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Severe Hypotension (severe + hypotension)
Selected AbstractsSevere hypotension during the development of low-nodal junctional rhythmACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 3 2009Y. Asakura No abstract is available for this article. [source] Severe hypotension related to cell salvaged blood transfusion in obstetricsANAESTHESIA, Issue 7 2010L. K. Kessack Summary Intra-operative blood cell salvage has recently been adopted for use in women at risk of significant haemorrhage during caesarean section. It has also been advocated for use in those patients who refuse allogenic blood transfusion. A 37-year-old pregnant woman (gravida 3, para 2) underwent an elective lower segment caesarean section at 36 weeks for an anterior, major placenta accreta (grade 4). The volume of cell salvaged blood collected during the procedure was 1870 ml. On starting the cell-salvaged blood transfusion, the blood pressure was noted to fall and this was temporally related to the transfusion of the cell-salvaged blood. We review the recent literature and case reports on hypotension related to cell-salvaged blood transfusion. [source] Echocardiographic Diagnosis of Right Ventricular Inflow Compression Associated with Pectus Excavatum During Spinal Fusion in Prone PositionCONGENITAL HEART DISEASE, Issue 3 2009James M. Galas MD ABSTRACT Introduction., Pectus excavatum is commonly viewed as a benign condition. Associated alterations in hemodynamics are rare. We present an unusual case of right ventricular inflow obstruction and hemodynamic compromise as a consequence of pectus excavatum encountered during surgical intervention. Case., a 15-year-old male with pectus excavatum and thoracolumbar scoliosis developed severe hypotension after induction of general anesthesia and placement in the prone position for elective spinal fusion. A transesophageal echocardiogram revealed anterior compression of the right heart by the sternum with peak and mean right ventricular inflow gradients of 7 and 4 mm Hg, respectively. The gradient resolved with supine positioning and was reproduced with direct compression of the sternum. Conclusions., Although pectus excavatum is generally a benign condition, the cardiologist should be aware of the potential for serious hemodynamic compromise related to positioning in these patients. [source] Pleth variability index predicts hypotension during anesthesia inductionACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 5 2010M. TSUCHIYA Background: The pleth variability index (PVI) is a new algorithm used for automatic estimation of respiratory variations in pulse oximeter waveform amplitude, which might predict fluid responsiveness. Because anesthesia-induced hypotension may be partly related to patient volume status, we speculated that pre-anesthesia PVI would be able to identify high-risk patients for significant blood pressure decrease during anesthesia induction. Methods: We measured the PVI, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) in 76 adult healthy patients under light sedation with fentanyl to obtain pre-anesthesia control values. Anesthesia was induced with bolus administrations of 1.8 mg/kg propofol and 0.6 mg/kg rocuronium. During the 3-min period from the start of propofol administration, HR, SBP, DBP, and MAP were measured at 30-s intervals. Results: HR, SBP, DBP, and MAP were significantly decreased after propofol administration by 8.5%, 33%, 23%, and 26%, respectively, as compared with the pre-anesthesia control values. Linear regression analysis that compared pre-anesthesia PVI with the decrease in MAP yielded an r value of ,0.73. Decreases in SBP and DBP were moderately correlated with pre-anesthesia PVI, while HR was not. By classifying PVI >15 as positive, a MAP decrease >25 mmHg could be predicted, with sensitivity, specificity, positive predictive, and negative predictive values of 0.79, 0.71, 0.73, and 0.77, respectively. Conclusion: Pre-anesthesia PVI can predict a decrease in MAP during anesthesia induction with propofol. Its measurement may be useful to identify high-risk patients for developing severe hypotension during anesthesia induction. [source] Aging Increases the Interleukin-1,,Induced INOS Gene Expression and Nitric Oxide (NO) Production in Vascular Smooth Muscle CellsJOURNAL OF CARDIAC SURGERY, Issue 6 2002Gabriel HH Chan Objectives: Inducible form of nitric oxide synthase (iNOS) is induced by cytokines (e.g. interleukin-1, (IL-1,)) during pathological conditions, such as sepsis. Excessive NO synthesis in blood vessels during sepsis can result in massive vasodilation and life-threatening hypotension. In addition, chronic expression of iNOS contributes to onset of diabetes, autoimmune diseases, arthritis, renal toxicity, and neurodegenerative disorders. The purpose of the present study was to examine the effect of aging on the levels of