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Background: Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality worldwide. Traditional methods of estimating blood loss and monitoring vital signs often delay intervention. The Shock Index (SI), calculated as heart rate divided by systolic blood pressure, is a potential early indicator of hemodynamic instability in PPH.Aim was to evaluate the role of SI and other vital signs like mean arterial pressure (MAP), pulse pressure (PP) and diastolic blood pressure (DBP) in predicting adverse maternal outcomes following PPH. METHODS: This prospective observational study included 70 women with PPH at a tertiary care hospital. Monitoring occurred at 15, 30 and 60 minutes postpartum. Blood loss was measured gravimetrically. SI thresholds and vital signs were analyzed to assess their correlation with blood loss severity and maternal outcomes. Results: SBP, DBP and MAP showed significant declines with increasing blood loss. SI values rose consistently, with higher thresholds correlating with adverse outcomes. An SI =1 was linked to the need for operative interventions, while an SI >1.3 indicated ICU admissions and increased morbidity. AMTSL reduced PPH incidence but required strict adherence to protocols. Conclusion: SI is a reliable and cost-effective tool for early identification of hemodynamic instability in PPH. It aids in timely interventions, especially in resource-limited settings. Standardizing SI in clinical practice can improve maternal outcomes. Future studies should validate these findings across diverse settings and populations. [ABSTRACT FROM AUTHOR]

Background: Managing hemodynamic instability in critically ill patients due to cardiovascular disease or, in particular, coronary artery disease requires an integrated and responsive approach. The complexity lies in simultaneously addressing the underlying cardiovascular pathology and managing its systemic effects. The complexity described above involves a careful balance of interventions, including fluid and electrolyte management, pharmacological support, and, in some cases, mechanical circulatory support. The dynamic nature of hemodynamic instability necessitates constant vigilance and rapid adaptation of treatment strategies to align with the evolving clinical picture. So, this study aims to investigate the knowledge, attitude, and practice of Palestinian critical care nurses about hemodynamic instability in patients with cardiovascular diseases. Method: A cross-sectional design was conducted on 300 nurses in 30 hospitals in the West Bank and East Jerusalem of Palestine. Data were collected using a self-administered questionnaire composed of four sections covering the socio-demographics, knowledge, attitudes, and practices of the sample. Quantitative statistical analysis was done using Statistical Package for Social Sciences (SPSS) software. Results: The nurses demonstrated an almost low overall level of knowledge about hemodynamic instability, with a mean score of 2.7 on a 7-points scale. Additionally, nurses generally expressed a high positive attitude toward their practice, with a mean score of 3.8 on a 5-point scale. Although; Palestinian nurses showed a low level of knowledge about hemodynamic instability but expressed positive attitudes toward their practice. The practice level was also moderate with a mean score of 2.3 on a 5-point scale. Significant differences were found with a higher attitude of male nurses and higher knowledge with bachelor or higher educational levels. Other variables showed non-significant differences. Conclusions: Several challenges were identified, including lack of training and resources, within this study context. Educational interventions and improved access to resources could improve nurses' knowledge and practice in managing hemodynamic instability. [ABSTRACT FROM AUTHOR]

Intraoperative hypotension (IOH) is a common occurrence during anesthesia administration for various surgical procedures and is linked to postoperative adverse outcomes. Factors contributing to IOH include hypovolemia, vasodilation, and impaired contractility, often combined with patient comorbidities. Strategies for mitigating IOH have been developed and are continually being updated with new research and technological advancements. These strategies include personalized blood pressure thresholds, pharmacologic measures, and the use of predictive tools. However, the management of IOH also requires careful consideration of patient-specific comorbidities and the use of appropriate treatment options. [ABSTRACT FROM AUTHOR]

Abstract Background Managing hemodynamic instability in critically ill patients due to cardiovascular disease or, in particular, coronary artery disease requires an integrated and responsive approach. The complexity lies in simultaneously addressing the underlying cardiovascular pathology and managing its systemic effects. The complexity described above involves a careful balance of interventions, including fluid and electrolyte management, pharmacological support, and, in some cases, mechanical circulatory support. The dynamic nature of hemodynamic instability necessitates constant vigilance and rapid adaptation of treatment strategies to align with the evolving clinical picture. So, this study aims to investigate the knowledge, attitude, and practice of Palestinian critical care nurses about hemodynamic instability in patients with cardiovascular diseases. Method A cross-sectional design was conducted on 300 nurses in 30 hospitals in the West Bank and East Jerusalem of Palestine. Data were collected using a self-administered questionnaire composed of four sections covering the socio-demographics, knowledge, attitudes, and practices of the sample. Quantitative statistical analysis was done using Statistical Package for Social Sciences (SPSS) software. Results The nurses demonstrated an almost low overall level of knowledge about hemodynamic instability, with a mean score of 2.7 on a 7-points scale. Additionally, nurses generally expressed a high positive attitude toward their practice, with a mean score of 3.8 on a 5-point scale. Although; Palestinian nurses showed a low level of knowledge about hemodynamic instability but expressed positive attitudes toward their practice. The practice level was also moderate with a mean score of 2.3 on a 5-point scale. Significant differences were found with a higher attitude of male nurses and higher knowledge with bachelor or higher educational levels. Other variables showed non-significant differences. Conclusions Several challenges were identified, including lack of training and resources, within this study context. Educational interventions and improved access to resources could improve nurses’ knowledge and practice in managing hemodynamic instability.

Background. Coronary heart disease (CHD) is one of the most common diseases in Ukraine and worldwide. Open myocardial revascularisation procedures require general anaesthesia with endotracheal intubation. Prevention of peri-intubation hypotension in elderly patients with CHD is relevant today. The purpose was to improve the safety of surgery in elderly CHD patients by determining the induction schedule for anaesthesia with minimal cardiodepressant and vasodilator effects. Materials and methods. A cohort prospective randomized study of 40 patients with ASA III–IV who underwent off-pump coronary artery bypass grafting. Their mean age was 67.00 ± 5.78 years. The participants were divided into 2 groups based on the type of induction agent: group 1 — propofol 1.5 mg/kg, fentanyl 2.0 μg/kg; group 2 — propofol 1.5 mg/kg, fentanyl 2.0 μg/kg, ketamine 0.5 mg/kg. Relaxation: pipecuronium bromide 0.1 mg/kg. Hemodynamic parameters were recorded at the following stages: 1) upon arrival to the operating room; 2) before it; 3) after intubation; 4) 25 minutes after intubation. Results. After the administration of induction drugs, a significant difference was observed only in mean arterial pressure (MAP): group 1 — 72.71 ± 4.76 %, group 2 — 81.29 ± 5.4 % of the baseline, p = 0.0001. At the third stage, a statistically significant difference between the groups was determined in three indicators: MAP (86.74 ± 8.82 %, 92.34 ± 7.26 %; p < 0.05), stroke volume index (SVI) (99.91 ± 2.94 %, 109.63 ± 8.16 %, p < 0.05), cardiac index (CI) (96.63 ± 11.77 %, 110.38 ± 12.37 %, p < 0.05). At the fourth stage, a statistical difference between the groups was observed in MAP (74.87 ± 7.90 % in group 1 vs. 86.47 ± 6.07 % in group 2, p < 0.05), SVI (87.09 ± 5.30 % in group 1 vs. 108.21 ± 8.32 % in group 2, p < 0.05), ejection fraction (88.26 ± 3.58 % in group 1 vs. 106.89 ± 6.22 % in group 2, p < 0.05), CI (79.59 ± 10.11 % in group 1 vs. 108.29 ± 9.95 % in group 2, p < 0.05), systemic vascular resistance index (91.13 ± 9.34 % in group 1 vs. 77.86 ± 9.83 % in group 2, p < 0.05). Conclusions. The addition of ketamine to the classic combination of propofol and fentanyl increases the effectiveness and reduces the percentage of possible potential complications by stabilizing hemodynamics during anaesthetic support for coronary artery bypass grafting in older patients with CHD.

