L'hypotension induite par la rachianesthésie lors des césariennes chez les patientes avec pré-éclampsie

Introduction. L'objectif de ce travail était d'étudier l'hypotension au cours de la rachianesthésie pour césarienne chez les patientes présentant une pré-éclampsie (groupe PE) en comparaison avec les patientes non pathologiques (groupe NPE). Patientes et Méthodes. Il s'agit d'une étude prospective et comparative sur six mois après approbation du comité d'éthique de notre établissement. Nous avons inclus les patientes opérées pour césariennes sous rachianesthésie. Le critère de regroupement était la présence ou non d'une pré-éclampsie. Les variables étudiées étaient l'hypotension, sa sévérité et les moyens thérapeutiques. L'analyse statistique a été réalisée avec le logiciel SPSS 20.0, en utilisant les tests de Student, de Man Withney et de Khi 2 avec un seuil de significativité de 0,05. Résultats. Nous avons colligé 113 patientes d'âge moyen de 28,19±6,42 ans, avec un terme moyen de grossesse de 38,41±2,83 semaines d'aménorrhées. Le taux d'hypotension induite était de 65,61% dans le groupe des patientes sans prééclampsie et de 34,67% chez les patientes pré-éclamptiques (p<0,001). Les besoins en éphédrine pour la correction de l'hypotension étaient de 3,45±3,15 mg pour le groupe NPE versus 8,98±4,40 mg pour le groupe PE, (p<0,001), le volume de sérum physiologique perfusé en remplissage vasculaire était de 870,55±181,33 ml (NPE) versus 635,12±99,98 ml (PE), (p<0,001). Conclusion. L'hypotension est moins fréquente et moins sévère chez la pré-éclamptique par apport à la non prééclamptique au cours de la rachianesthésie pour césarienne

Chá Verde Atenua a Hipotensão Induzida por Exercício: Um Estudo Randomizado, Placebo-Controlado / Green Tea Attenuates Hypotension Induced by Physical Exercise: A Randomized, Placebo Controlled Study

Fundamentos: Estudos mostram que a administração crônica de chá verde reduz a pressão arterial (PA) de repouso, enquanto que uma única sessão de exercício também promove redução da PA. Objetivo: Investigar se uma única dose de chá verde antes da sessão de exercício melhora a hipotensão pós exercício (HPE). Métodos: Estudo randomizado, placebo-controlado, duplo cego. Quinze pacientes hipertensos (53 ± 3,3 anos) participaram de duas sessões: chá verde + exercício (CVE) e placebo + exercício (PLE). Trinta minutos após ingestão de 2 g de chá verde ou placebo, os pacientes realizaram 60 minutos de caminhada na esteira a 60-85% da frequência cardíaca máxima. A PA foi medida em repouso e a cada 10 minutos após o exercício por 60 minutos. As amostras de sangue foram colhidas antes da ingestão do chá verde ou placebo e imediatamente após o exercício para determinar as concentrações de malondialdeído (MDA) e nitrito (NO). Resultados: No dia PLE, a HPE foi detectada em todos os tempos pós-exercício (redução na PA de 6,5 a 11,8 mmHg), enquanto que no dia CVE, HPE ocorreu somente aos 20 e 40 minutos pós-exercício, respectivamente. A redução na pressão sanguínea foi significativamente maior no PLE aos 10, 20 e 30 minutos pós-exercício em comparação a CVE. Além disso, CVE causou uma resposta diastólica hipertensiva, enquanto no dia PLE, a HPE diastólica foi observada somente aos 20 minutos pós-exercício. Não foram observadas mudanças nas concentrações de MDA ou NO em resposta ao exercício. Conclusão: A suplementação com chá verde anterior a uma sessão de exercício aeróbico atenuou a HPE sistólica e induziu uma resposta hipertensiva ao exercício aeróbico em pacientes hipertensos