expression of iNOS induced by a low concentration (5 ng/ml) of IL-1, in VSMCs. Methods: Gene expression of iNOS was determined by RT-PCR and analysis of the PCR products by both agarose gel electrophoresis and capillary electrophoresis with laser-induced fluorescence detector (CE-LIF). This new CE-LIF technique, just developed in our laboratory, provides greater than 1,000 fold better sensitivity compared to agarose gels. The production of nitrite, the stable metabolite of NO, was measured (by a modified Griess reaction) in the media of cultured VSMCs isolated from young and elderly rats (3-month and 20-months old, respectively) of both genders following the exposure to IL-1, (5 ng/ml). VSMCs were used in their 1st passage to avoid phenotypic changes that typically occur in cultures of VSMCs after 3-10 passages. Results: IL-1, (5 ng/ml) caused a much larger increase in iNOS mRNA in VSMCs of elderly rats as compared to young rats. Furthermore, IL-1, (5 ng/ml) had no significant effect on nitrite levels in VSMCs of young, but significantly increased nitrite levels by 7.9 fold in VSMCs from elderly male rats and by 2.6 fold in VSMCs from elderly female rats, as compared to young rats. A report had previously shown that the neuropeptide CGRP could synergistically enhance the expression of iNOS caused by IL-1, in later passages (10-15 passages) of rat aortic VSMCs (i.e. phenotypically modulated VSMCs). We found that IL-1, and CGRP together did not act synergistically to increase production of nitrite in our phenotypically normal (1st passage) VSMCs. Conclusion: IL-1,, at a low concentration (5 ng/ml), preferentially induces iNOS expression and increases production of NO in VSMCs of elderly rats as compared to young rats. The data suggest that aging enhances the responsiveness of VSMCs to the iNOS-inducing actions of the cytokine IL-1,. This may be a contributing factor in the increased risk of developing severe hypotension in elderly patients with sepsis. (Supported by a Direct Grant for Research). [source] Successful treatment with enoximone for severe poisoning with atenolol and verapamil: a case reportACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 6 2004C. Sandroni Combined poisoning with calcium channel blockers (CCBs) and beta-blockers is usually associated with severe hypotension and heart failure. Due to the block of the beta receptors, treatment with adrenergic agonists, even at high doses, can be insufficient, and beta-independent inotropes, such as glucagon, may be required. Phosphodiesterase III (PDEIII) inhibitors represent a possible alternative to glucagon in these cases as they have an inotropic effect which is not mediated by a beta receptor. [source] Severe intoxication after an intentional overdose of amlodipineACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 8 2003L. Rasmussen Intoxication with 280 mg of amlodipine caused severe hypotension, third-degree heart block and hyperkalaemia in a 36-year-old female patient. The patient was initially treated with fluids, dopamine, calcium chloride, and epinephrine without effect. The patient was then given a bolus injection of insulin and glucose as a temporary mean to treat the hyperkalaemia. We observed a rise in blood pressure (BP) after insulin was given and the BP was subsequently responsive to epinephrine. A possible positive inotropic effect of insulin therapy in patients with calcium channel blocker intoxication is in accordance with previous findings. In conclusion, it is suggested that hyperinsulinaemia-euglycaemia therapy may be considered as a first-line therapy in calcium channel blocker intoxication. [source] Does dopexamine influence regional vascular tone and oxygenation during intestinal hypotension?ACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 10 2002S. Lehtipalo Background: Local effects of dopexamine on intestinal vascular tone and oxygenation were investigated during intestinal hypotension. To this end, we employed an experimental model, in which the superior mesenteric arterial pressure (PSMA) was controlled by an adjustable perivascular clamp. This approach enabled us to keep the intestinal perfusion pressure (IPP) constant in the face of any systemic circulatory alterations. Methods: In 11 barbiturate-anesthetized pigs, we instrumented the superior mesenteric circulation for assessments of vascular resistance (RMES), IPP, jejunal mucosal perfusion (Laser Doppler) and intestinal tissue oxygenation (microoximetry). Measurements were carried out before and during dopexamine infusions (0.5 and 1.0 µg·kg,1·min,1) at a freely variable PSMA (i.e. the perivascular clamp fully open) and at a PSMA of 50 mmHg and 30 mmHg. Results: At a constant PSMA of 50 mmHg, dopexamine had no significant intestinal vascular effects. However, at a constant PSMA of 30 mmHg, both doses of dopexamine were associated with decreases in RMES. Effects of dopexamine on intestinal