficient (1.5 ± 0.4 vs. 1.8 ± 0.6, p = 0.06)]. After VD, only group 1 improved CAN parameters [TP (2.5 ± 0.4 vs. 2.8 ± 0.6, p = 0.01) and VLF (2.2 ± 0.4 vs. 2.4 ± 0.5, p = 0.03). Group 1 presented a reduction in morning SBP (120 ± 20 vs. 114 ± 17 mmHg, p = 0.038) and in morning SBP surge (13 ± 13 vs. 5 ± 14, p = 0.04). High-dose VD was associated with improved CAN parameters and reduced awake SBP and morning SBP surge. These findings suggest that VD may benefit patients with cardiovascular autonomic neuropathy. ISRCTN32601947, registration date: 31/07/2017.

Hemodynamic Management Strategies in Pediatric Septic Shock: Ten Concepts for the Bedside Practitioner

The three pathophysiologic contributors to septic shock include varying combinations of hypovolemia (relative > absolute), decreased vascular tone or vasoplegia, and myocardial dysfunction. The three pillars of hemodynamic support include fluid boluses, vasopressors with or without inotrope infusions. The three end-points of hemodynamic resuscitation include an adequate cardiac output (CO), adequate mean arterial pressure (MAP) and diastolic blood pressure (DBP) for organ perfusion, and avoiding congestion (worse filling) parameters. Only 33-50% of septic patients show post-fluid bolus CO improvements; this may be sustained in ≥10% on account of sepsis-mediated glycocalyx injury. A pragmatic approach is to administer a small bolus (10 mL/kg over 20-30 min) and judge the response based on clinical perfusion markers, pressure elements, and congestive features. Vasoplegia marked by low DBP is a major contributor to hypotension in septic shock. Hence, a strategy of restricted fluid bolus with early low-dose norepinephrine (NE) (0.05-0.1 µg/kg/min) can be helpful. NE may also be useful in septic myocardial dysfunction (SMD) as an initial agent to maintain adequate coronary perfusion and DBP while minimizing tachycardia and providing inotropy. Severe SMD may benefit from additional inotropy (epinephrine/dobutamine). Except vasopressin, most vasoactive drugs may safely be administered via a peripheral route. The lowest MAP (5th centile for age) may be an acceptable target, provided end-organ perfusion is satisfactory. A clinical individualized approach combining the history, serial physical examination, laboratory analyses, available monitoring tools, and repeated assessment to individualize circulatory support may to lead to better outcomes than one-size-fits-all algorithms.

Correlates of Spontaneous Blood Pressure Reduction Following Severe Inpatient Hypertension Development

BACKGROUND

Severe hypertension (sHTN) is prevalent in 10% of hospitalized patients and treatment guidelines are lacking. As such, patients who develop sHTN might unnecessarily receive antihypertensive medications which could lead to worse outcomes. Our goal was to investigate correlates of spontaneous blood pressure (BP) reduction to help guide future treatment decisions and avoid harm associated with aggressive BP treatment.

METHODS

This is a retrospective cohort study of hospitalized adults between 2016 and 2020 who developed sHTN, SBP >180 or DBP >110 mm Hg, after admission. Spontaneous BP reduction was defined as a SBP <160 and a DBP <100 mm Hg achieved within 3 h of sHTN in the absence of antihypertensive therapy. Multivariable logistic regression was used to identify correlates of spontaneous BP reduction.

RESULTS

Of the 12,825 patients who developed sHTN, 44.2% had spontaneous BP reduction. After adjustment, we found that patients most likely to experience a BP drop received steroids before onset of sHTN (Odds ratio [OR]: 1.3 [1.09, 1.56]), had higher potassium levels on admission (OR: 1.2 [1.09, 1.24]) and were more likely to have a history of chronic pulmonary disease (OR: 1.1 [1.01, 1.18]) or cardiac arrythmia (OR: 1.1 [1.01, 1.18]). While numerically different, these differences were not clinically relevant.

