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Zeng W, Deng Z, Gao Y, Sun G, Li X, Yuan D. Downregulation of connexin 43-based gap junctions underlies propofol-induced excessive relaxation in hypertensive vascular smooth muscle cells. Cell Commun Signal 2023; 21:163. [PMID: 37381027 DOI: 10.1186/s12964-023-01176-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/25/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Postinduction hypotension caused by propofol remains a non-negligible problem for anesthesiologists, and is especially severe in chronic hypertensive patients with long-term vasoconstriction and decreased vascular elasticity. The functional change in gap junctions composed of Cx43 (Cx43-GJs) is reported as the biological basis of synchronized contraction or relaxation of blood vessels. Thus, we investigated the role of Cx43-GJs in propofol-induced dramatic blood pressure fluctuations in chronic hypertensive patients, and their internal mechanisms. METHODS Human umbilical artery smooth muscle cells (HUASMCs) were pretreated with long-term angiotensin II (Ang II), with or without propofol, to simulate the contraction and relaxation of normal and hypertensive VSMCs during anesthesia induction. The levels of F-actin polymerization and MLC2 phosphorylation were used as indicators to observe the contraction and relaxation of HUASMCs. Different specific activators, inhibitors and siRNAs were used to explore the role of Cx43-GJs and Ca2+ as well as the RhoA/ LIMK2/cofilin and RhoA/MLCK signaling pathways in the contraction and relaxation of normal and hypertensive HUASMCs. RESULTS Both F-actin polymerization and MLC2 phosphorylation were significantly enhanced in Ang II-pretreated HUASMCs, along with higher expression of Cx43 protein and stronger function of Cx43-GJs than in normal HUASMCs. However, with propofol administration, similar to Gap26 and Cx43-siRNA, the function of Cx43-GJs in Ang II-pretreated HUASMCs was inhibited compared with that in normal HUASMCs, accompanied by a larger decrease in intracellular Ca2+ and the RhoA/LIMK2/cofilin and RhoA/MLCK signaling pathways. Eventually F-actin polymerization and MLC2 phosphorylation were more dramatically decreased. However, these effects could be reversed by RA with enhanced Cx43-GJ function. CONCLUSION Long-term exposure to Ang II significantly enhanced the expression of the Cx43 protein and function of Cx43-GJs in HUASMCs, resulting in the accumulation of intracellular Ca2+ and the activation of its downstream RhoA/LIMK2/cofilin and RhoA/MLCK signaling pathways, which maintained HUASMCs in a state of excessive-contraction. With inhibition of Cx43-GJs by propofol in Ang II-pretreated HUASMCs, intracellular Ca2+ and its downstream signaling pathways were dramatically inhibited, which ultimately excessively relaxed HUASMCs. This is the reason why the blood pressure fluctuation of patients with chronic hypertension was more severe after receiving propofol induction. Video Abstract.
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Affiliation(s)
- Weiqi Zeng
- Department of Anesthesiology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Zhizhao Deng
- Department of Anesthesiology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Yingxin Gao
- Department of Anesthesiology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Guoliang Sun
- Department of Anesthesiology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China.
| | - Xianlong Li
- Department of Anesthesiology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China.
| | - Dongdong Yuan
- Department of Anesthesiology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China.
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Cui Q, Che L, Zang H, Yu J, Xu L, Huang Y. Association between preoperative autonomic nervous system function and post-induction hypotension in elderly patients: a protocol for a cohort study. BMJ Open 2023; 13:e067400. [PMID: 36717143 PMCID: PMC9887722 DOI: 10.1136/bmjopen-2022-067400] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Post-induction hypotension (PIH), which is prevalent among elderly patients, is associated with adverse perioperative outcomes. As a critical part of blood pressure regulation, baroreflex control is believed to be closely related to intraoperative blood pressure fluctuations. Spontaneous baroreflex sensitivity and heart rate variability measurement can aid evaluation of patients' autonomic function. This study aims to determine the association between preoperative decreased baroreflex function and PIH in elderly patients. METHODS AND ANALYSIS This prospective cohort study will enrol patients who are 65 years old and above, scheduled for elective non-cardiac surgery under general anaesthesia, and American Society of Anesthesiologists physical status I-III (n=180). Baseline assessment will include routine preoperative evaluations as well as symptoms and anamneses associated with baroreflex failure. Preoperative autonomic function monitoring will be performed through 20 min of continuous beat-to-beat heart rate and blood pressure monitoring using LiDCO rapid (Masimo Corporation, USA). The primary outcome will be PIH. Detailed use of anaesthetic agents during induction and maintenance will be documented for adjustment in multivariable analyses. ETHICS AND DISSEMINATION The Research Ethics Committee of Peking Union Medical College Hospital approved the study protocol (I-22PJ008). We aim to publish and disseminate our findings in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05425147.
