Severe refractory hypotension during induction of general anesthesia in patient after 48 hours of azilsartan discontinuation: A case report
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SUBMITTER: Lee J
PROVIDER: S-EPMC10681524 | biostudies-literature | 2023 Nov
REPOSITORIES: biostudies-literature
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Project description:BackgroundPost-induction hypotension frequently occurs and can lead to adverse outcomes. As target-controlled infusion (TCI) obviates the need to calculate the infusion rate manually and helps safer dosing with prompt titration of the drug using complex pharmacokinetic models, the use of TCI may provide a better hemodynamic profile during anesthesia induction. This study aimed to compare TCI versus manual induction and to determine the hemodynamic risk factors for post-induction hypotension.MethodsA total of 200 ASA grade 1-3 patients, aged 24 to 82 years, were recruited and randomly assigned to the TCI (n = 100) or manual induction groups (n = 100). Hemodynamic parameters were monitored with the pressure-recording analytic method. The propofol dosage was adjusted to keep the Bispectral Index between 40 and 60.ResultsPost-induction hypotension was significantly higher in the manual induction group than in the TCI group (34% vs. 13%; p < 0.001, respectively). The propofol induction dose did not differ between the groups (TCI: 155 (135-180) mg; manual: 150 (120-200) mg; p = 0.719), but the induction time was significantly longer in the TCI group (47 (35-60) s vs. 150 (105-220) s; p < 0.001, respectively). In the multivariable Cox regression model, the presence of hypertension, stroke volume index (SVI), cardiac power output (CPO), and anesthesia induction method were found to predict post-induction hypotension (p = 0.032, p = 0.013, p = 0.024, and p = 0.015, respectively).ConclusionTCI induction with propofol provided better hemodynamic stability than manual induction, and the presence of hypertension, a decrease in the pre-induction SVI, and the CPO could predict post-induction hypotension.
| S-EPMC10455971 | biostudies-literature
Project description:IntroductionIn geriatric patients, hypotension is often reported after general anesthesia induction using propofol. Remimazolam is a novel short-acting sedative. However, the incidence of hypotension after general anesthesia induction using remimazolam in geriatric patients remains unclear. This study aims to compare the incidence of hypotension associated with remimazolam and propofol in patients aged ≥80 years.MethodsThis single-center, double-blind, randomized, two-arm parallel group, standard treatment-controlled, interventional clinical trial will include 90 patients aged ≥80 years undergoing elective surgery under general anesthesia who will be randomized to receive remimazolam or propofol for induction. The primary outcome is the incidence of hypotension after general anesthesia induction, occurring between the start of drug administration and 3 min after intubation. We define hypotension as mean blood pressure <65 mmHg. The primary outcome will be analyzed using the full analysis set. The incidence of hypotension in the two groups will be compared using the Mantel-Haenszel χ2 test. Subgroup analysis of the primary outcome will be performed based on the Charlson comorbidity index, clinical frailty scale, hypertension in the ward, and age. Secondary outcomes will be analyzed using the Fisher's exact test, Student's t test, and Mann-Whitney U test, as appropriate. Logistic regression analysis will be performed to explore the factors associated with the incidence of hypotension after anesthesia induction.DiscussionOur trial will determine the efficacy of remimazolam in preventing hypotension and provide evidence on the usefulness of remimazolam for ensuring hemodynamic stability during general anesthesia induction in geriatric patients.Trial registrationThe study has been registered with UMIN Clinical Trials Registry (UMIN000042587), on June 30, 2021.
