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Aims: Intraoperative hypotension is a risk factor for kidney, heart and cognitive postoperative complications. Literature suggests that the use of low‐dose peripheral norepinephrine (NOR) reduces organ dysfunction, yet its administration remains unstandardized. In this work we develop a pharmacokinetic (PK)/pharmacodynamic (PD) model of NOR and its effect on mean arterial pressure (MAP). Methods: From June 2018 to December 2021, we included patients scheduled for elective neurosurgery and requiring vasopressors for intraoperative hypotension management at Lariboisière Hospital, Paris. Low doses of NOR were administered peripherally, and successive arterial blood samples were collected to track its plasmatic concentration. We used a compartmental modelling approach for NOR PK. We developed and compared 2 models for NOR PD on MAP. Model comparison was done using Bayes information criteria. The resulting PK/PD model parameters were fitted over the entire population and linked to age, weight, height and sex. Results: We included 29 patients (age 52 [46–64] years, 69% female). NOR median time to peak effect on MAP was 74 [53–94] s. After bolus administration, MAP increased by 24% (15–31%). A 2‐comparment model with depot best captured NOR PK. NOR PD effect on MAP was well represented by both Emax and Windkessel models, with better results for the former. We found that age, height and weight as well as history of smoking and hypertension were correlated with model parameters. Conclusion: We have developed a PK/PD model to accurately track norepinephrine plasma concentration and its effect on MAP over time, which could serve for target‐controlled infusion. [ABSTRACT FROM AUTHOR]

INTRODUCTION During the administration of general anesthesia, the procedures of direct laryngoscopy and endotracheal intubation result in a significant rise in heart rate, arterial pressure, and dysrhythmias in around 90% of patients. These modifications can provide a significant risk to patients with brain or coronary diseases. The aim of present study is to assess the attenuation of hemodynamic changes during laryngoscopy and endotracheal intubation with oral gabapentin versus oral clonidine. MATERIAL AND METHODS The present double blind randomized controlled trial was conducted among patient undergoing elective surgeries under general anesthesia at Govt. Mohan Kumaramangalam Medical College, during the study period of one year. 90 patients were distributed to three groups using sealed envelope technique. Group A of patients received single dose oral 150 µg clonidine, Group B of patients received single dose oral 200 µg clonidine and Group C patients received single dose oral 800 mg gabapentin . Hemodynamic parameters were noted at different time interval and results were analyzed. RESULTS The mean age of subjects was between the age group of 40-50 years and male were higher in number as compared to female. The heart rate was higher in the clonidine 200 group as compared to other two but results were non-significant with (P>0.05). No Significant difference in mean SBP, DBP and MAP was observed at all time intervals. (p>0.05). CONCLUSION Oral clonidine and gabapentin reduce direct laryngoscopy haemodynamics. Gabapentin has fewer adverse effects than clonidine. Compared to -200mcg, 150mcg has no adverse effects. [ABSTRACT FROM AUTHOR]

Background and Aims: The second-generation supraglottic airway device is conventionally inserted blindly, which might result in suboptimal placement. Limited literature exists on under-vision insertion techniques, particularly in paediatric patients. The primary objective of this study was to compare the oropharyngeal leak pressure (OPLP) between the blind insertion of the LMA Blockbuster® and the Miller laryngoscope-guided insertion in children. Secondary outcomes included the number of insertion attempts, haemodynamic disturbances, insertion time and airway complications. Methods: This randomised controlled trial study enroled 100 patients aged 1–4 years undergoing elective surgery. Patients were randomised into blind insertion (Group A) or Miller laryngoscope-guided insertion (Group B) of the LMA Blockbuster®. The primary outcome measure was OPLP. Insertion time, haemodynamic changes and postoperative complications were also assessed. The Chi-square, Fisher’s exact and t-test were applied appropriately, with the significance level set at P < 0.05. Results: Significantly higher mean OPLP was observed in Group B compared to Group A - 27.9 [standard deviation (SD): 1.58] cmH2O versus 25.94 (SD: 0.63) cmH2O [mean difference (MD): 1.96 (95% confidence interval {CI}: 1.48, 2.44; P < 0.001)]. Mean insertion time was longer in Group B, that is, 11.9 (SD: 1.91) s versus 8.7 (SD: 0.6) s [MD: 3.2 s; (95% CI: 2.63, 3.76; P < 0.001)]; however, the difference was not clinically relevant. First-attempt insertion, haemodynamic stability and postoperative complications were comparable (P > 0.05). Conclusion: Miller laryngoscope-guided under-vision insertion of LMA Blockbuster® improves alignment with epiglottic structures compared to blind insertion.

Mohammad Abu Shaphe,1 Mohammed M Alshehri,1 Ramzi Abdu Alajam,1 Bushra Alfaifi,1 Ali Hakamy,2 Monira I Aldhahi,3 Ausaf Ahmad,4 Ashfaque Khan,5 Aafreen,5 Abdur Raheem Khan5 1Department of Physical Therapy, College of Nursing and Health Sciences, Jazan University, Jazan, Saudi Arabia; 2Respiratory Therapy Department, College of Nursing and Health Sciences, Jazan University, Jazan, Saudi Arabia; 3Department of Rehabilitation Sciences, College of Health and Rehabilitation Sciences, Princess Nourah bint Abdulrahman University (PNU), Riyadh, Saudi Arabia; 4Department of Community Medicine, Kalyan Singh Government Medical College Bulandshahr, Uttar Pradesh, India; 5Department of Physiotherapy, Integral University, Lucknow, IndiaCorrespondence: Abdur Raheem Khan, Department of Physiotherapy, Integral University, Lucknow, India, Email abdul.fortis@gmail.comBackground: Hypertension (HTN) is prevalent in individuals with type 2 Diabetes Mellitus (T2DM), doubling the risk of developing chronic complications. Despite normal routine checks, many patients with diabetes exhibit abnormal blood pressure (BP) profiles identified by 24-hour ambulatory Blood Pressure monitoring (ABPM). This study aimed to analyse blood pressure variability in patients with diabetes to enhance current knowledge and improve clinical practice.Methods: This cross-sectional study obtained ethical approval from Jazan University and involved 58 patients with type 2 Diabetes Mellitus (T2DM) who adhered to the strict inclusion and exclusion criteria. Comprehensive clinical and laboratory data, including demographic, clinical, and essential laboratory parameters, were collected using a standardized form. Blood Pressure (BP) was meticulously monitored using the Sun Tech Oscar 2 ABPMR device, with measurements commencing between 8 am and 10 am, extending over 24 hours. The study calculated averages and evaluated systolic and diastolic percentage dipping during 24-hour, daytime, and night-time intervals. Participants classified as “dippers” experienced a BP reductions of at least 10%.Results: Fifty-eight normotensive T2DM patients, with a mean age of 45.51 ± 6.7 years, were monitored over 24 months. Among the 58 individuals assessed using ABPM, a non-dipping pattern was observed in 45 participants (77.58%), whereas 13 (22.41%) exhibited a dipping pattern. Postprandial and fasting blood sugar levels were distinct; the dipper group demonstrated better post-meal glucose control (p=0.02), whereas the non-dipper group had superior fasting glucose control (p=0.04). The dipper group showed a higher 24-hour average systolic BP (p=0.00) and increased dipping percentages for systolic and diastolic BP during sleep.Conclusion: Over 77% of ABPM-evaluated individuals showed non-dipping patterns, with a higher BMI being strongly associated. Laboratory findings revealed distinct variations in the postprandial and fasting blood sugar levels, suggesting a potential genetic predisposition.Keywords: hypertension, T2DM, ABPM, cardiovascular, haemodynamic

