Search Results (60)

This review explores the advantages of ivabradine in the management of cardiac surgery patients, particularly highlighting its heart rate (HR)-reducing properties, its role in minimizing the impact of atrial fibrillation, and its contributions to improving left ventricular diastolic function, as well as reducing pain, stress, and anxiety. In parallel, studies provide evidence that ivabradine influences endothelial inflammatory responses through mechanisms such as biomechanical modulation. Unlike traditional beta-blockers that may induce hypotension, ivabradine selectively inhibits hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, allowing for effective HR reduction without compromising blood pressure stability. This characteristic is particularly beneficial for patients at risk of atrial fibrillation post-surgery, where HR control is crucial for cardiovascular stability. This is an area in which ivabradine appears to play a role prophylactically, possibly in combination with beta-blockers. Furthermore, ivabradine has been associated with enhanced diastolic parameters in left ventricular function, reflecting its potential to improve surgical outcomes in patients with compromised heart function. In addition to its cardiovascular benefits, it appears to alleviate psychological stress and anxiety, common in postoperative settings, by moderating the neuroendocrine response to stress, thereby reducing stress-induced hormone levels. Furthermore, it has notable analgesic properties, contributing to pain management through its action on HCN channels in both the peripheral and central nervous systems. Collectively, these findings indicate that ivabradine may serve as a valuable therapeutic agent in the perioperative care of cardiac surgery patients, addressing both physiological and psychological challenges during recovery. Full article

Background/Objectives: Perioperative hypotension during kidney transplantation poses a risk to graft function and survival. Angiotensin II (AngII) is an endogenous vasoconstrictor targeting the renin–angiotensin–aldosterone system (RAAS) to increase blood pressure. Black patients may have a different response to synthetic angiotensin II (AT2S) compared to non-Black patients, given differential expressions in renin profiles. The purpose of this study is to assess the difference between Black and non-Black patients in total vasopressor duration and usage when AT2S is first line for hypotension during kidney transplantation. Methods: A single-center, retrospective cohort study comparing Black and non-Black patients who required AT2S as a first-line vasopressor for hypotension during the perioperative period of kidney transplantation. Results: The primary outcome evaluating total usage of vasopressors found that Black patients required longer durations of vasopressors (36.9 ± 66.8 h vs. 23.7 ± 31.7 h; p = 0.022) but no difference in vasopressor amount (0.07 ± 0.1 NEE vs. 0.05 ± 0.1 NEE; p = 0.128) compared to non-Black patients. Regression analysis found that body weight was associated with the duration of vasopressors (p < 0.05), while baseline systolic blood pressure was inversely associated with it. Longer duration of vasopressors and duration of transplant surgery were associated with delayed graft function in regression analysis (p < 0.05). Conclusions: Black patients had a longer duration of vasopressors, but this was not driven by differences in usage of AT2S. As baseline weight was significantly higher in Black patients and associated with duration of usage, perhaps the metabolic differences in our Black patients led to the observed differences. Regardless, longer durations of vasopressors were associated with delayed graft function, making this an area of utmost importance for continued investigation. Full article

