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Abstract
Massive trauma remains the leading cause of mortality among people aged younger than 45 years. In this review, we discuss the initial care and diagnosis of trauma patients followed by a comparison of resuscitation strategies. We discuss various strategies including use of whole blood and component therapy, examine viscoelastic techniques for management of coagulopathy, and consider the benefits and limitations of the resuscitation strategies and consider a series of questions that will be important for researchers to answer to provide the best and most cost-effective therapy for severely injured patients.
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Affiliation(s)
- Carter M Galbraith
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 619 19th Street South, JT 845, Birmingham, AL 35249, USA
| | - Brant M Wagener
- Division of Critical Care Medicine, University of Alabama at Birmingham, 901 19th Street South, PBMR 302, Birmingham, AL 35294, USA; Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th Street South, PBMR 302, Birmingham, AL 35294, USA
| | - Athanasios Chalkias
- Department of Anesthesiology, University of Thessaly, Biopolis, Larisa 41500, Greece; Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Shahla Siddiqui
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, 12401 East 17th Avenue, 7th Floor, Aurora, CO 80045, USA.
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How to end the 'venous return' controversy. Eur J Anaesthesiol 2022; 39:629-630. [PMID: 35759296 DOI: 10.1097/eja.0000000000001689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Chalkias A, Laou E, Papagiannakis N, Spyropoulos V, Kouskouni E, Theodoraki K, Xanthos T. Assessment of Dynamic Changes in Stressed Volume and Venous Return during Hyperdynamic Septic Shock. J Pers Med 2022; 12:jpm12050724. [PMID: 35629145 PMCID: PMC9146182 DOI: 10.3390/jpm12050724] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/19/2022] [Accepted: 04/28/2022] [Indexed: 02/04/2023] Open
Abstract
The present work investigated the dynamic changes in stressed volume (Vs) and other determinants of venous return using a porcine model of hyperdynamic septic shock. Septicemia was induced in 10 anesthetized swine, and fluid challenges were started after the diagnosis of sepsis-induced arterial hypotension and/or tissue hypoperfusion. Norepinephrine infusion targeting a mean arterial pressure (MAP) of 65 mmHg was started after three consecutive fluid challenges. After septic shock was confirmed, norepinephrine infusion was discontinued, and the animals were left untreated until cardiac arrest occurred. Baseline Vs decreased by 7% for each mmHg decrease in MAP during progression of septic shock. Mean circulatory filling pressure (Pmcf) analogue (Pmca), right atrial pressure, resistance to venous return, and efficiency of the heart decreased with time (p < 0.001 for all). Fluid challenges did not improve hemodynamics, but noradrenaline increased Vs from 107 mL to 257 mL (140%) and MAP from 45 mmHg to 66 mmHg (47%). Baseline Pmca and post-cardiac arrest Pmcf did not differ significantly (14.3 ± 1.23 mmHg vs. 14.75 ± 1.5 mmHg, p = 0.24), but the difference between pre-arrest Pmca and post-cardiac arrest Pmcf was statistically significant (9.5 ± 0.57 mmHg vs. 14.75 ± 1.5 mmHg, p < 0.001). In conclusion, the baseline Vs decreased by 7% for each mmHg decrease in MAP during progression of hyperdynamic septic shock. Significant changes were also observed in other determinants of venous return. A new physiological intravascular volume existing at zero transmural distending pressure was identified, termed as the rest volume (Vr).
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Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece;
- Outcomes Research Consortium, Cleveland, OH 44195, USA
- Hellenic Society of Cardiopulmonary Resuscitation, 11528 Athens, Greece
- Correspondence:
| | - Eleni Laou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece;
| | - Nikolaos Papagiannakis
- First Department of Neurology, Eginition University Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | | | - Evaggelia Kouskouni
- Department of Biopathology, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 15772 Athens, Greece;
| | - Theodoros Xanthos
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus;
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Yu J, Che L, Zhu A, Xu L, Huang Y. Goal-Directed Intraoperative Fluid Therapy Benefits Patients Undergoing Major Gynecologic Oncology Surgery: A Controlled Before-and-After Study. Front Oncol 2022; 12:833273. [PMID: 35463383 PMCID: PMC9019364 DOI: 10.3389/fonc.2022.833273] [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: 12/11/2021] [Accepted: 03/04/2022] [Indexed: 11/30/2022] Open
Abstract
Background Fluid management during major gynecologic oncology surgeries faces great challenges due to the distinctive characteristics of patients with gynecologic malignancies as well as features of the surgical procedure. Intraoperative goal-directed fluid therapy (GDFT) has been proven to be effective in reducing postoperative complications among major colorectal surgeries; however, the efficacy of GDFT has not been fully studied in gynecologic malignancy surgeries. This study aimed to discuss the influence of GDFT practice in patients undergoing major gynecologic oncology surgery. Methods This study was a controlled before-and-after study. From June 2015 to June 2018 in Peking Union Medical College Hospital, a total of 300 patients scheduled for elective laparotomy of gynecological malignancies were enrolled and chronologically allocated into two groups, with the earlier 150 patients in the control group and the latter 150 patients in the GDFT group. The GDFT protocol was applied by Vigileo/FloTrac monitoring of stroke volume and fluid responsiveness to guide intraoperative fluid infusion and the use of vasoactive agents. The primary outcome was postoperative complications within 30 days after surgery. The secondary outcome included length of stay and time of functional recovery. Results A total of 249 patients undergoing major gynecologic oncology surgery were analyzed in the study, with 129 in the control group and 120 patients in the GDFT group. Patients in the GDFT group had higher ASA classifications and more baseline comorbidities. GDFT patients received significantly less fluid infusion than the control group (15.8 vs. 17.9 ml/kg/h), while fluid loss was similar (6.9 vs. 7.1 ml/kg/h). GDFT was associated with decreased risk of postoperative complications (OR = 0.572, 95% CI 0.343 to 0.953, P = 0.032), especially surgical site infections (OR = 0.127, 95% CI 0.003 to 0.971, P = 0.037). The postoperative bowel function recovery and length of hospital stay were not significantly different between the two groups. Conclusion Goal-directed intraoperative fluid therapy is associated with fewer postoperative complications in patients undergoing major gynecologic oncology surgery.