Background and Aims: One major limitation of the spinal block remains the inability to extend the duration of the block intraoperatively unless planned before with spinal or epidural catheters and/or intrathecal additives. This study was designed to compare the effects of intravenous dexmedetomidine versus low-dose ketamine–dexmedetomidine combination infusion on spinal anaesthesia in lower limb orthopaedic surgeries. Methods: This randomised study was conducted in 60 patients scheduled for unilateral lower limb surgeries under spinal anaesthesia. Patients were randomised into Group D (n = 30) (0.5 µg/kg of intravenous (IV) dexmedetomidine bolus followed by maintenance infusion at 0.5 µg/kg/h) and Group LKD (n = 30) (IV bolus of 0.5 µg/kg of dexmedetomidine and 0.2 mg/kg of ketamine, followed by maintenance infusions of dexmedetomidine and ketamine at 0.5 µg/kg/h and 0.2 mg/kg/h, respectively). Ramsay Sedation Scale score of 3–4 was maintained. The t-test or the Wilcoxon–Mann–Whitney U test was used to compare the parameters between groups. Results: The mean sacral segment 1 (S1) regression time was 390.3 [standard deviation (SD):84.38] [95% confidence interval (CI): 360.13, 420.53] versus 393.23 (SD: 93.01) (95% CI: 363.04, 423.43) min in Group D versus Group LKD respectively ((P = 0.701). The number of episodes of hypotension was significantly higher in Group D (19 patients) compared to Group LKD (nine patients) (P = 0.001). Pre- and postoperative stress markers (24 h) and the incidence of postoperative nausea and shivering were comparable between the two groups (P > 0.05). Tramadol requirement in the postoperative period was significantly less in Group LKD compared to Group D (P = 0.003). Conclusion: The duration of S1 regression was similar between group dexmedetomidine (Group D) and group low-dose ketamine and dexmedetomidine (Group LKD).

Abstract Background Rapid sequence intubation (RSI) have been shown to be effective in preventing reflux aspiration in patients with a full stomach during anaesthesia induction and endotracheal intubation. However, there is currently no standardized operation protocol or anaesthesia induction drug standard for RSI. Furthermore, there is a lack of evidence regarding the use of RSI in patients older than 65. In this study, we aimed to investigate the cardiovascular effects of different doses of alfentanil combined with propofol and etomidate during RSI in elderly patients aged 65–80 years. Methods A total of 96 patients aged 65–80 years who underwent general anaesthesia with tracheal intubation were selected for this study. The patients were randomly assigned to one of four groups using a random number table. Group A patients received an induction dose of 10 µg/kg alfentanil, group B patients received 15 µg/kg alfentanil, group C patients received 20 µg/kg alfentanil, and group D patients received 25 µg/kg alfentanil. Heart rate (HR), mean arterial pressure (MAP), cardiac index (CI), and ejection fraction (EF) were measured at three time points: 5 min before anaesthesia induction (T0), 1 min after endotracheal intubation (T1), and 5 min after endotracheal intubation (T2). Concurrently, 4 ml of arterial blood was collected from patients at three time points, and the concentrations of norepinephrine (NE) and cortisol (Cor) in plasma were detected. Occurrences of hypertension, hypotension, bradycardia and tachycardia during anesthesia induction to 5 min after tracheal intubation were noted. Results Compared with T0, the HR, MAP, NE and Cor concentrations in group A and group B were increased at the T1 and T2 time points, CI and EF values were decreased (P 0.05). Additionally, they were not significant in group D at the T1 time point (P > 0.05), but decreased at the T2 time point (P

Objectives: Aneurysm number (An) is a novel prediction tool utilizing parameters of pulsatility index (PI) and aneurysm geometry. An has been shown to have the potential to differentiate intracranial aneurysm (IA) rupture status. The objective of this study is to investigate the feasibility and accuracy of An for IA rupture status prediction using Australian based clinical data. Methods: A retrospective study was conducted across three tertiary referral hospitals between November 2017 and November 2020 and all saccular IAs with known rupture status were included. Two sets of An values were calculated based on two sets of PI values previously reported in the literature. Results: Five hundred and four IA cases were included in this study. The results demonstrated no significant difference between ruptured and unruptured status when using An ≥1 as the discriminator. Further analysis showed no strong correlation between An and IA subtypes. The area under the curve (AUC) indicated poor performance in predicting rupture status (AUC1 = 0.55 and AUC2 = 0.56). Conclusions: This study does not support An ≥1 as a reliable parameter to predict the rupture status of IAs based on a retrospective cohort. Although the concept of An is supported by hemodynamic aneurysm theory, further research is needed before it can be applied in the clinical setting. Advances in knowledge: This study demonstrates that the novel prediction tool, An, proposed in 2020 is not reliable and that further research of this hemodynamic model is needed before it can be incorporated into the prediction of IA rupture status. [ABSTRACT FROM AUTHOR]

Background: Observational data suggest that the subset of patients with heart failure related CS (HF-CS) now predominate critical care admissions for CS. There are no dedicated HF-CS randomised control trials completed to date which reliably inform clinical practice or clinical guidelines. We sought to identify aspects of HF-CS care where both consensus and uncertainty may exist to guide clinical practice and future clinical trial design, with a specific focus on HF-CS due to acute decompensated chronic HF. Methods: A 16-person multi-disciplinary panel comprising of international experts was assembled. A modified RAND/University of California, Los Angeles, appropriateness methodology was used. A survey comprising of 34 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9 (1–3 as inappropriate, 4–6 as uncertain and as 7–9 appropriate). Results: Of the 34 statements, 20 were rated as appropriate and 14 were rated as inappropriate. Uncertainty existed across all three domains: the initial assessment and management of HF-CS; escalation to temporary Mechanical Circulatory Support (tMCS); and weaning from tMCS in HF-CS. Significant disagreement between experts (deemed present when the disagreement index exceeded 1) was only identified when deliberating the utility of thoracic ultrasound in the immediate management of HF-CS. Conclusion: This study has highlighted several areas of practice where large-scale prospective registries and clinical trials in the HF-CS population are urgently needed to reliably inform clinical practice and the synthesis of future societal HF-CS guidelines. [ABSTRACT FROM AUTHOR]

Introduction: In the field of anaesthesiology, attenuation of pressor response is one of the keenly researched subjects. As a standard practice we use rigid laryngoscope to view the larynx and adjacent structures for facilitating endotracheal intubation. This causes direct trauma to the oropharynx and larynx and apart from this it also causes stimulation resulting in a rise in heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure. Tachycardia, hypertension, and dysrhythmias all occur during laryngoscopy and intubations. Aim: This study was done to compare the efficacy of dexmedetomidine 1 µg/kg; and labetalol 0.3 mg/kg in attenuating the cardiovascular responses to Laryngoscopy and Intubation, and to observe for adverse effects if any of these two in the specified dosage. Materials and Methods: This randomized comparative double - blinded study was conducted in Kamineni medical college in the year JAN-DEC 2023. After obtaining ethical committee approval, the study population was chosen all the patients were assessed preoperatively with history, clinical examination, and required investigations, informed written consent was obtained from the patient. The patients were randomly allocated into two groups. Group D (n: 45) received Dexmedetomidine 1 µg/kg in 10ml normal saline IV. Over 10 min, and subsequently 5min after induction of anesthesia was done. Group L (n: 45) received Labetalol 0.3 mg/kg 10 ml normal saline IV. over 10 min, 5 min prior to induction of anesthesia. All patients were pre medicated with Inj. Midazolam 2 mg and Inj. Glycopyrrolate 0.2 mg IV. 45 min before surgery Heart rate, systolic and diastolic blood pressure, and oxygen saturation were recorded as the baseline value. Results: There was a reduction in the heart rate and mean arterial pressure response to intubation in both Dexmedetomidine and Labetalol groups, but when both the groups were compared there was a statistically significant reduction of heart rate and arterial pressure response to intubation in Dexmeditomidine group (p< 0.05). There was no significant hypotension or bradycardia in any of the groups. Conclusion: We conclude that Dexmeditomidine 1 µg/Kg given slowly over 10 minutes intravenously 5 minutes before induction, attenuates the cardiovascular responses to laryngoscopy and intubation in a better manner than Labetalol 0.3mg/Kg. [ABSTRACT FROM AUTHOR]

