Central Haemodynamics and Prediction of Cardiovascular Events in Patients With Erectile Dysfunction

BACKGROUND

We investigated whether central hemodynamics predict major adverse cardiovascular events (MACEs) in erectile dysfunction (ED) patients beyond traditional risk factors.

METHODS

MACEs in relation to aortic pressures and augmentation index (AIx) were analyzed in 398 patients (mean age, 56 years) with ED but without established cardiovascular (CV) disease.

RESULTS

During the mean follow-up period of 6.5 years, a total of 29 (6.5%) MACEs occurred. The adjusted relative risk of MACEs was 1.062 (95% confidence interval (CI), 1.016-1.116) for a 10-mm Hg increase of aortic systolic pressure, 1.119 (95% CI, 1.036-1.155) for a 10-mm Hg increase of aortic pulse pressure (PP), and 1.191 (95% CI, 1.056-1.372) for a 10% absolute increase of AIx. While aortic pressures and AIx did not significantly improve the C-statistic models, the calibration for all indices was satisfactory. Regarding reclassification, the integrated discrimination improvement index (IDI) indicated improvement in risk discrimination of the models that included AIx and aortic PP compared to the reference model in identifying MACEs (IDI = 0.0069; P = 0.024, and IDI = 0.0060; P = 0.036, respectively). The based on categories for 10-year coronary heart disease risk and adapted at 6.5 years overall net reclassification index showed marginal and indicative risk reclassification for AIx (15.7%, P = 0.12) and aortic PP (7.2%, P = 0.20) respectively.

CONCLUSIONS

Our results show for the first time that higher central pressures and AIx are associated with increased risk for a MACE in ED patients without known CV disease. Considering the adverse prognostic role of central hemodynamics on outcomes, the present findings may explain part of the increased CV risk associated with ED.

CVP and PAoP Measurements Are Discordant During Fluid Therapy After Traumatic Brain Injury

The objective of the study was to compare measurements of central venous pressure (CVP) and pulmonary artery occlusion pressures (PAoP) as estimates of intravascular volume during the first 96 hours of fluid therapy after traumatic brain injury (TBI). One thousand five hundred ten simultaneous CVP and PAoP measurements from 31 patients entered into the National Acute Brain Injury Study: Hypothermia (NABISH:H) protocol were retrospectively compared. The effect of fluid administration and body temperature upon the paired measurements was statistically assessed. Agreement between CVP and PAoP values was poor. The CVP and PAoP were equal in only 11% of paired values. The CVP was always higher than PAoP in 1 patient, whereas PAoP always exceeded the CVP in 5 others. In 74% of the pairs, the PAoP was higher than the CVP, whereas in 15%, CVP was greater than PAoP. For any CVP measurement, the PAoP was either 3 mm Hg above or below the CVP in 67% of the pairs and at least 5 mm Hg above or below the CVP in 21% of the pairs. In 21 (68%) patients, PAoP was= 5 mm Hg above CVP in more than 4 readings, a clinically important difference. Discordance was not attributed to the fluid administered or to the temperature protocol. Neurological outcome appears affected by the volume of fluid administration. However, during initial therapy, estimates of intravascular volume provided by the CVP and PAoP are discordant. Although documented in other clinical conditions, the disparity noted here after TBI has not been previously reported. Assessment of intravascular volume to avoid hypovolemia should utilize other measurement techniques.

Vena cava compression syndrome in patients with obesity presenting with edema and thrombosis

OBJECTIVE

Obesity is a risk factor for cardiovascular disease and venous thrombosis. Previous studies have shown that in late pregnancy a compression of the inferior vena cava (VCI) leads to a hypotensive syndrome. The objective of this study was to explore the correlation between obesity and an elevated pressure in the VCI simulating obesity-induced vena cava compression syndrome.

METHODS

A left and right heart catheterization was performed in 29 patients. After right atrial pressure measurement, the catheter was pulled back through the VCI, and the pressure gradient between the thoracic and abdominal vena cava was measured. We determined the correlation between the BMI and the pressure gradient.

RESULTS

In 29 patients, a high BMI was associated with an increased pressure gradient between the thoracic and abdominal vena cava (r = 0.66). This correlation was particularly close in patients with a BMI >30 kg/m(2) (P = 0.0008). Two patients had complications such as recurrent thrombosis, with one of them having the highest pressure gradient of 16 mm Hg.

CONCLUSIONS

Because mechanical obstruction of the VCI leads to an increased risk for venous thrombosis in patients with obesity, this finding needs to be considered in the decision-making for interventional treatments like bariatric surgery.

Seventy-two hour gas exchange performance and hemodynamic properties of NOVALUNG®iLA as a gas exchanger for arteriovenous carbon dioxide removal

Objective: Acute respiratory failure is complicated by acidosis and altered end-organ perfusion. NOVA-LUNG®iLA is an interventional lung assist (ILA) device for arteriovenous carbon dioxide removal (AVCO2R). The present study was conducted to evaluate the device for short-term CO2 removal performance and hemodynamic response.

Methods: Six adult sheep received cannulation of the jugular vein and carotid artery. The ILA-AVCO2R circuit was placed on the sheep for 72 hours. Hemodynamics and PaCO2 were measured; CO2 removal was calculated while varying sweep gas flow rates (Qg), device blood flow rates (Qb), and PaCO2.

Results: Hemo-dynamic variables remained normal throughout the 72 hour study. CO2 removal increased with increases in Qgor Qb. Mean CO2 removal was 119.3 ml/min for Qb 1L/min, Qg 5 L/min, and PaCO2 40 - 50 mmHg.PaCO2 was directly proportional to CO2 clearance (R-0.72, p B/0.001).

Conclusion: NOVALUNG®iLA can provide near total CO2 removal with Qb 1 - 2 L/min,Qg 5 L/min, and minimal flow resistance (3.889/0.82 mmHg/L/min). PaCO2 correlates with CO2 removal and is dependent on Qb and Qg.

ANESTHETIC MANAGEMENT DURING COMBINED LIVER AND KIDNEY TRANSPLANTATION

Combined liver and kidney transplantation is a highly demanding and challenging procedure for anesthesiologists due to the lengthy and complicated nature of the procedure, the critical patient condition and the need to balance the intravascular volume to maintain the venous outflow of the hepatic allograft and also the diuresis of the renal allograft. Intravascular volume management and coagulation control, seem to be the most important issues during combined liver and kidney transplantation. There is sparsity of data in the literature concerning the anesthetic and fluid management in CLKT. We present and discuss the anesthetic management in a case series in three patients, who underwent combined liver and kidney transplantation in our institution during the last two years.

Intraoperative hemodynamics predict postoperative mortality in orthotopic liver transplantation

Liver transplantation remains the only curative treatment option for a variety of end-stage liver diseases. Prediction of major adverse events following surgery has traditionally focused on static predictors that are known prior to surgery. The effects of intraoperative management can now be explored due to the archiving of high-resolution monitoring data. We extracted intraoperative hemodynamic trend data of 55 patients undergoing orthotopic liver transplantation (OLT) and computed 12 features from the systolic arterial blood pressure (ABP), cardiac index, central venous pressure (CVP), and stroke volume variation (SVV) signals. Using a logistic regression classifier with a leave-one-out cross-validation procedure, we selected subsets of these features to predict mortality up to 180 days after surgery. Best performance was achieved with a combination of 3 features - median absolute deviation (MAD) of ABP, median CVP, and time spent with SVV <; 10% - reaching an area under the receiver-operating characteristic (or c-statistic) of 0.808. Odds ratios (OR) computed from the coefficients of the multivariate logistic regression model constructed from these features showed that greater time spent with SVV <; 10% (OR = 0.981 min(-1), p = 0.001) and greater MAD of systolic ABP (OR = 0.696 mmHg(-1), p = 0.026) were significantly associated with survival. Adding preoperative measures such as age and serum concentrations of albumin, bilirubin, and creatinine failed to improve performance of the prediction model. These results show that the course of intraoperative hemodynamics can predict 180-day mortality after OLT.

[Effect of esmolol on fluid responsiveness and hemodynamic parameters in patients with septic shock]

OBJECTIVE

To study the effects of esmolol on fluid responsiveness and hemodynamic parameters in patients with septic shock.

METHODS

A prospective self-control study was conducted. Fifteen septic shock patients undergoing mechanical ventilation admitted to Department of Critical Care Medicine of Yijishan Hospital from January 2015 to August 2015 were enrolled. All patients enrolled in this study were given the treatment based on American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) Consensus 2012. Esmolol was intravenously injected at a beginning rate of 6 mg · kg⁻¹ · h⁻¹, and then the dose was adjusted to reduce heart rate by 10% from baseline. The changes in hemodynamic and systemic oxygen metabolism indexes were monitored by pulse indicator continuous cardiac output (PiCCO) before and 2 hours after the esmolol administration, and the fluid responsiveness was evaluated by stroke volume variation (SVV). SVV ≥ 10% was considered to be a positive fluid responsiveness.

