1
|
Hong A, Boukthir S, Levé C, Joachim J, Mateo J, Le Gall A, Mebazaa A, Gayat E, Cartailler J, Vallée F. "Association of velocity-pressure loop-derived values recorded during neurosurgical procedures with postoperative organ failure biomarkers: a retrospective single-center study". Anaesth Crit Care Pain Med 2024:101405. [PMID: 38997007 DOI: 10.1016/j.accpm.2024.101405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 05/24/2024] [Accepted: 06/02/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND Perioperative renal and myocardial protection primarily depends on preoperative prediction tools, along with intraoperative optimization of cardiac output (CO) and mean arterial pressure (MAP). We hypothesise that monitoring the intraoperative global afterload angle (GALA), a proxy of ventricular afterload derived from the velocity pressure (VP) loop, could better predict changes in postoperative biomarkers than the recommended traditional MAP and CO. METHOD This retrospective monocentric study included patients programmed for neurosurgery with continuous VP loop monitoring. Patients with hemodynamic instability were excluded. Those presenting a 1-day post-surgery increase in creatinine, B-type natriuretic peptide, or troponin Ic us were labelled Bio+, Bio- otherwise. Demographics, intra-operative data and comorbidities were considered as covariates. The study aimed to determine if intraoperative GALA monitoring could predict early postoperative biomarker disruption. RESULT From November 2018 to November 2020, 86 patients were analysed (Bio+/Bio- = 47/39). Bio + patients were significantly older (62[54-69] versus 42[34-57] years, p < 0.0001), More often hypertensive (25% vs. 9%, p = 0.009), and more frequently treated with antihypertensive drugs (31.9% vs. 7.7%, p = 0.013). GALA was significantly larger in Bio+ patients (40[31-56] vs. 23[19-29] °, p < 0.0001), while CO, MAP, and cumulative time spent <65mmHg were similar between groups. GALA exhibited strong predictive performances for postoperative biological deterioration (AUC=0.88[0.80-0.95]), significantly outperforming MAP (MAP AUC=0.55[0.43-0.68], p < 0.0001). CONCLUSION GALA under general anaesthesia prove more effective in detecting patients at risk of early cardiac or renal biological deterioration, compared to classical hemodynamic parameters.
Collapse
Affiliation(s)
- Alex Hong
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Cambodia China friendship preah kossamak hospital 316d St 150, Phnom Penh, Cambodia
| | - Sonia Boukthir
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.
| | - Charlotte Levé
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jona Joachim
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Joaquim Mateo
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Arthur Le Gall
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Alexandre Mebazaa
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Inserm, UMRS-942, Paris. France
| | - Etienne Gayat
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Inserm, UMRS-942, Paris. France
| | - Jérôme Cartailler
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Inserm, UMRS-942, Paris. France
| | - Fabrice Vallée
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Inserm, UMRS-942, Paris. France; Laboratoire de Mécanique des Solides (LMS), Ecole Polytechnique, CNRS, Palaiseau, France
| |
Collapse
|
2
|
Park DH, Kim TW, Kim MS, Han W, Lee DE, Kim GS, Jeong CY. Cardiac arrest caused by accidental severe hypothermia and myocardial infarction during general anesthesia. J Int Med Res 2021; 49:300060520987945. [PMID: 33499678 PMCID: PMC7844464 DOI: 10.1177/0300060520987945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Therapeutic hypothermia is often used for traumatic brain injury because of its neuroprotective effect and decreased secondary brain injury. However, this procedure lacks clinical evidence supporting its efficacy, and adverse outcomes have been reported during general anesthesia. A 61-year-old man with a history of percutaneous coronary intervention (PCI) was admitted with traumatic brain injury. Immediately after admission, he underwent mild therapeutic hypothermia with a target temperature of 33.0°C for neuroprotection. During general anesthesia for emergency surgery because he developed a mass effect, hypothermic cardiac arrest occurred following an additional decrease in the core body temperature. Moreover, myocardial infarction caused by restenosis of the previous PCI lesion also contributed to the cardiac arrest. Although the patient recovered spontaneous circulation after an hour-long cardiopulmonary resuscitation with rewarming, he eventually died of subsequent repetitive cardiac arrests. When anesthetizing patients undergoing therapeutic hypothermia, caution is required to prevent adverse outcomes that can be caused by unintentional severe hypothermia and exacerbation of underlying heart disease.
