급성 허혈성 뇌병소에 대한 혈압강하의 영향에 관한 실험적 연구

허춘웅,박춘근,김문찬,김달수,하영수,강준기,송진언 대한신경외과학회 1986 Journal of Korean neurosurgical society Vol.15 No.1

Controlled hypotension and temporary clip of feeding artery are used to reduce bleeding and to facilitate the neurosurgical operations, especially in intracranial aneurysm surgery, but the microvasculature of acute ischemic brain from impaired blood flow is quite susceptible to decrease in blood pressure and blood volume. The reversibility of brain damage following an ischemic brain lesion depends on the amount of regional cerebral blood flow as well as the severity of ischemia. The present study was designed to elucidate the effect of controlled hypotension on cerebral blood flow, cerebrovascular resistance, and pathological changes in acute ischemic brain lesion. Cerebral ischemia was induced in cats by middle cerebral artery occlusion for 6 hours through the transorbital appraoch. Forty-nine cats were divided into 3 groups, namely control group with mean blood pressure maintained at normal after right middle cerebral artery occlusion, hemorrhagic hypotension group with mean blood pressure decreased to 80, 60, and 40 ㎜Hg by with drawing of blood after right middle cerebral artery occlusion and drug-induced hypotension group with mean blood pressure decreased to 80, 60, and 40 ㎜Hg with arfonad infusion after right middle cerebral artery occlusion Regional cerebral blood flow was measured by the hydrogen clearance method following middle cerebral artery clipping and gradual decreasing mean blood pressure. Cerebrovascular resistance was calculated after regional cerebral blood flow was measured and size of infarct were examined in each groups after the experiment was completed. Results were as follows: 1) In control group, regional cerebral blood flow and cerebrovascular resistance of the right parietal area with mean blood pressure maintained at normal after right middle cerebral artery occlusion were 19.4±2.1㎖/2.1㎖/100g/min and 5.5±0.4㎜Hg/㎖/100g/min. The size of cerebral infarct was minimal in 71% of the control group. 2) In hemorrhagic hypotension group, regional cerebral blood flow of the right parietal area with mean blood pressure decreased to 80, 60, and 40 ㎜Hg was 17.6 ±1.5, 15.4±3.8, and 7.8±2.9㎖/100g/min respectively, thus 6, 25, and 57% lower than the control group. Cerebrovascular resistance of the right parietal area with mean blood pressure at 80 and 60㎜Hg was 4.7±0.1 and 4.5±0.3㎜Hg/㎖/100g/min respectively, thus showing a gradual decrease in relation to the decreasing mean blood pressure. With mean blood pressure reduced to 40 ㎜Hg, the cerebrovascular resistance drastically increased to 5.1±0.5㎜Hg/㎖/100g/min. When mean blood pressure was reduced to 60 and 40 ㎜Hg, the size of infarct was marked in 57 and 85% of the hemorrhagic hypotension group. 3) In drug-induced hypotension group, regional cerebral blood flow of the right parietal area with mean blood pressure reduced to 80, 60, and 40 ㎜Hg was 19.1±2.3, 17.8±3.1, and 7.4±2.7㎖/100g/min respectively, thus 2, 10, and 38% lower than the control group. The regional cerebral blood flow of the right parietal area in the drug-induced hypotension group was slightly higher than the hemorrhagic hypotension group when mean blood pressure was reduced to 80 or 60㎜Hg, while there was no significant difference of regional cerebral blood flow in the both groups when mean blood pressure was reduced to 40㎜Hg. Cerebrovascular resistance of the right parietal area with mean blood pressure at 80 and 60 ㎜Hg was 4.1±0.3 and 3.1±0.2㎜Hg/㎖/100g/min respectively, thus showing a gradual decrease in relation to decreasing mean blood pressure. With mean blood pressure reduced to 40㎜Hg, the cerebrovascular resistance was 5.6±0.9㎜Hg/㎖/100g/min, thus higher than the hemorrhagic hypotension group. When mean blood pressure was decreased to 60 and 40 ㎜Hg, the size of infarct was marked in 42 and 85% of the drug-induced hypotension group. The extent of cerebral infarct was more extensive in the hemorrhagic hypotension group than in the drug-induced hypotension. 4) In the contralateral hemisphere of the infarct, there was no change in regional cerebral blood flow when the mean blood pressure was decreased to 80 and 60㎜Hg but when the mean blood pressure decreased to 40㎜Hg, the regional cerebral blood flow was markedly reduced in all groups. When the mean blood pressure decreased to 60 ㎜Hg there was no change in cerebrovascular resistance, however when the mean blood pressure was at 40 ㎜Hg, there was a drastic increase in cerebrovascular resistance in all groups. Due to loss of autoregulation in the ischemic brain lesion, the regional cerebral blood flow depends on the brain perfusion pressure and accordingly when there is ischemic brain lesion., the hemorrhagic hypotension produces serious brain infarction and edema than drug-induced hypotension.