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Affiliation(s)
- Quexuan Cui
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Lu Che
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Han Zang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiawen Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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Association between temporal patterns of baroreflex sensitivity after traumatic brain injury and prognosis: a preliminary study. Neurol Sci 2023; 44:1653-1663. [PMID: 36609622 PMCID: PMC10102132 DOI: 10.1007/s10072-022-06579-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) may lead to an increase in intracranial pressure (ICP) as well as impairment of cerebral vascular reactivity and the autonomic nervous system. This study aimed to investigate individual patterns of changes in baroreflex sensitivity (BRS) along with the assessment of pressure reactivity index (PRx) and ICP after TBI. MATERIALS AND METHODS Twenty-nine TBI patients with continuous arterial blood pressure (ABP) and ICP monitoring were included. BRS was calculated using the sequential cross-correlation method. PRx was estimated using slow-wave oscillations of ABP and ICP. Outcome was assessed using the Glasgow Outcome Scale. RESULTS Pooled data analysis of the lower breakpoint during the week that followed TBI revealed that BRS reached a minimum about 2 days after TBI. In patients with good outcome, there was a significant increase in BRS during the 7 days following TBI: rp = 0.21; p = 0.008 and the temporal changes in BRS showed either a "U-shaped" pattern or a gradual increase over time. The BRS value after 1.5 days was found to be a significant predictor of mortality (cut-off BRS = 1.8 ms/mm Hg; AUC = 0.83). In patients with poor outcome, ICP and PRx increased while BRS remained low. CONCLUSIONS We found an association between temporal patterns of BRS and prognosis in the early days following TBI. Further research in a larger cohort of patients is needed to confirm the weight of these preliminary observations for prediction of prognosis in TBI patients.
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Uryga A, Nasr N, Kasprowicz M, Woźniak J, Goździk W, Burzyńska M. Changes in autonomic nervous system during cerebral desaturation episodes in aneurysmal subarachnoid hemorrhage. Auton Neurosci 2022; 239:102968. [DOI: 10.1016/j.autneu.2022.102968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/16/2021] [Accepted: 02/21/2022] [Indexed: 10/19/2022]
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Uryga A, Nasr N, Kasprowicz M, Budohoski K, Sykora M, Smielewski P, Burzyńska M, Czosnyka M. Relationship Between Baroreflex and Cerebral Autoregulation in Patients With Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2022; 12:740338. [PMID: 35095711 PMCID: PMC8790510 DOI: 10.3389/fneur.2021.740338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Common consequences following aneurysmal subarachnoid hemorrhage (aSAH) are cerebral vasospasm (CV), impaired cerebral autoregulation (CA), and disturbance in the autonomic nervous system, as indicated by lower baroreflex sensitivity (BRS). The compensatory interaction between BRS and CA has been shown in healthy volunteers and stable pathological conditions such as carotid atherosclerosis. The aim of this study was to investigate whether the inverse correlation between BRS and CA would be lost in patients after aSAH during vasospasm. A secondary objective was to analyze the time-trend of BRS after aSAH. Materials and Methods: Retrospective analysis of prospectively collected data was performed at the Neuro-Critical Care Unit of Addenbrooke's Hospital (Cambridge, UK) between June 2010 and January 2012. The cerebral blood flow velocity (CBFV) was measured in the middle cerebral artery using transcranial Doppler ultrasonography (TCD). The arterial blood pressure (ABP) was monitored invasively through an arterial line. CA was quantified by the correlation coefficient (Mxa) between slow oscillations in ABP and CBFV. BRS was calculated using the sequential cross-correlation method using the ABP signal. Results: A total of 73 patients with aSAH were included. The age [median (lower-upper quartile)] was 58 (50–67). WFNS scale was 2 (1–4) and the modified Fisher scale was 3 (1–3). In the total group, 31 patients (42%) had a CV and 42 (58%) had no CV. ABP and CBFV were higher in patients with CV during vasospasm compared to patients without CV (p = 0.001 and p < 0.001). There was no significant correlation between Mxa and BRS in patients with CV, neither during nor before vasospasm. In patients without CV, a significant, although moderate correlation was found between BRS and Mxa (rS = 0.31; p = 0.040), with higher BRS being associated with worse CA. Multiple linear regression analysis showed a significant worsening of BRS after aSAH in patients with CV (Rp = −0.42; p < 0.001). Conclusions: Inverse compensatory correlation between BRS and CA was lost in patients who developed CV after aSAH, both before and during vasospasm. The impact of these findings on the prognosis of aSAH should be investigated in larger studies.
