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Boland W, Datta D, Namazzi R, Bond C, Conroy AL, Mellencamp KA, Opoka RO, John CC, Rivera ML. Peripheral Perfusion Index in Ugandan Children With Plasmodium falciparum Severe Malaria: Secondary Analysis of Outcomes in a 2014-2017 Cohort Study. Pediatr Crit Care Med 2024:00130478-990000000-00385. [PMID: 39324855 DOI: 10.1097/pcc.0000000000003624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
OBJECTIVES Continuous, noninvasive tools to monitor peripheral perfusion, such as perfusion index (PI), can detect hemodynamic abnormalities and assist in the management of critically ill children hospitalized with severe malaria. In this study of hospitalized children with severe malaria, we aimed to assess whether PI correlates with clinical markers of perfusion and to determine whether combining PI with these clinical measures improves identification of children with greater odds of mortality. DESIGN Post hoc analysis of a prospective, multicenter, cohort study conducted between 2014 and 2017. SETTING Two referral hospitals in Central and Eastern Uganda. PATIENTS Six hundred children younger than 5 years old with severe malaria and 120 asymptomatic community children. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS PI was measured at 6-hour intervals for the first 24 hours of hospitalization. We compared PI to standard clinical perfusion measures such as capillary refill time, presence of cold peripheral limbs, or temperature gradient. Admission PI was highly correlated with clinical measures of perfusion. Admission PI was lower in children with severe malaria compared with asymptomatic community children; and, among the children with severe malaria, PI was lower in those with clinical features of poor perfusion or complications of severe malaria, such as shock and hyperlactatemia (all p < 0.02). Among children with severe malaria, lower admission PI was associated with greater odds of mortality after adjustment for age, sex, and severe malaria criteria (adjusted odds ratio, 2.4 for each log decrease in PI [95% CI, 1.0-5.9]; p = 0.045). Diagnostically, the presence of two consecutive low PI measures (< 1%) predicted mortality, with a sensitivity of 50% and a specificity of 76%. CONCLUSIONS In severe malaria, PI correlates with clinical complications (including shock and elevated serum lactate) and may be useful as an objective, continuous explanatory variable associated with greater odds of later in-hospital mortality.
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Affiliation(s)
- Wesley Boland
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Caitlin Bond
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Kagan A Mellencamp
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Michael Lintner Rivera
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
- Division of Pediatric Critical Care, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
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Sun X, He H, Xu M, Long Y. Peripheral perfusion index of pulse oximetry in adult patients: a narrative review. Eur J Med Res 2024; 29:457. [PMID: 39261939 PMCID: PMC11389527 DOI: 10.1186/s40001-024-02048-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 09/02/2024] [Indexed: 09/13/2024] Open
Abstract
The peripheral perfusion index (PI) is derived from pulse oximetry and is defined as the ratio of the pulse wave of the pulsatile portion (arteries) to the non-pulsatile portion (venous and other tissues). A growing number of clinical studies have supported the use of PI in various clinical scenarios, such as guiding hemodynamic management and serving as an indicator of outcome and organ function. In this review, we will introduce and discuss this traditional but neglected indicator of the peripheral microcirculatory perfusion. Further clinical trials are required to clarify the normal and critical values of PI for different monitoring devices in various clinical conditions, to establish different standards of PI-guided strategies, and to determine the effect of PI-guided therapy on outcome.
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Affiliation(s)
- Xiaotong Sun
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Huaiwu He
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China.
| | - Mengru Xu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Yun Long
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
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Tan G, Huguenard AL, Donovan KM, Demarest P, Liu X, Li Z, Adamek M, Lavine K, Vellimana AK, Kummer TT, Osbun JW, Zipfel GJ, Brunner P, Leuthardt EC. The effect of transcutaneous auricular vagus nerve stimulation on cardiovascular function in subarachnoid hemorrhage patients: a safety study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.03.24304759. [PMID: 38633771 PMCID: PMC11023641 DOI: 10.1101/2024.04.03.24304759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Introduction Subarachnoid hemorrhage (SAH) is characterized by intense central inflammation, leading to substantial post-hemorrhagic complications such as vasospasm and delayed cerebral ischemia. Given the anti-inflammatory effect of transcutaneous auricular vagus nerve stimulation (taVNS) and its ability to promote brain plasticity, taVNS has emerged as a promising therapeutic option for SAH patients. However, the effects of taVNS on cardiovascular dynamics in critically ill patients, like those with SAH, have not yet been investigated. Given the association between cardiac complications and elevated risk of poor clinical outcomes after SAH, it is essential to characterize the cardiovascular effects of taVNS to ensure this approach is safe in this fragile population. Therefore, we assessed the impact of both acute taVNS and repetitive taVNS on cardiovascular function in this study. Methods In this randomized clinical trial, 24 SAH patients were assigned to either a taVNS treatment or a Sham treatment group. During their stay in the intensive care unit, we monitored patient electrocardiogram (ECG) readings and vital signs. We compared long-term changes in heart rate, heart rate variability, QT interval, and blood pressure between the two groups. Additionally, we assessed the effects of acute taVNS by comparing cardiovascular metrics before, during, and after the intervention. We also explored acute cardiovascular biomarkers in patients exhibiting clinical improvement. Results We found that repetitive taVNS did not significantly alter heart rate, QT interval, blood pressure, or intracranial pressure. However, taVNS increased overall heart rate variability and parasympathetic activity compared to the sham treatment. The increase in parasympathetic activity was most pronounced from 2-4 days after initial treatment (Cohen's d = 0.50). Acutely, taVNS increased heart rate, blood pressure, and peripheral perfusion index without affecting the corrected QT interval, intracranial pressure, or heart rate variability. The acute post-treatment elevation in heart rate was more pronounced in patients who experienced a decrease of more than one point in their Modified Rankin Score at the time of discharge. Conclusions Our study found that taVNS treatment did not induce adverse cardiovascular effects, such as bradycardia or QT prolongation, supporting its development as a safe immunomodulatory treatment approach for SAH patients. The observed acute increase in heart rate after taVNS treatment may serve as a biomarker for SAH patients who could derive greater benefit from this treatment. Trial registration NCT04557618.
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Endo H, Sekiguchi R, Kinoshita M, Tanaka K. Peripheral venous dilation using flow-mediated dilation response: A randomized crossover study. J Vasc Access 2024:11297298241273642. [PMID: 39171370 DOI: 10.1177/11297298241273642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND Venodilation is crucial in enhancing the success rate of peripheral intravenous cannulation. Flow-mediated dilation (FMD) is a vasodilatory response initiated by temporary ischemia followed by reperfusion. This crossover study aimed to test the hypothesis that FMD induces dilation of the peripheral veins of the forearm. METHODS Fifteen healthy volunteers underwent the FMD and control conditions in a randomized order. FMD involved a 5-min occlusion of blood flow in the brachial artery, followed by reperfusion, achieved by inflating and deflating a cuff placed on the upper arm. The control condition involved participants remaining at rest. The primary outcome measure was a change in the cross-sectional area of the cephalic vein post-intervention. The secondary outcomes included changes in venous diameter and perfusion index (PI). RESULTS FMD significantly increased the cross-sectional area of the cephalic vein compared with the control condition (relative change to baseline: 37.7% (31.4) vs 2.2% (11.7)), with a mean difference of 35.4% (95% confidence interval (CI): 16.4-54.5, p = 0.001). Both longitudinal and transverse diameters were significantly expanded with FMD compared to the control (relative change to baseline: 15.7% (15.4) vs 2.6% (3.6), p = 0.004; 18.9% (15.6) vs -0.0 (10.2), p = 0.003, respectively). Additionally, PI significantly increased with FMD compared with the control (relative change to baseline: 77.8% (56.9) vs 14.6% (36.0)), with a mean difference of 63.2% (95% CI: 31.2-95.2, p = 0.001). CONCLUSION FMD application induced dilation of the cephalic vein of the forearm. The findings suggest that FMD is an effective technique for dilating the venous area and potentially improving the success rate of peripheral intravenous cannulation.