Background and Objectives: The perioperative use of beta-blockers remains controversial due to conflicting evidence of their risks and benefits. The aim of this study was to evaluate the association between chronic beta-blocker (bb) therapy and perioperative cardiac events in non-cardiac surgeries using 24 h continuous Holter monitoring. Materials and Methods: A prospective observational study was conducted on patients undergoing elective or emergency non-cardiac surgery at a Romanian tertiary care hospital. The patients were divided into two groups: G1 (not receiving Bb) and G2 (on chronic Bb). The incidences of perioperative cardiac events, such as severe bradycardia (<40 b/min), new-onset atrial fibrillation (AF), extrasystolic arrhythmia (Ex), and sustained ventricular tachycardia (sVT) and arterial hypotension, were compared between the two groups using clinical, electrocardiography (ECG), and Holter ECG data. Beta-blocker indications, complications, and outcomes were analyzed using chi-squared tests and logistic regression. Results: A total of 100 consecutive patients (63% men, mean age of 53.7 years) were enrolled in the study. G2 included 30% (n = 30) of patients on chronic beta-blocker therapy. The indications included atrial fibrillation (46.7%, n = 14), arterial hypertension (36.7%, n = 11), extrasystolic arrhythmias (10%, n = 3), and chronic coronary syndrome (6.6%, n = 2). Beta-blocker use was significantly associated with severe bradycardia (n = 6; p < 0.001) in G2, whereas one patient in G1 had bradycardia, and 15 and 1 patients had hypotension (p < 0.001) in G1 and G2, respectively. The bradycardia and arterial hypotension cases were promptly treated and did not influence the patients’ prognoses. The 14 patients with AF in G2 had a 15-fold higher odds of requiring beta-blockers (p < 0.001, odds ratio (OR) = 15.145). No significant associations were found between beta-blocker use and the surgery duration (p = 0.155) or sustained ventricular tachycardia (p = 0.857). Ten patients developed paroxysmal postoperative atrial fibrillation (AF), which was related to longer surgery durations (165 (150–180) vs. 120 (90–150) minutes; p = 0.002) and postoperative anemia [hemoglobin (Hg): 10.4 (9.37–12.6) vs. 12.1 (11–13.2) g/dL; p = 0.041]. Conclusions: Patients under chronic beta-blocker therapy undergoing non-cardiac surgery have a higher risk of perioperative bradycardia and hypotension. Continuous Holter monitoring proved effective in detecting transient arrhythmic events, emphasizing the need for careful perioperative surveillance of these patients, especially the elderly, in order to prevent cardiovascular complications These findings emphasize the necessity of tailored perioperative beta-blocker strategies and support further large-scale investigations to optimize risk stratification and management protocols. Full article

Background: Hypotension following epidural labor analgesia (ELA) is its most common complication, affecting approximately 20% of patients and posing risks to both maternal and fetal health. As digital tools and predictive analytics increasingly shape perioperative and obstetric anesthesia practices, real-world implementation data are needed to guide their integration into clinical care. Current monitoring practices rely on intermittent non-invasive blood pressure (NIBP) measurements, which may delay recognition and treatment of hypotension. The Hypotension Prediction Index (HPI) algorithm uses continuous arterial waveform monitoring to predict hypotension for potentially earlier intervention. This clinical trial evaluated the feasibility, acceptability, and efficacy of continuous HPI-guided treatment in reducing time-to-treatment for ELA-associated hypotension and improving maternal hemodynamics. Methods: This was a prospective randomized controlled trial design involving healthy pregnant individuals receiving ELA. Participants were randomized into two groups: Group CM (conventional monitoring with NIBP) and Group HPI (continuous noninvasive blood pressure monitoring). In Group HPI, hypotension treatment was guided by HPI output; in Group CM, treatment was based on NIBP readings. Feasibility, appropriateness, and acceptability outcomes were assessed among subjects and their bedside nurse using the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM) instruments. The primary efficacy outcome was time-to-treatment of hypotension, defined as the duration between onset of hypotension and administration of a vasopressor or fluid therapy. This outcome was chosen to evaluate the clinical responsiveness enabled by HPI monitoring. Hypotension is defined as a mean arterial pressure (MAP) < 65 mmHg for more than 1 min in Group CM and an HPI threshold < 75 for more than 1 min in Group HPI. Secondary outcomes included total time in hypotension, vasopressor doses, and hemodynamic parameters. Results: There were 30 patients (Group HPI, n = 16; Group CM, n = 14) included in the final analysis. Subjects and clinicians alike rated the acceptability, appropriateness, and feasibility of the continuous monitoring device highly, with median scores ≥ 4 across all domains, indicating favorable perceptions of the intervention. The cumulative probability of time-to-treatment of hypotension was lower by 75 min after ELA initiation in Group HPI (65%) than Group CM (71%), although this difference was not statistically significant (log-rank p = 0.66). Mixed models indicated trends that Group HPI had higher cardiac output (β = 0.58, 95% confidence interval −0.18 to 1.34, p = 0.13) and lower systemic vascular resistance (β = −97.22, 95% confidence interval −200.84 to 6.40, p = 0.07) throughout the monitoring period. No differences were found in total vasopressor use or intravenous fluid administration. Conclusions: Continuous monitoring and precision hypotension treatment is feasible, appropriate, and acceptable to both patients and clinicians in a labor and delivery setting. These hypothesis-generating results support that HPI-guided treatment may be associated with hemodynamic trends that warrant further investigation to determine definitive efficacy in labor analgesia contexts. Full article

