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Zhao X, Zhang Y, Kou M, Wang Z, He Q, Wen Z, Chen J, Song Y, Wu S, Huang C, Huang W. The exploration of perioperative hypotension subtypes: a prospective, single cohort, observational pilot study. Front Med (Lausanne) 2024; 11:1358067. [PMID: 38952866 PMCID: PMC11215119 DOI: 10.3389/fmed.2024.1358067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 06/05/2024] [Indexed: 07/03/2024] Open
Abstract
Background Hypotension is a risk factor for postoperative complications, but evidence from randomized trials does not support that a higher blood pressure target always leads to optimized outcomes. The heterogeneity of underlying hemodynamics during hypotension may contribute to these contradictory results. Exploring the subtypes of hypotension can enable optimal management of intraoperative hypotension. Methods This is a prospective, observational pilot study. Patients who were ≥ 45 years old and scheduled to undergo moderate-to-high-risk noncardiac surgery were enrolled in this study. The primary objective of this pilot study was to investigate the frequency and distribution of perioperative hypotension and its subtypes (hypotension with or without cardiac output reduction). The exposure of hypotension and its subtypes in patients with and without myocardial or acute kidney injury were also explored. Results Sixty patients were included in the analysis. 83% (50/60) of the patients experienced perioperative hypotension. The median duration of hypotension for each patient was 8.0 [interquartile range, 3.1-23.3] minutes. Reduced cardiac output was present during 77% of the hypotension duration. Patients suffering from postoperative myocardial or acute kidney injury displayed longer duration and more extensive exposure in all hypotension subtypes. However, the percentage of different hypotension subtypes did not differ in patients with or without postoperative myocardial or acute kidney injury. Conclusion Perioperative hypotension was frequently accompanied by cardiac output reduction in moderate-to-high-risk noncardiac surgical patients. However, due to the pilot nature of this study, the relationship between hypotension subtypes and postoperative myocardial or acute kidney injury still needs further exploration. Clinical trial registration https://www.chictr.org.cn/showprojEN.html?proj=134260, CTR2200055929.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Shihui Wu
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chanyan Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenqi Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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2
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Litvinova O, Bilir A, Parvanov ED, Niebauer J, Kletecka-Pulker M, Kimberger O, Atanasov AG, Willschke H. Patent landscape review of non-invasive medical sensors for continuous monitoring of blood pressure and their validation in critical care practice. Front Med (Lausanne) 2023; 10:1138051. [PMID: 37497278 PMCID: PMC10366595 DOI: 10.3389/fmed.2023.1138051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/20/2023] [Indexed: 07/28/2023] Open
Abstract
Objectives Continuous non-invasive monitoring of blood pressure is one of the main factors in ensuring the safety of the patient's condition in anesthesiology, intensive care, surgery, and other areas of medicine. The purpose of this work was to analyze the current patent situation and identify directions and trends in the application of non-invasive medical sensors for continuous blood pressure monitoring, with a focus on clinical experience in critical care and validation thereof. Materials and methods The research results reflect data collected up to September 30, 2022. Patent databases, Google Scholar, the Lens database, Pubmed, Scopus databases were used to search for patent and clinical information. Results An analysis of the patent landscape indicates a significant increase in interest in the development of non-invasive devices for continuous blood pressure monitoring and their implementation in medical practice, especially in the last 10 years. The key players in the intellectual property market are the following companies: Cnsystems Medizintechnik; Sotera Wireless INC; Tensys Medical INC; Healthstats Int Pte LTD; Edwards Lifesciences Corp, among others. Systematization of data from validation and clinical studies in critical care practice on patients with various pathological conditions and ages, including children and newborns, revealed that a number of non-invasive medical sensor technologies are quite accurate and comparable to the "gold standard" continuous invasive blood pressure monitoring. They are approved by the FDA for medical applications and certified according to ISO 81060-2, ISO 81060-3, and ISO/TS 81060-5. Unregistered and uncertified medical sensors require further clinical trials. Conclusion Non-invasive medical sensors for continuous blood pressure monitoring do not replace, but complement, existing methods of regular blood pressure measurement, and it is expected to see more of these technologies broadly implemented in the practice in the near future.
