Normal cardiac output, oxygen delivery and oxygen extraction

Methemoglobin as a marker of acute anemic stress in cardiac surgery

Biological evidence supports plasma methemoglobin as a biomarker for anemia-induced tissue hypoxia. In this translational planned substudy of the multinational randomized controlled transfusion thresholds in cardiac surgery (TRICS-III) trial, which included adults undergoing cardiac surgery requiring cardiopulmonary bypass with a moderate-to-high risk of death, we investigated the relationship between perioperative hemoglobin concentration (Hb) and methemoglobin; and evaluated its association with postoperative outcomes. The primary endpoint was a composite of death, myocardial infarction, stroke, and severe acute kidney injury at 28 days. We observe weak non-linear associations between decreasing Hb and increasing methemoglobin, which were strongest in magnitude at the post-surgical time point. Increased levels of post-surgical methemoglobin were associated with a trend toward an elevated risk for stroke and exploratory neurological outcomes. Our generalizable study demonstrates post-surgical methemoglobin may be a marker of anemia-induced organ injury/dysfunction, and may have utility for guiding personalized approaches to anemia management. Clinicaltrials.gov registration NCT02042898.

Hypoxische, anämische und kardial bedingte Hypoxämie: Wann beginnt die Hypoxie im Gewebe?

Bei einer Hypoxämie ist oft der Sauerstoffgehalt noch im unteren Normbereich, sodass keine Hypoxie im Gewebe vorliegt. Wird die Hypoxie-Schwelle im Gewebe bei einer hypoxisch, anämisch und auch kardial bedingten Hypoxämie erreicht, kommt es im Zellstoffwechsel, unabhängig von der Genese, zu identischen Gegenregulationen. Im klinischen Alltag wird diese pathophysiologische Tatsache mitunter ignoriert, obwohl je nach Hypoxämie-Ursache die Beurteilung und die Therapie stark unterschiedlich sind. Während für die anämische Hypoxämie restriktive und allgemein akzeptierte Regeln in den Transfusionsrichtlinien festgelegt sind, wird bei einer hypoxischen Hypoxie früh die Indikation zu einer meist invasiven Beatmung gestellt. Die klinische Beurteilung und Indikationsstellung fokussiert dabei auf die Parameter Sauerstoffsättigung, Sauerstoffpartialdruck und Oxygenierungsindex. Während der Corona-Pandemie sind Fehlinterpretationen der Pathophysiologie sichtbar geworden und haben vermutlich zu überflüssigen Intubationen geführt. Für die Behandlung einer hypoxischen Hypoxie mittels invasiver Beatmung aber gibt es keine Evidenz. Im vorliegenden Review wird auf die Pathophysiologie der verschiedenen Hypoxieursachen unter besonderer Berücksichtigung der Intubation und Beatmung auf der Intensivstation eingegangen.

Pericytes and the Control of Blood Flow in Brain and Heart

Pericytes, attached to the surface of capillaries, play an important role in regulating local blood flow. Using optogenetic tools and genetically encoded reporters in conjunction with confocal and multiphoton imaging techniques, the 3D structure, anatomical organization, and physiology of pericytes have recently been the subject of detailed examination. This work has revealed novel functions of pericytes and morphological features such as tunneling nanotubes in brain and tunneling microtubes in heart. Here, we discuss the state of our current understanding of the roles of pericytes in blood flow control in brain and heart, where functions may differ due to the distinct spatiotemporal metabolic requirements of these tissues. We also outline the novel concept of electro-metabolic signaling, a universal mechanistic framework that links tissue metabolic state with blood flow regulation by pericytes and vascular smooth muscle cells, with capillary K_ATP and Kir2.1 channels as primary sensors. Finally, we present major unresolved questions and outline how they can be addressed.

Three Physiological Components That Influence Regional Cerebral Tissue Oxygen Saturation

Near-infrared spectroscopy (NIRS) measurement of regional cerebral tissue oxygen saturation (rcStO2) has become a topic of high interest in neonatology. Multiple studies have demonstrated that rcStO2 measurements are feasible in the delivery room during immediate transition and resuscitation as well as after admission to the neonatal intensive care unit. Reference ranges for different gestational ages, modes of delivery, and devices have already been published. RcStO2 reflects a mixed tissue saturation, composed of arterial (A), venous (V), and capillary signals, derived from small vessels within the measurement compartment. The A:V signal ratio fluctuates based on changes in oxygen delivery and oxygen consumption, which enables a reliable trend monitoring of the balance between these two parameters. While the increasing research evidence supports its use, the interpretation of the absolute values of and trends in rcStO2 is still challenging, which halts its routine use in the delivery room and at the bedside. To visualize the influencing factors and improve the understanding of rcStO2 values, we have created a flowchart, which focuses on the three major physiological components that affect rcStO2: oxygen content, circulation, and oxygen extraction. Each of these has its defining parameters, which are discussed in detail in each section.

Morphology of the nutrient artery and its foramen in relation to femoral bone perfusion rates of laying and non-laying hens

If arteries penetrate bones through foramina, regional artery blood flow rates can be estimated from the foramen sizes. Femoral bone blood flow rates estimated from nutrient foramen sizes were previously not absolute, but only a relative blood flow index (Qi ), because the size relationship between the foramen and the occupying artery was unknown. The current study used vascular contrast and micro-computerized tomographic scanning to investigate femoral nutrient foramen and nutrient artery sizes in three groups of sub-adult chickens (non-laying hens, laying hens, and roosters) of similar ages. The results indicate that the cross-sectional area of the nutrient artery lumen occupies approximately 20.2 ± 4.1% of the foramen for femora with only one foramen. Artery lumen size is significantly correlated with foramen size. Vascular contrast imaging is capable of estimating blood flow rates through nutrient arteries, as blood flow rates estimated from artery lumen casts are similar to blood flow rates measured by infusion of fluorescent-labeled microspheres. Laying hens tend to have higher nutrient artery perfusion rates than non-laying hens, probably due to extra oxygen and calcium requirements for eggshell production, although the calculated blood flow difference was not statistically significant. Histological embedding and sectioning along with vascular contrast imaging reveal variable nutrient foramen morphology and nutrient artery location among femora with more than one nutrient foramen.

Titration of inspired oxygen in preterm infants with hypoxemic respiratory failure using near-infrared spectroscopy and pulse oximetry: A new approach

BACKGROUND

Titration of inspired oxygen is a challenge in preterm infants with hypoxemic respiratory failure (HRF). Monitoring of brain oxygen by near-infrared spectroscopy (NIRS) has been proven to minimize the burden of hyperoxia and hypoxemia; with a better understanding of cerebral autoregulation, integrating NIRS and pulse oximetry for titrating inspired oxygen in preterm infants is a novel approach.

