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Sejersen C, Christiansen T, Secher NH. To identify normovolemia in humans: The stroke volume response to passive leg raising vs. head-down tilt. Physiol Rep 2022; 10:e15216. [PMID: 35854636 PMCID: PMC9296869 DOI: 10.14814/phy2.15216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 06/15/2023] Open
Abstract
Volume responsiveness can be evaluated by tilting maneuvers such as head-down tilt (HDT) and passive leg raising (PLR), but the two procedures use different references (HDT the supine position; PLR the semi-recumbent position). We tested whether the two procedures identify "normovolemia" by evaluating the stroke volume (SV) and cardiac output (CO) responses and whether the peripheral perfusion index (PPI) derived from pulse oximetry provides similar information. In randomized order, 10 healthy men were exposed to both HDT and PLR, and evaluations were made also when the subjects fasted. Central cardiovascular variables were derived by pulse contour analysis and changes in central blood volume assessed by thoracic electrical admittance (TEA). During HDT, SV remained stable (fasted 110 ± 16 vs. 109 ± 16 ml; control 113 ± 16 vs. 111 ± 16 ml, p > 0.05) with no change in CO, TEA, PPI, or SV variation (SVV). In contrast during PLR, SV increased (fasted 108 ± 17 vs. 117 ± 17 ml; control 108 ± 18 vs. 117 ± 18 ml, p < 0.05) followed by an increase in TEA (p < 0.05) and CO increased when subjects fasted (6.7 ± 1.5 vs. 7.1 ± 1.5, p = 0.007) with no change in PPI or SVV. In conclusion, SV has a maximal value for rest in supine men, while PLR restores SV as CBV is reduced in a semi-recumbent position and the procedure thereby makes healthy volunteers seem fluid responsive.
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Affiliation(s)
- Casper Sejersen
- Department of AnaesthesiaInstitute for Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Till Christiansen
- Department of AnaesthesiaInstitute for Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Niels H. Secher
- Department of AnaesthesiaInstitute for Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
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2
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Ma GG, Xu LY, Luo JC, Hou JY, Hao GW, Su Y, Liu K, Yu SJ, Tu GW, Luo Z. Change in left ventricular velocity time integral during Trendelenburg maneuver predicts fluid responsiveness in cardiac surgical patients in the operating room. Quant Imaging Med Surg 2021; 11:3133-3145. [PMID: 34249640 PMCID: PMC8250022 DOI: 10.21037/qims-20-700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 03/03/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fluid responsiveness is an important topic for clinicians. We investigated whether changes in left ventricular outflow tract (LVOT) velocity time integral (VTI) during a Trendelenburg position (TP) maneuver can predict fluid responsiveness as a non-invasive marker in coronary artery bypass graft (CABG) surgery patients in the operating room. METHODS This prospective, single-center observational study, performed in the operating room, enrolled 65 elective CABG patients. Hemodynamic data coupled with transesophageal echocardiography monitoring of the LVOT VTI and the peak velocity were collected at each step [baseline 1, TP, baseline 2 and fluid challenge (FC)]. Patients whose VTI increased ≥15% after FC (500 mL of Gelofusine infusion within 30 min) were considered responders. RESULTS Twenty-eight (43.1%) patients were responders to fluid administration. VTI changes during the TP maneuver predicted fluid responsiveness with an area under the receiver operating characteristic curve (AUC) of 0.90 (95% CI, 0.79-0.96), with a sensitivity of 100%, and a specificity of 70% at a threshold of 10% (gray zone, 8-15%). The increase in VTI during the TP was correlated with the VTI changes induced by FC (r=0.61, P<0.0001). Changes in peak velocity and pulse pressure during the TP were poorly predictive of fluid responsiveness, with an AUC of 0.72 (95% CI: 0.60-0.82) and 0.66 (95% CI: 0.53-0.77), respectively. CONCLUSIONS An increase in VTI induced by the TP could predict fluid responsiveness in CABG patients in the operating room. However, changes in peak velocity and pulse pressure stimulated by the TP could not reliably predict fluid responsiveness.
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Affiliation(s)
- Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Center of Critical Care Medicine, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Li-Ying Xu
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jun-Yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- 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
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Escalante G, Stevenson SW, Barakat C, Aragon AA, Schoenfeld BJ. Peak week recommendations for bodybuilders: an evidence based approach. BMC Sports Sci Med Rehabil 2021; 13:68. [PMID: 34120635 PMCID: PMC8201693 DOI: 10.1186/s13102-021-00296-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/02/2021] [Indexed: 01/10/2023]
Abstract
Bodybuilding is a competitive endeavor where a combination of muscle size, symmetry, "conditioning" (low body fat levels), and stage presentation are judged. Success in bodybuilding requires that competitors achieve their peak physique during the day of competition. To this end, competitors have been reported to employ various peaking interventions during the final days leading to competition. Commonly reported peaking strategies include altering exercise and nutritional regimens, including manipulation of macronutrient, water, and electrolyte intake, as well as consumption of various dietary supplements. The primary goals for these interventions are to maximize muscle glycogen content, minimize subcutaneous water, and reduce the risk abdominal bloating to bring about a more aesthetically pleasing physique. Unfortunately, there is a dearth of evidence to support the commonly reported practices employed by bodybuilders during peak week. Hence, the purpose of this article is to critically review the current literature as to the scientific support for pre-contest peaking protocols most commonly employed by bodybuilders and provide evidence-based recommendations as safe and effective strategies on the topic.
