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Isolated hypotension after the induction of general anesthesia refractory to fluids and vasopressors: An indicator of anaphylaxis

Mok CS, Vanessa L

Med J Malaysia, 2021 03;76(2):267-269.
PMID: 33742644

Differentiating between anaphylaxis and hypotension during general anaesthesia is difficult, especially when patients present with only hypotension and without any of the other classical features of anaphylaxis. We report the successful management of an anaphylactic reaction to rocuronium that presented as isolated hypotension in a 45-year-old Indonesian man presented with lacerations on the scalp and right pinna caused by an assault to the head after the induction of general anaesthesia, refractory to fluids and high doses of vasopressors. This case highlights that a possible indicator of anaphylaxis can be the presence of isolated hypotension during.

Matched MeSH terms: Hypotension
Fulltext Shock in children

Sinniah, Davendralingam

International e-Journal of Science, Medicine & Education, 2012;6(10):0-0.
MyJurnal

Shock, a major cause of morbidity and mortality in children, is the the most anxiety-provoking emergency that needs to be addressed urgently and effectively by the attending paediatrician. It is a state where the metabolic demands of the tissue are not met due to circulatory dysfunction. Unlike adults, hypotension is a very late feature of shock in children. As the child’s condition worsens, the clinical presentation of the different causes of shock become similar, and nullify any aetiological differences. Regardless of the type of shock, the final common pathway is inadequate tissue perfusion and oxygen supply to meet cellular demands. Delayed recognition and treatment result in progression from compensated reversible shock to uncompensated irreversible shock with widespread multiple system
organ failure to death. This paper reviews the physiological basis, and pathophysiological classification of the various types of shock and their respective aetiologies. The clinical features of the different types of shock are described, and current diagnostic and therapeutic strategies are applied for the most effective and appropriate treatment for resuscitating the child in shock. A strong index of suspicion, early recognition, timely intervention and transfer to an intensive care unit are critical for successful outcomes in the management of paediatric shock.

Matched MeSH terms: Hypotension
Fulltext Amitraz poisoning: a case report

Choor, C.K., Santha, K.N.

Medicine & Health, 2011;6(2):123-125.
MyJurnal

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.

Matched MeSH terms: Hypotension
Fulltext Early management of head injury in adults in primary care

Liew BS, Zainab K, Cecilia A, Zarina Y, Clement T

Malays Fam Physician, 2017;12(1):22-25.
PMID: 28503270

Head injury is common and preventable. Assessment of the head injury patient includes airway, cervical spine protection, breathing, circulation, haemorrhage control and the Glasgow Coma Scale. Hypotension, hypoxia, hypocarbia and hypercarbia should be avoided by continuous monitoring of vital signs and hourly head chart to prevent secondary brain injury. This paper aims to assist primary healthcare providers to select the appropriate patient for transfer and imaging for further management of head injury.

Matched MeSH terms: Hypotension
Injection speed of spinal anaesthesia for Caesarean delivery in Asian women and the incidence of hypotension: A randomised controlled trial

Chiang CF, Hasan MS, Tham SW, Sundaraj S, Faris A, Ganason N

J Clin Anesth, 2017 Jun;39:82-86.
PMID: 28494915 DOI: 10.1016/j.jclinane.2017.03.025

STUDY OBJECTIVE: The purpose of this investigation was to determine if a slower speed of spinal anaesthesia injection would reduce the incidence of hypotension.
STUDY DESIGN: Randomised controlled trial.
SETTING: Tertiary level hospital in Malaysia.
PATIENTS: 77 patients undergoing elective Caesarean delivery.
INTERVENTION: Differing speeds of spinal injection.
MEASUREMENTS: Systolic blood pressure was assessed every minute for the first 10min and incidence of hypotension (reduction in blood pressure of >30% of baseline) was recorded. The use of vasopressor and occurrence of nausea/vomiting were also recorded.
MAIN RESULTS: 36 patients in SLOW group and 41 patients in FAST group were recruited into the study. There was no significant difference in blood pressure drop of >30% (p=0.497) between the two groups. There was no difference in the amount of vasopressor used and incidence of nausea/vomiting in both groups.
CONCLUSION: In our study population, there was no difference in incidence of hypotension and nausea/vomiting when spinal injection time is prolonged beyond 15s to 60s.
TRIAL REGISTRATION: ClinicalTrials.govNCT02275897. Registered on 15 October 2014.