RESULTS

In 15 patients, 9 were male and 6 female, with an age of 65 ± 16. Among them 10 patients suffered from pulmonary infection, and 5 patients with abdominal infection. Acute physiology and chronic health evaluation II (APACHE II) score was 21 ± 9; sequential organ failure score (SOFA) was 8 ± 4.28-day mortality was 40.0%. SVV was significantly decreased after esmolol infusion as compared with baseline [(14 ± 5)% vs. (17 ± 7)%, t = 2.400, P = 0.031]. Heart rate [HR (bpm): 100 ± 4 vs. 112 ± 8, t = 8.161, P = 0.000], cardiac output [CO (L/min): 6.13 ± 1.45 vs. 7.88 ± 1.82, t = 4.046, P = 0.001], cardiac index [CI (mL · s⁻¹ · m⁻²): 51.51 ± 11.00 vs. 66.18 ± 11.48, t = 4.131, P = 0.001], stroke volume index [SVI (mL/m²): 31.0 ± 6.4 vs. 35.4 ± 6.5, t = 2.577, P = 0.020], the maximum rate of left ventricular pressure rise [dp/dt max (mmHg/s): 927 ± 231 vs. 1,194 ± 294, t = 3.775, P = 0.002], global ejection fraction (GEF: 0.21 ± 0.05 vs. 0.24 ± 0.06, t = 3.091, P = 0.008), cardiac function index (CFI: 5.03 ± 1.37 vs. 6.59 ± 1.92, t = 4.769, P = 0.000) showed significant decrease during esmolol infusion. On the other hand, central venous pressure [CVP (mmHg, 1 mmHg = 0.133 kPa): 9 ± 3 vs. 8 ± 3, t = -3.617, P = 0.003], diastolic blood pressure (DBP, mmHg: 69 ± 15 vs. 66 ± 13, t = -2.656, P = 0.019), systemic vascular resistance index (SVRI, kPa · s · L⁻¹ · m⁻²: 206.8 ± 69.8 vs. 206.8 ± 69.8, t = -3.255, P = 0.006 ) were significantly increased during esmolol infusion. No significant difference was found in systolic blood pressure [SBP (mmHg): 120 ± 25 vs. 123 ± 18, t = 0.678, P = 0.509], mean arterial pressure [MAP (mmHg): 86 ± 18 vs. 85 ± 14, t = -0.693, P = 0.500], global end diastolic volume index [GEDVI (mL/m²): 614 ± 84 vs. 618 ± 64, t = 0.218, P = 0.830], extravascular lung water index [EVLWI (mL/kg): 5.99 ± 1.50 vs. 5.73 ± 1.14, t = -1.329, P = 0.205], central venous oxygen saturation (ScvO₂: 0.711 ± 0.035 vs. 0.704 ± 0.048, t = -0.298, P = 0.773), arterial blood lactate [Lac (mmol/L): 3.1 ± 0.3 vs. 3.0 ± 0.4, t = -0.997, P = 0.345], and difference of central venous-arterial carbon dioxide partial pressure [Pcv-aCO₂ (mmHg): 4.1 ± 0.9 vs. 4.7 ± 0.5, t = 1.445, P = 0.182] as compared with those before esmolol treatment.

CONCLUSION

Heart rate control with esmolol infusion may reduce fluid responsiveness, cardiac function, heart rate and cardiac output without adverse effect on systemic perfusion in septic shock patients.

[Improvement effect of early goal-directed therapy on the prognosis in patients with septic shock]

OBJECTIVE

To evaluate the effect of the early goal-directed therapy (EGDT) on mortality in patients with septic shock, and to analyze the risk factors of mortality.

METHODS

A retrospective controlled study was conducted. Complete clinical data of patients with septic shock admitted to emergency intensive care unit (EICU) of Sichuan Provincial People's Hospital from May 1994 to December 2014 were recorded and analyzed. According to the International Guidelines for Management of Severe Sepsis and Septic Shock ( SSC ) with the time of promulgation as dividing point, the patients were divided into two groups as before and after the publication of the guideline, i.e. early group (from May 1994 to April 2004) and late group (from May 2004 to December 2014). The patients of the late group were subdivided into 6-hour and 24-hour reaching standard groups and non-reaching standard group according to the time of reaching standard of EGDT. All patients were divided into death group and survival group according to the 28-day survival. The patients in early group were not treated according to EGDT guidance, so only age, the case history of chronic disease, the main site of infection, organ dysfunction, vital signs, urine output, the amount of fluid for resuscitation, blood routine, blood gas analysis, time for starting antibiotics treatment, the use of vasoactive drugs and hormone, etc. were recorded. The central venous pressure (CVP), central venous oxygen saturation (ScvO₂), blood lactate (Lac), and the monitor of other parameters of patients in late group were consummated late. The relationship of EGDT compliance standard time and tissue perfusion index recovery time between the two groups of patients was observed. The risk factor for mortality was analyzed by multiple factors logistic regression.

RESULTS

(1) 134 patients were included, and the overall 28-day mortality was 49.25%. (2) The 6-hour EGDT compliance rate of early group was 0 (0/58), and it was 28.95% (22/76) in late group (χ² = 20.087, P = 0.000). Compared with the early group, the 6-hour urine volume in the late group was significantly increased (mL · h⁻¹ · kg⁻¹: 1.72 ± 1.04 vs. 0.89 ± 0.24, t = 11.950, P = 0.001), 6-hour mean arterial pressure (MAP, mmHg, 1 mmHg = 0.133 kPa) was elevated (64.24 ± 3.90 vs. 56.21 ± 5.95, t = 6.444, P = 0.012), the use of antibiotics within 1 hour was increased (76.32% vs. 48.28%, χ² = 11.250, P = 0.001), the use of vasocative drugs (21.05% vs. 89.66%, χ² = 61.942, P = 0.000) and hormone (8.57% vs. 34.48%, χ² = 14.871, P = 0.000) were lowered, and the 28-day mortality rate was lowered significantly [34.21% (26/76) vs. 68.96% (40/58), χ² = 15.897, P = 0.000]. The difference was not statistically significant in the total recovery of liquid volume between late group and early group (mL: 1,856.31 ± 805.81 vs. 1,903.1 ± 897.11, t = 0.101, P = 0.752). (3) In all patients, it was shown by single factor analysis that the age, infection sites , altered mental status at admission, white blood cell (WBC) before treatment, 6-hour urine output after treatment, the number of organ with failure, the use of antibiotics within 1 hour, and incidence of acute renal injury (AKI) or acute lung injury/acute respiratory distress syndrome (ALI/ARDS) within 24 hours were risk factors of 28-day death (P < 0.05 or P < 0.01). In the late group, it was shown by single factor analysis that the age, the case history of chronic disease, infection sites, WBC, pH value, Lac, and ScvO₂ before treatment, 6-hour urine output after treatment, the number of organ with failure, the use of antibiotics within 1 hour, and incidence of AKI or ALI/ARDS within 24 hours were risk factors of 28-day death (P < 0.05 or P < 0.01). It was shown by the logistic regression analysis that aging [odds ratio (OR) = 4.81, P = 0.02], failure of 2 organs (OR = 28.63, P = 0.00) or ≥ 3 organs (OR = 62.69, P = 0.00) were the independent risk factors for mortality in patients with septic shock. (4) The 76 patients of late group were subdivided into three groups, namely 6-hour reaching standard of EGDT group (n = 22), 24-hour reaching standard of EGDT group (n = 28), and non-reaching standard of EGDT group (n = 28). Compared with those before treatment, the Lac after therapy was decreased obviously both in 6-hour EGDT group and 24-hour EGDT group, and the CVP, MAP, and ScvO2 were increased significantly. The Lac in 6-hour EGDT group was lowered more significantly as compared with that in 24-hour EGDT group (mmol/L: 1.64 ± 0.40 vs. 3.01 ± 1.13, P < 0.01), while MAP and ScvO2 were increased significantly [MAP (mmHg): 81.82 ± 18.01 vs. 69.01 ± 9.63; ScvO₂: 0.718 ± 0.034 vs. 0.658 ± 0.036, P < 0.05 and P < 0.01]. The urine output in both reaching standard of EGDT groups was more than 0.5 mL · h⁻¹ · kg⁻¹ without statistically different significance. The 28-day mortality rate of 24-hour EGDT group was 14.29%, and it was 0 in 6-hour EGDT group.

CONCLUSIONS

Mortality was as high as 68.96% during 10 years when the period before the use of 2004 SSC, and the mortality rate was lowered to 34.21% during 10 years during which the early fluid resuscitation treatment was based on EGDT. Aging and failure of more than 2 organs were independent risk factors for mortality in patients with septic shock. Compared with reaching the standard of EGDT within 24 hours, reaching the standard of EGDT within 6 hours can rapidly reverse hypoxic-ischemic tissue, thereby improving the prognosis of the patient with lowering of mortality rate.

Early Fluid Resuscitation and High Volume Hemofiltration Decrease Septic Shock Progression in Swine

This study aimed to assess the effects of early fluid resuscitation (EFR) combined with high volume hemofiltration (HVHF) on the cardiopulmonary function and removal of inflammatory mediators in a septic shock swine model. Eighteen swine were randomized into three groups: control (n = 6) (extracorporeal circulating blood only), continuous renal replacement therapy (CRRT) (n = 6; ultrafiltration volume = 25 mL/Kg/h), and HVHF (n = 6; ultrafiltration volume = 85 mL/Kg/h). The septic shock model was established by intravenous infusion of lipopolysaccharides (50 µg/kg/h). Hemodynamic parameters (arterial pressure, heart rate, cardiac output, stroke volume variability, left ventricular contractility, systemic vascular resistance, and central venous pressure), vasoactive drug parameters (dose and time of norepinephrine and hourly fluid intake), pulmonary function (partial oxygen pressure and vascular permeability), and cytokines (interleukin-6 and interleukin-10) were observed. Treatment resulted in significant changes at 4-6 h. HVHF was beneficial, as shown by the dose of vasoactive drugs, fluid intake volume, left ventricular contractility index, and partial oxygen pressure. Both CRRT and HVHF groups showed improved removal of inflammatory mediators compared with controls. In conclusion, EFR combined with HVHF improved septic shock in this swine model. The combination decreased shock progression, reduced the need for vasoactive drugs, and alleviated the damage to cardiopulmonary functions.

[The application of combined central venous pressure and oxygen metabolism parameters monitoring in diagnosing septic shock-induced left ventricular dysfunction]

OBJECTIVE

To evaluate the value of central venous pressure (CVP), central venous oxygen saturation (ScvO₂) and venous-arterial carbon dioxide partial pressure gradient (Pv-aCO₂)) in the diagnosis of septic shock-induced left ventricular dysfunction.