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Affiliation(s)
- Jiawen Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Che
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Afang Zhu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Alvarado Sánchez JI, Caicedo Ruiz JD, Diaztagle Fernández JJ, Ospina Tascon GA, Monge Garcia MI, Ruiz Narvaez GA, Cruz Martínez LE. Changes of operative performance of pulse pressure variation as a predictor of fluid responsiveness in endotoxin shock. Sci Rep 2022. [DOI: https://doi.org/10.1038/s41598-022-06488-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AbstractSeveral limitations regarding pulse pressure variation (PPV) use have been reported. Our aim was to describe changes in the PPV operative performance as a predictor of fluid responsiveness during the development of a swine endotoxin shock model and to assess hemodynamic variables associated with PPV changes. A swine porcine endotoxin shock model was established (Escherichia Coli 055:B5 endotoxin) in 7 pigs, and 3 pigs were included in the control group. The endotoxin was infused until the mean arterial pressure (MAP) dropped below 50 mmHg (TH0); then, the model animal was reanimated with fluids and vasopressors. We performed fluid challenges every hour for 6 h. ROC curve analysis and a linear mixed model were performed. The area under the curve of PPV decreased from 0.95 (0.81–1.00) to 0.60 (0.17–1.00) at TH0. Its cutoff increased from 10.5 to 22.00% at TH0. PPV showed an inverse relationship with stroke volume, mean systemic filling pressure, MAP, and systemic vascular resistance (SVR) (p < 0.001, AIC = 111.85). The PPV operative performance as a predictor of fluid responsiveness decreased with the progression of shock. This could lead to an inverse association between PPV and the following variables: MAP and SVR.
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Alvarado Sánchez JI, Caicedo Ruiz JD, Diaztagle Fernández JJ, Ospina Tascon GA, Monge Garcia MI, Ruiz Narvaez GA, Cruz Martínez LE. Changes of operative performance of pulse pressure variation as a predictor of fluid responsiveness in endotoxin shock. Sci Rep 2022; 12:2590. [PMID: 35173214 PMCID: PMC8850593 DOI: 10.1038/s41598-022-06488-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 01/31/2022] [Indexed: 11/09/2022] Open
Abstract
Several limitations regarding pulse pressure variation (PPV) use have been reported. Our aim was to describe changes in the PPV operative performance as a predictor of fluid responsiveness during the development of a swine endotoxin shock model and to assess hemodynamic variables associated with PPV changes. A swine porcine endotoxin shock model was established (Escherichia Coli 055:B5 endotoxin) in 7 pigs, and 3 pigs were included in the control group. The endotoxin was infused until the mean arterial pressure (MAP) dropped below 50 mmHg (TH0); then, the model animal was reanimated with fluids and vasopressors. We performed fluid challenges every hour for 6 h. ROC curve analysis and a linear mixed model were performed. The area under the curve of PPV decreased from 0.95 (0.81–1.00) to 0.60 (0.17–1.00) at TH0. Its cutoff increased from 10.5 to 22.00% at TH0. PPV showed an inverse relationship with stroke volume, mean systemic filling pressure, MAP, and systemic vascular resistance (SVR) (p < 0.001, AIC = 111.85). The PPV operative performance as a predictor of fluid responsiveness decreased with the progression of shock. This could lead to an inverse association between PPV and the following variables: MAP and SVR.
