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Erdem Ö, de Graaff JC, Hilty MP, Kraemer US, de Liefde II, van Rosmalen J, Ince C, Tibboel D, Kuiper JW. Microcirculatory Monitoring in Children with Congenital Heart Disease Before and After Cardiac Surgery. J Cardiovasc Transl Res 2023; 16:1333-1342. [PMID: 37450208 PMCID: PMC10721654 DOI: 10.1007/s12265-023-10407-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
In this prospective observational study, we investigated whether congenital heart disease (CHD) affects the microcirculation and whether the microcirculation is altered following cardiac surgery with cardiopulmonary bypass (CPB). Thirty-eight children with CHD undergoing cardiac surgery with CPB and 35 children undergoing elective, non-cardiac surgery were included. Repeated non-invasive sublingual microcirculatory measurements were performed with handheld vital microscopy. Before surgery, children with CHD showed similar perfused vessel densities and red blood cell velocities (RBCv) but less perfused vessels (p < 0.001), lower perfusion quality (p < 0.001), and higher small vessel densities (p = 0.039) than children without CHD. After cardiac surgery, perfused vessel densities and perfusion quality of small vessels declined (p = 0.025 and p = 0.032), while RBCv increased (p = 0.032). We demonstrated that CHD was associated with decreased microcirculatory perfusion and increased capillary recruitment. The microcirculation was further impaired after cardiac surgery. Decreased microcirculatory perfusion could be a warning sign for altered tissue oxygenation and requires further exploration.
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Affiliation(s)
- Özge Erdem
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Ulrike S Kraemer
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Inge I de Liefde
- Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jan Willem Kuiper
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
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Govender K, Cabrales P. Extracorporeal circulation impairs microcirculation perfusion and organ function. J Appl Physiol (1985) 2022; 132:794-810. [PMID: 35085033 PMCID: PMC8917920 DOI: 10.1152/japplphysiol.00726.2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a procedure used to aid respiratory function in critical patients, involving extracorporeal circulation (ECC) of blood. There is a limited number of studies quantifying the hemodynamic effects of ECC procedures on the microcirculation. We sought to mimic veno-arterial-ECMO flow conditions by use of a scaled-down circuit primed with either lactate Ringer (LR) or 5% human serum albumin (HSA). The circuit was first tested using benchtop runs with blood, and subsequently used for in vivo experiments in Golden Syrian hamsters instrumented with a dorsal window chamber to allow for quantification of microvascular hemodynamics and functional capillary density (FCD). Results showed significant impairment in FCD, and a reduction of arteriolar and venular blood flow, with HSA providing significant higher blood flows and FCD compared with LR. Changes in hematocrit and RBC labeling after ECC reflected a shift in plasma volume, which may stem from a loss in intravascular oncotic pressure due to priming fluids. The distribution of hemoglobin oxygen saturation in the microvasculature showed a significant decrease in venules after ECC. In addition, major organs such as the kidney and heart showed increases in both inflammatory and damage markers. These results suggest that ECC impairs microvasculature function and promotes ischemia and hypoxia in the tissues, which can be vital to understanding comorbid clinical outcomes from ECC procedures such as acute kidney injury and multiorgan dysfunction.NEW & NOTEWORTHY ECC reduces microvascular perfusion, with no full recovery 24 h after ECC. HSA performed better as compared with LR in terms of FCD and venule flow, as well as venule oxygen saturation. Increases in inflammatory and damage markers in key organs were observed within all organs analyzed.