METHODS

Consecutive patients with septic shock were enrolled from September 2013 to September 2014 in ICU at Peking Union Medical College Hospital. The data of CVP, Pv-aCO₂) and ScvO₂) were recorded and analyzed. According to the left ventricular ejection fraction (LVEF) tested by bedside echocardiography, the patients were divided into two groups: new onset of left ventricular dysfunction (LVEF < 50%) group and non-left ventricular dysfunction (LVEF ≥ 50%) group. A diagnostic model was created by logistic regression. The diagnostic performance and cut-off values of CVP, Pv-aCO₂, ScvO₂) were determined using receiver operating characteristic (ROC) curve analysis.

RESULTS

Among 93 patients enrolled, 39 were diagnosed with left ventricular dysfunction. In the new onset group, CVP [(12.5 ± 3.9) mmHg (1 mmHg = 0.133 kPa) vs (10.4 ± 2.5) mmHg; P = 0.005] and Pv-aCO₂[(7.5 ± 3.9) mmHg vs (4.5 ± 2.6) mmHg; P < 0.001] were significantly higher than those in the non-left ventricular dysfunction group, while Scv2 [(62.4 ± 10.5)% vs (72.6 ± 9.0)%; P < 0.001] was significantly lower. As far as the diagnostic value of these three parameters were concerned for left ventricular dysfunction, the sensitivity of CVP ≥ 12.5 mmHg was 46.2%, specificity 81.5% with an area under ROC curve (AUCROC) 0.674; the sensitivity of Pv-aCO₂≥ 5.0 mmHg 76.9%, specificity 37.0%, AUCROC 0.738; the sensitivity of ScvO₂≤ 65.8% 64.1%, specificity 78.6%, AUCROC 0.775. When the cut-off values were determined by ROC, the diagnostic performance of the model was ≥ 0.377 with the sensitivity, specificity and AUCROC 82.1%, 79.6% and 0.835, respectively.

CONCLUSION

In patients with septic shock, the logistic regression model established by CVP, Pv-aCO₂and ScvO₂contributes to the diagnosis of septic shock-induced left ventricular dysfunction.

[Esmolol improves clinical outcome and tissue oxygen metabolism in patients with septic shock through controlling heart rate]

OBJECTIVE

To investigate whether esmolol could improve clinical outcome and tissue oxygen metabolism by controlling heart rate (HR) in patients with septic shock.

METHODS

A single-center double-blinded randomized controlled trial was conducted. The patients suffering from septic shock received 6-hour early goal directed herapy (EGDT) with pulmonary artery wedge pressure ≥ 12 mmHg (1 mmHg = 0.133 kPa) or central venous pressure CVP) ≥ 12 mmHg requiring norepinephrine to maintain mean arterial pressure (MAP) ≥ 65 mmHg and HR ≥ 95 bpm admitted to intensive care unit (ICU) of Guangdong General Hospital from September 2013 to September 2014 were enrolled. They were randomly divided into esmolol group and control group by computer-based random number generator. All patients received conventional basic treatment, while those in the esmolol group received in addition persistent esmolol infusion by micro pump with dosage of 0.05 mg · kg(-1) · min(-1) with the dosage adjusted to maintain HR lower than 100 bpm within 24 hours. The patients in control group did not receive drug intervention for HR. The primary end-points consisted of length of stay in ICU and 28-day mortality. The secondary end-points included hemodynamic parameters [HR, MAP, CVP, cardiac index (CI), stroke volume index (SVI), systemic vascular resistance index (SVRI)] and tissue oxygen metabolism parameters [central venous oxygen saturation (ScvO2), lactate level (Lac)] before and 24, 48, 72 hours after the treatment.

RESULTS

A total of 48 patients with septic shock were enrolled with 24 patients in esmolol group and 24 in control group. (1) The primary end-points: compared with control group, the length of stay in the ICU in the esmolol group was significantly shortened (days: 13.75 ± 8.68 vs. 21.70 ± 6.06, t = 3.680, P = 0.001), and 28-day mortality was significantly lowered [25.0% (6/24) vs. 62.5% (15/24 ), χ2 = 6.857, P = 0.009]. (2) The secondary end-points: there were no significant difference in the hemodynamic and tissue metabolism parameters before treatment between two groups. No significant difference was found between before and after treatment of all above parameters in control group. HR and Lac in the esmolol group were obviously declined, SVI, SVRI, SCvO2 were gradually increased, but no significant difference in MAP, CVP, and CI was found. Compared with the control group, HR in the esomolol group was significantly lowered (bpm: 84.4 ± 3.5 vs. 111.2 ± 7.2, P < 0.01), SVRI and ScvO2 were significantly increased from 24 hours [SVRI (kPa · s · L(-1) ·m(-2)): 137.9 ± 1.6 vs. 126.9 ± 1.3, ScvO2: 0.652 ± 0.017 vs. 0.620 ± 0.017, both P < 0.01]; SVI was significantly increased (mL/m2: 39.9 ± 2.2 vs. 36.8 ± 1.7, P < 0.01) and Lac level significantly declined from 48 hours (mmol/L: 2.8 ± 0.3 vs. 3.4 ± 0.3, P < 0.01).

CONCLUSION

The results demonstrate that HR controlled by a titrated esmolol infusion given to septic shock patients was associated with an improvement in tissue metabolism, reduction in the length of ICU stay and lowering of 28-day mortality.

Effect of Acute Normovolemic Hemodilution Combined with Controlled Low Central Venous Pressure on Blood Coagulation Function and Blood Loss in Patients Undergoing Resection of Liver Cancer Operation

BACKGROUND/AIMS

This paper aims to investigate the effect of acute normovolemic hemodilution (ANH) used with controlled low central venous pressure (LCVP) technology on perioperative bleeding and coagulation in hepatocellular carcinoma operation patients.

METHODOLOGY

A total of 60 cases undergoing hepatic resection operation were randomly divided into the control group, LCVP group (Group II), and ANH + LCVP group (Group III). The changes of hemodynamic indexes at different time points in each group were observed and recorded, along with the volume of allogenous blood transfusion and the number of patients undergoing allogenous blood transfusion.

RESULTS

Compared with Group I (control), there was evident reduction of the bleeding volume, allogenic blood transfusion volume, and number of patients undergoing allogenic blood transfusion in Groups II and III.

CONCLUSION

The application of ANH combined with LCVP in hepatic resection can evidently reduce intraoperative hemorrhages and homologous blood transfusions; moreover, it has no significant adverse effect on the coagulation function.

THE BENEFICIAL VALUES OF TRANSOESOPHAGEAL DOPPLER IN INTRAOPERATIVE FLUID GUIDANCE VERSUS STANDARD CLINICAL MONITORING PARAMETERS IN INFANTS UNDERGOING KASAI OPERATION

BACKGROUND

Fluid overload in infants can result from inappropriate volume expansion (VE). The aim of this work was to evaluate the beneficial values of Transoesophageal Doppler TED in intraoperative fluid guidance versus standard clinical monitoring parameters in infants undergoing Kasai operation.

METHODS

Forty infants scheduled for Kasai procedure were randomly allocated into two groups (Doppler and clinical group). In Doppler group decided to provide VE (10-30 m1/kg of Hydroxyethyl starches HES) when the index stroke volume decreased by ≥ 15% from the baseline value, in clinical group, hemodynamic variables triggering colloid administration mean arterial blood pressure (MAP) less than 20% below baseline or central venous pressure (CVP) < 5 cmH2O in both groups: Ringer's acetate was infused at constant rate (6 m 1/kg/h). Standard and TED-derived data were recorded before and after VE. Follow up the postoperative outcome and hospital stay.

RESULTS

There were significantly lower mean volume of HES (42.85 ± 3.93 versus 84 ± 14.29 ml) and percent of infants required it (30% versus 90%) associated with earlier tolerance to oral feeding (2 ± 0.66 versus 3.4 ± 0.51), shorter hospital stay (5.30 ± 0.47 versus 6.7 ± [symbols: see text] days) and lower rate of chest infection (15% versus 30%) in Doppler group than clinical group. There was no difference between the two studied groups regarding heart rate, MAP.

CONCLUSIONS

TED guided intraoperative fluid intake in infants undergoing Kasai operation optimize fluid consumption and improve outcome associated with shorter hospital stay.

Stroke Volume Variation for the Evaluation of Circulating Blood Volume after Living Donor Liver Transplantation

BACKGROUND/AIMS

Stroke volume variation (SVV) is a sensitive, functional preload index for evaluating responsiveness to volume loading in patients during liver transplantation (LT). However, there have been few reports concerning the experience of using SVV after LT.

METHODOLOGY

Of 61 patients who underwent living donor LT (LDLT) at our institute, we used only central venous pressure (CVP) to guide fluid management in the first 52 patients (conventional group) and used both SVV and CVP in the next 9 patients (SVV group). The boundary values used for fluid management were 10mmHg for CVP and 10% for SVV. Changes in SVV and CVP were compared.

RESULTS

In the SVV group, SVV was less than 10% in all patients when the diuretic phase appeared. However, CVP was more than 10mmHg in only 4 cases (44.4%). Between surgery and the removal of endotracheal tubes, the lowest the ratio between arterial oxygen tension and fractional inspired oxygen (PaO2/FiO2 ratio) in the SVV group (290.7 ± 100.5) was significantly higher than that in the conventional group (205.6 ± 98.9, P = 0.017).

CONCLUSION

Postoperative fluid management using SVV may be especially useful after LDLT. Monitoring the circulating blood volume using a 10% SVV index is useful for avoiding lung edema after LT.

[Effects on vascular permeability with different fluid resuscitation regimens during burn stage in swines]

OBJECTIVE

To explore the effects of different fluid resuscitation regimens on vascular permeability during burn stage in swines.

METHODS

A total of 24 Guangxi-BAMA miniature swines were numbered from 1 to 24 and randomly divided by EXCEL 2007 into 4 groups of succinylated gelatin, hydroxyethyl starch (HES 130/0.4), Parkland (lactated Ringer's solution) and allogeneic plasma (n = 6 each). The model of severe burn shock was established. And fluid resuscitation therapy was applied according to the established regimens of burn shock fluid resuscitation. The parameters of heart rate, blood pressure, urine volume, central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) were recorded. Blood samples were collected prior to burns and at intervals of 4, 8, 24 and 48 h post-burns. The plasma colloidal osmotic pressure was measured. Evens blue was intravenously injected at 30 min before sacrificing. Then lung tissue samples were obtained and pulmonary vascular permeability index (PMPI) was measured. Statistical analyses were performed.