CONCLUSIONS

Our findings indicate that almost half the patients who develop sHTN have spontaneous BP reduction. Conventional clinical and demographic characteristics were not strong predictors of spontaneous BP reduction following sHTN development. More research is needed to confirm our findings and help guide treatment of sHTN.

The impact of sprint interval training versus moderate intensity continuous training on blood pressure and cardiorespiratory health in adults: a systematic review and meta-analysis

Background

Although aerobic exercise is the primary modality recommended for the treatment of hypertension, it remains unclear whether high-intensity all-out sprint interval training (SIT) can result in greater reductions of blood pressure (BP) and cardiorespiratory health. This systematic review aims to compare the impact of SIT versus Moderate-intensity continuous training (MICT) on improvements in resting systolic blood pressure (SBP), diastolic blood pressure (DBP) and maximal oxygen uptake (VO2 max) among adults.

Methods

We conducted a systematic search of three online databases (PubMed, Embase, and Web of Science) from January 2000 to July 2023 to identify randomized controlled trials that compared the chronic effects of SIT versus MICT on BP in participants with high or normal blood pressure. We extracted information on participant characteristics, exercise protocols, BP outcomes, and intervention settings. Furthermore, the changes in VO2 max between the two groups were analyzed using a meta-analysis. The pooled results were presented as weighted means with 95% confidence intervals (CI).

Results

Out of the 1,874 studies initially were found, eight were included in this review, totaling 169 participants. A significant decrease in SBP (MD = -2.82 mmHg, 95% CI [-4.53 to -1.10], p = 0.08, I2 =45%) was observed in the SIT group compared to before the training, but no significant decrease in DBP (MD = -0.75 mmHg, 95% CI [-1.92 to 0.42], p = 0.16, I2 = 33%) was observed. In contrast, both SBP (MD = -3.00 mmHg, 95% CI [-5.31 to -0.69], p = 0.68, I2 = 0%) and DBP (MD = -2.11 mmHg, 95% CI [-3.63 to -0.60], p = 0.72, I2 = 0%) significantly decreased in the MICT group with low heterogeneity. No significant difference was found in resting SBP and DBP between SIT and MICT after the intervention. Both SIT and MICT significantly increased VO2 peak, with SIT resulting in a mean difference (MD) of 1.75 mL/kg/min (95% CI [0.39-3.10], p = 0.02, I2 = 61%), and MICT resulting in a mean difference of 3.10 mL/kg/min (95% CI [1.03-5.18], p = 0.007, I2 = 69%). MICT was more effective in improving VO2 peak (MD = -1.36 mL/kg/min, 95% CI [-2.31 to 0.40], p = 0.56, I2 = 0%). Subgroup analysis of duration and single sprint time showed that SIT was more effective in reducing SBP when the duration was ≥8 weeks or when the sprint time was <30 s.

Conclusion

Our meta-analysis showed that SIT is an effective intervention in reducing BP and improving cardiorespiratory fitness among adults. Consequently, SIT can be used in combination with traditional MICT to increase the variety, utility, and time efficiency of exercise prescriptions for different populations.

Effect of machine learning-guided haemodynamic optimization on postoperative free flap perfusion in reconstructive maxillofacial surgery: A study protocol

AIMS

Intraoperative hypotension and liberal fluid haemodynamic therapy are associated with postoperative medical and surgical complications in maxillofacial free flap surgery. The novel haemodynamic parameter hypotension prediction index (HPI) has shown good performance in predicting hypotension by analysing arterial pressure waveform in various types of surgery. HPI-based haemodynamic protocols were able to reduce the duration and depth of hypotension. We will try to determine whether haemodynamic therapy based on HPI can improve postoperative flap perfusion and tissue oxygenation by improving intraoperative mean arterial pressure and reducing fluid infusion.