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Affiliation(s)
- Jorge Iván Alvarado Sánchez
- Department of Physiological Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia. .,Department of Anaesthesiology, Centro Policlínico del Olaya, Bogotá, Colombia.
| | - Juan Daniel Caicedo Ruiz
- Department of Physiological Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Juan Jose Diaztagle Fernández
- Department of Physiological Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia.,Department of Internal Medicine, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | | | | | | | - Luis Eduardo Cruz Martínez
- Department of Physiological Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia.,Department of Internal Medicine, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
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Tsen LC, Gelman S. The Venous System during Pregnancy, Part 2: Clinical Implications of the Venous System. Int J Obstet Anesth 2022; 50:103274. [DOI: 10.1016/j.ijoa.2022.103274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/17/2022] [Indexed: 10/19/2022]
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The venous system during pregnancy. Part 1: physiologic considerations on the venous system. Int J Obstet Anesth 2022; 50:103273. [DOI: 10.1016/j.ijoa.2022.103273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/13/2022] [Accepted: 02/17/2022] [Indexed: 12/20/2022]
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Gouel-Cheron A, Neukirch C, Kantor E, Malinovsky JM, Tacquard C, Montravers P, Mertes PM, Longrois D. Clinical reasoning in anaphylactic shock: addressing the challenges faced by anaesthesiologists in real time: A clinical review and management algorithms. Eur J Anaesthesiol 2021; 38:1158-1167. [PMID: 33973926 DOI: 10.1097/eja.0000000000001536] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute hypersensitivity reactions to drugs occur infrequently during anaesthesia and the peri-operative period. When clinical presentation includes the classical triad, erythema, cardiovascular abnormalities and increased airway pressure, the diagnosis is evident and the challenge is to prescribe a therapeutic regimen according to guidelines and to manage refractory signs in a timely manner. In many situations, however, the initial clinical signs are isolated, such as increased airway pressure or arterial hypotension. Rendering a differential diagnosis with causes and mechanisms other than acute hypersensitivity reactions (AHRs) is difficult, delaying treatment with possible worsening of the clinical signs, and even death, in previously healthy individuals. In these difficult diagnostic situations, clinical reasoning is mandatory, and guidelines do not explicitly explain the elements on which clinical reasoning can be built. In this article, based on clinical evidence whenever available, experimental data and pathophysiology, we propose algorithms that have been evaluated by experts. The goal of these algorithms is to provide explicit elements on which the differential diagnosis of AHRs can be made, accelerating the implementation of adequate therapy.
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Affiliation(s)
- Aurelie Gouel-Cheron
- From the Anaesthesiology and Critical Care Medicine Department, DMU PARABOL, Bichat Hospital, AP-HP (AGC, EK, PM, DL), Antibody in Therapy and Pathology, Pasteur Institute, UMR 1222 INSERM, Paris, France (AGC), Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA (AGC), Pulmonology Department, Bichat Hospital, AP-HP, Paris University (CN), INSERM UMR 1152, Paris University, DHU FIRE, Paris (CN, PM), Anaesthesiology and Critical Care Medicine Department, Maison Blanche Hospital, Centre Hospitalier Universitaire de Reims, Reims (JM-M), Anaesthesiology and Critical Care Medicine Department, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg (CT, PM-M), Paris University (PM, DL), EA 3072, Institut de Physiologie, FMTS, Faculté de Médecine de Strasbourg, Université de Strasbourg, Strasbourg (PM-M) and INSERM1148, Paris, France (DL)
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Teixeira-Neto FJ, Valverde A. Clinical Application of the Fluid Challenge Approach in Goal-Directed Fluid Therapy: What Can We Learn From Human Studies? Front Vet Sci 2021; 8:701377. [PMID: 34414228 PMCID: PMC8368984 DOI: 10.3389/fvets.2021.701377] [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: 04/29/2021] [Accepted: 07/06/2021] [Indexed: 11/13/2022] Open
Abstract
Resuscitative fluid therapy aims to increase stroke volume (SV) and cardiac output (CO) and restore/improve tissue oxygen delivery in patients with circulatory failure. In individualized goal-directed fluid therapy (GDFT), fluids are titrated based on the assessment of responsiveness status (i.e., the ability of an individual to increase SV and CO in response to volume expansion). Fluid administration may increase venous return, SV and CO, but these effects may not be predictable in the clinical setting. The fluid challenge (FC) approach, which consists on the intravenous administration of small aliquots of fluids, over a relatively short period of time, to test if a patient has a preload reserve (i.e., the relative position on the Frank-Starling curve), has been used to guide fluid administration in critically ill humans. In responders to volume expansion (defined as individuals where SV or CO increases ≥10–15% from pre FC values), FC administration is repeated until the individual no longer presents a preload reserve (i.e., until increases in SV or CO are <10–15% from values preceding each FC) or until other signs of shock are resolved (e.g., hypotension). Even with the most recent technological developments, reliable and practical measurement of the response variable (SV or CO changes induced by a FC) has posed a challenge in GDFT. Among the methods used to evaluate fluid responsiveness in the human medical field, measurement of aortic flow velocity time integral by point-of-care echocardiography has been implemented as a surrogate of SV changes induced by a FC and seems a promising non-invasive tool to guide FC administration in animals with signs of circulatory failure. This narrative review discusses the development of GDFT based on the FC approach and the response variables used to assess fluid responsiveness status in humans and animals, aiming to open new perspectives on the application of this concept to the veterinary field.