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Affiliation(s)
- Guillermo Escalante
- Department of Kinesiology, California State University- San Bernardino, CA San Bernardino, USA
| | | | - Christopher Barakat
- Competitive Breed LLC, FL Tampa, USA
- Human Performance Laboratory, The University of Tampa, FL Tampa, USA
| | - Alan A. Aragon
- Department of Family and Consumer Sciences, California State University- Northridge, Los Angeles, CA USA
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Minini A, Abraham P, Malbrain MLNG. Predicting fluid responsiveness with the passive leg raising test: don't be fooled by intra-abdominal hypertension! ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:799. [PMID: 32647724 PMCID: PMC7333095 DOI: 10.21037/atm.2019.12.14] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Andrea Minini
- Department of Intensive Care Medicine, University Hospital Brussels (UZB), Jette, Belgium
| | - Paul Abraham
- Anaesthesiology and Critical Care Medicine Department, Hôpital Edouard-Herriot, Lyon cedex, France
| | - Manu L N G Malbrain
- Department of Intensive Care Medicine, University Hospital Brussels (UZB), Jette, Belgium.,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Jette, Belgium
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Behem CR, Gräßler MF, Trepte CJC. [Central venous pressure in liver surgery : A primary therapeutic goal or a hemodynamic tessera?]. Anaesthesist 2018; 67:780-789. [PMID: 30203329 DOI: 10.1007/s00101-018-0482-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Central venous pressure (CVP) is deemed to be an important parameter of anesthesia management in liver surgery. To reduce blood loss during liver resections, a low target value of CVP is often propagated. Although current meta-analyses have shown a connection between low CVP and a reduction in blood loss, the underlying studies show methodological weaknesses and advantages with respect to morbidity and mortality can hardly be proven. The measurement of the CVP itself is associated with numerous limitations and influencing factors and the measures to reduce the CVP have been insufficiently investigated with respect to hepatic hemodynamics. The definition of a generally valid target area for the CVP must be called into question. The primary objective is to maintain adequate oxygen supply and euvolemia. The CVP should be regarded as a mosaic stone of hemodynamic management.
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Affiliation(s)
- C R Behem
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistraße 52, 20246, Hamburg, Deutschland.
| | - M F Gräßler
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistraße 52, 20246, Hamburg, Deutschland
| | - C J C Trepte
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistraße 52, 20246, Hamburg, Deutschland
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Fakhari S, Bilehjani E, Farzin H, Pourfathi H, Chalabianlou M. The effect of passive leg-raising maneuver on hemodynamic stability during anesthesia induction for adult cardiac surgery. Integr Blood Press Control 2018; 11:57-63. [PMID: 29922085 PMCID: PMC5995276 DOI: 10.2147/ibpc.s126514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction Some cardiac patients do not tolerate the intravenous fluid load commonly administered before anesthesia induction. This study investigated preinduction passive leg-raising maneuver (PLRM) as an alternative method to fluid loading before cardiac anesthesia. Methods and materials During a 6-month period, 120 adult elective heart surgery patients were enrolled in this study and allocated into 2 groups: PLRM group vs control group (n=60). Anesthesia was induced using midazolam, fentanyl, and cisatracurium. Initially, 250 mL of fluid was administrated intravenously in all of patients before anesthesia induction. Then in the PLRM group, PLRM was performed starting 2 minutes before anesthesia induction and continued for 20 minutes after tracheal intubation. In the control group, anesthesia was induced in a simple supine position. Heart rate, invasive mean arterial blood pressure (MAP), and central venous pressure (CVP) were recorded before PLRM, before anesthetic induction, before laryngoscopy, and at 5, 10, and 20 minutes after tracheal intubation. The hypotension episode rate (MAP <70 mmHg) and CVP changes were compared between the 2 groups. The predictive value of the ≥3 mmHg increase in CVP value in response to PLRM for hypotension prevention was defined. Results Hypotension rates were lower in the PLRM group (63.3% vs 81.6%; P-value 0.04), and MAP was higher among PLRM patients immediately before anesthetic injection, before laryngoscopy, and 20 minutes after intubation, compared to the control group. PLRM increased CVP by 3.57±4.9 mmHg (from 7.50±2.94 to 11.05±3.55 mmHg), which required several minutes to reach peak value, returning to baseline after 15 minutes. This change did not correlate to subsequent MAP changes; an increase in the CVP value ≥3 mmHg decreased the postinduction hypotension rate by 62.50%. Conclusion Preinduction PLRM can provide a more stable hemodynamic status in adult cardiac surgery patients and decreases anesthesia-induced hypotension rates by 62.50%. Rate of the changes in the CVP value caused by PLRM is not predictive of subsequent MAP changes.