Pheochromocytoma, a rare catecholamine-secreting tumor, poses significant perioperative challenges due to its potential for severe hemodynamic instability. Careful management of patients with pheochromocytoma is critical for patient safety and favorable outcomes. The diagnostic workup focuses on biochemical analysis of plasma or urinary metanephrines, followed by imaging for tumor localization and genetic testing to identify hereditary syndromes. Preoperative management emphasizes adequate alpha-adrenergic blockade followed by beta-blockade to stabilize cardiovascular function. Anesthetic planning requires meticulous attention to volume status, cardiovascular optimization, and intraoperative monitoring to mitigate the risks of hypertensive crises and hypotension. Postoperative care must account for ongoing hemodynamic and metabolic fluctuations. A multidisciplinary, protocol-driven approach is essential to improve outcomes in patients undergoing pheochromocytoma resection. This paper provides a comprehensive overview of the genetic, biochemical, clinical, and anesthetic considerations involved in the diagnosis and perioperative management of pheochromocytoma. Full article

Background/Objectives: The use of angiotensin II (AT2S) as a vasopressor in patients receiving angiotensin receptor blockers (ARBs) prior to kidney transplant (KT) raises theoretical concerns. At our center, AT2S is the first-line vasopressor during KT. This study evaluated the hemodynamic and clinical effects of pre-transplant ARBs on AT2S use in KT. Methods: This single-center, retrospective cohort trial included patients with hypertension ≥ 18 years old on antihypertensive therapy who received AT2S as the first-line vasopressor peri-transplant. Patients were divided into ARB and non-ARB cohorts. Primary outcomes included total AT2S duration, time with SBP < 120 mmHg, and need for additional vasopressor support. Results: A total of 65 patients were analyzed: 22 in the ARB group and 43 in the non-ARB group. There were no significant differences in the frequency or duration of SBP < 120 mmHg or additional vasopressor requirements between groups (p > 0.05). Hospital and ICU stay length, safety, and adverse drug events were also similar. Conclusions: Contrary to theoretical concerns and observations in other distributive shock populations, no significant hemodynamic or clinical differences were observed in the response to AT2S in patients with pre-transplant ARB use. Full article

Background: Hypotension is a common adverse event after the induction of general anesthesia and may lead to serious complications. The Tricuspid Annular Plane Systolic Excursion (TAPSE)/Pulmonary Arterial Systolic Pressure (PASP) ratio is an echocardiographic parameter reflecting right ventricular (RV) function and pulmonary circulation. This study aimed to evaluate the predictive value of the TAPSE/PASP ratio for hypotension after general anesthesia induction. Methods: This prospective observational study included 79 patients with no known cardiac disease who were scheduled for elective surgery and classified as having a physical status of I–III according to the American Society of Anesthesiologists (ASA). TAPSE, PASP, and RV function were assessed using transthoracic echocardiography (TTE) within 5–30 min before surgery, and their hemodynamic changes after general anesthesia induction were recorded. Results: Data analysis revealed a significant association between the TAPSE/PASP ratio and the occurrence of hypotension following the induction of general anesthesia (p < 0.001). In addition, a cut-off value of ≤1.98 was determined for predicting hypotension, which demonstrated a sensitivity of 72.5% and a specificity of 64.1% (AUC = 0.733, 95% CI: 0.621–0.826, p < 0.001). Conclusions: The TAPSE/PASP ratio is a potential predictor of hypotension following the induction of general anesthesia. Further studies are required to validate its predictive accuracy and clinical utility in perioperative hemodynamic management. Full article