RESULTS

All swines survived shock stage. The inter-group comparison revealed no statistical difference in heart rate, blood pressure, urine volume, CVP or PCWP. The plasma colloidal osmotic pressures (mmHg, 1 mmHg = 0.133 kPa) of four groups at each interval were as follows: (1) pre-burn: 25.4 ± 1.0, 25.9 ± 0.9, 25.5 ± 1.1, 25.0 ± 1.0; (2) 4 h: 24.3 ± 1.0, 25.6 ± 0.9, 13.2 ± 0.5, 25.0 ± 1.1; (3) 8 h: 23.3 ± 0.8, 25.2 ± 1.2, 12.7 ± 0.5, 24.0 ± 0.9; (4) 24 h: 22.0 ± 0.8, 23.1 ± 1.0, 12.4 ± 0.4, 23.3 ± 0.8; (5) 48 h: 22.3 ± 0.8, 24.1 ± 0.8, 18.1 ± 0.4, 23.5 ± 0.9. No statistically significant differences existed at the intervals of pre-burn between four groups (all P > 0.05). The HES 130/0.4 group at 8 h was significantly higher than that of allogeneic plasma group at the same interval (P < 0.05). The Parkland group at 4, 8, 24, 48 h were significantly lower than those of allogeneic plasma group (all P < 0.05). The succinylated gelatin group at 8, 24, 48 h, the HES 130/0.4 group at 8, 24, 48 h, the Parkland group at 4, 8, 24, 48 h and allogeneic plasma at 8, 24, 48 h decreased versus those at pre-burns (all P < 0.05). No statistically significant differences existed in pulmonary vascular permeability between the groups of succinylated gelatin (7.6 ± 0.9) µg/g, HES 130/0.4 (7.9 ± 1.8) µg/g, and allogeneic plasma (7.6 ± 1.2) µg/g, but all lower than the Parkland group (26.1 ± 2.3) µg/g (all P < 0.05).

CONCLUSIONS

Natural colloid or artificial colloid (HES 130/0.4 or succinylated gelatin) have similar effects on vascular permeability in swines with severe burns during shock stage. Both are superior to the Parkland group.

[Efficacies of fluid resuscitation as guided by lactate clearance rate and central venous oxygen saturation in patients with septic shock]

OBJECTIVE

To estimate the efficacies of fluid resuscitations as guided by lactate clearance rate (LC) and central venous oxygen saturation (ScvO₂) in patients with septic shock.

METHODS

100 patients diagnosed with septic shock from June 2012 to June 2014 in department of critical care medicine of sixteen hospitals were enrolled. They were randomly divided into two groups of study and control (each n = 50). After a diagnosis of sepsis shock, they were treated symptomatically timely and fluid resuscitation was started as early as possible according to the 2008 Guideline for Managing Sepsis & Septic Shock. Central venous pressure (CVP) ≥ 8 mmHg (1 mmHg = 0.133 kPa), mean arterial pressure (MAP) ≥ 65 mmHg, urine output ≥ 0.5 ml × kg⁻¹ × h⁻¹, ScvO₂≥ 70% and LC ≥ 10% (or lactate ≤ 2.0 mmol) served as target values for fluid resuscitation therapy in study group versus CVP ≥ 8 mmHg, MAP ≥ 65 mmHg, urine output ≥ 0.5 ml × kg⁻¹ × h⁻¹ and ScvO₂≥ 70% in control group. The general conditions and clinical characteristics, changes in CVP, MAP, urine output, ScvO₂, lactate level and/or LC before (0 hour) and every hour (1-6 h) after the start of fluid resuscitation and other related outcome indicators were recorded.

RESULTS

No significant difference existed in general data. The 28-day mortality was 40% for study group versus 56% for control group. There was no significant inter-group difference (P > 0.05). The time of mechanical ventilation and length of intensive care unit (ICU) stay were lower in study group than those in control group [mechanical ventilation time (11.200 ± 17.069) vs (15.760 ± 14.215), P = 0.150; length of ICU stay (13.240 ± 17.127) vs (23.980 ± 18.298), P = 0.003]. The 28-day mortality was independently associated with LC and ScvO₂reaching target values for fluid resuscitation in study group (χ² = 10.930, P = 0.001) while the 28-day mortality was independently associated with ScvO₂reaching target value for fluid resuscitation in control group (χ² = 6.395, P = 0.011). Among all patients, the 28-day mortality was independently associated with ScvO₂reaching target value for fluid resuscitation (χ² = 14.530, P = 0.000), but not LC (χ² = 1.175, P = 0.278).

CONCLUSION

A combination of LC and ScvO₂may serve an index in confirming the endpoint of fluid resuscitation for patients with septic shock. Fluid resuscitation therapy under the guidance of LC and ScvO₂is more accurate and reliable than the guidance of ScvO₂alone.

[Central venous-to-arterial carbon dioxide difference in critically ill pediatric patients with septic shock]

OBJECTIVE

To assess the value of central venous-to-arterial carbon dioxide difference [ P( cv-a) CO₂] in evaluation of disease severity and prognosis in children with septic shock who already had central venous oxygen saturation (ScvO₂) higher than 70% after early resuscitation.

METHOD

In this prospective study, 48 septic shock children seen in Shanghai Children's Hospital, Shanghai Jiao Tong University were enrolled from Jun 2012 to May 2014. 36(75.0%) were male, 12 (25.0%) were female, the average age was (31.9 ± 24.5) months. The critically ill patients with septic shock were treated to achieve ScvO₂greater than 70% depending on early goal-directed therapy (EGDT). All patients were divided into two groups, based on P(cv-a)CO₂, low P(cv-a)CO₂group with P(cv-a)CO₂< 6 mmHg (1 mmHg = 0.133 kPa) and high P(cv-a)CO₂group with P(cv-a)CO₂≥ 6 mmHg. The parameters of hemodynamics including mean blood pressure (MAP), heart rate (HR), central venous pressure (CVP), perfusion-related parameters [ScvO₂, P(cv-a)CO₂, serum lactate (Lac), Lac clearance rate], pediatric critical illness score, PRISMIII score, and 28 days in-hospital mortality were recorded for all patients.

RESULT

Of the 48 cases with septic shock whose ScvO₂was higher than 70%, 17 patients (35.4%) had high P(cv-a)CO₂( ≥ 6 mmHg) and 31 (65.6%) had lower P(cv-a)CO₂(<6 mmHg). There were no significant differences between the 2 groups of patients in age, PRISMIII score and PCIS (P > 0.05 ), but Lac and P(cv-a)CO₂values were significantly different ( P < 0.05). Low P(cv-a) CO₂group patients had lower 28 days mortality than high P(cv-a) CO₂group[11/17 vs. 32.3% (10/31), P < 0.05]; 24 h after resuscitation, compared with high P(cv-a) CO₂group, low P(cv-a) CO₂group patients had lower Lac values [(2.0 ± 1.3) vs.( 2.7 ± 1.2) mmol/L, P < 0.05]. Low P(cv-a) CO₂group patients had shorter duration of vasoactive drugs use [(16 ± 14) vs. (44 ± 21)h, P < 0.05], 24 h Lac clearance rate was significantly higher for low P(cv-a) CO₂group than for high P(cv-a) CO₂group[ (31 ± 10) % vs. (26 ± 6)%, P < 0.05].

CONCLUSION

When ScvO₂> 70% was achieved after early resuscitation in septic shock children, P(cv-a) CO₂is a sensitive biomarker to assess tissue perfusion, and high P(cv-a) CO₂group patients had poor outcome.

Effect of acute normovolemic hemodilution combined with controlled low central venous pressure on cerebral oxygen metabolism of patients with hepalobectomy

BACKGROUND/AIMS

The effect of acute normovolemic hemodilution (ANH) combined with controlled low central venous pressure (LCVP) on the cerebral oxygen metabolism of patients with hepalobectomy.

METHODOLOGY

Undergoing hepatic resection operation in 60 cases, were randomly divided into control group, LCVP group (Group II) and ANH + LCVP group (Group IIl). Before hemodilution (T1), decrease of CVP (T2) and increase of CVP (T3) and at the end of surgery (T4), the blood was sampled via the jugular vein bulb and radial artery for blood gas analysis.

RESULTS

Compared with group I, the CaO2 of group II at T3 and T4 was increased; in group III, CaO2 and Da-jvO2 at T2 and T3 were decreased, CjvO2 at T2 decreased, and CaO2 and CjvO2 at T4 increased. Compared with group II, CaO2, CjvO2 and Da-jvO2 of group III at T2 and T3 were decreased. CERO2 of the three groups at T3 and T4 were all decreased (P<0.05 or 0.01). The jugular venous oxygen saturation (SjvO2) and VADL of the three groups at each time point were all within the normal range.

CONCLUSION

The moderate ANH combined with LCVP had no adverse effect on the cerebral oxygen metabolism of the patients with the hepalobectomy.

Non-invasive bedside assessment of central venous pressure: scanning into the future

BACKGROUND

Noninvasive evaluation of central venous pressure (CVP) can be achieved by assessing the Jugular Venous Pressure (JVP), Peripheral Venous Collapse (PVC), and ultrasound visualization of the inferior vena cava. The relative accuracy of these techniques compared to one another and their application by trainees of varying experience remains uncertain. We compare the application and utility of the JVP, PVC, and handheld Mini Echo amongst trainees of varying experience including a medical student, internal medicine resident, and cardiology fellow. We also introduce and validate a new physical exam technique to assess central venous pressures, the Anthem sign.