Harmattan is a season characterized by dust, cold, and sub-humid trade winds in Sub-Saharan countries. It’s similar to meteorological phenomena like Asian dust storms, Santa Ana winds, Australian bushfires, and Saharan dust in the Caribbean. It causes profound changes in the cardiorespiratory system in apparently healthy individuals and increases the risk of hospitalization in susceptible individuals. Exposure to these extreme conditions has been associated with alterations in autonomic function and baroreceptor sensitivity thus resulting in dysregulation of blood pressure control mechanisms. Baroreceptors are critical regulators of hemodynamics and cardiovascular function. They play a vital role in the short-term responses to blood pressure perturbation and are essential for acute restoration of blood pressure following cold exposure. Harmattan wind contains a barrage of chemicals, dust, and particulate matters depending on industrialization, natural and human activities. Particulate matter from Harmattan dust can trigger systemic inflammation and oxidative stress, exacerbating endothelial dysfunction and impairing vascular reactivity thus contributing to the pathogenesis of alterations in baroreceptor insensitivity, and cardiovascular diseases, including hypertension and atherosclerosis. Furthermore, fine particulate matter from dust may penetrate deep into the respiratory tract, activating pulmonary sensory receptors and eliciting reflex responses that influence autonomic tone. The presence of rich acrolein smokes and non-essential heavy metals such as cadmium, lead, and mercury in Harmattan wind also reduces baroreflex sensitivity, culminating in a sustained increase in diastolic and systolic blood pressure. This integrated review aims to provide valuable insights into how changes in each of these environmental constituents alter vital pathophysiologic and immunologic mechanisms of the body leading to baroreceptor instability and ultimately hemodynamic imbalance using available primary studies. Understanding this intricate interplay is crucial for implementing targeted interventions and informed public health strategies to mitigate the adverse effects of extreme environmental exposure and ultimately reduce poor health outcomes in the affected regions.

Abstract Background In cardiac surgical procedures, patients carrying high-risk profiles are prone to encompass complicated cardiopulmonary bypass (CPB) separation. Intraoperative transesophageal echocardiography (TEE), a readily available tool, is utilized to detect cardiac structural and functional pathologies as well as to facilitate clinical management of CPB separation, especially in the episodes of hemodynamic compromise. However, the conventional TEE examination, always performed in a liberal fashion without any restriction of view acquisition, is relatively time-consuming; there appear its flaws in the context of critically severe status. We therefore developed the perioperative rescue transesophageal echocardiography (PReTEE), a simplified three-view TEE protocol consisting of midesophageal four chamber, midesophageal left ventricular long axis, and transgastric short axis. Methods This is a single-center and randomized controlled trial which will be implemented in Peking Union Medical College Hospital, Beijing, China. A total of 46 TEE scans are schemed to be performed by 6 operators participating in and randomly assigned to either the PReTEE or the conventional TEE group. This study is purposed to investigate whether the efficiency of discriminating leading causes of difficult CPB wean-off can be significantly improved via an abbreviated sequence of TEE views. The primary outcome of interest is the difference between the groups of PReTEE and the conventional TEE in the successful discrimination of etiologies in specified 120 s. Cox proportional hazards model will be further employed to calculate the outcome difference. Discussion The estimated results of this trial are oriented at verifying whether a simplified TEE exam sequence can improve the efficiency of etiologies discrimination during CPB separation in cardiac surgery. Trial registration ClinicalTrials.gov NCT05960552. Registered on 6 July 2023.

Background: Surgical resection for pheochromocytoma (PCC) is still challenging. This study assessed the perioperative outcomes of adrenalectomy for PCC and investigated the risk factors for intraoperative hemodynamic instability (HI). Methods: This retrospective study included 571 patients with adrenal tumors who underwent adrenalectomy at Kobe University Hospital and other related hospitals between April 2008 and October 2023. The perioperative outcomes of laparoscopic adrenalectomy were compared between PCC (n = 92) and non‐PCC (n = 464) groups. In addition, we investigated several potential risk factors for intraoperative HI in patients with PCC (n = 107; open, n = 11; laparoscopic, n = 92; robot‐assisted, n = 4). Results: While patients with PCC had a significantly larger amount of blood loss in comparison to those with non‐PCC (mean, 70 and 30 mL, respectively; p = 0.004), no significant difference was observed in the rate of perioperative grade ≥III complications (1.1% vs. 0.6%; p = 0.516), and no perioperative mortality was observed in either group. A tumor size of ≥40 mm, with preoperative hypertension and urinary metanephrines at a level ≥3 times the upper limit of the normal value, were found to be significant predictors of HI, with odds ratios of 2.74 (p = 0.025), 3.91 (p = 0.005), and 3.83 (p = 0.004), respectively. Conclusions: Our data suggest that laparoscopic adrenalectomy for PCC may be as safe as that for other types of adrenal tumors and that large tumors and hormonally active disease may be risk factors for intraoperative HI. The optimal perioperative management for PCC with these risk factors should be established. [ABSTRACT FROM AUTHOR]

Individuals with spinal cord injury (SCI) at and above T6 experience impaired descending cortical control of the autonomic nervous system, which predisposes them to blood pressure (BP) disorders including persistent hypotension. The primary aim of this investigation was to determine the effects of midodrine, 10 mg, administered daily over a 30-day period in the home environment, compared to placebo, on laboratory assessments of BP, cerebral blood flow velocity (CBFv), and cognitive performance in hypotensive individuals with chronic SCI. This prospective, randomized, placebo-controlled, double-blind, crossover trial was conducted in 15 individuals with tetraplegia. In the first 30-day period, five participants were randomized to midodrine and 10 were randomized to placebo; participants were then crossed over to the second 30-day period following a 14-day washout. Laboratory assessments of BP, CBFv, and cognitive performance were measured before and after each of the two study arms. Systolic BP (SBP) was significantly increased following midodrine administration compared to placebo (116 ± 23 mm Hg vs 94 ± 16 mm Hg; p =.002). In addition, diastolic CBFv was increased after midodrine administration compared to placebo (31.0 ± 11.2 vs 25.6 ± 9.1 cm/s; p =.04). However, there were no significant drug by time interaction effects for systolic or mean CBFv (p >.172) and cognitive performance (p =.689). The results suggest significant increases in SBP and diastolic CBFv without appreciable effects on cognition after 30 days of midodrine administration. Further investigation is needed to identify effective antihypotensive treatment options that not only normalize BP but also improve CBFv and cognition. [ABSTRACT FROM AUTHOR]