Background/Objectives: Effective pain management following thoracic surgery remains challenging yet crucial for optimal patient outcomes. This literature review compares the efficacy, safety, and clinical outcomes of different perioperative analgesia methods in thoracic surgery patients, focusing on paravertebral block (PVB), intercostal nerve block (ICNB), epidural analgesia (EPI), erector spinae plane block (ESPB), and patient-controlled analgesia (PCA). Methods: A systematic search was conducted across medical databases, yielding ten relevant randomized controlled trials and meta-analyses. Results: The evidence indicates that paravertebral block provides superior pain control with lower opioid requirements, fewer adverse events, and higher patient satisfaction compared to other methods. While epidural analgesia offers pain control comparable to PVB, it is associated with higher technical failure rates and side effects, including urinary retention, nausea/vomiting, and hypotension. ICNB and ESPB demonstrate efficacy superior to systemic analgesia but generally inferior to PVB in terms of pain scores and opioid consumption. Conclusions: This review highlights the need for individualized approaches to perioperative pain management in thoracic surgery, with paravertebral block emerging as a preferred option due to its favorable efficacy and safety profile. Full article

Equine anesthesia is related to high morbidity and mortality rates and recent studies suggested that the period of recovery remains the phase associated with the greatest risk of mortality in horses. Intraoperative hypotension, hypoxemia, and hypercapnia are recognized as potential determinants of recovery quality. This study, conducted at the Equine University Hospital of Liege, aimed to explore how these factors influence recovery outcomes and compare complications between non-emergency and emergency procedures. We analyzed data from 1057 horses, with a mean weight of 498 kg (ranging from 150 to 850 kg) and a mean age of 10.7 (ranging from 0.5 to 37 years), undergoing standardized general anesthesia for non-emergency and emergency procedures to assess which factors influence recovery quality. Recoveries were graded as ‘good’ or ‘bad’ and age, sex, breed, American Society of Anesthesiologists (ASA) physical status classification, weight, anesthesia duration, presence of hypotension, hypoxemia, and hypercapnia were compared with a logistic regression analysis. Our findings highlight the multifactorial nature of anesthetic recovery in horses, with breed, age, anesthesia and recovery duration, and emergency status emerging as significant influencing factors. Additionally, monitoring and managing hypoxemia and hypotension remain critical due to their recognized impact on recovery quality. However, despite their clinical relevance, the specific effects of these variables on anesthetic recovery in horses remain insufficiently studied, emphasizing the need for further research to refine perioperative management strategies and improve outcomes. Full article

Introduction: Microvascular free flap surgery is a treatment method for patients with head and neck cancer requiring reconstruction surgery. Patients undergoing this complex, long-lasting surgery are prone to prolonged episodes of intraoperative hypotension, which is associated with increased incidence of postoperative mortality, morbidity, and free flap failure. A new technology recently approved, named the Hypotension Prediction Index (HPI), allows precise hemodynamic monitoring of patients under general anesthesia, with a significant reduction of intraoperative hypotension events. This study aims to assess the impact of the Hypotension Prediction Index (HPI) on the incidence and severity of intraoperative hypotension in patients undergoing free flap surgery. Methods and analysis: Eligible patients will be randomly assigned to one of two groups: Group A, receiving invasive blood pressure monitoring with standard medical therapy, or Group B, undergoing hemodynamic monitoring using the Hypotension Prediction Index (HPI) software. The primary outcome is the time-weighted average (TWA) of mean arterial pressure (MAP) < 65 mmHg. Secondary outcomes include free flap viability and perioperative complications. Ethics and dissemination: Ethics approval was obtained from the Poznan University of Medical Sciences Ethics Committee (KB-560/22; date 1 July 2022). Results will be submitted for publication in a peer-reviewed journal. Trial registration number: NCT 05738603. Full article