METHODS

We present here a study protocol for a single centre, randomized, controlled trial (n = 42) in maxillofacial patients undergoing free flap surgery. Patients will be randomized into an intervention or a control group. In the intervention, group haemodynamic optimization will be guided by machine learning algorithm and functional haemodynamic parameters presented by the HemoSphere platform (Edwards Lifesciences, Irvine, CA, USA), most importantly, HPI. Tissue oxygen saturation of the free flap will be monitored noninvasively by near-infrared spectroscopy during the first 24 h postoperatively. The primary outcome will be the average value of tissue oxygen saturation in the first 24 h postoperatively.

Safety of Intravenous Push Valproate Compared with Intravenous Piggyback at a Tertiary Academic Medical Center

BACKGROUND AND OBJECTIVES

Data are limited regarding the safety associated with administering valproate sodium by intravenous push (IVP) compared with intravenous piggyback (IVPB). The objective of this retrospective pre-post analysis was to compare the safety profile of valproate administration via IVPB from March to May 2022 and IVP from June to August 2022.

METHODS

A total of 890 IVPB and 440 IVP administrations were included. The major endpoint of this analysis was the incidence of infusion site reactions (infiltration or phlebitis).

RESULTS

The incidence of documented intravenous (IV) site reactions demonstrated minimal differences between both IVPB and IVP administration cohorts. Based on the Naranjo algorithm, all IVPB and IVP infusion site reactions were classified as possible or doubtful. Additional safety endpoints included bradycardia, hypotension, or sedation attributable to valproate sodium administration. Similar safety profiles were observed, including valproate-associated bradycardia, hypotension, and sedation events. All safety events were further classified as possible or doubtful by the Naranjo algorithm. Time from pharmacist verification to valproate administration was also collected. The mean time from pharmacist order verification to valproate administration was significantly faster in the IVP cohort compared to the IVPB cohort.

CONCLUSION

IVP valproate administration may be considered safe, allowing for more optimal clinical and operational outcomes in the acute care setting.

Effects of the Chinese heart-healthy diet (Sichuan cuisine) on lowering blood pressure in adults with hypertension: a randomized controlled feeding trial

BACKGROUND AND OBJECTIVES

Sichuan cuisine is characterized by high salt and oil content. We aimed to evaluate the effects of the Sichuan cuisine version of Chinese heart-healthy diet (CHH diet-SC) on blood pressure reduction among hypertensive adults.

METHODS AND STUDY DESIGN

The Chinese heart-healthy diet (CHH) trial was a multicenter randomized controlled feeding trial among Chinese hypertensive people. We conducted a secondary analysis of the CHH trial using data from the Sichuan center in Southwest China. Fifty-three people aged 25 to 75 years with a mean systolic blood pressure (SBP) between 130 and 159 mmHg were enrolled. Eligible participants underwent a 1-week run-in period with the typical local diet and were randomized 1:1 to consume the CHH diet-SC (n=27) or typical local diet (n=26) for the next 4-week. The primary outcome was the net change in SBP, the secondary outcomes included diastolic blood pressure (DBP), mean arterial pressure (MAP), and the rate of BP control.

RESULTS

Compared with the control group, the CHH diet-SC decreased cooking salt, oil, and red meat content and increased inclusion of whole grains, fruits, seafood, low-fat dairy, soybean, and nuts; the SBP experienced reductions of 7.54, 8.60, 9.14, and 10.1 mmHg at the end of weeks 1 through 4; the DBP was reduced 4.01 mmHg at week 4; the MAP was significantly reduced 6.02 mmHg finally; and rate of BP control significantly increased (p<0.05).

CONCLUSIONS

Adoption of the CHH diet-SC for 4 weeks can significantly reduce BP and increase the rate of BP control in hypertensive adults.

Preventing cognitive decline by reducing BP target (PCOT): A randomized, pragmatic, multi-health systems clinical trial

BACKGROUND

Growing evidence suggests that intensive lowering of systolic blood pressure (BP) may prevent mild cognitive impairment (MCI) and dementia. However, current guidelines provide inconsistent recommendations regarding optimal BP targets, citing safety concerns of excessive BP lowering in the diverse population of older adults. We are conducting a pragmatic trial to determine if an implementation strategy to reduce systolic BP to <130 and diastolic BP to <80 mmHg will safely slow cognitive decline in older adults with hypertension when compared to patients receiving usual care.