Introduction: Acute kidney injury (AKI) significantly disrupts vital renal functions and is a common and serious condition in intensive care units (ICUs). AKI leads to extended hospital stays, increases mortality rates, and often necessitates nephrology consultations. Continuous renal replacement therapy (CRRT) plays a central role in managing AKI, requiring a multidisciplinary approach involving nephrologists, intensivists, and anesthesiologists. This study examines the clinical profile and progression of AKI in ICU patients requiring CRRT, with a focus on CRRT indications and modalities. Materials and Methods: We conducted a single-center retrospective observational study on ICU patients with AKI requiring CRRT from January to December 2019. AKI diagnosis followed the RIFLE criteria, and patients who received CRRT for less than 36 h were excluded. Data collected included demographics, hemodynamic parameters, and renal function parameters, with follow-ups at 1 week, 1 month, 6 months, and 12 months. Statistical analyses evaluated outcomes and transitions between CRRT and other renal replacement therapies. Results: Among 123 evaluated patients, 95 met inclusion criteria. Fifteen patients received CRRT for less than 36 h, with an early mortality rate of 80%. The final cohort comprised 80 patients who underwent CRRT for over 36 h, with a mean age of 65.3 years (SD = 13.6) and a Charlson index of 6.4. Patients were categorized based on primary diagnosis into heart failure, cardiac surgery, sepsis, other surgeries, and miscellanea groups. Mortality rates were highest in the heart failure and miscellanea groups. Significant variability was observed in therapy transitions and long-term outcomes. Continuous venovenous hemodiafiltration (CVVHDF) was the most frequently used CRRT modality. Conclusions: This study highlights the variability in CRRT practices and the poor prognosis for critically ill patients with AKI requiring CRRT. Timely nephrology consultation and tailored treatment plans may improve patient outcomes and optimize CRRT utilization. Future research should focus on refining CRRT protocols and exploring preventive strategies for AKI. [ABSTRACT FROM AUTHOR]

Background: Adrenalectomy for pheochromocytoma (PHEO) is challenging because of the high risk of intraoperative hemodynamic instability (HDI). This study aimed to compare the incidence and risk factors of intraoperative HDI between laparoscopic left adrenalectomy (LLA) and laparoscopic right adrenalectomy (LRA). Methods: We retrospectively analyzed two hundred and seventy-one patients aged > 18 years with unilateral benign PHEO of any size who underwent transperitoneal laparoscopic adrenalectomy at our hospitals between September 2016 and September 2023. Patients were divided into LRA (N = 122) and LLA (N = 149) groups. Univariate and multivariate logistic regression analyses were used to predict intraoperative HDI. In multivariate analysis for the prediction of HDI, right-sided PHEO, PHEO size, preoperative comorbidities, and preoperative systolic blood pressure were included. Results: Intraoperative HDI was significantly higher in the LRA group than in the LLA (27% vs. 9.4%, p < 0.001). In the multivariate regression analysis, right-sided tumours showed a higher risk of intraoperative HDI (odds ratio [OR] 5.625, 95% confidence interval [CI], 1.147–27.577, p = 0.033). The tumor size (OR 11.019, 95% CI 3.996–30.38, p < 0.001), presence of preoperative comorbidities [diabetes mellitus, hypertension, and coronary heart disease] (OR 7.918, 95% CI 1.323–47.412, p = 0.023), and preoperative systolic blood pressure (OR 1.265, 95% CI 1.07–1.495, p = 0.006) were associated with a higher risk of HDI in both LRA and LLA, with no superiority of one side over the other. Conclusion: LRA was associated with a significantly higher intraoperative HDI than LLA. Right-sided PHEO was a risk factor for intraoperative HDI. [ABSTRACT FROM AUTHOR]

ObjectiveBlood pressure fluctuations are a common hemodynamic alteration following carotid artery stenting either with transfemoral (TFCAS) or transcarotid (TCAR) approach and are thought to be related to alteration in baroreceptor function due to angioplasty and stent expansion. These fluctuations are particularly worrisome in the high-risk patient population referred for CAS. This study aims to evaluate the outcomes of patients who required the administration of intravenous blood pressure medication (IVBPmed) for hypotension or hypertension after CAS.MethodsAll patients undergoing carotid revascularization in the Vascular Quality Initiative (VQI) database between 2016 and 2021 were included. We compared outcomes of patients who required postoperative IVBPmed to treat hyper- or hypotension with normotensive patients. In-hospital outcomes were compared using multivariable logistic regression. One-year outcomes were assessed using Kaplan-Meier survival and multivariable Cox proportional hazard regression analyses.ResultsWe identified 38,510 patients undergoing CAS (57.7% TCAR and 42.3% TFCAS), of which, 30% received IVBPmed for treatment of either postoperative hypertension (12.6%) or hypotension (16.4%). In multivariable analysis, postoperative hypotension was associated with a higher risk of stroke, death, or myocardial infarction (MI) (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.6-3.6; P < .001), stroke or death (OR, 2.9; 95% CI, 2.4-3.5; P < .001), stroke (OR, 2.6; 95% CI, 2.1-3.2; P < .001), death (OR, 3.5; 95% CI, 2.6-4.8; P < .001), MI (OR, 4.7; 95% CI, 3.3-6.7; P < .001), and bleeding (OR, 1.96; 95% CI, 1.4-2.7; P < .001) compared with normotensive patients. Postoperative hypertension was associated with a higher risk of stroke, death, or MI (OR, 3.6; 95% CI, 3-4.4; P < .001), stroke or death (OR, 3.3; 95% CI, 2.7-4.1; P < .001), stroke (OR, 3.7; 95% CI, 3-4.7; P < .001), death (OR, 2.7; 95% CI, 1.9-3.9; P < .001), MI (OR, 5.7; 95% CI, 3.9-8.3; P < .001), and bleeding (OR, 1.9; 95% CI, 1.4-2.7; P < .001) compared with normotensive patients.ConclusionsPostoperative hypertension or hypotension requiring IVBPmed after CAS is associated with an increased risk of in-hospital stroke, death, MI, and bleeding. Postoperative hypertension is associated with worse survival at 1 year. This study indicates that the need for IVBPmed after CAS is not benign; therefore, these patients necessitate aggressive perioperative medical management and safe techniques to avoid hypo and hypertension. Close follow-up and continue medical management are needed to maximize these patients' survival.

PurposeThe incidence of hemodynamic instability associated with dexmedetomidine (DEX) sedation has been reported to exceed 50%, with substantial inter-individual variability in response. Genetic factors have been suggested to contribute significantly to such variation. The aim of this study was to identify the clinical, pharmacokinetic, and genetic factors associated with DEX-induced hemodynamic instability in pediatric anesthesia patients.MethodsA cohort of 270 pediatric patients scheduled for elective interventional surgery received an intranasal dose of 3 mcg·kg-1 of dexmedetomidine, and subsequent propofol induction was conducted when patients had a UMSS of 2–4. The primary endpoint was hemodynamic instability—defined as a composite of hypotension and/or bradycardia, which is characterized by a 20% reduction from age-specific baseline values. Plasma concentrations of dexmedetomidine were determined, and single-nucleotide polymorphisms (SNPs) were genotyped. A validated population pharmacokinetic model was used to estimate pharmacokinetic parameters. LASSO regression was used to identify significant factors, and a Cox’s proportional hazards model-derived nomogram for hemodynamic instability was developed.ResultsHemodynamic instability was observed in 52 out of 270 patients (209 events), resulting in a cumulative incidence of 16.30% at 90 min, as estimated by Kaplan–Meier estimation, and it was associated with a median time to event of 35 min. The interval time between DEX initiation and propofol induction was 16 min (IQR: 12–22 min). The cumulative incidence was 8.2% within 22 min after DEX initiation. The identified significant risk factors for DEX-associated hemodynamic instability included weight, DEX clearance, concomitant propofol use, and the following gene variants UGT2B10 rs1841042 (hazard ratio (HR):1.41, 95% confidence interval (CI): 1.12–1.79), CYP2A6 rs8192733 (HR:0.28, 95%CI:0.09–0.88), ADRA2B rs3813662 (HR:1.39,95%CI:1.02–1.89), CACNA2D2 rs2236957 (HR:1.46, 95%CI:1.09–1.96), NR1I2 rs3814057 (HR:0.64, 95%CI:0.43–0.95), and CACNB2 rs10764319 (HR:1.40,95%CI:1.05–1.87). The areas under the curve for the training and test cohorts were 0.881 and 0.762, respectively. The calibration curve indicated excellent agreement.ConclusionThe predictive nomogram, which incorporates genetic variants (UGT2B10, CYP2A6, ADRA2B, CACNA2D2, NR1I2, and CACNB2) along with clinical factors such as weight, DEX clearance, and propofol use, may help prevent DEX-associated hemodynamic instability. Delayed hemodynamic instability is likely to occur after 35-min DEX initiation in patients with lower DEX clearance after propofol induction.