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Affiliation(s)
- Krianthan Govender
- Functional Cardiovascular Engineering Laboratory, Bioengineering Department, University of California San Diego, La Jolla, California
| | - Pedro Cabrales
- Functional Cardiovascular Engineering Laboratory, Bioengineering Department, University of California San Diego, La Jolla, California
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3
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Niemann L, Kutter A, Joerger F, Wieser M, Hartnack S, Steblaj B. The impact of vatinoxan on microcirculation after intramuscular coadministration with medetomidine in Beagle dogs – a blinded cross-over study. Vet Anaesth Analg 2022; 49:336-343. [DOI: 10.1016/j.vaa.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 04/17/2021] [Accepted: 07/15/2021] [Indexed: 10/19/2022]
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Stamou SC, McHugh MA, Conway BD, Nores M. Role of Moderate Hypothermia and Antegrade Cerebral Perfusion during Repair of Type A Aortic Dissection. Int J Angiol 2018; 27:190-195. [PMID: 30410289 DOI: 10.1055/s-0038-1675204] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
The goal of this study was to compare early postoperative outcomes and actuarial survival between patients who underwent repair of acute type A aortic dissection with deep or moderate hypothermia. A total of 132 consecutive patients from a single academic medical center underwent repair of acute type A aortic dissection between January 2000 and June 2014. Of those, 105 patients were repaired under deep hypothermia (< 24 C°), while 27 patients were repaired under moderate hypothermia (≥24 C°). Median ages were 62 years (range: 27-86) and 59 years (range: 35-83) for patients repaired under deep hypothermia compared with patients repaired under moderate hypothermia, respectively ( p = 0.451). Major morbidity, operative mortality, and 10-year actuarial survival were compared between groups. Operative mortality was 17.1 and 7.4% in the deep and moderate hypothermia groups, respectively ( p = 0.208). Incidence of permanent stroke was 12.4% in the deep hypothermic circulatory arrest group and 0% in the moderate hypothermia group ( p = 0.054). Actuarial 5- and 10-year survival demonstrated a trend for lower long-term mortality with moderate hypothermia compared with deep hypothermia (69% 5-year and 54% 10-year for deep hypothermia vs. 79% 5-year and 10-year for moderate hypothermia, log-rank p = 0.161). Moderate hypothermia is a safe and efficient alternative to deep hypothermia and may have protective benefits. Stroke rate was lower with moderate hypothermia.
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Affiliation(s)
- Sotiris C Stamou
- Department of Cardiovascular Surgery, JFK Medical Center, Atlantis, Florida
| | - Michael A McHugh
- University of Iowa Hospitals and Clinics, University of Iowa, Iowa City, Iowa
| | - Brian D Conway
- University of Iowa Hospitals and Clinics, University of Iowa, Iowa City, Iowa
| | - Marcos Nores
- Department of Cardiovascular Surgery, JFK Medical Center, Atlantis, Florida
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5
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Lee K, Priezzhev A, Shin S, Yaya F, Meglinski I. Characterization of shear stress preventing red blood cells aggregation at the individual cell level: The temperature dependence. Clin Hemorheol Microcirc 2017; 64:853-857. [PMID: 27767973 DOI: 10.3233/ch-168020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The novel measure of the red blood cells (RBC) aggregation (RBC-A) - the critical (minimum) shear stress (CSS) to prevent the cells from aggregation was found to be a promising clinically significant parameter. However, the absolute values of this parameter were found to change significantly depending on the shearing geometry (cup-and-bob, cone-plate or microchannel-flow) and have different temperature dependences along with it. The direct confirmation of these dependences aimed to find out the correct values is still pending. OBJECTIVE In this work, we aim to assess the absolute values of CSS at different temperatures. METHODS The single cell level measurements of CSS were performed using optical tweezers. The measurements were carried out in heavily diluted suspensions of RBCs in plasma. RESULTS The temperature dependent changes in CSS were measured at the points (22 and 38°C), in which the cup-and-bob and cone-plate systems yielded about 1.5-fold different values, while the microchannel-flow system yielded a constant value. The single cell CSS were found to be 362±157 mPa (22°C) and 312±57 mPa (38°C). CONCLUSIONS Our results prove that the microfluidic-flow approach is reflecting the RBC-A correctly. While the CSS values measured with other systems show the temperature dependent effect of the shearing geometry.