Background: Studies have shown that chronic administration of green tea decreases blood pressure (BP) at rest, while a single exercise session also promotes reduction of BP. Objective: To investigate whether if a single dose of green tea prior to aerobic exercise session improves post-exercise hypotension (PEH). Methods: Randomized, double-blind, placebo controlled study. Fifteen hypertensive patients (53 ± 3.3 years) participated in two study sessions: green tea+exercise (GTE) and placebo+exercise (PLE). Thirty minutes after ingesting 2g of green tea or placebo, they performed 60 minutes of treadmill walking at 60 to 85% of maximum heart rate. BP was measured at rest and at every 10 minutes after exercise for 60 minutes. Blood samples were taken before ingestion of green tea or placebo and immediately after exercise to determine malondialdehyde (MDA) and nitrite (NO) concentrations. Results: On PLE day, systolic PEH was detected at all post-exercise time points (BP reduction by 6.5-11.8 mmHg), whereas on GTE day, PEH was found only at 20 and 40 minutes post-exercise (BP reduction by 5.9 and 5.8 mmHg, respectively). BP reduction was significantly higher in PLE at 10, 20 and 30 minutes post-exercise compared with GTE. In addition, GTE resulted in hypertensive diastolic response, while on PLE day, diastolic PEH was seen only at 20 minutes post-exercise. No changes in MDA or NO concentrations in response to exercise were observed. Conclusion: Green tea supplementation prior to an aerobic exercise session attenuated systolic PEH and induced diastolic hypertensive response to aerobic exercise in hypertensive patients

Conduct protocol in emergency: Acute adrenal insufficiency / Protocolo de condutas em emergência: insuficiência adrenal aguda

Summary Introduction: Acute adrenal insufficiency or addisonian crisis is a rare comorbidity in emergency; however, if not properly diagnosed and treated, it may progress unfavorably. Objective: To alert all health professionals about the diagnosis and correct treatment of this complication. Method: We performed an extensive search of the medical literature using specific search tools, retrieving 20 articles on the topic. Results: Addisonian crisis is a difficult diagnosis due to the unspecificity of its signs and symptoms. Nevertheless, it can be suspected in patients who enter the emergency room with complaints of abdominal pain, hypotension unresponsive to volume or vasopressor agents, clouding, and torpor. This situation may be associated with symptoms suggestive of chronic adrenal insufficiency such as hyperpigmentation, salt craving, and association with autoimmune diseases such as vitiligo and Hashimoto's thyroiditis. Hemodynamically stable patients may undergo more accurate diagnostic methods to confirm or rule out addisonian crisis. Delay to perform diagnostic tests should be avoided, in any circumstances, and unstable patients should be immediately medicated with intravenous glucocorticoid, even before confirmatory tests. Conclusion: Acute adrenal insufficiency is a severe disease that is difficult to diagnose. It should be part of the differential diagnosis in cases of hypotensive patient who is unresponsive to vasoactive agents. Therefore, whenever this complication is considered, health professionals should aim specifically at this pathology.

Resumo Introdução: a insuficiência adrenal aguda ou crise addisoniana é uma comorbidade rara na emergência; porém, se não diagnosticada e tratada de forma correta, pode evoluir de maneira desfavorável. Objetivo: alertar a todos os profissionais da saúde sobre o diagnóstico e tratamento corretos dessa complicação. Método: foi realizada uma ampla pesquisa na literatura médica, por meio de ferramentas específicas, sendo selecionados 20 artigos sobre o tema. Resultados: a crise addisoniana é de difícil diagnóstico pela inespecificidade de seus sinais e sintomas. No entanto, pode ser suspeitada em pacientes que chegam à emergência com queixa de dor abdominal, hipotensão não responsiva a volume ou a agentes vasopressores, obnubilação e torpor. Esse quadro pode vir associado a sintomas sugestivos de insuficiência adrenal crônica, como hiperpigmentação e avidez por sal, bem como a doenças autoimunes, como vitiligo e tireoidite de Hashimoto. Pacientes estáveis hemodinamicamente podem passar por métodos diagnósticos mais apurados para se confirmar ou descartar a crise addisoniana. Os exames diagnósticos não podem retardar, em hipótese alguma, o tratamento de pacientes instáveis, que deve ser iniciado imediatamente com glicocorticoide endovenoso, inclusive antes das provas confirmatórias. Conclusão: a insuficiência adrenal aguda é uma patologia grave e de difícil diagnóstico, que deve fazer parte do diagnóstico diferencial do médico ao atender um paciente hipotenso sem reposta à infusão de drogas vasoativas. Logo, na suspeita dessa complicação, o profissional não deve tardar a agir especificamente nessa patologia.

Conservative treatment of Angle Class III malocclusion with anterior crossbite

Angle Class III malocclusion is characterized by anteroposterior dental discrepancy which might be associated or not with skeletal changes. Class III molar relationship is associated with vertical or lingually tipped mandibular incisors and a usually concave profile. These characteristics seriously affect facial esthetics and most frequently are the reason why patients seek orthodontic treatment. This case was presented to the committee of the Brazilian Board of Orthodontics and Facial Orthopedics (BBO) as part of the requisites to become a BBO Diplomate.

