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Kim YH, Lee JH. Prediction of fluid responsiveness in spontaneously breathing patients with hemodynamic stability: a prospective repeated-measures study. Sci Rep 2024; 14:14451. [PMID: 38914634 PMCID: PMC11196262 DOI: 10.1038/s41598-024-65554-8] [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: 03/20/2024] [Accepted: 06/20/2024] [Indexed: 06/26/2024] Open
Abstract
Evaluating fluid responsiveness with dynamic parameters is recommended for fluid management. However, in hemodynamically stable patients who are breathing spontaneously, accurately measuring stroke volume variation via echocardiography and passive leg raising is challenging due to subtle SV changes. This study aimed to identify normal SV changes in healthy volunteers and evaluate the precision of hemodynamic parameters in screening mild hypovolemia in patients. This prospective, repeated-measures, cross-sectional study screened 269 subjects via echocardiography. Initially, 45 healthy volunteers underwent a fluid challenge test, the outcomes of which served as criteria to screen 215 ICU patients. Among these patients, 53 underwent additional fluid challenge testing. Hemodynamic parameters, including medians of maximum velocity time integrals (VTImaxs), peak velocity of VTImax (PV), internal jugular vein diameters (IJVD), and area (IJVA) were repeatedly measured first at a 60° upper body elevation (UBE), second in a supine position, third at UBE, fourth in a supine position, and lastly in a supine position after fluid loading. The hemodynamic responses to the position changes were compared between 83 fluid non-responders and 15 fluid responders. Fluid responsiveness was defined as fluid-induced medians' change of VTImaxs (fluid-induced median VTImax change) ≥ 10%. None of the healthy volunteers showed the mean value of repeatedly measured medians of VTImaxs ≥ 7%, following either UBE position (UBE-induced median VTImax change) or fluid loading (fluid-induced median VTImax change). UBE-induced median VTImax and PV changes were significantly correlated with fluid responsiveness (p < 0.001, AUC 0.959; p < 0.001, AUC 0.804). The significant correlations were demonstrated via multivariable analysis using binary logistic regression (p = 0.001, OR 90.1) and the correlation coefficient (R2 = 0.793) using linear regression analysis. UBE-induced median VTImax changes (≥ 11.8% and 7.98%) predicted fluid-induced median VTImax changes ≥ 10% and 7% (AUC 0.959 and 0.939). The collapsibility and variation of IJVD and IJVA showed no significant correlation. An increase in the mean value of medians of repeatedly measured VTImaxs transitioning from an UBE to a supine position, effectively screened mild hypovolemia and demonstrated a significant correlation with fluid responsiveness in spontaneously breathing patients maintaining hemodynamic stability.
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Affiliation(s)
- Yong Hwan Kim
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158 Palyong-ro, Masanhoiwon-gu, Changwon-si, Gyeongsangnam-do, 51353, South Korea
| | - Jae Hoon Lee
- Department of Emergency Medicine, Dong-A University College of Medicine, 26 Daesin Gonwon-Ro, Seo-Gu, Busan, 49201, South Korea.
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Pei D, Wang S, Sun C. Effect of passive leg raising on the cross-sectional area of the right internal jugular vein in patients with obesity: a randomised controlled trial protocol. BMJ Open 2024; 14:e085044. [PMID: 38719285 PMCID: PMC11086179 DOI: 10.1136/bmjopen-2024-085044] [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: 02/09/2024] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Venous access in patients with obesity presents significant challenges. The success of central venous catheterisation largely depends on the cross-sectional area (CSA) of the internal jugular vein (IJV). While techniques like the Trendelenburg position have been traditionally used to increase IJV CSA, recent studies suggest its ineffectiveness in patients with obesity. Conversely, the potential of the effect of passive leg raising (PLR) has not been thoroughly investigated in this group of patients. METHODS This protocol outlines a planned randomised controlled trial to evaluate the effect of PLR on the CSA of the IJV in patients with obesity slated for central venous catheterisation. The protocol involves dividing 40 participants into two groups: one undergoing PLR and another serving as a control group without positional change. The protocol specifies measuring the CSA of the IJV via ultrasound as the primary outcome. Secondary outcomes will include the success rates of right IJV cannulation. The proposed statistical approach includes the use of t-tests to compare the changes in CSA between the two groups, with a significance threshold set at p<0.05. ETHICS APPROVAL This study has been approved by the Institutional Review Board of Shanghai Tongren Hospital. All the participants will provide informed consent prior to enrolment in the study. Regarding the dissemination of research findings, we plan to share the results through academic conferences and peer-reviewed publications. Additionally, we will communicate our findings to the public and professional communities, including patient advocacy groups. TRIAL REGISTRATION NUMBER ChiCTR: ChiCTR2400080513.
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Affiliation(s)
- Dongliang Pei
- Tongren Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shuyan Wang
- Tongren Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chenmin Sun
- Tongren Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
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Kimura N, Yamada Y, Hakozaki Y, Kaneko J, Kamei J, Taguchi S, Akiyama Y, Yamada D, Fujimura T, Kume H. Upper extremity contact pressure measurement in robot-assisted pelvic surgery. J Robot Surg 2024; 18:179. [PMID: 38642236 PMCID: PMC11032272 DOI: 10.1007/s11701-024-01951-5] [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: 03/13/2024] [Accepted: 04/14/2024] [Indexed: 04/22/2024]
Abstract
Upper extremity complications are often a problem in robot-assisted pelvic surgery (RAPS) with the lithotomy-Trendelenburg position (LT-position). This study focused on upper extremity contact pressure (UEP) and examined the relationship between UEP and upper extremity complications. From May 2020 to April 2022 at the University of Tokyo Hospital, UEP was measured in 155 patients undergoing RARP and 20 patients undergoing RARC. A total of 350 sets of UEP were investigated in this study. UEP was measured using a portable interface pressure sensor (Palm Q, Cape CO., Kanagawa, Japan) in the preoperative lithotripsy position (L-position), preoperative LT-position, and postoperative L-position. UEP was increased in the preoperative LT-position than in the preoperative L-position (right side 5.2 mmHg vs. 17.1 mmHg, left side 5.3 mmHg vs. 17.1 mmHg, P < 0.001, respectively), and was decreased in the postoperative L-position than in preoperative LT-position (right side 17.1 mmHg vs. 10.8 mmHg, left side 17.1 mmHg vs. 10.6 mmHg, P < 0.001, respectively). Eleven upper extremities developed shoulder pain. UEP of the preoperative LT-position tended to be higher in the upper extremity exhibiting shoulder pain (25.6 mmHg (15.4-30.3) vs. 17.1 mmHg (12.0-24.4) P = 0.0901). UEP measurements may help prevent postoperative shoulder pain.
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Affiliation(s)
- Naoki Kimura
- Department of Urology, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuta Yamada
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Yuji Hakozaki
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Kaneko
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Kamei
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoru Taguchi
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshiyuki Akiyama
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Daisuke Yamada
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tetsuya Fujimura
- Department of Urology, Jichi Medical University, Shimotsuke City, Tochigi, Japan
| | - Haruki Kume
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Yang W, Wang S, Gu W, Bigambo FM, Wang Y, Wang X. Blood pressure response to clonidine in children with short stature is correlated with postural characteristics: a retrospective cross-sectional study. BMC Pediatr 2024; 24:39. [PMID: 38218818 PMCID: PMC10787478 DOI: 10.1186/s12887-023-04506-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: 08/14/2023] [Accepted: 12/22/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Clonidine stimulation test has been widely used in the diagnosis of growth hormone deficiency in children with short stature with a high level of reliability. However, it may cause hypotension, which usually appears as headache, dizziness, bradycardia, and even syncope. It is well known that elevating the beds to make patients' feet above their cardiac level might relieve this discomfort. However, the real efficiency of this method remains to be proved while the best angle for the elevated bed is still unclear. METHODS A total of 1200 children with short stature were enrolled in this retrospective cross-sectional study. Age, gender, weight, and basic systolic and diastolic blood pressure were collected. Blood pressure at 1, 2, 3, and 4 h after stimulation tests were recorded. The participants were divided into 3 groups based on the angles of the elevated foot of their beds named 0°, 20°, and 40° groups. RESULTS At one hour after the commencement of the tests, participants lying on the elevated beds showed a higher mean increase on the change of pulse pressure. The difference in the angles of the elevated beds did not show statistical significance compared with those who did not elevate their beds (0.13 vs. 2.83, P = 0.001; 0.13 vs. 2.18, P = 0.005; 2.83 vs. 2.18, P = 0.369). When it came to 4 h after the tests began, participants whose beds were elevated at an angle around 20° had a significantly higher mean increase in the change of pulse pressure values compared with those whose beds were elevated at an angle around 40° (1.46 vs. -0.05, P = 0.042). CONCLUSION Elevating the foot of the beds of the patients who are undergoing clonidine stimulation tests at an angle of 20°might be a good choice to alleviate the hypotension caused by the tests.