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Affiliation(s)
- K Lee
- Optoelectronics and Measurement Techniques, University of Oulu, Oulu, Finland.,Department of Physics, M. V. Lomonosov Moscow State University, Moscow, Russia
| | - A Priezzhev
- Department of Physics, M. V. Lomonosov Moscow State University, Moscow, Russia.,International Laser Centre, M. V. Lomonosov Moscow State University, Moscow, Russia
| | - S Shin
- School of Mechanical Engineering, Korea University, Seoul, Korea
| | - F Yaya
- Optoelectronics and Measurement Techniques, University of Oulu, Oulu, Finland.,Faculty of Science & Technology, Jean Monnet University, Saint-Étienne, France
| | - I Meglinski
- Optoelectronics and Measurement Techniques, University of Oulu, Oulu, Finland
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Goedeke J, Apelt N, Kamler M. The cooling tube: A novel small animal model of systemic hypothermia in awake Syrian Golden Hamsters (mesocricetus auratus). Clin Hemorheol Microcirc 2014; 60:335-46. [PMID: 24958332 DOI: 10.3233/ch-141854] [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: 11/15/2022]
Abstract
Hypothermia is increasingly used as a therapeutic strategy in a diversity of clinical scenarios. Its impact on mammalian physiology, particularly on the microcirculatory changes of critical organ systems, are, however, incompletely understood. Close examination of the literature reveals a marked paucity of small animal models of rapid systemic hypothermia. All published models introduce important microvascular confounders by investigating either local cooling processes or using anaesthetised animals. Here we present the first rapid systemic hypothermia model in an awake hamster. We developed a waterstream cooled copper tube system for standardized systemic temperature control. With this novel system core body temperature (Tc) in 14 awake animals could be precisely stabilised at temperatures of 30°C and 18°C (7 animals, respectively) within 10-20 min. Rewarming was achieved over 10-15 min. Tolerance of the procedure was excellent. Hamsters did not show any behavioural changes in the mild hypothermia group. In the deep hypothermia group 6 of 7 animals regained normal behaviour within 2-11 hs. As hypothermia was induced in dorsal skinfold chamber bearing animals this model seems suitable for investigation of microcirculatory purposes.Advantages over previously established experimental hypothermia models are significant. Amongst these, the possibility of visualization of microcirculation, the lack of microcirculation confounding factors such as anaesthetic drugs, the ability for precise Tc control and rapid induction of hypothermia are prominent.
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Affiliation(s)
- Jan Goedeke
- Department of Pediatric Surgery, Dr. von Haunersches Kinderspital, Ludwig-Maximilians-University, Munich, Germany
| | - Nadja Apelt
- Department of Pediatric Surgery, Dr. von Haunersches Kinderspital, Ludwig-Maximilians-University, Munich, Germany
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery, Herzzentrum Essen-Huttrop, Essen, Germany
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Donndorf P, Park H, Vollmar B, Alms A, Gierer P, Steinhoff G, Kaminski A. Impact of closed minimal extracorporeal circulation on microvascular tissue perfusion during surgical aortic valve replacement: intravital imaging in a prospective randomized study. Interact Cardiovasc Thorac Surg 2014; 19:211-7. [PMID: 24796334 DOI: 10.1093/icvts/ivu131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Closed minimal extracorporeal circulation (MECC) systems currently do not represent the standard of surgical care for open-heart surgery. Yet, considering the beneficial results reported for coronary artery bypass graft (CABG) surgery, we used an MECC system in aortic valve replacement (AVR) and analysed the effects on intraoperative microvascular perfusion in comparison with conventional open extracorporeal circulation (CECC). METHODS In the current study, we analysed alterations in microvascular perfusion at 4 predefined time points (T1-T4) during surgical AVR utilizing orthogonal polarization spectral (OPS) imaging. Twenty patients were randomized for being operated on utilizing either MECC or CECC. Changes in functional capillary density (FCD, cm/cm(2)), mircovascular blood flow velocity (mm/s) and vessel diameter (μm) were analysed by a blinded investigator. RESULTS