Closed pelvic fractures can lead to severe complications, including hemodynamic instability (HI) and mortality. Accurate prediction of these risks is crucial for effective clinical management. This study aimed to utilize various machine learning (ML) algorithms to predict HI and death in patients with closed pelvic fractures and identify relevant risk factors. The retrospective study included 208 patients diagnosed with pelvic fractures and admitted to Suning Traditional Chinese Medicine Hospital between 2019 and 2023. Among these, 133 cases were identified as closed PFs. Patients with closed fractures were divided into a training set (n = 115) and a test set (n = 18). The training set was further stratified into two groups based on hemodynamic stability: Group A (patients with HI) and Group B (patients with hemodynamic stability). A total of 40 clinical variables were collected, and multiple machine learning algorithms were employed to develop predictive models, including logistic regression (LR), C5.0 Decision Tree (DT), Naive Bayes (NB), support vector machine (SVM), K-nearest neighbors (KNN), random Forest (RF), and artificial neural network (ANN). Additionally, factor analysis was performed to assess the interrelationships between variables. The RF and LR algorithms outperformed traditional methods—such as central venous pressure (CVP) and intra-abdominal pressure (IAP) measurements—in predicting HI. The RF model achieved an average under the ROC (AUC) of 0.92, with an accuracy of 0.86, precision of 0.81, and an F1 score of 0.87. The LR model had an average AUC of 0.82 but shared the same accuracy, precision, and F1 score as the RF model. Key risk factors identified included TILE grade, heart rate (HR), creatinine (CR), white blood cell count (WBC), fibrinogen (FIB), and lactic acid (LAC), with LAC levels >3.7 and an injury severity score (ISS) >13 as significant predictors of HI and mortality. In conclusion, the RF and LR algorithms are effective in predicting HI and mortality risk in patients with closed PFs, enhancing clinical decision-making and improving patient outcomes.

A splenic artery pseudoaneurysm (SAP) is a rare vascular entity that is becoming increasingly recognized as a potential complication of bariatric surgery. This is a case of a 36-year-old woman brought by ambulance to a regional emergency department with abdominal pain, collapse, and gross haemodynamic instability 2 years post-laparoscopic sleeve gastrectomy. She received aggressive resuscitation in the emergency department but could not be stabilized and so underwent an emergency laparotomy. Intra-operatively, she was found to have a ruptured SAP with active bleeding, which was managed with a splenectomy. A high index of suspicion is required in any patient presenting with abdominal pain and circulatory collapse in the context of previous bariatric surgery. In rural or regional settings without immediate access to interventional radiology services, the most appropriate management option will almost invariably be an emergency laparotomy and splenectomy due to the risk of deterioration during patient transfer. [ABSTRACT FROM AUTHOR]

Abstract Background Tension pneumomediastinum (TPM) is a rare but critical condition characterized by the accumulation of air in the mediastinum, leading to increased intrathoracic pressure and cardiovascular compromise. This case report is novel due to the rarity of TPM arising from blunt chest trauma and the necessity for emergent surgical intervention after initial conservative management failed. Case presentation A 63-year-old male presented with severe chest pain and dyspnea following a high-impact motor vehicle collision. Initial assessment revealed tachypnea, tachycardia, and hypotension, along with extensive subcutaneous emphysema over the chest and neck. Imaging confirmed pneumomediastinum and bilateral pneumothoraxes, consistent with TPM. Despite initial management with high-flow oxygen and bilateral chest tube insertion, the patient’s condition deteriorated, necessitating emergent mediastinal decompression via an anterior subxiphoid incision. This intervention resulted in immediate hemodynamic improvement. Conclusions This case underscores the importance of recognizing TPM in patients with chest trauma and highlights the need for prompt surgical intervention in cases of hemodynamic instability. Early and accurate diagnosis and timely surgical management are crucial for improving patient outcomes in TPM.

Background: Hyperlactatemia after cardiac surgery is common. However, the association and the implications of hyperlactatemia on the prognosis after cardiopulmonary bypass (CPB) remains controversial. This study investigated the associations between early-onset hyperlactatemia and the need for doses of inotropes and vasopressors during weaning from CPB, hemodynamic stability after weaning from CPB, and the duration of postoperative mechanical ventilation. Patients and Methods: This prospective cohort study included 300 patients who underwent elective on-pump coronary artery bypass grafting (CABG) surgery and had normal systolic function >55%. Serum lactate levels were measured 1 h before induction, upon initiation of CPB, after removal of aortic cannula and on admission to the intensive care unit (ICU). Patients were divided into two groups: patients with lactate levels

Abstract Background Pneumomediastinum and pneumorrachis are rare complications following epidural analgesia, that can either be asymptomatic or rarely can produce mild to moderate severity symptoms. Most reported cases regarding the presentation of these two entities with epidural analgesia concern asymptomatic patients, however there are cases reporting post-dural puncture headache and respiratory manifestations. Case presentation We present a case where a combined lumbar epidural and spinal anesthesia was performed using the loss of resistance to air technique (LOR), on a 78-year-old Greek (Caucasian) male undergoing a total hip replacement. Despite being hemodynamically stable throughout the operation, two hours following epidural analgesia the patient manifested a sudden drop in blood pressure and heart rate that required the administration of adrenaline to counter. Pneumomediastinum, pneumorrachis and paravertebral soft tissue emphysema were demonstrated in a Computed Tomography scan. We believe that injected air from the epidural space and surrounding tissues slowly moved towards the mediastinum, stimulating the para-aortic ganglia causing parasympathetic stimulation and therefore hypotension and bradycardia. Conclusion Anesthesiologists should be aware that epidural analgesia using the LOR to technique injecting air could produce a pneumomediastinum and pneumorrachis, which in turn could produce hemodynamic instability via parasympathetic stimulation.

Background Ovarian pregnancy is a rare type of ectopic pregnancy, accounting for 0.5% to 1% of all ectopic pregnancies, with an incidence ranging from 1 in 2,100 to 1 in 60,000 pregnancies. Due to its rarity and the lack of common risk factors, diagnosing ovarian pregnancy is often challenging and typically occurs during surgical exploration. Case Presentation We present the case of a 40-year-old woman who experienced severe pelvic pain, light vaginal bleeding, and 8 weeks of amenorrhea. Upon arrival at the hospital, she was hemodynamically unstable, with low blood pressure and a rapid heart rate. An ultrasound revealed an empty uterus, an irregular mass on her right ovary, and free fluid in the pelvis. Her beta-hCG level was elevated, and her hemoglobin level was low. Given the suspicion of an ectopic pregnancy, she underwent emergency surgery. During the operation, the surgical team discovered a large amount of clotted blood and a ruptured mass on her left ovary measuring 10 x 9.5 cm. Due to heavy bleeding, they performed a left oophorectomy and salpingectomy. Histopathological analysis later confirmed the diagnosis of ovarian pregnancy. Conclusion This case underscores the challenges in diagnosing ovarian pregnancy and highlights the necessity for prompt surgical intervention, particularly in unstable patients. Early detection and appropriate management are critical to prevent life-threatening complications.