Background:Dengue infection is one of the common tropical infectious diseases. Clinicalmanifestations of cardiacinvolvement can vary widely, from an incidental finding to severe cardiac failure resulting in death. Aim:To assess the prevalence and clinical significance of major acute cardiovascular events after dengue infection. Methods:A comprehensive longitudinal investigation took place at a tertiaryhealthcare facilitylocated inRaigad (Maharashtra). The sampling techniqueinvolved the inclusion of 140 eligible dengue fever cases who were selected on a first come first serve basisafter the beginning of the study.A previous history of any cardiac disease, history of chronic kidney disease(CKD), pregnant women and children, as well as admission ECG suggestive of old ischemicchanges, and use of medications affecting heart rate were excluded from the study. Results: Prevalence of cardiac inflammation in dengue fever cases were 26.4%. The elevatedhs-Troponin-T (pg/ml) in 25.0% cases and elevated CK-MB (U/L) in 23.6% cases.1st-degree heart block in 10.8%,2nd-degree heart block in 2.7%, complete heart block in 2.7%, atrial fibrillation in 10.8%, ST elevation in 5.4%, ventricular tachycardia in 2.7% and sinus tachycardi a in 13.5%. 37.8% cases found EF <40.0% echocardiography, 24.3% cases EF 40-50% and regional wall motion abnormality (RWMA) in 51.4% cases. Conclusion: Our study revealed that patients withnormal echo, ECG and serum levels of markers of cardiac injury are atlow risk for mortality and hence may need less monitoring or therapeutic intervention. Our study elucidates various significantfindings that advocate for tailored interventions, heightened awareness of cardiac involvement, andstrategic use of diagnostic tools. [ABSTRACT FROM AUTHOR]

Peripheral arterial stenoses (PAS) are commonly investigated with duplex ultrasound (DUS) and angiography, but these are not functional tests. Fractional flow reserve (FFR), a pressure based index, functionally assesses the ischaemic potential of coronary stenoses, but its utility in PAS is unknown. FFR in the peripheral vasculature in patients with limb ischaemia was investigated. Patients scheduled for angioplasty and or stenting of isolated iliac and superficial femoral artery stenoses were recruited. Resting trans-lesional pressure gradient (P d / P a) and FFR were measured after adenosine provoked hyperaemia using an intra-arterial 0.014 inch flow and pressure sensing wire (ComboWire XT, Philips). Prior to revascularisation, exercise ABPI (eABPI) and DUS derived peak systolic velocity ratio (PSVR) of the index lesion were determined. Calf muscle oxygenation was measured using blood oxygenation level dependent cardiovascular magnetic resonance prior to and after revascularisation. Forty-one patients (32, 78%, male, mean age 65 ± 11 years) with 61 stenoses (iliac 32; femoral 29) were studied. For lesions < 80% stenosis, resting P d / P a was not influenced by the degree of stenosis (p =.074); however, FFR was discriminatory, decreasing as the severity of stenosis increased (p =.019). An FFR of < 0.60 was associated with critical limb threatening ischaemia (area under the curve [AUC] 0.87; 95% CI 0.75 – 0.95), in this study performing better than angiographic % stenosis (0.79; 0.63 – 0.89), eABPI (0.72; 0.57 – 0.83), and PSVR (0.65; 0.51 – 0.78). FFR correlated strongly with calf oxygenation (rho, 0.76; p <.001). A greater increase in FFR signalled resolution of symptoms and signs (ΔFFR 0.25 ± 0.15 vs. 0.13 ± 0.09; p =.009) and a post-angioplasty and stenting FFR of > 0.74 predicted successful revascularisation (combined sensitivity and specificity of 95%; AUC 0.98; 0.91 – 1.00). This pilot study demonstrates that FFR can objectively measure the functional significance of PAS that compares favourably with visual and DUS based assessments. Its role as a quality control adjunct that confirms optimal vessel patency after angioplasty and or stenting also merits further investigation. [ABSTRACT FROM AUTHOR]

Background: To attenuate the intubation response, over the decades many pharmacological and non-pharmacological techniques have been practiced. In this study we have compared topical 10% lignocaine spray after induction of anaesthesia versus intravenous preservative free 2% lignocaine to suppress the intubation response. Materials and Methods: 60 patients posted for surgery under general anaesthesia were randomly divided into two groups after obtaining the written informed consent. The patients were either administered 10% lignocaine spray or loxicard 2% before intubation. Hemodynamic response was observed and tabulated from intubation to 10 minutes after intubation. Results: In our study, we have noticed that there was a decrease in hemodynamic parameter in both the groups. However, the response was more significant in group SP compared to group IV. The p value was less than 0.05. Conclusion: We have concluded that lignocaine 10% spray is better than IV lignocaine to suppress the intubation response without any adverse effects. [ABSTRACT FROM AUTHOR]

Background: The surgeries performed with securement of airway with endotracheal tube placement will be followed by extubation at the end of surgical procedure. Extubation may be associated with upper airway obstruction, laryngospasm, bronchospasm, tachycardia, hypertension and dysrhythmiasTracheal. Extubation evokes various haemodynamic stress response in the form of tachycardia, raised blood pressure,changes in the heart rhythm which is detrimental to susceptible patients. Hence a study is needed to find a pharmacological drug to attenuate the stress response to extubation. Aims and Objectives: To analyze the efficacy of iv labetalol 0.25/mg/kg in attenuation of haemodynamic response to extubation. Materials & Methods: 64 participants belonging to ASA 1 or 2 of age group 18 – 55yrs were randomly divided into groups of 2. Group Lt received injection Labetalol iv 0.25mg/kg and group Ct received normal saline. Heart rate,systolic and diastolic blood pressure were recorded at baseline, 2,5,8 minutes after drug infusion, at extubation, and 1,3,5,8,10 and 15 minutes post extubation. Results and Observations: Group Lt showed lowered heart rate, systolic and diastolic blood pressure at extubation and 15minutes post extubation compared to group CT. Conclusion: Injection Labetalol iv 0.25mg/kg effectively attenuated the haemodynamic stress response to extubation. [ABSTRACT FROM AUTHOR]

BackgroundThe concept of a “textbook outcome” is emerging as a metric for ideal surgical outcomes. We aimed to evaluate the impact of an advanced haemodynamic monitoring (AHDM) algorithm on achieving a textbook outcome in patients undergoing hepatobiliary–pancreatic surgery.MethodsThis retrospective, multicentre observational study was conducted across private and public teaching sectors in Victoria, Australia. We studied patients managed by a patient-specific, surgery-specific haemodynamic algorithm or via usual care. The primary outcome was the effect of using a patient-specific, surgery-specific AHDM algorithm for achieving a textbook outcome, with adjustment using propensity score matching. The textbook outcome criteria were defined according to the International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery and Nationwide Analysis of a Novel Quality Measure in Pancreatic Surgery.ResultsOf the 780 weighted cases, 477 (61.2%, 95% CI: 57.7%–64.6%) achieved the textbook outcome. Patients in the AHDM group had a higher rate of textbook outcomes [n = 259 (67.8%)] than those in the Usual care group [n = 218 (54.8%); p

