Effect of remimazolam vs. propofol on hemodynamics during general anesthesia induction in elderly patients: Single-center, randomized controlled trial

The current study aimed to compare the effects between remimazolam and propofol on hemodynamic stability during the induction of general anesthesia in elderly patients.We used propofol at a rate of 60 mg/(kg·h)in the propofol group(group P)or remimazolam at a rate of 6 mg/(kg·h)in the remimazolam group(group R)for the induction.A processed electroencephalogram was used to determine whether the induction was successful and when to stop the infusion of the study drug.We measured when patients entered the operating room(T_(0)),when the induction was successful(T_(1)),and when before(T_(2))and 5 min after successful endotracheal intubation(T_(3)).We found that mean arterial pressure(MAP)was lower at T_(1–3),compared with T_(0) in both groups,but higher at T_(2) in the group R,whileΔMAP_(T0–T2) andΔMAP_(max) were smaller in the group R(ΔMAP_(T0–T2):the difference between MAP at time point T_(0) and T_(2),ΔMAP_(max):the difference between MAP at time point T_(0) and the lowest value from T_(0) to T_(3)).Cardiac index and stroke volume index did not differ between groups,whereas systemic vascular resistance index was higher at T_(1–3) in the group R.These findings show that remimazolam,compared with propofol,better maintains hemodynamic stability during the induction,which may be attributed to its ability to better maintain systemic vascular resistance levels.

Oral blood pressure augmenting agents for intravenous vasopressor weaning

Intravenous(IV)vasopressors are essential in the management of hypotension and shock.Initiation of oral vasoactive agents to facilitate weaning of IV vasopressors to liberate patients from the intensive care unit is common despite conflicting evidence regarding the benefits of this practice.While midodrine appears to be the most frequently studied oral vasoactive agent for this purpose,its adverse effect profile may preclude its use in certain populations.In addition,some patients may require persistent use of IV vasopressors for hypotension refractory to midodrine.The use of additional and alternative oral vasoactive agents bearing different mechanisms of action is emerging.This article provides a comprehensive review of the pharmacology,clinical uses,dosing strategies,and safety considerations of oral vasoactive agents and their application in the inten-sive care setting.

Addison's disease caused by adrenal tuberculosis may lead to misdiagnosis of major depressive disorder: A case report

BACKGROUND Addison’s disease(AD)is a rare but potentially fatal disease in Western countries,which can easily be misdiagnosed at an early stage.Severe adrenal tuberculosis(TB)may lead to depression in patients.CASE SUMMARY We report a case of primary adrenal insufficiency secondary to adrenal TB with TB in the lungs and skin in a 48-year-old woman.The patient was misdiagnosed with depression because of her depressed mood.She had hyperpigmentation of the skin,nails,mouth,and lips.The final diagnosis was adrenal TB that resulted in the insufficient secretion of adrenocortical hormone.Adrenocortical hormone test,skin biopsy,T cell spot test of TB,and adrenal computed tomography scan were used to confirm the diagnosis.The patient’s condition improved after hormone replacement therapy and TB treatment.CONCLUSION Given the current status of TB in high-burden countries,outpatient doctors should be aware of and pay attention to TB and understand the early symptoms of AD.

Risk factors associated with intraoperative persistent hypotension in pancreaticoduodenectomy

BACKGROUND Intraoperative persistent hypotension(IPH)during pancreaticoduodenectomy(PD)is linked to adverse postoperative outcomes,yet its risk factors remain unclear.AIM To clarify the risk factors associated with IPH during PD,ensuring patient safety in the perioperative period.METHODS A retrospective analysis of patient records from January 2018 to December 2022 at the First Affiliated Hospital of Nanjing Medical University identified factors associated with IPH in PD.These factors included age,gender,body mass index,American Society of Anesthesiologists classification,comorbidities,medication history,operation duration,fluid balance,blood loss,urine output,and blood gas parameters.IPH was defined as sustained mean arterial pressure<65 mmHg,requiring prolonged deoxyepinephrine infusion for>30 min despite additional deoxyepinephrine and fluid treatments.RESULTS Among 1596 PD patients,661(41.42%)experienced IPH.Multivariate logistic regression identified key risk factors:increased age[odds ratio(OR):1.20 per decade,95%confidence interval(CI):1.08-1.33](P<0.001),longer surgery duration(OR:1.15 per additional hour,95%CI:1.05-1.26)(P<0.01),and greater blood loss(OR:1.18 per 250-mL increment,95%CI:1.06-1.32)(P<0.01).A novel finding was the association of arterial blood Ca^(2+)<1.05 mmol/L with IPH(OR:2.03,95%CI:1.65-2.50)(P<0.001).CONCLUSION IPH during PD is independently associated with older age,prolonged surgery,increased blood loss,and lower plasma Ca^(2+).