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Affiliation(s)
- Olena Litvinova
- National University of Pharmacy of the Ministry of Health of Ukraine, Kharkiv, Ukraine
| | - Aylin Bilir
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Emil D. Parvanov
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Department of Translational Stem Cell Biology, Research Institute of the Medical University of Varna, Varna, Bulgaria
| | - Josef Niebauer
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
- University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria
- REHA Zentrum Salzburg, Salzburg, Austria
| | - Maria Kletecka-Pulker
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Institute for Ethics and Law in Medicine, University of Vienna, Vienna, Austria
| | - Oliver Kimberger
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Atanas G. Atanasov
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Institute of Genetics and Animal Biotechnology of the Polish Academy of Sciences, Jastrzebiec, Warsaw, Poland
| | - Harald Willschke
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
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Briesenick L, Schaade A, Bergholz A, Hoppe P, Kouz K, Krause L, Flick M, Saugel B. Energy Expenditure Under General Anesthesia: An Observational Study Using Indirect Calorimetry in Patients Having Noncardiac Surgery. Anesth Analg 2023; 137:169-175. [PMID: 36622833 DOI: 10.1213/ane.0000000000006343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Perioperative hemodynamic management aims to optimize organ perfusion pressure and blood flow-assuming this ensures that oxygen delivery meets cellular metabolic needs. Cellular metabolic needs are reflected by energy expenditure. A better understanding of energy expenditure under general anesthesia could help tailor perioperative hemodynamic management to actual demands. We thus sought to assess energy expenditure under general anesthesia. Our primary hypothesis was that energy expenditure under general anesthesia is lower than preoperative awake resting energy expenditure. METHODS We conducted an observational study on patients having elective noncardiac surgery at the University Medical Center Hamburg-Eppendorf (Germany) between September 2019 and March 2020. We assessed preoperative awake resting energy expenditure, energy expenditure under general anesthesia, and energy expenditure after surgery using indirect calorimetry. We compared energy expenditure under general anesthesia at incision to preoperative awake resting energy expenditure using a Wilcoxon signed-rank test for paired measurements. RESULTS We analyzed 60 patients. Median (95% confidence interval [CI]) preoperative awake resting energy expenditure was 953 (95% CI, 906-962) kcal d -1 m -2 . Median energy expenditure under general anesthesia was 680 (95% CI, 642-711) kcal d -1 m -2 -and thus 263 (95% CI, 223-307) kcal d -1 m -2 or 27% (95% CI, 23%-30%) lower than preoperative awake resting energy expenditure ( P < .001). CONCLUSIONS Median energy expenditure under general anesthesia is about one-quarter lower than preoperative awake resting energy expenditure in patients having noncardiac surgery.
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Affiliation(s)
- Luisa Briesenick
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annika Schaade
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Hoppe
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karim Kouz
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Flick
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, Ohio
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Roth S, Fox H, M’Pembele R, Morshuis M, Lurati Buse G, Hollmann MW, Huhn R, Bitter T. Noninvasive evaluation of the hemodynamic status in patients after heart transplantation or left ventricular assist device implantation. PLoS One 2022; 17:e0275977. [PMID: 36240190 PMCID: PMC9565384 DOI: 10.1371/journal.pone.0275977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/27/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Hemodynamic assessment is crucial after heart transplantation (HTX) or left ventricular assist device (LVAD) implantation. Gold-standard is invasive assessment via thermodilution (TD). Noninvasive pulse contour analysis (NPCA) is a new technology that is supposed to determine hemodynamics completely noninvasive. We aimed to validate this technology in HTX and LVAD patients and conducted a prospective single-center cohort study. METHODS Patients after HTX or LVAD implantation underwent right heart catheterization including TD. NPCA using the CNAP Monitor (V.5.2.14; CNSystems Medizintechnik AG, Graz, Austria) was performed simultaneously. Three TD measurements were compared with simultaneous NPCA measurements for hemodynamic assessment. To describe the agreement between TD and NPCA, Bland-Altman analysis was done. RESULTS In total, 28 patients were prospectively enrolled (HTX: n = 10, LVAD: n = 18). Bland-Altman analysis revealed a mean bias of +1.05 l/min (limits of agreement ± 4.09 l/min, percentage error 62.1%) for cardiac output (CO). In LVAD patients, no adequate NPCA signal could be obtained. In 5 patients (27.8%), any NPCA signal could be detected, but was considered as low signal quality. CONCLUSION In conclusion, according to our limited data in a small cohort of HTX and LVAD patients, NPCA using the CNAP Monitor seems not to be suitable for noninvasive evaluation of the hemodynamic status.