This study aimed to compare whether Bispectral Index (BIS) reduces the consumption of the anaesthetic drug and improves recovery time in coronary artery-bypass grafting off-pump (CABG-OP) surgery without awareness during surgery (ADS). The study was a single centre, prospective, randomised, and double-blind comparative research on ASA 3 patients booked for elective CABG-OP operation under general anaesthesia (GA). Patients received either propofol or isoflurane anaesthesia, and their consumption was calculated and compared. The conventional groups CPG-1 and CIG-3 received propofol and isoflurane, and haemodynamic parameters (± 20% of initial values) were considered for anaesthesia. The groups BPG-2 and BIG-4 received propofol and isoflurane, and BIS (value 50±5) was used to maintain anaesthesia. In addition, haemodynamic parameters, awakening conditions, length of intubation, hospital stay and drug utilisation were recorded. To explicit ADS, patients were interviewed 24 hours after extubation. The quantity of propofol used was 178 ± 11 ml in CPG-1 and 117 ± 6 ml in BPG-2, with a 34.26% reduction with BIS. The isoflurane used was 39 ± 8 ml in CIG-3 and 25± 6ml in BIG-4, with a 35.89% reduction in isoflurane requirement. This difference was statistically significantly low with BIS monitored anaesthesia compared to conventional anaesthesia. The length of intubation was 2.2 ±1.27 and 2.3 ±1.49 hours in groups BPG-2 and BIG-4, respectively (p

Background: Endotracheal extubation is one of the frequently performed procedure in the practice of Anaesthesia. This study was done to observe the haemodynamic responses during tracheal extubation and to compare the efficacy of IV diltiazem 0.3 mg/kg wih IV Lidocaine 1 mg/kg versus 0.2 mg/kg and 0.1 mg /kg IV Diltiazem with 1mg/kg IV Lignocaine in attenuating the hemodynamic response to tracheal extubation. Methods: 120 patients aged 20 to 60 yrs, belonging to ASA I and II, normotensive were included in the study and they were randomly allocated into 3 groups of 40 each. • Group –I The patient who receive injection Diltiazem 0.1mg/kg and inj Lignocaine 1mg/kg i.v. (n=40) • Grade –II The patients who receive injection Diltiazem 0.2mg/kg and inj. Lignocaine 1mg/kg i.v. (n=40) • Group -III The patients who receive injection Diltiazem 0.3mg/kg and inj.Lignocaine 1mg/kg i.v. (n=40) 2 min before extubation. At the end of the surgery, heart rate (HR), systolic blood pressure (SBP) diastolic blood pressure (DBP) and mean arterial pressure [MAP] were recorded served as base line values. Results: After tracheal extubation, all the haemodynamic parameters increase from base line,0.3 mg/kg inj. Diltiazem along with 1mg/kg inj Lignocaine provide better haemodynamic stability when compared with 0.1 mg/kg and 0.2 mg/kg inj Diltiazem along with inj. Lignocaine 1mg/kg each. 0.2 mg/kg inj. Diltiazem along with 1mg/kg inj Lignocaine provide better haemodynamic stability when compared with 0.1 mg inj Diltiazem with inj. Lignocaine 1mg/kg. Conclusions: Based on the findings of our study, we concluded that combination effect of Inj. Lignocaine and Inj. Diltiazem, Attenuate the hemodynamic response to extubation. 0.3mg/kg Diltiazem with 1mg/kg Lignocaine is superior to 0.2mg/kg and 0.1 mg/kg Diltiazem with 1mg/kg Lignocaine in attenuating the hemodynamic response to extubation. 0.2mg/kg Diltiazem with 1mg/kg Lignocaine is superior to 0.1mg/kg Diltiazem with 1mg /kg lignocaine in attenuating the hemodynamic response to extubation. Further studies are required to evaluate the advantage, beneficial effect and safety of Diltiazem in comparison with other drugs when used for the purpose of attenuating the hemodynamic changes associated with extubation. [ABSTRACT FROM AUTHOR]

BackgroundHypotension occurs frequently during surgery and may be associated with adverse complications. Vasopressor titration is frequently used to correct hypotension, but requires considerable time and attention, potentially reducing the time available for other clinical duties. To overcome this issue, we have developed a closed-loop vasopressor (CLV) controller to help correct hypotension more efficiently. The aim of this randomised controlled study was to evaluate whether the CLV controller was superior to traditional vasopressor management at minimising hypotension in patients undergoing abdominal surgery.MethodsThirty patients scheduled for elective intermediate-to high-risk abdominal surgery were randomised into two groups. In the CLV group, hypotension was corrected automatically via the CLV controller system, which adjusted the rate of a norepinephrine infusion according to MAP values recorded using an advanced haemodynamic device. In the control group, management of hypotension consisted of standard, manual adjustment of the norepinephrine infusion. The primary outcome was the percentage of time that a patient was hypotensive, defined as MAP

Propofol and remifentanil are frequently combined for the induction and maintenance of general anaesthesia. Both propofol and remifentanil cause vasodilation and potentially reduce arterial BP. We aimed to develop a mechanism-based model that characterises the haemodynamic interactions between remifentanil and propofol. Data from two clinical trials in healthy volunteers were analysed using remifentanil-alone, propofol-alone, and combination groups. We evaluated remifentanil effects on haemodynamics using a previously developed mechanism-based haemodynamic model of propofol. The interaction between propofol and remifentanil was explored using the principles of the general pharmacodynamic interaction (GPDI) model. Remifentanil alone increased the dissipation rate of total peripheral resistance by 50% at 3.0 ng ml−1. Additionally, the dissipation rates of HR and stroke volume were attenuated by 4.8% and 4.9% per 1 ng ml−1 increase in remifentanil concentration, respectively. The maximal effect of propofol alone in decreasing the production rate of total peripheral resistance was 78%, which decreased to 32% when combined with remifentanil 4 ng ml−1. The effects of remifentanil on HR and stroke volume were attenuated by propofol with maximum decreases of 11.9% and 21.2%, respectively. Goodness-of-fit plots and prediction-corrected visual predictive check plots showed good predictive performance of the models. The structure of the previous mechanism-based haemodynamic model for propofol was able to describe the effects of remifentanil alone on haemodynamic variables. The GPDI model provided a good framework for characterising the pharmacodynamic interaction between remifentanil and propofol on haemodynamic properties. NCT02043938; NCT03143972. [ABSTRACT FROM AUTHOR]

Background: This study was conducted to compare the efficacy of oral clonidine 200 mcg with oral gabapentin 900 mg in attenuating haemodynamic response to endotracheal intubation with regard to heart rate, blood pressure (systolic and diastolic), mean arterial pressure, and rate pressure product. We also wanted to ascertain the effectiveness of oral clonidine 200 mcg with oral gabapentin 900 mg or vice versa in attenuating haemodynamic response to laryngoscopy and endotracheal intubation. Methods: This was a hospital-based study conducted among 100 ASA1 and ASA2 patients posted for surgeries under general anaesthesia in KIMS, IEC/D/-49/2017, from 16th November 2017 to 23rd October 2018, after obtaining clearance from the institutional ethics committee and written informed consent from the study participants. Results: Both groups showed attenuation of stress response. In gabapentin group, there was an increase in SBP, DBP and MBP up to 3 minutes, RPP up to 4 minutes HR up to 10 minutes after that, it was maintained below the baseline. In clonidine group, there was no rise in systolic and diastolic blood pressure, mean arterial blood pressure or rate pressure product compared to the baseline from the 1st minute of intubation which was statistically significant (p<0.0001). Post extubation, clonidine group patients were more sedated than those in gabapentin group. Conclusion: Both clonidine and gabapentin attenuate the stress response to laryngoscopy and intubation. When both of these drugs were compared, clonidine attenuated the stress response to laryngoscopy and intubation better than gabapentin and afforded good haemodynamic stability. Post extubation, clonidine group patients were more sedated than those in gabapentin group. [ABSTRACT FROM AUTHOR]