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Affiliation(s)
- Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Nathalie Nasr
- INSERM UMR 1297, Institute of Cardiovascular and Metabolic Diseases (I2MC), Toulouse, France.,Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Karol Budohoski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marek Sykora
- Department of Neurology, St. John's Hospital, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Małgorzata Burzyńska
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, Wrocław, Poland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Institute of Electronic Systems, Faculty of Electronics and Information Technology, Warsaw University of Technology, Warsaw, Poland
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Cholinesterase activity in serum during general anesthesia in patients with or without vascular disease. Sci Rep 2021; 11:16687. [PMID: 34404888 PMCID: PMC8371088 DOI: 10.1038/s41598-021-96251-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 08/06/2021] [Indexed: 11/08/2022] Open
Abstract
Maintaining hemodynamic stability during the induction and maintenance of anesthesia is one of the challenges of the anesthesiologist. Patients with vascular disease are at increased risk of instability due to imbalance between the sympathetic and parasympathetic parts of the autonomic nervous system, a balance accessible by serum cholinesterase activity. We aim to characterize the dynamics of cholinesterase activity in patients undergoing general anesthesia (GA) and surgery. This was a prospective study of 57 patients undergoing ambulatory or vascular surgery under GA. Cholinesterase activity was measured before the induction of anesthesia, after 15 min and at the end of surgery by calculating the capacity of serum acetylcholinesterase (AChE) and butyrylcholinesterase to hydrolyze AcetylThioCholine. Data on atherosclerotic disease, anesthesia management were analyzed. Both AChE and total cholinergic status (CS) decreased significantly after GA induction at 15 min and even more so by the end of surgery. Vascular surgery patients had lower baseline cholinesterase activity compared to ambulatory surgery patients. Patients requiring intraoperative administration of phenylephrine for hemodynamic support (21.1%) had a significantly lower level of AChE and CS compared to untreated patients. Our findings serve as a mirror to the sympathetic/parasympathetic imbalance during GA, with a marked decrease in the parasympathetic tone. The data of a subgroup analysis show a correlation between low cholinesterase activity and an increase in the need for hemodynamic support.
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Bari V, Fantinato A, Vaini E, Gelpi F, Cairo B, De Maria B, Pistuddi V, Ranucci M, Porta A. Impact of propofol general anesthesia on cardiovascular and cerebrovascular closed loop variability interactions. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Baroreceptors are mechanosensitive elements of the peripheral nervous system that maintain homeostasis by coordinating physiologic responses to external and internal stimuli. While it is recognized that carotid and cardiopulmonary baroreceptor reflexes modulate autonomic output to mitigate excessive fluctuations in arterial blood pressure and to maintain intravascular volume, increasing evidence suggests that baroreflex pathways also project to key regions of the central nervous system that regulate somatosensory, somatomotor, and central nervous system arousal. In addition to maintaining autonomic homeostasis, baroreceptor activity modulates the perception of pain, as well as neuroimmune, neuroendocrine, and cognitive responses to physical and psychologic stressors. This review summarizes the role that baroreceptor pathways play in modulating acute and chronic pain perception. The contribution of baroreceptor function to postoperative outcomes is also presented. Finally, methods that enhance baroreceptor function, which hold promise in improving postoperative and pain management outcomes, are presented.