Intraprocedural rupture (IPR) during coil embolization (CE) of an intracranial aneurysm is a significant clinical concern that necessitates a comprehensive understanding of its clinical and hemodynamic predictors. Between January 2012 and December 2023, 435 saccular cerebral aneurysms were treated with CE at our institution. The inclusion criterion was extravasation or coil protrusion during CE. Postoperative data were used to confirm rupture points, and computational fluid dynamics (CFD) analysis was performed to assess hemodynamic characteristics, focusing on maximum pressure (Pmax) and wall shear stress (WSS). IPR occurred in six aneurysms (1.3%; three ruptured and three unruptured), with a dome size of 4.7 ± 1.8 mm and a D/N ratio of 1.5 ± 0.5. There were four aneurysms in the internal carotid artery (ICA), one in the anterior cerebral artery, and one in the middle cerebral artery. ICA aneurysms were treated using adjunctive techniques (three balloon-assisted, one stent-assisted). Two aneurysms (M1M2 and A1) were treated simply, yet had relatively small and misaligned domes. CFD analysis identified the rupture point as a flow impingement zone with Pmax in five aneurysms (83.3%). Time-averaged WSS was locally reduced around this area (1.3 ± 0.7 [Pa]), significantly lower than the aneurysmal dome (p < 0.01). Hemodynamically unstable areas have fragile, thin walls with rupture risk. A microcatheter was inserted along the inflow zone, directed towards the caution area. These findings underscore the importance of identifying hemodynamically unstable areas during CE. Adjunctive techniques should be applied with caution, especially in small aneurysms with axial misalignment, to minimize the rupture risk. [ABSTRACT FROM AUTHOR]

Background: Pneumomediastinum and pneumorrachis are rare complications following epidural analgesia, that can either be asymptomatic or rarely can produce mild to moderate severity symptoms. Most reported cases regarding the presentation of these two entities with epidural analgesia concern asymptomatic patients, however there are cases reporting post-dural puncture headache and respiratory manifestations. Case presentation: We present a case where a combined lumbar epidural and spinal anesthesia was performed using the loss of resistance to air technique (LOR), on a 78-year-old Greek (Caucasian) male undergoing a total hip replacement. Despite being hemodynamically stable throughout the operation, two hours following epidural analgesia the patient manifested a sudden drop in blood pressure and heart rate that required the administration of adrenaline to counter. Pneumomediastinum, pneumorrachis and paravertebral soft tissue emphysema were demonstrated in a Computed Tomography scan. We believe that injected air from the epidural space and surrounding tissues slowly moved towards the mediastinum, stimulating the para-aortic ganglia causing parasympathetic stimulation and therefore hypotension and bradycardia. Conclusion: Anesthesiologists should be aware that epidural analgesia using the LOR to technique injecting air could produce a pneumomediastinum and pneumorrachis, which in turn could produce hemodynamic instability via parasympathetic stimulation. [ABSTRACT FROM AUTHOR]

Background: Pulmonary embolism (PE) is a potentially life-threatening condition. Admission and treatment in the intensive care unit (ICU) is an important element in critically ill PE patients. Objectives: We aimed to identify risk factors for ICU admission and differences in patient profiles regarding risk factors and comorbidities between PE patients who had to be admitted to an ICU and those who were treated in a normal ward without ICU. Methods: We used the German nationwide inpatient sample to analyze all hospitalizations of PE patients in Germany from 2016 to 2020 stratified for ICU admission. Results: Overall, 484,859 hospitalized PE patients were treated in German hospitals from 2016 to 2020. Among these, 92,313 (19.0%) were admitted to ICU. Patients treated in ICU were younger (69.0 [IQR, 58.0-78.0] vs 72.0 [IQR, 60.0-80.0] years; P < .001) and had higher prevalence of cardiovascular risk factors and comorbidities. In-hospital case fatality rate was elevated in PE patients treated in ICU (22.7% vs 10.7%; P < .001), and ICU admission was independently associated with increased in-hospital case fatality (odds ratio [OR], 2.54; 95% CI, 2.49-2.59; P < .001). Independent risk factors for ICU admission comprised PE with imminent or present decompensation (OR, 3.30; 95% CI, 3.25-3.35; P < .001), hemodynamic instability (OR, 4.49; 95% CI, 4.39-4.59; P < .001), arterial hypertension (OR, 1.20; 95% CI, 1.18-1.22; P < .001), diabetes mellitus (OR, 1.16; 95% CI, 1.14-1.18; P < .001), obesity (OR, 1.300; 95% CI, 1.27-1.33; P < .001), surgery (OR, 2.55; 95% CI, 2.50-2.59; P < .001), stroke (OR, 2.86; 95% CI, 2.76-2.96; P < .001), pregnancy (OR, 1.45; 95% CI, 1.21-1.74; P < .001), heart failure (OR, 1.74; 95% CI, 1.71-1.77; P < .001), atrial fibrillation/flutter (OR, 1.69; 95% CI, 1.66-1.73; P < .001), chronic obstructive pulmonary disease (OR, 1.21; 95% CI, 1.18-1.24; P < .001), and renal failure (OR, 1.92; 95% CI, 1.88-1.95; P < .001). Conclusion: ICU treatment is an important element in the treatment of PE patients. Besides hemodynamic compromise, cardiovascular risk factors, stroke, pregnancy, and cardiopulmonary as well as renal comorbidities were independent predictors of ICU admission. Necessity of ICU admission was afflicted by increased case fatality.

Ying Zhang,1,&ast; Xinxin Wang,1,&ast; Xiaoqiao Sang,1,&ast; Zhou Zhou,1 Guangrong Dai,1 Xiaobao Zhang1,2 1Department of Anesthesiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, Jiangsu, People’s Republic of China; 2The First Affiliated Hospital of Kangda College of Nanjing Medical University, Lianyungang, Jiangsu, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Xiaobao Zhang, The Affiliated Lianyungang Hospital of Xuzhou Medical University, No. 6 Zhenhua East Road, Lianyungang, Jiangsu, People’s Republic of China, Email hotdog100@163.comPurpose: Post-induction hypotension (PIH) is a common clinical phenomenon linked to increased morbidity and mortality in various non-cardiac surgeries. Patients with surgery in the afternoon may have preoperative hypovolemia caused by prolonged fasting and dehydration, which increases the risk of hypotension during the induction period. However, studies on the fluid therapy in early morning combating PIH remain inadequate. Therefore, we aimed to investigate the influence of prophylactic high-volume fluid in the early morning of the operation day on the incidence of PIH during non-cardiac surgery after noon.Patients and Methods: We reviewed the medical records of patients who underwent non-cardiac surgery after noon between October 2021 and October 2022. The patients were divided into two groups based on whether they received a substantial volume of intravenous fluid (high-volume group) or not (low-volume group) in the early morning of the surgery day. We investigated the incidence of PIH and intraoperative hypotension (IOH) as well as the accumulated duration of PIH in the first 15 minutes. In total, 550 patients were included in the analysis.Results: After propensity score matching, the incidence of PIH was 39.7% in the high-volume group and 54.1% in the low-volume group. Multivariate logistic regression analysis showed that patients in the high-volume group had lower incidence of hypotension after induction compared with the low-volume group (odds ratio, 0.55; 95% CI, 0.34– 0.89; p = 0.016). The high-volume fluid infusion in the preoperative morning was significantly correlated with the decreased duration of PIH (p = 0.013), but no statistical difference was observed for the occurrence of IOH between the two groups (p = 0.075).Conclusion: The fluid therapy of more than or equal to 1000 mL in the early morning of the surgery day was associated with a decreased incidence of PIH compared with the low-volume group in patients undergoing non-cardiac surgery after noon.Keywords: anesthesia induction, hypotension, fluid optimization, preoperative rehydration, hemodynamic instability