Galvanic vestibular stimulation (GVS) helps stabilize subjects when balance and posture are compromised. This work aimed to define the cortical regions that GVS activates in normal subjects. We used functional near‐infrared spectroscopy (fNIRS) to test the hypothesis that GVS activates similar cortical areas as a passive movement. We used transcranial current stimulation (cathode in the right mastoid process and anode in the FPz frontopolar point) of bipolar direct current (2 mA), false GVS (sham), vibration (neutral stimulus), and back and forth motion (positive control of vestibular movement) in 18 clinically healthy volunteers. Seventy‐two brain scans were performed, applying a crossover‐type experimental design. We measured the heart rate, blood pressure, body temperature, head capacitance, and resistance before and after the experiment. The haemodynamic changes of the cerebral cortex were recorded with an arrangement of 26 channels in four regions to perform an ROI‐level analysis. The back‐and‐forth motion produced the most significant oxygenated haemoglobin (HbO2) increase. The response was similar for the GVS stimulus on the anterior and posterior parietal and right temporal regions. Sham and vibrational conditions did not produce significant changes ROI‐wise. The results indicate that GVS produces a cortical activation coherent with displacement percept. [ABSTRACT FROM AUTHOR]

Invasive arterial blood pressure monitoring is the standard of practice in terms of intraoperative blood pressure surveillance during liver transplantation. While this is an ideal, achieving reliable arterial access can be extremely challenging in the paediatric and neonatal population, repeated attempts at arterial cannulation are not without risk and alternative best practice means of haemodynamic monitoring are not clearly established. We describe a case of paediatric liver transplantation in a 3.9 kg infant that was complicated by difficult arterial cannulation, and we suggest that, when reasonable attempts to achieve intra-arterial access have failed, it is safe to proceed with paediatric liver transplantation with non-invasive blood pressure monitoring at 2 min intervals throughout the case and 1 min intervals at reperfusion. We recognise the unique technical challenges in paediatric liver transplant anaesthesia, and we advocate for the establishment of formal clinical training competencies in line with adult practice recommendations. We recommend the use of the Seldinger technique under ultrasound guidance as a first-line approach when difficult arterial cannulation is anticipated, and we discuss techniques for alternative approaches. We suggest that additional alternative means of haemodynamic monitoring should be considered when arterial access cannot be established; however, as no method demonstrates absolute superiority, one or a combination of techniques should be considered, depending on local availability and expertise. [ABSTRACT FROM AUTHOR]

Simple Summary: Pimobendan is a drug that improves cardiac output and contractility in dogs with mitral valve disease and dilated cardiomyopathy, as well as in healthy adult dogs. The intravenous injectable formulation has shown immediate cardiovascular effects in dogs without pro-arrhythmogenic effects. Our study aims to assess the haemodynamic effects of the intravenous administration of pimobendan at a dose of 0.15 mg/kg intravenously in healthy senior dogs undergoing general anaesthesia for surgical procedures. The results of this study showed that pimobendan improves cardiac function parameters measured with an oesophageal Doppler monitor in senior dogs with no previous heart disease. Pimobendan could be used during general anaesthesia in senior dogs when there is concern about the possible presence of impaired cardiac function. There were no significant changes in blood pressure or heart rate. In the present study, continuous haemodynamic monitoring showed that the effects appeared from the first minute and continued for at least 20 min. Pimobendan is an inotropic and vasodilator drug with no sympathomimetic effects. This study aimed to evaluate the haemodynamic effects of pimobendan during anaesthesia in healthy senior dogs. A prospective, randomised, triple-blinded, placebo-controlled clinical study was conducted. Thirty-three dogs (median [range]: 9 [7, 12] years) were anaesthetised for surgical procedures. The dogs were randomly allocated into two groups: eighteen dogs received intravenous pimobendan at a dose of 0.15 mg/kg (PIMOBENDAN), and fifteen dogs received intravenous saline solutions at a dose of 0.2 mL/kg (PLACEBO). Data were recorded before, 1 min, 10 min, and 20 min after injection. Velocity-time integral (VTI), peak-velocity (PV), and mean-acceleration (MA) were measured using an oesophageal Doppler monitor (ODM). Heart rate and mean arterial pressure were also registered. The data were analysed using a two-way ANOVA for trimmed means. Statistical differences were considered if p < 0.05. Twenty minutes after injection, the VTI (13.0 cm [10.4, 22.3]), PV (95.0 [83.0, 160] m/s), and MA (12.6 [9.40, 17.0] m/s2) were significantly higher in the PIMOBENDAN group compared to the PLACEBO group (VTI: 10.5 [6.50, 17.4] cm, PV: 80.0 [62.0, 103] m/s and MA: 10.2 [7.00, 16.0] ms2). No significant differences were observed in the rest of the variables. Using pimobendan during anaesthesia increases VTI, PV, and MA, as measured by an ODM. [ABSTRACT FROM AUTHOR]

Background & Method: The aim of present study is to compare study of dexmedetomidine and labetalol for attenuation of haemodynamic stress response to laryngoscopy and intubation. 90 ASA I and II patients aged 15- 60 years undergoing elective ENT surgeries (mastoidectomy, FESS, stapedectomy and myringoplasty) under general anesthesia were chosen for the study. After obtaining ethics committee approval, the study population was chosen. All the patients were assessed preoperatively with history, clinical examination, and required investigations Result: The mean heart rate, mean systolic and mean diastolic blood pressure after injection. There is statistically significant difference in mean heart rate of patients across 3 groups (p< 0.01). The mean heart rate of group D is lower than that of both the group L and P. There is no statistical difference in the mean systolic diastolic blood pressure and SPO2 among 3 groups. Conclusion: 90 ASA I and II patient's aged15- 60 years undergoing elective ENT surgeries (mastoidectomy, FESS, stapedectomy and myringoplasty) under general anesthesia were chosen for the study. After obtaining ethics committee approval, the study population was chosen. Informed written consent obtained from the patient. Heartrate, systolic and diastolic blood pressure and oxygen saturation were recorded as base line value. Dexmeditomidine 1p/Kg given slowly over 10 minutes intravenously 5 minutes prior to induction, attenuates the cardiovascular responses to laryngoscopy and intubation in a better manner than Labetalol 0.5mg/Kg. [ABSTRACT FROM AUTHOR]

Aims Echocardiography has shown to categorize heart failure (HF) patients according to haemodynamic profiles. Whether left ventricular (LV) global longitudinal strain (LV-GLS) could integrate echo-derived haemodynamic profiles to risk stratify chronic HF patients is still unknown. Methods and results Chronic HF outpatients with LV ejection fraction (LV-EF) <50% (n = 351) and LV-GLS assessment were evaluated and divided according to four haemodynamic phenotypes based on LV stroke volume index (SVI), LV filling pressure (LVFP), and right ventricular (RV) function: normal output-normal LVFP (NO-NP), normal output-high LVFP (NO-HP), low output-no RV dysfunction (LO-NRVD), and low output-RV dysfunction (LO-RVD). RV function was defined using the tricuspid annular plane systolic excursion and RV free-wall longitudinal strain. The median follow-up duration was 3.3 years. The combination of all-cause mortality and HF hospitalization was the primary endpoint. Secondary endpoints were all-cause mortality and cardiovascular mortality. The prevalence of NO-NP, NO-HP, LO-NRVD, and LO-RVD were 38%, 22%, 30%, and 10%, respectively. The haemodynamic model independently predicted primary and secondary outcomes, with incremental prognostic information over LV-EF (all P -values <0.001 for C -statistics). When univariate Cox regression analysis was performed to assess the prognostic stratification capability of LV-GLS in different haemodynamic subgroups, we observed a reduction in LV-GLS hazard ratios from the NO-NP to the LO-RVD for every endpoint. Conclusion There was a continuum in LV-GLS impairment across the spectrum of haemodynamic phenotypes and its prognostic value resulted variable depending on the types of chronic HF patients. The highest prognostic information added by LV-GLS was in patients with normal SVI. [ABSTRACT FROM AUTHOR]

