Role of heart rate variability in predicting the severity of severe acute pancreatitis

Heart Rate Variability Measurement through a Smart Wearable Device: Another Breakthrough for Personal Health Monitoring?

Heart rate variability (HRV) is a measurement of the fluctuation of time between each heartbeat and reflects the function of the autonomic nervous system. HRV is an important indicator for both physical and mental status and for broad-scope diseases. In this review, we discuss how wearable devices can be used to monitor HRV, and we compare the HRV monitoring function among different devices. In addition, we have reviewed the recent progress in HRV tracking with wearable devices and its value in health monitoring and disease diagnosis. Although many challenges remain, we believe HRV tracking with wearable devices is a promising tool that can be used to improve personal health.

Electroacupuncture at Neiguan (PC6) attenuates cardiac dysfunction caused by cecal ligation and puncture via the vagus nerve

PURPOSE

Previous studies proved the benefits of electroacupuncture (EA) on heart in ischemia reperfusion injury and chronic heart failure. However, the role of EA on sepsis-induced cardiac dysfunction has rarely been elucidated before. In this study, we aimed to investigate the effects of EA on cardiac dysfunction in a rat model of sepsis and to speculate the underlying mechanisms.

METHODS

Sepsis was induced by cecum ligation and puncture in anesthetized rats. EA at the acupoint "Neiguan (PC6)" was applied 0.5 h after the induction of sepsis for 20 min. Heart rate variability was obtained immediately after EA to evaluate autonomic balance. Echocardiography was performed at 6 h and 24 h after sepsis induction in vivo. Measurements of hemodynamics, blood gases, cytokines and biochemistry were collected at 24 h. Cardiac tissue underwent immunofluorescence staining to determine the expression of α7 nicotinic acetylcholine receptor (α7nAChR) on macrophages.

RESULTS

EA increased vagus nerve activity, prevented the development of hyperlactatemia, attenuated the decline of left ventricle ejection fraction, suppressed systemic and cardiac inflammation and alleviated the histopathological manifestations of heart in sepsis rats. Furthermore, the cardiac tissue from EA treated rats showed increased expressions of α7nAChR on macrophages. The cardio-protective and anti-inflammatory effects of EA were partly or completely prevented in rats with vagotomy.

CONCLUSION

EA at PC6 attenuates left ventricle dysfunction and decreases inflammation in sepsis-induced cardiac dysfunction. The cardio-protective effects of EA are mediated through vagus nerve mediated cholinergic pathway.

Comprehensive Mechanism, Novel Markers and Multidisciplinary Treatment of Severe Acute Pancreatitis-Associated Cardiac Injury - A Narrative Review

Acute pancreatitis (AP) is one of the common acute abdominal inflammatory diseases in clinic with acute onset and rapid progress. About 20% of the patients will eventually develop into severe acute pancreatitis (SAP) characterized by a large number of inflammatory cells infiltration, gland flocculus flaky necrosis and hemorrhage, finally inducing systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). Pancreatic enzyme activation, intestinal endotoxemia (IETM), cytokine activation, microcirculation disturbance, autonomic nerve dysfunction and autophagy dysregulation all play an essential role in the occurrence and progression of SAP. Organ dysfunction is the main cause of early death in SAP. Acute kidney injury (AKI) and acute lung injury (ALI) are common, while cardiac injury (CI) is not, but the case fatality risk is high. Many basic studies have observed obvious ultrastructure change of heart in SAP, including myocardial edema, cardiac hypertrophy, myocardial interstitial collagen deposition. Moreover, in clinical practice, patients with SAP often presented various abnormal electrocardiogram (ECG) and cardiac function. Cases complicated with acute myocardial infarction and pericardial tamponade have also been reported and even result in stress cardiomyopathy. Due to the molecular mechanisms underlying SAP-associated cardiac injury (SACI) remain poorly understood, and there is no complete, unified treatment and sovereign remedy at present, this article reviews reports referring to the pathogenesis, potential markers and treatment methods of SACI in recent years, in order to improve the understanding of cardiac injury in severe pancreatitis.