After the start of extracorporeal circulation and aortic cross-clamping (T2), both groups showed a significant drop in FCD, but with a significantly higher FCD in the MECC group (153.1 ± 15.0 cm/cm² in the CECC group vs 160.8 ± 12.2 cm/cm² in the MECC group, P = 0.034). During the late phase of the cardiopulmonary bypass (CPB) (T3), the FCD was still significantly depressed in both treatment groups (153.5 ± 14.6 cm/cm² in the CECC group, P <0.05 vs 'T1'; 159.5 ± 12.4 cm/cm² in the MECC group, P <0.05 versus 'T1'). After termination of CPB (T4), the FCD recovered in both groups to baseline values. Microvascular blood flow velocity tended to remain at a higher level in the MECC group, whereas haemodilution during CPB was significantly reduced in the MECC group. CONCLUSIONS The use of MECC in AVR did not affect procedural safety and, resulted in beneficial preservation of microvascular blood flow velocity and significantly reduced haemodilution during CPB. In contrast to CABG surgery, the use of MECC did not improve FCD during surgical AVR. Clinical advantages possibly resulting from attenuated haemodilution and preservation of microvascular blood flow velocity require further validation in larger patient cohorts.
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Affiliation(s)
- Peter Donndorf
- Department of Cardiac Surgery, University of Rostock, Rostock, Germany
| | - Hannah Park
- Department of Cardiac Surgery, University of Rostock, Rostock, Germany
| | - Brigitte Vollmar
- Institute of Experimental Surgery, University of Rostock, Rostock, Germany
| | - Angela Alms
- Department of Anesthesiology and Intensive Care Medicine, University of Rostock, Rostock, Germany
| | - Philipp Gierer
- Department of Trauma and Reconstructive Surgery, University of Rostock, Rostock, Germany
| | - Gustav Steinhoff
- Department of Cardiac Surgery, University of Rostock, Rostock, Germany
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8
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van Eps AW, Pollitt CC, Underwood C, Medina-Torres CE, Goodwin WA, Belknap JK. Continuous digital hypothermia initiated after the onset of lameness prevents lamellar failure in the oligofructose laminitis model. Equine Vet J 2013; 46:625-30. [PMID: 24004323 DOI: 10.1111/evj.12180] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 08/22/2013] [Indexed: 11/25/2022]
Abstract
REASONS FOR PERFORMING STUDY Prophylactic digital hypothermia reduces the severity of acute laminitis experimentally but there is no evidence for its efficacy as a treatment once lameness has already developed. OBJECTIVES To investigate the therapeutic effects of digital hypothermia, applied after the onset of lameness, in an experimental acute laminitis model. STUDY DESIGN Randomised, controlled (within subject), blinded, experimental trial. METHODS Eight Standardbred horses underwent laminitis induction using the oligofructose model. Once lameness was detected at the walk, one forelimb was continuously cooled (CRYO), with the other forelimb maintained at ambient temperature (NON-RX). Dorsal lamellar sections (proximal, middle and distal) harvested 36 h after the onset of lameness/initiation of cryotherapy were analysed by 2 blinded observers: laminitis pathology was scored (0 [normal] to 4 [severe]) and morphometric analyses performed. RESULTS Median (interquartile range) histological scores were greater (P<0.05) in NON-RX (proximal 2.8 [2.5-4]; middle 3.5 [2-4]; distal 2.5 [2-3.8]) compared with CRYO limbs (proximal 0.5 [0.5-1.4]; middle 1 [0.6-1]; distal 0.75 [0.5-1]). There was complete physical separation of lamellar dermis from epidermis (score of 4) in 4 of the NON-RX feet at one or more section level(s), which was not observed in any CRYO sections. Histomorphometry was thus limited to sections that remained intact; there was a trend of increased total (TELL) and secondary (SELL) epidermal lamellar length and decreased secondary epidermal lamellar width (SELW) in NON-RX limbs compared with CRYO at all 3 levels; differences were significant (P<0.05) for SELL and SELW in the distal sections. CONCLUSIONS Digital hypothermia reduced the severity of lamellar injury and prevented lamellar structural failure (complete dermoepidermal separation) when initiated at the detection of lameness in an acute laminitis model. This study provides the first evidence to support the use of therapeutic digital hypothermia as a treatment for acute laminitis.