BACKGROUND:Vasopressor agents are used to prevent intraoperative hypotension and ensure adequate perfusion. Vasopressors are usually administered as intermittent boluses or manually adjusted infusions, but this practice requires considerable time and attention. We have developed a closed-loop vasopressor (CLV) controller to correct hypotension more efficiently. Here, we conducted a proof-of-concept study to assess the feasibility and performance of CLV control in surgical patients. METHODS:Twenty patients scheduled for elective surgical procedures were included in this study. The goal of the CLV system was to maintain MAP within 5 mm Hg of the target MAP by automatically adjusting the rate of a norepinephrine infusion using MAP values recorded continuously from an arterial catheter. The primary outcome was the percentage of time that patients were hypotensive, as defined by a MAP of 5 mm Hg below the chosen target. Secondary outcomes included the total dose of norepinephrine, percentage of time with hypertension (MAP>5 mm Hg of the chosen target), raw percentage "time in target" and Varvel performance criteria. RESULTS:The 20 subjects (median age: 64 years [52-71]; male (35%)) underwent elective surgery lasting 154 min [124-233]. CLV control maintained MAP within ±5 mm Hg of the target for 91.6% (85.6-93.3) of the intraoperative period. Subjects were hypotensive for 2.6% of the intraoperative period (range, 0-8.4%). Additional performance criteria for the controller included mean absolute performance error of 2.9 (0.8) and mean predictive error of 0.5 (1.0). No subjects experienced major complications. CONCLUSIONS:In this proof of concept study, CLV control minimised perioperative hypotension in subjects undergoing moderate- or high-risk surgery. Further studies to demonstrate efficacy are warranted. TRIAL REGISTRY NUMBER:NCT03515161 (ClinicalTrials.gov).

Abstract Aims There are limited data about the intraprocedural haemodynamic study performed immediately before and after transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis (AS). We aimed to evaluate the acute haemodynamic impact of TAVI in patients with severe AS and to investigate invasive and non‐invasive parameters predicting all‐cause mortality. Methods and results A total of 245 consecutive AS patients (43% male, mean age 80.3 ± 7.3 years) undergoing TAVI were enrolled. Intraprocedural left heart catheterization (LHC) and echocardiogram before and after TAVI were performed. The clinical endpoint was the death for any cause. LHC after TAVI revealed significant changes in aortic and left ventricular (LV) pressures, including indexes of intrinsic myocardial contractility and diastolic function such as positive dP/dT (1128.9 ± 398.7 vs. 806.3 ± 247.2 mmHg/s, P ˂ 0.001) and negative dP/dT (1310.7 ± 431.1 vs. 1075.1 ± 440.8 mmHg/s, P ˂ 0.001). Post‐TAVI echo showed a significant reduction in LV end‐diastolic (P = 0.036) and end‐systolic (P ˂ 0.001) diameters, improvement in LV ejection fraction (from 55 ± 12% to 57.2 ± 10.5%, P ˂ 0.001), and pulmonary artery systolic pressure (42.1 ± 14.2 vs. 33.1 ± 10.7 mmHg, P

Right heart failure can be defined as a clinical syndrome consisting of signs and symptoms of heart failure resulting from right ventricular dysfunction. Function is normally altered due to three mechanisms: (1) pressure overload (2) volume overload, or (3) a decrease in contractility due to ischaemia, cardiomyopathy or arrythmias. Diagnosis is based upon a combination of clinical assessment plus echocardiographic, laboratory and haemodynamic parameters, and clinical risk assessment. Treatment includes medical management, mechanical assist devices and transplantation if recovery is not observed. Distinct attention to special circumstances such as left ventricular assist device implantation should be sought. The future is moving towards new therapies, both pharmacological and device centered. Immediate diagnosis and management of RV failure, including mechanical circulatory support where needed, alongside a protocolized approach to weaning is important in successfully managing right ventricular failure.

Introduction: Hypotension is the most common serious adverse event associated with Spinal Anaesthesia (SA) and is associated with nausea and vomiting leading to pulmonary aspiration, respiratory depression and cardiac arrest. Phenylephrine (PE) and Ephedrine (EP) are vasopressors commonly used for prevention of hypotension associated with SA. Aim: To compare the efficacy and safety of PE and EP in prevention of hypotension induced by SA in women during Lower Segment Caesarean Section (LSCS) surgery. Materials and Methods: The present randomised clinical study was conducted on 60 women, between 18-36 years of age and a Heart Rate (HR) of 60-100 per minute randomised to receive either 100 mcg Intravenous (i.v.) bolus of PE, or 12 mg i.v. of EP during intrathecal block. Women having intraoperative hypotension were injected additional doses of vasopressor. Cardiovascular parameters were recorded at baseline (before block) and then at 1, 5, 10, 15, 30, 40 and 60 minutes. Further, safety was also assessed based on hypotension events and adverse events reported during immediate postoperative period. Data analysis was done using IBM SPSS 17 and a p-value <0.05 was considered statistically significant. Results: The mean age of the study participants in PE and EP group was 26.67±5.40 and 26.23±4.59 years, respectively. Significant differences were observed between PE and EP groups for change in Systolic Blood Pressure (SBP) after 1, 10, 30, 40 and 60 minutes. Overall, there was a slight fall in SBP with PE, whereas, with EP there was a slight rise in SBP. Also, the Diastolic Blood Pressure (DBP) was maintained with EP throughout the 60 minute period, whereas with PE there was an initial rise in DBP followed by a slight fall in DBP. The Mean Arterial Pressure (MAP) was well maintained with PE throughout, whereas with EP there was a fall in MAP after 15 minutes. However, these changes were not clinically significant. The Pulse Rate (PR) was lower with PE compared to EP group at time points of 1, 5, 15 and 20 minutes. The mean respiratory rates and blood oxygen saturation were similar with PE and EP administration (p>0.05). A total of 13 (43.3%) patients in the PE group and 14 (46%) in the EP group had adverse events excluding hypotensive patients. Conclusion: According to the findings of the present study, the i.v. bolus of 100 mcg PE and 12 mg EP administered immediately after SA are equally effective in prevention of maternal hypotension and do not cause any significant cardiovascular and respiratory effects. [ABSTRACT FROM AUTHOR]

Aims In heart failure (HF), pulmonary venous hypertension (PVH) produces pulmonary hypertension (PH) with remodeling of pulmonary veins (PV) and arteries (PA). In a porcine PVH model, we performed proteomic-based bioinformatics to investigate unique pathophysiologic mechanisms mediating PA and PV remodeling. Methods and results Large PV were banded (PVH, n  = 10) or not (Sham, n  = 9) in piglets. At sacrifice, PV and PA were perfusion labelled for vessel-specific histology and proteomics. The PA and PV were separately sampled with laser-capture micro-dissection for mass spectrometry. Pulmonary vascular resistance [Wood Units; 8.6 (95% confidence interval: 6.3, 12.3) vs. 2.0 (1.7, 2.3)] and PA [19.9 (standard error of mean, 1.1) vs. 10.3 (1.1)] and PV [14.2 (1.2) vs. 7.6 (1.1)] wall thickness/external diameter (%) were increased in PVH (P  < 0.05 for all). Similar numbers of proteins were identified in PA (2093) and PV (2085) with 94% overlap, but biological processes differed. There were more differentially expressed proteins (287 vs. 161), altered canonical pathways (17 vs. 3), and predicted upstream regulators (PUSR; 22 vs. 6) in PV than PA. In PA and PV, bioinformatics indicated activation of the integrated stress response and mammalian target of rapamycin signalling with dysregulated growth. In PV, there was also activation of Rho/Rho-kinase signalling with decreased actin cytoskeletal signalling and altered tight and adherens junctions, ephrin B, and caveolae-mediated endocytosis signalling; all indicating disrupted endothelial barrier function. Indeed, protein biomarkers and the top PUSR in PV (transforming growth factor-beta) suggested endothelial to mesenchymal transition in PV. Findings were similar in human autopsy specimens. Conclusion These findings provide new therapeutic targets to oppose pulmonary vascular remodeling in HF-related PH. [ABSTRACT FROM AUTHOR]