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Affiliation(s)
- Francisco José Teixeira-Neto
- Departmento de Cirurgia Veterinária e Reprodução Animal, Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, Brazil
| | - Alexander Valverde
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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Amelard R, Robertson AD, Patterson CA, Heigold H, Saarikoski E, Hughson RL. Optical Hemodynamic Imaging of Jugular Venous Dynamics During Altered Central Venous Pressure. IEEE Trans Biomed Eng 2021; 68:2582-2591. [PMID: 33769929 DOI: 10.1109/tbme.2021.3069133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE An optical imaging system is proposed for quantitatively assessing jugular venous response to altered central venous pressure. METHODS The proposed system assesses sub-surface optical absorption changes from jugular venous waveforms with a spatial calibration procedure to normalize incident tissue illumination. Widefield frames of the right lateral neck were captured and calibrated using a novel flexible surface calibration method. A hemodynamic optical model was derived to quantify jugular venous optical attenuation (JVA) signals, and generate a spatial jugular venous pulsatility map. JVA was assessed in three cardiovascular protocols that altered central venous pressure: acute central hypovolemia (lower body negative pressure), venous congestion (head-down tilt), and impaired cardiac filling (Valsalva maneuver). RESULTS JVA waveforms exhibited biphasic wave properties consistent with jugular venous pulse dynamics when time-aligned with an electrocardiogram. JVA correlated strongly (median, interquartile range) with invasive central venous pressure during graded central hypovolemia (r = 0.85, [0.72, 0.95]), graded venous congestion (r = 0.94, [0.84, 0.99]), and impaired cardiac filling (r = 0.94, [0.85, 0.99]). Reduced JVA during graded acute hypovolemia was strongly correlated with reductions in stroke volume (SV) (r = 0.85, [0.76, 0.92]) from baseline (SV: 79 ± 15 mL, JVA: 0.56 ± 0.10 a.u.) to -40 mmHg suction (SV: 59 ± 18 mL, JVA: 0.47 ± 0.05 a.u.; p 0.01). CONCLUSION The proposed non-contact optical imaging system demonstrated jugular venous dynamics consistent with invasive central venous monitoring during three protocols that altered central venous pressure. SIGNIFICANCE This system provides non-invasive monitoring of pressure-induced jugular venous dynamics in clinically relevant conditions where catheterization is traditionally required, enabling monitoring in non-surgical environments.
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Kamali Shahri SM, Contarino C, Chifari F, Mahmoudi M, Gelman S. Function of arteries and veins in conditions of simulated cardiac arrest. ACTA ACUST UNITED AC 2021; 11:157-164. [PMID: 33842286 PMCID: PMC8022231 DOI: 10.34172/bi.2021.13] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/17/2020] [Accepted: 10/20/2020] [Indexed: 12/24/2022]
Abstract
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Introduction: The study examined the behavior of vasculature in conditions of eliminated cardiac function using mathematical modeling. In addition, we addressed the question of whether the stretch-recoil capability of veins, at least in part accounts for the slower response to simulated cardiac arrest. Methods: In the first set of computational experiments, blood flow and pressure patterns in veins and arteries during the first few seconds after cardiac arrest were assessed via a validated multi-scale mathematical model of the whole cardiovascular system, comprising cardiac dynamics, arterial and venous blood flow dynamics, and microcirculation. In the second set of experiments, the effects of stretch-recoil zones of venous vessels with different diameters and velocities on blood velocity and dynamic pressure analyzed using computational fluid dynamics (CFD) modeling. Results: In the first set of experiments, measurement of changes in velocity, dynamic pressure, and fluid flow revealed that the venous system responded to cardiac arrest more slowly compared to the arteries. This disparity might be due to the intrinsic characteristics of the venous system, including stretch-recoil and elastic fiber composition. In the second set of experiments, we attempted to determine the role of the stretch-recoil capability of veins in the slower response to cardiac arrest. During the second set of experiments, we found that this recoil behavior increased dynamic pressure, velocity, and blood flow. The enhancement in dynamic pressure through combining the results from both experiments yielded a 15-40% increase in maximum dynamic pressure due to stretch-recoil, depending on vein diameter under normal conditions. Conclusion: In the situation of cardiac arrest, the vein geometry changes continue, promoting smooth responses of the venous system. Moreover, the importance of such vein behavior in blood displacement may grow as the pressure on the venous side gradually decreases with time. Our experiments suggest that the driving force for venous return is the pressure difference that remains within the venous system after the energy coming from every ventricular systole spent to overcome the resistance created by arterial and capillary systems.