Matched MeSH terms: Hypotension/etiology*; Hypotension/epidemiology; Hypotension/prevention & control
Fulltext Life-Threatening Dyskalaemia after Barbiturate Coma Therapy: The Strategy of Management

Tat YB, Hassan WMNW, Chuen TY, Ghani ARI

Malays J Med Sci, 2017 Mar;24(2):100-105.
PMID: 28894410 MyJurnal DOI: 10.21315/mjms2017.24.2.13

Barbiturate coma therapy (BCT) is a treatment option that is used for refractory intracranial hypertension after all other options have been exhausted. Although BCT is a brain protection treatment, it also has several side effects such as hypotension, hepatic dysfunction, renal dysfunction, respiratory complications and electrolyte imbalances. One less concerning but potentially life-threatening complication of BCT is dyskalaemia. This complication could present as severe refractory hypokalaemia during the therapy with subsequent rebound hyperkalaemia after cessation of the therapy. Judicious potassium replacement during severe refractory hypokalaemia and gradual cessation of the therapy to prevent rebound hyperkalaemia are recommended strategies to deal with this complication, based on previous case series and reports. In this case report, we show that these strategies were applicable in improving severe hypokalaemia and preventing sudden, life-threatening rebound hyperkalaemia. However, even with use of these strategies, BCT patients could still present with mild, asymptomatic hyperkalaemia.

Matched MeSH terms: Hypotension
Blood pressure lowering therapy in older people: Does it really cause postural hypotension or falls?

Zia A, Kamaruzzaman SB, Tan MP

Postgrad Med, 2015 Mar;127(2):186-93.
PMID: 25622817 DOI: 10.1080/00325481.2015.996505

Hypertension is a highly prevalent condition among older people, but many physicians avoid aggressive treatment in this age group due to concerns about adverse effects such as orthostatic hypotension and falls. Orthostatic hypotension, which also increases in prevalence with increasing age, has been considered to be associated with antihypertensive therapy. Both orthostatic hypotension and antihypertensive medications are considered independent yet closely related predictors for falls among older people. The prescription of antihypertensive therapy among the elderly remains a long-standing controversy in geriatric medicine due to ongoing concerns about potential complications such as falls, despite conclusive evidence supporting the treatment of hypertension even among the very elderly. However, recent evidence suggests a dose-dependent relationship between blood pressure lowering therapy and falls among older individuals with preexisting risk factors for falls. In response to the spate of revisions in hypertension treatment targets for older patients in international guidelines and the recent evidence on antihypertensive therapy and falls, this review article examines the complex relationship between hypertension, antihypertensives, orthostatic hypotension, and falls among older patients.

Matched MeSH terms: Hypotension, Orthostatic/chemically induced*
Fulltext Comparison between preloading with 10 ml/kg and 20 ml/kg of Ringer's lactate in preventing hypotension during spinal anaesthesia for caesarean section

Muzlifah KB, Choy YC

Med J Malaysia, 2009 Jun;64(2):114-7.
PMID: 20058569 MyJurnal

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.

Matched MeSH terms: Hypotension/prevention & control*
Colonoscopy in elderly Asians: a prospective evaluation in routine clinical practice

Ma WT, Mahadeva S, Kunanayagam S, Poi PJ, Goh KL

J Dig Dis, 2007 May;8(2):77-81.
PMID: 17532819

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.