METHODS

We studied the impact of integrated monitoring of oxygen saturation by pulse oximetry (SpO₂ ) and cerebral regional tissue oxygen (crRTO) by NIRS during a stepwise oxygen reduction test (ORT) on reducing oxygen requirement in preterm infants with HRF. The correlation between SpO₂ with crRTO, and fractional oxygen extraction (FOE) was assessed, concordance levels (r > 0.5) were determined during the assessment period and were considered as a sign of impaired autoregulation. The primary outcome was the achievement of significantly lower FiO₂ at 72 h after the start of the integrated monitoring.

RESULTS

A total of 38 preterm infants were included, 27 had normal cerebral autoregulation (CAR) (Group 1) in whom SpO₂ was poorly correlating with crRTO with (r < 0.5) and had a significantly greater percentage of reduction below baseline in FiO₂ (mean: 34%). Eleven infants had impaired CAR (Group 2) with SpO₂ significantly correlating with crRTO (r > 0.5) and had a linear trend of FOE inverse to SpO₂ and crRTO; this was considered as an arterial saturation dependent oxygen delivery (SadDO₂ ).

CONCLUSION

Integrated monitoring of preterm infants by SpO₂ and crRTO was associated with easier weaning of oxygen with less burden of both hyperoxia and hypoxemia.

Regional femoral bone blood flow rates in laying and non-laying chickens estimated with fluorescent microspheres

The metabolic rate of vertebrate bone tissue is related to bone growth, repair and homeostasis, which are all dependent on life stage. Bone metabolic rate is difficult to measure directly, but absolute blood flow rate () should reflect local tissue oxygen requirements. A recent ‘foramen technique’ has derived an index of blood flow rate () by measuring nutrient foramen sizes of long bones. is assumed to be proportional to ; however, the assumption has never been tested. This study used fluorescent microsphere infusion to measure femoral bone in anaesthetized non-laying hens, laying hens and roosters. Mean mass-specific cardiac output was 338±38 ml min⁻¹ kg⁻¹, and the two femora received 0.63±0.10% of this. Laying hens had higher wet bone mass-specific to femora (0.23±0.09 ml min⁻¹ g⁻¹) than the non-laying hens (0.12±0.06 ml min⁻¹ g⁻¹) and roosters (0.14±0.04 ml min⁻¹ g⁻¹), presumably associated with higher bone calcium mobilization during eggshell production. Estimated metabolic rate of femoral bone was 0.019 ml O₂ min⁻¹ g⁻¹. Femoral increased significantly with body mass, but was not correlated with nutrient foramen radius (r), probably because of a narrow range in foramen radius. Over all 18 chickens, femoral shaft was 1.07±0.30 ml min⁻¹ mm⁻¹. Mean in chickens was significantly higher than predicted by an allometric relationship for adult cursorial bird species, possibly because the birds were still growing.

Summary: Femoral bone blood flow, measured using fluorescent microspheres, is approximately two times higher in laying hens than in non-laying hens and roosters. Blood flow values were related to foramen sizes.

Regional and interindividual relationships between cerebral perfusion and oxygen metabolism

Quantitative measurements of resting cerebral blood flow (CBF) and metabolic rate of oxygen (CMRO₂) show large between-subject and regional variability, but the relationships between CBF and CMRO₂ measurements regionally and globally are not fully established. Here, we investigated the between-subject and regional associations between CBF and CMRO₂ measures with independent and quantitative PET techniques. We included resting CBF and CMRO₂ measurements from 50 healthy volunteers (aged 22-81 yr), and calculated the regional and global values of oxygen delivery (Do₂) and oxygen extraction fraction (OEF). Linear mixed-model analysis showed that CBF and CMRO₂ measurements were closely associated regionally, but no significant between-subject association could be demonstrated, even when adjusting for arterial Pco₂ and hemoglobin concentration. The analysis also showed regional differences of OEF, reflecting variable relationship between Do₂ and CMRO₂, resulting in lower estimates of OEF in thalami, brainstem, and mesial temporal cortices and higher estimates of OEF in occipital cortex. In the present study, we demonstrated no between-subject association of quantitative measurements of CBF and CMRO₂ in healthy subjects. Thus, quantitative measurements of CBF did not reflect the underlying between-subject variability of oxygen metabolism measures, mainly because of large interindividual OEF variability not accounted for by Pco₂ and hemoglobin concentration.NEW & NOTEWORTHY Using quantitative PET-measurements in healthy human subjects, we confirmed a regional association of CBF and CMRO₂, but did not find an association of these values across subjects. This suggests that subjects have an individual coupling between perfusion and metabolism and shows that absolute perfusion measurements does not serve as a surrogate measure of individual measures of oxygen metabolism. The analysis further showed smaller, but significant regional differences of oxygen extraction fraction at rest.

A broad diversity in oxygen affinity to haemoglobin

Oxygen affinity to haemoglobin is indicated by the p50 value (pO₂ at 50% O₂Hb) and critically determines cellular oxygen availability. Although high Hb-O₂ affinity can cause tissue hypoxia under conditions of well O₂ saturated blood, individual differences in p50 are commonly not considered in clinical routine. Here, we investigated the diversity in Hb-O₂ affinity in the context of physiological relevance. Oxyhaemoglobin dissociation curves (ODCs) of 60 volunteers (18–40 years, both sexes, either endurance trained or untrained) were measured at rest and after maximum exercise (VO₂max) test. At rest, p50 values of all participants ranged over 7 mmHg. For comparison, right shift of ODC after VO₂max test, representing the maximal physiological range to release oxygen to the tissue, indicated a p50 difference of up to 10 mmHg. P50 at rest differs significantly between women and men, with women showing lower Hb-O₂ affinity that is determined by higher 2,3-BPG and BPGM levels. Regular endurance exercise did not alter baseline Hb-O₂ affinity. Thus, p50 diversity is already high at baseline level and needs to be considered under conditions of impaired tissue oxygenation. For fast prediction of Hb-O₂ affinity by blood gas analysis, only venous but not capillary blood samples can be recommended.

Discussion: can upper extremity (deltoid) near infrared spectroscopy be used to assess cerebral tissue bed saturation on femorally cannulated veno-arterial extracorporeal membrane oxygenation patients?