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Affiliation(s)
- Wentao Yang
- Department of Endocrinology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, China
| | - Shanshan Wang
- Department of Emergency, Pediatric Intensive Care unit, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Wei Gu
- Medical Clinical Research Center, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Francis Manyori Bigambo
- Department of Endocrinology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, China
| | - Yubing Wang
- Department of Endocrinology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, China.
| | - Xu Wang
- Department of Endocrinology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Rd, Nanjing, 210008, China.
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Ezzy M, Alameer E. Predictors and Preventive Strategies of Bleeding After Thyroid Surgery. Cureus 2023; 15:e47575. [PMID: 38021981 PMCID: PMC10666654 DOI: 10.7759/cureus.47575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Postoperative compressive neck hematoma occurs in approximately 0.1% to 1.7% of cases, most occurring within the first six hours after surgery. Thyroid pathology, patient predisposition, and surgical technique are major risk factors for postoperative hematoma. This narrative review describes current perspectives on predicting and preventing bleeding following thyroid surgery. Predictors of bleeding after thyroid surgery include patient-related factors such as male sex and age, surgery-related factors like total thyroidectomy and operations for thyroid malignancy, and surgeon-related factors. Hemostasis is the primary focus after preserving critical structures in thyroid surgery. The clamp-and-tie technique has been the standard method for dividing the thyroid gland's main vascular pedicles for many years. Bipolar electrocautery has been used for vessels of small size. However, advanced bipolar and ultrasound energy and hybrid devices are now available options that may reduce operative time without increasing costs or complications. In cases where small bleeders close to critical structures are present and the clamp-and-tie technique is not feasible, hemostatic agents are commonly used. Drains do not appear to provide any significant benefits in preventing the sequelae of bleeding after thyroid surgery.
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Affiliation(s)
- Mohsen Ezzy
- Department of Surgery, College of Medicine, Jazan University, Jazan, SAU
| | - Ehab Alameer
- Department of Surgery, College of Medicine, Jazan University, Jazan, SAU
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Pranskunas A, Gulbinaite E, Navickaite A, Pranskuniene Z. Differences in Hemodynamic Response to Passive Leg Raising Tests during the Day in Healthy Individuals: The Question of Normovolemia. Life (Basel) 2023; 13:1606. [PMID: 37511981 PMCID: PMC10381249 DOI: 10.3390/life13071606] [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: 06/21/2023] [Revised: 07/06/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The passive leg-raising (PLR) test was developed to predict fluid responsiveness and reduce fluid overload. However, the hemodynamic response of healthy individuals to the PLR test and how it changes during the day, between the morning and evening, after individuals have consumed food and fluids, has not been profoundly explored. This study aimed to compare the systemic hemodynamic changes in healthy individuals between morning and evening PLR tests. METHODS In this study, the PLR test was performed twice a day. The first PLR test was performed between 08h00 and 09h00 in the morning, while the second PLR test was performed between 20h00 and 21h00 in the evening. Hemodynamic parameters were measured using an impedance cardiography monitor, and a cutoff value of a 10% increase in stroke volume (SV) during the PLR test was used to differentiate between preload responders and non-responders. RESULTS We included 50 healthy volunteers in this study. When comparing the morning and evening PLR test results, we found no PLR-induced differences in heart rate (-3 [-8-2] vs. -2 [-8-4] beats/min, p = 0.870), SV (11 [5-22] vs. 12 [4-20] mL, p = 0.853) or cardiac output (0.7 [0.2-1.3] vs. 0.8 [0.1-1.4] L/min, p = 0.639). We also observed no differences in the proportion of preload responders during the PLR test between the morning and evening (64% vs. 66%, p = 0.99). However, there was a moderate agreement between the two PLR tests (morning and evening) (kappa = 0.429, p = 0.012). There was a moderate correlation between the changes in SV between the two PLR tests (rs = 0.50, p < 0.001). CONCLUSION In young, healthy individuals, we observed no change in the systemic hemodynamic responsiveness to the PLR test between the morning and evening, without restriction of fluid and food intake.
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Affiliation(s)
- Andrius Pranskunas
- Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Eiveniu g. 2, 50161 Kaunas, Lithuania
| | - Egle Gulbinaite
- Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, A. Mickeviciaus g. 9, 44307 Kaunas, Lithuania
| | - Aiste Navickaite
- Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, A. Mickeviciaus g. 9, 44307 Kaunas, Lithuania
| | - Zivile Pranskuniene
- Institute of Pharmaceutical Technologies, Lithuanian University of Health Sciences, Sukileliu pr. 13, 50166 Kaunas, Lithuania
- Department of Drug Technology and Social Pharmacy, Lithuanian University of Health Sciences, Sukileliu pr. 13, 50166 Kaunas, Lithuania
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Lin YY, Chang HA, Kao YH, Chuu CP, Chiang WF, Chang YC, Li YK, Chu CM, Chan JS, Hsiao PJ. Investigation of the underuse of adrenaline (epinephrine) and prognosis among patients with anaphylaxis at emergency department admission. Front Med (Lausanne) 2023; 10:1163817. [PMID: 37484849 PMCID: PMC10360193 DOI: 10.3389/fmed.2023.1163817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 06/01/2023] [Indexed: 07/25/2023] Open
Abstract
Background Anaphylaxis is a potentially fatal condition; in severe cases of anaphylaxis, the cardiovascular system is often heavily involved. Adrenaline (epinephrine) is a cornerstone of the initial treatment of anaphylaxis. The use of epinephrine remains below expectations in clinical practice. Whether the underuse of epinephrine affects the prognosis of patients with anaphylaxis is still unclear. Materials and methods This retrospective study included patients with anaphylaxis between 2011 and 2020 who were admitted to an emergency department (ED) in Taiwan. All patients were divided into two groups based on the use of epinephrine (or not), and we compared the demographic characteristics, allergens, clinical manifestations, management, and patient outcomes. Results We reviewed the records of 314 subjects (216 males, 98 females; mean age: 52.78 ± 16.02 years) who visited our ED due to anaphylaxis; 107 (34.1%) and 207 (65.9%) patients were categorized into the epinephrine use group and the non-epinephrine use group, respectively. Arrival via ambulance (p = 0.019), hypotension (p = 0.002), airway compromise (p < 0.001) and altered consciousness (p < 0.001) were the deciding factors for epinephrine use among anaphylactic patients in the ED. The epinephrine use group had higher rates of other inotropic agent usage and fluid challenge. More than 90% of patients received bed rest, steroids, antihistamines, and monitoring. The epinephrine use group had a longer ED length of stay (387.64 ± 374.71 vs. 313.06 ± 238.99 min, p = 0.03) and a greater need of hospitalization. Among all severe symptoms, hypotension was the most tolerated decision factor for not using epinephrine. In this retrospective analysis, some patients with serious anaphylaxis did not experience adverse outcomes or death even without the use of epinephrine at ED admission. Emergent care focuses first on the airway, breathing, and circulation (ABC) and may compensate for the underusage of epinephrine. This could be the reason why epinephrine was underused among patients with anaphylaxis in the ED. Conclusion In summary, early ABC management continues to play an important role in treating patients with severe anaphylaxis, even when epinephrine is not immediately available in clinical scenarios.