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Affiliation(s)
- Hiroya Endo
- Department of Anesthesiology, Tokushima University Hospital, Tokushima, Japan
| | - Ryo Sekiguchi
- Department of Anesthesiology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Michiko Kinoshita
- Department of Anesthesiology, Tokushima University Hospital, Tokushima, Japan
| | - Katsuya Tanaka
- Department of Anesthesiology, Tokushima University Hospital, Tokushima, Japan
- Department of Anesthesiology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
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Davis WT, Valdez-Delgado KK, Bennett C, Mann-Salinas E, Burnett GM, Bedford T, Albright-Trainer B, Savell SC, Sorensen D. Reliability of Continuous Noninvasive Hemoglobin Monitoring in Healthy Participants During En Route Care Training. Mil Med 2024; 189:448-455. [PMID: 39160881 DOI: 10.1093/milmed/usae151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/23/2024] [Accepted: 03/19/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Current standards for hemoglobin monitoring during air transports of U.S. combat wounded are invasive and intermittent. Fielded pulse co-oximeters can noninvasively measure total hemoglobin, but this parameter is not currently utilized. The primary objective of this study was to assess the percentage of vital sign measurements with successful capture of total noninvasive hemoglobin measurement using spectrophotometry-based technology for Hb (SpHb) measurements in healthy participants during training flights. Secondary objectives were to assess the feasibility of a novel electronic data capture mechanism from usual patient movement items and perform a pilot analysis of SpHb changes in healthy participants during transitions from ground to air transport. METHODS We conducted a feasibility study enrolling healthy participants who had hemodynamic monitoring during usual U.S. Air Force Critical Care Air Transport (CCAT) flight training exercises from 2022 to 2023. Usual CCAT monitoring equipment and currently used Masimo Rainbow® pulse co-oximeters had the capability to measure SpHb. After each training exercise, the study team wirelessly downloaded case files from patient monitors utilizing the Battlefield Assisted Trauma Distributed Observation Kit (BATDOKTM) Case Downloader application. We then calculated point and precision estimates for the percentage of time for successful SpHb capture during the exercise and compared this to pulse oximetry (SpO2) capture. An a priori precision analysis for percentage of flight-time with successful SpHb data capture and descriptive statistics were performed. This study received Exempt Determination by the 59th Medical Wing IRB. RESULTS We analyzed 26 records with mean monitoring durations of 94.5 [59.3-119.9] minutes during ground phases and 78.0 [59.9-106.5] minutes during flight phases. SpHb measures were successfully captured for 97.7% (n = 4,620) of possible ground measurements and 97.2% (n = 3,973) of possible in-flight measurements compared to 99.5% ground and 98.2% in-flight capture for SpO2. Mean intervals of missing SpHb data were 2 ± 5 minutes on the ground and 4 ± 6 minutes in-flight. Mean SpHb increased by 0.93 ± 0.96 g/dL during the ground phase, but had minimal changes during ascent, cruising altitude or descent. The BATDOKTM Case downloader completed transfer for all files. CONCLUSION Masimo Rainbow® SpHb pulse co-oximeters reliably captured continuous, noninvasive hemoglobin measurements using usual CCAT patient movement items in healthy participants during both ground and flight training. The BATDOKTM Case Downloader successfully imported case files from CCAT patient monitors. Mean SpHb measures had a small increase during the ground phase of monitoring followed by minimal changes when transitioning to flight altitude.
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Affiliation(s)
- William T Davis
- En route Care Research Center/59 MDW/ST, Defense Health Agency, Sam Houston, TX 78234, USA
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | | | - Christopher Bennett
- En route Care Research Center/59 MDW/ST, Defense Health Agency, Sam Houston, TX 78234, USA
| | - Elizabeth Mann-Salinas
- En route Care Research Center/59 MDW/ST, Defense Health Agency, Sam Houston, TX 78234, USA
| | - Gregory M Burnett
- Air Force Research Laboratory, 711 Human Performance Wing, Wright-Patterson AFB, OH 45433, USA
| | - Theresa Bedford
- Air Force Research Laboratory, 711 Human Performance Wing, Wright-Patterson AFB, OH 45433, USA
| | - Brooke Albright-Trainer
- Department of Anesthesiology, VCU Health, Richmond, VA 23249, USA
- Central VA Health Care System, Richmond, VA 23249, USA
| | - Shelia C Savell
- En route Care Research Center/59 MDW/ST, Defense Health Agency, Sam Houston, TX 78234, USA
| | - Derek Sorensen
- Air Force Research Laboratory, 711 Human Performance Wing, Wright-Patterson AFB, OH 45433, USA
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Lau FF, Agerskov M, Thusholdt ANW, Højlund J, Meyhoff CS, Jans Ø, Foss NB. Peripheral perfusion index stratifies risk in patients with intraoperative anemia: A multicentre cohort study. J Clin Anesth 2024; 95:111472. [PMID: 38613938 DOI: 10.1016/j.jclinane.2024.111472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/20/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024]
Abstract
STUDY OBJECTIVE Evidence for red blood cell (RBC) transfusion thresholds in the intraoperative setting is limited, and current perioperative recommendations may not correspond with individual intraoperative physiological demands. Hemodynamics relevant for the decision to transfuse may include peripheral perfusion index (PPI). The objective of this prospective study was to assess the associations of PPI and hemoglobin levels with the risk of postoperative morbidity and mortality. DESIGN Multicenter cohort study. SETTING Bispebjerg and Hvidovre University Hospitals, Copenhagen, Denmark. PATIENTS We included 741 patients who underwent acute high risk abdominal surgery or hip fracture surgery. INTERVENTIONS No interventions were carried out. MEASUREMENTS Principal values collected included measurements of peripheral perfusion index and hemoglobin values. METHODS The study was conducted using prospectively obtained data on adults who underwent emergency high-risk surgery. Subjects were categorized into high vs. low subgroups stratified by pre-defined PPI levels (PPI: > 1.5 vs. < 1.5) and Hb levels (Hb: > 9.7 g/dL vs. < 9.7 g/dL). The study assessed mortality and severe postoperative complications within 90 days. MAIN RESULTS We included 741 patients. 90-day mortality was 21% (n = 154), frequency of severe postoperative complications was 31% (n = 231). Patients with both low PPI and low Hb had the highest adjusted odds ratio for both 90-day severe postoperative complications (2.95, [1.62-5.45]) and 90-day mortality (3.13, [1.45-7.11]). A comparison of patients with low PPI and low Hb to those with high PPI and low Hb detected significantly higher 90-day mortality risk in the low PPI and low Hb group (OR 8.6, [1.57-162.10]). CONCLUSION High PPI in acute surgical patients who also presents with anemia was associated with a significantly better outcome when compared with patients with both low PPI and anemia. PPI should therefore be further investigated as a potential parameter to guide intraoperative RBC transfusion therapy.
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Affiliation(s)
- Frederik F Lau
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Marianne Agerskov
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anna N W Thusholdt
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Øivind Jans
- Department of Anesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Sirkiä J, Panula T, Kaisti M. Non-Invasive Hemodynamic Monitoring System Integrating Spectrometry, Photoplethysmography, and Arterial Pressure Measurement Capabilities. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2310022. [PMID: 38647403 PMCID: PMC11199981 DOI: 10.1002/advs.202310022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/12/2024] [Indexed: 04/25/2024]
Abstract
Minimally invasive and non-invasive hemodynamic monitoring technologies have recently gained more attention, driven by technological advances and the inherent risk of complications in invasive techniques. In this article, an experimental non-invasive system is presented that effectively combines the capabilities of spectrometry, photoplethysmography (PPG), and arterial pressure measurement. Both time- and wavelength-resolved optical signals from the fingertip are measured under external pressure, which gradually increased above the level of systolic blood pressure. The optical channels measured at 434-731 nm divided into three groups separated by a group of channels with wavelengths approximately between 590 and 630 nm. This group of channels, labeled transition band, is characterized by abrupt changes resulting from a decrease in the absorption coefficient of whole blood. External pressure levels of maximum pulsation showed that shorter wavelengths (<590 nm) probe superficial low-pressure blood vessels, whereas longer wavelengths (>630 nm) probe high-pressure arteries. The results on perfusion indices and DC component level changes showed clear differences between the optical channels, further highlighting the importance of wavelength selection in optical hemodynamic monitoring systems. Altogether, the results demonstrated that the integrated system presented has the potential to extract new hemodynamic information simultaneously from macrocirculation to microcirculation.
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Affiliation(s)
- Jukka‐Pekka Sirkiä
- Department of ComputingUniversity of TurkuVesilinnantie 5Turku20500Finland
| | - Tuukka Panula
- Department of ComputingUniversity of TurkuVesilinnantie 5Turku20500Finland
| | - Matti Kaisti
- Department of ComputingUniversity of TurkuVesilinnantie 5Turku20500Finland
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Parladori R, Austin T, Smielewski P, Czosnyka M, Paoletti V, Vitali F, Corvaglia L, Martini S. Cardiovascular and cerebrovascular effects of caffeine maintenance in preterm infants during the transitional period. Pediatr Res 2024:10.1038/s41390-024-03194-4. [PMID: 38778228 DOI: 10.1038/s41390-024-03194-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/04/2024] [Accepted: 03/28/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND AND AIM Caffeine is routinely used for the prophylaxis of prematurity-related apnoeas. We aimed to evaluate the effect of caffeine maintenance on cardiovascular and cerebrovascular haemodynamics using a non-invasive multimodal monitoring in preterm infants during the transitional period. METHODS Infants <32 weeks' gestational age (GA) were enrolled in this observational prospective study. The following parameters were recorded before and after the administration of caffeine citrate 5 mg/kg using near-infrared spectroscopy, pulse oximetry and electrical velocimetry: heart rate, cardiac output, stroke volume, cardiac contractility, systemic vascular resistance (SVR), perfusion index, peripheral and cerebral oxygenation, cerebral fractional oxygen extraction, correlation index between cerebral oxygenation and heart rate (TOHRx, marker of cerebrovascular reactivity). Multilevel mixed-effects linear models were used to assess the impact of caffeine and of relevant clinical covariates on each parameter. RESULTS Seventy-seven infants (mean GA 29.3 ± 2.5 weeks, mean birthweight 1148 ± 353 g) were included. Caffeine administration was associated with increased SVR (B = 0.623, p = 0.004) and more negative TOHRx values (B = -0.036, p = 0.022), which suggest improved cerebrovascular reactivity. CONCLUSIONS Caffeine administration at maintenance dosage during postnatal transition is associated with increased systemic vascular tone and improved cerebrovascular reactivity. A possible role for caffeine-mediated inhibition of adenosine receptors may be hypothesized. IMPACT This study provides a thorough and comprehensive overview of multiple cerebrovascular and cardiovascular parameters, monitored non-invasively by combining near-infrared spectroscopy, electrical velocimetry and pulse oximetry, before and after the administration of caffeine at maintenance dosage in preterm infants during postnatal transition. Caffeine was associated with an improvement in cerebrovascular reactivity and with a slight but significant increase in systemic vascular resistance, with no additional effects on other cardiovascular and cerebrovascular parameters. Our results support the safety of caffeine treatment even during a phase at risk for haemodynamic instability such as postnatal transition and suggest potential beneficial effects on cerebral haemodynamics.