Continuous cerebral tissue saturation monitoring with near infrared spectroscopy may help clinicians identify cerebral desaturation early; however, patients have reported discomfort from near infrared spectroscopy monitoring pads on the forehead. This study aims to compare upper extremity near infrared spectroscopy monitoring to cerebral near infrared spectroscopy monitoring to assess its viability as a surrogate for cerebral saturation. A retrospective analysis of 10 femorally cannulated veno-arterial extracorporeal membrane oxygenation patients was performed comparing left (L) and right (R) upper extremity (deltoid) near infrared spectroscopy monitoring to cerebral near infrared spectroscopy monitoring (n = 20 data sets, 10 left and 10 right) and right radial blood gasses. Deltoid and cerebral near infrared spectroscopy values were recorded every 15 minutes for at least 24 hours when possible, were plotted on scatter grams, and were analyzed using Pearson product-moment coefficient (r). Based on the concept of covariance, a moderate-good relationship r = 0.50-0.75 was noted in 10% (n = 2) of the study group. A fair relationship r = 0.25-0.50 was noted in 50% (n = 10), and little or no relationship was noted in 40% (n = 8). None of the study group displayed a good to excellent relationship (r = 0.75 or above). In addition, coefficient of multiple determination for multiple regression R² was calculated and strong fit of the regression line was not noted. Although cerebral near infrared spectroscopy monitoring has been extremely helpful in identifying low cerebral tissue saturation on veno-arterial extracorporeal membrane oxygenation patients, the use of upper extremity (peripheral deltoid) tissue monitoring does not provide adequate correlation and should not be used as a surrogate to cerebral monitoring.

ATP- and voltage-dependent electro-metabolic signaling regulates blood flow in heart

Local control of blood flow in the heart is important yet poorly understood. Here we show that ATP-sensitive K⁺ channels (K_ATP), hugely abundant in cardiac ventricular myocytes, sense the local myocyte metabolic state and communicate a negative feedback signal-correction upstream electrically. This electro-metabolic voltage signal is transmitted instantaneously to cellular elements in the neighboring microvascular network through gap junctions, where it regulates contractile pericytes and smooth muscle cells and thus blood flow. As myocyte ATP is consumed in excess of production, [ATP]_i decreases to increase the openings of K_ATP channels, which biases the electrically active myocytes in the hyperpolarization (negative) direction. This change leads to relative hyperpolarization of the electrically connected cells that include capillary endothelial cells, pericytes, and vascular smooth muscle cells. Such hyperpolarization decreases pericyte and vascular smooth muscle [Ca²⁺]_i levels, thereby relaxing the contractile cells to increase local blood flow and delivery of nutrients to the local cardiac myocytes and to augment ATP production by their mitochondria. Our findings demonstrate the pivotal roles of local cardiac myocyte metabolism and K_ATP channels and the minor role of inward rectifier K⁺ (Kir2.1) channels in regulating blood flow in the heart. These findings establish a conceptually new framework for understanding the hugely reliable and incredibly robust local electro-metabolic microvascular regulation of blood flow in heart.

Bone foramen dimensions and blood flow calculation: best practices

Some blood vessels enter bones through foramina, leaving the size of the foramen as a gauge for estimating the rate of blood flow and hence the metabolic rate of the supplied tissues. Foramen dimensions have been measured using varied methods in previous foramen studies, to relate regional blood flows with associated physiological processes. With the increasing interests in this 'foramen technique', standard methods with minimized measurement errors are therefore required. This study provides details of microphotographic and micro-computerized tomographic methods, and introduces a new alternative method, which uses impression material to measure foramen dimensions. The three methods are compared and the results indicate that all of them are capable of obtaining precise and accurate foramen dimension values, although they all have limitations. A microphotograph of the external opening is suggested to be the standard method because of its ease of use, but the alternative methods provide more detailed information on foramen shape. If the foramen is mainly occupied by one artery, blood flow rates can be calculated from foramen size and artery wall-lumen ratio, which is evaluated from the literature survey in this study. If veins or nerves also penetrate the foramen, a relative index of blood flow rate is nevertheless possible for comparative purposes.

In vivo aerobic metabolism of the rainbow trout gut and the effects of an acute temperature increase and stress event

The fish gut is responsible for numerous potentially energetically costly processes, yet little is known about its metabolism. Here, we provide the first in vivo measurements of aerobic metabolism of the gut in a teleost fish by measuring gut blood flow, as well as arterial and portal venous oxygen content. At 10°C, gut oxygen uptake rate was 4.3±0.5 ml O₂ h^-1 kg^-1 (∼11% of whole-animal oxygen uptake). Following acute warming to 15°C, gut blood flow increased ∼3.4-fold and gut oxygen uptake rate increased ∼3.7-fold (16.0±3.3 ml O₂ h^-1 kg^-1), now representing ∼25% of whole-animal oxygen uptake. Although gut blood flow decreased following an acute stress event at 15°C, gut oxygen uptake remained unchanged as a result of a ∼2-fold increase in oxygen extraction. The high metabolic thermal sensitivity of the gut could have important implications for the overall aerobic capacity and performance of fish in a warming world and warrants further investigation.

Phenotypic heterogeneity of obesity-related brain vulnerability: one-size interventions will not fit all

Intact memory and problem solving are key to functional independence and quality of life in older age. Considering the unprecedented demographic shift toward a greater number of older adults than children in the United States in the next few decades, it is critically important for older adults to maintain work productivity and functional independence for as long as possible. Implementing early interventions focused on modifiable risk factors for cognitive decline at midlife is a strategy with the highest chance of success at present, bearing in mind the current lack of dementia cures. We present a selective, narrative review of evidence linking nutrition, body composition, vascular health, and brain function in midlife to highlight the phenotypic heterogeneity of obesity-related brain vulnerability and to endorse the development of individually tailored lifestyle modification plans for primary prevention of cognitive decline.