Collapse
Affiliation(s)
- Dong Ho Park
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Tae Woo Kim
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Mo Se Kim
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Woong Han
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Da Eun Lee
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Gyu Seong Kim
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| | - Chang Young Jeong
- Department of Anesthesiology and Pain Medicine, Eulji University Medical Center, Daejeon, Korea
| |
Collapse
|
3
|
Le Gall A, Gayat É, Joachim J, Cohen S, Hong A, Matéo J, Buxin C, Millasseau S, Mebazaa A, Vallée F. Velocity-pressure loops can estimate intrinsic and pharmacologically induced changes in cardiac afterload during non-cardiac surgery. An observational study. J Clin Monit Comput 2021; 36:545-555. [PMID: 33755846 DOI: 10.1007/s10877-021-00686-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 10/13/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Continuous measurement of aortic pressure and aortic flow velocity signals in the operating theatre allows us to draw velocity-pressure (Vel-Pre) loops. The global afterload angle (GALA), derived from the Vel-Pre loops, has been linked to cardiac afterload indicators. As age is the major determinant of constitutive arterial stiffness, we aimed to describe (1) the evolution of the GALA according to age in a large cohort of anesthetized patients and (2) GALA variations induced by haemodynamic interventions. METHODS We included patients for whom continuous monitoring of arterial pressure and cardiac output were indicated. Fluid challenges or vasopressors were administered to treat intra-operative hypotension. The primary endpoint was the comparison of the GALA values between young and old patients. The secondary endpoint was the difference in the GALA values before and after haemodynamic interventions. RESULTS We included 133 anaesthetized patients: 66 old and 67 young patients. At baseline, the GALA was higher in the old patients than in young patients (38 ± 6 vs. 25 ± 4 degrees; p < 0.001). The GALA was positively associated with age (p < 0.001), but the mean arterial pressure (MAP) and cardiac output were not. The GALA did not change after volume expansion, regardless of the fluid response, but it did increase after vasopressor administration. Furthermore, while a vasopressor bolus led to a similar increase in MAP, phenylephrine induced a more substantial increase in the GALA than noradrenaline (+ 12 ± 5° vs. + 8 ± 5°; p = 0.01). CONCLUSION In non-cardiac surgery, the GALA seems to be associated with both intrinsic rigidity (reflected by age) and pharmacologically induced vasoconstriction changes (by vasopressors). In addition, the GALA can discriminate the differential effects of phenylephrine and noradrenaline. These results should be confirmed in a prospective, ideally randomized, trial.
Collapse
Affiliation(s)
- Arthur Le Gall
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France.
- M3DISIM, Inria-Saclay, Palaiseau, France.
- LMS, École Polytechnique, CNRS, Palaiseau, France.
| | - Étienne Gayat
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
- Inserm, UMRS-942, Paris Diderot University, 02, rue Ambroise Paré, 75010, Paris, France
| | - Jona Joachim
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Samuel Cohen
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Alex Hong
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Joaquim Matéo
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Cédric Buxin
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Sandrine Millasseau
- Pulse Wave Consulting, 72 B rue de Montignon, 95320, Saint Leu La Foret, France
| | - Alexandre Mebazaa
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
- Inserm, UMRS-942, Paris Diderot University, 02, rue Ambroise Paré, 75010, Paris, France
| | - Fabrice Vallée
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
- Inserm, UMRS-942, Paris Diderot University, 02, rue Ambroise Paré, 75010, Paris, France
- M3DISIM, Inria-Saclay, Palaiseau, France
- LMS, École Polytechnique, CNRS, Palaiseau, France
| |
Collapse
|
4
|
Potential cardiovascular adverse events when phenylephrine is combined with paracetamol: simulation and narrative review. Eur J Clin Pharmacol 2015; 71:931-8. [PMID: 26022219 PMCID: PMC4500855 DOI: 10.1007/s00228-015-1876-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 05/20/2015] [Indexed: 11/23/2022]
Abstract
Background Increased bioavailability of phenylephrine is reported when combined with paracetamol in over-the-counter formulations for the symptomatic treatment of the common cold and influenza. Such formulations could increase phenylephrine-related cardiovascular adverse events particularly in susceptible individuals. Quantification of the effect of phenylephrine concentration on blood pressure allows simulation of potential adverse combination therapy effects. Methods MEDLINE and EMBASE databases were searched for papers discussing or describing any adverse effect, hypersensitivity or safety concerns related to phenylephrine alone or in combination with other drugs. The pharmacodynamic relationship between plasma phenylephrine concentration and mean arterial blood pressure was characterized using published observations of blood pressure changes after ophthalmic eye drops. The resulting pharmacokinetic and pharmacodynamic parameters were then used to predict mean arterial blood pressure (MAP) changes in that population if given an oral combination of phenylephrine and paracetamol. Results There were 1172 papers identified for examination. Forty-seven reports fulfilled the inclusion criteria. Increases in blood pressure and decreases in heart rate have been reported with doses over 15 mg. It has been estimated that a 20-mmHg increase in systolic blood pressure would occur with an oral dose of 45 mg phenylephrine in normotensive healthy people. Those taking monoamine oxidase inhibitors report increased systolic blood pressure of greater than 60 mmHg. Blood pressure and heart rate changes are potentiated in patients with underlying hypertension. Simulation showed a modest increase in MAP when phenylephrine 10 mg was co-administered with paracetamol 1 g (4.2 vs 12.3 mmHg). Conclusions Combination paracetamol phenylephrine oral therapy has potential to increase blood pressure more than phenylephrine alone in those with cardiovascular compromise. Electronic supplementary material The online version of this article (doi:10.1007/s00228-015-1876-1) contains supplementary material, which is available to authorized users.