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Lee SK, Jeong MA, Sung JM, Yeon HJ, Chang JH, Lim H. Effect of remifentanil infusion on the hemodynamic response during induction of anesthesia in hypertensive and normotensive patients: a prospective observational study. J Int Med Res 2019; 47:6254-6267. [PMID: 31680598 PMCID: PMC7045677 DOI: 10.1177/0300060519883568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The induction of general anesthesia may cause hemodynamic instability. Remifentanil is often administered to suppress the hemodynamic response. We aimed to evaluate the effect of remifentanil infusion on the hemodynamic response to induction of anesthesia in hypertensive and normotensive patients. Methods Patients were divided into two groups: Group H (n = 102) were hypertensive patients and Group C (n = 107) were normotensive patients. During induction, all patients received 1 µg/kg of remifentanil as a loading dose over 2 minutes, followed by a continuous infusion at 0.05 µg/kg/minute. We analyzed the systolic, diastolic, and mean pressures and heart rate pre-induction, pre-intubation, immediately post-intubation, and at 2, 4, 6, 8, and 10 minutes after intubation. Results The systolic, diastolic, and mean pressures before induction were significantly higher in group H compared with group C, but there was no significant difference between the two groups immediately after intubation. Blood pressures immediately after intubation were similar to the pre-induction blood pressure. There was no significant difference in heart rate between the two groups at any time point. Conclusions Remifentanil infusion effectively attenuates the hemodynamic response to induction of general anesthesia in hypertensive and normotensive patients.
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Affiliation(s)
- Soo Kyung Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi Ae Jeong
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Jeong Min Sung
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Hyo Jin Yeon
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Ji Hee Chang
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Hyunyoung Lim
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Republic of Korea
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Prasad V, Guerrisi M, Dauri M, Coniglione F, Tisone G, De Carolis E, Cillis A, Canichella A, Toschi N, Heldt T. Prediction of postoperative outcomes using intraoperative hemodynamic monitoring data. Sci Rep 2017; 7:16376. [PMID: 29180647 PMCID: PMC5703992 DOI: 10.1038/s41598-017-16233-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 11/08/2017] [Indexed: 12/13/2022] Open
Abstract
Major surgeries can result in high rates of adverse postoperative events. Reliable prediction of which patient might be at risk for such events may help guide peri- and postoperative care. We show how archiving and mining of intraoperative hemodynamic data in orthotopic liver transplantation (OLT) can aid in the prediction of postoperative 180-day mortality and acute renal failure (ARF), improving upon predictions that rely on preoperative information only. From 101 patient records, we extracted 15 preoperative features from clinical records and 41 features from intraoperative hemodynamic signals. We used logistic regression with leave-one-out cross-validation to predict outcomes, and incorporated methods to limit potential model instabilities from feature multicollinearity. Using only preoperative features, mortality prediction achieved an area under the receiver operating characteristic curve (AUC) of 0.53 (95% CI: 0.44–0.78). By using intraoperative features, performance improved significantly to 0.82 (95% CI: 0.56–0.91, P = 0.001). Similarly, including intraoperative features (AUC = 0.82; 95% CI: 0.66–0.94) in ARF prediction improved performance over preoperative features (AUC = 0.72; 95% CI: 0.50–0.85), though not significantly (P = 0.32). We conclude that inclusion of intraoperative hemodynamic features significantly improves prediction of postoperative events in OLT. Features strongly associated with occurrence of both outcomes included greater intraoperative central venous pressure and greater transfusion volumes.