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Affiliation(s)
- Yen-Yue Lin
- Department of Emergency, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Department of Emergency, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Life Sciences, National Central University, Taoyuan, Taiwan
| | - Hsin-An Chang
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yung-Hsi Kao
- Department of Life Sciences, National Central University, Taoyuan, Taiwan
| | - Chih-Pin Chuu
- Institute of Cellular and System Medicine, National Health Research Institutes, Zhunan, Taiwan
- Graduate Program for Aging, China Medical University, Taichung, Taiwan
| | - Wen-Fang Chiang
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ya-Chieh Chang
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yuan-Kuei Li
- Division of Colorectal Surgery, Department of Surgery, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan
| | - Chi-Ming Chu
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
- Department of Public Health, School of Public Health, China Medical University, Taichung, Taiwan
| | - Jenq-Shyong Chan
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Po-Jen Hsiao
- Department of Life Sciences, National Central University, Taoyuan, Taiwan
- Institute of Cellular and System Medicine, National Health Research Institutes, Zhunan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Monitoring, management, and outcome of hypotension in Intensive Care Unit patients, an international survey of the European Society of Intensive Care Medicine. J Crit Care 2021; 67:118-125. [PMID: 34749051 DOI: 10.1016/j.jcrc.2021.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/24/2021] [Accepted: 10/09/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Hypotension in the ICU is common, yet management is challenging and variable. Insight in management by ICU physicians and nurses may improve patient care and guide future hypotension treatment trials and guidelines. METHODS We conducted an international survey among ICU personnel to provide insight in monitoring, management, and perceived consequences of hypotension. RESULTS Out of 1464 respondents, 1197 (81.7%) were included (928 physicians (77.5%) and 269 nurses (22.5%)). The majority indicated that hypotension is underdiagnosed (55.4%) and largely preventable (58.8%). Nurses are primarily in charge of monitoring changes in blood pressure, physicians are in charge of hypotension treatment. Balanced crystalloids, dobutamine, norepinephrine, and Trendelenburg position were the most frequently reported fluid, inotrope, vasopressor, and positional maneuver used to treat hypotension. Reported complications believed to be related to hypotension were AKI and myocardial injury. Most ICUs do not have a specific hypotension treatment guideline or protocol (70.6%), but the majority would like to have one in the future (58.1%). CONCLUSIONS Both physicians and nurses report that hypotension in ICU patients is underdiagnosed, preventable, and believe that hypotension influences morbidity. Hypotension management is generally not protocolized, but the majority of respondents would like to have a specific hypotension management protocol.
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Effect of fluid strategy on stroke volume, cardiac output, and fluid responsiveness in adult patients undergoing major abdominal surgery: a sub-study of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial. Br J Anaesth 2021; 126:818-825. [PMID: 33632521 DOI: 10.1016/j.bja.2021.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 12/18/2020] [Accepted: 01/09/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND We designed a prospective sub-study of the larger Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial to measure differences in stroke volume and other haemodynamic parameters at the end of the intraoperative fluid protocols. The haemodynamic effects of the two fluid regimens may increase our understanding of the observed perioperative outcomes. METHODS Stroke volume and cardiac output were measured with both an oesophageal Doppler ultrasound monitor and arterial pressure waveform analysis. Stroke volume variation, pulse pressure variation, and plethysmographic variability index were also obtained. A passive leg raise manoeuvre was performed to identify fluid responsiveness. RESULTS Analysis of 105 patients showed that the primary outcome, Doppler monitor-derived stroke volume index, was higher in the liberal group: restrictive 38.5 (28.6-48.8) vs liberal 44.0 (34.9-61.9) ml m-2; P=0.043. Similarly, there was a higher cardiac index in the liberal group: 2.96 (2.32-4.05) vs 2.42 (1.94-3.26) L min-1 m-2; P=0.015. Arterial-pressure-based stroke volume and cardiac index did not differ, nor was there a significant difference in stroke volume variation, pulse pressure variation, or plethysmographic variability index. The passive leg raise manoeuvre showed fluid responsiveness in 40% of restrictive and 30% of liberal protocol patients (not significant). CONCLUSIONS The liberal fluid group from the RELIEF trial had significantly higher Doppler ultrasound monitor-derived stroke volume and cardiac output compared with the restrictive fluid group at the end of the intraoperative period. Measures of fluid responsiveness did not differ significantly between groups. CLINICAL TRIAL REGISTRATION ACTRN12615000125527.
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Luo JC, Su Y, Dong LL, Hou JY, Li X, Zhang Y, Ma GG, Zheng JL, Hao GW, Wang H, Zhang YJ, Luo Z, Tu GW. Trendelenburg maneuver predicts fluid responsiveness in patients on veno-arterial extracorporeal membrane oxygenation. Ann Intensive Care 2021; 11:16. [PMID: 33496906 PMCID: PMC7838230 DOI: 10.1186/s13613-021-00811-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/18/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Evaluation of fluid responsiveness during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support is crucial. The aim of this study was to investigate whether changes in left ventricular outflow tract velocity-time integral (ΔVTI), induced by a Trendelenburg maneuver, could predict fluid responsiveness during VA-ECMO. METHODS This prospective study was conducted in patients with VA-ECMO support. The protocol included four sequential steps: (1) baseline-1, a supine position with a 15° upward bed angulation; (2) Trendelenburg maneuver, 15° downward bed angulation; (3) baseline-2, the same position as baseline-1, and (4) fluid challenge, administration of 500 mL gelatin over 15 min without postural change. Hemodynamic parameters were recorded at each step. Fluid responsiveness was defined as ΔVTI of 15% or more, after volume expansion. RESULTS From June 2018 to December 2019, 22 patients with VA-ECMO were included, and a total of 39 measurements were performed. Of these, 22 measurements (56%) met fluid responsiveness. The R2 of the linear regression was 0.76, between ΔVTIs induced by Trendelenburg maneuver and the fluid challenge. The area under the receiver operating characteristic curve of ΔVTI induced by Trendelenburg maneuver to predict fluid responsiveness was 0.93 [95% confidence interval (CI) 0.81-0.98], with a sensitivity of 82% (95% CI 60-95%), and specificity of 88% (95% CI 64-99%), at a best threshold of 10% (95% CI 6-12%). CONCLUSIONS Changes in VTI induced by the Trendelenburg maneuver could effectively predict fluid responsiveness in VA-ECMO patients. Trial registration ClinicalTrials.gov, NCT03553459 (the TEMPLE study). Registered on May 30, 2018.
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Affiliation(s)
- Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Li Dong
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Medical Imaging, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun-Yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Li
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji-Li Zheng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Jie Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China.
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
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Obata K, Naito H, Yakushiji H, Obara T, Ono K, Nojima T, Tsukahara K, Yamada T, Sasaki A, Nakao A. Incidence and characteristics of medical emergencies related to dental treatment: a retrospective single-center study. Acute Med Surg 2021; 8:e651. [PMID: 33968415 PMCID: PMC8088391 DOI: 10.1002/ams2.651] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/19/2021] [Accepted: 03/31/2021] [Indexed: 11/24/2022] Open
Abstract
AIM Although uncommon, medical emergencies arise in general dental practice. Inadequate data on their severity and frequency makes targeting medical education for general dental practitioners difficult. This also makes planning for unexpected events challenging for practitioners and makes collaborating with emergency physicians burdensome. We aimed to clarify the incidence and characteristics of a dental outpatient department's medical emergencies. METHODS This single-center, retrospective, observational study was undertaken with patients who visited the dental outpatient department of Okayama University Hospital during the 8-year period. The primary outcome of the study was to identify the incidence and characteristics of medical emergencies in the dental outpatient department. Then we examined the timing of medical emergencies, administered medications, and final disposition (home/admission). RESULTS During the period, 1,146,929 patients were enrolled. Forty-two patients (0.0037%) were consulted as medical emergencies. More than 60% of the incidents were vasovagal syncope, and dehydration and hypoglycemia were the second most prevalent at 9.5%. The most common types of dental treatments were tooth extraction (45.2%), followed by general dental treatment (28.6%), and other dental surgery such as implant placement (14.3%). Types of medical emergencies occurred equally before, during, and after dental treatment. Antihypertensive agents, sedatives, or glucose were used. For patients with emergencies, 90.5% recovered during the day and returned home, and 9.5% were hospitalized. CONCLUSION The incidence of medical emergencies was low in our dental outpatient department. Knowledge of basic management principles, regular education for emergency care, and practicing first aid skills are mandatory for safe patient management.
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Affiliation(s)
- Kyoichi Obata
- Department of Oral and Maxillofacial SurgeryOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
- Department of Emergency, Critical Care and Disaster MedicineOkayama University Graduate School of Medicine Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Hiromichi Naito
- Department of Emergency, Critical Care and Disaster MedicineOkayama University Graduate School of Medicine Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Hiromasa Yakushiji
- Department of Emergency, Critical Care and Disaster MedicineOkayama University Graduate School of Medicine Dentistry and Pharmaceutical SciencesOkayamaJapan
- Yakushiji Jikei HospitalSojaJapan
| | - Takafumi Obara
- Department of Emergency, Critical Care and Disaster MedicineOkayama University Graduate School of Medicine Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Kisho Ono
- Department of Oral and Maxillofacial SurgeryOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Tsuyoshi Nojima
- Department of Emergency, Critical Care and Disaster MedicineOkayama University Graduate School of Medicine Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Kohei Tsukahara
- Department of Emergency, Critical Care and Disaster MedicineOkayama University Graduate School of Medicine Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Taihei Yamada
- Department of Emergency, Critical Care and Disaster MedicineOkayama University Graduate School of Medicine Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Akira Sasaki
- Department of Oral and Maxillofacial SurgeryOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Atsunori Nakao
- Department of Emergency, Critical Care and Disaster MedicineOkayama University Graduate School of Medicine Dentistry and Pharmaceutical SciencesOkayamaJapan
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12
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Rich K. Trendelenburg position in hypovolemic shock: A review. JOURNAL OF VASCULAR NURSING 2020; 37:71-73. [PMID: 30954203 DOI: 10.1016/j.jvn.2019.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/07/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Kathleen Rich
- Critical Care Clinical Nurse Specialist, Franciscan Health - Michigan City, 301 W. Homer St., Michigan City, Indiana 46360.