Background: Tension pneumomediastinum (TPM) is a rare but critical condition characterized by the accumulation of air in the mediastinum, leading to increased intrathoracic pressure and cardiovascular compromise. This case report is novel due to the rarity of TPM arising from blunt chest trauma and the necessity for emergent surgical intervention after initial conservative management failed. Case presentation: A 63-year-old male presented with severe chest pain and dyspnea following a high-impact motor vehicle collision. Initial assessment revealed tachypnea, tachycardia, and hypotension, along with extensive subcutaneous emphysema over the chest and neck. Imaging confirmed pneumomediastinum and bilateral pneumothoraxes, consistent with TPM. Despite initial management with high-flow oxygen and bilateral chest tube insertion, the patient's condition deteriorated, necessitating emergent mediastinal decompression via an anterior subxiphoid incision. This intervention resulted in immediate hemodynamic improvement. Conclusions: This case underscores the importance of recognizing TPM in patients with chest trauma and highlights the need for prompt surgical intervention in cases of hemodynamic instability. Early and accurate diagnosis and timely surgical management are crucial for improving patient outcomes in TPM. [ABSTRACT FROM AUTHOR]

A 41-year-old male, with a clear medical background, underwent laparoscopic cholecystectomy for uncomplicated acute cholecystitis. No complications were observed intraoperatively. Second day after operation, the patient developed intense right upper quadrant pain, dizziness, and hypotension with a hemoglobin drop to 8.8 g/dl. Subsequently, an urgent computed tomography was done, which identified subcapsular hepatic with an intraparenchymal hematoma, and therefore, the diagnosis of intrahepatic subcapsular hematoma (ISH) was made. After fluid resuscitation and blood transfusion, the hemodynamic status became stable with no further hemoglobin decline noted. Further serial imaging was conducted and showed no signs of expansion nor intra-abdominal hemorrhage and the conservative line of management was carried on. Nine days later, the patient was discharged home. This report emphasizes the importance of close monitoring of patients who undergo LC and the possibility of ISH, although being rare, in those who report acute abdominal pain and hemodynamic instability after LC. [ABSTRACT FROM AUTHOR]

The liver is the second most common solid organ injured in blunt and penetrating abdominal trauma. Non-operative management (NOM) has become the standard of care for liver injuries in stable patients, where transarterial embolization (TAE) represents the main treatment, increasing success rates and avoiding invasive surgical procedures. In hemodynamically (HD) unstable patients, operative management (OM) is the standard of care. To date, there are no consensus guidelines about the endovascular treatment of patients with HD instability or in ones that responded to initial infusion therapy. A review of the literature was performed for published papers addressing the outcome of using TAE as the primary treatment for HD unstable/transient responder trauma liver patients with hemorrhagic vascular lesions, both as a single treatment and in combination with surgical treatment, focusing additionally on the different definitions used in the literature of unstable and transient responder patients. Our review demonstrated a good outcome in HD unstable/transient responder liver trauma patients treated with TAE but there still remains much debate about the definition of unstable and transient responder patients. [ABSTRACT FROM AUTHOR]

Cardiovascular instability is common during the reperfusion phase of orthotopic liver transplantation (OLT), and some patients experience a postreperfusion syndrome (PRS). However, there are no reports comparing the cardiac dysfunction between patients with PRS and those without. Thus, the aim of this study was to evaluate cardiac dysfunction in patients exhibiting PRS. This observational retrospective study included 34 patients who underwent OLT and were monitored with transesophageal echocardiography (TEE). The right ventricular/left ventricular (RV/LV) end diastolic area, tricuspid annular plane systolic excursion (TAPSE), left ventricular ejection fraction (LVEF) by Simpson method, pulsed Doppler of the mitral valve, and tissue Doppler motion of the mitral annulus were determined. Echocardiographic measurements were registered at the beginning of surgery and at 1 and 30 min after vascular unclamping. Patients with PRS (PRS group) were identified, and their echocardiographic parameters of ventricular function were compared with those in patients without PRS (non-PRS group). To check the evolution of diastolic-systolic dysfunction, general linear model-repeated measures were estimated. No patient presented systolic/diastolic dysfunction on the basal echocardiogram. One minute after vascular unclamping, the incidence of RV dilation was 4.5 times greater in patients with PRS (Cramer´s V > 0.6), and the incidence of RV systolic dysfunction was 62.5% in patients with PRS compared to 15.40% in patients without PRS (Cramer´s V = 0.45). The incidence of LV systolic dysfunction was 25% in patients with PRS compared to 0% in those without (Cramer´s V = 0.45), and left ventricular diastolic dysfunction was 4.8 times greater in patients with PRS (Cramer´s V = 0.45). No patient presented diastolic dysfunction type III. There were significant differences between groups in the evolutionary pattern at 1 and 30 min after unclamping for RV dilation (p = 0.008) and for TAPSE (p = 0.014). Liver graft reperfusion may alter cardiac function. Cardiac dysfunction was more frequent in patients with PRS. These patients exhibited temporary dysfunction of the RV associated with a varying degree of LV diastolic-systolic dysfunction. Trial registration: clinicaltrials.gov (NCT05175534). January 03, 2022; "retrospectively registered". [ABSTRACT FROM AUTHOR]

(1) Background: Either pre-operative physical status or unstable hemodynamic changes has been reported to play a potential role in causing vital organ dysfunction. Therefore, we intended to investigate the impact of the American Society of Anesthesiologist (ASA) classification and intraoperative hemodynamic instability on non-surgical complications following orthopedic surgery. (2) Methods: We collected data on 6478 patients, with a mean age of 57.3 ± 16, who underwent orthopedic surgeries between 2018 and 2020. The ASA classification and hemodynamic data were obtained from an anesthesia database. Non-surgical complications were defined as a dysfunction of the vital organs. (3) Results: ASA III/IV caused significantly higher odds ratios (OR) of 17.49 and 40.96, respectively, than ASA I for developing non-surgical complications (p < 0.001). Non-surgical complications were correlated with a 20% reduction in systolic blood pressure (SBP), which was intraoperatively compared to the pre-operative baseline ((OR) = 1.38, p = 0.02). The risk of postoperative complications increased with longer durations of SBP < 100 mmHg, peaking at over 20 min ((OR) = 1.33, p = 0.34). (4) Conclusions: Extended intraoperative hypotension and ASA III/IV caused a significantly higher risk of adverse events occurring within the major organs. The maintenance of hemodynamic stability prevents non-surgical complications after orthopedic surgeries. [ABSTRACT FROM AUTHOR]

Percutaneous nephrolithotomy has become the standard procedure for the management of large kidney stones. Compared with other endo-urological techniques, it has a better fragmentation rate in a single session for kidney stones over 20 mm. It is therefore the recommended first-line treatment modality for large kidney stones. Bleeding is a well-known complication of this procedure, often requiring transfusion. In 0.8% of cases, bleeding can be severe, requiring surgical intervention to control hemostasis. Damage to the lumbar artery is a very rare event, and a potential complication. To our knowledge, this is the first report of lumbar artery involvement during percutaneous nephrolithotomy, complicated by severe bleeding and hemodynamic instability, necessitating conversion. Surgical exploration revealed a severed and bleeding lumbar artery. After hemostasis control by coagulation and ligation, the patient became stable. The patient was discharged on D3, where ureteroscopic lithotripsy was planned after collegial discussion with the patient. Based on this experience, it is important for the surgeon to have in mind certain principles and a thorough knowledge of the classic lateral lumbotomy approach to the kidney. [ABSTRACT FROM AUTHOR]