METHODS

The Preventing Cognitive Decline by Reducing BP Target Trial (PCOT) is an embedded randomized pragmatic clinical trial in 4000 patients from two diverse health-systems who are age ≥ 70 years with BP >130/80 mmHg. Participants are randomized to the intervention arm or usual care using a permuted block randomization within each health system. The intervention is a combination of team-based care with clinical decision support to lower home BP to <130/80 mmHg. The primary outcome is cognitive decline as determined by the change in the modified Telephone Interview for Cognitive Status (TICS-m) scores from baseline. As a secondary outcome, patients who decline ≥3 points on the TICS-m will complete additional cognitive assessments and this information will be reviewed by an expert panel to determine if they meet criteria for MCI or dementia.

CONCLUSION

The PCOT trial will address the effectiveness and safety of hypertension treatment in two large health systems to lower BP targets to reduce risk of cognitive decline in real-world settings.

Dietary Sodium Reduction Is Best for Reducing Blood Pressure: Controversies in Hypertension

The global burden of cardiovascular disease (CVD) continues to grow, as does the incidence of hypertension, one of the most important modifiable risk factors of CVD. Non-pharmacologic, population level interventions are critically needed to halt the hypertension pandemic, but there is an ongoing debate as to whether public policy efforts should focus more on dietary sodium reduction or increasing potassium. In this commentary, we summarize arguments in favor of policy geared towards reduced sodium intake. Recognizing increasing dietary sodium as one of the drivers of the hypertension pandemic is critical to developing public policy to reduce population level sodium exposure and blood pressure. We draw from a robust field of evidence to show that reducing sodium intake improves blood pressure in a linear fashion, across the lifespan, at an individual level and a population level, and may even reduce CVD events. While potassium plays an important role in blood pressure regulation, potassium interventions are less effective at reducing blood pressure, carry risk of hyperkalemia in select populations, and are more logistically challenging. There is an urgent need for nation-wide policies to reduce sodium intake to help stem the hypertension pandemic and prevent CVD.

Validation of Preload Assessment Technologies at Altitude in a Porcine Model of Hemorrhage

INTRODUCTION

Dynamic preload assessment measures including pulse pressure variation (PPV), stroke volume variation (SVV), pleth variability index (PVI), and hypotension prediction index (HPI) have been utilized clinically to guide fluid management decisions in critically ill patients. These values aid in the balance of correcting hypotension while avoiding over-resuscitation leading to respiratory failure and increased mortality. However, these measures have not been previously validated at altitude or in those with temporary abdominal closure (TAC).

METHODS

Forty-eight female swine (39 ± 2 kg) were separated into eight groups (n = 6) including all combinations of flight versus ground, hemorrhage versus no hemorrhage, and TAC versus no TAC. Flight animals underwent simulated aeromedical evacuation via an altitude chamber at 8000 ft. Hemorrhagic shock was induced via stepwise hemorrhage removing 10% blood volume in 15-min increments to a total blood loss of 40% or a mean arterial pressure of 35 mmHg. Animals were then stepwise transfused with citrated shed blood with 10% volume every 15 min back to full blood volume. PPV, SVV, PVI, and HPI were monitored every 15 min throughout the simulated aeromedical evacuation or ground control. Blood samples were collected and analyzed for serum levels of serum IL-1β, IL-6, IL-8, and TNF-α.

RESULTS

Hemorrhage groups demonstrated significant increases in PPV, SVV, PVI, and HPI at each step compared to nonhemorrhage groups. Flight increased PPV (P = 0.004) and SVV (P = 0.003) in hemorrhaged animals. TAC at ground level increased PPV (P < 0.0001), SVV (P = 0.0003), and PVI (P < 0.0001). When TAC was present during flight, PPV (P = 0.004), SVV (P = 0.003), and PVI (P < 0.0001) values were decreased suggesting a dependent effect between altitude and TAC. There were no significant differences in serum IL-1β, IL-6, IL-8, or TNF-α concentration between injury groups.