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Affiliation(s)
- Sebastian Roth
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Henrik Fox
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr Universität Bochum, Bad Oeynhausen, Germany
- Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - René M’Pembele
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Michiel Morshuis
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr Universität Bochum, Bad Oeynhausen, Germany
- Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Giovanna Lurati Buse
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Markus W. Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Amsterdam, The Netherlands
| | - Ragnar Huhn
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
- Department of Anesthesiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
- * E-mail:
| | - Thomas Bitter
- Department of Pneumology and Respiratory Medicine, Staedtisches Klinikum Braunschweig, Braunschweig, Germany
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Flick M, Jobeir A, Hoppe P, Kubik M, Rogge DE, Schulte-Uentrop L, Kouz K, Saugel B. A new noninvasive finger sensor (NICCI system) for cardiac output monitoring: A method comparison study in patients after cardiac surgery. Eur J Anaesthesiol 2022; 39:695-700. [PMID: 35792895 DOI: 10.1097/eja.0000000000001705] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The new noninvasive finger sensor system NICCI (Getinge; Gothenburg, Sweden) allows continuous cardiac output monitoring. We aimed to investigate its cardiac output measurement performance. OBJECTIVES To investigate the NICCI system's cardiac output measurement performance. DESIGN Prospective method comparison study. SETTING University Medical Center Hamburg-Eppendorf, Hamburg, Germany. PATIENTS Fifty-one patients after cardiac surgery. MAIN OUTCOME MEASURES We performed a method comparison study in 51 patients after cardiac surgery to compare NICCI cardiac output (CO NICCI ) and NICCI cardiac output calibrated to pulmonary artery thermodilution cardiac output measurement (CO NICCI-CAL ) with pulmonary artery thermodilution cardiac output (CO PAT ). As a secondary analysis we also compared CNAP cardiac output (CO CNAP ) and externally calibrated CNAP cardiac output (CO CNAP-CAL ) with CO PAT . RESULTS We analysed 299 cardiac output measurement pairs. The mean of the differences (95% limits of agreement) between CO NICCI and CO PAT was 0.6 (-1.8 to 3.1) l min -1 with a percentage error of 48%. The mean of the differences between CO NICCI-CAL and CO PAT was -0.4 (-1.9 to 1.1) l min -1 with a percentage error of 29%. The mean of the differences between CO CNAP and CO PAT was 1.0 (-1.8 to 3.8) l min -1 with a percentage error of 53%. The mean of the differences between CO CNAP-CAL and CO PAT was -0.2 (-2.0 to 1.6) l min -1 with a percentage error of 35%. CONCLUSION The agreement between CO NICCI and CO PAT is not clinically acceptable. TRIAL REGISTRATION The study was registered in the German Clinical Trial Register (DRKS00023189) after inclusion of the first patient on October 2, 2020.