Due to the global trend of the population ageing, an important task of modern medicine is to improve the provision of medical care for elderly patients. These people have reduced compensatory reserves of the body and numerous chronic pathologies, necessitating a more meticulous approach to anesthesia induction and maintenance by anesthesiologists. According to the authors, the use of propofol and fentanyl leads to decreased myocardial contractility and reduction in overall peripheral vascular resistance. However, the resulting decrease in perfusion pressure in vital organs and tissues, as a consequence of the aforementioned effects, is unacceptable in elderly patients with coronary heart disease (CHD). The aim . To analyze changes in hemodynamics in elderly patients undergoing coronary artery bypass grafting (CABG) during the induction of anesthesia. Materials and methods. A prospective study was conducted which included the results of examination of 20 patients with CHD over 60 years old who underwent CABG without the use of cardiopulmonary bypass at the National Amosov Institute of Cardiovascular Surgery (Kyiv, Ukraine). The mean age of the patients was 67.5±6.8 years. There were 16 (80%) men and 4 (20%) women. Typical manifestations of heart failure were noted (there were 1 [5%], 10 [50%] and 9 [45%] NYHA functional class I, II and III patients, respectively). Also, the patients were classified according to the Canadian classification of angina: 1 (5%), 9 (45%) and 10 (50%) patients fell within class I, II and III, respectively. Stage 2-3 hypertension was reported in 18 patients (90%). For induction of anesthesia, the following medications were used: propofol 1.5 mg/kg, fentanyl 2.0 μg/kg, and rocuronium bromide 0.1 mg/kg. Anesthesia maintenance included: propofol 4 mg/kg/hour, fentanyl 2.0 μg/kg/hour. Hemodynamic parameters saturation indices (SpO2), and transthoracic echocardiography parameters were recorded at the following stages: 1) upon the patient’s arrival in the operating room; 2) prior to tracheal intubation; 3) immediately after tracheal intubation; 4) 25 minutes after intubation. Results. Upon arrival in the operating room, the hemodynamic parameters reflected stable general condition of the examined patients. After administration of induction agents according to the study design, it was recorded that mean blood pressure (BP) was 72.7±4.76% (p

This prospective observational study will evaluate the change in heart rate (HR) during the periprocedural course of carotid artery stenting (CAS) via continuous monitoring using a wearable device. The participants were recruited from our outpatient clinic between April 2020 and March 2023. They were instructed to continuously wear the device from the last outpatient visit before admission to the first outpatient visit after discharge. The changes in HR of interest throughout the periprocedural course of CAS were assessed. In addition, the Bland-Altman analysis was adopted to compare the HR measurement made by the wearable device during CAS with that made by the electrocardiogram (ECG). A total of 12 patients who underwent CAS were included in the final analysis. The time-series analysis revealed that a percentage change in HR decrease occurred on day 1 following CAS and that the most significant HR decrease rate was 12.1% on day 4 following CAS. In comparing the measurements made by the wearable device and ECG, the Bland-Altman analysis revealed the accuracy of the wearable device with a bias of −1.12 beats per minute (bpm) and a precision of 3.16 bpm. Continuous HR monitoring using the wearable device indicated that the decrease in HR following CAS could persist much longer than previously reported, providing us with unique insights into the physiology of carotid sinus baroreceptors.

This document is a summary of two articles featured in Transplant Trial Watch. The first article discusses a randomized controlled trial that investigated the use of intraoperative haemoadsorption in orthotopic heart transplant patients. The study found statistically significant differences in various outcomes, including a lower vasoactive-inotropic score and shorter ICU stay for patients receiving hemoadsorption. The second article is a systematic review on the psychological impact of living kidney donation. The review found that while quantitative studies showed stable or improved quality of life for donors, qualitative studies revealed a more complex picture with some donors experiencing post-operative fatigue, anxiety, and depression. The review highlights the importance of regular follow-up and psychological assessment for donors. [Extracted from the article]

BackgroundVideo-assisted thoracoscopic surgery (VATS) has been widely performed for patients with lung cancer. Splenic rupture after VATS lung procedures is a very rare and serious event.Case presentationWe reported a case with hemodynamic instability after left lower VATS lobectomy. There was no evidence of diaphragmatic injury during the surgery. Computed tomography (CT) showed spleen injury and large amount of fluid in the abdominal cavity. Emergent laparotomy was performed, and splenic rupture was diagnosed. The patient underwent splenectomy, with two lacerations at the diaphragmatic surface of the spleen. The patient did well postoperatively and was discharged from the hospital on postoperative day 5.ConclusionThere are few similar cases reported in the literature. Persistent hemodynamic instability due to the rupture of spleen is life-threatening. In the situation of unexplained hypotension during VATS procedures (especially left-sided approaches), the possibility of splenic injury and rupture should be considered. Abdominal ultrasonography and/or CT examinations should be carried out for prompt diagnosis and treatment of such rare complication.

Background: Endovascular intervention is now the primary line of therapy for arterial injury brought on by pelvic trauma since it can significantly reduce considerable morbidity associated with surgery and can swiftly access and control bleeding sites. Despite international guidelines and widespread awareness of the role of angioembolization in clinical practice, robust evidence comparing the outcomes of angioembolization in hemodynamically stable and unstable patients is still lacking. This study aims to directly compare the outcomes of angioembolization for the treatment of pelvic traumatic arterial injury in patients with hemodynamic stability vs. hemodynamic instability. Methods: In our multicenter retrospective investigation, we analyzed data from consecutive patients who underwent, from January 2020 to May 2023, angioembolization for traumatic pelvic arterial injury. Results: In total, 116 angioembolizations were performed. Gelatin sponges (56.9%) and coils (25.9%) were the most widely used embolic agents. The technical and clinical success rates were 100% and 91.4%, respectively. No statistically significant differences were observed between the two groups in terms of technical success, clinical success, procedure-related complication rate, or 30-day bleeding-related mortality. Conclusions: Angioembolization is an effective and safe option for the management of traumatic pelvic arterial lesions even in hemodynamically unstable patients, despite technical variations such as greater use of prophylactic angioembolization.

Abstract Background Predicting the onset of hemodynamic instability before it occurs remains a sought-after goal in acute and critical care medicine. Technologies that allow for this may assist clinicians in preventing episodes of hemodynamic instability (EHI). We tested a novel noninvasive technology, the Analytic for Hemodynamic Instability-Predictive Indicator (AHI-PI), which analyzes a single lead of electrocardiogram (ECG) and extracts heart rate variability and morphologic waveform features to predict an EHI prior to its occurrence. Methods Retrospective cohort study at a quaternary care academic health system using data from hospitalized adult patients between August 2019 and April 2020 undergoing continuous ECG monitoring with intermittent noninvasive blood pressure (NIBP) or with continuous intraarterial pressure (IAP) monitoring. Results AHI-PI’s low and high-risk indications were compared with the presence of EHI in the future as indicated by vital signs (heart rate > 100 beats/min with a systolic blood pressure