Wearable Patch Heart Rate Variability is An Early Marker of Systemic Inflammation During Experimental Human Endotoxemia

INTRODUCTION

Early diagnosis and treatment can reduce the risk of organ failure and mortality in systemic inflammatory conditions. Heart rate variability (HRV) has potential for early identification of the onset of systemic inflammation, as it may detect changes in sympathetic nervous system activity resulting from the developing inflammatory response before clinical signs appear. With the use of new methodologies, we investigated the onset and kinetics of HRV changes as well as several inflammatory parameters and symptoms during experimental human endotoxemia, a model of systemic inflammation in humans in vivo.

MATERIAL AND METHODS

Healthy volunteers were intravenously administered lipopolysaccharide (LPS, n = 15) or placebo (n = 15). HRV was determined using a wireless wearable device, and parameters low to high frequency (LF:HF) ratio, root mean square of the successive differences (RMSSD), and standard deviation of normal-to-normal R-R intervals (SDNN)were calculated through 1-min-rolling 6-minute windows. Plasma cytokine levels and flu-like symptoms and vital signs were serially assessed.

RESULTS

The increase in LF:HF ratio, reflecting sympathetic predominance, was more pronounced in the LPS group compared to the placebo group, with the difference becoming statistically significant 65 minutes following LPS administration (1.63 [1.42-1.83] vs. 1.28 [1.11-1.44], p = 0.005). Significant between-group differences in RMSSD and SDNN were observed from 127 and 140 minutes post-LPS administration onwards, respectively. Plasma cytokine levels showed significant between-group differences staring 60 minutes post-LPS. For symptom score, heart rate, temperature and diastolic blood pressure, significant differences compared with the placebo group were observed at 90, 118, 120, and 124 minutes post-LPS, respectively.

CONCLUSION

In a controlled human model of systemic inflammation, elevations in the LF:HF ratio followed very shortly after elevations in plasma cytokine levels and preceded onset of flu-like symptoms and alterations in vital signs. HRV may represent a promising non-invasive tool for early detection of a developing systemic inflammatory response.

Electrocardiogram Heart Rate as a Predictor of Severity in Acute Alcohol-Related Pancreatitis With Alcohol Withdrawal Syndrome

Background The severity of acute alcohol-related pancreatitis (AAP) with alcohol withdrawal syndrome (AWS) has not been studied. Electrocardiogram (ECG) has not been used as a predictor of severity in patients with AWS and acute pancreatitis. Objectives The study aimed to determine whether the ECG heart rate (HR) could predict the severity of AAP; secondarily, whether AWS influenced the severity of AAP based on Acute Physiology and Chronic Health Evaluation (APACHE) II and Bedside Index for Severity in Acute Pancreatitis (BISAP). Methods Demographics, comorbid illnesses, AWS, biochemistry, ECG, arterial blood gases, and CT findings were noted in patients with AAP. The severity of pancreatitis was scored into mild, moderate, and severe based on CT. BISAP, APACHE II, and ECG heart rate-APACHE (E-APACHE) were compared in patients with and without AWS. A receiver operating characteristic curve was used to find the best predictor of severity. Results Among 138 patients (M=128), 94 had AWS. ECG changes (≥1) were seen in 50%. Patients with AWS were younger, had consumed alcohol for a shorter duration, had higher systemic inflammatory response syndrome (SIRS), APACHE II, and E-APACHE II scores. APACHE II and E-APACHE II correlated significantly with severity grading, HR, alcohol duration, and AWS. HR was the best predictor of severe pancreatitis; E-APACHE was the best predictor for moderately severe pancreatitis. Conclusions Mostly, AAP appears to be mild; >2/3rds have AWS. ECG findings were seen in 50%. HR has not been previously studied in patients with both AAP and AWS and is an easy and inexpensive test to predict the severity of pancreatitis in this cohort.

Complex dynamics of skin sympathetic nerve activities as a prognostic predictor for critically ill patients

BACKGROUND

The skin sympathetic nerve activity (SKNA) is a new method to measure sympathetic nerve activity by using conventional ECG electrodes. We developed a novel approach to analyze the complexity of SKNA time series under different time scales and showed its prognostic significance in patients receiving critical care.