Femoral bone perfusion through the nutrient foramen during growth and locomotor development of western grey kangaroos (Macropus fuliginosus)

The nutrient artery passes through the nutrient foramen on the shaft of the femur and supplies more than half of the total blood flow to the bone. Assuming that the size of the nutrient foramen correlates with the size of the nutrient artery, an index of blood flow rate (Q_i) can be calculated from nutrient foramen dimensions. Interspecific Q_i is proportional to locomotor activity levels in adult mammals, birds and reptiles. However, no studies have yet estimated intraspecific Q_i to test for the effects of growth and locomotor development on bone blood flow requirements. In this study, we used micro-CT and medical CT scanning to measure femoral dimensions and foramen radius to calculate femoral Q_i during the in-pouch and post-pouch life stages of western grey kangaroos (Macropus fuliginosus) weighing 5.7 g to 70.5 kg and representing a 12,350-fold range in body mass. A biphasic scaling relationship between Q_i and body mass was observed (breakpoint at ca. 1-5 kg body mass right before permanent pouch exit), with a steep exponent of 0.96±0.09 (95% CI) during the in-pouch life stage and a statistically independent exponent of -0.59±0.90 during the post-pouch life stage. In-pouch joeys showed Q_i values that were 50-100 times higher than those of adult diprotodont marsupials of the same body mass, but gradually converged with them as post-pouch adults. Bone modelling during growth appears to be the main determinant of femoral bone blood flow during in-pouch development, whereas bone remodelling for micro-fracture repair due to locomotion gradually becomes the main determinant when kangaroos leave the pouch and become more active.

Rest and exercise hemodynamic and metabolic findings in active duty soldiers referred for cardiac catheterization to exclude heart disease: Insights from past invasive cardiopulmonary exercise testing using multisensor high fidelity catheters

OBJECTIVE

This study describes results of iCPET from the past, which used submaximal stress and multisensor high-fidelity catheters to exclude heart disease in a unique population of young adults.

BACKGROUND

There has been resurgence in comprehensive hemodynamic evaluation of complex cardiovascular patients. Although dynamic assessments during cardiac catheterization have become commonplace, there remains limited information regarding left and right heart hemodynamic changes during supine exercise in young adults.

METHODS

The study population was derived from a retrospective review of catheterization records at Brooke Army Medical Center for active duty patients (ages: 19-40 years) in whom hemodynamic waveforms were obtained with multisensor high-fidelity catheters and supine exercise testing (53.1 ± 12.6 watts) and angiography performed to exclude heart disease. We report findings from 41 males and 1 female (ages: 19-40 years) found free of heart disease.

RESULTS

Submaximal exercise was associated with ≈ fourfold (P < 0.001) increase in minute ventilation (VE), O₂ consumption (VO₂ ) and carbon dioxide production (VCO₂ ). VE/VCO₂ ratio decreased (-16.8 ± 13.9%, P < 0.001) and VE/VCO₂ slope was 22.6 ± 0.6 (±SE). Cardiac index (CI) increased with VO₂ (ΔCI/ΔVO₂ slope = 7.6 ± 2.2). Heart rate increased nearly 10 bpm per 100 mL O₂ /min/M² , whereas, changes in stroke volume were more variable. Pulmonary artery (PA) saturations fell from 77 to 55% (P < 0.001). No change was noted in mean right atrial pressures; PA pressures increased ≈10 mm Hg (P < 0.001). Pulmonary capillary wedge and left ventricular end-diastolic pressures increased ≈2 mm Hg (P < 0.001) but variability noted between individuals.

CONCLUSION

This study provides insight into past practices of invasive cardiopulmonary testing and furthers the understanding of metabolic and hemodynamic changes in a young population during supine submaximal exercise. © 2017 Wiley Periodicals, Inc.

Oxygen Delivery and Oxygen Consumption in Pediatric Fluid Refractory Septic Shock During the First 42 h of Therapy and Their Relationship to 28-Day Outcome

Background: In septic shock, both oxygen delivery (DO₂) and oxygen consumption (VO₂) are dysfunctional. The current therapeutic regimens are geared to normalize global oxygen delivery (DO₂) to tissues via goal directed therapies but mortality remains high at 10-20%. Methods: We studied cardiac index (CI), systemic vascular resistance index (SVRI), central venous oxygen saturation (ScvO2), central venous pressure (CVP), peripheral oxygen saturation (SpO2), mean blood pressure (MBP), body temperature, blood lactate, base excess and hemoglobin concentration (Hb) in a cohort of children admitted in "fluid-refractory" severe septic shock to pediatric intensive care, over 4.5-years. We calculated their 6 h global oxygen delivery (DO2) and global oxygen consumption (VO2) over the first 42 h and looked at factors associated with VO2/DO2 ratio (i.e., global oxygen extraction, gO2ER) and 28-day mortality. Results: Sixty-two children mean age (SD) 7.19 (5.44) years were studied. Fifty-seven (93%) children were sedated and mechanically ventilated and all received adrenaline or noradrenaline or both and added milrinone in 6 (9.6%). At 28 days, 9 (14.5%) were dead. The global oxygen extraction ratio (gO2ER) was consistently lower amongst the survivors and independently predicted mortality (ROC AUC = 0.75). A lactate level of 4 mmol/l or above, when associated with a concurrent metabolic acidosis predicted mortality with a sensitivity of 100% (95% CI 90.5-100) and a specificity of 67.7% (95% CI 62.2-72.9). A gO2ER of 0.48 or above on admission to the PICU was associated with death with a 66.7% sensitivity (95%CI 29.9-92.5) and 90.5% specificity (95%CI 79.3-96.8). A global O2ER of >0.48 combined with a concurrent blood lactate >4.0 mmol/l at any time within the first 42 h of therapy predicted death with a sensitivity of 63.9% (95% CI, 46.2-79.1) and specificity of 97.8% (95% CI, 95.7-99.0). A radar plot identified MBP-CVP difference, and CI as additional goals of therapy that may offer a survival benefit. Conclusions: Global O2ER of >0.48 with a concurrent blood lactate >4.0 mmol/l in children with metabolic acidosis was an independent factor associated with death in fluid resistant septic shock. Trends of gO2ER seem useful to recognize survivors and non-survivors early in the illness.

In vivo real-time imaging of cutaneous hemoglobin concentration, oxygen saturation, scattering properties, melanin content, and epidermal thickness with visible spatially modulated light

We present the real-time single snapshot multiple frequency demodulation - spatial frequency domain imaging (SSMD-SFDI) platform implemented with a visible digital mirror device that is capable of imaging and monitoring dynamic turbid medium and processes over a large field of view. One challenge in quantitative imaging of biological tissue such as the skin is the complex structure rendering techniques based on homogeneous medium models to fail. To address this difficulty we have also developed a novel method that maps the layered structure to a homogeneous medium for spatial frequency domain imaging. The varying penetration depth of spatially modulated light on its wavelength and modulation frequency is used to resolve the layered structure. The efficacy of the real-time SSMD-SFDI platform and this two-layer model is demonstrated by imaging forearms of 6 healthy subjects under the reactive hyperemia protocol. The results show that our approach not only successfully decouples light absorption by melanin from that by hemoglobin and yields accurate determination of cutaneous hemoglobin concentration and oxygen saturation, but also provides reliable estimation of the scattering properties, the melanin content and the epidermal thickness in real time. Potential applications of our system in imaging skin physiological and functional states, cancer screening, and microcirculation monitoring are discussed at the end.