Predictability of passive leg raising test on anesthesia-induced hypotension in patients undergoing cardiac surgery

김현주,정유선,김준현,백재현,길남수,임영진,전윤석 대한마취통증의학회 2013 Anesthesia and pain medicine Vol.8 No.2

Background: Hypotension often occurs after induction of general anesthesia. Although preload status has been considered as an important factor for the occurrence of this hypotension, there have been inconsistent results on this topic. The dynamic preload parameters have not been studied as a predictor of hypotension, and therefore we hypothesized that the passive leg raising (PLR) test,a dynamic preload parameter, could predict anesthesia-induced hypotension and conducted a prospective clinical study. Methods: In 40 patients undergoing elective cardiac surgery,mean arterial pressure (MAP), stroke volume variation, stroke volume (SV) and cardiac index (CI) were measured using arterial line and FloTracTM/VigileoTM system before, during and after PLR test, respectively. Occurrence of anesthesia-induced hypotension was recorded. The ability of PLR test to predict hypotension was evaluated by receiver operating characteristic (ROC) curve analysis. Results: The incidence of hypotension was 90%, which includes 12.5% of refractory hypotension. Changes in MAP and CI induced by PLR test predicted hypotension (area under ROC curves: 0.722and 0.788, respectively). Changes in SV and CI induced by PLR test predicted refractory hypotension (area under ROC curves: 0.863and 0.789, respectively). Conclusions: Our results suggest that PLR test can predict hypotension and refractory hypotension occurring after induction of anesthesia in patients undergoing cardiac surgery.

입원 노인환자의 체위성 저혈압 위험요인에 관한 연구

송미순,유수정 서울대학교 간호대학 간호과학 연구소 1994 간호학 논문집 Vol.8 No.1

The purpose of this study were to identify the risk factors of postural hypotension and prevalence of postural hypotension, and to test whether these risk factors explain occurrence of postural hypotension among hospitalized elderly. The subjects of this study were 101 hospitalized elderly patients aged over 60 in a large university hospital. Only those who could stand up from dorsorecumbent position without assistance were included in the subjects. Data were collected from the 10th of August to the 25th of September 1993. Subjects were interviewed with structured questionnaire in order to ask experience of previous falls, hours in bed per day, symptoms related to postural hypotension. Data related to personal characteristics such as age, diagnosis, medication, weight and height were collected by review of hospital chart. Blood pressure was taken at dorsorecumbent position and at 1 minute after change of position to standing, when subject gets out of the bed in the morning. The same procedure was repeated after breakfast in order to test the influence of food intake on occurrence of postural hypotension. For data analysis, spss/pc+ program were utilized for descriptive statistics, t-test, x²-test, McNemar-test, correlation and discriminant analysis. The result of study were as following. 1) The three significant variables which explain the occurrence of postural hypotension were the number of current medication, the number of diseases and hours in bed per day. Age was not found as significant variable in explaining the occurrence of postural hypotension in this study. 2) The prevalence of postural hypotension was 36.7% at the time when the subjects get up in the morning. The mean drop of systolic blood pressure developed by change of position from dorsorecumbent to standing was 25.81 mmHg among postural hypotension subjects. 3) The hit ratio of discriminant function with the number of current medication, the number of diseases and hours in bed per day was 74.26% with sensitivity 54.1% and specificity 85.9%. 4) The prevalence of postural hypotension after breakfast was 27.7% and mean drop of systolic blood pressure was 22.68mmHg. Only 2.0% of subjects newly developed postural hypotension after breakfast, compare to earlier time blood pressure measurement. The result of this study in return provide valuable nursing practice guidelines for prevention of postural hypotension. Nurses working with elderly should identify these risk factors of postural hypotension and intervene to prevent postural hypotension during their clinical practice.