Abstract Aim Echo‐derived haemodynamic classification, based on forward‐flow and left ventricular (LV) filling pressure (LVFP) correlates, has been proposed to phenotype patients with heart failure and reduced ejection fraction (HFrEF). To assess the prognostic relevance of baseline echocardiographically defined haemodynamic profile in ambulatory HFrEF patients before starting sacubitril/valsartan. Methods and results In our multicentre, open‐label study, HFrEF outpatients were classified into 4 groups according to the combination of forward flow (cardiac index; CI:< or ≥2.0 L/min/m2) and early transmitral Doppler velocity/early diastolic annular velocity ratio (E/e′: ≥ or

Abstract The inodilator levosimendan, in clinical use for over two decades, has been the subject of extensive clinical and experimental evaluation in various clinical settings beyond its principal indication in the management of acutely decompensated chronic heart failure. Critical care and emergency medicine applications for levosimendan have included postoperative settings, septic shock, and cardiogenic shock. As the experience in these areas continues to expand, an international task force of experts from 15 countries (Austria, Belgium, China, Croatia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Spain, Sweden, Switzerland, and the USA) reviewed and appraised the latest additions to the database of levosimendan use in critical care, considering all the clinical studies, meta-analyses, and guidelines published from September 2019 to November 2021. Overall, the authors of this opinion paper give levosimendan a “should be considered” recommendation in critical care and emergency medicine settings, with different levels of evidence in postoperative settings, septic shock, weaning from mechanical ventilation, weaning from veno-arterial extracorporeal membrane oxygenation, cardiogenic shock, and Takotsubo syndrome, in all cases when an inodilator is needed to restore acute severely reduced left or right ventricular ejection fraction and overall haemodynamic balance, and also in the presence of renal dysfunction/failure.

Introduction: Hypotension is the most common serious adverse event associated with Spinal Anaesthesia (SA) and is associated with nausea and vomiting leading to pulmonary aspiration, respiratory depression and cardiac arrest. Phenylephrine (PE) and Ephedrine (EP) are vasopressors commonly used for prevention of hypotension associated with SA. Aim: To compare the efficacy and safety of PE and EP in prevention of hypotension induced by SA in women during Lower Segment Caesarean Section (LSCS) surgery. Materials and Methods: The present randomised clinical study was conducted on 60 women, between 18-36 years of age and a Heart Rate (HR) of 60-100 per minute randomised to receive either 100 mcg Intravenous (i.v.) bolus of PE, or 12 mg i.v. of EP during intrathecal block. Women having intraoperative hypotension were injected additional doses of vasopressor. Cardiovascular parameters were recorded at baseline (before block) and then at 1, 5, 10, 15, 30, 40 and 60 minutes. Further, safety was also assessed based on hypotension events and adverse events reported during immediate postoperative period. Data analysis was done using IBM SPSS 17 and a p-value 0.05). A total of 13 (43.3%) patients in the PE group and 14 (46%) in the EP group had adverse events excluding hypotensive patients. Conclusion: According to the findings of the present study, the i.v. bolus of 100 mcg PE and 12 mg EP administered immediately after SA are equally effective in prevention of maternal hypotension and do not cause any significant cardiovascular and respiratory effects.

Haemodynamic changes in mitral regurgitation underlie triggering of patient’s symptoms and development of heart failure. A number of endovascular methods for the correction of mitral regurgitation successfully counteract pathological hemodynamics and thus manage to improve both the manifestations of heart failure and the patient's symptoms. This article is a review of the physiology of the mitral valve and the changes that occur in the presence of mitral regurgitation. The peculiarities of the hemodynamics of the left atrium in the conditions of mitral regurgitation and after some types of transcatheter treatment – edge-to-edge correction of the valve with Mitraclip and the implantation of an occluder in paraprosthetic mitral regurgitation are considered. The change in left atrial parameters immediately after correction of the defect is of value both for the assessment of immediate procedural success and for the patient's prognosis.

Introduction: Cancer patients experience higher levels of pathological anxiety than other patients. Though several studies have reported perioperative use of melatonin in alleviating preoperative anxiety with minimal side effects, research on the perioperative use of melatonin in oncology patients is scarce. Aim: To analyse the preoperative anxiolysis, sedation, sleepiness and hemodynamic response to intubation after premedication with oral melatonin at two different doses of 0.3 mg/kg and 0.5 mg/kg body weight and comparing them with placebo. Materials and Methods: This was randomised controlled trial on a total of 90 cancer patients aged 18-60 years undergoing elective surgeries under general anaesthesia were randomised into three groups of 30 patients each. Oral melatonin 0.3 mg/kg, oral melatonin 0.5 mg/kg, and placebo were given to patients in Groups A, B, and C, respectively. The Visual Analogue Score (VAS), Ramsay Sedation Scale (RSS), and Stanford Sleepiness Scale (SSS) were used to assess anxiety, sedation, and sleepiness before and 90 minutes after premedication. Heart rate (HR), systolic (SBP), diastolic (DBP), and mean arterial (MAP) blood pressures were also measured. For intragroup comparison, a paired t-test and for intergroup comparison, ANOVA (Analysis of Variance) and difference-in-differences regression analysis were performed. Results: The three groups (group A: oral melatonin 0.3 mg/kg, group B: oral melatonin 0.5 mg/kg, group C: placebo) each having 30 patients were comparable with regard to demographic profiles with insignificant p-value. Melatonin had no significant anxiolytic impact when compared to placebo (p>0.05). However, melatonin offered considerable sedation and haemodynamic stability in a dose-dependent manner. Melatonin 0.5 mg/kg (group B) gave better sedation (RSS score: 3.30±0.11) and haemodynamic stability (fall in Mean Heart Rate: by 7.4 after premedication) than melatonin 0.3 mg/kg) (RSS score: 2.77±0.12; fall in mean Heart rate after premedication: by 7.76) than the placebo (RSS score: 2.17±0.07; fall in mean Heart Rate: by 0.2). Conclusion: Oral melatonin provides better sedation and haemodynamic stability during endotracheal intubation in a dose-dependent manner when compared to placebo. But when required for sole anxiolysis melatonin was similar to placebo. Further studies are warranted to explore the safe dose for the anxiolytic effect of oral melatonin in cancer patients

Introduction: Ambulatory anaesthesia is a rapidly growing subspecialty. Although its history is as old as the history of general anesthesia itself, it has emerged as a recognized concept and is evolving over the past couple of decades. Propofol and Sevoflurane have increased the ability of the anaesthesiologist to provide a successful day-care experience. Aims: The aim of the study was to compare the induction and recovery characteristics of Propofol and Sevoflurane when they are used as single induction and maintenance anaesthetic agent in adult day care tonsillectomies. Materials and methods: This was a randomized prospective study carried out after obtaining ethical committee and institutional approval. 60 patients were randomly allocated to either the Propofol or the Sevoflurane group by lots. Each group had 30 patients and was named 'P' for Propofol and 'S' for Sevoflurane. Their age ranged from 13 to 40 years. All the patients were assessed and those with normal clinical, biochemical, radiological and haematological parameters were selected. Results: Despite the low blood gas solubility of Sevoflurane, inhalation induction of anaesthesia was slower than intravenous induction with Propofol. Though the incidence of induction complications was more with Sevoflurane group, it did not compromise tracheal intubation or haemodynamics except for bradycardia observed in three patients. Equal incidence of apnoea in both groups is attributable to the enhancement of the ventilatory depressant effect of Propofol and Sevoflurane by the opioid Fentanyl. Shorter emergence time in the Sevoflurane group did not translate into a shorter hospital study. Increased incidence of PONV and pain did not affect the time for home readiness. Conclusion: Sevoflurane is found to be a useful alternative for elective procedures of short duration. [ABSTRACT FROM AUTHOR]