CONCLUSIONS

Based on our study, PPV and SVV are increased during flight and in the presence of TAC. Pleth variability index is slightly increased with TAC at ground level. Hypotension prediction index demonstrated no significant changes regardless of altitude or TAC status, however this measure was less reliable once the resuscitation phase was initiated. Pleth variability index may be the most useful predictor of preload during aeromedical evacuation as it is a noninvasive modality.

Safety of Levosimendan in Pediatric Patients: An Up-to-Date Systematic Review

BACKGROUND

The potential risks associated with the use of levosimendan in the pediatric population has not been systematically evaluated. This study aimed to review the available evidence regarding the safety of this treatment.

METHODS

Bio Med Central, PubMed, Embase, and the Cochrane Central Register of clinical trials were searched for studies describing levosimendan administration in the pediatric population in any setting. Relevant studies were independently screened, selected, and their data extracted by two investigators. The authors excluded: reviews, meta-analyses, as well as basic research and trials involving patients >18 years old. The primary outcome was the number and the type of adverse side effects reported during levosimendan administration.

RESULTS

The updated systematic review included 48 studies, enrolling a total of 1,271 pediatric patients who received levosimendan as treatment (790 patients in the 11 studies that reported side effects). The primary adverse effects of levosimendan administration were hypotension and cardiac arrhythmias, particularly tachycardia. Hypotension occurred in approximately 28.9% of patients, while arrhythmia occurred in about 12.3% of patients. Meta analysis of RCTs revealed a rate of all-cause mortality of 2.0% (8 out of 385) in the levosimendan group compared to 3.9% (15 out of 378) in the control group (dobutamine, milrinone or placebo) (risk ratio [RR] = 0.55; 95% confidence interval [CI] = 0.25-1.21; P = 0.14; I2 = 0%) CONCLUSIONS: Hypotension and cardiac arrhythmia are the most reported side effects of levosimendan in pediatric patients. However, adverse events remain underreported, especially in randomized trials.

Blood Pressure Goals: Is Cerebral Saturation the New Mean Arterial Pressure?

OBJECTIVE

 The objective of this article was to correlate hypotension and cerebral saturation from near-infrared spectroscopy (cNIRS) in neonates on dopamine.

STUDY DESIGN

 Retrospective review of neonates receiving dopamine between August 2018 and 2019 was performed. Hypotension thresholds included mean arterial pressure (MAP) of postmenstrual age (PMA) ± 5 and 30 mm Hg and gestational age (GA) ± 5 mm Hg. Time below threshold MAP was compared with time with cerebral hypoxia (cNIRS <55%).

RESULTS

 Hypotension occurred 6 to 33% of the time on dopamine in 59 cases. Hypotension did not correlate with abnormal cNIRS overall, within PMA subgroups or by outcomes. Hypotensive periods with MAP < GA had fewer corresponding percent time with abnormal cNIRS events (3.7 ± 1.3%) compared with MAP < PMA (11.9 ± 4.9%, p < 0.003) or 30 mm Hg thresholds (12.2 ± 4.7%, p < 0.0001). In most premature infants, mean cNIRS values during hypotension were still within normal range (57 ± 6%).

CONCLUSION

 cNIRS may be a more clinically relevant measure than MAP for the assessment of neonatal hypotension.

KEY POINTS

· Hypotension occurred 6 to 33% of the time on dopamine in 59 cases.. · Hypotension did not correlate with abnormal cNIRS overall, within PMA subgroups or by outcomes.. · MAP. · We found no cNIRS difference between IVH grades, mortality, average Hct, lactates, or urine output.. · cNIRS may be a more clinically relevant measure than MAP for the assessment of neonatal hypotension..