Collapse
|
5
|
Guillamet MCV, Rhee C, Patterson AJ. Cardiovascular management of septic shock in 2012. Curr Infect Dis Rep 2012; 14:493-502. [PMID: 22941043 DOI: 10.1007/s11908-012-0279-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Septic shock is a major cause of morbidity and mortality throughout the world. Source control, antimicrobial therapy, early goal-directed fluid resuscitation, and infusion of vasoactive pharmaceuticals remain the cornerstones of treatment. However, the cardiovascular management of septic shock is evolving. Basic science and clinical researchers have identified novel drug targets and are testing the efficacy of new therapeutic agents. For example, prevention of microvascular leak during septic shock is the focus of active investigations and may soon provide considerable benefit to patients. Among the important topics that will be discussed in this review are the following: the role of vascular endothelial dysfunction in microvascular leak, the impact of cytokines upon structural and functional proteins within the endothelial barrier and within the heart, and the ability of selective vasopressin 1a receptor agonists to minimize tissue edema and improve hemodynamic status.
Collapse
|
6
|
Crystal GJ. Alpha1 Agonists and Myocardial Blood Flow—There Is More to the Story! Anesth Analg 2012; 114:477; author reply 477-8. [DOI: 10.1213/ane.0b013e31823b26d2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
7
|
Thiele RH, Nemergut EC, Lynch C. The Clinical Implications of Isolated Alpha1 Adrenergic Stimulation. Anesth Analg 2011; 113:297-304. [DOI: 10.1213/ane.0b013e3182120ca5] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
8
|
Thiele RH, Nemergut EC, Lynch C. The physiologic implications of isolated alpha(1) adrenergic stimulation. Anesth Analg 2011; 113:284-96. [PMID: 21519050 DOI: 10.1213/ane.0b013e3182124c0e] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Phenylephrine and methoxamine are direct-acting, predominantly α(1) adrenergic receptor (AR) agonists. To better understand their physiologic effects, we screened 463 articles on the basis of PubMed searches of "methoxamine" and "phenylephrine" (limited to human, randomized studies published in English), as well as citations found therein. Relevant articles, as well as those discovered in the peer-review process, were incorporated into this review. Both methoxamine and phenylephrine increase cardiac afterload via several mechanisms, including increased vascular resistance, decreased vascular compliance, and disadvantageous alterations in the pressure waveforms produced by the pulsatile heart. Although pure α(1) agonists increase arterial blood pressure, neither animal nor human studies have ever shown pure α(1)-agonism to produce a favorable change in myocardial energetics because of the resultant increase in myocardial workload. Furthermore, the cost of increased blood pressure after pure α(1)-agonism is almost invariably decreased cardiac output, likely due to increases in venous resistance. The venous system contains α(1) ARs, and though stimulation of α(1) ARs decreases capacitance and may transiently increase venous return, this gain may be offset by changes in afterload, venous compliance, and venous resistance. Data on the effects of α(1) stimulation in the central nervous system show conflicting changes, while experimental animal data suggest that renal blood flow is reduced by α(1)-agonists, and both animal and human data suggest that gastrointestinal perfusion may be reduced by α(1) tone.
Collapse
Affiliation(s)
- Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908, USA.
| | | | | |
Collapse
|
9
|
Affiliation(s)
- Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital Bern, Bern, Switzerland
| |
Collapse
|