METHODS

Patients presenting for their regularly scheduled echocardiograms at the hospital echo department had clinical evaluations of their CVP using these non-invasive bedside techniques. The examiners were blinded to the echo results, each other's assessments, and patient history; their CVP estimates were compared to the gold standard level 3 echo-cardiographer's estimates at the completion of the study.

RESULTS

325 patients combined were examined (mean age 65, s.d. 16 years). When compared to the gold standard of central venous pressure by a level 3 echocardiographer, the JVP was the most sensitive at 86%, improving with clinical experience (p<0.01). The classic PVC technique and Anthem sign had better specificity compared to the JVP. Mini Echo estimates were comparable to physical exam assessments.

CONCLUSIONS

JVP evaluation is the most sensitive physical examination technique in CVP assessments. The PVC techniques along with the newly described Anthem sign may be of value for the early learner who still has not mastered the art of JVP assessment and in obese patients in whom JVP evaluation is problematic. Mini Echo estimates of CVPs are comparable to physical examination by trained clinicians and require less instruction. The use of Mini Echo in medical training should be further evaluated and encouraged.

[Prognostic value of decreased vasopressin modulation in the late-phase of septic shock patients]

OBJECTIVE

To investigate the prognostic value of decreased vasopressin (VP) modulation in the late-phase of septic shock.

METHODS

A prospective study was conducted. Fifty-five septic shock patients hospitalized in intensive care unit (ICU) of the First Hospital of Hebei Medical University from January 2012 to February 2014 were enrolled. All patients received 3% hypertonic saline solution infusion. Serum concentrations of sodium and VP were measured before and after hypertonic saline solution infusion. Patients with ratio of difference in sodium and VP before and after infusion of 3% hypertonic saline (ΔVP/ΔNa)≤0.5 pg/mmol were defined as non-responders, and who >0.5 pg/mmol were defined as responders. The levels of lactic acid, C-reactive protein (CRP), and vasoactive drug [dopamine (DA) and norepinephrine (NE)] usage between the two groups were compared. The 28-day mortality, live time in the dead, and ICU day in survivors were analyzed between the two groups. The receiver operating characteristic curve (ROC curve) was drawn to assess prognostic value of VP.

RESULTS

There were 30 cases (54.5%) in non-responsive group, and 25 (45.5%) in responsive group. There were no significant differences in the age, acute physiology and chronic health evaluation II (APACHEII) score, central venous pressure (CVP), blood pressure, plasma albumin level, sodium level before and after hypertonic saline solution infusion between the two groups. The baseline level of VP in the non-responsive group was markedly lower than that of the responsive group (ng/L: 10.66 ± 1.57 vs. 17.13 ± 5.12, t=6.091, P<0.001). After hypertonic saline solution infusion, the VP level was also significantly decreased compared with that in the responsive group (ng/L: 11.65 ± 1.74 vs. 22.50 ± 5.31, t=9.758, P<0.001). The non-responders showed higher lactic acid (mmol/L: 3.04 ± 0.55 vs. 2.28 ± 0.38, t=-5.881, P<0.001) and CRP (mg/L: 117.9 ± 23.0 vs. 94.9 ± 17.0, t=-4.143, P<0.001), and received larger dosage of vasoactive drugs [DA (μg × kg⁻¹ × min⁻¹): 14.8 ± 3.9 vs. 8.9 ± 1.6, t=-5.725, P<0.001; NE (μg × kg⁻¹ × min⁻¹): 0.96 ± 0.42 vs. 0.40 ± 0.09, t=-5.625, P<0.001] for maintaining blood pressure compared with those in responders. The non-responsive group showed higher 28-day mortality (66.7% vs. 40.0%, χ² =3.911, P=0.048) and longer ICU day (days: 9.9 ± 2.3 vs. 6.7 ± 1.7, t=-4.044, P<0.001), but the live time in the dead showed no difference between non-responsive group and responsive group (days: 5.8 ± 1.9 vs. 6.1 ± 2.3, t=0.384, P=0.704). ROC curve showed that the area under ROC curve (AUC) for ΔVP/ΔNa predicting the outcome was 0.828, and the ΔVP/ΔNa threshold value of 0.5 pg/mmol had the sensitivity of 66.7% and specificity of 64.0% for prediction of the outcome (95% confidence interval: 0.722-0.934).

CONCLUSIONS

Osmotic pressure-regulated VP secretion was impaired and decreased in the late-phase of septic shock, and made the sense in prognosis.

[Role of central venous pressure, global end diastolic volume index and extravascular lung water index in evaluating fluid resuscitation in patients with septic shock]

OBJECTIVE

To explore the role of central venous pressure (CVP), global end diastolic volume index (GEDI) and extravascular lung water index (ELWI) monitoring in patients with septic shock during fluid resuscitation by pulse induced continuous cardiac output (PiCCO) test.

METHODS

Forty-six patients with severe sepsis and septic shock were enrolled in this study. Hemodynamic monitoring was performed during fluid resuscitation and the data including CVP, GEDI and ELWI were collected to analyze their relationship and the clinical values.

RESULTS

In patients with septic shock, CVP showed a weak linear correlation with GEDI during fluid resuscitation (r=0.137, P=0.009). In the subgroups stratified with CVP cut-off values of 8 mmHg and 12 mmHg, the correlation coefficient between CVP and GEDI was 0.149 (P=0.029) in CVP<8 mmHg group, 0.075 (P=0.462) in 8 mmHg ≤ CVP ≤ 12 mmHg group, and 0.049 (P=0.726) in CVP>12 mmHg group. In the total of 367 data groups obtained, CVP showed no linear correlation with ELWI (r=0.040, P=0.445). In the CVP subgroups, CVP and ELWI were weakly correlated in CVP<8 mmHg group (r=0.221, P=0.001), but they showed no correlations in 8 mmH g≤ CVP ≤ 12 mmHg and CVP>12 mmHg groups (r=-0.047, P=0.646; r=0.042, P=0.765).

CONCLUSION

There is no significant linear correlation between CVP and GEDI or between CVP and ELWI in patients with septic shock. CVP can not reflect the circulatory blood volume or the degree of pulmonary edema.

[Variations of renal vascular score and resistive indices in septic shock patients]

OBJECTIVE

To assess the variations of renal vascularization scale and resistive index in septic shock patients during the first 6 h in intensive care unit (ICU).

METHODS

A total of 39 septic shock patients were prospectively enrolled to receive echocardiographic and renal ultrasound examinations. And the data of mean arterial pressure (MAP), central venous pressure (CVP), cardiac output (CO), renal vascularization scale (VS) and resistive index (RI) were recorded.

RESULTS

Among 19 patients without an increase of CVP, 8 of them showed significant increase in MAP and CO. Six of 8 patients with increases both in MAP and CO displayed an increase of VS while only 1 out of the remaining 11 patients had an increase of VS (P = 0.027). Among 20 patients with an increase of CVP, 9 of them showed no significant increase in MAP or CO. Eight out of 9 patients without significant increase in MAP or CO displayed a decrease of VS while only 2 out of the remaining 11 patients displayed a decrease of VS (P = 0.086). They were divided into two groups according to the variations of MAP, CVP and CO respectively. No significant change of RI was found between oh and 6 h in each group.

CONCLUSION

The renal vascularization scale increases in patients with increases both in CO and MAP while CVP remains almost unchanged. No significant relationship exists between resistive index and such hemodynamic parameters as CO, MAP and CVP.

Usefulness of stroke volume index obtained with the FloTrac/ Vigileo system for the prediction of acute kidney injury after radical esophagectomy

PURPOSE

To assess the impact of stroke volume index (SVI) at the end of esophagectomy upon postoperative renal function.

METHODS

We reviewed medical records of 128 patients undergoing esophagectomy. Intraoperative hemodynamics were monitored with the FloTrac sensor/Vigileo monitor system in addition to standard monitors. Patients were divided into two groups according to SVI at the end of surgery: the normal SVI group (n = 76), with SVI ≥ 35 ml/m2, and the low SVI group (n = 52), with SVI<35 ml/m2. We compared postoperative renal function, indicated by serum creatinine and estimated glomerular filtration rate, on post-operative days 0 through 3. We also compared numbers of patients who developed postoperative acute kidney injury (AKI).

RESULTS

Although there were no intergroup differences in preoperative renal function or other intraoperative hemodynamic variables, including arterial pressure, central venous pressure, stroke volume variation, a volume of infusion, urine output, and the total intraoperative in-out balance, estimated glomerular filtration rate was significantly lower and serum creatinine was significantly higher in the low SVI group than in the normal SVI group on postoperative days 1 and 2 (P<0.05). In addition, more patients developed postoperative AKI in the low SVI group than in the normal SVI group (12 of 52 vs. 5 of 76, P = 0.015).

CONCLUSIONS

Low SVI at the end of esophagectomy may represent a risk factor for AKI in the early postoperative period. Further studies are required to examine whether maintaining SVI above 35 ml/m2 reduces the incidence of AKI after esophagectomy.

[The role of end-tidal carbon dioxide partial pressure in fluid responsiveness assessment in septic shock patient]

OBJECTIVE

To assess whether end-tidal carbon dioxide partial pressure (PETCO2) can predict the fluid responsiveness in septic shock patients.

METHODS

Septic shock patients under mechanical ventilation without spontaneous breathing and with the need of a fluid challenge test were included in this study.Heart rate, central venous pressure, pulse pressure, PETCO2, and CI before and after the fluid challenge test were conducted in all the patients.

RESULTS

Of the 48 septic shock patients included, 34 had preload responsiveness, 14 had no responsiveness. ΔCI and ΔPETCO2 after the fluid challenge test in "volume responders" were (0.85 ± 0.47) L×min(-1)×m(-2) and (3.5 ± 2.5) mmHg respectively, which were higher than those in "no volume responders"(P < 0.05). The fluid-induced changes in PETCO2 and CI were correlated (r = 0.072, P < 0.05). The AUCROC of fluid challenge-induced ΔPETCO2 as the predictor for volume responsiveness was 0.943, and its sensitivity was 87.9% and specificity was 93.4% with a critical value of 5%. The AUCROC of ΔPP as the predictor for volume responsiveness was 0.801, and its sensitivity was 68.1% and specificity was 73.2% with a critical value of 10%.