Sexually dimorphic skeletal muscle and cardiac dysfunction in a mouse model of limb girdle muscular dystrophy 2i

The fukutin-related protein P448L mutant mouse replicates many pathologies common to limb girdle muscular dystrophy 2i (LGMD2i) and is a potentially strong candidate for relevant drug screening studies. Because striated muscle function remains relatively uncharacterized in this mouse, we sought to identify metabolic, functional and histological metrics of exercise and cardiac performance. This was accomplished by quantifying voluntary exercise on running wheels, forced exercise on respiratory treadmills and cardiac output with echocardiography and isoproterenol stress tests. Voluntary exercise revealed few differences between wild-type and P448L mice. By contrast, peak oxygen consumption (VO₂peak) was either lower in P448L mice or reduced with repeated low intensity treadmill exercise while it increased in wild-type mice. P448L mice fatigued quicker and ran shorter distances while expending 2-fold more calories/meter. They also received over 6-fold more motivational shocks with repeated exercise. Differences in VO₂peak and resting metabolic rate were consistent with left ventricle dysfunction, which often develops in human LGMD2i patients and was more evident in female P448L mice, as indicated by lower fractional shortening and ejection fraction values and higher left ventricle systolic volumes. Several traditional markers of dystrophinopathies were expressed in P448L mice and were exacerbated by exercise, some in a muscle-dependent manner. These include elevated serum creatine kinase and muscle central nucleation, smaller muscle fiber cross-sectional area and more striated muscle fibrosis. These studies together identified several markers of disease pathology that are shared between P448L mice and human subjects with LGMD2i. They also identified novel metrics of exercise and cardiac performance that could prove invaluable in preclinical drug trials.NEW & NOTEWORTHY Limb-girdle muscular dystrophy 2i is a rare dystroglycanopathy that until recently lacked an appropriate animal model. Studies with the FKRP P448L mutant mouse began assessing muscle structure and function as well as running gait. Our studies further characterize systemic muscle function using exercise and cardiac performance. They identified many markers of respiratory, cardiac and skeletal muscle function that could prove invaluable to better understanding the disease and more importantly, to preclinical drug trials.

Kv1.3 channels facilitate the connection between metabolism and blood flow in the heart

The connection between metabolism and flow in the heart, metabolic dilation, is essential for cardiac function. We recently found redox-sensitive Kv1.5 channels play a role in coronary metabolic dilation; however, more than one ion channel likely plays a role in this process as animals null for these channels still showed limited coronary metabolic dilation. Accordingly, we examined the role of another Kv1 family channel, the energetically linked Kv1.3 channel, in coronary metabolic dilation. We measured myocardial blood flow (contrast echocardiography) during norepinephrine-induced increases in cardiac work (heart rate x mean arterial pressure) in WT, WT mice given correolide (preferential Kv1.3 antagonist), and Kv1.3-null mice (Kv1.3-/- ). We also measured relaxation of isolated small arteries mounted in a myograph. During increased cardiac work, myocardial blood flow was attenuated in Kv1.3-/- and in correolide-treated mice. In isolated vessels from Kv1.3-/- mice, relaxation to H2 O2 was impaired (vs WT), but responses to adenosine and acetylcholine were equivalent to WT. Correolide reduced dilation to adenosine and acetylcholine in WT and Kv1.3-/- , but had no effect on H2 O2 -dependent dilation in vessels from Kv1.3-/- mice. We conclude that Kv1.3 channels participate in the connection between myocardial blood flow and cardiac metabolism.

The impact of integrated evaluation of hemodynamics using targeted neonatal echocardiography with indices of tissue oxygenation: a new approach

OBJECTIVE

To study the impact of integrated evaluation of hemodynamics (IEH) using targeted neonatal echocardiography, together with regional tissue oxygenation, fractional oxygen extraction using near-infrared spectroscopy on the management of infants with compromised hemodynamics.

STUDY DESIGN

Retrospective cohort comparison of two groups of infants with compromised hemodynamics. EPOCH 1: did not undergo IEH (January 2012 to March 2014); EPOCH 2: underwent IEH (April 2014 to December 2015). The primary outcome was the time to recovery.

RESULTS

In all, 340 infants were included; 158 underwent IEH with a median (IQR) of 2 (1 to 3) evaluations per infant. Reasons for assessment included PDA (60%), compromised systemic circulation (14%) and clinically suspected pulmonary hypertension (22%). The time to recovery was shorter in IEH group in patients with compromised systemic circulation median (IQR), 32 h (24 to 63) compared with none IEH group 71 h (36 to 96), pulmonary hypertension 63 h (14.2 to 102) in IEH group compared with 68 h (24 to 240) in none IEH group, there were fewer PDA-related complications in preterm infants with PDA in IEH group.

CONCLUSION

IEH was associated with shorter time to clinical recovery in infants with compromised hemodynamics.

The effect of 30 to 60 minutes of forced-air pre-warming on maintaining intraoperative core temperatures during the first hour post-anesthesia induction in adult patients undergoing general anesthesia: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to identify the effectiveness of 30 to 60 minutes of forced-air pre-warming on maintaining intraoperative core temperatures in adult patients undergoing general anesthesia. The review question will focus on the effects of forced-air pre-warming on preventing redistribution hypothermia in the first hour post induction of anesthesia, which is considered the most critical due to an internal core-to-peripheral redistribution of body heat and subsequent loss of heat to the operative room surroundings.

The Role of Oxidative Stress in Myocardial Ischemia and Reperfusion Injury and Remodeling: Revisited

Oxidative and reductive stress are dual dynamic phases experienced by the cells undergoing adaptation towards endogenous or exogenous noxious stimulus. The former arises due to the imbalance between the reactive oxygen species production and antioxidant defenses, while the latter is due to the aberrant increase in the reducing equivalents. Mitochondrial malfunction is the common denominator arising from the aberrant functioning of the rheostat that maintains the homeostasis between oxidative and reductive stress. Recent experimental evidences suggest that the maladaptation during oxidative stress could play a pivotal role in the pathophysiology of major cardiovascular diseases such as myocardial infraction, atherosclerosis, and diabetic cardiovascular complications. In this review we have discussed the role of oxidative and reductive stress pathways in the pathogenesis of myocardial ischemia/reperfusion injury and diabetic cardiomyopathy (DCM). Furthermore, we have provided impetus for the development of subcellular organelle targeted antioxidant drug therapy for thwarting the deterioration of the failing myocardium in the aforementioned cardiovascular conditions.