A má oclusão de Classe III de Angle é caracterizada por uma discrepância dentária anteroposterior, que pode ou não estar acompanhada por alterações esqueléticas. Observa-se uma relação molar de Classe III associada ao posicionamento vertical ou retroinclinado dos incisivos inferiores e, geralmente, perfil facial côncavo. Esse aspecto gera grande comprometimento estético na face, sendo justamente esse o fator que, na maioria das vezes, motiva o paciente a procurar pelo tratamento ortodôntico. O presente caso clínico foi apresentado à Diretoria do Board Brasileiro de Ortodontia e Ortopedia Facial (BBO) como parte dos requisitos para a obtenção do título de Diplomado pelo BBO.

Eletroacupuntura para tratamento de hipotensão induzida por isofluorano em cavalos / Electroacupuncture treatment for isoflurane induced hypotension in horses

Objetivou-se avaliar a eficiência do tratamento da hipotensão arterial com eletroacupuntura comparativamente à dobutamina em equinos. Foram avaliados seis cavalos adultos, saudáveis, mantidos em anestesia inalatória, com isofluorano, em ventilação mecânica. Após a estabilização da anestesia, foi induzida hipotensão arterial, através do incremento da concentração do isofluorano, iniciando-se um dos tratamentos: DOB: dobutamina (1,5µg kg-1 min-1, infusão contínua intravenosa); EA: estímulo elétrico no acuponto pericárdio 6 (PC6), bilateralmente; SHAM: estímulo elétrico em ponto falso de acupuntura. Foram mensurados: frequência cardíaca (FC), pressão arterial média (PAM), temperatura retal (T), concentração final expirada de isofluorano (ETiso), variáveis hemogasométricas, concentração sérica de aspartato aminotransferase (AST) e creatina fosfoquinase (CK), tempo e qualidade da recuperação pós-anestésica. Houve incremento na PAM de 50%, 36,6% e 7,5% nos tratamentos DOB, EA e SHAM, respectivamente. Não houve diferença entre os grupos nas variáveis hemogasométricas, FC, T, ETiso, CK, AST, tempo e qualidade de recuperação pós-anestésica. Conclui-se que o tratamento com dobutamina foi mais efetivo para o tratamento da hipotensão em cavalos sob anestesia inalatória quando comparado ao estímulo elétrico do acuponto PC6 ou ponto falso de acupuntura...

This study aimed to evaluate the efficacy of electroacupuncture compared to the dobutamine treatment of hypotension in equines. Six adult horses were maintained in isoflurane anesthesia with mechanical ventilation. After anesthesia was established, the isoflurane concentration was raised until hypotension was achieved. After that the animals were treated with a constant rate of 1.5mg kg -1min-1 intravenous dobutamine (DOB), electroacupunture to pericardium 6 (PC-6) acupoint (EA) and false point treatment (SHAM). Heart rate (HH), median arterial blood pressure (MAP), rectal temperature (T), isoflurane end-tidal concentration, arterial blood gases, creatine kinase (CK), aspartate transaminase (AST), recovery time and quality of recovery were investigated. The MAP increased 50%, 36.5% and 7.5%% in DOB, EA and SHAM treatments, respectively. HH, T, arterial blood gases, CK, AST, recovery time and quality of recovery did not differ among treatments. It was concluded that the dobutamine treatment was more effective than EA and SHAM treatments for the reversion of isoflurane induced hypotension in horses...

Actualización del bundle de reanimación inicial y monitorización integral de la perfusión tisular en la sepsis severa / Initial resuscitation bundle and monitoring tissue perfusion in severe sepsis

Sepsis is a global health problem. Despite recent advances in understanding its pathophysiology and clinical trials testing potential new therapies, mortality remains unacceptably high. In fact, sepsis is the leading cause of death in non-coronary intensive care units around the world. However, during the past decade, some studies have highlighted that early recognition of sepsis and an appropriate initial approach are fundamental determinants of prognosis. A systematic approach to the harmful triad of sepsis-related hypotension, tissue hypoperfusion and organ dysfunction, with low-cost, easy to implement, and effective interventions, can significantly improve the chances of survival. In this article, we will update the evidence supporting the initial resuscitation bundle for patients with severe sepsis, and discuss the physiological basis for perfusion monitoring during septic shock resuscitation.

