Hypotension in Cirrhosis

Vora, Ravi; Subramanian, Ram

doi:10.1002/cld.764

Cited by 11 publications

(7 citation statements)

References 10 publications

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“…This results in the activation of neurohumoral mechanisms aimed at maintaining adequate tissue perfusion, including beta-adrenergic signaling and the renin-angiotensin-aldosterone system. In patients with portal hypertension, these mechanisms increase cardiac contractility and promote salt and water retention[ 7 ]. When a severe infection ensues, macrovascular[ 8 , 9 ] and microvascular[ 10 ] vasodilatory effects are exaggerated, further decreasing the effective circulating volume and potentiating the neurohumoral response (Figure 1A ).…”

Section: Pathophysiology Of Portal Hypertensionmentioning

confidence: 99%

“…Although patients with cirrhosis were underrepresented in these trials, recent epidemiologic studies suggest parallel improvement in survival among this subset, indicating that management in the ICU is warranted[ 3 - 6 ]. While patients with compensated cirrhosis may respond to the same interventions and may have comparable outcomes to those without cirrhosis[ 7 ], patients with decompensated cirrhosis and clinically significant portal hypertension have marked local and systemic hemodynamic aberrations and hepatic functional impairment that may profoundly impact their management and prognosis. Consequently, the care of these patients should be appropriately tailored based on their unique pathophysiology.…”

Section: Introductionmentioning

confidence: 99%

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Emerging concepts in the care of patients with cirrhosis and septic shock

Jiménez¹,

Garcia‐Tsao²,

Saffo³

2023

World J Hepatol

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Septic shock impacts approximately 6% of hospitalized patients with cirrhosis and is associated with high rates of morbidity and mortality. Although a number of landmark clinical trials have paved the way for incremental improvements in the diagnosis and management of septic shock in the general population, patients with cirrhosis have largely been excluded from these studies and critical knowledge gaps continue to impact the care of these individuals. In this review, we discuss nuances in the care of patients with cirrhosis and septic shock using a pathophysiology-based approach. We illustrate that septic shock may be challenging to diagnose in this population in the context of factors such as chronic hypotension, impaired lactate metabolism, and concomitant hepatic encephalopathy. Furthermore, we demonstrate that the application of routine interventions such as intravenous fluids, vasopressors, antibiotics, and steroids should be carefully considered among those with decompensated cirrhosis in light of hemodynamic, metabolic, hormonal, and immunologic disturbances. We propose that future research should include and characterize patients with cirrhosis in a systematic manner, and clinical practice guidelines may need to be refined accordingly.

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Section: Pathophysiology Of Portal Hypertensionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Emerging concepts in the care of patients with cirrhosis and septic shock

Jiménez¹,

Garcia‐Tsao²,

Saffo³

2023

World J Hepatol

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“…A baseline hypotension with mean arterial pressure (MAP) of 60–65 mmHg is commonly seen and well tolerated in stable cirrhotic patients through compensatory mechanisms to maintain organ perfusion. Subtle insults, such as propofol sedation, may result in significant hypotension and even circulation compromise 7 . Moreover, increased distribution volume 8 may increase propofol dosage, which may further deteriorate hemodynamic instability during the procedure and delay recovery after the procedure.…”

Section: Introductionmentioning

confidence: 99%

“…Subtle insults, such as propofol sedation, may result in significant hypotension and even circulation compromise. 7 Moreover, increased distribution volume 8 may increase propofol dosage, which may further deteriorate hemodynamic instability during the procedure and delay recovery after the procedure. A combination of opioids and propofol for endoscopic procedures can decrease the total dosage of propofol as well as its cardiovascular side-effects, 9,10 but respiratory depression caused by opioids is a major concern for cirrhotic patients, especially for patients with massive ascites.…”

Section: Introductionmentioning

confidence: 99%

Safety and tolerability of esketamine in propofol based sedation for endoscopic variceal ligation with or without injection sclerotherapy: Randomized controlled trial