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Affiliation(s)
- Seyed Mehdi Kamali Shahri
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, MA, USA
| | | | | | - Morteza Mahmoudi
- Precision Health Program and Department of Radiology, Michigan State University, MI, USA
| | - Simon Gelman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, MA, USA
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Polanco TO, Shamsunder MG, Hicks MEV, Seier KP, Tan KS, Oskar S, Dayan JH, Disa JJ, Mehrara BJ, Allen RJ, Nelson JA, Afonso AM. Goal-directed fluid therapy in autologous breast reconstruction results in less fluid and more vasopressor administration without outcome compromise. J Plast Reconstr Aesthet Surg 2021; 74:2227-2236. [PMID: 33745850 DOI: 10.1016/j.bjps.2021.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 12/03/2020] [Accepted: 01/24/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Aggressive or restricted perioperative fluid management has been shown to increase complications in patients undergoing microsurgery. Goal-directed fluid therapy (GDFT) aims to administer fluid, vasoactive agents, and inotropes according to each patient's hemodynamic indices. This study assesses GDFT impact on perioperative outcomes of autologous breast reconstruction (ABR) patients, as there remains a gap in management understanding. We hypothesize that GDFT will have lower fluid administration and equivocal outcomes compared to patients not on GDFT. METHODS A single-center retrospective review was conducted on ABR patients from January 2010-April 2017. An enhanced recovery after surgery (ERAS) using GDFT was implemented in April 2015. With GDFT, patients were administered intraoperative fluids and vasoactive agents according to hemodynamic indices. Patients prior to April 2015 were included in the pre-ERAS cohort. Primary outcomes included the amount and rate of fluid delivery, urine output (UOP), vasopressor administration, major (i.e., flap failure) and minor (i.e., seroma) complications, and length of stay (LOS). RESULTS Overall, 777 patients underwent ABR (ERAS: 312 and pre-ERAS: 465). ERAS patients received significantly less total fluid volume (ERAS median: 3750 mL [IQR: 3000-4500 mL]; pre-ERAS median: 5000 mL [IQR 4000-6400 mL]; and p<0.001), had lower UOP, were more likely to receive vasopressor agents (47% vs 35% and p<0.001), and had lower LOS (ERAS: 4 days [4-5]; pre-ERAS: 5 [4-6]; and p<0.001) as compared to pre-ERAS patients. Complications did not differ between cohorts. CONCLUSIONS GDFT, as part of ERAS, and the prudent use of vasopressors were found to be safe and did not increase morbidity in ABR patients. GDFT provides individualized perioperative care to the ABR patient.
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Affiliation(s)
- Thais O Polanco
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Meghana G Shamsunder
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Madeleine E V Hicks
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Kenneth P Seier
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Kay See Tan
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Sabine Oskar
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Joseph H Dayan
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Joseph J Disa
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Babak J Mehrara
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Robert J Allen
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Jonas A Nelson
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States.
| | - Anoushka M Afonso
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
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Reply to: stressed volume and fluid responsiveness. Eur J Anaesthesiol 2021; 38:88-89. [PMID: 33273382 DOI: 10.1097/eja.0000000000001282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Venous Pulse Wave Velocity variation in response to a simulated fluid challenge in healthy subjects. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2020.102177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Diaper J, Schiffer E, Barcelos GK, Luise S, Schorer R, Ellenberger C, Licker M. Goal-directed hemodynamic therapy versus restrictive normovolemic therapy in major open abdominal surgery: A randomized controlled trial. Surgery 2020; 169:1164-1174. [PMID: 33143931 DOI: 10.1016/j.surg.2020.09.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/15/2020] [Accepted: 09/22/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The aim of this study was to compare the occurrence of postoperative complications in patients undergoing elective open abdominal surgery and receiving intraoperative goal-directed hemodynamic therapy or restrictive normovolemic therapy. METHODS A total of 401 patients were randomized in the goal-directed hemodynamic therapy or restrictive normovolemic therapy groups. A cardiac output monitor was used in all goal-directed hemodynamic therapy patients and was left at the discretion of anesthetists in charge of patients in the restrictive normovolemic therapy group. The primary outcome was a composite morbidity endpoint (30-day mortality and complications grade 2-4 according to Dindo-Clavien classification). Secondary outcomes were the hospital duration of stay, the incidence of pulmonary, cardiovascular, and renal complications up to 30 days after surgery, and midterm survival. RESULTS Intraoperatively, the goal-directed hemodynamic therapy group received higher intravenous fluid volumes (mean of 10.8 mL/kg/h and standard deviation of 4.0) compared with the restrictive normovolemic therapy group (mean of 7.2 mL/kg/h and standard deviation of 2.0; P < .001). On the first postoperative day, similar fluid volumes were infused in the 2 groups. The primary outcome occurred in 57.7% of goal-directed hemodynamic therapy and 53.0% of restrictive normovolemic therapy (relative risk, 1.09 [95% confidence interval, 0.91-1.30]), and there was no significant difference between groups for any secondary outcomes. CONCLUSION Among patients undergoing major open abdominal surgery, the goal-directed hemodynamic therapy and the restrictive normovolemic therapy were associated with similar incidence of moderate-to-severe postoperative complications and hospital resource use.
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Affiliation(s)
- John Diaper
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Eduardo Schiffer
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland
| | - Gleicy Keli Barcelos
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Stéphane Luise
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Raoul Schorer
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland
| | - Marc Licker
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland.