Background/Objectives: Transurethral resection of bladder tumor (TURBT) is commonly performed in elderly patients and often requires repeated procedures. A high proportion of non-procedural time in TURBT affects operating room utilization, highlighting the need for a safe and efficient anesthesia method. This study aimed to compare remimazolam-based monitored anesthesia care (MAC) guided by analgesia nociception index (ANI) monitoring to inhalation-based general anesthesia (GA) for TURBT, focusing on induction and emergence time (IAET). Methods: Forty-six patients who underwent TURBT were randomly assigned into either the MAC group or GA group. The primary outcome was the IAET. The secondary outcomes included hospital and anesthesia charges, safety (intraoperative hypotension and desaturation), and feasibility (surgeon and patient satisfaction) of both anesthetic methods. Results: The MAC group demonstrated a significantly shorter IAET (14 vs. 25 min, p < 0.001) and lower anesthesia cost (USD 152 vs. USD 195, p < 0.001). The MAC group showed better hemodynamic stability with a lower incidence of hypotension (29% vs. 73%, p = 0.004). Seven patients (33%) in the MAC group experienced intraoperative desaturation; all patients recovered without complications through the jaw-thrust maneuver. Patient satisfaction was equally high in both groups, and surgeon satisfaction, though slightly lower with MAC (71% vs. 100% rating “excellent”, p = 0.009), remained acceptable. Conclusions: Remimazolam-based MAC, guided by ANI monitoring, offers significant advantages including shorter IAET, reduced costs, and improved safety for TURBT, particularly in patients with small tumors. These findings support MAC as a promising alternative to GA for TURBT, as it enhances perioperative outcomes and operating room efficiency. Full article

Background: Acute kidney injury (AKI) is a critical medical condition characterized by a sudden decline in renal function, often resulting in severe complications and increased mortality. In the context of spine surgery, particularly for adult spine deformities, the risk of AKI is significant due to the complexity and duration of these procedures, as well as the substantial intraoperative blood loss and hemodynamic instability they can entail. Despite advancements in surgical and perioperative care, AKI remains a major concern. This paper presents a case report of AKI following spine deformity surgery and conducts a comprehensive literature review to evaluate the incidence and risk factors associated with AKI in this specific surgical population. Methods: A systematic literature search was conducted across the PubMed, Medline, and Cochrane Library databases, focusing on studies published between January 2000 and December 2023. The inclusion criteria targeted studies reporting on adult patients undergoing spine surgery, specifically detailing the incidence and risk factors of AKI. Exclusion criteria included studies on pediatric patients, non-English publications, and those lacking clear AKI diagnostic criteria. Data from the selected studies were independently extracted by two reviewers and analyzed using descriptive statistics and meta-analysis techniques where applicable. The case report highlights a patient who developed AKI following extensive spine surgery for Adult Spine Deformity (ASD), detailing the clinical course, diagnostic approach, and management strategies employed. Results: The literature review revealed that the incidence of AKI in spine surgery varies widely and is influenced by factors such as patient demographics, type of surgery, and perioperative management. Identified risk factors include significant blood loss, prolonged operative time, intraoperative hypotension, and the use of nephrotoxic drugs. The findings underscore the importance of vigilant perioperative monitoring and proactive management strategies to mitigate the risk of AKI. These strategies include optimizing hemodynamic stability, minimizing blood loss, and careful management of nephrotoxic medications. Conclusions: By integrating a detailed case report with a thorough review of the existing literature, this paper aims to enhance the understanding of AKI in spine surgery and inform clinical practices to improve patient outcomes. Full article