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Affiliation(s)
- Roberta Parladori
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Topun Austin
- Neonatal Intensive Care Unit, The Rosie Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Vittoria Paoletti
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesca Vitali
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Silvia Martini
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
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Guo Q, Lian H, Wang G, Zhang H, Wang X. Prospective Evaluation of the Peripheral Perfusion Index in Assessing the Organ Dysfunction and Prognosis of Adult Patients With Sepsis in the ICU. J Intensive Care Med 2024:8850666241252758. [PMID: 38748544 DOI: 10.1177/08850666241252758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Background: The peripheral perfusion index (PI) reflects microcirculatory blood flow perfusion and indicates the severity and prognosis of sepsis. Method: The cohort comprised 208 patients admitted to the intensive care unit (ICU) with infection, among which 117 had sepsis. Demographics, medication history, ICU variables, and laboratory indexes were collected. Primary endpoints were in-hospital mortality and 28-day mortality. Secondary endpoints included organ function variables (coagulation function, liver function, renal function, and myocardial injury), lactate concentration, mechanical ventilation time, and length of ICU stay. Univariate and multivariate analyses were conducted to assess the associations between the PI and clinical outcomes. Sensitivity analyses were performed to explore the associations between the PI and organ functions in the sepsis and nonsepsis groups. Result: The PI was negatively associated with in-hospital mortality (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.15 to 0.55), but was not associated with 28-day mortality. The PI was negatively associated with the coagulation markers prothrombin time (PT) (β -0.36, 95% CI -0.59 to 0.13) and activated partial thromboplastin time (APTT) (β -1.08, 95% CI -1.86 to 0.31), and the myocardial injury marker cardiac troponin I (cTnI) (β -2085.48, 95% CI -3892.35 to 278.61) in univariate analysis, and with the PT (β -0.36, 95% CI -0.60 to 0.13) in multivariate analysis. The PI was negatively associated with the lactate concentration (β -0.57, 95% CI -0.95 to 0.19), mechanical ventilation time (β -23.11, 95% CI -36.54 to 9.69), and length of ICU stay (β -1.28, 95% CI -2.01 to 0.55). Sensitivity analyses showed that the PI was significantly associated with coagulation markers (PT and APTT) and a myocardial injury marker (cTnI) in patients with sepsis, suggesting that the associations between the PI and organ function were stronger in the sepsis group than the nonsepsis group. Conclusion: The PI provides new insights for assessing the disease severity, short-term prognosis, and organ function damage in ICU patients with sepsis, laying a theoretical foundation for future research.
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Affiliation(s)
- Qirui Guo
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guangjian Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Krone S, Bokoch MP, Kothari R, Fong N, Tallarico RT, Sturgess-DaPrato J, Pirracchio R, Zarbock A, Legrand M. Association between peripheral perfusion index and postoperative acute kidney injury in major noncardiac surgery patients receiving continuous vasopressors: a post hoc exploratory analysis of the VEGA-1 trial. Br J Anaesth 2024; 132:685-694. [PMID: 38242802 DOI: 10.1016/j.bja.2023.11.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 10/26/2023] [Accepted: 11/24/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND The peripheral perfusion index is the ratio of pulsatile to nonpulsatile static blood flow obtained by photoplethysmography and reflects peripheral tissue perfusion. We investigated the association between intraoperative perfusion index and postoperative acute kidney injury in patients undergoing major noncardiac surgery and receiving continuous vasopressor infusions. METHODS In this exploratory post hoc analysis of a pragmatic, cluster-randomised, multicentre trial, we obtained areas and cumulative times under various thresholds of perfusion index and investigated their association with acute kidney injury in multivariable logistic regression analyses. In secondary analyses, we investigated the association of time-weighted average perfusion index with acute kidney injury. The 30-day mortality was a secondary outcome. RESULTS Of 2534 cases included, 8.9% developed postoperative acute kidney injury. Areas and cumulative times under a perfusion index of 3% and 2% were associated with an increased risk of acute kidney injury; the strongest association was observed for area under a perfusion index of 1% (adjusted odds ratio [aOR] 1.32, 95% confidence interval [CI] 1.00-1.74, P=0.050, per 100%∗min increase). Additionally, time-weighted average perfusion index was associated with acute kidney injury (aOR 0.82, 95% CI 0.74-0.91, P<0.001) and 30-day mortality (aOR 0.68, 95% CI 0.49-0.95, P=0.024). CONCLUSIONS Larger areas and longer cumulative times under thresholds of perfusion index and lower time-weighted average perfusion index were associated with postoperative acute kidney injury in patients undergoing major noncardiac surgery and receiving continuous vasopressor infusions. CLINICAL TRIAL REGISTRATION NCT04789330.
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Affiliation(s)
- Sina Krone
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA; Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Michael P Bokoch
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Rishi Kothari
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Nicholas Fong
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Roberta T Tallarico
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Jillene Sturgess-DaPrato
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Romain Pirracchio
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Matthieu Legrand
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA; INI-CRCT Network, Nancy, France.
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11
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Sharma V, Barker SJ, Sorci R, Park L, Wilson WC. Racial effects on masimo pulse oximetry: impact of low perfusion index. J Clin Monit Comput 2024; 38:347-354. [PMID: 38238634 PMCID: PMC10995008 DOI: 10.1007/s10877-023-01113-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/21/2023] [Indexed: 04/06/2024]
Abstract
PURPOSE Evaluate the SpO2-SaO2 difference between Black and White volunteer subjects having a low perfusion index (Pi) compared to those having a normal Pi. METHODS The Pi data were abstracted from electronic files collected on 7183 paired SpO2-SaO2 samples (3201 Black and 3982 White) from a recently reported desaturation study of 75 subjects (39 Black and 36 White) where SaO2 values were sequentially decreased from 100 to 70%. The Pi values from that dataset were divided into two groups (Pi ≤ 1 or Pi > 1) for analysis. A Pi value ≤ 1 was considered "low perfusion" and a Pi value > 1 was considered "normal perfusion". Statistical calculations included values of bias (mean difference of SpO2-SaO2), precision (standard deviation of the difference), and accuracy (root-mean-square error [ARMS]). During conditions of low perfusion (Pi ≤ 1, range [0.1 to 1]), overall bias and precision were + 0.48% ± 1.59%, while bias and precision were + 0.19 ± 1.53%, and + 0.91 ± 1.57%, for Black and White subjects, respectively. RESULTS During normal perfusion (Pi > 1, range [1 to 12]), overall bias and precision were + 0.18% ± 1.34%, while bias and precision were -0.26 ± 1.37%, and - 0.12 ± 1.31%, for Black and White subjects, respectively. ARMS was 1.37% in all subjects with normal perfusion and 1.64% in all subjects with low perfusion. CONCLUSION Masimo SET® pulse oximeters with RD SET® sensors are accurate for individuals of both Black and White races when Pi is normal, as well as during conditions when Pi is low. The ARMS for all conditions studied is well within FDA standards. This study was conducted in healthy volunteers during well-controlled laboratory desaturations, and results could vary under certain challenging clinical conditions.
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Affiliation(s)
- Vikrant Sharma
- Vice President, Optical Sciences, Masimo Corp, Irvine, CA, USA
| | | | - Rebecca Sorci
- Director, Clinical Publication Review and Communications, Masimo Corp, Irvine, CA, USA
| | - Linus Park
- Vice President Regulatory Affairs, Masimo Corp, Irvine, CA, USA
| | - William C Wilson
- Executive Vice President, Clinical Research Operations and Medical Affairs, Masimo Corp, Irvine, CA, USA.
