Hypertensive urgencies-emergencies are important and common events. They are defined as a severe elevation in BP, higher than 180/120 mmHg, associated or not with the evidence of new or worsening organ damage for emergencies and urgencies respectively. Anamnestic information, physical examination and instrumental evaluation determine the following management that could need oral (for urgencies) or intravenous (for emergencies) anti-hypertensives drugs. The choice of the specific drugs depend on the underlying causes of the crisis, patient's demographics, cardiovascular risk and comorbidities. For emergencies a maximum BP reduction of 20-25% within the first hour and then to 160/110-100 over next 2-6 h, is considered appropriate with a further gradual decrease over the next 24-48 h to reach normal BP levels. In the case of hypertensive urgencies, a gradual lowering of BP over 24-48 h with an oral medication is the best approach and an aggressive BP lowering should be avoided. Subsequent management with particular attention on chronic BP values control is important as the right treatment of the acute phase.
Background: Venovenous ECMO is a lifesaving technique for patients with severe respiratory failure. Management of carbon dioxide (CO2) levels at ECMO start is crucial, as recent studies found an association between rapid CO2 shifts and increased incidence of neurological complications. Purpose: To describe the role of end tidal CO2 (etCO2) monitoring at the ECMO start to minimize carbon dioxide shifts. Research design: Retrospective cohort study. Methods: We performed a retrospective analysis of patients who started venovenous ECMO support at our institution between 2011 and 2021. We analysed the minute-by-minute variations of etCO2, ventilatory parameters and arterial blood gas before and after the ECMO start. Results: 36 patients with a complete dataset of parameters were included. After the ECMO start, minute ventilation was progressively reduced from 10.8±;3.3 to 2.9±1.2 L/min (p<0.001). etCO2 did not vary significantly (baseline 37±10 vs 35±9 mmHg 20 minutes after ECMO start, p = 0.36). Despite a stable etCO2 level, a mild drop of arterial CO2 tension (9.5 mmHg, corresponding to a 18% change) was recorded at the first ABG sampled after the ECMO start. No patient developed neurological complications after the ECMO commencement. Conclusion: etCO2 monitoring during ECMO start is feasible and allows to adjust gas flow and ventilator settings to limit changes in arterial CO2 levels.
Objective: Definitive data on acute management of Blood Pressure (BP) in neurological Hypertensive Emergencies (HE) are still lacking. Aim of our study was to evaluate BP values and management as a determinant of in-hospital mortality and early complications in stroke patients. Design and method: We collected data of 267 patients, who presented with ischemic stroke and BP > 180/120 mmHg at the Emergency Department of Niguarda Hospital from 2015 to 2017. In-hospital mortality, hospitalization length and discharge disability (evaluated with modified Rankin score – mRs) were considered as outcomes. Results: Mean age was 75.7 ± 11.7 years with SBP values of 194.9 ± 14.9 mmHg at admission. 34.8% of the patients received anti-hypertensive treatment with those achieving a higher SBP reduction in comparison with the untreated one (dSBP 37.8 ± 26.8 mmHg vs 30.7 ± 20.8 mmHg p = 0.034). At the multivariate analysis in the overall population, no SBP values are related to all causes in-hospital mortality. Instead, higher admission SBP relates to high discharge disability and hospitalization length. Furthermore, SBP values at admission in Emergency Department appear as disability determinants in patients who did not receive systemic thrombolysis and in patients who did not receive antihypertensive drugs. In these two subgroups, higher SBP values at department entrance determine a higher in-hospital mortality. Conclusions: In overall population, no BP values are related to all causes in-hospital mortality while higher admission BP relates to high disability and hospitalization length.
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