Background Intraoperative hypotension is a risk factor for perioperative adverse outcomes and is highly prevalent in older patients. Frailty has been associated with hemodynamic instability but its impact on postinduction hypotension is unclear. Therefore, we assessed the association between frailty and postinduction hypotension in older patients. Methods We retrospectively evaluated electronic medical records of patients aged ≥65 years who were assessed for preoperative frailty and underwent noncardiac surgery under general anesthesia. Reported Edmonton Frail Scale (REFS) scores were used to stratify patients into a nonfrail (REFS scores 0–5), prefrail (6–7), and frail (8–18) groups. Postinduction hypotension was defined as a mean blood pressure below 65 mmHg or 20% from baseline occurring within the first 20 minutes after anesthesia induction and evaluated using multivariate logistic regression analysis. Results Independent factors related to postinduction hypotension in our sample (421 patients) were status of frail (REFS score ≥8) compared to nonfrail (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.44–5.18; p  = .002), lower baseline mean blood pressure in the operating room (OR, 0.98; 95% CI, 0.96–0.999; p  = .034) and at the presurgical center (OR, 0.96; 95% CI, 0.94–0.99; p  = .003), and orthopedic (compared to urologic) surgery (OR, 2.22; 95% CI, 1.14–4.30; p  = .019). Conclusion Preoperative frail status based on REFS scores is associated with postinduction hypotension. Frailty screening tool for older patients may enhance traditional risk calculators and improve patient selection for noncardiac surgery under general anesthesia. [ABSTRACT FROM AUTHOR]

Objective: Transcarotid artery revascularization (TCAR) is a relatively recent development in the management of carotid artery occlusive disease, the utilization of which is becoming more prevalent. This study aims to evaluate the timing, prevalence, and types of hemodynamic instability after TCAR. Methods: We performed a retrospective review of all TCAR procedures performed at two tertiary care academic medical centers within a single hospital system from 2017 through 2019. Demographics, comorbidities, preoperative patient factors, procedural details, and postoperative data were collected. Patients were assessed over 24 hours postoperatively for stroke, death, myocardial infarction (MI), and hemodynamic instability at 3, 6, 9, 12, and 24 hour intervals. Hemodynamic instability was defined as any vital sign abnormality which required pharmacological intervention with antihypertensive, vasopressor, and/or anti-arrhythmic agents. The incidence and timing of postoperative complications and hemodynamic instability were recorded. Results: During the study period, 76 patients 80 TCAR procedures. Out of 80 procedures, 64 (80.0%) were receiving home antihypertensive medication and 28 (35.0%) were symptomatic lesions preoperatively. Intraoperatively, one patient (1.3%) received atropine, 26 (32.5%) received glycopyrrolate, 76 (95%) underwent predilatation, and 16 (20.0%) underwent postdilatation. Postoperatively, a total of 22 cases (27.5%) required medication for acute control of blood pressure or heart rate, which reached a peak of 19 patients (23.8%) within the first 3 hours, and tapered to nine patients (11.3%) by the 24 hour mark. A total of three patients (3.75%) required initiation of pharmacological management after the three-hour mark. Six patients (7.5%) underwent stroke code workup, 4 (5.0%) of whom were confirmed to have stroke on CT. Average time to neurologic event was 3.9 hours. No patients experienced MI or death. Median ICU and hospital days for unstable patients were two and three, respectively, compared to one and one for stable patients. Conclusions: Hemodynamic instability is common after TCAR and reliably presents at or before postoperative hour 3. Hypo- followed by hyper-tension were the most common manifestations of hemodynamic instability. Regardless, unstable patients and stroke patients were more likely to require longer periods of time in the ICU and in the hospital overall. This may have implications for postoperative ICU resource management when deciding to transfer patients out of a monitored setting. Further study is required to establish relationships between pre- and intra-operative risk factors and outcomes such as hemodynamic instability and/or stroke. At present, one should proceed with careful evaluation of preoperative medications, strict management of postoperative hemodynamics, and clear communication among team members should all be employed to optimize outcomes. [ABSTRACT FROM AUTHOR]

Background: Surgery is the treatment of choice for pheochromocytoma. However, this surgery carries a risk of hemodynamic instability (HDI). The aim of this study was to report complications associated with this procedure, to identify risk factors for HDI during surgery, and its impact on postoperative outcomes. Methods: The charts of all patients who underwent adrenalectomy for pheochromocytoma in two academic centers between 2006 and 2020 were retrospectively reviewed. The primary outcome was HDI defined by a systolic blood pressure >160 mmHg or a mean blood pressure <60 mmHg intraoperatively. The secondary outcomes of interest were the total duration of HDI, the occurrence of intraoperative arrhythmia, perioperative cardiovascular events, and postoperative complications. Results: 205 patients were included. HDI occurred intraoperatively in 155 patients (75.6%) but only 6 (3.2%) experienced arrhythmia. Thirty-eight postoperative complications were reported (18.6%) but only nine were ≥3 according to Clavien-Dindo (4.4%). There were 10 postoperative cardiovascular events (5.7%). Patients with intraoperative HDI had higher rates of postoperative complications (21.3% vs 10%; P =.07), major postoperative complications (5.8% vs 0%; P =.12) and cardiovascular events (6.5% vs 0%; P =.12). Factors associated with intraoperative HDI in univariate analysis were age (OR = 8.14; P =.006), high blood pressure preoperatively (OR = 2.16; P =.04), tumor size (OR = 15.83; P =.0001), and urinary normetanephrine level (OR = 9.33; P =.04). Discussion: In multidisciplinary centers, the overall morbidity of adrenalectomy for pheochromocytoma is low. HDI during adrenalectomy for pheochromocytoma is highly prevalent but rarely associated with major cardiovascular events. There might be a link between HDI and postoperative cardiovascular events. [ABSTRACT FROM AUTHOR]

Objective: Acute kidney injury (AKI) in the neonatal period is associated with worst outcomes as increased mortality and increased length of hospital stay. Very low birth weight (VLBW) newborns are at higher risk for developing several other conditions that are associated with worst outcomes. Understanding the risk factors for AKI may help to prevent this condition and improve neonatal care for this population. Methods: This retrospective cohort study included 155 very low birth weight newborns admitted between 2015 and 2017. The authors compared the newborns who developed neonatal AKI with the non-AKI group and analyzed the main risk factors for developing AKI in the population. The authors also performed an analysis of the main outcomes defined as the duration of mechanical ventilation, length of stay, and death. Results: From the cohort, a total of 61 (39.4%) patients had AKI. The main risk factors associated with Neonatal AKI were necrotizing enterocolitis (aOR 7.61 [1.69 – 34.37]; p = 0.008), neonatal sepsis (aOR 2.91 [1.17 – 7.24], p = 0.021), and hemodynamic instability (aOR 2.99 [1.35 – 6.64]; p = 0.007). Neonatal AKI was also associated with an increase in the duration of mechanical ventilation in 9.4 days (p = 0.026) and in an increase in mortality 4 times (p = 0.009), after adjusting for the other variables. Conclusion: The present results highlight the importance of minimizing sepsis and necrotizing enterocolitis, as well as the importance of identifying hemodynamic instability, to prevent AKI and diminish the burden of morbimortality in VLBW newborns.

Penetrating cardiac injuries are rare but are one of the most urgent emergencies because they require early intervention in order to prevent death. The mortality rate of such injuries, including pre-hospitalization deaths, goes up to 90%. The most commonly injured heart chamber is the right ventricle since it takes over half of the anterior thoracic wall. The left ventricle is injured less often, but these patients usually have worse prognoses and higher mortality rates because such injuries lead to hemodynamic instability faster. We present a unique case of a suicide attempt in which the patient stabbed himself with a knife, penetrated the left ventricle, and survived even though he transected the second diagonal branch of the left anterior descending coronary artery and pulled the knife out of his chest. [ABSTRACT FROM AUTHOR]