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Affiliation(s)
- Moritz Flick
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (MF, AJ, PH, DER, LSU, KK, BS), the Department of Cardiovascular Surgery, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (MK), the Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (MK), the Clinic of Anesthesiology and Operative Intensive Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany (DER) and the Outcomes Research Consortium, Cleveland, Ohio, USA (BS)
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Recco DP, Roy N, Gregory AJ, Lobdell KW. Invasive and noninvasive cardiovascular monitoring options for cardiac surgery. JTCVS OPEN 2022; 10:256-263. [PMID: 36004243 PMCID: PMC9390282 DOI: 10.1016/j.xjon.2022.02.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 02/17/2022] [Indexed: 11/10/2022]
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Rali AS, Butcher A, Tedford RJ, Sinha SS, Mekki P, Van Spall HGC, Sauer AJ. Contemporary Review of Hemodynamic Monitoring in the Critical Care Setting. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hemodynamic assessment remains the most valuable adjunct to physical examination and laboratory assessment in the diagnosis and management of shock. Through the years, multiple modalities to measure and trend hemodynamic indices have evolved with varying degrees of invasiveness. Pulmonary artery catheter (PAC) has long been considered the gold standard of hemodynamic assessment in critically ill patients and in recent years has been shown to improve clinical outcomes among patients in cardiogenic shock. The invasive nature of PAC is often cited as its major limitation and has encouraged development of less invasive technologies. In this review, the authors summarize the literature on the mechanism and validation of several minimally invasive and noninvasive modalities available in the contemporary intensive care unit. They also provide an update on the use of focused bedside echocardiography.
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Amy Butcher
- Department of Cardiovascular Anesthesia and Critical Care, Baylor College of Medicine, Houston, TX
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Shashank S Sinha
- Division of Cardiology, Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | - Pakinam Mekki
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Harriette GC Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Andrew J Sauer
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS
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Schiewe R, Bein B. [Hemodynamic Monitoring 2.0 - What is Possible on Normal Wards?]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:277-291. [PMID: 35451034 DOI: 10.1055/a-1472-4341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Life threatening events after surgery often occur on the ward. These events could be prevented by early detection of clinical deterioration of patients' health status during ward care. Therefore, an adequate monitoring could help to identify patients at risk, since there is an imbalance of monitoring intensity and the occurrence of life-threatening events during hospital stay.Additional monitoring on the general ward could lead to more patient safety. The practicability of additional monitoring needs to be considered, and therefore the use of available monitoring systems on the ward is limited. Capillary refill time (CRT) and the passive leg raise test (PLR) seem to be usable intermittent monitoring techniques.Continuous monitoring systems ensure a better detection of unwanted events and hemodynamic trends. However, the increased workload for the nursing staff and tethered monitors are unfavorable. Future trends of developing wireless monitoring systems are of paramount importance in this respect. Controlling artefacts is crucial for the successful balance between false alarms and "missed events". An adequate reaction is needed when detecting adverse events to avoid a "failure to rescue".
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9
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Christiani M, Grosicki GJ, Flatt AA. Cardiac-autonomic and hemodynamic responses to a hypertonic, sugar-sweetened sports beverage in physically active men. Appl Physiol Nutr Metab 2021; 46:1189-1195. [PMID: 33761293 DOI: 10.1139/apnm-2021-0138] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Hydration practices may confound heart rate variability (HRV) measurements when collected in the pre-training period. We aimed to determine the effects of ingesting a hypertonic, sugar-sweetened sports beverage on HRV and hemodynamic parameters in physically active young men. Fifteen subjects consumed 591 mL of Gatorade (6% carbohydrate, ∼330 mOsmol/kg), 591 mL water, or 10 mL water (control) in random order on separate days following overnight fasting. HRV and hemodynamics were evaluated in 5-min windows immediately before (T1) and 5-10 min (T2), 25-30 min (T3), 40-45 min (T4), and 55-60 min (T5) post-drinking. Root-mean square of successive differences and the standard deviation of normal RR intervals increased post-water intake at all time-points relative to T1 (P < 0.05). No increases were observed post-Gatorade intake, though small effect sizes were noted at T2 and T3 (P > 0.05, ES = 0.27-0.32). Systemic vascular resistance increased at T2 post-Gatorade intake and at T2 and T3 post-water intake (P < 0.05). No interactions were observed for blood pressure measures, stroke volume, or cardiac output. Gatorade does not evoke cardiovascular adjustments to the same magnitude as water. Practitioners should wait at least 45 min to record HRV post-Gatorade intake and >60 min post-water intake. Novelty: Equal volumes of cold water and Gatorade produce inequivalent cardiac-autonomic and hemodynamic responses. HRV responses of greater amplitude and duration were observed following intake of water versus Gatorade. Failure to account for recent fluid intake may result in misinterpretation of autonomic status.