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12
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Iizuka Y, Yoshinaga K, Amitani S, Nishiyama S, Fukano K, Miyazawa K, Kitajima A, Sawada I, Otsuka Y, Sanui M. Prediction of preload dependency using phenylephrine-induced peripheral perfusion index during general anaesthesia: a prospective observational study. BMC Anesthesiol 2024; 24:88. [PMID: 38431582 PMCID: PMC10908037 DOI: 10.1186/s12871-024-02478-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/28/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Tracking preload dependency non-invasively to maintain adequate tissue perfusion in the perioperative period can be challenging.The effect of phenylephrine on stroke volume is dependent upon preload. Changes in stroke volume induced by phenylephrine administration can be used to predict preload dependency. The change in the peripheral perfusion index derived from photoplethysmography signals reportedly corresponds with changes in stroke volume in situations such as body position changes in the operating room. Thus, the peripheral perfusion index can be used as a non-invasive potential alternative to stroke volume to predict preload dependency. Herein, we aimed to determine whether changes in perfusion index induced by the administration of phenylephrine could be used to predict preload dependency. METHODS We conducted a prospective single-centre observational study. The haemodynamic parameters and perfusion index were recorded before and 1 and 2 min after administering 0.1 mg of phenylephrine during post-induction hypotension in patients scheduled to undergo surgery. Preload dependency was defined as a stroke volume variation of ≥ 12% before phenylephrine administration at a mean arterial pressure of < 65 mmHg. Patients were divided into four groups according to total peripheral resistance and preload dependency. RESULTS Forty-two patients were included in this study. The stroke volume in patients with preload dependency (n = 23) increased after phenylephrine administration. However, phenylephrine administration did not impact the stroke volume in patients without preload dependency (n = 19). The perfusion index decreased regardless of preload dependency. The changes in the perfusion index after phenylephrine administration exhibited low accuracy for predicting preload dependency. Based on subgroup analysis, patients with high total peripheral resistance tended to exhibit increased stroke volume following phenylephrine administration, which was particularly prominent in patients with high total peripheral resistance and preload dependency. CONCLUSION The findings of the current study revealed that changes in the perfusion index induced by administering 0.1 mg of phenylephrine could not predict preload dependency. This may be attributed to the different phenylephrine-induced stroke volume patterns observed in patients according to the degree of total peripheral resistance and preload dependency. TRIAL REGISTRATION University Hospital Medical Information Network (UMIN000049994 on 9/01/2023).
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Affiliation(s)
- Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Koichi Yoshinaga
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan.
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311- 1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Shizuka Amitani
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Seiya Nishiyama
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Kentaro Fukano
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Keika Miyazawa
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Asuka Kitajima
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Ikumi Sawada
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Yuji Otsuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
- Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
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13
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Rixen M, Weickmann J, Gebauer RA, Weidenbach M, Markel F, Michaelis A, Dähnert I, Wüstenfeld J, Münch D, Poschart M, Sieber A, Schagatay E, Paech C. First Real-Life Data on the Diving Response in Healthy Children. Pediatr Cardiol 2024; 45:314-322. [PMID: 38177487 DOI: 10.1007/s00246-023-03370-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/30/2023] [Indexed: 01/06/2024]
Abstract
Swimming and diving are popular recreational activities, representing an effective option in maintaining and improving cardiovascular fitness in healthy people. To date, only little is known about the cardiovascular adaption to submersion in children. This study was conducted to improve an understanding thereof. We used a stepwise apnea protocol with apnea at rest, apnea with facial immersion, and at last apnea during whole body submersion. Continuous measurement of heart rate, oxygen saturation, and peripheral resistance index was done. Physiologic data and analysis of influencing factors on heart rate, oxygen saturation, and peripheral vascular tone response are reported. The current study presents the first data of physiologic diving response in children. Data showed that facial or whole body submersion leads to a major drop in heart rate, and increase of peripheral resistance, while the oxygen saturation seems to be unaffected by static apnea in most children, with apnea times of up to 75 s without change in oxygen saturation.
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Affiliation(s)
- Mareike Rixen
- Department for Pediatric Cardiology, University of Leipzig - Heart Center, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Johannes Weickmann
- Department for Pediatric Cardiology, University of Leipzig - Heart Center, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Roman Antonin Gebauer
- Department for Pediatric Cardiology, University of Leipzig - Heart Center, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Michael Weidenbach
- Department for Pediatric Cardiology, University of Leipzig - Heart Center, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Franziska Markel
- Department for Pediatric Cardiology, University of Leipzig - Heart Center, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Anna Michaelis
- Department for Pediatric Cardiology, University of Leipzig - Heart Center, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Ingo Dähnert
- Department for Pediatric Cardiology, University of Leipzig - Heart Center, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Jan Wüstenfeld
- Department of Sports Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Institut for Applied Training Science, Marschnerstrasse 29, Leipzig, Germany
| | - David Münch
- Landestauchsportverband Sachsen E.V, Am Sportforum 3, 04105, Leipzig, Germany
| | - Max Poschart
- SC DHfK Leipzig E.V, Am Sportforum 10, 04105, Leipzig, Germany
| | - Arne Sieber
- Oxygen Scientific GmbH, Eichbachgasse 151, 8041, Graz, Austria
| | - Erika Schagatay
- Environmental Physiology Group, Department of Health Sciences, Mid Sweden University, Östersund, Sweden
| | - Christian Paech
- Department for Pediatric Cardiology, University of Leipzig - Heart Center, Strümpellstr. 39, 04289, Leipzig, Germany.
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14
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Bakcek Akcelik O, Ayhan H, Ali Aksoy O, Alp Goksel B, Caliskan E, Ceylan A, Ozgenc Cinar O. Development of a pig model of spontaneous pressure injury: A randomized self-controlled study. J Tissue Viability 2024:S0965-206X(24)00004-4. [PMID: 38369386 DOI: 10.1016/j.jtv.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/28/2023] [Accepted: 01/24/2024] [Indexed: 02/20/2024]
Affiliation(s)
- Ozgu Bakcek Akcelik
- Yuksek Ihtisas University, Vocational School of Health Services, Department of Medical Services and Techniques, Operating Room Services Program, Turkiye.
| | - Hatice Ayhan
- University of Health Sciences, Gulhane Faculty of Nursing, Ankara, Turkiye.
| | - Okan Ali Aksoy
- University of Health Sciences, Gulhane Instıtute of Health Science, Animal Breeding and Research Center, Ankara, Turkiye.
| | - Berk Alp Goksel
- University of Health Sciences, Gulhane Instıtute of Health Science, Animal Breeding and Research Center, Ankara, Turkiye.
| | - Ercan Caliskan
- University of Health Sciences, Gulhane Training and Research Hospital, Department of Dermatology, Ankara, Turkiye.
| | - Ahmet Ceylan
- Ankara University, Faculty of Veterinary Medicine, Department of Histology-Embryology Dıskapı, Ankara, Turkiye.
| | - Ozge Ozgenc Cinar
- Ankara University, Faculty of Veterinary Medicine, Department of Histology-Embryology Dıskapı, Ankara, Turkiye.
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15
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Mallat J, Lemyze M, Fischer MO. Passive leg raising test induced changes in plethysmographic variability index to assess fluid responsiveness in critically ill mechanically ventilated patients with acute circulatory failure. J Crit Care 2024; 79:154449. [PMID: 37857068 DOI: 10.1016/j.jcrc.2023.154449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/20/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Passive leg raising (PLR) reliably predicts fluid responsiveness but requires a real-time cardiac index (CI) measurement or the presence of an invasive arterial line to achieve this effect. The plethysmographic variability index (PVI), an automatic measurement of the respiratory variation of the perfusion index, is non-invasive and continuously displayed on the pulse oximeter device. We tested whether PLR-induced changes in PVI (ΔPVIPLR) could accurately predict fluid responsiveness in mechanically ventilated patients with acute circulatory failure. METHODS This was a secondary analysis of an observational prospective study. We included 29 mechanically ventilated patients with acute circulatory failure in this study. We measured PVI (Radical-7 device; Masimo Corp., Irvine, CA) and CI (Echocardiography) before and during a PLR test and before and after volume expansion of 500 mL of crystalloid solution. A volume expansion-induced increase in CI of >15% defined fluid responsiveness. To investigate whether ΔPVIPLR can predict fluid responsiveness, we determined areas under the receiver operating characteristic curves (AUROCs) and gray zones for ΔPVIPLR. RESULTS Of the 29 patients, 27 (93.1%) received norepinephrine. The median tidal volume was 7.0 [IQR: 6.6-7.6] mL/kg ideal body weight. Nineteen patients (65.5%) were classified as fluid responders (increase in CI > 15% after volume expansion). Relative ΔPVIPLR accurately predicted fluid responsiveness with an AUROC of 0.89 (95%CI: 0.72-0.98, p < 0.001). A decrease in PVI ≤ -24.1% induced by PLR detected fluid responsiveness with a sensitivity of 95% (95%CI: 74-100%) and a specificity of 80% (95%CI: 44-97%). Gray zone was acceptable, including 13.8% of patients. The correlations between the relative ΔPVIPLR and changes in CI induced by PLR and by volume expansion were significant (r = -0.58, p < 0.001, and r = -0.65, p < 0.001; respectively). CONCLUSIONS In sedated and mechanically ventilated ICU patients with acute circulatory failure, PLR-induced changes in PVI accurately predict fluid responsiveness with an acceptable gray zone. TRIAL REGISTRATION ClinicalTrials.govNCT03225378.
