Twenty patients undergoing various surgical procedures were anaesthetised using hypotensive anaesthesia using labetalol and halothane. The technique is safe, predictable and cheap. This technique also offers the advantage of usage of less blood, thus minimising the complications of transfusion induced diseases like hepatitis and AIDS.
Among several alkaloids, including dimeric indoles, isolated from Uncaria callophylla, gambirine which is an alkaloid unique to this plant, has been found to be another hypotensive principle from the plant. Intravenous injections of gambirine in the dose range of 0.2 to 10.0 mg/kg caused a dose-related fall in both systolic and diastolic blood pressures as well as heart rate. At all doses gambirine showed a prompt onset of action and at the higher doses (5.0-10 mg/kg), marked persistence of hypotension accompanied by severe bradycardia were observed. In addition, higher doses of gambirine produced a more marked decrease in diastolic than systolic pressure while at lower doses both decreased equally. It is suggested that the hypotensive effect of gambirine may be peripheral in origin and is associated, at least in part, with a cardiac action.
We have evaluated the effects of a B2 receptor antagonist (B5630) of kinins on BK and captopril-induced acute hypotensive responses in anaesthetized SHR. Intravenous treatment of BK (1.0 microgram) and captopril (0.3 mg/kg) caused significant (p < 0.05) fall in the SBP and DBP. Whereas BK caused greater fall in the SBP (p < 0.05), DBP (p < 0.01) and duration of hypotension (p < 0.05) when administered after captopril (Fig 1 and 2). All the hypotensive effects of BK and captopril were significantly antagonised (p < 0.05) in the presence of B5630 (2.0 mg/kg). Further, the duration of hypotensive responses of BK and captopril were blocked (p < 0.05) by B5630. The agonists and BK-antagonist did not cause significant (p > 0.05) alterations in HR during the entire investigation. These findings provide evidence to support the suggestion that B2 receptor might be involved in the regulation of the hypotensive actions of BK and captopril. Kinins should also have valuable functions in the antihypertensive property of captopril-like drugs.
Thrombolytic therapy is a well-established therapy in acute myocardial infarction (AMI), reducing mortality and infarct size. This study is a retrospective analysis of survival and complications after the use of streptokinase at Hospital Universiti Sains Malaysia. Streptokinase was first used here in March 1990. Between then and February 1992, 126 patients were admitted to the Coronary Care Unit. Thirty-two patients who fulfilled our criteria for thrombolytic treatment were given an hour intravenous infusion of 1.5 MU streptokinase, and started on aspirin. A control group of 64 patients selected from before March 1990, and matched for age, sex and site of infarct, was given standard therapy. The survival at 4 weeks post-AMI was 91% in the streptokinase therapy group and 91% in both groups (p > 0.05). The complications encountered were reperfusion arrhythmias (2 patients), hypotension(1), maculopapular rash(1) and gum bleeding(1). None of these complications were statistically increased when compared to the control group and none resulted in the death of a patient. We conclude that streptokinase therapy can be given safely in a rural Malaysian setting. Our survival and complication rates are comparable with other published series.
The aim of the study was to determine the effect of pro-phylactic low dose dopamine infusion on renal function in ventilated premature newborns with respiratory dis-tress syndrome (RDS). A prospective, randomised con-trolled trial was conducted, using low dose dopamine [2.5μg/kg/min] in the treatment of preterm babies with gestational age 28-36 weeks requiring mechanical ventilation for RDS within six hours of age. Thirty-six babies were enrolled and 19 babies were randomly assigned to the treatment groups. The renal function after 72 hours for the treatment and control groups respectively were: urine output (ml/kg/hour) 3.3±0.4 and 3.0±0.3 [p=0.55], urine specific gravity 1006±0.6 and 1006±1.0 [p=0.68], fractional excretion of sodium 4.1±0.8 and 2.6±0.4 [p=0.10], fractional excretion of potassium 37.44 ± 5.6 and 16.49 ± 2.2 [p=0.001], glomerular filtration rate (ml/day/1.72m2) 16±2.6 and 25.6±4.5 [p=0.06]. There were no significant differ-ences in the frequency of hypotension, oliguria and sep-sis between the two groups. There were seven deaths (36.8%) in the treatment group (six due to sepsis and one due to prematurity) and two deaths (11.8%) in the control group (both due to sepsis) (p = 0.13). In con-clusion prophylactic low-dose dopamine infusion did not improve the renal function in ventilated premature babies with respiratory distress syndrome. The results of this study do not support the routine use of prophylac-tic low-dose dopamine in ventilated preterm babies with respiratory distress syndrome.
