Cardiovascular, Hemodynamic, and Critical Care Considerations in the Patient With Necrotizing Enterocolitis
David J. Hackam in Necrotizing Enterocolitis, 2021
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).
Therapy of acute myocardial infarction
Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich in Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
Early administration of an ACEI to acute MI patients has been evaluated in several large trials. The first of these, the second Cooperative New Scandinavian Enalapril Survival Study (CONSENSUS-2), was discontinued after 6000 patients were enrolled due to a higher frequency of adverse outcomes in patients receiving IV enalapril (97). Moreover, patients over 70 years of age experienced an increased incidence of serious hypotension. In contrast, the third Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI-3) and ISIS-4 trials reported small but statistically significant reductions in mortality in patients receiving oral captopril or lisinopril within 24 hours of MI onset (98,99). In addition, patients 70 years or older treated with lisinopril in GISSI-3 experienced a 14% reduction in the combined endpoint of death or severe left ventricular dysfunction at 6-month follow-up (p = 0.01) (100). The Survival of Myocardial Infarction Long-term Evaluation (SMILE) investigators randomized 1556 patients with anterior MI who were not candidates for fibrinolytic therapy to either the ACEI zofenopril or placebo within the first 24 hours after symptom onset (101). The incidence of death or severe HF at 6-week follow-up was reduced 34% by zofenopril, and this benefit was maintained for one year. Moreover, the absolute benefit was threefold greater in individuals over 65 years of age compared with younger patients.
Acute disorders of the respiratory tract
Janet M Rennie, Giles S Kendall in A Manual of Neonatal Intensive Care, 2013
In ill babies, blood pressure (BP) is most easily and safely monitored with a direct recording of arterial BP from an indwelling cannula. Normal values are given in Appendix 3. Babies with severe RDS are often hypotensive in the first few hours of life. In some cases the hypotension is due to hypovolaemia, in others it is due to depression of cardiac and vascular function by severe metabolic disturbance and hypoxaemia. Whatever the cause, hypotension must be corrected as a matter of urgency in sick infants, particularly if there is reduced capillary filling, raised lactate and oliguria. There is no universally agreed definition of neonatal hypotension, which in any case relates to gestational age. A good general rule is to aim to keep the mean BP above the baby’s gestational age in weeks, with the systolic pressure being at least 10 mmHg higher than this. If the hypotensive baby’s PCV is less than 40%, he should be given a blood transfusion; but if his haematocrit is at least 45%, normal saline (0.9%) should be used, otherwise polycythaemia may develop.
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.
Home blood pressure monitoring to improve hypertension control: a narrative review of international guideline recommendations
Published in Blood Pressure, 2021
John Andraos, Luma Munjy, Michael S. Kelly
Recommendations with the greatest disagreement were related to guidance on timing of evening BP measurements. Among the guidelines reviewed, three offered no recommendation regarding evening BP measurements with regard to meals [6,7,14], three recommend measuring before the evening meal [8,16,17], three recommend measuring before bedtime [5,12,13], and one guideline specifies measuring evening 2-hours after the evening meal [11]. Postprandial hypotension, defined as a reduction in SBP of 20 mmHg or more within 2 h of a meal, is common in elderly patients and may or may not be symptomatic [22]. To minimise the postprandial hypotension, which may produce artificially low evening BP values, evening BP should be measured before meals, or at least 2-hours after. When interpreting home BP readings, the average SBP and DBP should be used to assess BP control, rather than assessing the proportion of days controlled. Consistent among all included guidelines was an average home BP of 135/85 mmHg or higher corresponded to an office-measured BP of 140/90 mmHg or more, and should prompt treatment intensification. While most guidelines (6 out of 11) recommend routine calibration of home BP monitors against office-BP, specific details regarding when and how often this should be done are lacking. At a minimum, annual evaluation of patients’ HBPM technique and the accuracy of their HBPM seems appropriate.