Matched MeSH terms: Hypotension/chemically induced
Hypotensive anesthesia in the management of a posterior suprachoroidal foreign body

Hashim H, Lim KS, Choong YY, Nor NM

Retina, 2005 Jan;25(1):87-9.
PMID: 15655449
Matched MeSH terms: Hypotension, Controlled*
Effects of metabolic acidosis--a review with case reports

Khawaja AA

Med J Malaya, 1971 Mar;25(3):229-33.
PMID: 4253255
Matched MeSH terms: Hypotension/etiology*
Initial clinical experiences with Althesin (CT 1341) in Malaysian patients

Delilkan AE

Anaesth Intensive Care, 1974 May;2(2):171-4.
PMID: 4447237
Matched MeSH terms: Hypotension/chemically induced
Fulltext Evaluation of Two New Indices of Blood Pressure Variability Using Postural Change in Older Fallers

Goh CH, Ng SC, Kamaruzzaman SB, Chin AV, Poi PJ, Chee KH, et al.

Medicine (Baltimore), 2016 May;95(19):e3614.
PMID: 27175670 DOI: 10.1097/MD.0000000000003614

To evaluate the utility of blood pressure variability (BPV) calculated using previously published and newly introduced indices using the variables falls and age as comparators.While postural hypotension has long been considered a risk factor for falls, there is currently no documented evidence on the relationship between BPV and falls.A case-controlled study involving 25 fallers and 25 nonfallers was conducted. Systolic (SBPV) and diastolic blood pressure variability (DBPV) were assessed using 5 indices: standard deviation (SD), standard deviation of most stable continuous 120 beats (staSD), average real variability (ARV), root mean square of real variability (RMSRV), and standard deviation of real variability (SDRV). Continuous beat-to-beat blood pressure was recorded during 10 minutes' supine rest and 3 minutes' standing.Standing SBPV was significantly higher than supine SBPV using 4 indices in both groups. The standing-to-supine-BPV ratio (SSR) was then computed for each subject (staSD, ARV, RMSRV, and SDRV). Standing-to-supine ratio for SBPV was significantly higher among fallers compared to nonfallers using RMSRV and SDRV (P = 0.034 and P = 0.025). Using linear discriminant analysis (LDA), 3 indices (ARV, RMSRV, and SDRV) of SSR SBPV provided accuracies of 61.6%, 61.2%, and 60.0% for the prediction of falls which is comparable with timed-up and go (TUG), 64.4%.This study suggests that SSR SBPV using RMSRV and SDRV is a potential predictor for falls among older patients, and deserves further evaluation in larger prospective studies.

Matched MeSH terms: Hypotension, Orthostatic/complications; Hypotension, Orthostatic/physiopathology*
The effect of prophylactic metaraminol on systemic hypotension caused by induction of anaesthesia with propofol in patients over 55 years old

Chiu CL, Tew GP, Wang CY

Anaesthesia, 2001 Sep;56(9):893-7.
PMID: 11531679

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.

Matched MeSH terms: Hypotension/chemically induced; Hypotension/prevention & control*
Fulltext A Pharmacological Examination of the Cardiovascular Effects of Malayan Krait (Bungarus candidus) Venoms

Chaisakul J, Rusmili MR, Hodgson WC, Hatthachote P, Suwan K, Inchan A, et al.

Toxins (Basel), 2017 03 29;9(4).
PMID: 28353659 DOI: 10.3390/toxins9040122

Cardiovascular effects (e.g., tachycardia, hypo- and/or hypertension) are often clinical outcomes of snake envenoming. Malayan krait (Bungarus candidus) envenoming has been reported to cause cardiovascular effects that may be related to abnormalities in parasympathetic activity. However, the exact mechanism for this effect has yet to be determined. In the present study, we investigated thein vivoandin vitrocardiovascular effects ofB. candidusvenoms from Southern (BC-S) and Northeastern (BC-NE) Thailand. SDS-PAGE analysis of venoms showed some differences in the protein profile of the venoms.B. candidusvenoms (50 µg/kg-100 µg/kg, i.v.) caused dose-dependent hypotension in anaesthetised rats. The highest dose caused sudden hypotension (phase I) followed by a return of mean arterial pressure to baseline levels and a decrease in heart rate with transient hypertension (phase II) prior to a small decrease in blood pressure (phase III). Prior administration of monovalent antivenom significantly attenuated the hypotension induced by venoms (100 µg/kg, i.v.). The sudden hypotensive effect of BC-NE venom was abolished by prior administration of hexamethonium (10 mg/kg, i.v.) or atropine (5 mg/kg, i.v.). BC-S and BC-NE venoms (0.1 µg/kg-100 µg/ml) induced concentration-dependent relaxation (EC50= 8 ± 1 and 13 ± 3 µg/mL, respectively) in endothelium-intact aorta. The concentration-response curves were markedly shifted to the right by pre-incubation with L-NAME (0.2 mM), or removal of the endothelium, suggesting that endothelium-derived nitric oxide (NO) is likely to be responsible for venom-induced aortic relaxation. Our data indicate that the cardiovascular effects caused byB. candidusvenoms may be due to a combination of vascular mediators (i.e., NO) and autonomic adaptation via nicotinic and muscarinic acetylcholine receptors.