Orthostatic Hypotension: QTc Interval Prolongation during Head-Up Tilt

Background: The QT interval shortens in response to sympathetic stimulation. Head-up tilt-table (HUT) testing is a straightforward way to achieve brisk sympathetic stimulation. There is not enough information about the response of the QT interval to HUT, particularly, in patients with orthostatic hypotension (OH). Objective: Analyse the response of the RR, QT and QTc intervals in patients with OH and reflex syncope (NM) during HUT and find differences between groups. Methods: We reviewed the electrocardiograms and compare the RR and QT/QTc intervals during 1) baseline;2) HUT plus hyperventilation;3) positive test. Results: We studied 137 patients, 62 control group (no syncope and negative HUT). On average, the RR HUT interval was shorter than the resting RR by −171 ± 110.4 ms in controls;−228.6 ± 119.4 ms (NM) and −194 ± (OH) (P Conclusion: Significant differences between the reflex group and the OH during a positive test, the QTc decreased in the NM group, but in the OH population increased. This observation has not been described. We hypothesize that QTc prolongation could reflect autonomic nervous system downregulation and could explain to a degree, the increased mortality in this group.

Effect Study of the Recombinant Human Brain Natriuretic Peptide in Patients with Heart Failure Combined with Hypotension

Objective: This paper aims to investigate the effect of applying recombinant human brain natriuretic peptide in patients with heart failure combined with hypotension. Recombinant human brain natriuretic peptide is a synthetic polypeptide drug that is primarily used to treat acute heart failure. Its mechanism of action closely mimics that of human endogenous brain natriuretic peptide. By binding to receptors on cardiomyocytes, it exerts its pharmacological effects. Methods: For the study, 76 heart failure patients with hypotension were selected from our hospital between May 2022 and June 2023. These patients were divided into two groups: a control group and an observation group, each comprising 38 patients. The control group received dopamine treatment, while the observation group was treated with recombinant brain natriuretic peptide. The objective was to compare the effects of the treatments in both groups by analyzing cardiac function indices and levels of vasoactive substances to identify any significant differences in outcomes. Results: The overall response rate of the patients in the observation group and the control group was 94.74% and 73.68%, significantly higher as compared with the observation group (P 0.05). After the following treatment, BNP, ANNP and urine output in the observation group were significantly different compared with the control group, of the statistical significance (P Conclusion: For the treatment of heart failure patients with hypotension, the clinical application of recombinant human brain natriuretic peptide is the most ideal, and significantly improves the cardiac function of patients, which is worth popularizing.

A Case Report of Recurrent Guillain-Barré Syndrome with Orthostatic Hypotension Syncope as the First Symptom

Guillain⁃Barré syndrome (GBS) is an immune-mediated peripheral neuropathy with acute or subacute onset of flaccid paralysis of the limbs with symmetrical hypesthesia and autonomic nerve involvement [1]. The clinical manifestations of autonomic nerve damage are complex and varied, which may involve extensive or limited autonomic function damage, including abnormalities of the skin, pupil, urinary tract, gastrointestinal tract, cardiovascular system, body temperature, lacrimal and salivary glands, and sexual function, etc. [2], and some patients may even have autonomic nerve damage as the only symptom, which is a variant of GBS and is prone to misdiagnosis or underdiagnosis. Recurrence of GBS is rare, and the manifestations of recurrence are often similar to those of the first symptoms [3], but the patient admitted to our hospital had syncope as the main clinical manifestation of recurrence, which was completely different from that of the first incidence, and syncope is not a common and typical clinical manifestation of GBS, so misdiagnosis is highly likely.