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13
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Dreesen P, Schoutteten MK, Vande Velde N, Kaminski I, Heylen L, De Moor B, Malbrain ML, Gyselaers W. Increased Intra-Abdominal Pressure During Laparoscopic Pneumoperitoneum Enhances Albuminuria via Renal Venous Congestion, Illustrating Pathophysiological Aspects of High Output Preeclampsia. J Clin Med 2020; 9:jcm9020487. [PMID: 32054051 PMCID: PMC7074134 DOI: 10.3390/jcm9020487] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/13/2020] [Accepted: 02/09/2020] [Indexed: 01/31/2023] Open
Abstract
Intra-abdominal hypertension (IAH) causes severe organ dysfunction. Our aim is to evaluate the effect of increased intra-abdominal pressure (IAP) on renal function, hypothesizing that venous congestion may increase proteinuria and fluid retention without endothelial dysfunction. Three urine samples were collected from 32 non-pregnant women undergoing laparoscopic-assisted vaginal hysterectomy (LAVH) and from 10 controls placed in Trendelenburg position for 60 min. Urine sampling was done before (PRE), during or immediately after (PER), and two hours after (POST) the procedure. Urinary albumin, protein and creatinine concentrations were measured in each sample, and ratios were calculated and compared within and between groups. During LAVH, the albumin/creatinine ratio (ACR) increased and persisted POST-procedure, which was not observed in controls. A positive correlation existed between the LAVH duration and the relative change in both ACR and protein/creatinine ratio (PCR) PER- and POST-procedure. Iatrogenic IAH increases urinary ACR and PCR in non-pregnant women via a process of venous congestion. This mechanism might explain the presentation of one specific subtype of late-onset preeclampsia, where no drop of maternal cardiac output is observed.
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Affiliation(s)
- Pauline Dreesen
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
- Future Health, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
| | - Melanie K. Schoutteten
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
- Future Health, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
- Department of Nephrology, Catharina Ziekenhuis, 5623 EJ Eindhoven, The Netherlands
| | - Nele Vande Velde
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
| | - Iris Kaminski
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
| | - Line Heylen
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
- Department of Nephrology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
| | - Bart De Moor
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
- Department of Nephrology, Jessa Ziekenhuis, 3500 Hasselt, Belgium
| | - Manu L.N.G. Malbrain
- Department of Intensive Care, Universitair Ziekenhuis Brussel, 1090 Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, 1050 Brussels, Belgium
| | - Wilfried Gyselaers
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
- Department of Obstetrics & Gynecology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
- Correspondence: ; Tel.: +32-89327524
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14
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Demirci OL, Çıkrıkçı Işık G, Çorbacıoğlu ŞK, Çevik Y. Comparing Pleth variability index (PVI) variation induced by passive leg raising and Trendelenburg position in healthy volunteers. Am J Emerg Med 2019; 38:278-281. [PMID: 31109779 DOI: 10.1016/j.ajem.2019.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/07/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Osman Lütfi Demirci
- Kecioren Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey
| | - Gülşah Çıkrıkçı Işık
- University of Health Sciences, Kecioren Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey.
| | | | - Yunsur Çevik
- University of Health Sciences, Kecioren Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey
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15
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Tannvik TD, Rimehaug AE, Wigen MS, Løvstakken L, Kirkeby-Garstad I. Ventriculo-arterial interaction may be assessed by Oscillatory Power Fraction. Clin Physiol Funct Imaging 2019; 39:308-314. [PMID: 31038817 DOI: 10.1111/cpf.12573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 04/25/2019] [Indexed: 11/29/2022]
Abstract
The rate of energy transfer from the left ventricle to the aorta is viewed in terms of mean power (MP) and total power (TP). The difference between MP and TP is due to the pulsatility of the circulation and is known as oscillatory power (OP). OP is considered the energy spent to accelerate the blood flow. The aim of this study was to investigate the baseline left ventricular oscillatory power fraction (OP/TP) and how this was affected by acute cardiovascular dysfunction and altered preload. Twenty-eight patients undergoing elective coronary artery bypass graft surgery were included. Before administration of anaesthesia, we simultaneously recorded an arterial pressure curve and instantaneous cardiac outflow with pulsed wave Doppler. Postoperatively, prior to extubation, these measurements were repeated in neutral, Trendelenburg and reverse-Trendelenburg position. The final measurements were taken on the awake patient the day after the operation. TP is the mean of the instantaneous product of the flow and pressure curves. MP was calculated by multiplying mean arterial pressure with mean cardiac output. The oscillatory power fraction is therefore calculated as (TP-MP)/TP. The oscillatory power fraction in neutral position decreased from 23% preoperatively to 16% immediately postoperatively (P<0·001) and increased again to 19% the first postoperative day (P = 0·001). The oscillatory power fraction also increased from 16% in neutral to 19% in Trendelenburg (P = 0·001) and decreased comparing to neutral, to 14% in reverse-Trendelenburg (P = 0·04). The oscillatory power fraction is situation-dependent and is influenced by both the operation and the altered preload.
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Affiliation(s)
- Tomas Dybos Tannvik
- Department of Anaesthesia and Intensive Care, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norges Teknisk-Naturvitenskapelige Universitet, Trondheim, Norway
| | - Audun Eskeland Rimehaug
- Department of Anaesthesia and Intensive Care, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Morten Smedsrud Wigen
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norges Teknisk-Naturvitenskapelige Universitet, Trondheim, Norway
| | - Lasse Løvstakken
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norges Teknisk-Naturvitenskapelige Universitet, Trondheim, Norway
| | - Idar Kirkeby-Garstad
- Department of Anaesthesia and Intensive Care, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norges Teknisk-Naturvitenskapelige Universitet, Trondheim, Norway
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16
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Lanfranconi F, Ferri A, Pollastri L, Bartesaghi M, Novarina M, De Vito G, Beretta E, Tremolizzo L. Impact of Hanging Motionless in Harness on Respiratory and Blood Pressure Reflex Modulation in Mountain Climbers. High Alt Med Biol 2019; 20:122-132. [PMID: 31009248 PMCID: PMC6602116 DOI: 10.1089/ham.2018.0089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Harness hang syncope (HHS) is a risk that specifically affects safety of harness users in mountain climbing. Aims: To evaluate individual patterns of breathing resulting from deranged cardiovascular reflexes triggering a syncopal event when a mismatch between cerebral O2 demand and supply is present. Results: Forty healthy participants [aged 39.1 (8.2) years] were enrolled in a motionless suspension test while hanging in harness. Respiratory gas exchange values were analyzed to assess the pattern of breathing (EpInWel, respiratory elastic power) and cardiovascular parameters were monitored (BP, blood pressure). Four participants experienced HHS after 30.0 (7.6) minutes, with an early manifestation of loss of control of both a sustainable EpInWel and BP, starting after 10–12 minutes. Among the other participants, two different reactions were observed during suspension: (1) group G1 tolerated 32.7 (11.4) minutes of suspension by a favorable adaptation of the EpInWel and BP parameters and (2) group G2 showed significantly shorter time of suspension 24.0 (10.4) minutes with unfavorable increase in EpInWel and BP. Conclusions: Greater resistance to HHS occurs in people developing less marked fluctuations of both respiratory and cardiovascular reflex responses. Conversely, wider fluctuations both in control of EpInWel and BP were observed in the event of decreased suspension tolerance or in syncopal events.