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Affiliation(s)
- A W van Eps
- Australian Equine Laminitis Research Unit, School of Veterinary Science, The University of Queensland, Gatton, Australia
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Donndorf P, Kühn F, Vollmar B, Rösner J, Liebold A, Gierer P, Steinhoff G, Kaminski A. Comparing microvascular alterations during minimal extracorporeal circulation and conventional cardiopulmonary bypass in coronary artery bypass graft surgery: A prospective, randomized study. J Thorac Cardiovasc Surg 2012; 144:677-83. [DOI: 10.1016/j.jtcvs.2012.05.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 04/04/2012] [Accepted: 05/15/2012] [Indexed: 10/28/2022]
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10
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De Blasi RA, Tonelli E, Arcioni R, Mercieri M, Cigognetti L, Romano R, Pinto G. In vivo effects on human skeletal muscle oxygen delivery and metabolism of cardiopulmonary bypass and perioperative hemodilution. Intensive Care Med 2011; 38:413-21. [DOI: 10.1007/s00134-011-2404-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 10/14/2011] [Indexed: 11/28/2022]
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VAN EPS AW, LEISE BS, WATTS M, POLLITT CC, BELKNAP JK. Digital hypothermia inhibits early lamellar inflammatory signalling in the oligofructose laminitis model. Equine Vet J 2011; 44:230-7. [DOI: 10.1111/j.2042-3306.2011.00416.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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12
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Donadello K, Favory R, Salgado-Ribeiro D, Vincent JL, Gottin L, Scolletta S, Creteur J, De Backer D, Taccone FS. Sublingual and muscular microcirculatory alterations after cardiac arrest: A pilot study. Resuscitation 2011; 82:690-5. [DOI: 10.1016/j.resuscitation.2011.02.018] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 01/25/2011] [Accepted: 02/11/2011] [Indexed: 01/19/2023]
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13
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Antegrade Cerebral Perfusion With Mild Hypothermia for Aortic Arch Replacement: Single-Center Experience in 245 Consecutive Patients. Ann Thorac Surg 2011; 91:1868-73. [DOI: 10.1016/j.athoracsur.2011.02.077] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Revised: 02/21/2011] [Accepted: 02/23/2011] [Indexed: 11/20/2022]
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Microvascular hemodynamics in human hypothermic circulatory arrest and selective antegrade cerebral perfusion. Crit Care Med 2010; 38:1548-53. [DOI: 10.1097/ccm.0b013e3181e2a3f9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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van Eps AW. Therapeutic hypothermia (cryotherapy) to prevent and treat acute laminitis. Vet Clin North Am Equine Pract 2010; 26:125-33. [PMID: 20381741 DOI: 10.1016/j.cveq.2010.01.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Digital hypothermia successfully reduces the severity of experimentally induced laminitis. Continuous-distal limb cryotherapy may be a useful technique in clinical cases that are at risk of developing laminitis. This article examines the effects of hypothermia on tissue as well as the rationale, and suggested protocols for the usage of distal limb cryotherapy in the prevention and treatment of laminitis.
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Affiliation(s)
- Andrew W van Eps
- School of Veterinary Science, University of Queensland, Slip Road, St Lucia, QLD 4072, Australia.