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Affiliation(s)
- Jihad Mallat
- Department of Critical Care Medicine, Arras Hospital, 6200 Arras, France; Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Normandy University, UNICAEN, ED 497, Caen, France.
| | - Malcolm Lemyze
- Department of Critical Care Medicine, Arras Hospital, 6200 Arras, France
| | - Marc-Olivier Fischer
- Institut Aquitain du Cœur, Clinique Saint Augustin, ELSAN, 114 Avenue d'Arès, 33 074 Bordeaux Cedex, France
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16
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Zhang R, Wang X, Jin J, Feng Y. Perfusion index ratio predicts successful upper thoracic paravertebral block: A prospective observational study. Eur J Anaesthesiol 2024; 41:73-76. [PMID: 37889533 DOI: 10.1097/eja.0000000000001911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Affiliation(s)
- Ran Zhang
- From the Department of Anesthesiology and Pain Medicine, Peking University People's Hospital, Beijing, China (RZ, XW, JJ, YF)
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17
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Højlund J, Petersen DR, Agerskov M, Foss NB. "The peripheral perfusion index discriminates haemodynamic responses to induction of general anaesthesia". J Clin Monit Comput 2023; 37:1533-1540. [PMID: 37289351 PMCID: PMC10651705 DOI: 10.1007/s10877-023-01035-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/15/2023] [Indexed: 06/09/2023]
Abstract
Induction of general anaesthesia is often accompanied by hypotension. Standard haemodynamic monitoring during anaesthesia relies on intermittent blood pressure and heart rate. Continuous monitoring systemic blood pressure requires invasive or advanced modalities creating a barrier for obtaining important information of the circulation. The Peripheral Perfusion Index (PPI) is obtained non-invasively and continuously by standard photoplethysmography. We hypothesized that different patterns of changes in systemic haemodynamics during induction of general anaesthesia would be reflected in the PPI. Continuous values of PPI, stroke volume (SV), cardiac output (CO), and mean arterial pressure (MAP) were evaluated in 107 patients by either minimally invasive or non-invasive means in a mixed population of surgical patients. 2 min after induction of general anaesthesia relative changes of SV, CO, and MAP was compared to the relative changes of PPI. After induction total cohort mean(± st.dev.) MAP, SV, and CO decreased to 65(± 16)%, 74(± 18)%, and 63(± 16)% of baseline values. In the 38 patients where PPI decreased MAP was 57(± 14)%, SV was 63(± 18)%, and CO was 55(± 18)% of baseline values 2 min after induction. In the 69 patients where PPI increased the corresponding values were MAP 70(± 15)%, SV 80(± 16)%, and CO 68(± 17)% (all differences: p < 0,001). During induction of general anaesthesia changes in PPI discriminated between the degrees of reduction in blood pressure and algorithm derived cardiac stroke volume and -output. As such, the PPI has potential to be a simple and non-invasive indicator of the degree of post-induction haemodynamic changes.
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Affiliation(s)
- Jakob Højlund
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark.
| | - David René Petersen
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark
- Currently Department of Anaesthesiology, CKO, Rigshospitalet, Capital Region, Denmark
| | - Marianne Agerskov
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark
| | - Nicolai Bang Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark
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18
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Dogan B, Kudu E, Danış F, Ozturk Ince E, Karaca MA, Erbil B. Comparative Analysis of Perfusion Index and End-Tidal Carbon Dioxide in Cardiac Arrest Patients: Implications for Hemodynamic Monitoring and Resuscitation Outcomes. Cureus 2023; 15:e50818. [PMID: 38249229 PMCID: PMC10797221 DOI: 10.7759/cureus.50818] [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] [Accepted: 12/19/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND During cardiopulmonary resuscitation (CPR), some parameters (e.g., intraarterial pressure measurement and end-tidal carbon dioxide (EtCO2)) indicate the quality and outcome of resuscitation. These parameters are generally based on monitoring the hemodynamic status. Perfusion index (PI) is a calculation from the photoplethysmography (PPG) signal and displays the proportion of pulsatile to non-pulsatile light absorption or reflection in the PPG signal. It helps to evaluate cardiac output and tissue perfusion in the care of a critical patient. Its most important advantages are that it can be easily measured with a pulse oximeter probe attached to the finger (non-invasive), can be objectively repeated, can be applied quickly, and is inexpensive. Normal PI values range from 0.2% to 20%. Despite being recognized as a valuable indicator of hemodynamics, there is limited information regarding its relevance in patients experiencing cardiac arrest. Although the PI is known to be a valuable parameter to indicate hemodynamics, information about its value in cardiac arrest patients is limited. This study aims to evaluate the performance of PI and EtCO2 in predicting the return of spontaneous circulation (ROSC) among cardiac arrest patients. METHODS This was a single-center, prospective, observational clinical study including both out-of-hospital and in-hospital adult cardiac arrest patients. The study was conducted from November 1, 2018 to April 30, 2019 at the Emergency Department (ED) of the Hacettepe University Hospital, Ankara, Turkey. The EtCO2 values of the patients were recorded at the time they were intubated (t0) and every five minutes (t5, t10, t15...) during CPR. Along with these measurements, PI values were measured with the Masimo Signal Extraction Technology device (Masimo, California, United States). The study's primary outcome was PI's performance in predicting the ROSC among cardiac arrest patients. The secondary outcomes of the study were the performance of EtCO2 in predicting the ROSC among cardiac arrest patients and the association between PI and EtCO2 values. RESULTS We included a total of 100 cases. The mean age of patients was 70.4 ± 13.4 years, and 65% were male. The ROSC was achieved in 29 patients. There was no statistical difference in PI values between the ROSC (+) and ROSC (-) groups at any minute. However, in the ROSC (+) group, EtCO2 values were observed to be high starting from the fifth minute (t5, p=0.010; t10, p<0.001; t15, p=0.014; t20, p=0.033; t25, p=0.003, respectively). There was no correlation between the PI and EtCO2 values at 0, 5, 10, 15, 20, and 25 minutes (t0, p=0.436; t5, p=0.154; t10, p=0.557; t15, p=0.740; t20 p=0.241; t25 p=0.201, respectively). CONCLUSION Measuring PI values during resuscitation in intubated cardiac arrest patients does not help clinicians predict the outcome. In addition, no correlation was found with EtCO2 values. However, EtCO2 values remained high in patients with the ROSC from the fifth minute onward. Further larger-scale studies are needed regarding the optimal use of PI in cardiac arrest patients.
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Affiliation(s)
- Baki Dogan
- Emergency Medicine, Medical Point Gaziantep Hospital, Gaziantep, TUR
| | - Emre Kudu
- Emergency Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, TUR
| | - Faruk Danış
- Emergency Medicine, Bolu Izzet Baysal Training and Research Hospital, Bolu, TUR
| | | | - Mehmet A Karaca
- Emergency Medicine, Hacettepe University Hospital, Ankara, TUR
| | - Bulent Erbil
- Emergency Medicine, Hacettepe University Hospital, Ankara, TUR
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19
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Silber HA, Gilotra NA, Miller TL. Noninvasive Point of Care Device for Assessing Cardiac Response to Acute Volume Changes. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2023; 16:219-227. [PMID: 37908436 PMCID: PMC10614661 DOI: 10.2147/mder.s416845] [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: 04/25/2023] [Accepted: 10/04/2023] [Indexed: 11/02/2023] Open
Abstract
Purpose The change in the amplitude of a peripheral pulse in response to a Valsalva maneuver has diagnostic utility for assessing volume status at the bedside. We have developed a device to automatically quantify the Valsalva pulse response (VPR) to a standardized Valsalva maneuver that the device guides a user to perform. In this study, we sought to determine whether VPR by the device, Indicor, is sensitive enough to detect the acute increase in central pressure and volume load that occurs with a passive leg raise (PLR) in healthy volunteers. Methods Healthy volunteers were tested semirecumbently at 45 degrees, then again after being leaned back on a pivoted wedge with legs raised at 45 degrees and torso and head flat, and then again in the semirecumbent position. The device recorded a finger photoplethysmography (PPG) signal during a 10-second expiratory effort of 20 mmHg as guided by the device. VPR was automatically calculated as the ratio of the end-Valsalva pulse amplitude to the baseline pulse amplitude. Results In the 30 participants who completed testing, VPR increased from baseline to PLR in every participant, from 0.34 ± 0.13 to 0.60 ± 0.14 (p < 0.0001). Back upright, VPR decreased back to 0.33 ± 0.10 (p < 0.0001 versus PLR; NS versus baseline position). Conclusion In this proof-of-concept study of healthy participants, the Indicor device, a noninvasive, convenient device that automatically calculates VPR from a finger photoplethysmography signal during a standardized Valsalva maneuver, was sensitive enough to detect the increase in VPR that occurred with an acute central volume load from a PLR. Future studies should examine whether VPR responds differently to a PLR in heart failure patients with abnormal cardiac performance and/or congestion.