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Vanpeteghem CM, Bruneel BY, Lecoutere IM, De Hert SG, Moerman AT. Ephedrine and phenylephrine induce opposite changes in cerebral and paraspinal tissue oxygen saturation, measured with near-infrared spectroscopy: a randomized controlled trial. J Clin Monit Comput 2020; 34:253-259. [PMID: 31165350 DOI: 10.1007/s10877-019-00328-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/28/2019] [Indexed: 11/24/2022]
Abstract
While the effects of phenylephrine (PE) and ephedrine (E) on cerebral oxygen saturation (rScO2) already has been studied, the effect on paraspinal oxygen saturation (rSpsO2) is still unexplored. This study aims to assess the effect of PE and E on rScO2 and rSpsO2, measured with near-infrared spectroscopy. A randomized 4-treatment cross-over trial was designed in 28 patients under BIS-titrated anaesthesia with sevoflurane. If MAP decreased more than 20% from baseline, incremental doses of PE and/or E were given according to the randomization (group I: E-PE-E, group II: PE-E-PE, group III: E-E-E, group IV: PE-PE-PE). rScO2 and rSpsO2 on T3-T4, T9-T10 and L1-L2 were recorded. Differences in rSO2 (post-pretreatment) within each group were analyzed with paired Student's t test. Differences in effects of PE and E on rScO2 and rSpsO2 were analyzed with linear mixed-modelling. Following PE administration, rScO2 decreased significantly (- 2.7% ± 3.5), while it remained stable following E (- 0.6% ± 3.6). Contrastingly, rSpsO2 at T3-T4, T9-T10 and L1-L2 slightly increased following PE (0.4% ± 2.5, 0.7% ± 2.0 and - 0.1% ± 1.4, respectively), while it decreased after E administration (- 1.3% ± 3.4%, - 0.7% ± 2.6% and - 1.3% ± 2.7%, respectively). Compared to E, PE administration was associated with a significant decrease in rScO2 (- 2.1%, 95% CI [- 3.1%, - 1.2%], p < 0.001). In contrast, compared to PE, E was associated with a significant decrease in rSpsO2 at T3-T4, T9-T10 and L1-L2 (- 2.0%, 95% CI [- 2.8, - 1.1], p < 0.001; - 1.4%, 95% CI [- 2.4%, - 0.4%], p = 0.006; and - 1.5%, 95% CI [- 2.3%, - 0.8%], p < 0.001, respectively). An opposite effect on rScO2 and rSpsO2 was observed after bolus administration of PE and E.
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Affiliation(s)
- Caroline M Vanpeteghem
- Department of Anaesthesiology and Perioperative Medicine, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Bas Y Bruneel
- Department of Anaesthesiology and Perioperative Medicine, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Isabeau M Lecoutere
- Department of Anaesthesiology and Perioperative Medicine, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Stefan G De Hert
- Department of Anaesthesiology and Perioperative Medicine, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Anneliese T Moerman
- Department of Anaesthesiology and Perioperative Medicine, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium
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End-Expiratory Occlusion Test During Increase of Vasomotor Tone in a Rabbit Model of Hemorrhage. Sci Rep 2020; 10:1257. [PMID: 31988341 PMCID: PMC6985311 DOI: 10.1038/s41598-020-58096-2] [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: 07/05/2019] [Accepted: 11/30/2019] [Indexed: 11/25/2022] Open
Abstract
End-expiratory occlusion test (EEOT) has been proposed as a preload responsiveness test that overcomes several limitations of pulse pressure (PPV) and stroke volume (SVV) variations. We compared the ability of EEOT versus SVV and PPV to predict fluid responsiveness during the increase of the vasomotor tone in a rabbit model of hemorrhage. Ten rabbits were anesthetized, paralyzed, and mechanically ventilated during basal load (BL), after progressive blood withdrawal (BW), and after volume replacement. Other two sets of data were obtained during vasomotor increase by phenylephrine (PHE) infusion in BL and BW. We estimated the change of stroke volume (∆SVEEOT) and aortic flow (∆AoFEEOT) during the EEOT. PPV and SVV were obtained by the variation of beat-to-beat PP and SV, respectively. Baseline PPV, SVV, ∆SVEEOT, and ∆AoFEEOT increased significantly after BW, with a decrease of aortic flow (P < 0.05). PHE induced a significant decrease of PPV and SVV, but without affecting ∆SVEEOT, and ∆AoFEEOT. We conclude that ∆SV and ∆AoF during EEOT kept the ability to predict fluid responsiveness during PHE infusion in a rabbit hemorrhage model. This result may suggest the advantage of EEOT with respect to SVV and PPV in predicting fluid responsiveness during vasomotor tone increase.
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Gumbert SD, Kork F, Jackson ML, Vanga N, Ghebremichael SJ, Wang CY, Eltzschig HK. Perioperative Acute Kidney Injury. Anesthesiology 2020; 132:180-204. [PMID: 31687986 PMCID: PMC10924686 DOI: 10.1097/aln.0000000000002968] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Perioperative organ injury is among the leading causes of morbidity and mortality of surgical patients. Among different types of perioperative organ injury, acute kidney injury occurs particularly frequently and has an exceptionally detrimental effect on surgical outcomes. Currently, acute kidney injury is most commonly diagnosed by assessing increases in serum creatinine concentration or decreased urine output. Recently, novel biomarkers have become a focus of translational research for improving timely detection and prognosis for acute kidney injury. However, specificity and timing of biomarker release continue to present challenges to their integration into existing diagnostic regimens. Despite many clinical trials using various pharmacologic or nonpharmacologic interventions, reliable means to prevent or reverse acute kidney injury are still lacking. Nevertheless, several recent randomized multicenter trials provide new insights into renal replacement strategies, composition of intravenous fluid replacement, goal-directed fluid therapy, or remote ischemic preconditioning in their impact on perioperative acute kidney injury. This review provides an update on the latest progress toward the understanding of disease mechanism, diagnosis, and managing perioperative acute kidney injury, as well as highlights areas of ongoing research efforts for preventing and treating acute kidney injury in surgical patients.