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Affiliation(s)
- Varesh Prasad
- Harvard-MIT Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, MA, USA. .,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Maria Guerrisi
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy.,Department of Emergency and Critical Care Medicine, Pain Medicine and Anaesthesiology, University Hospital "Tor Vergata", Rome, Italy
| | - Filadelfo Coniglione
- Department of Clinical Science and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy.,Department of Emergency and Critical Care Medicine, Pain Medicine and Anaesthesiology, University Hospital "Tor Vergata", Rome, Italy.,University "Our Lady of Good Counsel", Tirana, Albania
| | - Giuseppe Tisone
- Department of Experimental Medicine and Surgery, University of Rome "Tor Vergata", Rome, Italy
| | - Elisa De Carolis
- Department of Emergency and Critical Care Medicine, Pain Medicine and Anaesthesiology, University Hospital "Tor Vergata", Rome, Italy
| | - Annagrazia Cillis
- Department of Emergency and Critical Care Medicine, Pain Medicine and Anaesthesiology, University Hospital "Tor Vergata", Rome, Italy
| | - Antonio Canichella
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Nicola Toschi
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy.,Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Thomas Heldt
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.,Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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A Retrospective Observational Study of Anesthetic Induction Dosing Practices in Female Elderly Surgical Patients: Are We Overdosing Older Patients? Drugs Aging 2017; 33:737-746. [PMID: 27581549 DOI: 10.1007/s40266-016-0394-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND/OBJECTIVES Despite guidelines suggesting a 25-50 % reduction in induction doses of intravenous anesthetic agents in the elderly (≥65 years), we hypothesized that practitioners were not sufficiently correcting drug administration for age, contributing to an increased incidence of hypotension in older patients undergoing general anesthesia. STUDY DESIGN We conducted a retrospective, observational study in a tertiary-care academic hospital. The study included 768 female patients undergoing gynecologic surgeries who received propofol-based induction of general anesthesia. MAIN OUTCOME MEASURES Weight-adjusted anesthetic induction dosing, age-associated differences in dosing by ASA-PS (American Society of Anesthesiology-Physical Status), and hemodynamic outcomes between younger (18-64 years, n = 537) and older (≥65 years, n = 231) female patients were analyzed. RESULTS Older patients received lower doses of propofol and midazolam than younger patients (propofol: 2.037 ± 0.783 vs 2.322 ± 0.834 mg/kg, p < 0.001; midazolam: 0.013 ± 0.014 vs 0.023 ± 0.042 mg/kg, p < 0.001). However, practitioners still consistently exceeded the FDA recommended dose (1-1.5 mg/kg) of propofol for elderly patients. There was no significant difference in the doses of fentanyl administered between the two age groups (1.343 ± 0.744 vs 1.363 ± 0.763 μg/kg, p = 0.744), and doses of fentanyl in older patients exceeded the recommended dose (0.5-1.0 μg/kg). Corresponding to observed overdosing of induction agents, older patients experienced larger decreases in post-induction blood pressure and were more likely to receive vasopressor therapy. CONCLUSIONS Anesthetic induction doses of fentanyl and propofol were not sufficiently corrected in older patients in accordance with recommendations. Significantly greater frequency of post-induction hypotension occurred amongst older patients. Quality improvement efforts may lead to improved outcomes in this vulnerable population.
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Huang D, Zhou J, Su D, Yu W, Chen J. Variations of perioperative baroreflex sensitivity in hypertensive and normotensive patients. Clin Exp Hypertens 2017; 39:74-79. [PMID: 28060537 DOI: 10.1080/10641963.2016.1210624] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Impaired baroreflex sensitivity (BRS) is a marker of autonomous dysfunction, which may play an important role in the long-term development of hypertension. Perioperative patients with hypertension are rapidly increasing in all populations worldwide. OBJECTIVE To estimate the value of BRS for hypertension in a surgery cohort. METHODS An observational and cross-sectional study was performed, involving 96 patients who underwent video-assisted thoracoscopic pulmonary lobectomy or segmentectomy. Invasive blood pressure and heart rate before and after giving nitroglycerin were measured in 48 normotensive patients and 48 hypertensive patients (25 and 23 undergoing regular treatment hypertensive [HR] and irregular treatment hypertensive [HI], respectively) while entering the operation room, 30 minutes after skin incision, and 10 minutes after skin suture. RESULTS BRSpreoperative of hypertensive group (Group H) was lower than normotensive group (Group N) (3.49 ± 1.55 vs. 5.75 ± 4.15 ms/mmHg; P < 0.05). BRSintraoperative of Group H was lower than Group N (1.70 ± 1.18 vs. 2.84 ± 1.11 ms/mmHg; P < 0.05). BRSpreoperative of patients in irregular-treated group (Group HI) was lower than regular-treated group (Group HR) (2.92 ± 1.36 vs. 4.31 ± 1.87 ms/mmHg; P < 0.05). BRSintraoperative of Group HI was lower than Group HR (1.45 ± 0.90 vs. 2.08 ± 1.82 ms/mmHg; P < 0.05). BRSintraoperative and BRSpostoperative were lower than BRSpreoperative in each group (P < 0.01). CONCLUSION The perioperative autonomic nerve function was significantly impaired in hypertensive patients. This effect was less pronounced for those who were on regular antihypertensive treatment. Attention should be paid to maintain the stability of cardiovascular function, to ensure patients can go through perioperative period safely.