Thoracic endovascular aortic repair (TEVAR) of aortic aneurysms and dissections involving the arch has evolved over the last two decades. Compared to conventional surgical methods, endovascular repair offers a less invasive treatment option with lower risk and faster recovery. Endografts used in TEVAR vary in design depending on the procedure and application. Novel endografts (e.g., branched stent-graft) were developed to ensure perfusion of blood to the supra-aortic vessels, but their haemodynamic performance and long-term durability have not been adequately studied. This review focuses on the use of computational modelling to study haemodynamics in commercially available endografts designed for complex aortic arch repair. First, we summarise the currently adopted workflow for computational fluid dynamics (CFD) modelling, including geometry reconstruction, boundary conditions, flow models, and haemodynamic metrics of interest. This is followed by a review of recently (2010-present) published CFD studies on complex aortic arch repair, using both idealized and patient-specific models. Finally, we introduce some of the promising techniques that can be potentially applied to predict post-operative outcomes. [ABSTRACT FROM AUTHOR]

Background and Purpose: HERG blocking drugs known for their propensity to trigger Torsades de Pointes (TdP) were reported to induce a sympatho-vagal coactivation and to enhance High Frequency heart rate (HFHR) and QT oscillations (HFQT) in telemetric data. The present work aimed to characterize the underlying mechanism(s) leading to these autonomic changes.Experimental Approach: Effects of 15 torsadogenic hERG blocking drugs (astemizole, chlorpromazine, cisapride, droperidol, ibutilide, dofetilide, haloperidol, moxifloxacin, pimozide, quinidine, risperidone, sotalol, sertindole, terfenadine, and thioridazine) were assessed by telemetry in beagle dogs. Haemodynamic effects on diastolic and systolic arterial pressure were analysed from the first doses causing QTc prolongation and/or HFQT oscillations enhancement. Autonomic control changes were analysed using the high frequency autonomic modulation (HFAM) model.Key Results: Except for moxifloxacin and quinidine, all torsadogenic hERG blockers induced parasympathetic activation or sympatho-vagal coactivation combined with enhancement of HFQT oscillations. These autonomic effects result from reflex compensatory mechanisms in response to mild haemodynamic side effects. These haemodynamic mechanisms were characterized by transient HR acceleration during HF oscillations. A phenomenon of concealed QT prolongation was unmasked for several torsadogenic hERG blockers under β-adrenoceptor blockade with atenolol. Resulting enhancement of HFQT oscillations was shown to contribute directly to triggering dofetilide-induced ventricular arrhythmias.Conclusion and Implications: This work supports for the first time a contribution of haemodynamic side properties to ventricular arrhythmias triggered by torsadogenic hERG blocking drugs. These haemodynamic side effects may constitute a second component of their arrhythmic profile, acting as a trigger alongside their intrinsic arrhythmogenic electrophysiological properties. [ABSTRACT FROM AUTHOR]

Lippia alba (erva-cidreira) is often mentioned in Brazilian ethnopharmacological studies. Although its leaves have been used to treat hypertension, few studies have evaluated its hypotensive effects. This work aimed to evaluate the haemodynamic effects of Lippia alba methanolic extract and to characterise its chemical composition. Normotensive rats received an intravenous injection of L. alba extract. Systolic, diastolic, mean arterial pressures, and electrocardiographic data were analysed. 1 H-qNMR and LC-MS were used to assess the chemical composition. L. alba extract had significant hypotensive effects on systolic, diastolic, and mean arterial pressure. Acteoside was identified as major compound (292.6 ± 2.7 mg/g). Sixty-one other compounds were tentatively identified, mainly phenylethanoids, flavonoids, and iridoids. L. alba extract reduces systolic, diastolic, mean arterial pressure, and appears to be associated with a reduction in heart rate. Acteoside, a known hypotensive compound, may be responsible for these effects, but other structurally similar minority compounds may also contribute.

Background and Aims: The second-generation supraglottic airway device is conventionally inserted blindly, which might result in suboptimal placement. Limited literature exists on under-vision insertion techniques, particularly in paediatric patients. The primary objective of this study was to compare the oropharyngeal leak pressure (OPLP) between the blind insertion of the LMA Blockbuster ® and the Miller laryngoscope-guided insertion in children. Secondary outcomes included the number of insertion attempts, haemodynamic disturbances, insertion time and airway complications., Methods: This randomised controlled trial study enroled 100 patients aged 1-4 years undergoing elective surgery. Patients were randomised into blind insertion (Group A) or Miller laryngoscope-guided insertion (Group B) of the LMA Blockbuster ® . The primary outcome measure was OPLP. Insertion time, haemodynamic changes and postoperative complications were also assessed. The Chi-square, Fisher's exact and t -test were applied appropriately, with the significance level set at P < 0.05., Results: Significantly higher mean OPLP was observed in Group B compared to Group A - 27.9 [standard deviation (SD): 1.58] cmH 2 O versus 25.94 (SD: 0.63) cmH 2 O [mean difference (MD): 1.96 (95% confidence interval {CI}: 1.48, 2.44; P < 0.001)]. Mean insertion time was longer in Group B, that is, 11.9 (SD: 1.91) s versus 8.7 (SD: 0.6) s [MD: 3.2 s; (95% CI: 2.63, 3.76; P < 0.001)]; however, the difference was not clinically relevant. First-attempt insertion, haemodynamic stability and postoperative complications were comparable ( P > 0.05)., Conclusion: Miller laryngoscope-guided under-vision insertion of LMA Blockbuster ® improves alignment with epiglottic structures compared to blind insertion., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Indian Journal of Anaesthesia.)

Aims: Haemodynamic assessment can be determinant in phenotyping cardiogenic shock (CS) and guiding patient management. Aim of this study was to evaluate the correlation between echocardiographic and invasive assessment of haemodynamics in acute decompensated heart failure-related CS (ADHF-CS)., Methods and Results: All consecutive ADHF-CS patients (SCAI shock stage ≥B) undergoing right heart catheterization (RHC) between 2020 and 2022 were prospectively enrolled. Patients underwent echocardiography 30 min before RHC. The evaluated haemodynamic parameters and their echocardiographic estimates ('e') comprised cardiac index (CI), wedge pressure (WP), pulmonary artery pressures (PAP), cardiac power output (CPO) and pulmonary artery pulsatility index (PAPi). Hundred and one ADHF-CS patients (56 ± 11 years, 64% SCAI shock stage C, left ventricular ejection fraction 29 ± 5%) were included. Good correlation was found for CI, systolic PAP, RAP, and CPO (Pearson r > 0.8 for all), moderate correlation for ePAPi (r = 0.67) and PVR (r = 0.51), while estimation of WP was weak. The sensitivity and specificity of eCI to identify low output state (CI ≤2.2 L/min/m2) were 0.97 and 0.73, respectively, those of eWP for elevated filling pressures (WP >15 mmHg) were 0.84 and 0.55, those of ePAPs for PAPs ≥35 mmHg were 0.87 and 0.63, those of eCPO for CPO <0.6 W were 0.76 and 0.85, those of ePAPi for PAPi <1.85 were 0.89 and 0.92. Echocardiographic phenotyping of CS showed a good agreement with invasive classification (K value 0.457, P < 0.001)., Conclusion: Echocardiographic estimation of haemodynamics and subsequent phenotypization of CS is feasible with good agreement with invasive evaluation., Competing Interests: Conflict of interest: none declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)