| S-EPMC9524631 | biostudies-literature
Project description:Post-induction hypotension (PIH) during general anesthesia is a serious concern due to its high incidence and association with adverse postoperative outcomes and prognosis. We prospectively enrolled consecutive 1,603 patients scheduled for non-cardiac and cardiac surgery under general anesthesia. The primary outcome was defined as the lowest mean blood pressure from induction of general anesthesia to the start of surgery: post-induction blood pressure (PIB). Multivariable regression analysis was used to investigate the relationships between PIB and preoperative echocardiographic measurements, types and doses of anesthetic agents, and preoperative comorbidities and oral medication. Left ventricle regional wall motion abnormality (RWMA) and lower estimated glomerular filtration rate significantly associated lower PIB. Factors significantly associated with higher PIB were high BMI, beta blockers, high pre-induction mean blood pressure, and starting induction in the afternoon. Sevoflurane and prophylactic norepinephrine use were associated with higher PIB as anesthetic interventions. Significant interactions were found between sevoflurane and RWMA (P for interaction: 0.01). This is the first study to demonstrate the feasibility of intervening in the selection of anesthetic agents based on echocardiographic findings and to recommend the use of sevoflurane and prophylactic norepinephrine for the prevention of PIH, especially in patients with RWMA.
| S-EPMC11519647 | biostudies-literature
Project description:BackgroundHypotension is common after anesthesia induction and may have adverse outcomes. The aim of this study was to investigate whether arterial elastance (Ea) is a predictor of post-induction hypotension.MethodsBetween January and June 2022, the hemodynamic parameters of 85 patients who underwent major surgery under general anesthesia were prospectively evaluated. The noncalibrated pulse contour device MostCare (Vytech, Vygon, Padua, Italy) was used to measure hemodynamic parameters before and after anesthesia induction. The duration of the measurements was determined from one minute before induction to 10 min after induction. Hypotension was defined as a greater than 30% decrease in mean arterial pressure from the pre-induction value and/or systolic arterial pressure of less than 90 mmHg. The patients were divided into post-induction hypotension (-) and (+) groups. For the likelihood of post-induction hypotension, a multivariate regression model was used by adding significantly different pre-induction parameters to the post-induction hypotension group.ResultsThe incidence of post-induction hypotension was 37.6%. The cut-off value of the pre-induction Ea for the prediction of post-induction hypotension was ≥1.08 mmHg m-2mL-1 (0.71 [0.59-0.82]). In the multivariate regression model, the likelihood of postinduction hypotension was 3.5-fold (1.4-9.1), increased by only an Ea ≥ 1.08 mmHg m-2mL-1.ConclusionPre-induction Ea showed excellent predictability of hypotension during anesthetic induction and identified patients at risk of general anesthesia induction-related hypotension.
| S-EPMC10179039 | biostudies-literature
Project description:BackgroundPost-induction hypotension (PIH) often occurs during general anesthesia induction. This study aimed to investigate blood catecholamine levels during induction of general anesthesia in patients with PIH undergoing laparoscopic cholecystectomy.MethodsThis prospective study included 557 adult patients who underwent laparoscopic cholecystectomy under general anesthesia. PIH was defined as a greater than 20% decrease in systolic blood pressure from the pre-induction value, a systolic arterial pressure of less than 90 mmHg, or both. Plasma concentrations of epinephrine and norepinephrine during the induction of general anesthesia were determined using enzyme-linked immunosorbent assay. Multivariate logistic regression analysis evaluated the association between the clinical factors and PIH.ResultsOf the 557 patients, 390 had PIH, and the remaining 167 were allocated to the non-PIH group. Changes in blood adrenaline, noradrenaline levels, or both were more pronounced in the PIH than in the non-PIH group (p<0.05). Age, body mass index, a history of hypertension, preoperative systolic blood pressure, and propofol or sufentanil dose were independent predictors of PIH.ConclusionThe changes of blood catecholamines in patients with more stable hemodynamics during the induction of general anesthesia are smaller than that in patients with post-induction hypotension.Trial registrationChiCTR2200055549, 12/01/2022.