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Affiliation(s)
- Harry A Silber
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisha A Gilotra
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomas L Miller
- Enalare Therapeutics, Inc, Princeton, NJ, USA
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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20
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Hung KC, Liu CC, Huang YT, Wu JY, Chen JY, Ko CC, Lin CM, Hsing CH, Yew M, Chen IW. Predictive Efficacy of the Perfusion Index for Hypotension following Spinal Anesthesia in Parturient Undergoing Elective Cesarean Section: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2023; 13:2584. [PMID: 37568947 PMCID: PMC10417716 DOI: 10.3390/diagnostics13152584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
This meta-analysis assessed the predictive efficacy of perfusion index for hypotension following spinal anesthesia (SA) in parturients undergoing elective cesarean section (CS). Electronic databases, including Google Scholar, EMBASE, Cochrane Library, and MEDLINE, were searched from inception to June 2023. The primary outcome was the diagnostic accuracy of the perfusion index in predicting the probability of perioperative hypotension following SA. The review included 12 studies involving 2009 patients, published between 2017 and 2023. The pooled sensitivity and specificity were 0.81 (95% confidence interval (CI) = 0.72-0.87) and 0.75 (95% CI = 0.67-0.82), respectively. Additionally, the pooled area under the curve (AUC) was calculated as 0.84 (95% CI = 0.81-0.87), suggesting a moderate to good accuracy of the diagnostic test. Using Fagan's nomogram plot, the positive likelihood ratio (LR) and negative LR were found to be 3 and 0.26, respectively. The results demonstrated that the perfusion index exhibited an acceptable level of accuracy in predicting perioperative hypotension after spinal anesthesia in parturients undergoing elective CS. These findings highlight the potential value of incorporating a perfusion index as a useful tool for clinicians to integrate into routine clinical practice, which necessitates further large-scale studies for verification.
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Affiliation(s)
- Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan; (K.-C.H.)
| | - Chien-Cheng Liu
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City 82456, Taiwan
- Department of Nursing, College of Medicine, I-Shou University, Kaohsiung City 82445, Taiwan
- School of Medicine, I-Shou University, Kaohsiung City 82445, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 70101, Taiwan
| | - Jheng-Yan Wu
- Department of Nutrition, Chi Mei Medical Center, Tainan City 71004, Taiwan
| | - Jen-Yin Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan; (K.-C.H.)
| | - Ching-Chung Ko
- Department of Medical Imaging, Chi Mei Medical Center, Tainan City 71004, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan City 71710, Taiwan
| | - Chien-Ming Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan; (K.-C.H.)
| | - Chung-Hsi Hsing
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan; (K.-C.H.)
- Department of Medical Research, Chi Mei Medical Center, Tainan City 71004, Taiwan
| | - Ming Yew
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan; (K.-C.H.)
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City 73657, Taiwan
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21
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Lambert Cause J, Solé Morillo Á, da Silva B, García-Naranjo JC, Stiens J. Novel Multi-Parametric Sensor System for Comprehensive Multi-Wavelength Photoplethysmography Characterization. SENSORS (BASEL, SWITZERLAND) 2023; 23:6628. [PMID: 37514922 PMCID: PMC10384342 DOI: 10.3390/s23146628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023]
Abstract
Photoplethysmography (PPG) is widely used to assess cardiovascular health. However, its usage and standardization are limited by the impact of variable contact force and temperature, which influence the accuracy and reliability of the measurements. Although some studies have evaluated the impact of these phenomena on signal amplitude, there is still a lack of knowledge about how these perturbations can distort the signal morphology, especially for multi-wavelength PPG (MW-PPG) measurements. This work presents a modular multi-parametric sensor system that integrates continuous and real-time acquisition of MW-PPG, contact force, and temperature signals. The implemented design solution allows for a comprehensive characterization of the effects of the variations in these phenomena on the contour of the MW-PPG signal. Furthermore, a dynamic DC cancellation circuitry was implemented to improve measurement resolution and obtain high-quality raw multi-parametric data. The accuracy of the MW-PPG signal acquisition was assessed using a synthesized reference PPG optical signal. The performance of the contact force and temperature sensors was evaluated as well. To determine the overall quality of the multi-parametric measurement, an in vivo measurement on the index finger of a volunteer was performed. The results indicate a high precision and accuracy in the measurements, wherein the capacity of the system to obtain high-resolution and low-distortion MW-PPG signals is highlighted. These findings will contribute to developing new signal-processing approaches, advancing the accuracy and robustness of PPG-based systems, and bridging existing gaps in the literature.
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Affiliation(s)
- Joan Lambert Cause
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel (VUB), 1050 Brussels, Belgium
- Department of Biomedical Engineering, Universidad de Oriente, Santiago de Cuba 90500, Cuba
| | - Ángel Solé Morillo
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel (VUB), 1050 Brussels, Belgium
| | - Bruno da Silva
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel (VUB), 1050 Brussels, Belgium
| | | | - Johan Stiens
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel (VUB), 1050 Brussels, Belgium
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22
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Chu T, Xin Y, Zhou S, Xu A. Perfusion index for early identification of regional anesthesia effectiveness: a narrative review. Minerva Anestesiol 2023; 89:671-679. [PMID: 36799293 DOI: 10.23736/s0375-9393.23.17065-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Regional anesthesia (RA) is a common and irreplaceable technique in clinical, which can be used in different surgery sites and control of acute and chronic pain, especially for outpatients, pediatrics and the elderly. RA demands are increasing during COVID-19 pandemic because many surgeries could be performed under RA to reduce the risk of cross-infection between patients and health care workers. Early and accurate identification of the effects of RA can help physicians make timely decisions about whether to supplement analgesics or switch to general anesthesia, which will save time and improve patient satisfaction in a busy operating room. Perfusion index (PI) is a parameter derived from photoplethysmography (PPG) and represents the ratio of pulsatile and non-pulsatile blood flow at monitoring sites. It reflects local perfusion and is mainly affected by stroke volume and vascular tone. With characteristics of non-invasive, rapid, simple, and objective, PI is widely used in clinical practice, such as fluid responsiveness prediction, nociceptive assessment, etc. Recently, many studies have assessed the accuracy of PI in early prediction of RA success, including brachial plexus block, sciatic nerve block, neuraxial anesthesia, paravertebral block, caudal block and stellate ganglion block. Successful RA often parallels increased PI. In this narrative review, we describe the principles and influencing factors of PI, and introduce the effects of PI on early identification of RA effectiveness.
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Affiliation(s)
- Tiantian Chu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yueyang Xin
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Siqi Zhou
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Aijun Xu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China -
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23
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Kim D, Lee C, Bae H, Kim J, Oh EJ, Jeong JS. Comparison of the perfusion index as an index of noxious stimulation in monitored anesthesia care of propofol/remifentanil and propofol/dexmedetomidine: a prospective, randomized, case-control, observational study. BMC Anesthesiol 2023; 23:183. [PMID: 37237353 DOI: 10.1186/s12871-023-02116-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Dexmedetomidine, one of the sedatives, has an analgesic effect. We aimed to investigate postoperative analgesia with dexmedetomidine as adjuvants for procedural sedation using perfusion index (PI). METHODS In this prospective, randomized, case-control, observational study, 72 adult patients, 19-70 years, who were scheduled for chemoport insertion under monitored anesthesia care were performed. According to the group assignment, remifentanil or dexmedetomidine was simultaneously infused with propofol. The primary outcome was PI 30 min after admission to the post anesthesia care unit (PACU). And, pain severity using numerical rating scale (NRS) score and the relationship between NRS score and PI were investigated. RESULTS During PACU staying, PI values were significantly different between the two groups PI values at 30 min after admission to the PACU were 1.3 (0.9-2.0) in the remifentanil group and 4.5 (2.9-6.8) in the dexmedetomidine group (median difference, 3; 95% CI, 2.1 to 4.2; P < 0.001). The NRS scores at 30 min after admission to the PACU were significantly lower in the dexmedetomidine group (P = 0.002). However, there was a weak positive correlation between NRS score and PI in the PACU (correlation coefficient, 0.188; P = 0.01). CONCLUSION We could not find a significant correlation between PI and NRS score for postoperative pain control. Using PI as a single indicator of pain is insufficient. TRIAL REGISTRATION Clinical Trial Registry of Korea, https://cris.nih.go.kr : KCT0003501, the date of registration: 13/02/2019.