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Affiliation(s)
- Francesca Lanfranconi
- 1 School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,2 Foundation Monza and Brianza for the Mother and Her Child, Monza, Italy
| | - Alessandra Ferri
- 1 School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,3 Institute for Health and Sport, Victoria University, Melbourne, Australia
| | | | | | | | - Giovanni De Vito
- 1 School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Egidio Beretta
- 1 School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Lucio Tremolizzo
- 1 School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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17
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Paranjape VV, Shih AC, Garcia-Pereira FL. Use of a modified passive leg-raising maneuver to predict fluid responsiveness during experimental induction and correction of hypovolemia in healthy isoflurane-anesthetized pigs. Am J Vet Res 2019; 80:24-32. [PMID: 30605039 DOI: 10.2460/ajvr.80.1.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the use of a modified passive leg-raising maneuver (PLRM) to predict fluid responsiveness during experimental induction and correction of hypovolemia in isoflurane-anesthetized pigs. ANIMALS 6 healthy male Landrace pigs. PROCEDURES Pigs were anesthetized with isoflurane, positioned in dorsal recumbency, and instrumented. Following induction of a neuromuscular blockade, pigs were mechanically ventilated throughout 5 sequential experimental stages during which the blood volume was manipulated so that subjects transitioned from normovolemia (baseline) to hypovolemia (blood volume depletion, 20% and 40%), back to normovolemia, and then to hypervolemia. During each stage, hemodynamic variables were measured before and 3 minutes after a PLRM and 1 minute after the pelvic limbs were returned to their original position. The PLRM consisted of raising the pelvic limbs and caudal portion of the abdomen to a 15° angle relative to the horizontal plane. RESULTS Hemodynamic variables did not vary in response to the PLRM when pigs were normovolemic or hypervolemic. When pigs were hypovolemic, the PLRM resulted in a significant increase in cardiac output and decrease in plethysomographic variability index and pulse pressure variation. When the pelvic limbs were returned to their original position, cardiac output and pulse pressure variation rapidly returned to their pre-PLRM values, but the plethysomographic variability index did not. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested a modified PLRM might be useful for identification of hemodynamically unstable animals that are likely to respond to fluid therapy. Further research is necessary to validate the described PLRM for prediction of fluid responsiveness in clinically ill animals.
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18
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Zogheib E, Maizel J, Cherradi N, Benammar A, Labont B, Hchikat A, Bernasinski M, Trojette F, Slama M, Dupont H. The presence of elastic compression stockings reduces the fluid responsiveness of patients in the operating room. Minerva Anestesiol 2018; 84:1279-1286. [PMID: 29756692 DOI: 10.23736/s0375-9393.18.12461-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The aim of this study was to investigate whether elastic compression stockings (ECS) can affect fluid responsiveness parameters before and during passive leg raising (PLR) maneuvers. METHODS In the operating room (OR), we performed a prospective study including patients referred for cardiac surgery. Blood pressure (BP), ΔPP, heart rate (HR), central venous pressure (CVP), stroke volume (SV) and aortic blood flow (ABF) (by esophageal doppler) were measured according to four conditions: supine position without ECS (baseline 1), lower limbs raised to an angle of 45° (PLR 1), returned to the supine position with ECS (baseline 2), then a second PLR maneuver with ECS was performed (PLR 2). RESULTS Twenty patients were included. BP, SV, ABF and CVP increased significantly. ΔPP and HR decreased during PLR 1. At baseline 2, HR and ΔPP decreased significantly compared to baseline 1. During PLR 2, increase of SV (4% [9]) and ABF (4% [9]), and the decrease of ΔPP (-19% [104]) were significantly lower than those observed at PLR 1 (7% [21] P=0.05; 9% [8] P=0.02 and -66% [40] P=0.02, respectively). Eleven patients presented a ΔPP≥13% at baseline 1. Only 1 patient still presented a ΔPP≥13% with ECS at baseline 2. Only 3/9 patients with an increase of ABF ≥10% and 2/11 patients with an increase of PP ≥12% during the PLR 1 presented similar results during PLR 2. CONCLUSIONS In the OR, ECS provoke a self-fluid loading increasing ABF, decreasing ΔPP and PLR response. The presence of ECS should be considered when managing hemodynamic parameters of patients.
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Affiliation(s)
- Elie Zogheib
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France - .,INSERM U 1088, Jules Verne University of Picardy, Amiens, France -
| | - Julien Maizel
- INSERM U 1088, Jules Verne University of Picardy, Amiens, France.,Unit of Medical Intensive Care, Amiens University Hospital, Amiens, France
| | - Nabil Cherradi
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France.,Department of Anesthesiology and Critical Care Medicine, Montgarde Hospital CHPM, Aubergenville, France
| | - Ammar Benammar
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Béatrice Labont
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Abdel Hchikat
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Michael Bernasinski
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Faouzi Trojette
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Michel Slama
- INSERM U 1088, Jules Verne University of Picardy, Amiens, France.,Unit of Medical Intensive Care, Amiens University Hospital, Amiens, France
| | - Hervé Dupont
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France.,INSERM U 1088, Jules Verne University of Picardy, Amiens, France
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19
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Elwan MH, Roshdy A, Reynolds JA, Elsharkawy EM, Eltahan SM, Coats TJ. What is the normal haemodynamic response to passive leg raise? A study of healthy volunteers. Emerg Med J 2018; 35:544-549. [PMID: 29728410 DOI: 10.1136/emermed-2017-206836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 10/13/2017] [Accepted: 04/27/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Passive leg raise (PLR) is used as self-fluid challenge to optimise fluid therapy by predicting preload responsiveness. However, there remains uncertainty around the normal haemodynamic response to PLR with resulting difficulties in application and interpretation in emergency care. We aim to define the haemodynamic responses to PLR in spontaneously breathing volunteers using a non-invasive cardiac output monitor, thoracic electrical bioimpedance, TEB (PLR-TEB). METHODS We recruited healthy volunteers aged 18 or above. Subjects were monitored using TEB in a semirecumbent position, followed by PLR for 3 min. The procedure was repeated after 6 min at the starting position. Correlation between the two PLRs was assessed using Spearman's r (rs). Agreement between the two PLRs was evaluated using Cohen Kappa with responsiveness defined as ≥10% increase in stroke volume. Parametric and non-parametric tests were used as appropriate to evaluate statistical significance of baseline variables between responders and non-responders. RESULTS We enrolled 50 volunteers, all haemodynamically stable at baseline, of whom 49 completed the study procedure. About half of our subjects were preload responsive. The ∆SV in the two PLRs was correlated (rs=0.68, 95% CI 0.49 to 0.8) with 85% positive concordance. Good agreement was observed with Cohen Kappa of 0.67 (95% CI 0.45 to 0.88). Responders were older and had significantly lower baseline stroke volume and cardiac output. CONCLUSION Our results suggest that the PLR-TEB is a feasible method in spontaneously breathing volunteers with reasonable reproducibility. The age and baseline stroke volume effect suggests a more complex underlying physiology than commonly appreciated. The fact that half of the volunteers had a positive preload response, against the 10% threshold, leads to questions about how this measurement should be used in emergency care and will help shape future patient studies.
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Affiliation(s)
- Mohammed H Elwan
- Department of Emergency Medicine, Alexandria University, Alexandria, Egypt.,Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Ashraf Roshdy
- Department of Critical Care Medicine, Alexandria University, Alexandria, Egypt.,General Intensive Care Unit, Queen Elizabeth, Lewisham and Greenwich NHS Trust, London, UK
| | - Joseph A Reynolds
- Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Salah M Eltahan
- Department of Cardiology, Alexandria University, Alexandria, Egypt
| | - Timothy J Coats
- Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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20
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Judickas Š, Gineitytė D, Kezytė G, Gaižauskas E, Šerpytis M, Šipylaitė J. Is the Trendelenburg position the only way to better visualize internal jugular veins? Acta Med Litu 2018; 25:125-131. [PMID: 30842701 PMCID: PMC6392601 DOI: 10.6001/actamedica.v25i3.3859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background. A larger cross-sectional area (CSA) of the internal jugular vein (IJV) makes catheterization easier and the Trendelenburg position is used to achieve this. Unfortunately, it is not comfortable for conscious patients. The aim was to evaluate the impact of alternative manoeuvres on the enlargement of the CSA of the IJV and to compare these manoeuvres with the Trendelenburg position. Materials and methods. A prospective study of 63 healthy volunteers was conducted. Two-dimensional ultrasound images of right IJV (RIJV) and left IJV (LIJV) were recorded at the level of the cricoid cartilage in the supine position with and without head rotation by 30 degrees during various manoeuvres. Results. The CSA of the RIJV and the LIJV significantly increased using hold of deep breath (mean size (cm2) RIJV 1.59 ± 0.82, LIJV 1.07 ± 0.64; both p < 0.001) and the Trendelenburg position (mean size (cm2) RIJV 1.5 ± 0.68, LIJV 0.99 ± 0.54; both p < 0.001). The 45-degree passive leg raise increased the CSA of only the RIJV (mean size (cm2) 1.17 ± 0.61, p = 0.024). These manoeuvres were compared with the Trendelenburg position. There was no significant difference in the size of the CSA using hold of deep breath on the LIJV (p = 0.08) and the RIJV (p = 0.203). The passive leg raise had a significantly weaker impact on the size of the CSA (p < 0.001 for both sides). Conclusions. Hold of deep breath and 45-degree passive leg raise (the latter limited for the right side only) are alternative manoeuvres to improve visualization of internal jugular veins for conscious patients. Hold of deep breath was as effective as the Trendelenburg position.