Chen

Wang

et al. 2023

Digestive Endoscopy

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ObjectivesEsketamine is an S (+) enantiomer of ketamine with greater potency and similar psychomimetic effects compared to racemic ketamine. We aimed to explore the safety of esketamine in different doses as an adjuvant to propofol in patients undergoing endoscopic variceal ligation (EVL) with or without injection sclerotherapy.MethodsOne hundred patients were randomized to receive sedation with propofol 1.5 mg/kg in combination with sufentanil 0.1 μg/kg (group S), esketamine 0.2 mg/kg (group E0.2), esketamine 0.3 mg/kg (group E0.3), or esketamine 0.4 mg/kg (group E0.4) for EVL (n = 25 each). Hemodynamic and respiratory parameters were recorded during the procedure. The primary outcome was the incidence of hypotension; secondary outcomes included the incidence of desaturation, positive and negative syndrome scale (PANSS) after the procedure, pain score after the procedure, and secretion volume.ResultsThe incidence of hypotension was significantly lower in groups E0.2 (36%), E0.3 (20%), and E0.4 (24%) than in group S (72%). The incidence of SpO2 ≤94% was significantly lower in group E0.4 (4%) than in group S (32%). No significant intergroup difference was found in the PANSS assessment.ConclusionsCombining 0.4 mg/kg esketamine with propofol sedation was optimal to facilitate EVL with stable hemodynamic status and better respiratory function during the procedure, without significant psychomimetic side‐effects.Trial registrationChinese Clinical Trial Registry (Trial ID: ChiCTR2100047033, http://www.chictr.org.cn/showproj.aspx?proj=127518).

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“…For example, patients with advanced heart failure or cirrhosis may develop hypotension. Clinical trials have shown that low blood pressure occurs in 10%−15% of patients with heart failure, 11 while hypotension is also a complication of cirrhosis stemming from portal hypertension which results in splanchnic and systemic vasodilation 12 . Therefore, multiple factors may account for the observed association between systolic blood pressure reading ≥140 mmHg and in‐hospital mortality.…”

Section: Discussionmentioning

confidence: 99%

Systolic blood pressure levels and mortality in Australian medical inpatients

Tsang,

Bacchi,

Kovoor

et al. 2023

J of Clinical Hypertension

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The epidemiology of elevations in blood pressure is incompletely characterized, particularly in Australia. Given the lack of evidence regarding the frequency and the optimal management of in‐hospital hypertension, the authors performed a multicenter retrospective cohort study of consecutive medical admissions in South Australia over a 2‐year period to investigate systolic blood pressure levels and their association with in‐hospital mortality. Among 16 896 inpatients, 76% had at least one systolic blood pressure reading of ≥140 mmHg and 11.7% of ≥180 mmHg during hospitalization. A statistically significant negative relationship was observed between having at least one reading ≥140 mmHg and a likelihood of in‐hospital mortality (odds ratio 0.41, 95% CI: 0.35 to 0.49, P < .001). Our results suggest that elevations in systolic blood pressure are common in Australian medical inpatients. However, the inverse association observed between systolic blood pressure values ≥140 mmHg and in‐hospital mortality warrants further research to determine the clinical significance and optimal management of blood pressure elevations in this group.

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Hypotension in Cirrhosis

Abstract: http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/13-6-reading-vora a video presentation of this article Answer questions and earn https://www.wileyhealthlearning.com/Activity/6798610/disclaimerspopup.aspx

Cited by 11 publications

References 10 publications

Emerging concepts in the care of patients with cirrhosis and septic shock

Emerging concepts in the care of patients with cirrhosis and septic shock

Safety and tolerability of esketamine in propofol based sedation for endoscopic variceal ligation with or without injection sclerotherapy: Randomized controlled trial

Systolic blood pressure levels and mortality in Australian medical inpatients

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