oxygen delivery and extraction were minimal during these procedures, while a minor decrease in intestinal tissue oxygen tension was observed during dopexamine administration at the lowest IPP level. Conclusion: At very low intestinal perfusion pressures (approximately 30 mmHg) dopexamine produces intestinal vasodilation in excess of what is produced by intrinsic autoregulation. This suggests that there is a vasodilatory reserve in the intestine under such conditions and that a pharmacological vasodilator like dopexamine may improve intestinal circulation during regional severe hypotension. [source] Overdose of methyldopa, indapamide and theophylline resulting in prolonged hypotension, marked diuresis and hypokalaemia in an elderly patient,PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 10 2009Thomas Y. K. Chan MBChB Abstract An 89-year-old man with a history of hypertension, chronic obstructive pulmonary disease, personality disorder and previous attempts of self-poisoning attempted suicide by swallowing two mouthfuls of tablets (methyldopa 250,mg, theophylline SR 200,mg, indapamide 2.5,mg and paracetamol 500,mg). He had prolonged, severe hypotension, necessitating the use of 3000,ml of Gelofusine® and almost 2 days of intravenous norepinephrine infusion. He had marked diuresis for 4.5 days, requiring continuous and bolus infusions of intravenous fluids. He had marked renal potassium loss, requiring vigorous potassium replacement therapy. Multiple-dose activated charcoal was used to enhance theophylline elimination. The plasma paracetamol level was below the treatment line. Methyldopa via its metabolite stimulates postsynaptic , -adrenergic receptors in cardiovascular control centres in the brain, causing a reduction in peripheral sympathetic tone and a fall in arterial blood pressure and heart rate. In overdose, it causes hypotension, bradycardia and drowsiness. The natriuretic, kaliuretic and vasodilatory effects of indapamide are exaggerated in overdose, resulting in diuresis, hypokalaemia and hypotension. Theophylline markedly increases the level of circulating catecholamines, which stimulate the vascular ,2 -adrenergic receptors with decreased peripheral vascular resistance. Peripheral vasodilation and hypotension occur in significant theophylline poisoning. Intracellular shift of potassium results in hypokalaemia. The prescribing physicians should recognise elderly patients at a high risk of self-poisoning and avoid using drugs with a high toxicity in overdose (e.g. theophylline and methyldopa). Restricting access to hazardous drugs (in overdose) would be of paramount importance to reduce the number of severe acute poisoning cases and case-fatalities. Copyright © 2009 John Wiley & Sons, Ltd. [source] Beneficial Effect of Preventative Intra-Aortic Balloon Pumping in High-Risk Patients Undergoing First-Time Coronary Artery Bypass Grafting,A Single Center ExperienceARTIFICIAL ORGANS, Issue 8 2009Qingcheng Gong Abstract Although intra-aortic balloon pumping (IABP) has been used widely as a routine cardiac assist device for perioperative support in coronary artery bypass grafting (CABG), the optimal timing for high-risk patients undergoing first-time CABG using IABP is unknown. The purpose of this investigation is to compare preoperative and preventative IABP insertion with intraoperative or postoperative obligatory IABP insertion in high-risk patients undergoing first-time CABG. We reviewed our IABP patients' database from 2002 to 2007; there were 311 CABG patients who received IABP treatment perioperatively. Of 311 cases, 41 high-risk patients who had first-time on-pump or off-pump CABG (presenting with three or more of the following criteria: left ventricular ejection fraction less than 0.45, unstable angina, CABG combined with aneurysmectomy, or left main stenosis greater than 70%) entered the study. We compared perioperatively the clinical results of 20 patients who underwent preoperative IABP placement (Group 1) with 21 patients who had obligatory IABP placement intraoperatively or postoperatively during CABG (Group 2). There were no differences in preoperative risk factors, except left ventricular aneurysm resection, between the two groups. There were no differences in indications for high-risk patients between the two groups. The mean number of grafts was similar. There were no significant differences in the need for inotropes, or in cerebrovascular, gastrointestinal, renal, and infective complications postoperatively. There were no IABP-related complications in either group. Major adverse cardiac event (severe hypotension and/or shock, myocardial infarction, and severe hemodynamic instability) was higher in Group 2 (14 [66.4%] vs. 1 [5%], P < 0.0001) during surgery. The time of IABP pumping in Group 1 was shorter than in Group 2 (72.5 ± 28.9 h vs. 97.5 ± 47.7 h, P < 0.05). The duration of ventilation and intensive care unit stay