Manejo da hipotensão após raquianestesia em cesarianas / Management of hypotension after rachianestesia in cesarean sections

A hipotensão materna após raquianestesia em cesarianas é um evento extremamente frequente na prática anestésica em sala de parto. O manejo com vasopressores é a melhor conduta diante do quadro, sendo o uso da fenilefrina o mais seguro e eficaz. A resposta ao tratamento é mais bem avaliada através de parâmetros clínicos não-invasivos.

Maternal hypotension after spinal anesthesia for cesarian sections is an extremely common event in anesthesia delivery room. The treatment with vasopressors is the better behavior in the case, with the use of phenylephrine as safe and effective. The response to treatment is best assessed by non-invasive clinical parameters.

Eficacia comparativa de la atropina, dosis distintas, en el control de bradicardia e hipotensión durante la anestesia. 2008-2009 / Comparative efficacy of atropine, different doses, in the control of bradycardia e hipotension during anesthesia. 2008-2009

Objetivo: Determinar si el uso de atropina pre-medicada a dosis de 0,005 mg/kg, es más eficaz en el control de Frecuencia Cardiaca (FC) y Presión Arterial Media (PAM), que el uso a dosis de 0,01 mg/kg, durante la anestesia. Material y métodos: Se realizó estudio experimental, tipo ensayo clínico controlado, ciego, con asignación aleatoria. Se incluyeron 260 pacientes entre 18 y 85 años, divididos en dos grupos comparables en edad, riesgo anestésico y distintas técnicas anestésicas, grupo 1(n=130) estudio y grupo 2 (n=130) control. Resultados: La edad media estudiada fue 48,91 ±19,18 años. La FC media basal en grupo estudio fue 84,02±17.13 latidos/minuto y control 74,73± 13,27 latidos/minuto (p<0.05); después de atropina, 84.36 ±20.2 y 77.42 ±11.3 latidos/minuto respectivamente, (p<0.05).El análisis del comportamiento de FC y PAM intraoperatoria Grupo estudio: 9 pacientes (6,92%) bradicardia (< de 60 latidos /minuto) y PAM normal, 8 (6,15%) taquicardia y PAM normal y en 113 (86,92 %) la PAM y la FC normales. Control: 2 (1. 53%) bradicardia e hipotensión, 1 (0,76%) taquicardia y PAM normal y 127 (97,69%) frecuencia cardiaca y PAM normales. Se encontró correlación Pearson entre dosis atropina y FC intra-operatoria, inversa -0,104 y significación 0,095. P> 0,01n.s. dosis y PAM valor 0,217 y significación 0,000. (p<0.01). Conclusión: La administración de una dosis terapéutica de atropina 0,01 mg/kg, y 0,005 mg/kg mantiene la FC y PAM intra-operatoria dentro de rangos de normalidad en pacientes ASA I y ASA II, para anestesia quirúrgica según resultados. (AU)

Objective: To determine if the use of atropine pre-medicated at dose of 0.005 mg/kg, is more effective in the control of cardiac frequency and blood pressure, that the use at doses of 0.01 mg/kg during anesthesia. Material and methods: It was realized a experimental, type clinical test controlled, blind, with random assignment . 260 Patients were included between 18 to 85 years, divided into two groups were comparable inage, anesthetic risk and different anaesthetic techniques, group 1(n=130), study and group 2 (n = 130) control. Results: The average age studied was 48.91 ±19.18 years.The Average basal FC in study group was 84. 02±17.13 beats/minute and control 74. 73± 1327 beats/minute (p < 0.05); After atropine, 84.36 ±20.2 and 77.42 ±11.3 beats/minute respectively (p < 0.05). The analysis of the behavior of FCand intraoperative PAM Group study: 9 (6. 92%) bradycardia patients (< of 60 beats minute) and normal PAM, 8 (6. 15%) tachycardia and PAM normal and 113 (86. 92%) normal the PAM and the FC. Control: 2 (1. 53%) bradycardia and hypotension, 1 (0. 76 percent) tachycardia and normal PAM and 127 (97. 69%) frequency cardiac normal and PAM. It was found Pearson correlation between dose atropine and FC intraoperative , reverse -0.104 and significance 0.095 . P > 0. 01n. s. dose and PAM value 0. 217 and significance 0000. (p < 0.01). Conclusion: The administration of a therapeutic dose of atropine 0.01 mg/kg, and 0.005 mg/kg keeps the FC and intraoperative PAM with in ranges of normality in ASA I and II ASA, patients for surgical anesthesia according to results. (AU)

Perioperative hypotension and myocardial ischemia: Diagnostic and therapeutic approaches.