Matched MeSH terms: Hypotension/chemically induced*; Hypotension/physiopathology
Fulltext Purpura Fulminans: A rare presentation of Streptococcus Pneumoniae infection

Teo HG, Wong JY, Ting TLL

BMJ Case Rep, 2017 Oct 20;2017.
PMID: 29054893 DOI: 10.1136/bcr-2017-221150

A previously healthy man presented with fever for 2 days and rapidly progressive purpuric rash for 1 day. He progressed into hypotension, disseminated intravascular coagulation and refractory shock despite resuscitation and early antibiotic commencement. Blood culture grew Streptococcus pneumoniae This case report highlights the fact that purpura fulminans can be a rare presentation of S. pneumoniae infection as well.

Matched MeSH terms: Hypotension/etiology; Hypotension/microbiology*
Fulltext Prevalence of falls and its associated factors among elderly diabetes in a tertiary center, Malaysia

Azidah AK, Hasniza H, Zunaina E

Curr Gerontol Geriatr Res, 2012;2012:539073.
PMID: 22693496 DOI: 10.1155/2012/539073

The purpose of this study is to determine the prevalence of falls and its associated factors among elderly diabetes type 2 patients attending a tertiary center in Malaysia. We conducted a cross-sectional study among 288 elderly diabetes type 2. The data collected includes data on sociodemographic, diabetes history, comorbid diseases, drug use, and activity of daily living (Barthel's index). The patient also was examined physically, and balance and gait assessment was carried out. Prevalence of falls among elderly diabetes was 18.8%. Female gender (OR: 2.54, P < 0.05), age group more than 75 (OR: 2.97, P < 0.05), retinopathy (OR: 2.19, P < 0.05), and orthostatic hypotension (OR: 2.87, P < 0.05) were associated with higher risk for falls. High balance and gait score was associated with reduced risk of fall in elderly diabetes (OR: 0.89, P < 0.05). In conclusion, the factors that are associated with higher risk for falls among elderly diabetes were female sex, age group more than 75, presence of retinopathy, and orthostatic hypotension. Those who had higher balance and gait score were found to be less likely to fall compared with those with lower score.
Study site: Hospital Universiti Sains Malaysia, Kelantan, Malaysia
Questionnaires, Scales, Device: Tinetti Balance and Gait Assessment; 5.07 Semmes- Weinstein monofilament; Barthel’s index
Study site: Diabetic clinic, Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia

Matched MeSH terms: Hypotension, Orthostatic
Fulltext Involvement of inflammation and adverse vascular remodelling in the blood pressure raising effect of repeatedly heated palm oil in rats