METHODS

This study measured SKNA in patients admitted to an intensive care unit (ICU). Each recording is 10-minute long with 10000Hz sampling rate. Multi-scale fluctuation analysis (MSFA) was developed to quantify the variation within each time scale after removing the linear trend. The prognostic value of SKNA was combined with traditional prognostics scoring system to improve the predictive values.

RESULTS

155 patients were recruited. After 30 and 90 days, 30 and 48 patients expired. MSFA was significantly higher in survival group than mortality group for 30-day (0.487 ± 0.185 vs 0.401 ± 0.045, p = 0.018) and 90-day (0.499 ± 0.196 vs 0.414 ± 0.061, p = 0.001) follow-up. Sequential Organ Failure Assessment (SOFA) score was significantly lower in the survival group compared to the expired group for 30-day and 90-day (4.1 ± 2.9 vs. 5.5 ± 4.1, p = 0.032 and 3.9 ± 3.0 vs. 5.4 ± 3.5, p = 0.012). The Kaplan-Meier survival analysis showed MSFA lower than 0.401 (log-rank test:4.96, p = 0.03) or with SOFA score lower than 5 (log-rank test:5.49, p = 0.019) have a significantly higher mortality rate. A multivariate Cox regression model showed that the MSFA is an independent predictor for 30-day mortality (HR = 2.35, 1.08-5.09, p = 0.031) and 90-day mortality (HR = 1.96, 1.08-3.58, p = 0.027).

CONCLUSION

MSFA was a significant prognostic predictor for critically ill patients. MSFA adding to SOFA score could help improve risk prediction.

Intercostal artery damage and massive hemothorax after thoracocentesis by central venous catheter: A case report

Central venous catheters (CVCs) are widely used in various puncture and drainage operations in intensive care units (ICUs) in recent years. Compared to conventional operating devices, CVC was welcomed by clinicians because of the advantages of easy use, less damage to the body and convenient fixation process. We came across a patient with severe acute pancreatitis (SAP) who developed cardiac arrest due to thoracic cavity massive bleeding 24 h after thoracocentesis with CVC. Thoracotomy surgery was carried out immediately, which confirmed an intercostal artery injury. The patient was discharged from hospital without any neurological complications two months later. Here we report this case to remind all the emergency department and ICU physicians to pay more attention to the complication of thoracic cavity bleeding following thoracocentesis conducted by CVC.

Heart rate variability in critical care medicine: a systematic review

BACKGROUND

Heart rate variability (HRV) has been used to assess cardiac autonomic activity in critically ill patients, driven by translational and biomarker research agendas. Several clinical and technical factors can interfere with the measurement and/or interpretation of HRV. We systematically evaluated how HRV parameters are acquired/processed in critical care medicine.

METHODS

PubMed, MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (1996-2016) were searched for cohort or case-control clinical studies of adult (>18 years) critically ill patients using heart variability analysis. Duplicate independent review and data abstraction. Study quality was assessed using two independent approaches: Newcastle-Ottowa scale and Downs and Black instrument. Conduct of studies was assessed in three categories: (1) study design and objectives, (2) procedures for measurement, processing and reporting of HRV, and (3) reporting of relevant confounding factors.

RESULTS

Our search identified 31/271 eligible studies that enrolled 2090 critically ill patients. A minority of studies (15; 48%) reported both frequency and time domain HRV data, with non-normally distributed, wide ranges of values that were indistinguishable from other (non-critically ill) disease states. Significant heterogeneity in HRV measurement protocols was observed between studies; lack of adjustment for various confounders known to affect cardiac autonomic regulation was common. Comparator groups were often omitted (n = 12; 39%). This precluded meaningful meta-analysis.

CONCLUSIONS

Marked differences in methodology prevent meaningful comparisons of HRV parameters between studies. A standardised set of consensus criteria relevant to critical care medicine are required to exploit advances in translational autonomic physiology.

Hydrogen-Rich Saline Attenuates Acute Hepatic Injury in Acute Necrotizing Pancreatitis by Inhibiting Inflammation and Apoptosis, Involving JNK and p38 Mitogen-Activated Protein Kinase-dependent Reactive Oxygen Species

OBJECTIVES

The objective of this study was to study the role of hydrogen-rich saline (HRS) on acute hepatic injury (AHI) in acute necrotizing pancreatitis (ANP).