| S-EPMC11198742 | biostudies-literature
Project description:ObjectiveThe effect of anesthetic management (general anesthesia [GA], conscious sedation, or local anesthesia) on functional outcome and the role of blood pressure management during endovascular treatment (EVT) for acute ischemic stroke is under debate. We aimed to determine whether hypotension during EVT under GA is associated with functional outcome at 90 days.MethodsWe retrospectively collected data from patients with a proximal intracranial occlusion of the anterior circulation treated with EVT under GA. The primary outcome was the distribution on the modified Rankin Scale at 90 days. Hypotension was defined using two thresholds: a mean arterial pressure (MAP) of 70 mm Hg and a MAP 30% below baseline MAP. To quantify the extent and duration of hypotension, the area under the threshold (AUT) was calculated using both thresholds.ResultsOf the 366 patients included, procedural hypotension was observed in approximately half of them. The occurrence of hypotension was associated with poor functional outcome (MAP <70 mm Hg: adjusted common odds ratio [acOR], 0.57; 95% confidence interval [CI], 0.35-0.94; MAP decrease ≥30%: acOR, 0.76; 95% CI, 0.48-1.21). In addition, an association was found between the number of hypotensive periods and poor functional outcome (MAP <70 mm Hg: acOR, 0.85 per period increase; 95% CI, 0.73-0.99; MAP decrease ≥30%: acOR, 0.90 per period; 95% CI, 0.78-1.04). No association existed between AUT and functional outcome (MAP <70 mm Hg: acOR, 1.000 per 10 mm Hg*min increase; 95% CI, 0.998-1.001; MAP decrease ≥30%: acOR, 1.000 per 10 mm Hg*min; 95% CI, 0.999-1.000).ConclusionsOccurrence of procedural hypotension and an increase in number of procedural hypotensive periods were associated with poor functional outcome, whereas the extent and duration of hypotension were not. Randomized clinical trials are needed to confirm our hypothesis that hypotension during EVT under GA has detrimental effects.
| S-EPMC8221480 | biostudies-literature
Project description:Administration of a single propofol bolus dose for anesthesia induction causes hypotension. We included 160 patients (74 males and 86 females; mean age, 42.4 ± 10.7 [range: 18-60] years) with the American Society of Anesthesiologists status I-II undergoing elective surgery under general anesthesia. Using simple randomization, the patients were divided into a conventional group (n = 80; received 2 mg/kg propofol at a rate of 250 mg/min) and titrated group (n = 80; received propofol at a rate of 1 mg/kg/min until the Observer's Assessment of Alertness/Sedation scale score reached 1 point). Fentanyl (4 µg/kg) and cisatracurium (0.2 mg/kg) were administered, as appropriate. Systolic blood pressure, diastolic blood pressure, mean blood pressure, and heart rate were recorded at different time points. Propofol consumption, hypotension, and other adverse events were recorded. All the patients were intubated without awareness. Compared with the conventional group, the titrated group showed more stable blood pressure (p < 0.05), as well as a lower decrease in systolic blood pressure, mean blood pressure at 1 and 3 min, and diastolic blood pressure at 1 min after propofol administration (p < 0.01). Moreover, compared with the conventional group, the titrated group showed a lower post-intubation hypotension incidence (9 vs. 19 cases; p = 0.04), as well as lower total propofol dosage and propofol dose per kilogram of body weight (93.57 ± 14.40 mg vs. 116.80 ± 22.37 mg and 1.73 ± 0.27 mg/kg vs. 2.02 ± 0.08 mg/kg, respectively, p < 0.01). Compared with conventional propofol usage, titrated propofol administration can reduce the incidence of hypotension and propofol consumption during anesthesia induction.
| S-EPMC10360076 | biostudies-literature
Project description:Arterial hypotension during the early phase of anesthesia can lead to adverse outcomes such as a prolonged postoperative stay or even death. Predicting hypotension during anesthesia induction is complicated by its diverse causes. We investigated the feasibility of developing a machine-learning model to predict postinduction hypotension. Naïve Bayes, logistic regression, random forest, and artificial neural network models were trained to predict postinduction hypotension, occurring between tracheal intubation and incision, using data for the period from between the start of anesthesia induction and immediately before tracheal intubation obtained from an anesthesia monitor, a drug administration infusion pump, an anesthesia machine, and from patients' demographics, together with preexisting disease information from electronic health records. Among 222 patients, 126 developed postinduction hypotension. The random-forest model showed the best performance, with an area under the receiver operating characteristic curve of 0.842 (95% confidence interval [CI]: 0.736-0.948). This was higher than that for the Naïve Bayes (0.778; 95% CI: 0.65-0.898), logistic regression (0.756; 95% CI: 0.630-0.881), and artificial-neural-network (0.760; 95% CI: 0.640-0.880) models. The most important features affecting the accuracy of machine-learning prediction were a patient's lowest systolic blood pressure, lowest mean blood pressure, and mean systolic blood pressure before tracheal intubation. We found that machine-learning models using data obtained from various anesthesia machines between the start of anesthesia induction and immediately before tracheal intubation can predict hypotension occurring during the period between tracheal intubation and incision.