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Affiliation(s)
- Sam D. Gumbert
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Felix Kork
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Maisie L. Jackson
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Naveen Vanga
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Semhar J. Ghebremichael
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Christy Y. Wang
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Holger K. Eltzschig
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
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Affiliation(s)
- Rafael Dalmau
- Department of Anesthesiology, Hospital Español de Rosario, Rosario, Santa Fe, Argentina
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25
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Brengelmann GL. Venous return and the physical connection between distribution of segmental pressures and volumes. Am J Physiol Heart Circ Physiol 2019; 317:H939-H953. [PMID: 31518160 DOI: 10.1152/ajpheart.00381.2019] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
More than sixty years ago, Guyton and coworkers related their observations of venous return to a mathematical model. Showing steady-state flow (F) as proportional to the difference between mean systemic pressure (Pms) and right atrial pressure (Pra), the model fit their data. The parameter defined by the ratio (Pms - Pra)/F, first called an "impedance," came to be called the "resistance to venous return." The interpretation that Pra opposes Pms and that, to increase output, the heart must act to reduce back pressure at the right atrium was widely accepted. Today, the perceived importance of Pms is evident in the efforts to find reliable ways to estimate it in patients. This article reviews concepts about venous return, criticizing some as inconsistent with elementary physical principles. After review of basic background topics-the steady-state vascular compliance; stressed versus unstressed volume-simulations from a multicompartment model based on data and definitions from Rothe's classical review of the venous system are presented. They illustrate the obligatory connection between flow-dependent compartment pressures and the distribution of volume among vascular compartments. An appendix shows that the pressure profile can be expressed either as decrements relative to arterial pressure or as increments relative to Pra (the option taken in the original model). Conclusion: The (Pms - Pra)/F formulation was never about Pms physically driving venous return; it was about how intravascular volume distributes among compliant compartments in accordance with their flow-dependent distending pressures, arbitrarily expressed relative to Pra rather than arterial pressure.
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Affiliation(s)
- George L Brengelmann
- Department of Physiology and Biophysics, University of Washington, Seattle, Washington
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Complex effects of continuous vasopressor infusion on fluid responsiveness during liver resection. Eur J Anaesthesiol 2019; 36:667-675. [DOI: 10.1097/eja.0000000000001046] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Denault A, Shaaban Ali M, Couture EJ, Beaubien-Souligny W, Bouabdallaoui N, Brassard P, Mailhot T, Jacquet-Lagrèze M, Lamarche Y, Deschamps A. A Practical Approach to Cerebro-Somatic Near-Infrared Spectroscopy and Whole-Body Ultrasound. J Cardiothorac Vasc Anesth 2019; 33 Suppl 1:S11-S37. [DOI: 10.1053/j.jvca.2019.03.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Affiliation(s)
- Rafael Dalmau
- Department of Anesthesiology, Hospital Español de Rosario, Rosario, Argentina
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Implementation of closed-loop-assisted intra-operative goal-directed fluid therapy during surgery. Eur J Anaesthesiol 2019; 36:303-304. [PMID: 30817361 DOI: 10.1097/eja.0000000000000947] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Deflandre E, Delande S, Cauvain J, Geradon P, Donneau AF, Lacroix S, Van Dyck M. Influence of Sternotomy on Delta Pulse Pressure and Delta Down During Open Chest Cardiac Surgery: A Preliminary Study. J Cardiothorac Vasc Anesth 2018; 33:2201-2207. [PMID: 30581108 DOI: 10.1053/j.jvca.2018.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Delta pulse pressure and delta down are used as dynamic preload indicators of fluid responsiveness during closed chest surgery. There are few data regarding their accuracy in open chest surgery. The present study aimed to evaluate the influence of sternotomy on the accuracy of both delta pulse pressure and delta down. DESIGN Prospective study. SETTING Single institution, nonacademic hospital. PARTICIPANTS The study comprised 127 adult patients scheduled for elective open chest cardiac surgery. INTERVENTIONS Delta pulse pressure and delta down were calculated for all patients before and 10 minutes after sternotomy. MEASUREMENTS AND MAIN RESULTS Statistical analyses were performed to assess the influence of sternotomy on the accuracy of delta down and delta pulse pressure. Mann-Whitney and Bland-Altman analyses demonstrated a significant influence of sternotomy on delta pulse pressure values but not on delta down values. Among patients who had a positive delta down and/or delta pulse pressure before sternotomy, sternotomy significantly modified the delta pulse pressure value (p = 0.02), but not the delta down value (p = 0.22). The kappa coefficient indicated a very good agreement between delta down before and after sternotomy (0.83) and a fair agreement between delta pulse pressure before and after sternotomy (0.4). The difference between kappa coefficients was highly significant (p < 0.001). CONCLUSIONS Within the study population, sternotomy significantly influenced delta pulse pressure but not delta down. In this preliminary study, delta down appeared to be more accurate to evaluate fluid responsiveness during open chest surgery than did delta pulse pressure. Before promoting delta down in current practice, confirmation is needed on a larger scale.