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Affiliation(s)
- Dan Huang
- a Department of Anesthesiology, Renji Hospital, School of Medicine , Shanghai Jiaotong University , Shanghai , China
| | - Jie Zhou
- a Department of Anesthesiology, Renji Hospital, School of Medicine , Shanghai Jiaotong University , Shanghai , China
| | - Diansan Su
- a Department of Anesthesiology, Renji Hospital, School of Medicine , Shanghai Jiaotong University , Shanghai , China
| | - Weifeng Yu
- a Department of Anesthesiology, Renji Hospital, School of Medicine , Shanghai Jiaotong University , Shanghai , China
| | - Jie Chen
- a Department of Anesthesiology, Renji Hospital, School of Medicine , Shanghai Jiaotong University , Shanghai , China
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Lavanga M, Baselli G, Fumagalli F, Ristagno G, Ferrario M. The possible role of the vagal nervous system in the recovery of the blood pressure control after cardiac arrest: a porcine model study. Physiol Meas 2016; 38:63-76. [PMID: 27941230 DOI: 10.1088/1361-6579/38/1/63] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Previous studies have proved that the baroreceptor reflex (baroreflex) control of heart rate can be used for stratification of post-infarction population and, in general, cardiovascular disease populations. Many methods have been proposed to estimate the so-called baroreflex sensitivity (BRS) expressed as ms mmhg-1. Most of the studies that exploit BRS focus mainly on acute myocardial infarction (AMI) and there are no important works that investigate the role of BRS immediately after cardiac arrest (CA). The present work is a continuation of the published work of Ristagno et al (2014 Shock 41 72-8). In particular, the main objectives are: (1) to study the evolution of BRS after CA and following cardiopulmonary resuscitation (CPR); (2) to verify if the recovery of cardiovascular stability and arterial blood pressure is accompanied by a recovery of BR in a porcine model; (3) to investigate the possible causes of the BRS variations in response to CA and following cardiopulmonary resuscitation. All the BRS estimators adopted in this study show a significant decrease after CA. However, partial recovery is obtained in the last hours of post resuscitation. Analysis of impulse response showed a decrease in peak delay after CA and was significantly shorter 4 hours after CPR. This finding hints at a compensation mechanism: a faster response when baroreflex gain is not fully restored. The increase in the speed of baroreflex response is in line with the hypothesis of a key role of the parasympathetic nervous system, which is known to act at a higher firing rate.
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Affiliation(s)
- Mario Lavanga
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, P.zza Leonardo da Vinci 32, Milan, Italy. ESAT-STADIUS, KU Leuven, Kasteelpark Arenberg 10, box 2446, 3001 Leuven, Belgium
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Duggento A, Bianciardi M, Passamonti L, Wald LL, Guerrisi M, Barbieri R, Toschi N. Globally conditioned Granger causality in brain-brain and brain-heart interactions: a combined heart rate variability/ultra-high-field (7 T) functional magnetic resonance imaging study. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2016; 374:20150185. [PMID: 27044985 PMCID: PMC4822445 DOI: 10.1098/rsta.2015.0185] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/05/2016] [Indexed: 05/24/2023]
Abstract
The causal, directed interactions between brain regions at rest (brain-brain networks) and between resting-state brain activity and autonomic nervous system (ANS) outflow (brain-heart links) have not been completely elucidated. We collected 7 T resting-state functional magnetic resonance imaging (fMRI) data with simultaneous respiration and heartbeat recordings in nine healthy volunteers to investigate (i) the causal interactions between cortical and subcortical brain regions at rest and (ii) the causal interactions between resting-state brain activity and the ANS as quantified through a probabilistic, point-process-based heartbeat model which generates dynamical estimates for sympathetic and parasympathetic activity as well as sympathovagal balance. Given the high amount of information shared between brain-derived signals, we compared the results of traditional bivariate Granger causality (GC) with a globally conditioned approach which evaluated the additional influence of each brain region on the causal target while factoring out effects concomitantly mediated by other brain regions. The bivariate approach resulted in a large number of possibly spurious causal brain-brain links, while, using the globally conditioned approach, we demonstrated the existence of significant selective causal links between cortical/subcortical brain regions and sympathetic and parasympathetic modulation as well as sympathovagal balance. In particular, we demonstrated a causal role of the amygdala, hypothalamus, brainstem and, among others, medial, middle and superior frontal gyri, superior temporal pole, paracentral lobule and cerebellar regions in modulating the so-called central autonomic network (CAN). In summary, we show that, provided proper conditioning is employed to eliminate spurious causalities, ultra-high-field functional imaging coupled with physiological signal acquisition and GC analysis is able to quantify directed brain-brain and brain-heart interactions reflecting central modulation of ANS outflow.
