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Cardiovascular, Hemodynamic, and Critical Care Considerations in the Patient With Necrotizing Enterocolitis
Published in David J. Hackam, Necrotizing Enterocolitis, 2021
Christine C. Pazandak, Zachary A. Vesoulis, Misty Good
Hypotension is a perplexing problem for neonatologists. Although the ideal treatment approach is still under debate, even the mere definition of hypotension is not well established. One of the earliest studies by Zubrow et al. suggested that a normal mean arterial blood pressure (MABP) in a preterm infant should be greater than or equal to the estimated gestational age (EGA) in weeks, an approach that has been widely accepted into daily practice (9, 10). However, this study used only noninvasive blood pressure measurements, taken over long intervals (9). Accordingly, low blood pressure by this definition does not necessarily translate into inadequate end-organ perfusion (11, 12). A later retrospective study by Dempsey et al. demonstrated that extremely low-birth-weight (ELBW) infants with permissive hypotension (by the Zubrow definition) in the first 24 hours of life with signs of adequate end-organ perfusion had similar outcomes to infants who were normotensive, calling into question this “rule of thumb” (13). As a result, there has been a shift toward a functional definition of hypotension encompassing low blood pressure measurements in addition to signs of inadequate end-organ perfusion (14–16). Using the outcome of intraventricular hemorrhage (IVH), Miall-Allen et al. provided evidence to support the practice of maintaining the MABP above 30 mmHg, as the risk of IVH increases subsequent to the length of time a MABP is spent below 30 mmHg (1).
Management of vascular complications during nonvascular operations
Published in Sachinder Singh Hans, Mark F. Conrad, Vascular and Endovascular Complications, 2021
Kush Sharma, M. Ashraf Mansour
Initial access to the abdomen with a needle (Veress) or trocar is usually blind, as the course of entry cannot be observed with the laparoscope. Safe and effective management of a major vessel injury starts with early recognition. The most likely signs of injury to a major vessel are immediate hemoperitoneum or poor visualization of the peritoneal cavity due to blood that cannot be attributed to bleeding from anterior abdominal wall.26 Hemodynamic changes from bleeding would first be seen in the form of sinus tachycardia. When bleeding is present, any degree of insufflation can result in a possible gas embolism.26 When this is suspected, the anesthesiologist should be alerted. It is possible with a venous injury that the gas used for insufflation gains access to the central circulation causing an “air lock” and preventing blood from circulating to the lungs.28 If this occurs, it can cause sudden severe hypotension. With “Durant's maneuver,” the patient is placed in the left lateral decubitus position in an attempt to displace the air bubble away from the pulmonary circulation.28
The patient with acute cardiovascular problems
Published in Peate Ian, Dutton Helen, Acute Nursing Care, 2020
Whilst many may respond to initial therapies, those with acute heart failure may need additional circulatory support, requiring transfer to a higher level of care. Where hypotension persists, organ damage can occur. In intensive care, vasoactive medication and or inotropic support can enhance both the circulation and organ perfusion. Intubation ventilation and renal replacement therapy may also be required.
How can we better manage hypotensive syndromes in older adults?
Published in Expert Review of Cardiovascular Therapy, 2022
Hypotensive syndromes should be considered in any elderly patient with falls, syncope, dizziness, or cardiac or cerebral ischemic symptoms. The evolving evidence points out that it is a cardiovascular risk factor. Both non-pharmacological and medication management can be considered in subjects with these syndromes. Nonpharmacologic treatment is always the first step in the management of these conditions. Most of the current medications used for hypotensive syndromes were evaluated in fewer clinical trials, and there is a need for high-quality large, randomized clinical studies for these medications. The predominant outcome measure used in these studies is related to BP values. Only few studies have used symptom or function improvement as an outcome measure. Long-term follow-up studies are lacking with the medications used to treat hypotensive syndromes. Future clinical trials are needed to better manage these conditions.
Lipid emulsion for the treatment of acute organophosphate poisoning: an Open-Label randomized trial
Published in Clinical Toxicology, 2022
Ashok Kumar Pannu, Sahil Garg, Ashish Bhalla, Deba Prasad Dhibar, Navneet Sharma
All study patients had ingestion of OP for self-harm. The OPs used were chlorpyrifos (n = 10), phorate (n = 7), dichlorvos (n = 3), triazophos (n = 1), and unidentified compounds (n = 24). Before arrival at our center, the median time elapsed was 8 h (IQR, 6.5–14; range, 2–48), and the majority (n = 24) admitted between 6–12 h of ingestion. 46.7% (n = 21) received a preliminary treatment at the previous health care center. All patients had a cholinergic crisis at presentation. Respiratory distress (n = 34, 75.6%), muscle fasciculation (n = 31, 68.9%), altered sensorium (n = 26, 57.8%) were common clinical manifestations. Hypotension was detected in 7 (15.6%) patients. According to the Peradeniya score, at-admission toxidrome severity was mild, moderate, and severe in 22.2%, 66.7%, and 11.1% cases.
Feasibility, Effectiveness and Safety of Prehospital Intravenous Bolus Dose Nitroglycerin in Patients with Acute Pulmonary Edema
Published in Prehospital Emergency Care, 2020
Casey Patrick, Brad Ward, Jordan Anderson, Kelly Rogers Keene, Elizabeth Adams, Rebecca E. Cash, Ashish R. Panchal, Robert Dickson
This study reports on the feasibility, effectiveness and safety of prehospital administration of IV NTG for treatment of CHF with APE. A 16% reduction in SBP was noted during EMS transport, which is well within accepted parameters for blood pressure control even in the setting of hypertensive emergency (17). Greater than 90% of all patients treated with IV nitroglycerin were correctly identified as decompensated CHF with APE based on the final ED diagnosis. The 2% rate of hypotension observed following treatment with bolus IV nitroglycerin is consistent with that seen in larger studies (7, 8, 18). The single occurrence of hypotension seen in this study resolved without additional treatment or significant clinical consequences. The results suggest that prehospital administration of high dose IV nitroglycerin may be both safe and effective in the prehospital setting of decompensated CHF with APE.