Requisite Role of Kv1.5 Channels in Coronary Metabolic Dilation

RATIONALE

In the working heart, coronary blood flow is linked to the production of metabolites, which modulate tone of smooth muscle in a redox-dependent manner. Voltage-gated potassium channels (Kv), which play a role in controlling membrane potential in vascular smooth muscle, have certain members that are redox-sensitive.

OBJECTIVE

To determine the role of redox-sensitive Kv1.5 channels in coronary metabolic flow regulation.

METHODS AND RESULTS

In mice (wild-type [WT], Kv1.5 null [Kv1.5(-/-)], and Kv1.5(-/-) and WT with inducible, smooth muscle-specific expression of Kv1.5 channels), we measured mean arterial pressure, myocardial blood flow, myocardial tissue oxygen tension, and ejection fraction before and after inducing cardiac stress with norepinephrine. Cardiac work was estimated as the product of mean arterial pressure and heart rate. Isolated arteries were studied to establish whether genetic alterations modified vascular reactivity. Despite higher levels of cardiac work in the Kv1.5(-/-) mice (versus WT mice at baseline and all doses of norepinephrine), myocardial blood flow was lower in Kv1.5(-/-) mice than in WT mice. At high levels of cardiac work, tissue oxygen tension dropped significantly along with ejection fraction. Expression of Kv1.5 channels in smooth muscle in the null background rescued this phenotype of impaired metabolic dilation. In isolated vessels from Kv1.5(-/-) mice, relaxation to H2O2 was impaired, but responses to adenosine and acetylcholine were normal compared with those from WT mice.

CONCLUSIONS

Kv1.5 channels in vascular smooth muscle play a critical role in coupling myocardial blood flow to cardiac metabolism. Absence of these channels disassociates metabolism from flow, resulting in cardiac pump dysfunction and tissue hypoxia.

Hemoglobin optimization and transfusion strategies in patients undergoing cardiac surgery

Although red blood cells (RBCs) transfusion is sometimes associated with adverse reactions, anemia could also lead to increased morbidity and mortality in high-risk patients. For these reasons, the definition of perioperative strategies that aims to detect and treat preoperative anemia, prevent excessive blood loss, and define “optimal” transfusion algorithms is crucial. Although the treatment with preoperative iron and erythropoietin has been recommended in some specific conditions, several controversies exist regarding the benefit-to-risk balance associated with these treatments. Further studies are needed to better define the indications, dosage, and route of administration for preoperative iron with or without erythropoietin supplementation. Although restrictive transfusion strategies in patients undergoing cardiac surgery have been shown to effectively reduce the incidence and the amount of RBCs transfusion without increase in side effects, some high-risk patients (e.g., symptomatic acute coronary syndrome) could benefit from higher hemoglobin concentrations. Despite all efforts made last decade, a significant amount of work remains to be done to improve hemoglobin optimization and transfusion strategies in patients undergoing cardiac surgery.

Optimizing mean arterial pressure in septic shock: a critical reappraisal of the literature

Guidelines recommend that a mean arterial pressure (MAP) value greater than 65 mm Hg should be the initial blood pressure target in septic shock, but what evidence is there to support this statement? We searched Pubmed and Google Scholar by using the key words 'arterial pressure', 'septic shock', and 'norepinephrine' and retrieved human studies published between 1 January 2000 and 31 July 2014. We identified seven comparative studies: two randomized clinical trials and five observational studies. The results of the literature review suggest that a MAP target of 65 mm Hg is usually sufficient in patients with septic shock. However, a MAP of around 75 to 85 mm Hg may reduce the development of acute kidney injury in patients with chronic arterial hypertension. Because of the high prevalence of chronic arterial hypertension in patients who develop septic shock, this finding is of considerable importance. Future studies should assess interactions between time, fluid volumes administered, and doses of vasopressors.

Appetite and gut hormone responses to moderate-intensity continuous exercise versus high-intensity interval exercise, in normoxic and hypoxic conditions

This study investigated the effects of continuous moderate-intensity exercise (MIE) and high-intensity interval exercise (HIIE) in combination with short exposure to hypoxia on appetite and plasma concentrations of acylated ghrelin, peptide YY (PYY), and glucagon-like peptide-1 (GLP-1). Twelve healthy males completed four, 2.6 h trials in a random order: (1) MIE-normoxia, (2) MIE-hypoxia, (3) HIIE-normoxia, and (4) HIIE-hypoxia. Exercise took place in an environmental chamber. During MIE, participants ran for 50 min at 70% of altitude-specific maximal oxygen uptake (V˙O2max) and during HIIE performed 6 × 3 min running at 90% V˙O2max interspersed with 6 × 3 min active recovery at 50% V˙O2max with a 7 min warm-up and cool-down at 70% V˙O2max (50 min total). In hypoxic trials, exercise was performed at a simulated altitude of 2980 m (14.5% O2). Exercise was completed after a standardised breakfast. A second meal standardised to 30% of participants' daily energy requirements was provided 45 min after exercise. Appetite was suppressed more in hypoxia than normoxia during exercise, post-exercise, and for the full 2.6 h trial period (linear mixed modelling, p <0.05). Plasma acylated ghrelin concentrations were lower in hypoxia than normoxia post-exercise and for the full 2.6 h trial period (p <0.05). PYY concentrations were higher in HIIE than MIE under hypoxic conditions during exercise (p = 0.042). No differences in GLP-1 were observed between conditions (p > 0.05). These findings demonstrate that short exposure to hypoxia causes suppressions in appetite and plasma acylated ghrelin concentrations. Furthermore, appetite responses to exercise do not appear to be influenced by exercise modality.