Ng CY, Kamisah Y, Faizah O, Jubri Z, Qodriyah HM, Jaarin K

Int J Vasc Med, 2012;2012:404025.
PMID: 22778962 DOI: 10.1155/2012/404025

Oil thermoxidation during deep frying generates harmful oxidative free radicals that induce inflammation and increase the risk of hypertension. This study aimed to investigate the effect of repeatedly heated palm oil on blood pressure, aortic morphometry, and vascular cell adhesion molecule-1 (VCAM-1) expression in rats. Male Sprague-Dawley rats were divided into five groups: control, fresh palm oil (FPO), one-time-heated palm oil (1HPO), five-time-heated palm oil (5HPO), or ten-time-heated palm oil (10HPO). Feeding duration was six months. Blood pressure was measured at baseline and monthly using tail-cuff method. After six months, the rats were sacrificed and the aortic arches were dissected for morphometric and immunohistochemical analyses. FPO group showed significantly lower blood pressure than all other groups. Blood pressure was increased significantly in 5HPO and 10HPO groups. The aortae of 5HPO and 10HPO groups showed significantly increased thickness and area of intima-media, circumferential wall tension, and VCAM-1 than other groups. Elastic lamellae were disorganised and fragmented in 5HPO- and 10HPO-treated rats. VCAM-1 expression showed a significant positive correlation with blood pressure. In conclusion, prolonged consumption of repeatedly heated palm oil causes blood pressure elevation, adverse remodelling, and increased VCAM-1, which suggests a possible involvement of inflammation.

Matched MeSH terms: Hypotension
Fulltext Doing less is better: challenges in complex polytrauma management - case report

Farah, N.A., Johar, M.J., Ismail, M.S.

Medicine & Health, 2018;13(1):251-258.
MyJurnal

Damage control resuscitation, characterized by hemostatic resuscitation with blood products, rapid arrest of bleeding and when possible, permissive hypotension with restricted fluid load form a structured approach in managing a polytrauma patient. When complicated with traumatic rhabdomyolysis however, permissive hypotension strategy may cause more harm resulting in subsequent ischaemicreperfusion injury and acute kidney injury. We present a case involving a 20-yearold man who was rolled over by a lorry and sustained an open unstable pelvic fracture with vascular injury and left lower limb ischaemia. Permissive hypotension strategy was pursued for 4 hours prior to bleeding control in OT. This was followed by protracted surgery of 6 hours. Coagulopathy, acute kidney injury and rhabdomyolysis ensued in the post-operative period and patient succumbed to his injury on Day 3 post-trauma. Challenges and pitfalls in managing a complex polytrauma patient and recent evidences on damage control resuscitation is discussed.

Matched MeSH terms: Hypotension
Fulltext Intraocular pressure: the effect of short-term fasting and its association with fluid and fat status

Nur Raihan Esa, Nor Azwani Mohd Shukri, Norsham Ahmad, Mohd Radzi Hilmi, Md Muziman Syah Md Mustafa, Nura Syahiera Ibrahim, et al.

Malaysian Journal of Medicine and Health Sciences, 2020;16(2):180-186.
MyJurnal

Introduction: Short-term fasting may influence intraocular pressure (IOP) due to alteration of fluid (total body water;
TBW, and water intake) and fat (total body fat; TBF). This study aimed: i) to compare IOP values within and between,
fasting and non-fasting periods; and ii) to assess the association between IOP and, TBW and TBF. Methods: Thirty
healthy participants aged 21.8±1.1 years were assessed on two different periods (fasting vs. non-fasting). During each
period, the IOP, TBW and TBF values were assessed for four times (morning, afternoon, evening, late-evening). The
IOP was measured using AccuPen® tonopen, while TBW and TBF were assessed by using a Tanita body composition
analyser. Results: During fasting, the IOP value in the afternoon (14.53±2.33 mmHg) was significantly higher than in
the evening (12.43±2.73 mmHg, p=0.009) and late-evening (12.60±2.44 mmHg, p=0.003). No significant difference
in IOP was observed during non-fasting period. The mean of IOP in the evening was significantly lower during fasting
compared to non-fasting (12.43±2.73 mmHg vs 13.75±2.53 mmHg, p=0.044). The IOP and TBW were negatively
correlated (r=-0.268; p=0.011) during non-fasting and showed no association during fasting period. There was no
significant correlation between IOP and TBF during both fasting and non-fasting periods. Conclusion: IOP reduction
during short-term fasting, together with the no association with TBF and TBW suggested that IOP is an independent
factor that reduces during fasting in healthy population.

Matched MeSH terms: Ocular Hypotension

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