Although perioperative hypotension is a common problem, its true incidence is largely unknown. There is evidence that postoperative outcome, including the incidence of myocardial adverse events, may be linked to the prolonged episodes of perioperative hypotension. Despite this, there are very few comprehensive resources available in the literature regarding diagnosis and management of these not so uncommon clinical occurrences, especially during non-cardiac surgery. Most anesthesia providers consider intraoperative hypotension to be caused by systemic vasodilatation and relative hypovolemia and so treat it empirically. The introduction of new monitoring devices including transesophageal echocardiography and arterial pressure waveform based stroke volume measurement have provided additional tools to narrow the differential diagnoses and initiate optimal treatment measures. Understanding the basic pathophysiology of hypotension and myocardial ischemia can further assist in providing goal directed management. This article serves as a comprehensive guide for anesthesiologists to diagnose and treat hypotension and myocardial ischemia. A summary of available techniques to monitor perioperative myocardial ischemia and their limitations are also discussed.

Segundo Consenso Clínico de la Sociedad Iberoamericana de Neonatología: manejo hemodinámico del recién nacido / Second Clinical Consensus of the Ibero-American Society of Neonatology: hemodynamic management of newborns

Este trabajo informa acerca del proceso y los resultados del Segundo Consenso Clínico de la SIBEN (Sociedad Iberoamericana de Neonatología), en el cual 80 neonatólogos de 23 países fueron invitados a participar y colaborar. Se desarrollaron varias preguntas de importancia clínico-fisiológica sobre el manejo hemodinámico del recién nacido. Los participantes fueron distribuidos en grupos, facilitando así la interacción y el trabajo conjunto, con la consigna de responder de tres a cinco preguntas mediante el análisis de bibliografía y factores locales. El Grupo de Consenso se reunió en Mar del Plata, Argentina, donde se llevaron a cabo diversas ponencias, debates y presentaciones. En total participaron 54 neonatólogos de 21 países, con el objetivo de desarrollar un consenso sobre aspectos que incluyeron conceptos y definiciones de inestabilidad hemodinámica, la fisiopatología del cuadro de compromiso hemodinámico, las estrategias terapéuticas recomendadas y el monitoreo hemodinámico. Se espera que esta experiencia internacional sirva como una iniciativa útil tanto para la búsqueda de futuros consensos como para reducir las disparidades existentes entre los tratamientos y resultados de los diferentes países de la Región.

This study reports on the process and results of the Second Clinical Consensus of the Ibero-American Society of Neonatology. Eighty neonatologists from 23 countries were invited to collaborate and participate in the event. Several questions of clinical-physiological importance in the hemodynamic management of newborns were addressed. Participants were divided into groups to facilitate interaction and teamwork, with instructions to respond to three to five questions by analyzing the literature and local factors. Meeting in Mar del Plata, Argentina, the Consensus Group served as a form for various presentations and discussions. In all, 54 neonatologists from 21 countries attended, with the objective of reaching a consensus on such matters as concepts and definitions of hemodynamic instability, the physiopathology of hemodynamic compromise, recommended therapy strategies, and hemodynamic monitoring. It is hoped that this international experience will serve as a useful initiative for future consensus building and reduction of the existing disparities among the countries of the Region in terms of treatment and outcomes.

Patent ductus arteriosus ligation and post-operative hemodynamic instability: Case report and framework for enhanced neonatal care.

Ligation of a patent ductus arteriosus can lead to severe cardiorespiratory compromise in preterm infants. This report reviews the postoperative course of a patient with significant cardiorespiratory instability following surgical ligation of the patent ductus arteriosus and presents a framework for enhanced cardiovascular care in this population. A preterm infant, born at 24 wk gestation underwent ligation of a large haemodynamically significant ductus arteriosus after failure of 2 courses of indomethacin. He developed systemic hypotension, which was aggressively treated with high doses of multiple cardiotropic agents. After 10 hr of refractory hypotension, the addition of hydrocortisone normalized blood pressure. This article outlines preprocedural categorization of infants according to ductal illness severity which facilitates the risk assignment for postoperative deterioration, development of clinical guidelines specific to the likely haemodynamic changes, enhanced role of functional echocardiography for guiding therapy, and interprofessional education.