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Affiliation(s)
- Šarūnas Judickas
- Clinic of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Greta Kezytė
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ernestas Gaižauskas
- Clinic of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Mindaugas Šerpytis
- Clinic of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Jūratė Šipylaitė
- Clinic of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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21
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Yonis H, Bitker L, Aublanc M, Perinel Ragey S, Riad Z, Lissonde F, Louf-Durier A, Debord S, Gobert F, Tapponnier R, Guérin C, Richard JC. Change in cardiac output during Trendelenburg maneuver is a reliable predictor of fluid responsiveness in patients with acute respiratory distress syndrome in the prone position under protective ventilation. Crit Care 2017; 21:295. [PMID: 29208025 PMCID: PMC5718075 DOI: 10.1186/s13054-017-1881-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/31/2017] [Indexed: 11/10/2022] Open
Abstract
Background Predicting fluid responsiveness may help to avoid unnecessary fluid administration during acute respiratory distress syndrome (ARDS). The aim of this study was to evaluate the diagnostic performance of the following methods to predict fluid responsiveness in ARDS patients under protective ventilation in the prone position: cardiac index variation during a Trendelenburg maneuver, cardiac index variation during an end-expiratory occlusion test, and both pulse pressure variation and change in pulse pressure variation from baseline during a tidal volume challenge by increasing tidal volume (VT) to 8 ml.kg-1. Methods This study is a prospective single-center study, performed in a medical intensive care unit, on ARDS patients with acute circulatory failure in the prone position. Patients were studied at baseline, during a 1-min shift to the Trendelenburg position, during a 15-s end-expiratory occlusion, during a 1-min increase in VT to 8 ml.kg-1, and after fluid administration. Fluid responsiveness was deemed present if cardiac index assessed by transpulmonary thermodilution increased by at least 15% after fluid administration. Results There were 33 patients included, among whom 14 (42%) exhibited cardiac arrhythmia at baseline and 15 (45%) were deemed fluid-responsive. The area under the receiver operating characteristic (ROC) curve of the pulse contour-derived cardiac index change during the Trendelenburg maneuver and the end-expiratory occlusion test were 0.90 (95% CI, 0.80–1.00) and 0.65 (95% CI, 0.46–0.84), respectively. An increase in cardiac index ≥ 8% during the Trendelenburg maneuver enabled diagnosis of fluid responsiveness with sensitivity of 87% (95% CI, 67–100), and specificity of 89% (95% CI, 72–100). The area under the ROC curve of pulse pressure variation and change in pulse pressure variation during the tidal volume challenge were 0.52 (95% CI, 0.24–0.80) and 0.59 (95% CI, 0.31–0.88), respectively. Conclusions Change in cardiac index during a Trendelenburg maneuver is a reliable test to predict fluid responsiveness in ARDS patients in the prone position, while neither change in cardiac index during end-expiratory occlusion, nor pulse pressure variation during a VT challenge reached acceptable predictive performance to predict fluid responsiveness in this setting. Trial registration ClinicalTrials.gov, NCT01965574. Registered on 16 October 2013. The trial was registered 6 days after inclusion of the first patient. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1881-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hodane Yonis
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Laurent Bitker
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Mylène Aublanc
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Sophie Perinel Ragey
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Zakaria Riad
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Floriane Lissonde
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Aurore Louf-Durier
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Sophie Debord
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Florent Gobert
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Romain Tapponnier
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France.,IMRB, INSERM 955Eq13, Créteil, France
| | - Jean-Christophe Richard
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. .,Université de Lyon, Université LYON I, Lyon, France. .,CREATIS INSERM 1044 CNRS 5220, Villeurbanne, France.
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Ozdemir M, Makay O, Icoz G, Akyildiz M. What adds Valsalva maneuver to hemostasis after Trendelenburg's positioning during thyroid surgery? Gland Surg 2017; 6:433-436. [PMID: 29142831 DOI: 10.21037/gs.2017.07.09] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Bleeding after thyroidectomy is life-threatening. The aim of the study was to evaluate whether controlling of further bleeding with Valsalva maneuver following Trendelenburg's positioning has an impact on hemostasis. Methods This prospective study included 68 consecutive patients undergoing thyroidectomy. Study protocol consisted of performing manual intra-abdominal pressure increase and Valsalva maneuver to check hemostasis and treating any bleeding point identified, after Trendelenburg's positioning. All identified bleeding points and treatments were recorded. Results Total number of bleeding points identified in Trendelenburg's tilt was 49, while it was 41 when using Valsalva maneuver. Abdominal pressure increase, carried out before Valsalva maneuver, identified 14 bleeding points, which was less than bleeding after Trendelenburg's positioning and Valsalva maneuver (P<0.05). All bleeding points, except 1 for Trendelenburg's positioning and 1 for Valsalva maneuver, were minor (<2 mm). Only 4.4% bleeding vessels required ties or stitching. Conclusions Valsalva maneuver helps to detect any further bleeding following Trendelenburg's positioning.
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Affiliation(s)
- Murat Ozdemir
- Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, Izmir, Turkey
| | - Ozer Makay
- Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, Izmir, Turkey
| | - Gokhan Icoz
- Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, Izmir, Turkey
| | - Mahir Akyildiz
- Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, Izmir, Turkey
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Lanfranconi F, Pollastri L, Corna G, Bartesaghi M, Novarina M, Ferri A, Miserocchi GA. The Elusive Path of Brain Tissue Oxygenation and Cerebral Perfusion in Harness Hang Syncope in Mountain Climbers. High Alt Med Biol 2017; 18:363-371. [PMID: 28981369 DOI: 10.1089/ham.2017.0028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Lanfranconi, Francesca, Luca Pollastri, Giovanni Corna, Manuela Bartesaghi, Massimiliano Novarina, Alessandra Ferri, and Giuseppe Andrea Miserocchi. The elusive path of brain tissue oxygenation and cerebral perfusion in harness hang syncope in mountain climbers. High Alt Med Biol. 18:363-371, 2017. AIM Harness hang syncope (HHS) is a risk that specifically affects wide ranges of situations requiring safety harnesses in mountains. An irreversible orthostatic stasis could lead to death if a prompt rescue is not performed. We aimed at evaluating the risk of developing HHS and at identifying the characteristics related to the pathogenesis of HHS. RESULTS Forty adults (aged 39.1 [8.2] years) were enrolled in a suspension test lasting about 28.7 (11.4) minutes. We measured cardiovascular parameters, and near infrared spectroscopy (NIRS) was used to assess cerebral hypoxia by changes in the concentration of oxyhemoglobin (Δ[HbO2]) and de-oxyhemoglobin (Δ[HHb]). In the four participants who developed HHS: (1) systolic and diastolic blood pressure showed ample oscillations with a final abrupt drop (∼30 mmHg); (2) Δ[HbO2] increased after 8-12 minutes of suspension and reached a plateau before HHS; and (3) Δ[HHb] decreased with a final abrupt increase before syncope. CONCLUSIONS Participants who developed HHS failed to activate cardiovascular reflexes that usually safeguard O2 availability to match the metabolic needs of the brain tissue. Since cerebral hypoxia was detected as an early phenomenon by Δ[HbO2] and Δ[HHb] changes, NIRS measurement appears to be the most important parameter to monitor the onset of HHS.