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Affiliation(s)
- Mark Christiani
- Biodynamics and Human Performance Center, Department of Health Sciences and Kinesiology, Georgia Southern University (Armstrong Campus), Savannah, Georgia, USA.,Biodynamics and Human Performance Center, Department of Health Sciences and Kinesiology, Georgia Southern University (Armstrong Campus), Savannah, Georgia, USA
| | - Gregory J Grosicki
- Biodynamics and Human Performance Center, Department of Health Sciences and Kinesiology, Georgia Southern University (Armstrong Campus), Savannah, Georgia, USA.,Biodynamics and Human Performance Center, Department of Health Sciences and Kinesiology, Georgia Southern University (Armstrong Campus), Savannah, Georgia, USA
| | - Andrew A Flatt
- Biodynamics and Human Performance Center, Department of Health Sciences and Kinesiology, Georgia Southern University (Armstrong Campus), Savannah, Georgia, USA.,Biodynamics and Human Performance Center, Department of Health Sciences and Kinesiology, Georgia Southern University (Armstrong Campus), Savannah, Georgia, USA
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10
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Saugel B, Bebert EJ, Briesenick L, Hoppe P, Greiwe G, Yang D, Ma C, Mascha EJ, Sessler DI, Rogge DE. Mechanisms contributing to hypotension after anesthetic induction with sufentanil, propofol, and rocuronium: a prospective observational study. J Clin Monit Comput 2021; 36:341-347. [PMID: 33523352 PMCID: PMC9122881 DOI: 10.1007/s10877-021-00653-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/07/2021] [Indexed: 11/30/2022]
Abstract
It remains unclear whether reduced myocardial contractility, venous dilation with decreased venous return, or arterial dilation with reduced systemic vascular resistance contribute most to hypotension after induction of general anesthesia. We sought to assess the relative contribution of various hemodynamic mechanisms to hypotension after induction of general anesthesia with sufentanil, propofol, and rocuronium. In this prospective observational study, we continuously recorded hemodynamic variables during anesthetic induction using a finger-cuff method in 92 non-cardiac surgery patients. After sufentanil administration, there was no clinically important change in arterial pressure, but heart rate increased from baseline by 11 (99.89% confidence interval: 7 to 16) bpm (P < 0.001). After administration of propofol, mean arterial pressure decreased by 23 (17 to 28) mmHg and systemic vascular resistance index decreased by 565 (419 to 712) dyn*s*cm−5*m2 (P values < 0.001). Mean arterial pressure was < 65 mmHg in 27 patients (29%). After propofol administration, heart rate returned to baseline, and stroke volume index and cardiac index remained stable. After tracheal intubation, there were no clinically important differences compared to baseline in heart rate, stroke volume index, and cardiac index, but arterial pressure and systemic vascular resistance index remained markedly decreased. Anesthetic induction with sufentanil, propofol, and rocuronium reduced arterial pressure and systemic vascular resistance index. Heart rate, stroke volume index, and cardiac index remained stable. Post-induction hypotension therefore appears to result from arterial dilation with reduced systemic vascular resistance rather than venous dilation or reduced myocardial contractility.
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. .,Outcomes Research Consortium, Cleveland, OH, USA.