Applicability of hypotension prediction index to surgical patients

Lee Kichang,정기태 조선대학교 의학연구원 2022 Medical Bilogical Science and Engineering Vol.5 No.2

Intraoperative hypotension, which frequently occurs during surgery, can lead to unfavorable results. However, general blood pressure monitoring has limitations in continuously detecting hypotension in a patient, and there is a risk of not recognizing the presence of hypotension. Even short-term hypotension can damage major organs. The hypotension prediction index (HPI) indicates the likelihood that a patient will develop hypotension within the next 5 to 15 minutes in a hemodynamically stable state without hypotension. The HPI algorithm was developed to calculate the probability of hypotension using a machine-learning algorithm to characterize continuous arterial pressure waveforms in 1,334 surgical and critically ill patients. HPI provides parameters for determining the cause of hypotension (preload, contractility, or afterload), such as stroke volume variability, dP/dtmax, and dynamic arterial elastance. Although there is still no standard protocol for preventing or treating hypotension using HPI values, predicting the risk continuously and the cause of hypotension during surgery in real-time may help prevent harmful hypotension during surgery. In this review, we introduce the concept of HPI and discuss whether it can be applied in actual clinical practice.

심혈관계 중환자에서 Propacetamol과 Acetaminophen 주사제의 저혈압 발생 비교

홍신영,금민정,김재송,손은선,유윤미 한국병원약사회 2020 병원약사회지 Vol.37 No.2

Background : Hypotension is a well known adverse effect of intravenous propacetamol and acetaminophen. Specially, it increases mortality, acute renal failure, and myocardial injury in intensive care units. However, there is limited data comparing hypotension incidences caused by intravenous propacetamol and acetaminophen. The purpose of this study was to investigate the incidences and risk factors of propacetamol- and acetaminophen-associated hypotension. Methods : From January 1, 2019 June 30, 2019, we retrospectively reviewed the electronic medical records of the heart intensive care unit (HICU) patients who received intravenous propacetamol or acetaminophen. Hypotension was defined as systolic blood pressure (SBP) <90 mmHg, a SBP decrease >30 mmHg from the baseline, or a >15% decrease in mean arterial pressure (MAP) within two hours after the first administration. Also, we identified the risk factors of hypotension in the hypotension incidence group by comparing with the control group. Results : We reviewed 98 patients on intravenous propacetmaol and 106 patients on intravenous acetaminophen. There was no significant difference in the hypotension incidence in both groups. However, the incidence of hypotension within one hour of administration was significantly higher in the propacetamol group (21.4%) than in the acetaminophen group (9.4%) (p=0.017). The risk factor analysis indicated that low albumin level (<3 g/dL) (OR: 2.847, 95% CI: 1.339-6.054, p=0.007) and high initial SBP (≥140 mmHg) (OR: 3.142, 95% CI: 1.304-7.574, p=0.011) highly correlated with hypotension incidence. Conclusion : The critically ill patients may have a potential risk of hypotension when administered propacetamol or acetaminophen. Thus, in critically ill patients, we highly recommend caution when administering these medications as well as essential blood pressure (BP) monitoring. The patients with low albumin level or high initial SBP may increase the risk of hypotension. Thus, we strongly close BP monitoring in high risk group patients.