| S-EPMC7162491 | biostudies-literature
Project description:BackgroundDuring the induction of general anesthesia, hemodynamic instability is a common occurrence in elderly hypertensive patients with increased arterial stiffness, which can cause undesirable complications. Pulse wave velocity (PWV) is an important indicator of arterial stiffness.ObjectivesInvestigate if preoperatively measured PWV is related to hemodynamic changes during induction of general anesthesia.DesignProspective, case control.SettingUniversity hospital.Patients and methodsThe study was carried out between December 2018 and December 2019 in patients 50 years or older scheduled for elective otolaryngology with endotracheal intubation and who had an American Society of Anesthesiologists (ASA) score of I or II. Patients diagnosed with hypertension (HT) or receiving treatment for hypertension for systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg were compared with non-hypertensive patients (non-HT) of matching age and gender.Main outcome measuresPWV values between HT and non-HT patients and hypotension rates at the 30th second of induction, the 30th second of intubation, and the 90th second of intubation between the HT and non-HT groups.Sample size139 (95 with HT and 44 non-HT) RESULTS: PWV was higher in the HT group than in the non-HT group (P<.001). Hypotension at the 30th second of intubation in the HT group was significantly more frequent than in the non-HT group (P=.025). PWV was higher in hypotensive (n=62) than in non-hypotensive patients but the difference was statistically significant only for PWV measured at 30th second of intubation (n=77) (P=.018).ConclusionsThe easily and non-invasively measured preoperative PWV may be an effective means of predicting hypotension during the induction of general anesthesia at the 30th second of intubation in HT patients.LimitationsNumbers of patients in the groups were not the same, and the study was not sufficiently powered to investigate the effect of hypertensive medications on PWV and arterial stiffness.Conflict of interestNone.
| S-EPMC10317492 | biostudies-literature
Project description:BackgroundHypotension often occurs following the induction of general anesthesia in elderly patients undergoing surgery and can lead to severe complications. This study assessed the effect of carotid corrected flow time (FTc) combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients.Materials and methodsThe prospective cohort study was divided into two parts. The first part (Part I) consisted of 112 elderly patients. Carotid FTc was measured using Color Doppler Ultrasound 5 min before anesthesia induction. Hypotension was defined as a decrease of greater than 30% in systolic blood pressure (SBP) or a decrease of greater than 20% in mean arterial pressure (MAP) from baseline, or an absolute SBP below 90 mmHg and MAP below 60 mmHg within 3 min after induction of general anesthesia. The predictive value of carotid FTc was determined using receiver operating characteristic (ROC) curve. The second part (Part II) consisted of 65 elderly patients. Based on the results in Part I, elderly patients with carotid FTc below the optimal cut-off value received perioperative fluid therapy at a volume of 8 ml/kg of balanced crystalloids (lactated Ringer's solution) in 30 min before induction. The effect of carotid FTc combined with perioperative fluid therapy was assessed by comparing observed incidence of hypotension after induction.ResultsThe area under the ROC for carotid FTc to predict hypotension after induction was 0.876 [95% confidence interval (CI) 0.800-0.952, P <0.001]. The optimal cut-off value was 334.95 ms (sensitivity of 87.20%; specificity of 82.20%). The logistic regression analysis revealed that carotid FTc is an independent predictor for post-induction hypotension in elderly patients. The incidence of post-induction hypotension was significantly lower ( P <0.001) in patients with carotid FTc less than 334.95 ms who received perioperative fluid therapy (35.71%) compared to those who did not (92.31%).ConclusionsCarotid FTc combined with the perioperative fluid therapy could significantly reduce the incidence of hypotension after the induction of general anesthesia in elderly patients.
| S-EPMC10871564 | biostudies-literature