| | - Elisa-Johanna Bebert
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Luisa Briesenick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Gillis Greiwe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Dongsheng Yang
- Departments of Quantitative Health Sciences and Outcomes Research, Lerner Research Institute and Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Chao Ma
- Departments of Quantitative Health Sciences and Outcomes Research, Lerner Research Institute and Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Edward J Mascha
- Departments of Quantitative Health Sciences and Outcomes Research, Lerner Research Institute and Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Dorothea E Rogge
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Personalised haemodynamic management targeting baseline cardiac index in high-risk patients undergoing major abdominal surgery: a randomised single-centre clinical trial. Br J Anaesth 2020; 125:122-132. [PMID: 32711724 DOI: 10.1016/j.bja.2020.04.094] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite several clinical trials on haemodynamic therapy, the optimal intraoperative haemodynamic management for high-risk patients undergoing major abdominal surgery remains unclear. We tested the hypothesis that personalised haemodynamic management targeting each individual's baseline cardiac index at rest reduces postoperative morbidity. METHODS In this single-centre trial, 188 high-risk patients undergoing major abdominal surgery were randomised to either routine management or personalised haemodynamic management requiring clinicians to maintain personal baseline cardiac index (determined at rest preoperatively) using an algorithm that guided intraoperative i.v. fluid and/or dobutamine administration. The primary outcome was a composite of major complications (European Perioperative Clinical Outcome definitions) or death within 30 days of surgery. Secondary outcomes included postoperative morbidity (assessed by a postoperative morbidity survey), hospital length of stay, mortality within 90 days of surgery, and neurocognitive function assessed after postoperative Day 3. RESULTS The primary outcome occurred in 29.8% (28/94) of patients in the personalised management group, compared with 55.3% (52/94) of patients in the routine management group (relative risk: 0.54, 95% confidence interval [CI]: 0.38 to 0.77; absolute risk reduction: -25.5%, 95% CI: -39.2% to -11.9%; P<0.001). One patient assigned to the personalised management group, compared with five assigned to the routine management group, died within 30 days after surgery (P=0.097). There were no clinically relevant differences between the two groups for secondary outcomes. CONCLUSIONS In high-risk patients undergoing major abdominal surgery, personalised haemodynamic management reduces a composite outcome of major postoperative complications or death within 30 days after surgery compared with routine care. CLINICAL TRIAL REGISTRATION NCT02834377.
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Miyazaki E, Maeda T, Ito S, Oi A, Hotta N, Tsukinaga A, Kanazawa H, Ohnishi Y. Accuracy and Trending Ability of Cardiac Index Measured by the CNAP System in Patients Undergoing Abdominal Aortic Aneurysm Surgery. J Cardiothorac Vasc Anesth 2020; 35:1439-1446. [PMID: 32888805 DOI: 10.1053/j.jvca.2020.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The CNAP system is a noninvasive monitor that provides a continuous arterial pressure waveform using an inflatable finger cuff. The authors hypothesized that dramatic changes in systemic vascular resistance index during abdominal aortic aneurysm (AAA) surgery might affect the accuracy of noninvasive pulse contour monitors. The aim of this study was to evaluate the accuracy and trending ability of cardiac index derived by the CNAP system (CICN) in patients undergoing AAA surgery. DESIGN Prospective clinical study. SETTING Cardiac surgery operating room in a single cardiovascular center. PARTICIPANTS Twenty patients who underwent elective AAA surgery. INTERVENTIONS CICN and cardiac index measured using 3-dimensional images (CI3D) were determined simultaneously at 8 points during the surgery. At aortic clamping and unclamping, the authors tested the trending ability of CICN using 4-quadrant plot analysis and polar plot analysis. MEASUREMENTS AND MAIN RESULTS The authors found a wide limit of agreement between CICN and CI3D (percentage error: 85.0%). The cubic splines, which show the relationship between systemic vascular resistance index and percentage CI discrepancy [(CICN-CI3D)/CI3D], were sloped positively. Four-quadrant plot analysis showed poor trending ability for CICN at both aortic clamping and unclamping (concordance rate: 29.4% and 57.9%, respectively). In the polar plot analysis, the concordance rates at aortic clamping and unclamping were 15.0% and 35.0%, respectively. CONCLUSIONS CICN is not interchangeable with CI3D in patients undergoing AAA surgery. The trending ability for CICN at aortic clamping and unclamping was below the acceptable limit. These inaccuracies might be secondary to the high systemic vascular resistance index during AAA surgery.