O efeito da natação e da hidroginástica sobre a pressão arterial pós-exercício de mulheres normotensas / The effect of swimming and water aerobics on post exxercise blood pressure of normotensive women

O decréscimo da pressão arterial (PA) para valores inferiores aos de repouso pré-exercício após uma sessão de exercício dinâmico foi denominado hipotensão pós-exercício. A prática de exercícios que induzam este fenômeno tem sido sugerida para prevenção e tratamento não medicamentoso da hipertensão arterial. O objetivo deste estudo foi analisar respostas da PA de jovens normotensas após uma sessão de natação, estilo crawl, bem como após uma sessão de hidroginástica. Participaram do estudo 10 mulheres fisicamente ativas e sem complicações cardiovasculares (26,6 +-2,91 anos; 21,95 +- 5,07% gordura), que realizaram 3 sessões experimentais em ordem aleatória 1) sessão de natação com duração de 20 minutos a 70% da FCres 2) sessão de hidroginástica com duração de 20 minutos a 70% da FCres 3) sessão controle. PA e freqüência cardíaca foram mensuradas durante 20 minutos pré-sessão e a cada 15 minutos durante 1 hora após as sessões. Foi empregada ANOVA para medidas repetidas para análise dos dados. Houve redução da pressão arterial sistólica (PAS) de 4,7mmHg após a natação e de 5,6mmHg após a hidroginástica aos 45 minutos de recuperação (p<0,05), mas não houve queda da pressão arterial diastólica (PAD). Ocorreu aumento da PAS e PAD no 15º minuto após a sessão de natação (p<0,05). Ambas modalidades induziram queda de PAS, entretanto, a natação gerou maior sobrecarga cardiovascular. Desta forma, caso o objetivo seja proteção cardiovascular, a hidroginástica pode ser preferível para a população estudada.

The decrease in blood pressure (BP) to below pre-exercise resting values after a session of dynamic exercise was named post-exercise hypotension, and the practice of exercises that evoke this phenomena has been suggested for prevention and treatment of hypertension. This study analyzed the responses of normotensive women blood pressure after a session of swimming, crawl style, and after a session of water aerobics. 10 physically active women with no cardiovascular complications participated in the study (26.6 +-2.91 years, 21.95 +-5.07% body fat), who underwent 3 experimental sessions in randomized order 1) 20 minutes of swimming session at 70% of HRres 2) 20 minutes of water aerobics session at 70% of HRres 3) control session. BP and heart rate were measured during 20 minutes pre-session, and each 15 minutes during 1 hour after the sessions. Repeated measures ANOVA was adopted for data analysis. Reduction of 4,7mmHg and 5,6mmHg on systolic blood pressure (SBP) was observed after swimming and water aerobics respectively (p<0,05) at 45 minutes of recovery, but no decrease in diastolic blood pressure (DBP) was found. There was an increase in SBP and DBP at 15 minutes after the swimming session (p<0.05). Conclusion: Both methods produced post exercise hypotension of SBP, however, the swimming session evoked a greater cardiovascular overload. Thus, if the aim is cardiovascular protection, the water aerobics may be preferable for the population studied.

Hipotensión arterial en la cesárea con anestesia espinal: revisión del tema / Arterial hypertension in cesarean section with spinal anaesthesia: topic review

La cesárea es quizás la cirugía más frecuentemente realizada en cualquier ambiente hospitalario que cuente con asistencia materna. La anestesia regional no solamente es la indicación inicial sino que es mandatoria por sus ventajas para la madre y el feto. El efecto adverso más apreciado de esta técnica lo constituye la hipotensión arterial, su frecuente ocurrencia y rápido comienzo durante la anestesia espinal han estimulado a los anestesistas a tratarla y prevenirla. Por tal motivo presentamos esta revisión que incluye fisiopatología, efectos sobre el feto, principales medicamentos y vías que se usan actualmente para su profilaxis y tratamiento.

Maybe cesarean section is the most frequent surgery done in every hospital environment that practice maternity assistance.The regional anaesthesia is not only the initial indication but also compulsory becuase of its advantages for the mother and the foetus. The most frequent adverse effect of this technique is the arterial hypertension, its frequent occurrence and its rapid begining during the the spinal anaesthesia which have encourage the anaesthetists to treat it and prevent it. That´s why we present this revision that includes pathophysiology, effects on the foetus, main medicaments and routes that are used today to its prophylaxis and treatment.