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Affiliation(s)
- Andrea Duggento
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome 'Tor Vergata', Rome, Italy
| | - Marta Bianciardi
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Luca Passamonti
- Istituto di Bioimmagini e Fisiologia Molecolare, Consiglio Nazionale delle Richerche, Catanzaro, Italy Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Lawrence L Wald
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Maria Guerrisi
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome 'Tor Vergata', Rome, Italy
| | - Riccardo Barbieri
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Nicola Toschi
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome 'Tor Vergata', Rome, Italy Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
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Stankovski T, Petkoski S, Raeder J, Smith AF, McClintock PVE, Stefanovska A. Alterations in the coupling functions between cortical and cardio-respiratory oscillations due to anaesthesia with propofol and sevoflurane. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2016; 374:rsta.2015.0186. [PMID: 27045000 PMCID: PMC4822446 DOI: 10.1098/rsta.2015.0186] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/09/2016] [Indexed: 05/24/2023]
Abstract
The precise mechanisms underlying general anaesthesia pose important and still open questions. To address them, we have studied anaesthesia induced by the widely used (intravenous) propofol and (inhalational) sevoflurane anaesthetics, computing cross-frequency coupling functions between neuronal, cardiac and respiratory oscillations in order to determine their mutual interactions. The phase domain coupling function reveals the form of the function defining the mechanism of an interaction, as well as its coupling strength. Using a method based on dynamical Bayesian inference, we have thus identified and analysed the coupling functions for six relationships. By quantitative assessment of the forms and strengths of the couplings, we have revealed how these relationships are altered by anaesthesia, also showing that some of them are differently affected by propofol and sevoflurane. These findings, together with the novel coupling function analysis, offer a new direction in the assessment of general anaesthesia and neurophysiological interactions, in general.
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Affiliation(s)
- Tomislav Stankovski
- Department of Physics, Lancaster University, Lancaster LA1 4YB, UK Faculty of Medicine, Ss. Cyril and Methodius University, 50 Divizija 6, Skopje 1000, Macedonia
| | - Spase Petkoski
- Institut de Neurosciences des Systèmes UMR_S 1106, Aix-Marseille Université, Marseille 13005, France
| | - Johan Raeder
- Department of Anaesthesiology, Oslo University Hospital, Oslo 0424, Norway
| | - Andrew F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster LA1 4RP, UK
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Aletti F, Gambarotta N, Penn AH, Ferrario M, Schmid-Schönbein GW. Heart period and blood pressure characteristics in splanchnic arterial occlusion shock-induced collapse. J Clin Monit Comput 2015; 31:167-175. [PMID: 26686691 DOI: 10.1007/s10877-015-9813-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 12/07/2015] [Indexed: 12/15/2022]
Abstract
The nature of hemodynamic instability typical of circulatory shock is not well understood, but an improved interpretation of its dynamic features could help in the management of critically ill patients. The objective of this work was to introduce new metrics for the analysis of arterial blood pressure (ABP) in order to characterize the risk of catastrophic outcome in splanchnic arterial occlusion (SAO) shock. Continuous ABP (fs = 1 kHz) was measured in rats during experimental SAO shock, which induced a fatal pressure drop (FPD) in ABP. The FPD could either be slow (SFPD) or fast (FFPD), with the latter causing cardiovascular collapse. Time series of mean arterial pressure, systolic blood pressure and heart period were derived from ABP. The sample asymmetry-based algorithm Heart Rate Characteristics was adapted to compute the Heart Period Characteristics (HPC) and the Blood Pressure Characteristics (BPC). Baroreflex sensitivity (BRS) was assessed by means of a bivariate model. The approach to FPD of the animals who collapsed (FFPD) was characterized by higher BRS in the low frequency band versus SFPD animals (0.36 ± 0.15 vs. 0.19 ± 0.12 ms/mmHg, p value = 0.0196), bradycardia as indicated by the HPC (0.76 ± 0.57 vs. 1.94 ± 1.27, p value = 0.0179) and higher but unstable blood pressure as indicated by BPC (3.02 ± 2.87 vs. 1.47 ± 1.29, p value = 0.0773). The HPC and BPC indices demonstrated promise as potential clinical markers of hemodynamic instability and impending cardiovascular collapse, and this animal study suggests their test in data from intensive care patients.