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16
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Elbers PWG, Craenen AJ, Driessen A, Stehouwer MC, Munsterman L, Prins M, van Iterson M, Bruins P, Ince C. Imaging the human microcirculation during cardiopulmonary resuscitation in a hypothermic victim of submersion trauma. Resuscitation 2009; 81:123-5. [PMID: 19963312 DOI: 10.1016/j.resuscitation.2009.09.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Revised: 09/05/2009] [Accepted: 09/26/2009] [Indexed: 11/19/2022]
Abstract
The microcirculation is essential for delivery of oxygen and nutrients to tissue. However, the human microvascular response to cardiopulmonary resuscitation (CPR) is unknown. We report on the first use of sidestream dark field imaging to assess the human microcirculation during CPR with a mechanical chest compression/decompression device (mCPR). mCPR was able to provide microvascular perfusion. Capillary flow persisted even during brief mCPR interruption. However, indices of microvascular perfusion were low and improved vastly after return of spontaneous circulation. Microvascular perfusion was relatively independent from blood pressure. The microcirculation may be a useful monitor for determining the adequacy of CPR.
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Affiliation(s)
- Paul W G Elbers
- Department of Anesthesia, Intensive Care and Pain Management, St. Antonius Ziekenhuis, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
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Microcirculatory Alterations in Cardiac Surgery: Effects of Cardiopulmonary Bypass and Anesthesia. Ann Thorac Surg 2009; 88:1396-403. [DOI: 10.1016/j.athoracsur.2009.07.002] [Citation(s) in RCA: 142] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 06/26/2009] [Accepted: 07/02/2009] [Indexed: 11/22/2022]
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Levin MA, Lin HM, Castillo JG, Adams DH, Reich DL, Fischer GW. Early on-cardiopulmonary bypass hypotension and other factors associated with vasoplegic syndrome. Circulation 2009; 120:1664-71. [PMID: 19822810 DOI: 10.1161/circulationaha.108.814533] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Vasoplegic syndrome is a form of vasodilatory shock that can occur after cardiopulmonary bypass (CPB). We hypothesized that the severity and duration of the decline in mean arterial pressure immediately after CPB is begun can be used as a predictor of patients will develop vasoplegia in the immediate post-CPB period and of poor clinical outcome. We quantified the decline in mean arterial pressure by calculating an area above the mean arterial blood pressure curve. METHODS AND RESULTS We retrospectively analyzed 2823 adult cardiac surgery cases performed between July 2002 and December 2006. Of these 2823, 577 (20.4%) were vasoplegic after separation from CPB. We found that 1645 patients (58.3%) had a clinically significant decline in mean arterial pressure after starting CPB (area above the mean arterial blood pressure curve >0) and were significantly more likely to become vasoplegic (23.0% versus 16.9%; odds ratio, 1.26; 95% confidence interval, 1.12 to 1.43; P<0.001). These patients were also far more likely either to die in hospital or to have a length of stay >10 days (odds ratio, 3.30; 95% confidence interval, 1.44 to 7.57; P=0.005). Additional risk factors for developing vasoplegia that were identified included the additive euroSCORE, procedure type, prebypass mean arterial pressure, length of bypass, administration of pre-CPB vasopressors, core temperature on CPB, pre- and post-CPB hematocrit, the preoperative use of beta-blockers or angiotensin-converting enzyme inhibitors, and the intraoperative use of aprotinin. CONCLUSIONS The results of this investigation suggest that it is possible to predict vasoplegia intraoperatively before separation from CPB and that the presence of a clinically significant area above the mean arterial blood pressure curve serves as a predictor of poor clinical outcome.