Extremes of hyper and hypotensions in pheochromocytoma-a perioperative management

We report a case of 30 years old female who presented with history of frequent headaches, palpitation, sweating along with mass abdomen. Hypertension was accelerated as ECG reflected sinus rhythm with left ventricular hypertrophy and no papilloedema. Ultrasound abdomen revealed right sided, well defined solid mass posterolateral to the inferior vena cava. Urine analysis revealed raised metabolite vanillylmandalic acid. Patient was diagnosed as a case of pheochrojnocytoma of the right suprarenal gland. After control of blood pressure, laparotomy under general anaesthesia was performed. A big tumour was excised. Histopathology confirmed the diagnosis of pheochromocytoma

Acute normovolemic hemodilution versus controlled hypotensive anesthesia in major orthopedic surgery

The purpose of this study was to investigate the efficacy and safety of controlled hypotension versus ANH as blood conservation methods during major orthopedic surgery. Forty patients, assigned to receive either ANH [HT= 30%] or controlled hypotension. General anesthesia was induced by fentanyl 2micro gm/kg intravenously, thiopental Na 5mg/kg intravenously and atracurim 0.5mg/kg. After induction of anesthesia but before surgery, the patients were classified into two groups according to the technique of blood conservation used: group I [20 patients] acute normovolemic hemodilution. The volume of blood withdrawn has been replaced simultaneously by infusion of identical volume of hydroxyethyl starch 6% in order to maintain normovolemia. Group II [20patients]: controlled hypotensive anesthesia. A mean of 1000 ml blood was predonated [20% of the total blood volume] in hemodilutio group. Blood loss was, significantly higher in ANH group. The total loss was 1500mL [ANH] vs. 1200 mL [in hypotensive group], [p < 0.05]. The average amount of blood transfusion was 262.5 ml [ANH group] vs. 187.5 ml [hypotensive group]. 50% went through surgery without receiving blood [ANH] vs. 60% [hypotensive group]. No renal, neurological or cardiopulmonary complications were registered. Also there was slight but significant metabolic acidosis. The acidosis was metabolic in origin because PaCO2 was kept constant and [Bic] and [BE] decreased significantly and it was not lactic acidosis as serum lactate remains within normal limit. It is considered as hyperchloermic metabolic acidosis as serum chloride significantly increased. Both ANH and hypotensive anesthesia can be used safely in patients undergo major orthopedic surgery however, Deliberate hypotension was the most effective means of reducing intraoperative bleeding and the time for this procedure was shorter than for normovolaemic haemodilution combined with autotransfusion. Also there was slight but significant metabolic acidosis

Management of low systemic vascular resistance hypotension following CPB. a comparative study between low dose vasopressin and norepinephrine

Post-cardiopulmonary bypass [CPB] low systemic vascular resistance [SVR] hypotension is attributed mainly to CPB activated systemic inflammatory response together with long CPB duration, long-term preoperative use angiotensin-converting enzyme [ACE] inhibitors or beta blockers, and inappropriate low vasopressin secretion. Vasopressin is a potent vasoconstrictor in various hypotensive states including post CPB vasodilatation. The aim of the present study was to compare the effects of low dose vasopressin infusion with norepinephrine on systemic hemodynamics, myocardial performance, internal mammary artery [IMA] graft blood flow, renal function, and clinical outcome. In patients undergoing elective on-pump coronary artery bypass grafting [CABG], hemodynamic variables were measured after weaning from CPB, and patients who had SVR < 800 dyne.s.cm-5, and systolic systemic blood pressure [SBP] < 80 mmHg or mean systemic blood pressure [MAP] < 60 mmHg despite proper volume resuscitation were enrolled in the study and were randomly allocated into 2 groups with 15 patients in each group. These patients received either vasopressin at 0.01-0.1 U/min [VP group], or norepinephrine at 0.01-0.2 microg/kg/min [NE group] to maintain MAP >70 mmHg. Hemodynamic variables were measured before; 1, 4, and 12 hours after the start of study drugs. Blood flow through IMA graft was measured before and 1 hour after infusion of the study drugs. Creatine kinase MB [CK-MB] serum concentrations were obtained immediately after surgery and at 24 hours and 48 hours postoperatively. Arterial lactate concentrations were measured before and at 1, and 4 hours after the start of study drugs. Serum creatinine was measured before and 24 hours and 48 hours after the start of the study drugs. Urine output was measured before and 4 hours after the start of the study drugs. The duration of vasopressor infusion and complications such as stroke or tachyarrhythmias were recorded. Extubation times, intensive care unit [ICU] and hospital length of stay were also recorded. Vasopressin compared to norepinephrine caused a significant increase in Cl, LVSWI, and postoperative urine output together with significant decrease in HR, postoperative CK-MB, duration of vasopressor infusion, and shorter extubation time. Both drugs resulted in a significant increase in MAP and SVR, a significant decrease in arterial lactate, together with non significant change-in IMA blood flow, postoperative serum creatinine, ICU and hospital length of stay, and the incidence of postoperative complications. low dose vasopressin infusion was found to be a valuable alternative to norepinephrine in management of low SVR hypotension after CPB