非低颅压引起的体位性头痛2例报告

以站立位出现或加重,卧位减轻或消失为特点的体位性头痛是低颅压（intracranial hypotension,IH）最典型的临床表现[1]。国际上已将这一类型的体位性头痛作为必备条件之一列入IH的诊断标准中[2]。当患者以体位性头痛为主要症状而就诊时,临床医生常高度怀疑IH,并针对IH给予相关治疗。然而,我院发现2例以上述类型的体位性头痛为主要临床表现的非IH患者,现将临床资料及分析报道如下。

血液透析相关性低血压危险因素及预防措施

血液透析过程并发低血压（intradialytic hypotension,IDH）是血液透析治疗中常见的急性并发症,致使透析充分性降低,严重影响患者的生存质量及预后,因此,对透析中易发IDH的危险因素采取有效的预防措施,保证透析治疗顺利进行尤为重要[1]。本文对引起血液透析并发IDH的影响因素进行Logistic回归分析,并探讨防治对策[1],报告如下。

儿童特发性直立性低血压

直立性低血压（orthostatic hypotension,OH）根据美国自主神经疾病协会（the American Autonomic Society）的定义为患者在直立后或在直立倾斜试验的3分钟内收缩压持续下降超过20mm Hg,或舒张压下降超过10mm Hg[1]。这是一种典型的交感神经血管收缩障碍的表现。大多数患者在发生低血压的同时,不伴有代偿性心率增快,仅有少部分自主神经病变较轻的患者可出现心率增快。

中成药注射制剂治疗低血压

0 引言 低血压(hypotension)或低血压状态(hypotensivestate)依据其产生的原因大致可分为生理性低血压、病理性低血压和原发性体位性低血压。低血压目前无特效治疗药物,一般宜加强体育锻炼、去除原发病因、中药治疗及对症处理。近年临床应用表明,中药参附注射液、参麦注射液及生脉注射液等临床治疗低血压有较好疗效。

疑似蛛网膜下腔出血的原发性低颅压1例报告

原发性低颅压（spontaneous intracranial hypotension,SIH）是一组因脑脊液压力降低,有些甚至测不出脑脊液压力而引起头痛的临床综合征,其典型的特点为MRI硬脑膜强化、脑组织下移和脑脊液减少。当临床症状不典型时,经常容易误诊。我们现报道1例伴有剧烈头痛的SIH,腰穿可见均一血性脑脊液,疑似蛛网膜下腔出血（subarachnoid hemorrhage,SAH）的病例,现报告如下。

乳突根治术后脑脊液耳漏致迟发性低颅压综合征延误诊断1例

1 临床资料 患者，女，47岁，因头痛5年，左耳溢液2年于2014-01-05收治我院。患者于5年前晨起突然出现剧烈头痛，自枕部逐渐放射至整个头部，伴头晕、高调持续性耳鸣、恶心呕吐，起立或活动时症状加重，卧位时头痛减轻，自服止痛药后有所好转，病程中无发热及昏迷。就诊于当地医院神经内科诊断为“血管性头痛”，予扩张血管、止痛及对症治疗数月，仍反复发作。头颅CT检查显示未见明显异常。近日患者头痛发作频繁，并伴左耳溢液，来我院就诊。查体：体温37.1℃，神志清，颈软，克氏症状（-），鼓膜缺如，周围伴清亮液体。颞骨CT示左侧乳突腔术后改变，内侧壁局限颅骨缺损，内侧紧邻乙状窦，结合临床有脑脊液耳漏可能（图1A）。追问病史，诉于20年前因左耳流脓，在当地医院诊断为慢性化脓性中耳炎，行乳突根治术。脑脊液压力：53 mmH2O。左耳溢液生化检查葡萄糖63.9 mg%，氯化物217 mEq/L。电测听：左耳重度混合性聋，左耳声导抗未引出。诊断：左脑脊液耳漏，左乳突根治术后，继发性低颅压综合征。