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Affiliation(s)
- Francesca Lanfranconi
- 1 Laboratory of Clinical Physiology and Sport Medicine, School of Medicine and Surgery, University of Milano-Bicocca , Monza, Italy
| | | | - Giovanni Corna
- 1 Laboratory of Clinical Physiology and Sport Medicine, School of Medicine and Surgery, University of Milano-Bicocca , Monza, Italy
| | | | | | - Alessandra Ferri
- 1 Laboratory of Clinical Physiology and Sport Medicine, School of Medicine and Surgery, University of Milano-Bicocca , Monza, Italy .,3 Clinical Exercise Science Research Program, Institute of Sport Exercise and Active Living (ISEAL), Victoria University , Melbourne, Australia
| | - Giuseppe Andrea Miserocchi
- 1 Laboratory of Clinical Physiology and Sport Medicine, School of Medicine and Surgery, University of Milano-Bicocca , Monza, Italy
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Sonny A, Sessler DI, You J, Kashy BK, Sarwar S, Singh AK, Sale S, Alfirevic A, Duncan AE. The response to Trendelenburg position is minimally affected by underlying hemodynamic conditions in patients with aortic stenosis. J Anesth 2017; 31:692-702. [PMID: 28707021 DOI: 10.1007/s00540-017-2384-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 06/22/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE Trendelenburg positioning is commonly used to temporarily treat intraoperative hypotension. The Trendelenburg position improves cardiac output in normovolemic or anesthetized patients, but not hypovolemic or non-anesthetized patients. Therefore, the response to Trendelenburg positioning may vary depending on patient population or hemodynamic conditions. We thus tested the hypothesis that the effectiveness of the Trendelenburg position, as indicated by an increase in cardiac output, improves after replacement of a stenotic aortic valve. Secondarily, we evaluated whether measurements of left ventricular preload, systolic function, or afterload were associated with the response to Trendelenburg positioning. METHODS This study is a secondary analysis of a clinical trial which included patients having aortic valve replacement (AVR) who were monitored with pulmonary artery catheters (NCT01187329). We examined changes in thermodilution cardiac output with Trendelenburg positioning before and after AVR. We also examined whether echocardiographic and hemodynamic measurements of preload, afterload, and systolic function were associated with changes in cardiac output during Trendelenburg positioning. RESULTS Thirty-seven patients were included. The median [IQR] cardiac output change with Trendelenburg positioning was -3% [-10%, 5%] before AVR versus +4% [-4%, 15%] after AVR. Estimated median difference in cardiac output with Trendelenburg was 5% (95% CI 1, 15%, P = 0.04) greater after AVR. The response to Trendelenburg positioning was largely independent of hemodynamic conditions. CONCLUSION The response to Trendelenburg positioning improved following AVR, but by a clinically unimportant amount. The response to Trendelenburg positioning was independent of hemodynamic conditions.
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Affiliation(s)
- Abraham Sonny
- Division of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA, 02114, USA.
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Jing You
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Babak Kateby Kashy
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Senior Care Physicians, Taylor, MI, USA
| | - Sheryar Sarwar
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Department of Family Medicine, St. Vincent Medical Group, Kokoma, IN, USA
| | - Akhil K Singh
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Shiva Sale
- Division of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH, USA
| | - Andrej Alfirevic
- Division of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH, USA
| | - Andra E Duncan
- Division of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH, USA
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Eika F, Blomkvist AW. ABC-tiltak på vaklende underlag. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2017; 137:605. [DOI: 10.4045/tidsskr.17.0258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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27
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Erdem E. The effects of passive leg raising and ultrafiltration stopping on blood pressure in hemodialysis patients. Int Urol Nephrol 2016; 48:877-82. [PMID: 26992937 DOI: 10.1007/s11255-016-1261-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/02/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE Hemodialysis-associated hypotension, one of the more serious issues in hemodialysis patients, can be treated by passive leg raising (PLR) and ultrafiltration (UF) stopping. We investigated the effects of PLR and UF stopping on blood pressure in hemodialysis patients. METHODS The study was conducted in 76 end-stage renal disease patients. After the second hour of dialysis, systolic and diastolic blood pressure (SBP and DBP) of the patients who did not develop intradialytic hypotension (IDH) were measured in the supine position. Thereafter, PLR was performed by raising the legs 20°; and after 3 min, SBP and DBP were measured again. UF was then stopped in the PLR position; SBP and DBP were repeated 3 min later. The same procedure was performed during IDH in the patients that developed IDH. RESULTS A mean 5-mmHg (p < 0.05) increase in SBP and a mean 2-mmHg increase in DBP (p < 0.05) were observed by PLR in the supine position. UF stopping during PLR increased SBP by a mean of 1 mmHg (p < 0.05) while no change was observed in DBP (p = ns). IDH occurred in 19 (25 %) patients. PLR positioning increases SBP and DBP by a mean of 8 mmHg (p < 0.05) and 3 mmHg (p < 0.05), respectively, in the supine position during IDH. During IDH, UF stopping in the PLR position did not significantly increase SBP and DBP in patients as compared to the PLR position. CONCLUSIONS SBP and DBP increase during PLR. UF stopping during PLR does not lead to a higher increase in blood pressure as compared to PLR positioning.
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Affiliation(s)
- Emre Erdem
- Diaverum Merzifon Hemodialysis Center, Merzifon, Amasya, Turkey.
- Diaverum Samsun Hemodialysis Center, Samsun, Turkey.
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Aneman A, Sondergaard S. Understanding the passive leg raising test. Intensive Care Med 2016; 42:1493-5. [PMID: 26846515 DOI: 10.1007/s00134-016-4228-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 01/12/2016] [Indexed: 12/20/2022]
Affiliation(s)
- Anders Aneman
- Liverpool Hospital, University of New South Wales, Sydney, Australia.
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Onal O, Apiliogullari S, Nayman A, Saltali A, Yilmaz H, Celik JB. The effectiveness of trendelenburg positioning on the cross-sectional area of the right internal jugular vein in obese patients. Pak J Med Sci 2015; 31:770-4. [PMID: 26430400 PMCID: PMC4578176 DOI: 10.12669/pjms.314.7326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: Trendelenburg positioning is a common approach used during internal jugular vein (IJV) cannulation. No evidence indicates that Trendelenburg positioning significantly increases the cross-sectional area (CSA) of the IJV in obese patients. The primary aim of this study was to determine the effectiveness of Trendelenburg positioning on the CSA of the right internal jugular vein assessed with ultrasound measurement in obese patients. Methods: Forty American Society of Anesthesiologists II patients with body mass index ≥30 kg/m2 undergoing various elective surgeries under general endotracheal anesthesia were enrolled. Ultrasound images of the right IJV were obtained in a transverse orientation at the cricoid level. We measured the CSA of the right IJV two different conditions in a sealed envelope were applied in random order: State 0, table flat (no tilt), with the patients in the supine position, and State T, in which the operating table was tilted 20° to the Trendelenburg position. Results: The change in the CSA of the IJV from the supine to the Trendelenburg position (1.80 cm2 vs 2.08cm2) was not significantly different. The CSA was paradoxically decreased in 10 of 36 patients when the position changed from State 0 to State T. Conclusions: Trendelenburg positioning does not significantly increase the mean CSA of the right IJV in obese patients. In fact, in some patients, this position decreases the CSA. The use of the Trendelenburg position for IJV cannulation in obese patients can no longer be supported.
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Affiliation(s)
- Ozkan Onal
- Ozkan Onal, Department of Anesthesia and Intensive Care, Selcuk University Medical Faculty, Konya, Turkey
| | - Seza Apiliogullari
- Seza Apiliogullari, Department of Anesthesia and Intensive Care, Selcuk University Medical Faculty, Konya, Turkey
| | - Alaaddin Nayman
- Alaaddin Nayman, Department of Interventional Radiology, Selcuk University Medical Faculty, Konya, Turkey
| | - Ali Saltali
- Ali Saltali, Department of Anesthesia and Intensive Care, Selcuk University Medical Faculty, Konya, Turkey
| | - Huseyin Yilmaz
- Huseyin Yilmaz, Department of General Surgery, Selcuk University Medical Faculty, Konya, Turkey
| | - Jale Bengi Celik
- Jale Bengi Celik, Department of Anesthesia and Intensive Care, Selcuk University Medical Faculty, Konya, Turkey
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Stens J, Oeben J, Van Dusseldorp AA, Boer C. Non-invasive measurements of pulse pressure variation and stroke volume variation in anesthetized patients using the Nexfin blood pressure monitor. J Clin Monit Comput 2015; 30:587-94. [PMID: 26318314 PMCID: PMC5023739 DOI: 10.1007/s10877-015-9759-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 08/20/2015] [Indexed: 11/25/2022]
Abstract
Nexfin beat-to-beat arterial blood pressure monitoring enables continuous assessment of hemodynamic indices like cardiac index (CI), pulse pressure variation (PPV) and stroke volume variation (SVV) in the perioperative setting. In this study we investigated whether Nexfin adequately reflects alterations in these hemodynamic parameters during a provoked fluid shift in anesthetized and mechanically ventilated patients. The study included 54 patients undergoing non-thoracic surgery with positive pressure mechanical ventilation. The provoked fluid shift comprised 15° Trendelenburg positioning, and fluid responsiveness was defined as a concomitant increase in stroke volume (SV) >10 %. Nexfin blood pressure measurements were performed during supine steady state, Trendelenburg and supine repositioning. Hemodynamic parameters included arterial blood pressure (MAP), CI, PPV and SVV. Trendelenburg positioning did not affect MAP or CI, but induced a decrease in PPV and SVV by 3.3 ± 2.8 and 3.4 ± 2.7 %, respectively. PPV and SVV returned back to baseline values after repositioning of the patient to baseline. Bland–Altman analysis of SVV and PPV showed a bias of −0.3 ± 3.0 % with limits of agreement ranging from −5.6 to 6.2 %. The SVV was more superior in predicting fluid responsiveness (AUC 0.728) than the PVV (AUC 0.636), respectively. The median bias between PPV and SVV was different for patients younger [−1.5 % (−3 to 0)] or older [+2 % (0–4.75)] than 55 years (P < 0.001), while there were no gender differences in the bias between PPV and SVV. The Nexfin monitor adequately reflects alterations in PPV and SVV during a provoked fluid shift, but the level of agreement between PPV and SVV was low. The SVV tended to be superior over PPV or Eadyn in predicting fluid responsiveness in our population.