실험견에서 유도저혈압이 위점막내 산도에 미치는 효과

김영재,박효성,김동욱,정순호,최영균,박진우,신치만,박주열 인제대학교 1998 仁濟醫學 Vol.19 No.2

유도저혈압은 외과 수술시에 출혈을 최소화하기 위해서 폭넓게 이용되고 있다. 그러나 저혈압은 장기에 관류압을 감소시켜 미세순환상의 장애를 유발하고 조직에 부적절한 산소공급을 초래할 수 있다. 최근에 소개된 gastric tonometer는 장허혈을 측정하기 위해 소개되었고, 간접적으로 위점막내 산도(gastric intramucosal pH: pHi)를 측정하는 비교적 비침습적인 감시 방법으로 내장혈류량의 적절성을 평가하는데 이용하고 있다. 내장순환에 적용되는 이러한 측정은 이론적으로 감소된 순환상의 혈류에 의한 부적절한 조직산소화를 초기에 탐지하는 지표가 되며, 그리고 위점막의 손상을 방지하기 위해 초기에 치료의 방침을 결정할 수 있다. Induced hypotension has been widely used in various types of surgery in order to minimize intraoperative bleeding. But reduction of organ perfusion pressure during induced hypotension may cause disturbances in microcirculatory bed, leading to inadequate tissue oxygen supply. The gastric tonometer recently provides an indirect method to measure gastric intramucosal pH(pHi) using a relatively non-invasive technique of assessing the adequacy of gut blood flow. Theoretically, this could be applied to measurements of the splanchnic circulation providing an early indicator of inadequate tissue oxygenation due to reduced blood flow in circulatory bed. This study was undertaken to evaluate influences of induced hypotension on pHi through hemodynamic variables, blood gas analysis and arterial lactate. Five adult mongrel dogs were used for this experiment. The study was divided into three sequential phases, that is, baseline, induced hypotension and recovery. Hypotension was induced by the infusion of sodium nitroprusside and esmolol, and maintained with mean arterial pressure(MAP) of 40 mmHg for 30 min. Oxygen delivery(DO2), oxygen consumption(VO2) , arterial lactate and pHi were significantly decreased(p<0.05) during induced hypotension compared to baseline and recovery phase. And oxygen delivery(DO2) was signifcantly increased(p<0.05), but pHi was significantly decreased (p<0.05) during recovery compared to baseline phase. pHi was linearly correlated to VO2 during induced hypotension and recovery(r = 0.68, y = 0.00095x+7.208, P = 0.03). In conclusion, the change of gastric intramucosal pH may be related with impairment in splanchnic oxygenation due to induced hypotension. And tonometrically measured gastric intramucosal pH is linearly correlated to VO2. Therefore measurement of gastric intramucosal pH may reflect as a useful index of systemic oxygenation when MAP and CI were decreased during induced hypotension.

척추마취 하 제왕절개술시 저혈압 예방을 위한 하지압박붕대법의 효과

이재우,강효석,백승권,최주연 대한마취통증의학회 2011 Anesthesia and pain medicine Vol.6 No.2

Background: Hypotension is the most frequent complication associated with spinal anesthesia during cesarean section. Prehydration and/or vasopressor therapy is commonly used for prevention of hypotension in cesarean deliveries. Wrapping of the legs is simple to perform before surgery and was reported be effective for the prevention of post spinal hypotension in a few obstetric units. So we investigated whether wrapping of the legs prevents post spinal hypotension during cesarean section. Methods: 45 patients were randomly allocated to one of 3 groups (15 in each group): prehydration with 10 ml/kg (group I), prehydration with 10 ml/kg and wrapping of the legs (group II), prehydration with 5 ml/kg and wrapping of the legs (group III). Hypotension was defined as a 20% decrease from initial systolic arterial pressure (SAP) or SAP lower than 90 mmHg and was treated with intravenous ephedrine (4 mg, repeated). Blood pressure was recorded before spinal anesthesia and every min for 10 min and then every 2 min for another 10 min after spinal anesthesia. Results: Group I showed a significant decrease in SAP compared to group II and group III 1min after spinal anesthesia, but after that,there was no significant difference between the three groups. Group II showed a significant difference in incidence of severe hypotension after spinal anesthesia compared with group I, but there was no difference of the incidence of hypotension between the three groups. Conclusions: Wrapping of the legs for prevention of post spinal hypotension during elective cesarean section reduces the severity of hypotension. (Anesth Pain Med 2011; 6: 173∼177)

글리포세이트 중독환자에서 저혈압 발생의 의의와 관련 인자

김동규,김용환,이준호,황성연,조광원,강문주,이동우,이영환,이경렬,이나경 대한응급의학회 2015 대한응급의학회지 Vol.26 No.3

Purpose: Recently, glyphosate-surfactant herbicide has been used increasingly because it is known for its low toxicity in mammals. However, some cases presented severe clinical complications including hypotension. Previous studies have shown that hypotension is a predictor of poor outcome and mortality. Therefore, we aimed to identify factors that may be related to hypotension in glyphosate intoxication. Methods: This retrospective study targeted patients with glyphosate intoxication who were admitted to the emergency department of a single hospital from January 1st, 2004 to November 2014. The data were collected retrospectively from clinical records and laboratory files. Using multivariate logistic analysis, data were analyzed retrospectively for association with hypotension. Results: Of the 245 patients, 63 patients (25.7%) had hypotension. The results of this study showed statistically significant differences in old age, underlying disease, amount of ingestion, GCS (Glasgow coma scale), White blood cell, hemoglobin, total bilirubin, glucose level, pH, bicarbonate, base excess, lactate level, AST (aspartate aminotransferase), creatinine level, saturation, Chest X-ray abnormality, and prolonged QTc (corrected QT interval) between hypotension group and non-hypotension group. By multivariate logistic analysis, GCS, creatinine level, chest X-ray abnormality, and prolonged QTc interval were associated with the cases presenting with hypotension. Conclusion: GCS, creatinine level, chest X-ray abnormality, and prolonged QTc interval were significant factors associated with hypotension in patients with glyphosate intoxication.