Cardiac autonomic neuropathy in patients with diabetes mellitus

Cardiac autonomic neuropathy(CAN)is an often overlooked and common complication of diabetes mellitus.CAN is associated with increased cardiovascular morbidity and mortality.The pathogenesis of CAN is complex and involves a cascade of pathways activated by hyperglycaemia resulting in neuronal ischaemia and cellular death.In addition,autoimmune and genetic factors are involved in the development of CAN.CAN might be subclinical for several years until the patient develops resting tachycardia,exercise intolerance,postural hypotension,cardiac dysfunction and diabetic cardiomyopathy.During its sub-clinical phase,heart rate variability that is influenced by the balance between parasympathetic and sympathetic tones can help in detecting CAN before the disease is symptomatic.Newer imaging techniques(such as scintigraphy)have allowed earlier detection of CAN in the pre-clinical phase and allowed better assessment of the sympathetic nervous system.One of the main difficulties in CAN research is the lack of a universally accepted definition of CAN;however,the Toronto Consensus Panel on Diabetic Neuropathy has recently issued guidance for the diagnosis and staging of CAN,and also proposed screening for CAN in patients with diabetes mellitus.A major challenge,however,is the lack of specific treatment to slow the progression or prevent the development of CAN.Lifestyle changes,improved metabolic control might prevent or slow the progression of CAN.Reversal will require combination of these treatments with new targeted therapeutic approaches.The aim of this article is to review the latest evidence regarding the epidemiology,pathogenesis,manifestations,diagnosis and treatment for CAN.

Prevalence of and risk factors for postprandial hypotension in older Chinese men

Objective To assess the prevalence of and risk factors for postprandial hypotension （PPH） among old and very old Chinese men. Methods The study included 349 Chinese men aged 65 and older, grouped into two age categories： group 1 （old） included 163 men aged 65 to 80 years; group 2 （very old） included 186 men aged over 80 years. Blood pressure changes after meals were assessed every 15 min by ambulatory blood pressure monitoring. Symptoms after meal ingestion and after standing up and changes in the baseline condition relative to blood pressure changes were observed continuously. Additional baseline data included body mass index, medical history, and medication use Results The prevalence of PPH was 59.3% overall and was significantly higher in group 2 than group 1 （63.4% vs. 54.6%, P 〈 0.05）. In group 2, the prevalence of PPH after breakfast （33.8%） and lunch （32.1%） were higher than that after supper （20.9%）, P 〈 0.05. Hypertension and age were significant risk factors for PPH （OR = 2.188, 95% CI： 1.134-4.223, P = 0.02; OR = 1.86, 95% CI： 1.112-3.11, P = 0.018, respectively）. In contrast, acarbose use was protective against PPH （OR = 0.4, 95% CI： 0.189-0.847, P = 0.017）. The decrease in blood pres- sure during PPH was 20-40 mmHg and the maximum was 90 mmHg. PPH usually occurred at 30-60 min after a meal and lasted 30-120 rnin. Conclusions These findings demonstrate that the prevalence of PPH in men aged over 80 years is significantly higher than those in men aged 65 to 80 years, and the blood pressure decline is also higher for men aged over 80 years. In addition, hypertension and age were main risk factors for PPH in the older men, which suggest that preventing and treating PPH is worthwhile.

Vasopressors in obstetric anesthesia: A current perspective

Vasopressors are routinely used to counteract hypotension after neuraxial anesthesia in Obstetrics. The understanding of the mechanism of hypotension and the choice of vasopressor has evolved over the years to a point where phenylephrine has become the preferred vasopressor. Due to the absence of definitive evidence showing absolute clinical benefit of one over the other, especially in emergency and high-risk Cesarean sections, our choice of phenylephrine over the other vasopressors like mephentermine, metaraminol, and ephedrine is guided by indirect evidence on fetalacid-base status. This review article evaluates the present day evidence on the various vasopressors used in obstetric anesthesia today.