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Affiliation(s)
- Jurre Stens
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Jeroen Oeben
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Ab A Van Dusseldorp
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Christa Boer
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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Nayman A, Onal IO, Apiliogullari S, Ozbek S, Saltali AO, Celik JB, Temizoz O, celik G. Ultrasound validation of Trendelenburg positioning to increase internal jugular vein cross-sectional area in chronic dialysis patients. Ren Fail 2015; 37:1280-4. [DOI: 10.3109/0886022x.2015.1073052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Weber U, Base E, Ristl R, Mora B. Effect of Preload Alterations on Left Ventricular Systolic Parameters Including Speckle-Tracking Echocardiography Radial Strain During General Anesthesia. J Cardiothorac Vasc Anesth 2015; 29:852-9. [PMID: 25910985 DOI: 10.1053/j.jvca.2014.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Frequently used parameters for evaluation of left ventricular systolic function are load-sensitive. However, the impact of preload alterations on speckle-tracking echocardiographic parameters during anesthesia has not been validated. Therefore, two-dimensional (2D) speckle-tracking echocardiography radial strain (RS) was assessed during general anesthesia, simulating 3 different preload conditions. DESIGN Single-center prospective observational study. SETTING University hospital. PARTICIPANTS Thirty-three patients with normal left ventricular systolic function undergoing major surgery. INTERVENTIONS Transgastric views of the midpapillary level of the left ventricle were acquired at 3 different positions. MEASUREMENTS AND MAIN RESULTS Fractional shortening (FS), fractional area change (FAC), and 2D speckle-tracking echocardiography RS were analyzed in the transgastric midpapillary view. Considerable correlation above 0.5 was found for FAC and FS in the zero and Trendelenburg positions (r = 0.629, r = 0.587), and for RS and FAC in the anti-Trendelenburg position (r = 0.518). In the repeated-measures analysis, significant differences among the values measured at the 3 positions were found for FAC and FS. For FAC, there were differences up to 2.8 percentage points between the anti-Trendelenburg position and the other 2 positions. For FS, only the difference between position zero and anti-Trendelenburg was significant, with an observed change of 1.66. Two-dimensional RS was not significantly different at all positions, with observed changes below 1 percentage point. CONCLUSIONS Alterations in preload did not result in clinically relevant changes of RS, FS, or FAC. Observed changes for RS were smallest; however, the variation of RS was larger than that of FS or FAC.
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Affiliation(s)
- Ulrike Weber
- Department of Anaesthesiology, General Intensive Care and Pain Control, Medical University of Vienna, Vienna, Austria.
| | - Eva Base
- Department of Anaesthesiology, General Intensive Care and Pain Control, Medical University of Vienna, Vienna, Austria
| | - Robin Ristl
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Bruno Mora
- Department of Anaesthesiology, General Intensive Care and Pain Control, Medical University of Vienna, Vienna, Austria
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O'Loughlin E, Ward M, Crossley A, Hughes R, Bremner AP, Corcoran T. Evaluation of the utility of the Vigileo FloTrac(™) , LiDCO(™) , USCOM and CardioQ(™) to detect hypovolaemia in conscious volunteers: a proof of concept study. Anaesthesia 2015; 70:142-9. [PMID: 25583188 DOI: 10.1111/anae.12949] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2014] [Indexed: 12/26/2022]
Abstract
It is important to detect and treat hypovolaemia; however, detection is particularly challenging in the conscious, spontaneously breathing patient. Eight healthy male volunteers were monitored using four minimally invasive monitors: Vigileo FloTrac(™) ; LiDCOrapid(™) ; USCOM 1A; and CardioQ(™) oesophageal Doppler. Monitor output and clinical signs were recorded during incremental venesection of 2.5% estimated blood volume aliquots to a total of 20% blood volume removed. A statistically significant difference from baseline stroke volume was detected after 2.5% blood loss using the LiDCO (p = 0.007), 7.5% blood loss using the USCOM (p = 0.019), and 12.5% blood loss using the CardioQ (p = 0.046) and the FloTrac (p = 0.028). Receiver operator characteristic curves for predicting > 10% blood loss had areas under the curve of 0.68-0.82. The minimally invasive cardiac output devices tested can detect blood loss by a reduction in stroke volume in awake volunteers, and may have a role in guiding fluid replacement in conscious patients with suspected hypovolaemia.
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Affiliation(s)
- E O'Loughlin
- Department of Anaesthesia, Fremantle Hospital, Perth, Western Australia, Australia; School of Medicine and Pharmacology, Perth, Western Australia, Australia
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Cherpanath TG, Aarts LP, Groeneveld JA, Geerts BF. Defining Fluid Responsiveness: A Guide to Patient-Tailored Volume Titration. J Cardiothorac Vasc Anesth 2014; 28:745-54. [DOI: 10.1053/j.jvca.2013.12.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Indexed: 11/11/2022]
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Godfrey GEP, Dubrey SW, Handy JM. A prospective observational study of stroke volume responsiveness to a passive leg raise manoeuvre in healthy non-starved volunteers as assessed by transthoracic echocardiography. Anaesthesia 2014; 69:306-13. [PMID: 24641636 DOI: 10.1111/anae.12560] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2013] [Indexed: 01/07/2023]
Abstract
Current guidelines for intra-operative fluid management recommend the use of increments in stroke volume following intravenous fluid bolus administration as a guide to subsequent fluid therapy. To study the physiological premise of this paradigm, we tested the hypothesis that healthy, non-starved volunteers would develop an increment in their stroke volume following a passive leg raise manoeuvre. Subjects were positioned supine and stroke volume was measured by transthoracic echocardiography at baseline, 30 s, 1 min, 3 min and 5 min after passive leg raise manoeuvre to 45°. Stroke volume was measured at end-expiration during quiet breathing, as the mean of three sequential measurements. Seventeen healthy volunteers were recruited; one volunteer in whom it was not possible to obtain Doppler measurements and a further five for reasons of poor Doppler image quality were not included in the study. Mean (SD) percentage difference from baseline to the largest change in stroke volume was 5.7 (9.6)% (p = 0.16). Of the 11 volunteers evaluated, five (45%) had stroke volume increases of greater than 10%. Mean (SD) maximum percentage change in cardiac index was 14.8 (9.7)% (p = 0.004). A wide variation in baseline stroke volume and response to the passive leg raise manoeuvre was seen, suggesting greater heterogeneity in the normal population than current clinical guidelines recognise.
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Affiliation(s)
- G E P Godfrey
- Department of Anaesthesia, Hillingdon Hospital, London, UK
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Might the Bainbridge reflex have a role in resuscitation when chest compression is combined with passive leg raising? Resuscitation 2013; 85:e21. [PMID: 24157632 DOI: 10.1016/j.resuscitation.2013.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 10/02/2013] [Indexed: 11/20/2022]
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Chadi BH. Reply letter: Passive leg elevation aids cardiopulmonary resuscitation. Resuscitation 2013; 84:e63. [PMID: 23410712 DOI: 10.1016/j.resuscitation.2013.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 02/06/2013] [Indexed: 11/16/2022]
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