Management of hypotension after spinal anesthesia administered for caesarean section

지영석 대한마취통증의학회 2017 Anesthesia and pain medicine Vol.12 No.2

Spinal anesthesia is widely used for parturients undergoing scheduled elective caesarean section. Hypotension associated with spinal anesthesia is a major concern in obstetrics. Preventive methods for post-spinal hypotension include intravenous fluid preloading, bolus or continuous injection of vasopressors. Intravenous fluid preloading reduces the incidence and severity of maternal hypotension during spinal anesthesia administered for cesarean section. Although fluid preloading prevents maternal hypotension, it is not advisable to delay spinal anesthesia for preloading a fixed volume of intravenous fluid. Ephedrine, the drug of choice to prevent maternal hypotension during spinal anesthesia for caesarean delivery, acts by maintaining the uteroplacental blood flow. Phenylephrine is also effective in reducing maternal hypotension during this procedure. Both the vasopressors are acceptable for preventing hypotension. However, in the absence of maternal bradycardia, phenylephrine is the preferred drug for the management of hypotension during regional anesthesia for caesarean section, because of its improved fetal acid-base status.

Macrolide계 항생제와 Calcium Channel Blocker 병용시 저혈압 위험성

이현정,최지영,김재연,송영천,곽혜선 한국병원약사회 2013 병원약사회지 Vol.30 No.2

Macrolide antibiotics including clarithromycin and erythromycin may potentiate the effects of calcium channel blockers (CCBs) by inhibiting cytochrome P450 isoenzyme 3A4. However, this potential drug interaction is widely underestimated, and its clinical consequences have not been well characterized. This study explored the risk of hypotension and consequently identified risk factors associated with the simultaneous use of CCBs and macrolide antibiotics. We conducted a case-crossover study involving inpatients between April 1, 2010 and March 31, 2011 at Asan Medical Center. The hypotension risks associated with the use of CCBs were evaluated by the pair-match analytic approach, comparing each patient's exposure to each macrolide antibiotic (erythromycin, clarithromycin or azithromycin) during a co-administered period (risk interval) and in the period preceding 30 days (control interval). 84 patients, who administered both medications over 3 days and had been received CCBs over 1 month before co-administration were incloded. They were divided into 2 groups according to the changes of the blood pressure values (Hypotension group n=24; Normal Blood Pressure group n=60). We compared the data between the 2 groups and found the risk factors of hypotension. Statistical analysis was performed using the PASW Statistics version 14.0 (SPSS). A p-value of <0.05 was considered statistically significant. A total of 84 patients with a mean (± SD, Standard Deviation) age of 66.4 (±13.7) years were studied, of whom 58 (69.0%) were male. The mean duration of the co-administration was 6.9 days. Systolic and diastolic blood pressure was reduced by 12.31±16.73 mmHg and 7.34±10.51 mmHg during the co-administration period compared to those in the period preceding 1 month, respectively The incidence of hypotension defined by the International Classification of Diseases-9 (ICD-9) was 28.6%. Although other risk factors (age, sex, type of CCBs, co-administration duration, etc.) were not statistically significant, erythromycin was the most strongly associated risk factor of hypotension (odds ratio [OR] 2.44, 95% confidence interval [CI] 1.15-5.18, p=0.04). A total of 9 patients were administered erythromycin in this study, and hypotension occurred in 55.6% of the patients. The frequency of hypotension, as a result of concomitant CCB and macrolide administration, appears to be small, however, we should be concerned about the risk of adverse effects that may occur. Co-administration of macrolide antibiotics and CCBs was associated with a reduction of blood pressure, particularly erythromycin. The preferential use of azithromycin should be considered when a macrolide antibiotic is required for patients already receiving a CCB. Clinicians should be aware of the potential interaction between these drugs, as well as the need for careful patient monitoring.