Clarification of the circulatory patho-physiology of anaesthesia - implications for high-risk surgical patients

The paper examines the effects of anaesthesia on circulatory physiology and their implications regarding improvement in perioperative anaesthetic management. Changes to current anaesthetic practice, recommended recently, such as the use of flow monitoring in high risk patients, are already beginning to have an impact in reducing complications but not mortality [1]. Better understanding of the patho-physiology should help improve management even further. Analysis of selected individual clinical trials has been used to illustrate particular areas of patho-physiology and how changes in practice have improved outcome. There is physiological support for the importance of achieving an appropriate rate of oxygen delivery (DO2), particularly following induction of anaesthesia. It is suggested that ensuring adequate DO2 during anaesthesia will avoid development of oxygen debt and hence obviate the need to induce a high, compensatory, DO2 in the post-operative period. In contrast to the usual assumptions underlying strategies requiring a global increase in blood flow [1] by a stroke volume near maximization strategy, blood flow control actually resides entirely at the tissues not at the heart. This is important as the starting point for understanding failed circulatory control as indicated by 'volume dependency'. Local adjustments in blood flow at each individual organ - auto-regulation - normally ensure the appropriate local rate of oxygen supply, i.e. local DO2. Inadequate blood volume leads to impairment of the regulation of blood flow, particularly in the individual tissues with least capable auto-regulatory capability. As demonstrated by many studies, inadequate blood flow first occurs in the gut, brain and kidney. The inadequate blood volume which occurs with induction of anaesthesia is not due to blood volume loss, but probably results from redistribution due to veno-dilation. The increase in venous capacity renders the existing blood volume inadequate to maintain venous return and pre-load. Blood volume shifted to the veins will, necessarily, also reduce the arterial volume. As a result stroke volume and cardiac output fall below normal with little or no change in peripheral resistance. The resulting pre-load dependency is often successfully treated with colloid infusion and, in some studies, 'inotropic' agents, particularly in the immediate post-operative phase. Treatment during the earliest stage of anaesthesia can avoid the build up of oxygen debt and may be supplemented by drugs which maintain or restore venous tone, such as phenylephrine; an alternative to volume expansion. Interpretation of circulatory patho-physiology during anaesthesia confirms the need to sustain appropriate oxygen delivery. It also supports reduction or even elimination of supplementary crystalloid maintenance infusion, supposedly to replace the "mythical" third space loss. As a rational evidence base for future research it should allow for further improvements in anaesthetic management.

Cognitive impairment and cardiovascular disease: so near, so far

In the spectrum of cognitive impairment, ranging from "pure" vascular dementia to Alzheimer's disease (AD), clinical interest has recently expanded from the brain to also include the vessels, shifting the pathophysiological focus from the leaves of synaptic dysfunction to the sap of cerebral microcirculation and the roots of cardiovascular function. From a diagnostic viewpoint, a thorough clinical evaluation of individuals presenting cognitive impairment might systematically include the assessment of the major cardiovascular rings of the chain linking regional perfusion to brain function: 1) lung (with assessment of asthma, chronic obstructive pulmonary disease, obstructive sleep apnea syndrome); 2) heart function (with clinical examination and echocardiography) and cardiovascular risk factors; 3) orthostatic hypotension (with medical history and measurement of heart rate and blood pressure in supine and upright positions); 4) aorta and large artery stiffness (with assessment of pulse wave velocity); 5) large cerebro-vascular vessel status (with neuroimaging techniques); 6) assessment of microcirculation (with cerebrovascular reactivity testing with transcranial Doppler sonography or MRI perfusion imaging); and 7) assessment of venous cerebral circulation. The apparent difference in approaches to "brain" and "vascular" environmental enrichment with physical, cognitive and sensorial training is conceptually identical to that of a constant gardener caring for an unhealthy tree, watering the leaves ("train the brain") or simply the roots ("mind the vessel"). The therapeutic difference probably consists in the amount and quality of water added to the tree, rather than by where one pours it, with either a top-down (leaves to roots) or bottom-up (roots to leaves) approach.

Moderate hyperventilation during intravenous anesthesia increases net cerebral lactate efflux

BACKGROUND

Hyperventilation is known to decrease cerebral blood flow (CBF) and to impair cerebral metabolism, but the threshold in patients undergoing intravenous anesthesia is unknown. The authors hypothesized that reduced CBF associated with moderate hyperventilation might impair cerebral aerobic metabolism in patients undergoing intravenous anesthesia.

METHODS

Thirty male patients scheduled for coronary surgery were included in a prospective, controlled crossover trial. Measurements were performed under fentanyl-midazolam anesthesia in a randomized sequence aiming at partial pressures of carbon dioxide of 30 and 50 mmHg. Endpoints were CBF, blood flow velocity in the middle cerebral artery, and cerebral metabolic rates for oxygen, glucose, and lactate. Global CBF was measured using a modified Kety-Schmidt technique with argon as inert gas tracer. CBF velocity of the middle cerebral artery was recorded by transcranial Doppler sonography. Data were presented as mean (SD). Two-sided paired t tests and one-way ANOVA for repeated measures were used for statistical analysis.

RESULTS

Moderate hyperventilation significantly decreased CBF by 60%, blood flow velocity by 41%, cerebral oxygen delivery by 58%, and partial pressure of oxygen of the jugular venous bulb by 45%. Cerebral metabolic rates for oxygen and glucose remained unchanged; however, net cerebral lactate efflux significantly increased from -0.38 (2.18) to -2.41(2.43) µmol min 100 g.

CONCLUSIONS

Moderate hyperventilation, when compared with moderate hypoventilation, in patients with cardiovascular disease undergoing intravenous anesthesia increased net cerebral lactate efflux and markedly reduced CBF and partial pressure of oxygen of the jugular venous bulb, suggesting partial impairment of cerebral aerobic metabolism at clinically relevant levels of hypocapnia.

Multimodal intraoperative monitoring: an observational case series in high risk patients undergoing major peripheral vascular surgery

Recent guidelines from the National Institute of Health and Care Excellence (NICE) and the UK National Health Service (NHS) have stipulated that intraoperative flow monitoring should be used in high-risk patients undergoing major surgery to improve outcomes and reduce costs. Depth of anaesthesia monitoring is also recommended for patients where excessive anaesthetic depth is poorly tolerated, along with cerebral oximetry in patients with proximal femoral fractures. The aims of this descriptive case series were to evaluate the impact of a multimodal intraoperative strategy and its effect on mortality and amputation rate for patients with critical leg ischaemia. In an observational case series, 120 elderly patients undergoing major infra-inguinal bypass between 2007 and 2012 were included in this retrospective analysis of prospectively collected data. Nominal cardiac output (nCO, LiDCOrapid, LiDCO Ltd, UK), bispectral index to monitor depth of anaesthesia (BIS, Covidien, USA) and cerebral oxygenation, rSO2 (Invos, Covidien, USA) readings were obtained before induction of general anaesthesia and throughout surgery. 30 day, 1-year mortality and amputation rates were analysed. Demographics and physiological parameters including correlation with V-POSSUM, age, gender and other co-morbidities were statistically analysed. Thirty-day mortality rate was 0.8% (n = 1). V-POSSUM scoring indicated a predicted mortality of 9%. Amputation rate was less than 2% at one year. Only 8% of patients (10 of 120) were admitted to a high dependency unit (HDU) postoperatively. 30-day mortality in our case series was lower than predicted by V-POSSUM scoring. Use of multimodal intraoperative monitoring with the specific aim of limiting build-up of oxygen debt should be subjected to a randomised controlled study to assess the reproducibility of these results.