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Affiliation(s)
- Erika Miyazaki
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takuma Maeda
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA.
| | - Shinya Ito
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Ayako Oi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Naoshi Hotta
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Akito Tsukinaga
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroko Kanazawa
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
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Continuous noninvasive pulse wave analysis using finger cuff technologies for arterial blood pressure and cardiac output monitoring in perioperative and intensive care medicine: a systematic review and meta-analysis. Br J Anaesth 2020; 125:25-37. [DOI: 10.1016/j.bja.2020.03.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/02/2020] [Accepted: 03/06/2020] [Indexed: 12/16/2022] Open
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The Value of the Inferior Vena Cava Area Distensibility Index and its Diameter Ratio for Predicting Fluid Responsiveness in Mechanically Ventilated Patients. Shock 2020; 52:37-42. [PMID: 31188800 DOI: 10.1097/shk.0000000000001238] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION It is necessary to evaluate fluid responsiveness before fluid resuscitation. We evaluated the value of inferior vena cava (IVC) area respiratory variation and the IVC diameter ratio (IVC DR) for predicting fluid responsiveness in mechanically ventilated patients. METHODS A prospective observational study was performed in the intensive care unit between December 2017 and March 2018. Mechanically ventilated patients were enrolled and received ultrasound monitoring. IVC diameter distensibility index from the subxiphoid area (IVC-sx DDI), IVC diameter distensibility index from the right midaxillary line (IVC-rm DDI), IVC area distensibility index (IVC ADI), and IVC DR in cross-section were calculated by ultrasound monitoring IVC parameters. The enrolled patients were classified as nonresponders group and responders group according to whether the cardiac output increased by >10% after passive leg raising. RESULTS Data from 67 mechanically ventilated patients were analyzed. 55.2% of patients had positive fluid responsiveness. The area of receiver operating characteristic curves evaluating the ability of the IVC-sx DDI, IVC-rm DDI, IVC ADI, and IVC DR to predict the fluid responsiveness were 0.702, 0.686, 0.749, and 0.829, respectively. IVC DR level of 1.43 was predictive of positive fluid responsiveness with 90.0% specificity and 67.6% sensitivity. IVC ADI level of 10.2% was predictive of positive fluid responsiveness with 40.0% specificity and 97.3% sensitivity. CONCLUSIONS IVC ADI and its diameter ratio in cross-section had more value than IVC diameter distensibility index for predicting fluid responsiveness in mechanically ventilated patients.
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Saugel B, Vokuhl C, Pinnschmidt HO, Rösch T, Petzoldt M, Löser B. Cardiovascular dynamics during peroral endoscopic myotomy for esophageal achalasia: a prospective observational study using non-invasive finger cuff-derived pulse wave analysis. J Clin Monit Comput 2020; 35:827-834. [PMID: 32504156 DOI: 10.1007/s10877-020-00541-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/26/2020] [Indexed: 11/24/2022]
Abstract
Peroral endoscopic myotomy (POEM) is natural orifice transluminal endoscopic surgery to treat esophageal achalasia. During POEM, cardiovascular dynamics can be impaired by capnoperitoneum, capnomediastinum, and systemic carbon dioxide accumulation. We systematically investigated changes in cardiovascular dynamics during POEM. We included 31 patients having POEM in this single-center prospective observational study. Before and every 5 min during POEM we measured mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), stroke volume index (SVI), and systemic vascular resistance index (SVRI) using non-invasive finger cuff-derived pulse wave analysis. During POEM, the median MAP was higher than the median baseline MAP of 77 (67;86) mmHg. HR (median at baseline: 67 (60;72) bpm), CI (2.8 (2.5;3.2) L/min/m2), SVI (42 (34;51) mL/m2), and SVRI (1994 (1652; 2559) dyn × s × cm-5 × m-2) remained stable during POEM. Mixed model-derived 95% confidence limits of hemodynamic variables during POEM were 72 to 106 mmHg for MAP, 65 to 79 bpm for HR, 2.7 to 3.3 L/min/m2 for CI, 37 and 46 mL/m2 for SVI, and 1856 and 2954 dyn × s × cm-5 × m-2 for SVRI. POEM is a safe procedure with regard to cardiovascular dynamics as it does not markedly impair MAP, HR, CI, SVI, or SVRI.