Background and Objectives: Remifentanil is a member of the fentanyl family and a short-acting, esterase-metabolized opioid that offers potential advantages over fentanyl in ophthalmic surgeries characterized by rapid patient turnover. This study aimed to compare two different analgesia induction regimes, remifentanil or fentanyl, with respect to intraoperative hypotensive events and perioperative process times in patients undergoing ophthalmic surgery under general anesthesia. Materials and Methods: Clinical data of 500 patients either receiving remifentanil infusion (R group, 0.4–0.5 μg/kg/min at induction, and then 0.1 µg/kg/min maintenance dose) or fentanyl bolus (F group, 1 μg/kg for induction followed by 0.1 μg/kg/min remifentanil maintenance dose) were analyzed in this retrospective study. All patients received a propofol injection as part of the induction and sevoflurane for the maintenance of anesthesia. We investigated hemodynamic events as defined by the administration of vasopressors, atropine and Akrinor (Theodrenaline and Cafedrine), as well as procedural times in the two groups. Results: There was no difference in hypotensive events between the two groups. However, there was a relationship between preoperative ASA (American Society of Anesthesiologists) status and vasopressor administration. The amount of propofol for the induction of anesthesia exhibited a significant correlation to the age of the patients (p < 0.05). The time from the end of anesthesia to discharge from the recovery room was significantly reduced by approximately 6 min per patient in the remifentanil group (p < 0.01). In conclusion, the induction of anesthesia with high-dose remifentanil combined with propofol can significantly shorten the time span to discharge from the recovery ward compared to fentanyl bolus administration, without an increase in the administration of vasopressors in patients undergoing ophthalmic surgery in general anesthesia. Conclusions: These findings suggest that remifentanil may be a more effective choice for anesthesia management in settings with high patient turnover. Full article

Sodium nitroprusside (SNP) is a powerful vasodilator approved for treating acute hypertensive crises, acute heart failure, aortic dissection, and both controlled perioperative hypotension and perioperative hypertension. Its unique ability to cause both venous and arterial dilation makes it an invaluable option in critical care settings. Despite concerns regarding its manageability due to potential toxicity, it is a safe choice if properly used, as highlighted by its short half-life and minimal side effects. This review aims to summarize its pharmacological properties, toxicology, and various clinical applications, particularly focusing on acute heart failure and hypertensive emergencies. Full article

Background: Hemodynamic instability is common during adrenalectomy for pheochromocytoma and paraganglioma (PPGL). Most analyses focus on the risk factors for intraoperative hypertension, but hypotension is a frequent and undesirable phenomenon during PPGL surgery. This study aimed to analyze the risk factors for hypotensive episodes during the removal of PPGL, and whether these episodes are always associated with concomitant intraoperative hypertensive events. Methods: A consecutive series of 121 patients (91.7% receiving preoperative alpha-blockade) treated with transperitoneal endoscopic adrenalectomy at a university hospital were analyzed, and pre- and intraoperative risk factors for intraoperative hypotension with or without intraoperative hypertension were analyzed using univariable and multivariable logistic regression analyses. Results: In total, 58 (56.2%) patients presented with intraoperative hypotension. Of these, 25 (20.7%) patients showed only hypotensive episodes but no hypertensive episodes (group 1), and 43 (35.5%) patients had both intraoperative hypotension and hypertension (group 2). The remaining 53 patients did not present with hypotension at all (group 3). When comparing group 1 (hypotension only) to all other patients with incidental diagnosis, higher age and lower preoperative diastolic arterial blood pressure (ABP) were significant risk factors for intraoperative hypotension; only the latter two were still significant in multivariate analysis. The significant risk factors for hypotension independent of hypertension (group 1 + 2 vs. group 3) were age and incidental diagnosis, pre-existing diabetes mellitus, and intraoperative use of remifentanil. Incidental diagnosis and use of remifentanil reached the level of significance in multivariate analysis. Conclusions: Since older age, incidental diagnosis of PPGL, lower preoperative ABP, and diabetes mellitus are risk factors for intraoperative hypotension, preoperative alpha-blocker treatment should be individualized for those at risk for hypotension. In addition, remifentanil should be used cautiously in the risk group. Full article