in Group 1 was significantly shorter than in Group 2, respectively (22.0 ± 1.6 h vs. 39.6 ± 2.1 h, P < 0.01 and 58.0 ± 1.5 h vs. 98.5 ± 1.9 h, P < 0.005). There were no differences in mortality between the two groups (n = 1 in Group 1 and n = 3 in Group 2). Preoperative and preventative insertion of IABP can be performed safely in selected high-risk patients undergoing CABG, with results comparable to those in patients who received obligatory IABP intraoperatively and postoperatively. Therefore, earlier IABP support as part of surgical strategy may help to improve the outcome in high-risk first-time CABG patients. [source] Unexpected Events during the Intrahospital Transport of Critically Ill PatientsACADEMIC EMERGENCY MEDICINE, Issue 6 2007Jonathan P.N. Papson MBBS Objectives:To examine unexpected events (UEs) that occur during the intrahospital transport of critically ill emergency department patients. Methods:This was a prospective observational study of consecutive intrahospital transports between March 2003 and June 2004. The escorting emergency physician completed the data collection document either during or immediately after the transport. This document detailed equipment-related UEs, patient instability and invasive line-related UEs, whether the UEs required intervention, and whether the UEs were potentially life threatening (serious UEs). Results:Of 339 transports observed, 230 (67.9%; 95% confidence interval [CI] = 62.6% to 72.7%) were associated with 604 UEs. Overall, there was a median of 1.0 UE per transport (range, 0,16). There were 277 (45.9%; 95% CI = 41.8% to 49.9%) UEs related to equipment, 158 (26.2%; 95% CI = 22.7% to 29.9%) related to patient instability, 156 (25.8%; 95% CI = 22.4% to 29.6%) related to equipment lines, and 13 (2.2%, 95% CI = 1.2% to 3.8%) miscellaneous UEs. The most common UEs were oxygen saturation probe failures, lead and line tangles, hypotension, and the wearing off of sedation and/or paralysis. Most UEs (478 [79.1%]; 95% CI = 75.6% to 82.3%) required an intervention. Emergency physicians had a significantly lower UE rate than residents. Thirty serious UEs occurred; 5.0% (95% CI = 3.4% to 7.1%) of UEs and 8.9% (95% CI = 6.2% to 12.5%) of transports were associated with a serious UE. The most common were severe hypotension, decreasing consciousness requiring intubation, and increased intracranial pressure. Conclusions:Unexpected events during the intrahospital transport of critically ill patients from the emergency department are common and can be potentially life threatening. Transporting physician experience is associated with UE rate. Strict adherence to and review of existing transport guidelines is recommended. [source] Progressive interstitial fibrosis of kidney allograft early after transplantation from a non-heart beating donor: possible role of persistent ischemic injuryCLINICAL TRANSPLANTATION, Issue 2010Kohsuke Masutani Masutani K, Kitada H, Yamada S, Tsuchimoto A, Noguchi H, Tsuruya K, Katafuchi R, Tanaka M, Iida M. Progressive interstitial fibrosis of kidney allograft early after transplantation from a non-heart beating donor: Possible role of persistent ischemic injury. Clin Transplant 2010: 24 (Suppl. 22): 70,74. © 2010 John Wiley & Sons A/S. Abstract:, The donor was 63-yr-old woman with subarachnoid hemorrhage. As she developed severe hypotension for more than four h before cardiac arrest, we biopsied the grafts and decided to transplant those kidneys. Recipient 1 was a 23-yr-old man on 13-yr dialysis program. After 19 d of delayed graft function (DGF), we discontinued hemodialysis (HD). However, the decrease in serum creatinine (sCr) was poor. The minimum sCr was 4.3 mg/dL on post-operative day (POD) 40, and increased to 6.5 mg/dL. The contralateral graft was transplanted to a 61-yr-old man (recipient 2) with 18-yr HD. After 15 d of DGF period, sCr decreased gradually and has been stable at 1.9 mg/dL. In recipient 1, graft biopsies performed on POD 15, 69, and 110, revealed progressive interstitial fibrosis and tubular atrophy (IF/TA) without evidences of acute rejection, tacrolimus associated injury, reflux nephropathy, or viral nephropathy. The second biopsy on POD 69 showed typical findings of acute tubular necrosis. We compared the clinical courses of the two recipients because certain features of recipient 1, such as age, duration of HD, total ischemic time, and body size were advantageous, whereas graft function was poorer than that in recipient 2. Recipient 1 developed severe anemia following the dissociation of graft function from recipient 2. In this case, posttransplant anemia and lower blood pressure might promote IF/TA through persistent ischemic tubular damage, and positive CMV antigenemia and its treatment could promote anemia. Especially in the kidney allograft from a marginal donor, we should consider various factors to obtain a better graft outcome. [source] | ||||||||||