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Christina Vokuhl
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Löser
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medicine Rostock, Schillingallee 35, 18057, Rostock, Germany.
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Fischer MO, Joosten A, Desebbe O, Boutros M, Debroczi S, Broch O, Malbrain ML, Ameloot K, Hofer CK, Bubenek-Turconi ŞI, Monnet X, Diouf M, Lorne E. Interchangeability of cardiac output measurements between non-invasive photoplethysmography and bolus thermodilution: A systematic review and individual patient data meta-analysis. Anaesth Crit Care Pain Med 2020; 39:75-85. [DOI: 10.1016/j.accpm.2019.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/29/2019] [Accepted: 05/27/2019] [Indexed: 01/30/2023]
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Best practice & research clinical anaesthesiology: Advances in haemodynamic monitoring for the perioperative patient: Perioperative cardiac output monitoring. Best Pract Res Clin Anaesthesiol 2019; 33:139-153. [PMID: 31582094 DOI: 10.1016/j.bpa.2019.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/01/2019] [Accepted: 05/16/2019] [Indexed: 12/15/2022]
Abstract
Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. Even established, invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution have still an evidence-based place in the perioperative setting, albeit only in special patient populations. Accumulating evidence suggests to use continuous haemodynamic monitoring, especially flow-based variables such as stroke volume or cardiac output to prevent occult hypoperfusion and, consequently, decrease morbidity and mortality perioperatively. However, there is still a substantial gap between evidence provided by randomised trials and the implementation of haemodynamic monitoring in daily clinical routine. Given the fact that perioperative morbidity and mortality are higher than anticipated and anaesthesiologists are in charge to deal with this problem, the recent advances in minimally invasive and non-invasive monitoring technologies may facilitate more widespread use in the operating theatre, as in addition to costs, the degree of invasiveness of any monitoring tool determines the frequency of its application, at least perioperatively. This review covers the currently available invasive, non-invasive and minimally invasive techniques and devices and addresses their indications and limitations.
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Saugel B, Cecconi M, Hajjar LA. Noninvasive Cardiac Output Monitoring in Cardiothoracic Surgery Patients: Available Methods and Future Directions. J Cardiothorac Vasc Anesth 2019; 33:1742-1752. [DOI: 10.1053/j.jvca.2018.06.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Indexed: 12/28/2022]
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Saugel B, Flick M, Bendjelid K, Critchley LAH, Vistisen ST, Scheeren TWL. Journal of clinical monitoring and computing end of year summary 2018: hemodynamic monitoring and management. J Clin Monit Comput 2019; 33:211-222. [PMID: 30847738 PMCID: PMC6420447 DOI: 10.1007/s10877-019-00297-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 02/21/2019] [Indexed: 12/05/2022]
Abstract
Hemodynamic management is a mainstay of patient care in the operating room and intensive care unit (ICU). In order to optimize patient treatment, researchers investigate monitoring technologies, cardiovascular (patho-) physiology, and hemodynamic treatment strategies. The Journal of Clinical Monitoring and Computing (JCMC) is a well-established and recognized platform for publishing research in this field. In this review, we highlight recent advancements and summarize selected papers published in the JCMC in 2018 related to hemodynamic monitoring and management.
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Centre of Anesthesiology and Intensive Care Medicine, University Medical Centre Hamburg- Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Moritz Flick
- Department of Anesthesiology, Centre of Anesthesiology and Intensive Care Medicine, University Medical Centre Hamburg- Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Karim Bendjelid
- Department of Anesthesiology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Lester A H Critchley
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shantin, N.T., Hong Kong.,The Belford Hospital, Fort William, The Highlands, Scotland, UK
| | - Simon T Vistisen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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21
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Noninvasive pulse contour analysis for determination of cardiac output in patients with chronic heart failure. Clin Res Cardiol 2018; 107:395-404. [DOI: 10.1007/s00392-017-1198-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 12/20/2017] [Indexed: 12/26/2022]
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