Using bispectral index and cerebral oximetry to guide hemodynamic therapy in high-risk surgical patients

High-risk surgery represents 12.5% of cases but contributes 80% of deaths in the elderly population. Reduction in morbidity and mortality by the use of intervention strategies could result in thousands of lives being saved and savings of up to £400m per annum in the UK. This has resulted in the drive towards goal-directed therapy and intraoperative flow optimization of high-risk surgical patients being advocated by authorities such as the National Institute of Health and Care Excellence and the Association of Anaesthetists of Great Britain and Ireland.Conventional intraoperative monitoring gives little insight into the profound physiological changes occurring as a result of anesthesia and surgery. The build-up of an oxygen debt is associated with a poor outcome and strategies have been developed in the postoperative period to improve outcomes by repayment of this debt. New monitoring technologies such as minimally invasive cardiac output, depth of anesthesia and cerebral oximetry can minimize oxygen debt build-up. This has the potential to reduce complications and lessen the need for postoperative optimization in high-dependency areas.Flow monitoring has thus emerged as essential during intraoperative monitoring in high-risk surgery. However, evidence suggests that current optimization strategies of deliberately increasing flow to meet predefined targets may not reduce mortality.Could the addition of depth of anesthesia and cerebral and tissue oximetry monitoring produce a further improvement in outcomes?Retrospective studies indicate a combination of excessive depth of anesthesia hypotension and low anesthesia requirement results in increased mortality and length of hospital stay.Near infrared technology allows assessment and maintenance of cerebral and tissue oxygenation, a strategy, which has been associated with improved outcomes. The suggestion that the brain is an index organ for tissue oxygenation, especially in the elderly, indicates a role for this technology in the intraoperative period to assess the adequacy of oxygen delivery and reduce the build-up of an oxygen debt.The aim of this article is to make the case for depth of anesthesia and cerebral oximetry alongside flow monitoring as a strategy for reducing oxygen debt during high-risk surgery and further improve outcomes in high-risk surgical patients.

Oxygen delivery: the principal role of the circulation

Autoregulation of blood flow to most individual organs is well known. The balance of oxygen supply relative to the rate of oxygen consumption ensures normal function. There is less reserve as regards oxygen supply than for any other necessary metabolite or waste product so oxygen supply is flow dependent. Reduced rate of supply compromises tissue oxygenation long before any other substance. The present report reiterates evidence from earlier studies demonstrating that the rate of oxygen delivery (DO2), for most individual tissues, is well sustained at a value bearing a ratio to oxygen consumption (VO2) which is specific for the organ concerned. For the brain DO2 is sustained at approximately three times the rate of oxygen consumption and for exercising skeletal muscle (below the anaerobic threshold), a ratio close to 1.5. The tissue-specific ratios are sustained in the face of alterations in local VO2 and lowered arterial oxygen content (CaO2). Tolerance varies between different organs. Hence, the role of the circulation is predominantly one of ensuring an adequate supply of oxygen. The precise values of the individual tissue DO2:VO2 ratios apply within physiological ranges which require further investigation.

Influence of rest and exercise at a simulated altitude of 4,000 m on appetite, energy intake, and plasma concentrations of acylated ghrelin and peptide YY

The reason for high altitude anorexia is unclear but could involve alterations in the appetite hormones ghrelin and peptide YY (PYY). This study examined the effect of resting and exercising in hypoxia (12.7% O2; ∼4,000 m) on appetite, energy intake, and plasma concentrations of acylated ghrelin and PYY. Ten healthy males completed four, 7-h trials in an environmental chamber in a random order. The four trials were control-normoxia, control-hypoxia, exercise-normoxia, and exercise-hypoxia. During exercise trials, participants ran for 60 min at 70% of altitude-specific maximal oxygen consumption (V̇o2max) and then rested. Participants rested throughout control trials. A standardized meal was consumed at 2 h and an ad libitum buffet meal at 5.5 h. Area under the curve values for hunger (assessed using visual analog scales) tended to be lower during hypoxic trials than normoxic trials (repeated-measures ANOVA, P = 0.07). Ad libitum energy intake was lower ( P = 0.001) in hypoxia (5,291 ± 2,189 kJ) than normoxia (7,718 ± 2,356 kJ; means ± SD). Mean plasma acylated ghrelin concentrations were lower in hypoxia than normoxia (82 ± 66 vs. 100 ± 69 pg/ml; P = 0.005) while PYY concentrations tended to be higher in normoxia (32 ± 4 vs. 30 ± 3 pmol/l; P = 0.059). Exercise suppressed hunger and acylated ghrelin and increased PYY but did not influence ad libitum energy intake. These findings confirm that hypoxia suppresses hunger and food intake. Further research is required to determine if decreased concentrations of acylated ghrelin orchestrate this suppression.

Effect of inspiration of 12% O₂ (balance N₂) on cardiac output, respiration, oxygen saturation, and oxygen delivery

Low arterial oxygen saturation (SaO(2)) will result in a reduced rate of arterial oxygen delivery to the tissues (DO(2)), unless there is a compensatory increase in cardiac output (CO) or haemoglobin concentration (Hb). An adequate DO(2) can therefore be maintained by increasing ventilation, CO, or both. Sustaining a tissue specific oxygen extraction is thought to play an important part in overall compensation. The present study has examined responses to acute hypoxic exposure in 8 volunteers (breathing 12% oxygen, balance nitrogen) and describes changes in CO, ventilation and the SaO(2). Aims included: examination of the extent of intersubject variations and seeing whether DO(2) was maintained. SaO(2), PCO(2), respiration (via stethograph) and Finapress (non-invasive) arterial blood pressure (BP) were recorded, firstly on air and then on 12% oxygen. CO was derived, off-line, from the BP record. CO was increased in 5 subjects (22%-45%) but was virtually unchanged in 3, and yet comparison for all 8 subjects showed that DO(2) on 12% oxygen was not significantly different from DO(2) on air (mean on air 1017 ml. min(-1); hypoxia 1080 ml. min(-1), p = 0.27). SaO(2) on 12% oxygen ranged between 85% and 93%. In conclusion, exposure to the same hypoxic gas mixture resulted in differing individual ventilatory and CO responses. However, DO(2) was well maintained.