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Affiliation(s)
- Eric Deflandre
- Department of Anesthesia, Clinique Saint-Luc de Bouge, Namur, Belgium; Department of Ambulatory Surgery, Clinique Saint-Luc de Bouge, Namur, Belgium; University of Liege, Liege, Belgium; Medical ASTES, Jambes, Belgium.
| | - Simon Delande
- Department of Anesthesia, Catholic University of Louvain, Brussels, Belgium
| | - Jerome Cauvain
- Department of Anesthesia, Catholic University of Louvain, Brussels, Belgium
| | - Pierre Geradon
- Department of Anesthesia, Catholic University of Louvain, Brussels, Belgium
| | | | - Simon Lacroix
- Department of Anesthesia, Clinique Saint-Luc de Bouge, Namur, Belgium
| | - Michel Van Dyck
- Department of Anesthesia, Catholic University of Louvain, Brussels, Belgium
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Egesborg AH, Sørensen H, Olesen ND, Secher NH. Phenylephrine increases near-infrared spectroscopy determined muscle oxygenation during head-up tilt in men. Scand J Clin Lab Invest 2018; 78:601-605. [DOI: 10.1080/00365513.2018.1528505] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Astrid H. Egesborg
- Copenhagen Muscle Research Centre, Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
| | - Henrik Sørensen
- Copenhagen Muscle Research Centre, Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
| | - Niels D. Olesen
- Copenhagen Muscle Research Centre, Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen Ø, Denmark
| | - Niels H. Secher
- Copenhagen Muscle Research Centre, Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
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Abstract
Abstract
The Pathophysiology of Aortic Cross-clamping and Unclamping. By Gelman S. ANesthesiology 1995; 82:1026–60. Reprinted with permission.
Aortic cross-clamping (AoX) and unclamping are associated with severe hemodynamic disturbances in virtually all organs and systems. The main hemodynamic changes induced by AoX result from an increase in impedance to aortic flow, an increase in systemic vascular resistance and afterload, blood volume redistribution caused by collapse and constriction of venous vasculature distal to the aortic clamp, and a subsequent increase in preload. Preload may not increase if the aorta is clamped distal to the celiac artery; in that case, blood volume from distal venous vasculature may be redistributed to the splanchnic vasculature without associated increases in preload. Increases in afterload and preload demand an increase in contractility, which results in an autoregulatory increase in coronary blood flow. Without increases in coronary blood flow and myocardial contractility, decompensation may occur. Aortic cross-clamping is associated with the formation and release of many mediators which constitute a double-edged sword: they may mitigate or aggravate the harmful hemodynamic effects of AoX and unclamping. Injuries to the lungs, kidneys, spinal cord, or abdominal viscera are caused mainly by ischemia and reperfusion of organs distal to aortic cross-clamping. A clear understanding of the pathophysiologic mechanisms involved in these processes should help to promote rational, well-focused, and effective measures to prevent and treat homeostatic disturbances occurring during AoX and unclamping.
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Brengelmann GL. Stressed and unstressed volumes of the peripheral vasculature. Can J Anaesth 2018; 65:1072-1073. [DOI: 10.1007/s12630-018-1155-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 01/05/2018] [Accepted: 01/05/2018] [Indexed: 11/30/2022] Open
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An analytical perspective on the venous return controversy. Can J Anaesth 2018; 65:1074-1075. [DOI: 10.1007/s12630-018-1156-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 02/05/2018] [Accepted: 05/16/2018] [Indexed: 10/14/2022] Open
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Dalmau R. The “stressed blood volume” revisited. Can J Anaesth 2018; 65:1070-1071. [DOI: 10.1007/s12630-018-1154-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 01/07/2018] [Accepted: 01/08/2018] [Indexed: 12/01/2022] Open
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Gelman S, Bigatello L. In reply: Why goal-directed hemodynamic therapy is often ineffective and how can we try to improve the results. Can J Anaesth 2018; 65:1076-1077. [PMID: 29882056 DOI: 10.1007/s12630-018-1157-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 10/14/2022] Open
Affiliation(s)
- Simon Gelman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Luca Bigatello
- Department of Anesthesiology, Critical Care, and Pain Medicine, St. Elizabeth Medical Center, Brighton, MA, USA
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Thiele RH. Venous circulation and the invisible hand. Can J Anaesth 2018; 65:231-234. [DOI: 10.1007/s12630-017-1046-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 11/22/2017] [Indexed: 10/18/2022] Open
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Phenylephrine and paradoxically increased muscle tissue oxygenation: is the mechanism related to local venoconstriction or augmented venous return? J Clin Monit Comput 2018; 32:1143. [PMID: 29335915 DOI: 10.1007/s10877-018-0102-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/12/2018] [Indexed: 10/18/2022]
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