CONCLUSION

The changes of PETCO2 induced by a fluid challenge test can predict fluid responsiveness with reliability, and have a better sensitivity and specificity than the changes of PP.

Role of vascular clamping in hepatic resection: a review

Hepatic resection is usually a complicated surgical procedure. In the course of liver organ resection overwhelming safety measures are extremely important simply because this organ has parallel vascular source. Expensive machines are launched in schedule operative practice without the proper evidence of their efficaciousness or efficiency in excess of less complicated procedures. Intermittent clamping of 10 minutes could be accomplished in the affected person with disadvantaged liver organ performance for instance in cirrhosis. Blended utilization of a balloon occlusion catheter, electrocautery and/or ultrasonic coagulating shear and endo-GIA staplers, generally seem to preserve satisfactory homeostasis which helps prevent gas embolization in the course of laparoscopic hepatectomy in human beings. Selection of clamping is perfectly up to the surgeons. For minimal hepatic resection some experts do not implement any clamping strategy. Collaboration amongst specialists and anesthetists is significant to ascertain this challenge throughout resection.

Anemia is associated with an increased central venous pressure and mortality in a broad spectrum of cardiovascular patients

BACKGROUND

Anemia is frequently observed in patients with cardiovascular disease. Multiple factors have been associated with anemia, but the role of hemodynamics is largely unknown. Therefore, we investigated the association between hemoglobin (Hb) levels, hemodynamics and outcome in a broad spectrum of cardiovascular patients.

METHODS AND RESULTS

A total of 2,009 patients who underwent right heart catheterization at the University Medical Center Groningen, the Netherlands, between 1989 and 2006 were identified and data were extracted from electronic databases. Anemia was defined by the WHO criteria (male, hemoglobin <13.0 g/dL; female, hemoglobin <12.0 g/dL). The associations between central venous pressure (CVP), cardiac index (CI), systemic vascular resistance (SVR), hemoglobin (Hb), anemia and all-cause mortality were assessed with linear, logistic and Cox-proportional hazards analysis. The mean age was 57 ± 15 years, 57 % were male, mean Hb was 13.2 ± 0.4 g/dL, and 27.4 % of the patients were anemic. Patients with anemia had higher CVP levels (7.0 ± 5.4 mmHg) compared to non-anemic patients (5.6 ± 4.1 mmHg; p < 0.001). CI was higher in anemic patients; 3.0 ± 2.9 vs. 2.9 ± 0.8 L/min/m(2) (p < 0.001), whereas SVR was lower (1,212 ± 479 vs. 1,356 ± 555 dyn s cm(-5), p < 0.001). CVP and CI were both independent predictors of anemia (OR 1.49; CI 1.24-1.81, p < 0.001 and OR 1.93; CI 1.54-2.42, p < 0.001, respectively). Hemoglobin and CVP were both independent predictors of survival. Independent of CI and renal function, patients with anemia and an elevated CVP had the worst prognosis (HR 2.17; 95 % CI 1.62-2.90; p < 0.001).

CONCLUSION

Anemia is common in cardiovascular patients and independently related to an elevated CVP and CI. Patients with anemia and an elevated CVP have the worst prognosis.

Controlled low central venous pressure reduces blood loss and transfusion requirements in hepatectomy

AIM: To evaluate the effect of low central venous pressure (LCVP) on blood loss and blood transfusion in patients undergoing hepatectomy.

METHODS: Electronic databases and bibliography lists were searched for potential articles. A meta-analysis of all randomized controlled trials (RCTs) investigating LCVP in hepatectomy was performed. The following three outcomes were analyzed: blood loss, blood transfusion and duration of operation.

RESULTS: Five RCTs including 283 patients were assessed. Meta-analysis showed that blood loss in the LCVP group was significantly less than that in the control group (MD = -391.95, 95%CI: -559.35--224.56, P < 0.00001). In addition, blood transfusion in the LCVP group was also significantly less than that in the control group (MD = -246.87, 95%CI: -427.06--66.69, P = 0.007). The duration of operation in the LCVP group was significantly shorter than that in the control group (MD = -18.89, 95%CI: -35.18--2.59, P = 0.02). Most studies found no significant difference in renal and liver function between the two groups.

CONCLUSION: Controlled LCVP is a simple and effective technique to reduce blood loss and blood transfusion during liver resection, and appears to have no detrimental effects on liver and renal function.

[Changes of the hemodynamics and extravascular lung water after different-volume fluid resuscitation in a piglet model of endotoxic shock]

OBJECTIVE

Practice recommendations have evolved, and consensus now exists among leading organizations such as the American College of Critical Care Medicine (ACCM) and Surviving Sepsis Campaign that fluid infusion is best initiated with boluses of 20 ml/kg, commonly requires 40-60 ml/kg but can be as much as 200 ml/kg if the liver is not enlarged and/or rales are not heard. The present study aimed to investigate and compare the changes of the hemodynamics and extravascular lung water after higher volume fluid resuscitation in a piglet model of endotoxic shock.

METHOD

Twenty piglets were used for establishing animal models of endotoxic shock by intravenous infusing lipopolysaccharide (LPS). The experimental animals were divided into three groups according to the volume infused during the resuscitation. The three groups received different volume of saline in less than an hour after endotoxic shock. By the PiCCO plus system, we investigated the changes of hemodynamics and extravascular lung water.

RESULT

After fluid resuscitation, global end diastolic volume inder, (GEDI) and intrathoracic blood volume index, (ITBI) markedly increased in the group of 80 ml/kg and 120 ml/kg, but there was no change in the group of 40 ml/kg. GEDI: Fifteen min after fluid resuscitation R1 was (261 ± 64) ml/m(2), R2 (457 ± 124) ml/m(2), R3 (413 ± 148) ml/m(2), 4 h R1 (251 ± 68) ml/m(2), R2 (422 ± 70) ml/m(2), R3 (470 ± 160) ml/m(2); ITBI: Fifteen min after fluid resuscitation R1 was (335 ± 69) ml/m(2), R2 (550 ± 179) ml/m(2), R3 (520 ± 183) ml/m(2), 4 h R1 (314 ± 84) ml/m(2), R2 (534 ± 96) ml/m(2), R3 (594 ± 200) ml/m(2) (R1 vs. R2 vs. R3, F = 26.373, P < 0.05; R1 vs. R2, R1 vs. R3, P < 0.05; R2 vs. R3, P > 0.05). CI of all three groups significantly decreased when the models were established. After fluid resuscitation, the base level was maintained in the group of 80 ml/kg and 120 ml/kg, but it was under the basic level in the group of 40 ml/kg.Fifteen min after fluid resuscitation R1 was (4.5 ± 0.7) L/(min·m(2)), R2 (6.4 ± 2.2) L/(min·m(2)), R3 (5.5 ± 0.7) L/(min·m(2)), 4 h R1 (4.1 ± 1.0) L/(min·m(2)), R2 (5.2 ± 0.9) L/(min·m(2)), R3 (5.1 ± 0.8) L/(min·m(2)). There was no significant difference in CI between these two groups (P > 0.05).ELWI of the group of 80 ml/kg and 120 ml/kg were still higher than that of the group of 40 ml/kg, 15 min after fluid resuscitation R1 was (19.2 ± 8.6) ml/kg, R2 (29.2 ± 5.5) ml/kg, R3 (23.4 ± 8.2) ml/kg, 4 h R1 (18.3 ± 6.5) ml/kg, R2 (23.8 ± 2.6) ml/kg, R3 (21.4 ± 3.9) ml/kg, but there was no significant difference in ELWI among the groups (P > 0.05).

CONCLUSION

Resuscitation with higher volume of fluid infusion in the early stage of endotoxic shock was more efficient to increase the preload and maintain the cardiac output at the baseline level, and might reduce the need for vasoactive agents. Meanwhile, resuscitation with higher volume of fluid in the early stage of endotoxic shock did not sharply increase the extravascular lung water.

Prediction of outcome in patients with liver dysfunction after left ventricular assist device implantation

Although postoperative liver dysfunction (LD) following left ventricular assist device (LVAD) implantation is associated with high mortality, outcome is difficult to predict in patients with liver dysfunction. We aimed to clarify factors affecting recovery from LD after VAD implantation. A total of 167 patients underwent LVAD implantation, of whom 101 developed early postoperative LD, defined as maximum total bilirubin (max T-bil) greater than 5.0 mg/dl within 2 weeks. We set two different end-points, unremitting LD, and 90-day mortality. The rates of early mortality (90 days) and recovery from LD were 36 % (36/101) and 72 % (73/101), respectively. Univariate analysis showed that preoperative body weight, preoperative mechanical support, preoperative T-bil and creatinine, left ventricular diastolic dimension, right VAD (RVAD) insertion, cardiopulmonary bypass time, postoperative cardiac index, and postoperative T-bil and central venous pressure (CVP) on postoperative day (POD) 3 (non-recovered vs recovered, 12.4 ± 4.5 vs 9.5 ± 3.6 mmHg) were higher in patients with unremitting LD. Preoperative T-bil, RVAD insertion, and T-bil and CVP on POD 3 (non-survivor vs survivor, 12.4 ± 4.4 vs 9.4 ± 3.6 mmHg) were also higher in non-survivors. Multivariate analysis demonstrated that CVP on POD 3 was predictive of recovery from postoperative LD (OR 0.730, P < 0.05) and 90-day mortality (OR 0.730, P < 0.05). A key outcome factor in patients who developed early postoperative LD after LVAD implantation was postoperative liver congestion with high CVP. To overcome postoperative LD, appropriate management of postoperative CVP level is important.