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Affiliation(s)
- Doyeon Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Changjin Lee
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - HanWool Bae
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Jung Oh
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University Scholl of Medicine, Gwangmyeong, Korea
| | - Ji Seon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, 06351, Gangnam, Seoul, Korea.
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24
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Oh C, Lee S, Song BS, Kwon S, Kim YH, Yoon SH, Shin YS, Ko Y, Lim C, Hong B. Comparative effects of desflurane and sevoflurane on intraoperative peripheral perfusion index: a retrospective, propensity score matched, cohort study. Sci Rep 2023; 13:2991. [PMID: 36878940 PMCID: PMC9988875 DOI: 10.1038/s41598-022-27253-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 12/28/2022] [Indexed: 03/08/2023] Open
Abstract
Desflurane is known to have a larger vasodilatory effect than that of sevoflurane. However, its generalizability and effect size in actual clinical practice are yet to be proven. Patients aged ≥ 18 years who underwent noncardiac surgery under general anesthesia using inhalation anesthetics (desflurane or sevoflurane) were matched 1:1 by propensity score. The mean intraoperative perfusion index (PI) of each patient were compared between the two groups. Propensity score matching of 1680 patients in the study cohort identified 230 pairs of patients. PI was significantly higher in the desflurane group (median of paired difference, 0.45; 95% CI 0.16 to 0.74, p = 0.002). PI durations below 1.0 and 1.5 were significantly longer in the sevoflurane group. Mean arterial pressure (MAP) and durations of low MAP did not differ significantly between the two groups. Generalized linear mixed models revealed that the use of sevoflurane, mean MAP, mean heart rate, age, and duration of anesthesia had significant negative effects (lower PI), whereas mean age-adjusted minimum alveolar concentration of inhalation agent had a positive effect on PI (higher value). Intraoperative PI was significantly higher in patients administered desflurane than sevoflurane. However, the impact of the choice between desflurane and sevoflurane on intraoperative PI in this clinical setting was minimal.
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Affiliation(s)
- Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Seounghun Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
- Department of Anesthesiology and Pain Medicine, Chungnam National University Sejong Hospital, Sejong, Republic of Korea
| | - Byong-Sop Song
- Core Laboratory of Translational Research, Biomedical Convergence Research Center, Chungnam National University Hospital, Daejeon, South Korea
| | - Sanghun Kwon
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea
| | - Yoon-Hee Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Seok-Hwa Yoon
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Yong Sup Shin
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Youngkwon Ko
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Chaeseong Lim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea.
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea.
| | - Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-Ro, Jung-Gu, Daejeon, 35015, Korea.
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea.
- Big Data Center, Biomedical Research Institute, Chungnam National University Hospital, Daejeon, South Korea.
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25
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Hong SW, Hwang MS, Kim JH, Kim M, Kim SH. Usefulness of the perfusion index for monitoring the response to intravenous ketamine infusion therapy in patients with complex regional pain syndrome. Pain Pract 2023. [PMID: 36840382 DOI: 10.1111/papr.13215] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 12/07/2022] [Accepted: 02/01/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND This study was performed to compare the perfusion index (PI) between affected and unaffected limbs in patients with complex regional pain syndrome (CRPS); it also evaluated the usefulness of the PI for monitoring the response to intravenous ketamine infusion therapy in such patients. METHODS In total, 46 patients with CRPS in one arm or leg were enrolled in this study. The PIs of the unaffected (PIControl ) and affected (PICRPS ) limbs were simultaneously evaluated before and after treatment. RESULTS PICRPS was significantly lower than PIControl at all time points. The change in PI from immediately before to 30 min after intravenous ketamine infusion therapy (TBefore and T30 min , respectively) in the affected limb was significantly correlated with the change in visual analog pain scale (VAS) between the two time points (r = 0.646, p < 0.001). The area under the curve for the changes in VAS and PICRPS between TBefore and T30 min was 0.928. The optimal threshold value for the change in PICRPS between TBefore and T30 min , to distinguish responders with a ≥ 50-point reduction in VAS score from nonresponders, was 22.60% with a sensitivity of 0.811 (95% CI: 0.774-0.848) and a specificity of 0.889 (95% CI: 0.848-0.930). Thirty-one patients showed a ≥ 50-point reduction in VAS score [67% (95% CI: 54%-80%)] and 15 patients showed a < 50-point reduction in VAS score [33% (95% CI: 20%-46%)]. Thirty patients showed an increased PI ≥ 22.60% [65% (95% CI: 50%-78%)] and 16 patients showed an increased PI < 22.60% [35% (95% CI: 22%-50%)]. Twenty-seven patients had a ≥ 50-point reduction in VAS score and an increased PI ≥ 22.60% [59% (95% CI: 44%-74%)]. Eleven patients had shown a < 50-point pain reduction in VAS score and increased PI < 22.60% [24% (95% CI: 13%-37%)]. CONCLUSION The PI significantly differed between affected and unaffected limbs in patients with CRPS. The PI may be useful for monitoring the response to intravenous ketamine therapy in patients with CRPS.
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Affiliation(s)
- Seung-Wan Hong
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Min-Sik Hwang
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jae Hun Kim
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Minjung Kim
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Seong-Hyop Kim
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.,Department of Medicine, Institute of Biomedical Science and Technology, Konkuk University School of Medicine, Seoul, Korea.,Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Korea
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26
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Desgranges FP, Bouvet L, Pereira de Souza Neto E, Evain JN, Terrisse H, Joosten A, Desebbe O. Non-invasive measurement of digital plethysmographic variability index to predict fluid responsiveness in mechanically ventilated children: A systematic review and meta-analysis of diagnostic test accuracy studies. Anaesth Crit Care Pain Med 2023; 42:101194. [PMID: 36640908 DOI: 10.1016/j.accpm.2023.101194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/25/2022] [Accepted: 01/02/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND To date, the use of the plethysmographic variability index (PVI) has not been recommended to guide fluid management in the paediatric surgical population. This systematic review and meta-analysis aimed to summarise available evidence about the diagnostic accuracy of digital PVI to predict fluid responsiveness in mechanically ventilated children. METHODS We searched the Pubmed, Embase and Web of Science databases, from inception to January 2022, to identify all relevant studies that investigated the ability of the PVI recorded at the finger to predict fluid responsiveness in mechanically ventilated children. Using a random-effects model, we calculated pooled values of diagnostic odds ratio, sensitivity, and specificity of PVI to predict the response to fluid challenge. RESULTS Eight studies met the inclusion criteria with a total of 283 patients and 360 fluid challenges. All the studies were carried out in a surgical setting. The area under the summary receiver operating characteristic curve of PVI to predict fluid responsiveness was 0.82. The pooled sensitivity, specificity, and diagnostic odds ratio of PVI for the overall population were 72.4% [95% CI: 65.3-78.7], 65.9% [58.5-72.8], and 9.26 [5.31-16.16], respectively. CONCLUSION Our results suggest that digital PVI is a reliable predictor for fluid responsiveness in mechanically ventilated children in the perioperative setting. The diagnostic performance of digital PVI reported in our work for discrimination between responders and non-responders to the fluid challenge was however not as high as previously reported in the adult population.
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Affiliation(s)
- François-Pierrick Desgranges
- Department of Anaesthesiology, L'Hôpital Nord-Ouest, Villefranche-sur-Saône Hospital, Villefranche-sur-Saône, France.
| | - Lionel Bouvet
- Department of Anaesthesiology and Intensive Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Bron, France; Research Unit APCSe VetAgro Sup UPSP 2016.A101, Claude Bernard Lyon 1 University, Marcy-l'Etoile, France
| | | | - Jean-Noël Evain
- Department of Anaesthesiology and Intensive Care, Grenoble Alpes University Hospital, Grenoble, France; Alps Research Assessment and Simulation Centre, Grenoble Alpes University Hospital, Grenoble, France; TIMC-IMAG Laboratory, UMR, CNRS 5525, Grenoble Alpes University, Grenoble, France
| | - Hugo Terrisse
- Department of Biostatistics, Grenoble Alpes University Hospital, Grenoble, France; TIMC-IMAG Laboratory, UMR, CNRS 5525, Grenoble Alpes University, Grenoble, France
| | - Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Villejuif, France
| | - Olivier Desebbe
- Department of Anaesthesiology and Intensive Care, Ramsay Santé, Sauvegarde Clinic, Lyon, France
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27
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Walker SB, Badke CM, Carroll MS, Honegger KS, Fawcett A, Weese-Mayer DE, Sanchez-Pinto LN. Novel approaches to capturing and using continuous cardiorespiratory physiological data in hospitalized children. Pediatr Res 2023; 93:396-404. [PMID: 36329224 DOI: 10.1038/s41390-022-02359-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/16/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
Continuous cardiorespiratory physiological monitoring is a cornerstone of care in hospitalized children. The data generated by monitoring devices coupled with machine learning could transform the way we provide care. This scoping review summarizes existing evidence on novel approaches to continuous cardiorespiratory monitoring in hospitalized children. We aimed to identify opportunities for the development of monitoring technology and the use of machine learning to analyze continuous physiological data to improve the outcomes of hospitalized children. We included original research articles published on or after January 1, 2001, involving novel approaches to collect and use continuous cardiorespiratory physiological data in hospitalized children. OVID Medline, PubMed, and Embase databases were searched. We screened 2909 articles and performed full-text extraction of 105 articles. We identified 58 articles describing novel devices or approaches, which were generally small and single-center. In addition, we identified 47 articles that described the use of continuous physiological data in prediction models, but only 7 integrated multidimensional data (e.g., demographics, laboratory results). We identified three areas for development: (1) further validation of promising novel devices; (2) more studies of models integrating multidimensional data with continuous cardiorespiratory data; and (3) further dissemination, implementation, and validation of prediction models using continuous cardiorespiratory data. IMPACT: We performed a comprehensive scoping review of novel approaches to capture and use continuous cardiorespiratory physiological data for monitoring, diagnosis, providing care, and predicting events in hospitalized infants and children, from novel devices to machine learning-based prediction models. We identified three key areas for future development: (1) further validation of promising novel devices; (2) more studies of models integrating multidimensional data with continuous cardiorespiratory data; and (3) further dissemination, implementation, and validation of prediction models using cardiorespiratory data.