METHODS

Rats were used for this study and an ANP model was induced by injecting 5% sodium taurocholate into the biliary-pancreatic duct. Experiments were performed in 3 groups: sham, ANP, and ANP + HRS (HRS). Animals were killed at 3, 12, and 24 hours after operation, and then blood and tissue samples were harvested. Various physiological, histological, and cellular and molecular parameters were analyzed.

RESULTS

Analyses of serum, lipase, alanine transaminase, and aspartate aminotransferase indicated that ANP-induced AHI model was established successfully and HRS attenuated hepatic dysfunction. Hepatic superoxide dismutase and malondialdehyde levels showed HRS against oxidative stress. Cellular and molecular analyses including p-p38, p-JNK, p-ERK, and caspase-3, caspase-9, NF-κB, and TNF-α in hepatic tissues revealed that HRS attenuated ANP-induced AHI by inhibiting apoptosis and phosphorylation of JNK and p38, as well as NF-κB activation.

CONCLUSIONS

Hydrogen-rich saline plays a protective role in ANP-induced AHI through inhibiting inflammation and apoptosis, involving JNK and p38 MAPK-dependent reactive oxygen species.

Ghrelin and gastroparesis as early predictors of clinical outcomes in acute pancreatitis

BACKGROUND

Impaired motor and hormonal gastrointestinal functions have been implicated in the pathogenesis of acute pancreatitis. The aim of the present study was to investigate the predictive value of the Gastroparesis Cardinal Symptom Index and serum ghrelin in the development of clinically meaningful outcomes in patients with acute pancreatitis.

METHODS

This was a prospective clinical study. The Gastroparesis Cardinal Symptom Index and serum ghrelin were measured for 48 h after hospitalization. Univariate and multivariate logistic regression analyses were conducted.

RESULTS

The Gastroparesis Cardinal Symptom Index total score alone on day 2 was a significant predictor of oral feeding intolerance in both unadjusted (odds ratio 1.21 (1.01-1.46), P = 0.04) and adjusted (odds ratio 1.30 (1.01-1.69), P = 0.05) analyses. Adding ghrelin to Gastroparesis Cardinal Symptom Index further improved prediction in both unadjusted (odds ratio 1.26 (1.02-1.56), P = 0.03) and adjusted (odds ratio 1.53 (1.00-2.35), P = 0.05) analyses.

CONCLUSION

This pilot study demonstrates that the Gastroparesis Cardinal Symptom Index has a potential to be used as a predictor of oral feeding intolerance. Ghrelin, when combined with the Gastroparesis Cardinal Symptom Index, may further improve the predictive accuracy. These findings need to be confirmed in larger studies.

Successful cardiopulmonary cerebral resuscitation in patient with severe acute pancreatitis

Severe acute pancreatitis (SAP) is a critical illness in clinical practice, which is characterized by intensive inflammatory response in the early phase and infected pancreatic necrosis in the later phase. Despite the knowledge of SAP and critical care support technology got significant progress in recent years, SAP still carries approximately 30%mortality rate. Some SAP patients also have many other kinds of underlying disease such as hyperlipidemia, hypertension, coronary atherosclerotic heart disease, and heart rhythm abnormalities, which are related to cardiopulmonary arrest to some extent. Thus, the incidence of unpredictive cardiopulmonary arrest is high. Recently, a SAP patient in our intensive care unit had sudden cardiac arrest. After 52 minutes of cardiopulmonary resuscitation, she had return of spontaneous circulation and regained consciousness within 2 hours. To our knowledge, there is no successful report after such long resuscitation in SAP patients. She was receiving continuous renal replacement therapy (CRRT) and continuous veno-venous hemofiltration, in the event of cardiopulmonary arrest. No study reported what kind of role CRRT can play when cardiac arrest occurs. Usually, we would stop existing CRRT when cardiac arrest occurred.We would not start CRRT for the complexity of operation and additional loss of blood. This time, we used CRRT to regulate electrolyte and acid-base imbalance and implement hypothermia brain protection, which played an important role in the patient that we report here.We strongly recommended a prolonged cardiopulmonary cerebral resuscitation in some not quite old SAP patients and continue to use existing CRRT but not remove it.