Inferior vena cava diameter and collapsibility index: a practical non-invasive evaluation of intravascular fluid volume in critically-ill patients

BACKGROUND

Assessment of intravascular volume status is an essential parameter for the diagnosis and management of critically-ill patients. Generally, central venous pressure (CVP), which is an invasive measure, has been recommended for this purpose. Since CVP has been associated with many complications, inferior vena cava diameter and collapsibility index (IVC-CI) were used in the present study to evaluate the intravascular volume status of critically-ill patients at Rajavithi Hospital.

OBJECTIVE

To conduct a prospective, cross-sectional study to evaluate the IVC diameter as a guidance for estimating the volume status in critically-ill patients by bedside ultrasonography, focusing on correlations between CVP and lVC-Cl and lVC diameter

MATERIAL AND METHOD

Critically-ill patients who had been placed with a functioning central venous catheter were prospectively enrolled. Evaluation of intravascular volume status was performed by bedside ultrasonography to measure the IVC diameters (IVCD), both end-inspiratory (iIVCD) and end-expiratory (eIVCD). The IVC collapsibility indices (IVC-CI) were calculated by an equation and then were compared with the CVP values.

RESULTS

Of the 70 enrolled patients, with a mean age of 63.8 +/- 1.9 years, 64.3% were intubated. The most common indication of ICU admission was sepsis with hemodynamic instability (80.0%). The volume status of patients was stratified by their CVP levels as hypovolemic 15.7%, euvolemic 32.9% and hypervolemic 51.4% which correspond with the IVC-CI of 45.69 +/- 16.16%, 31.23 +/- 16.77%, and 17.82 +/- 12.36% respectively (p < 0.001). The highest significant correlation was found between the CVP and IVC-CI (r = -0.612, p < 0.001). In addition, there was a significant correlation between CVP and iIVCD (r = 0.535, p < 0.001); and between the CVP and mean IVCD (r = 0.397, p = 0.001).

CONCLUSION

The present study supported the correlation between CVP and IVC-CI. The authors conclude that the IVC-CI can provide a useful guide for noninvasive intravascular volume status assessment of critically-ill patients.

[Application of PiCCO monitoring in patients with neurogenic pulmonary edema]

OBJECTIVE

To evaluate the application of pulse induced contour cardiac output (PiCCO) monitoring in patients with neurogenic pulmonary edema (NPE), and to assess the accuracy of capacity parameters such as intra thoracic blood volume index (ITBVI) and global end diastolic volume index (GEDVI) and pressure parameters such as central venous pressure (CVP) in estimating severity of NPE, and to assess the prognostic significance of extravascular lung water index (EVLWI) on patients with NPE.

METHODS

In this prospective study, 36 patients with NPE in the department of neurological intensive care unit (NICU) underwent PiCCO monitoring, including mean arterial pressure (MAP), cardiac index (CI), CVP, ITBVI, GEDVI, EVLWI, pulmonary vascular permeability index (PVPI). The correlation between ITBVI, GEDVI, CVP and EVLWI was assessed. According to the outcome, these patients were divided into nonsurvivor group and survivor group. The change in EVLWI before and after treatment was compared between two groups.

RESULTS

ITBVI, GEDVI were significantly and positively correlated with EVLWI, for the former r =0.54, P<0.001, and for the latter r=0.62, P<0.0001, but there was no significant correlation between CVP and EVLWI, r= 0.12, P>0.05. PVPI, EVLWI were significantly and negatively correlated with oxygenation index (PaO2 / FiO2), for the former r=-0.55, P< 0.001, and for the latter r=-0.48, P<0.05. The difference in EVLWI level before treatment between survivor group and nonsurvivor group was not statistically significant (8.6±2.6 ml/kg vs. 9.4±1.8 ml/kg, P>0.05). In survivor group, EVLWI level obviously declined after treatment (6.92±1.64 ml/kg vs. 8.64±2.62 ml/kg, P<0.05), EVLWI level of survivor group was significantly lower than that of nonsurvivor group (6.92±1.64 ml/kg vs. 9.88±2.44 ml/kg, P<0.05).

CONCLUSIONS

Capacity parameters such as GEDVI, ITBVI can assess EVLWI of NPE patients accurately and reliably. In NPE patients, the higher the PVPI and EVLWI, the lower the PaO2 / FiO2. By dynamic observation of the trends of EVLWI in NPE patients, we are able to assess the prognosis of these patients.

Fluid management guided by stroke volume variation failed to decrease the incidence of acute kidney injury, 30-day mortality, and 1-year survival in living donor liver transplant recipients

BACKGROUND

Low central venous pressure (CVP) produced by fluid restriction has been applied to liver transplant recipients in order to decrease blood loss. However, CVP is not reliable for monitoring intravascular volume and ventricular filling. In addition, doubts remain over the association between fluid restriction and acute kidney injury (AKI). We tested the utility of stroke volume variation (SVV), derived from the FloTrac/Vigileo system, as a decision-making tool in fluid management. We examined the differences in fluid administration, urine output, postoperative AKI, and 30-day and 1-year survival rates between liver transplant recipients with fluid management guided by SVV and CVP.

METHODS

We retrospectively collected data on our liver transplant recipients with a Model for End-stage Liver Disease score less than 30 and serum creatinine lower than 1.5 mg/dL from 2007 to 2010. Recipients in 2007 and 2008 who received CVP-guided fluid management served as the control group. Recipients in 2009 and 2010 who received fluid administration triggered by SVV were recruited as the study group. The estimated blood loss, urine output, and fluid administered during the operation were recorded. Renal function was assessed using the RIFLE criteria on postoperative days 1 and 5. We also recorded the 30-day and 1-year survival.

RESULTS

Significantly more diuretic use and urine output were noted in the control group in spite of similar fluid administration. However, there was no significant difference in blood loss, AKI, or 30-day and 1-year survival rates.

CONCLUSION

The outcomes of living donor liver transplant patients who had fluid therapy guided by an SVV less than 10% were similar to those of patients who were given fluids to reach a CVP of 10 mmHg. Our findings suggest that the two measures of vascular filling are similar in liver transplant recipients with demographic characteristics similar to those of our patients.

Hemodynamic monitoring in the intensive care unit

Patients in the intensive care unit are often critically ill with inadequate tissue perfusion and oxygenation. This inadequate delivery of substrates at the cellular level is a common definition of shock. Hemodynamic monitoring is the observation of cardiovascular physiology. The purpose of hemodynamic monitoring is to identify abnormal physiology and intervene before complications, including organ failure and death, occur. The most common types of invasive hemodynamic monitors are central venous catheters, pulmonary artery catheters, and arterial pulse-wave analysis. Ultrasonography is a noninvasive alternative being used in intensive care units for hemodynamic measurements and assessments.

Effects of arterial oxygen tension and cardiac output on venous saturation: a mathematical modeling approach

OBJECTIVES

Hemodynamic support is aimed at providing adequate O2 delivery to the tissues; most interventions target O2 delivery increase. Mixed venous O2 saturation is a frequently used parameter to evaluate the adequacy of O2 delivery.

METHODS

We describe a mathematical model to compare the effects of increasing O2 delivery on venous oxygen saturation through increases in the inspired O2 fraction versus increases in cardiac output. The model was created based on the lungs, which were divided into shunted and non-shunted areas, and on seven peripheral compartments, each with normal values of perfusion, optimal oxygen consumption, and critical O2 extraction rate. O2 delivery was increased by changing the inspired fraction of oxygen from 0.21 to 1.0 in steps of 0.1 under conditions of low (2.0 L.min(-1)) or normal (6.5 L.min(-1)) cardiac output. The same O2 delivery values were also obtained by maintaining a fixed O2 inspired fraction value of 0.21 while changing cardiac output.

RESULTS

Venous oxygen saturation was higher when produced through increases in inspired O2 fraction versus increases in cardiac output, even at the same O2 delivery and consumption values. Specifically, at high inspired O2 fractions, the measured O2 saturation values failed to detect conditions of low oxygen supply.

CONCLUSIONS

The mode of O2 delivery optimization, specifically increases in the fraction of inspired oxygen versus increases in cardiac output, can compromise the capability of the "venous O2 saturation" parameter to measure the adequacy of oxygen supply. Consequently, venous saturation at high inspired O2 fractions should be interpreted with caution.

Prognostic value and agreement of achieving lactate clearance or central venous oxygen saturation goals during early sepsis resuscitation

OBJECTIVES

Lactate clearance (LC) and central venous oxygen saturation (ScvO(2)) have been proposed as goals of early sepsis resuscitation. The authors sought to determine the agreement and prognostic value of achieving ScvO(2) or LC goals in septic shock patients undergoing emergency department (ED)-based early resuscitation.

METHODS

This was a preplanned analysis of a multicenter ED randomized controlled trial of early sepsis resuscitation targeting three variables: central venous pressure, mean arterial pressure, and either ScvO(2) or LC. Inclusion criteria included suspected infection, two or more systemic inflammation criteria, and either systolic blood pressure of <90 mm Hg after intravenous fluid bolus or lactate level of >4 mmol/L. Both ScvO(2) and LC were measured simultaneously. The ScvO(2) goal was defined as ≥70%. Lactate was measured at enrollment and every 2 hours until the goal was reached or up to 6 hours. LC goal was defined as a decrease of ≥10% from initial measurement. The primary outcome was in-hospital mortality.

RESULTS

A total of 203 subjects were included, with an overall mortality of 19.7%. Achievement of the ScvO(2) goal only was associated with a mortality rate of 41% (9/22), while achievement of the LC goal only was associated with a mortality rate of 8% (2/25; proportion difference = 33%; 95% confidence interval [CI] = 9% to 55%). No agreement was found between goal achievement (κ = -0.02), and exact test for matched pairs demonstrated no significant difference between discordant pairs (p = 0.78).

CONCLUSIONS

No agreement was found between LC and ScvO(2) goal achievement in early sepsis resuscitation. Achievement of a ScvO(2) ≥ 70% without LC ≥ 10% was more strongly associated with mortality than achievement of LC ≥ 10% with failure to achieve ScvO(2) ≥ 70%.