[ evaluation of frequency of hypotention in normal vaginal delivery with epidural anesthesia in Beheshti and Jorjani hospitals of Isfahan 2003]

Delivery pain is one of the most severe known pains that can be considered a critical experience in lifelong for every woman .Different methods has been introduced for reducing delivery pain such as non pharmacological methods [hypnotism, Acupuncture] and pharmacological methods [systemic drugs, inhalant anesthetics regional anesthesia]. Now, the most popular methods for pain relief in labor is regional anesthesia. The most common techniques are spinal, epidural, para cervical and pudendal anesthesia. The most effective ways for pain relief in labor is spinal and epidural block that Produces a complete pain relief in most women. The purpose of this study is determining the distribution of hypotention as a most common complication of epidural anesthesia in vaginal delivery that can lead to fetal distress and low APGAR score and cesarean section. This is a cross sectional [descriptive-analytic] study and 137 cases were studied. Most of them were 21-30 years old. This study was approved by the local committee of medical ethics. Gestational age was 37-42 weeks .This study was established in fall and winter of year 2003 at Beheshti and Jorjani hospitals. All of them were at the same conditions and all epidural blocks were done with the same anesthesiologist. The data analysis of all cases showed that the distribution of hypotention was 16.1%. Distribution of vertigo was 20.4% .The neonatal APGAR score of those mothers who had hypotention during delivery was [8 +/- 1.23] while APGAR score of those ones who didn't have hypotention was 9 or more [P<0.001]. Hypotension is a common side effect of epidural anesthesia and it can cause fetal distress and low APGAR score, but with infusion 500-1000 CC ringer lactate boxter before anesthesia, can reduce rate of hypotension, prevent hypoxia side effects and low score of APGAR. Of curse 1 degree reduction in APGAR score may be resulted from length of stage II of labor. So epidural anesthesia can be considered as a reliable and safe method for advertising vaginal delivery and reducing the number of unnecessary cesarean section

Comparison of colloid versus crystalloid preload for prevention of hypotension during spinal anesthesia for elective cesarean section in women with positive supine stress test

If parturient prone to develop caval compression in the supine position were identified before delivery; this might be a method of predicting hypotension during cesarean section under spinal anesthesia. Colloid preloading is thought to be superior to crystalloid in reducing the risk for spinal anesthetic induced hypotension. It is postulated that parturients preoperalively susceptible to the supine position would benefit the most from colloid preloading. The aim of this study is to compare colloid versus crystalloid preload for prevenilon of hypotension during spinal anesthesia for elective cesarean section in women with positive supine stress test [SST]. Forty healthy women, with term singleton normal pregnandes presenling for elective cesarean section under spinal anesthesia were included in the study. All patients were positivefir supine stress test [SST], they were divided into 2 equal groups [20 palients each], crystalloid preload group [group I] and colloid preload group [group II]. IViaternal hypotension, nausea, vomiting or dizziness and ephedrine requirements were recorded during the study. Induction-to-uterotomy interval, uterotomy-to-delivery interval and inlraoperative blood loss, were also recorded. Moreover, Apgar score and umbilical artery add-base status at delivery were measured. Our results showed that in patients received crystalloid preload [group I] the frequendes of occurrence of decreased systolic blood pressure below 100 mmHg or 20% from baseline, occurrence of vomiting, nausea or dizziness were 14[70%], 7[35%], 9[45%], and 7[35%], respectively, while, in palients received colloid preload [group II] were 6[30%], 1[5%], 2[10%], and 1[5%], respectively. So, patients received crystalloid preload showed a higher frequency of hypotension, vomiting, nausea and dizziness compared to colloid group [P<0.05], and also a greater need for ephedrine, mean[+SD] was 21[11.4] in group I compared to 7.25.3]mg in group II[P<0.05]. Pregnant women with a positive preoperative supine stress test constitute a subset at increased risk for clinically significant hypotension during cesarean delivery under spinal anesthesia. These women seem more likely to benefit from prophylaclic colloid solution preload