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Affiliation(s)
- Matthew A Levin
- Departments of Anesthesiology, Mount Sinai Medical Center, New York, NY 10029, USA
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Antegrade Cerebral Perfusion for Acute Type A Aortic Dissection in 120 Consecutive Patients. Ann Thorac Surg 2008; 85:465-9. [DOI: 10.1016/j.athoracsur.2007.10.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2007] [Revised: 10/02/2007] [Accepted: 10/03/2007] [Indexed: 11/18/2022]
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Martini WZ. The effects of hypothermia on fibrinogen metabolism and coagulation function in swine. Metabolism 2007; 56:214-21. [PMID: 17224335 DOI: 10.1016/j.metabol.2006.09.015] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Accepted: 09/10/2006] [Indexed: 11/22/2022]
Abstract
Clinical coagulopathy frequently occurs in the presence of hypothermia. The primary purpose of this study was to investigate the effects of hypothermia on clotting protein fibrinogen metabolism and on coagulation function in a swine model. Twelve pigs were randomly allocated into control and hypothermia groups. Hypothermia of 32 degrees C was induced using a blanket with circulating water at 4 degrees C. Fibrinogen synthesis and breakdown were quantified using a 6-hour stable isotope infusion with subsequent gas chromatograph and mass spectrometry analysis. Clotting enzyme thrombin generation kinetics was quantified at baseline and at the end of the infusion. Changes in fibrinogen metabolism and thrombin generation were correlated with coagulation function assessed by thromboelastography (TEG). Hypothermia decreased fibrinogen synthesis from the control value of 2.6 +/- 0.4 to 1.2 +/- 0.2 mg kg(-1) h(-1) (P < .05), with no effect on fibrinogen breakdown. Thrombin generation at the initiation phase was delayed by hypothermia, but there were no changes at the propagation phase. In thromboelastography measurements, the initial clotting time (R time) was prolonged from the baseline value of 3.01 +/- 0.13 to 4.30 +/- 0.24 minutes (P < .05) and clotting rapidity (angle alpha) was decreased from the baseline value of 72.30 +/- 0.90 to 65.34 +/- 1.07 (P < .05). Hypothermia caused no significant changes in clot strength (maximum amplitude) and clot lysis (LY(60)). We concluded that hypothermia caused a potential deficit in fibrinogen availability and a delay in thrombin generation, consequently inhibiting coagulation function. Our data support the current practices of rewarming and prescribing recombinant factor VIIa for hypothermic patients with coagulation defects.
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Nakazawa H, Nozaki M. Usefulness of warm fluid in acute burn resuscitation: an experimental study in dogs. TOHOKU J EXP MED 2005; 207:149-55. [PMID: 16141684 DOI: 10.1620/tjem.207.149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hypothermia is a common complication in patients with extensive burns, receiving massive volumes of fluid for resuscitation at ambient temperature. It is therefore important to maintain the body temperature of patients with extensive burns. The present study was performed to evaluate the usefulness of warm fluid for burn injury resuscitation. Ten dogs were used in this study. Full-thickness burns, involving 40% of the body surface, were generated in the backs of the animals. In the control group (n = 5), the fluid temperature was maintained at about 23 degrees C, while in other group (n = 5), the temperature of the fluid was maintained at 39 degrees C with a warming device. Cardiac output and urinary output were measured in both groups for up to 24 hours. The cardiac output decreased in all animals during the first two hours following injury. The cardiac dynamics remained depressed in the control group. By contrast, in animals treated with warm fluid, the cardiac output returned to the baseline level within 4 hours of resuscitative measures and then decreased slightly for the subsequent 20 hours. The urinary output was better in animals treated with warm fluid, indicating the improved hemodynamic state in these animals. These results suggested that the hemodynamic state in acute burn shock was ameliorated by the use of warm fluid. Therefore, warmed fluid resuscitation might be useful to perform immediate excision and grafting for the patients with extensive burns in acute burn shock.
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Affiliation(s)
- Hiroaki Nakazawa
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Medical Center East, 2-1-10 Nishi Ogu, Arakawa-ku, Tokyo, Japan.
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