Idiopathic dilatation of inferior vena cava

A case of isolated dilation of inferior vena cava with diminished inspiratory collapse is reported. There was no other abnormality. Diameter and collapsibility of IVC should be interpreted in collaboration with other clinical and echocardiographic parameters before drawing any definative conclusion.

[Effects of volume resuscitation on venous pressure gradient in hypovolemic patients undergoing mechanical ventilation]

OBJECTIVE

To investigate the value of venous pressure gradient [D(c-i)VP] between central venous pressure (CVP) and iliac vein pressure (IVP) in assessing the responsiveness to volume resuscitation in hypovolemic patient undergoing mechanical ventilation.

METHODS

Thirty hypovolemic patients undergoing mechanical ventilation, with maintenance of similar ventilation conditions, graded volume loading was performed with 250 ml Ringer lactate solution (LR) for each infusion in hypovolemic patients, until mean arterial pressure (MAP) ≥65 mm Hg(1 mm Hg = 0.133 kPa), CVP≥8 mm Hg, strong pulse, perfusion improvement (recovery in the end) were reached. Before infusion, 10 minutes after infusion, and at the end of recovery, the heart rate (HR), MAP, CVP, IVP, stroke volume (SV), thoracic fluid content (TFC) and D(c-i)VP were measured and recorded, the correlations between D(c-i)VP and TFC, SV before and after infusion were analyzed.

RESULTS

Before infusion, 10 minutes after infusion, and at the end of recovery, no significant difference was found in HR, MAP, CVP, and IVP,while D(c-i)VP (mm Hg) was obviously lowered (4.89 ± 1.70, 2.80 ± 1.44, 2.10 ± 1.30, respectively), and SV (ml) and TFC (ml) were significantly increased (SV was 42.0 ± 10.5, 49.0 ± 8.3, 58.0 ± 12.1, respectively; TFC was 30.0 ± 9.6, 38.0 ± 8.6, 43.0 ± 11.1, respectively), with statistical differences (P < 0.05 or P < 0.01). Negative correlations were found between D(c-i)VP and TFC, SV [r(1)=-0.580, P(1)=0.004; r(2)=-0.462, P(2) =0.017].

CONCLUSIONS

In the course of fluid resuscitation in hypovolemic patients undergoing mechanical ventilation, the D(c-i)VP was significantly reduced with fluid resuscitation. At the same time, significant correlations between D(c-i)VP, TFC and SV were demonstrated. The measurement of D(c-i)VP could help guide fluid resuscitation in hypovolemic patients undergoing mechanical ventilation.

Simulation of the Fontan circulation during rest and exercise

The Fontan palliation was introduced as surgical repair method for tricuspid atresia, creating a univentricular serial circulation. However, it is used as treatment for other life threatening complex congenital heart diseases as well. The variation of underlying pathologies treated with this palliation makes optimization difficult. To assist the optimization process, we adjusted a lumped parameter computational model of the biventricular circulation (CircAdapt) and evaluated the univentricular circulation. The model simulates beat-to-beat dynamics of the two cardiac chambers, the valves, and the systemic and pulmonary circulations. The univentricular circulation in rest and exercise was simulated. Exercise resulted in increased stroke volume, heart rate, pulse pressure, and stressed blood volume. Central venous pressure rose as a result of the constant pulmonary resistance, reducing systemic pressure drop. Reduced systemic pressure drop implies either reduction of systemic flow or further decrease of systemic resistance. Based on our simulation results, we conclude that exercise capacity in Fontan patients is limited due to increase of central venous pressure and the impossibility to reduce systemic resistance further, restricting systemic flow.

External jugular venous pressure as an alternative to conventional central venous pressure in right lobe donor hepatectomies

OBJECTIVES

Many centers have adopted central vein cannulation both for central venous pressure monitoring and fluid administration for right hepatectomy in living-liver donors. However, use of central venous catheters is associated with adverse events that are hazardous to patients and expensive to treat. This study sought to examine the use of external jugular venous pressure as an alternative to conventional central venous pressure in right lobe donor hepatectomies

MATERIALS AND METHODS

Forty ASA grade I adult living liver-donors without a known history of significant cardiac or pulmonary diseases were enrolled in this prospective observational study. Paired measurement of venous pressures (external jugular venous pressure and internal jugular venous pressure) were taken at the following times: after induction of anesthesia, 30 minutes after skin incision, during right lobe mobilization (every 15 minutes), during hepatic transaction (every 15 minutes), after right lobe resection (every 15 minutes), and after abdominal closure.

RESULTS

Paired measurements were equal in 47.5%, 53.5%, 61.5%, 46.3%, and 52.5% for after induction, after skin incision, right lobe mobilization, right lobe transection, after resection, and before abdominal closure periods. However, all measurements were within acceptable limits of bias measurements (± 2 mm Hg).

CONCLUSIONS

Central venous pressure catheter placement can be avoided and replaced by a less-invasive method such as external jugular venous pressure (which gave an acceptable estimate of central venous pressure in all phases of right lobe resection) in living-donor liver transplant and allowed equivalent monitor even during fluid restriction phases.

Central venous stenosis caused by traction of the innominate vein due to a tuberculosis-destroyed lung

We report a case of central venous stenosis due to a structural deformity caused by a tuberculosis-destroyed lung in a 65-year-old woman. The patient presented with left facial edema. She had a history of pulmonary tuberculosis, and the chest X-ray revealed a collapsed left lung. Angiography showed leftward deviation of the innominate vein leading to kinking and stenosis of the internal jugular vein. Stent insertion improved her facial edema.

[Successful anesthetic management for resection of a giant hepatic hemangioma with Kasabach-Merritt syndrome using FloTrac system]

Kasabach-Merritt syndrome (KMS) is a rare and severe coagulation disorder caused by vascular malformations within or outside the liver. It is characterized by profound thrombocytopenia, microangiopathic hemolytic anemia, and consumption coagulopathy. We successfully managed the anesthesia for a giant hemangioma resection complicated with KMS using FloTrac/Vigileo system. A 78-year-old woman (51 kg, 141 cm) was admitted for giant hemangioma with disseminated intravascular coagulation (DIC). General anesthesia was induced with sevoflurane and remifentanil. Epidural anesthesia was not induced because of coagulopathy. We evaluated arterial pressure-based cardiac output (APCO), stroke volume variation (SVV) as a predictor for fluid responsiveness, systolic blood pressure (SBP), and central venous pressure (CVP) during the operation. Prior to tumor resection, 6,000 ml of fluid was suctioned from the tumor. The increase of SVV and sudden decrease of APCO and SBP were recognized during surgical procedure. The SVV demonstrated marked changes in response to hemorrhage, and it was more sensitive than CVP change during operation. We conclude that SVV is an accurate predictor of intravascular hypovolemia, and it is a useful indicator for assessing the appropriateness and timing of applying fluid for improving circulatory stability during a giant hemoangioma resection.

[Evaluation of the hemodynamic state of critically ill cancer patients with central venous to arterial carbon dioxide difference]

OBJECTIVE

To evaluate the hemodynamic state of critically ill cancer patients using central venous-to-arterial carbon dioxide difference (Pcv-aCO(2)) and to direct the treatment.

METHODS

Clinical data of 47 cancer critically ill patients with acute physiology and chronic health evaluation II (APACHE II) score> 15 and unstable hemodynamic state were enrolled from intensive care unit of Tianjin Medical University Cancer Hospital from October 1st 2010 to May 31th 2011, were analyzed retrospectively. The patients were receiving the standard treatment according to the guidelines for 24 hours, the end-point of therapy was the standard of early goal direct therapy (EGDT). According to difference of sequential organ failure scores (ΔSOFA) of that after treatment and before treatment, the patients were divided into two groups: ΔSOFA≤ 1 (n = 27) and ΔSOFA> 1 (n = 20). The mean arterial pressure (MAP), urine output per hour, central venous pressure (CVP), oxygen saturation of central venous blood (ScvO(2)), the clearance of lactic acid, and Pcv-aCO(2) before treatment were compared with those after treatment, and their correlation with ΔSOFA was analysed.

RESULTS

There were no significant differences in MAP (mm Hg, 1 mm Hg = 0.133 kPa: 54.48 ± 4.95 vs. 54.45 ± 4.30), urine output per hour (ml:19.33 ± 4.53 vs. 20.55 ± 5.54), CVP(mm Hg: 3.48 ± 1.81 vs. 3.25 ± 1.16), ScvO(2) (0.571 ± 0.042 vs. 0.578 ± 0.047) of two groups before treatment (all P > 0.05), but in the group ΔSOFA≤1, the Pcv-aCO(2) (mm Hg: 7.80 ± 2.20 vs. 9.39 ± 0.97) and SOFA scores (6.33 ± 2.11 vs. 9.50 ± 1.24) were significantly lower than those of the group ΔSOFA>1 (all P < 0.01). There were no significant differences in MAP (mm Hg: 73.48 ± 6.12 vs. 71.30 ± 7.30), CVP (mm Hg: 6.85 ± 1.26 vs. 6.50 ± 1.28), ScvO(2) (0.693 ± 0.032 vs. 0.684 ± 0.039) between two groups after treatment (all P > 0.05), though their

RESULTS

data were improved compared with that of before treatment. However, there were significant differences in Pcv-aCO(2) (mm Hg: 3.02 ± 1.59 vs. 8.21 ± 2.23), urine output per hour (ml: 71.41 ± 6.74 vs. 51.70 ± 7.50), SOFA score (6.03 ± 2.56 vs. 10.05 ± 1.61), the clearance of lactic acid [(27.71 ± 11.46)% vs. -(0.78 ± 13.29)%, all P < 0.01]. There was significant correlation between urine output per hour, Pcv-aCO(2), clearance of lactic acid and ΔSOFA (r values were -0.712, 0.745, -0.631, all P < 0.05).

CONCLUSION

Pcv-aCO(2) could be used as an index of evaluating the cardiac index and the hemodynamic state, and it could be considered to be one of the indices of evaluating the therapeutic effect and prognosis.