Despite their proven value in reducing morbidity and mortality in different grades of heart failure, angiotensin converting enzyme (ACE) inhibitors continue to be underused. One reason for this is clinicians' apprehension of first-dose hypotension. We conducted a double-blind, randomised, placebo-controlled parallel group study to investigate the effect of various ACE inhibitors on first-dose hypotension. Eighty unselected patients were randomised into five treatment groups: placebo, captopril 6.25 mg, enalapril 2.5 mg, perindopril 2 mg and lisinopril 2.5 mg. Blood pressure was measured at baseline, half hourly for two hours and hourly for three hours after drug treatment. The maximum drops in mean arterial pressure (in mmHg +/- SD) were placebo 5.89 +/- 2.65, perindopril 5.29 +/- 2.49, enalapril 13.28 +/- 3.31, lisinopril 15.04 +/- 5.74 and captopril 16.76 +/- 5.74 (all p < 0.05 vs placebo except for perindopril). Perindopril, unlike the other ACE inhibitors studied, did not produce first-dose hypotension following its initiation in patients with congestive heart failure.
We conducted a double-blind, randomised, placebo-controlled study evaluating the efficacy of prophylactic metaraminol for preventing propofol-induced hypotension. Thirty patients aged 55-75 years undergoing general anaesthesia were randomly allocated to receive either metaraminol 0.5 mg or saline before administration of fentanyl 1 microg.kg(-1) and propofol 2 mg.kg(-1). Induction of anaesthesia was associated with a decrease in mean and systolic arterial pressure in both groups (p = 0.0001). However, there was no significant difference between the two groups. These results show that prophylactic use of metaraminol 0.5 mg does not prevent the decrease in blood pressure following fentanyl and propofol induction in older patients.
We developed a personal blood pressure monitoring system for patients with hypertension or hypotension. The system can be used to measure a patient's blood pressure at home and to transmit the data automatically to a hospital database via the Internet. The accuracy of blood pressure readings using the system was assessed by comparison with readings from a standard digital sphygmomanometer in four subjects. The measurement error for the systolic readings was 1.7-2.7% and for the diastolic readings 2.7-3.2%. The system therefore appears to be a promising means of assessing blood pressure remotely.
The determination of cerebral perfusion pressure (CPP) is regarded as vital in monitoring patients with severe traumatic brain injury. Besides indicating the status of cerebral blood flow (CBF), it also reveals the status of intracranial pressure (ICP). The abnormal or suboptimal level of CPP is commonly correlated with high values of ICP and therefore with poor patient outcomes. Eighty-two patients were divided into three groups of patients receiving treatment based on CPP and CBF, ICP alone, and conservative methods during two different observation periods. The characteristics of these three groups were compared based on age, sex, time between injury and hospital arrival, Glasgow Coma Scale score, pupillary reaction to light, surgical intervention, and computerized tomography scanning findings according to the Marshall classification system. Only time between injury and arrival (p = 0.001) was statistically significant. There was a statistically significant difference in the proportions of good outcomes between the multimodality group compared with the group of patients that underwent a single intracranial-based monitoring method and the group that received no monitoring (p = 0.003) based on a disability rating scale after a follow up of 12 months. Death was the focus of outcome in this study in which the multimodality approach to monitoring had superior results.
This study reviewed the trabeculectomies (TEs) carried out in University Malaya Medical Center between 1994 to 1998. One hundred and nine of 132 eyes operated were in the primary glaucoma group of which 63 (47.7%) were of the open angle type and 46 (34.8%) were of the angle closure type. Twenty-three eyes belong to the secondary glaucoma group. Sixty-five eyes had plain or non-augmented trabeculectomy (TE) while 20 were augmented with mitomycin C (MMC) and 11 with 5 flourouracil (5FU). In 31 eyes the plain TEs were combined with extracapsular cataract extraction (ECCE) and 4 with phacoemusification. One case had combined ECCE and augmented trabeculectomy with mitomycin-C. The patients were followed up at 1 month, 6 months, 1 year and 2 years. Ninety-four of 132 (71.2%) eyes had successful surgery with intraocular pressure (IOP) of less than 21 mmHg (tonometric success) at the end of 2 years. Four of these patients needed topical medication for the IOP control. More failures were seen in patients with cystic blebs than those with diffuse blebs. Complications include hypotony, shallow anterior chamber, cataracts and hyphaema. The majority of cases (53%) had no complications.
OBJECTIVE: To describe the glycaemic control, diabetes care and prevalence of complications in youth with type 2 diabetes from the Western Pacific Region.
RESEARCH DESIGN AND METHODS: Cross-sectional, clinic-based audit of 331 patients aged < 18 years from 56 centres in Australia, China-Beijing, China-Shanghai, China-Hong Kong, Indonesia, Japan, South Korea, Malaysia, Philippines, Singapore, Taiwan and Thailand. Clinical and management data were recorded along with glycated haemoglobin (HbA(1c)), lipids and complication rates.
MAIN OUTCOME MEASURES: Glycaemic control, complications, diabetes management.