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Affiliation(s)
- Federico Aletti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 20133, Milan, Italy.
- Department of Bioengineering, University of California San Diego, 9500 Gilman Drive MC 0412, La Jolla, CA, 92093-0412, USA.
| | - Nicolò Gambarotta
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 20133, Milan, Italy
| | - Alexander H Penn
- Department of Bioengineering, University of California San Diego, 9500 Gilman Drive MC 0412, La Jolla, CA, 92093-0412, USA
| | - Manuela Ferrario
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 20133, Milan, Italy
| | - Geert W Schmid-Schönbein
- Department of Bioengineering, University of California San Diego, 9500 Gilman Drive MC 0412, La Jolla, CA, 92093-0412, USA
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Introduction to the special issue: papers from the Society for Complex Acute Illness (SCAI). J Clin Monit Comput 2014; 27:373-4. [PMID: 23760647 DOI: 10.1007/s10877-013-9485-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Lipponen JA, Tarvainen MP, Laitinen T, Karjalainen PA, Vanninen J, Koponen T, Laitinen TM. Causal estimation of neural and overall baroreflex sensitivity in relation to carotid artery stiffness. Physiol Meas 2013; 34:1633-44. [DOI: 10.1088/0967-3334/34/12/1633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Porta A, Bari V, Bassani T, Marchi A, Pistuddi V, Ranucci M. Model-based causal closed-loop approach to the estimate of baroreflex sensitivity during propofol anesthesia in patients undergoing coronary artery bypass graft. J Appl Physiol (1985) 2013; 115:1032-42. [DOI: 10.1152/japplphysiol.00537.2013] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cardiac baroreflex is a fundamental component of the cardiovascular control. The continuous assessment of baroreflex sensitivity (BRS) from spontaneous heart period (HP) and systolic arterial pressure (SAP) variations during general anesthesia provides relevant information about cardiovascular regulation in physiological conditions. Unfortunately, several difficulties including unknown HP-SAP causal relations, negligible SAP changes, small BRS values, and confounding influences due to mechanical ventilation prevent BRS monitoring from HP and SAP variabilities during general anesthesia. We applied a model-based causal closed-loop approach aiming at BRS assessment during propofol anesthesia in 34 patients undergoing coronary artery bypass graft (CABG) surgery. We found the following: 1) traditional time and frequency domain approaches (i.e., baroreflex sequence, cross-correlation, spectral, and transfer function techniques) exhibited irremediable methodological limitations preventing the assessment of the BRS decrease during propofol anesthesia; 2) Granger causality approach proved that the methodological caveats were linked to the decreased presence of bidirectional closed-loop HP-SAP interactions and to the increased incidence of the HP-SAP uncoupling; 3) our model-based closed-loop approach detected the significant BRS decrease during propofol anesthesia as a likely result of accounting for the influences of mechanical ventilation and causal HP-SAP interactions; and 4) the model-based closed-loop approach found also a diminished gain of the relation from HP to SAP linked to vasodilatation and reduced ventricular contractility during propofol anesthesia. The proposed model-based causal closed-loop approach is more effective than traditional approaches in monitoring cardiovascular control during propofol anesthesia and indicates an overall depression of the HP-SAP closed-loop regulation.
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Affiliation(s)
- Alberto Porta
- Department of Biomedical Sciences for Health, Galeazzi Orthopedic Institute, University of Milan, Milan, Italy
| | - Vlasta Bari
- Gruppo Ospedaliero San Donato Foundation, Milan, Italy
- Department of Electronics Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Tito Bassani
- Humanitas Clinical and Research Center, Rozzano, Italy; and
| | - Andrea Marchi
- Humanitas Clinical and Research Center, Rozzano, Italy; and
| | - Valeria Pistuddi
- Department of Anesthesia and Intensive Care, Policlinico San Donato, San Donato Milanese, Italy
| | - Marco Ranucci
- Department of Anesthesia and Intensive Care, Policlinico San Donato, San Donato Milanese, Italy
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