Cardiac autonomic neuropathy: Risk factors, diagnosis and treatment

Cardiac autonomic neuropathy(CAN)is a serious complication of diabetes mellitus(DM)that is strongly associated with approximately five-fold increased risk of cardiovascular mortality.CAN manifests in a spectrum of things,ranging from resting tachycardia and fixed heart rate(HR)to development of"silent"myocardial infarction.Clinical correlates or risk markers for CAN are age,DM duration,glycemic control,hypertension,and dyslipidemia(DLP),development of other microvascular complications.Established risk factors for CAN are poor glycemic control in type 1 DM and a combination of hypertension,DLP,obesity,and unsatisfactory glycemic control in type 2DM.Symptomatic manifestations of CAN include sinus tachycardia,exercise intolerance,orthostatic hypotension(OH),abnormal blood pressure(BP)regulation,dizziness,presyncope and syncope,intraoperative cardiovascular instability,asymptomatic myocardial ischemia and infarction.Methods of CAN assessment in clinical practice include assessment of symptoms and signs,cardiovascular reflex tests based on HR and BP,short-term electrocardiography(ECG),QT interval prolongation,HR variability(24 h,classic24 h Holter ECG),ambulatory BP monitoring,HR turbulence,baroreflex sensitivity,muscle sympathetic nerve activity,catecholamine assessment and cardiovascular sympathetic tests,heart sympathetic imaging.Although it is common complication,the significance of CAN has not been fully appreciated and there are no unified treatment algorithms for today.Treatment is based on early diagnosis,life style changes,optimization of glycemic control and management of cardiovascular risk factors.Pathogenetic treatment of CAN includes:Balanced diet and physical activity;optimization of glycemic control;treatment of DLP;antioxidants,first of allα-lipoic acid(ALA),aldose reductase inhibitors,acetylL-carnitine;vitamins,first of all fat-soluble vitamin B1;correction of vascular endothelial dysfunction;prevention and treatment of thrombosis;in severe cases-treatment of OH.The promising methods include prescription of prostacyclin analogues,thromboxane A2 blockers and drugs that contribute into strengthening and/or normalization of Na^+,K^+-ATPase(phosphodiesterase inhibitor),ALA,dihomo-γ-linolenic acid(DGLA),ω-3 polyunsaturated fatty acids(ω-3 PUFAs),and the simultaneous prescription of ALA,ω-3 PUFAs and DGLA,but the future investigations are needed.Development of OH is associated with severe or advanced CAN and prescription of nonpharmacological and pharmacological,in the foreground midodrine and fludrocortisone acetate,treatment methods are necessary.

Acute complications of spinal cord injuries

The aim of this paper is to give an overview of acute complications of spinal cord injury(SCI). Along with motor and sensory deficits, instabilities of the cardiovascular, thermoregulatory and broncho-pulmonary system are common after a SCI. Disturbances of the urinary and gastrointestinal systems are typical as well as sexual dysfunction. Frequent complications of cervical and high thoracic SCI are neurogenic shock, bradyarrhythmias, hypotension, ectopic beats, abnormal temperaturecontrol and disturbance of sweating, vasodilatation and autonomic dysreflexia. Autonomic dysreflexia is an abrupt, uncontrolled sympathetic response, elicited by stimuli below the level of injury. The symptoms may be mild like skin rash or slight headache, but can cause severe hypertension, cerebral haemorrhage and death. All personnel caring for the patient should be able to recognize the symptoms and be able to intervene promptly. Disturbance of respiratory function are frequent in tetraplegia and a primary cause of both short and long-term morbidity and mortality is pulmonary complications. Due to physical inactivity and altered haemostasis, patients with SCI have a higher risk of venous thromboembolism and pressure ulcers. Spasticity and pain are frequent complications which need to be addressed. The psychological stress associated with SCI may lead to anxiety and depression. Knowledge of possible complications during the acute phase is important because they may be life threatening and/ or may lead to prolonged rehabilitation.

Sclerosing cholangitis following severe trauma: Description of a remarkable disease entity with emphasis on possible pathophysiologic mechanisms

MM： Persistent cholestasis is a rare complication of severe trauma or infections. Little is known about the possible pathomechanisms and the clinical course.METHODS： Secondary sclerosing cholangitis was diagnosed in five patients with persistent jaundice after severe trauma （one burn injury, three accidents, one power current injury）. Medical charts were retrospectively reviewed with regard to possible trigger mechanisms for cholestasis, and the clinical course was recorded.RESULTS： Diagnosis of secondary sclerosing cholangitis was based in all patients on the primary sclerosing cholangitis （PSC）-Iike destruction of the intrahepatic bile ducts at cholangiography after exclusion of PSC. In four patients, arterial hypotension with subsequent ischemia may have caused the bile duct damage, whereas in the case of power current injury direct thermal damage was assumed to be the trigger mechanism. The course of secondary liver fibrosis was rapidly progressive and proceeded to liver cirrhosis in all four patients with a follow-up 〉2 years. Therapeutic possibilities were limited.CONCLUSION： Posttraumatic sderosing cholangitis is a rare but rapidly progressive disease, probably caused by ischemia of the intrahepatic bile ducts via the peribiliary capillary plexus due to arterial hypotension.Gastroenterologists should be aware of this disease in patients with persistent cholestasis after severe trauma.