Early systemic insults following traumatic brain injury: association with biomarker profiles, therapy for intracranial hypertension, and neurological outcomes-an analysis of CENTER-TBI data

PURPOSE

We analysed the impact of early systemic insults (hypoxemia and hypotension, SIs) on brain injury biomarker profiles, acute care requirements during intensive care unit (ICU) stay, and 6-month outcomes in patients with traumatic brain injury (TBI).

METHODS

From patients recruited to the Collaborative European neurotrauma effectiveness research in TBI (CENTER-TBI) study, we documented the prevalence and risk factors for SIs and analysed their effect on the levels of brain injury biomarkers [S100 calcium-binding protein B (S100B), neuron-specific enolase (NSE), neurofilament light (NfL), glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), and protein Tau], critical care needs, and 6-month outcomes [Glasgow Outcome Scale Extended (GOSE)].

RESULTS

Among 1695 TBI patients, 24.5% had SIs: 16.1% had hypoxemia, 15.2% had hypotension, and 6.8% had both. Biomarkers differed by SI category, with higher S100B, Tau, UCH-L1, NSE and NfL values in patients with hypotension or both SIs. The ratio of neural to glial injury (quantified as UCH-L1/GFAP and Tau/GFAP ratios) was higher in patients with hypotension than in those with no SIs or hypoxia alone. At 6 months, 380 patients died (22%), and 759 (45%) had GOSE ≤ 4. Patients who experienced at least one SI had higher mortality than those who did not (31.8% vs. 19%, p < 0.001).

CONCLUSION

Though less frequent than previously described, SIs in TBI patients are associated with higher release of neuronal than glial injury biomarkers and with increased requirements for ICU therapies aimed at reducing intracranial hypertension. Hypotension or combined SIs are significantly associated with adverse 6-month outcomes. Current criteria for hypotension may lead to higher biomarker levels and more negative outcomes than those for hypoxemia suggesting a need to revisit pressure targets in the prehospital settings.

The effect of esketamine combined with propofol-induced general anesthesia on cerebral blood flow velocity: a randomized clinical trial

BACKGROUND

Esketamine is increasingly used in clinical anesthesia. The effect of esketamine on the blood flow velocity of the middle cerebral artery has a clinical guiding effect. To investigate the effect of esketamine combined with propofol-induced general anesthesia for endotracheal intubation on the blood flow velocity of middle cerebral artery and hemodynamics during the induction period.

METHODS

The randomized clinical trial included 80 patients aged 20-65 years who would undergo non-intracranial elective surgery under general anesthesia in our hospital from May 2022 to May 2023. The participants were divided into two groups based on anesthesia drugs: sufentanil 0.5μg/kg (group C) or 1.5mg/kg esketamine (group E). The primary outcome was variation value in average cerebral blood velocity. The secondary outcomes included cerebral blood flow velocities (CBFV), blood pressure (BP) and heart rate (HR) at four different time points: before induction of general anesthesia (T0), 1 min after the induction drug injected (T1), before endotracheal intubation (T2), and 1min after endotracheal intubation (T3). The occurrence of hypotension, hypertension, tearing and choking during induction was also documented.

RESULTS

The variation of average CBFV from time T0 to T2(ΔVm1) and the variation from time T3 to T0 (ΔVm2) were not obviously different. The median consumption of intraoperative sufentanil in group C was obviously lower than that in group E. At T1, the mean HR of group E was significantly higher than that of group C. At T2 and T3, the BP and HR of group E were obviously higher than that of group C. At T2, the CBFV in the group E were obviously higher than those in the group C. The incidence of hypotension was significantly reduced in the group E compared with the group C. There were no differences in the other outcomes.

CONCLUSIONS

The induction of esketamine combined with propofol does not increase the blood flow velocity of middle cerebral artery. Esketamine is advantageous in maintaining hemodynamic stability during induction. Furthermore, the administration of esketamine did not result in an increased incidence of adverse effects.

TRIAL REGISTRATION

15/06/2023 clinicaltrials.gov ChiCTR2300072518 https://www.chictr.org.cn/bin/project/edit?pid=176675 .