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Affiliation(s)
- Sarah B Walker
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Colleen M Badke
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Michael S Carroll
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kyle S Honegger
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Andrea Fawcett
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Debra E Weese-Mayer
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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28
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Iizuka Y, Yoshinaga K, Nakatomi T, Takahashi K, Yoshida K, Sanui M. A low peripheral perfusion index can accurately detect prolonged capillary refill time during general anesthesia: A prospective observational study. Saudi J Anaesth 2023; 17:33-38. [PMID: 37032676 PMCID: PMC10077788 DOI: 10.4103/sja.sja_634_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/20/2022] [Indexed: 12/24/2022] Open
Abstract
Background Capillary refill time (CRT) is the gold standard for evaluating peripheral organ perfusion; however, intraoperative CRT measurement is rarely used because it cannot be conducted continuously, and it is difficult to perform during general anesthesia. The peripheral perfusion index (PI) is another noninvasive method for evaluating peripheral perfusion. The PI can easily and continuously evaluate peripheral perfusion and could be an alternative to CRT for use during general anesthesia. This study aimed to determine the cutoff PI value for low peripheral perfusion status (prolonged CRT) by exploring the relationship between CRT and the PI during general anesthesia. Methods We enrolled 127 surgical patients. CRT and the PI were measured in a hemodynamically stable state during general anesthesia. A CRT >3 s indicated a low perfusion status. Results Prolonged CRT was observed in 27 patients. The median PI values in the non-prolonged and prolonged CRT groups were 5.0 (3.3-7.9) and 1.5 (1.2-1.9), respectively. There was a strong negative correlation between the PI and CRT (r = -0.706). The area under the receiver operating characteristic curve generated for the PI was 0.989 (95% confidence interval, 0.976-1.0). The cutoff PI value for detecting a prolonged CRT was 1.8. Conclusion A PI <1.8 could accurately predict a low perfusion status during general anesthesia in the operating room. A PI <1.8 could be used to alert the possibility of a low perfusion status in the operating room. Trial Registration University Hospital Medical Information Network (UMIN000043707; retrospectively registered on March 22, 2021, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno = R000049905).
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Affiliation(s)
- Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Koichi Yoshinaga
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Takeshi Nakatomi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Kyosuke Takahashi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Kyoko Yoshida
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
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29
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Liao Y, Xu C, Xia J, Ni H, Zhang Z, Ni C. Efficacy and safety of sympathetic radiofrequency thermocoagulation in the treatment of cold hypersensitivity. Front Neurol 2022; 13:1026334. [PMID: 36353132 PMCID: PMC9637867 DOI: 10.3389/fneur.2022.1026334] [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: 08/23/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background Cold hypersensitivity (CH) is a sensation of cold in the limbs and (or) body of a patient in an environment that is not considered cold by unaffected people, or a strong feeling of cold at a relatively low temperature. However, the currently available treatments are limited and often unsatisfactory. This study aimed to evaluate the clinical efficacy and safety of the sympathetic radiofrequency thermocoagulation (RF-TC) technique in patients with CH disorder. Methods The study is a retrospective analysis. A total of 71 were entered into the final analysis and all patients underwent computed tomography-guided thoracic (lumbar) sympathetic nerve RF-TC on an elective basis. The values of terminal temperature (T) and perfusion index (PI) of patients before and after treatment were recorded. Patients were followed up clinically at regular intervals and their Visual Analog Scale (VAS) and Pittsburgh Sleep Quality Index (PSQI) scores were recorded to detect postoperative complications and assess patient satisfaction with the treatment. Results All patients completed the radiofrequency treatment. Compared with the preoperative period, VAS and PSQI scores were significantly lower at all postoperative time periods (P < 0.001). Patients had significantly higher postoperative terminal temperatures and perfusion indices on the right and left sides than before surgery (P < 0.001). The overall patient satisfaction score was 4 (3–5) at 3 years of postoperative follow-up. There were 20 recurrences (28.2%). The main postoperative complications were postoperative local pain and compensatory hyperhidrosis. No other adverse events or deaths were observed. Conclusion RF-TC for CH could be a feasible, effective, and safe treatment option to improve patients' symptoms of cold sensation. Yet, more researches are needed to verify this potentially efficient and standardized treatment.
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Affiliation(s)
- Yuefeng Liao
- Department of Anesthesiology and Pain Research Center, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Chi Xu
- Department of Anesthesiology and Pain Research Center, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Jianmei Xia
- Department of Anesthesiology and Pain Research Center, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Huadong Ni
- Department of Anesthesiology and Pain Research Center, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Zhiqiang Zhang
- Department of Anesthesiology and Pain Research Center, The Affiliated Hospital of Jiaxing University, Jiaxing, China
- *Correspondence: Zhiqiang Zhang
| | - Chunjue Ni
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Chunjue Ni
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Muacevic A, Adler JR. Perfusion Index and Its Correlation With Intraoperative Hypotension in Lower-Segment Cesarean Section Under Spinal Anesthesia: A Prospective Observational Study in a Tertiary Care Hospital in Eastern India. Cureus 2022; 14:e30431. [PMID: 36276602 PMCID: PMC9579516 DOI: 10.7759/cureus.30431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/07/2022] Open
Abstract
Background Hypotension is commonly encountered in patients undergoing lower-segment cesarean section (LSCS) under the subarachnoid block (SAB) owing to decreased vascular resistance caused by the sympathetic blockade and decreased cardiac output because of blood pooling in blocked areas of the body. Perfusion index (PI) is a good indicator of systemic vascular resistance and can foretell hypotension. This study aimed to associate baseline PI with intraoperative hypotension after SAB in LSCS. Methodology This was a prospective observational study with a sample size of 50. The baseline PI was recorded every 10 seconds for one minute in a supine position on the right index finger at room temperature of 26°C to 28°C. The blood pressure (BP) and heart rate (HR) were recorded at an interval of one minute for three minutes. The mean of PI, BP, and HR were taken as the preoperative value. Spinal anesthesia was administered as per institutional protocol. Hypotension, defined as mean arterial pressure (MAP) <20% of baseline or MAP <60 mmHg was treated with vasopressors. Regression analysis with the Spearman correlation coefficient was done to correlate PI and hypotension. Results The incidence of hypotension in parturients with PI <2.85 was 28.6% (5/20) and in parturients with PI >2.85 was 82.8% (p < 0.001). The requirement of sympathomimetics was higher in parturients with PI >2.85.The area under the receiver operating characteristic curve was 0.8883. A cut-off PI value of 2.85 can identify parturients at risk for central neuraxial block-induced hypotension with a sensitivity of 80% and a specificity of 75% (p < 0.001). Conclusions The PI is a useful tool for predicting hypotension in healthy parturients undergoing elective cesarean section under SAB.
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Abstract
Ensuring and maintaining adequate tissue oxygenation at the microcirculatory level might be considered the holy grail of optimal hemodynamic patient management. However, in clinical practice we usually focus on macro-hemodynamic variables such as blood pressure, heart rate, and sometimes cardiac output. Other macro-hemodynamic variables like pulse pressure or stroke volume variation are additionally used as markers of fluid responsiveness. In recent years, an increasing number of technological devices assessing tissue oxygenation or microcirculatory blood flow have been developed and validated, and some of them have already been incorporated into clinical practice. In this review, we will summarize recent research findings on this topic as published in the last 2 years in the Journal of Clinical Monitoring and Computing (JCMC). While some techniques are already currently used as routine monitoring (e.g. cerebral oxygenation using near-infrared spectroscopy (NIRS)), others still have to find their way into clinical practice. Therefore, further research is needed, particularly regarding outcome measures and cost-effectiveness, since introducing new technology is always expensive and should be balanced by downstream savings. The JCMC is glad to provide a platform for such research.
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