RESULTS: Median age was 14.9 years (interquartile range 13.2-16.4 years) and median diabetes duration 2.3 years (1.4-3.6 years). Median HbA(1c) was 7% (5.9-9.9%) and HbA(1c) was > 7.5% in 40% of patients. In multiple regression analysis, glycaemic control varied significantly between countries (p = 0.02); higher HbA(1c) was associated with fewer home blood glucose measurements (p = 0.005) and higher insulin dose/kg (p < 0.0001). Blood glucose monitoring was performed by 65% of patients (range 33-96% by country). In 25% of patients, management consisted of diet alone or no treatment (range 0-53% by country); oral anti-diabetic drugs alone were used in 49%, insulin alone in 11% and both in 15%. Microalbuminuria was found in 8% and hypertension in 24%. The risk of hypertension increased with higher BMI (OR 1.16, 95% CI 1.09-1.24, p < 0.0001); antihypertensive agents were used in 4% of patients.
CONCLUSIONS: The management of type 2 diabetes in youth from the Western Pacific Region varies widely. Hypertension and microalbuminuria were frequent, but not commonly treated. Further investigation into the natural history and risk factors for complications in youth with type 2 diabetes is required to assist in developing evidence based management guidelines.
There is no consensus with respect to the use of analgesia during femoral arterial sheath removal after percutaneous coronary intervention (PCI). We performed a randomized controlled trial to assess the impact of intravenous sedation and local anesthesia during femoral sheath removal after PCI on patient comfort and the incidence of vasovagal reactions.
Colonoscopy is believed to be more complicated in elderly patients in Western countries. It is uncertain if the situation holds true among Asians. This study is to determine differences in colonoscopy performance and sedation complications between patients aged<65 years and those>or=65 years of age in an Asian population.
This prospective, randomized, study was designed to compare the effect of two different preloading volumes of Ringer's lactate for prevention of maternal hypotension induced by spinal anaesthesia for Caesarean section. Eighty ASA I or II obstetric patients were randomized to two groups. Group 1 (n = 40) received 20 ml/kg of Ringer's lactate and Group 2 (n = 40) 10 ml/kg of Ringer's lactate over 20 minutes before spinal anaesthesia. The lowest mean arterial pressure (MAP) for both groups were recorded at 15 minutes after giving spinal anaesthesia, This difference in the drop of MAP from base-line at 15 minutes (mean decrease of 12.5 mmHg from baseline), between preloading with 10 ml/kg and 20 ml/kg of Ringer's was statistically significant. Twelve patients from Group 1 required bolus doses of ephedrine and 15% of these needed additional crystalloid whereas two patients from Group 2 needed ephedrine boluses and 22% of these required additional crystalloid. The difference in frequency of requirement for treatment of hypotension was not statistically significant. There were five patients in Group 1 and six patients in Group 2 who experienced nausea and vomiting, the frequency of occurrence did not show any statistically significant difference between the two groups. In conclusion, for prevention of hypotension during spinal anaesthesia for Caesarean section, infusing 20 ml/kg or 10 ml/kg of Ringer's Lactate gave similar results and we do not recommend the use of a larger volume of crystalloid for preloading before spinal anaesthesia.
The brain is considered the most eloquent organ in the human body as its activities impacts on all other systems. Though protected physically (in a bony covering), physiologically through the blood-CSF barrier (from invading organisms and toxins) and hemodynamically through the phenomenon of cerebral autoregulation; the brain is open to insults of various kinds which can critically damage this structure. Intracellular Ca++ accumulation, excessive activation of excitatory amino acid receptors, lipid peroxidation and free radical releaserelated damage are but a few of the pathological processes that occur at the neuronal level leading to damage. The mechanism by which the brain can be provided protection when it is in a compromised state or likely to be compromised is known as cerebral protection. There are various modalities of pharmacologic (use of barbiturates, etomidate, isoflurane, steroids, Ca++, corticosteroids etc) and non-pharmacologic therapies (hypothermia, hyperventilation, induced hypotension, electrophysiologic monitoring, endovascular management etc) available for cerebral protection which finds place in the armamentarium of clinicians managing the critically injured brain. Our knowledge of the functioning of the brain at the molecular level and the various biochemico-pathological processes that are set into motion during critical states continues to evolve. This review article attempts to explain present understanding of the biochemical and pathological processes involved in neuronal damage while also looking at current available therapies (pharmacologic & nonpharmacologic) being utilized in different clinical settings.
Amitraz poisoning is rare and there has been no reported cases in the Malaysian literature. Ingestion of this compound carries many life threatening side effects. We describe a case of Amitraz poisoning in an 18 years old young adult. He developed hypotension, required ventilatory support and a day of intensive care unit stay. He had a quick recovery after he was treated symptomatically and was discharged well after 3 days.