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Affiliation(s)
- Solmaz Fakhari
- Cardiovascular Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Eissa Bilehjani
- Cardiovascular Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Haleh Farzin
- Cardiovascular Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hojjat Pourfathi
- Cardiovascular Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohsen Chalabianlou
- Cardiovascular Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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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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Yu WQ, Zhang Y, Zhang SY, Liang ZY, Fu SQ, Xu J, Liang TB. Impact of misplaced subclavian vein catheter into jugular vein on transpulmonary thermodilution measurement variables. J Zhejiang Univ Sci B 2016; 17:60-6. [PMID: 26739527 DOI: 10.1631/jzus.b1500167] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The subclavian vein (SCV) is usually used to inject the indicator of cold saline for a transpulmonary thermodilution (TPTD) measurement. The SCV catheter being misplaced into the internal jugular (IJV) vein is a common occurrence. The present study explores the influence of a misplaced SCV catheter on TPTD variables. METHODS Thirteen severe acute pancreatitis (SAP) patients with malposition of the SCV catheter were enrolled in this study. TPTD variables including cardiac index (CI), global end-diastolic volume index (GEDVI), intrathoracic blood volume index (ITBVI), and extravascular lung water index (EVLWI) were obtained after injection of cold saline via the misplaced SCV catheter. Then, the misplaced SCV catheter was removed and IJV access was constructed for a further set of TPTD variables. Comparisons were made between the TPTD results measured through the IJV and misplaced SCV accesses. RESULTS A total of 104 measurements were made from TPTD curves after injection of cold saline via the IJV and misplaced SCV accesses. Bland-Altman analysis demonstrated an overestimation of +111.40 ml/m(2) (limits of agreement: 6.13 and 216.70 ml/m(2)) for GEDVI and ITBVI after a misplaced SCV injection. There were no significant influences on CI and EVLWI. The biases of +0.17 L/(min·m(2)) for CI and +0.17 ml/kg for EVLWI were revealed by Bland-Altman analysis. CONCLUSIONS The malposition of an SCV catheter does influence the accuracy of TPTD variables, especially GEDVI and ITBVI. The position of the SCV catheter should be confirmed by chest X-ray in order to make good use of the TPTD measurements.
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Affiliation(s)
- Wen-qiao Yu
- Department of Hepatobiliary and Pancreatic Surgery and Intensive Care Unit, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310021, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery and Intensive Care Unit, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310021, China
| | - Shao-yang Zhang
- Department of Hepatobiliary and Pancreatic Surgery and Intensive Care Unit, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310021, China
| | - Zhong-yan Liang
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Shui-qiao Fu
- Department of Hepatobiliary and Pancreatic Surgery and Intensive Care Unit, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310021, China
| | - Jia Xu
- Department of Emergency, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Ting-bo Liang
- Department of Hepatobiliary and Pancreatic Surgery and Intensive Care Unit, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310021, China
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Chan CPY, Cheung PL, Man Tse M, Agarwal N, Narain S, Chan SSW, Smith BE, Graham CA, Rainer TH. Influence of different positions on hemodynamics derived from noninvasive transcutaneous Doppler ultrasound. Physiol Rep 2013; 1:e00062. [PMID: 24303147 PMCID: PMC3831890 DOI: 10.1002/phy2.62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 07/19/2013] [Accepted: 07/22/2013] [Indexed: 11/25/2022] Open
Abstract
A proper alignment of the ultrasound beam to the aortic or pulmonary outflow tracts is essential to acquire accurate signals. This study aimed to investigate the influence of different positions on the acquisition of Doppler signals using a noninvasive transcutaneous Doppler ultrasound. This was a prospective observational crossover study. Two operators performed hemodynamics measurements on each subject in supine, sitting, semirecumbent, passive leg raising (PLR) 20°, and PLR 60° positions using both aortic and pulmonary approaches. All Doppler flow profile images were assessed using the Fremantle and Prince of Wales Hospital criteria. Time required to obtain Doppler signals was recorded. A total of 60 subjects (50% males) aged 18–60 years old were investigated. In both sitting and semirecumbent positions, aortic stroke volume indexes (SVIs) and cardiac indexes (CIs) were significantly lower than those in the other three positions while the pulmonary CIs were comparable to that in the supine position. In the sitting position, the aortic signal qualities were lower and the time to obtain the pulmonary Doppler signals was prolonged. Instead, the signal quality and the time to obtain the Doppler signals in the semirecumbent position were similar to those in the other three positions using the pulmonary approach. PLR did not cause a significant increase in SVI regardless of the degree of leg elevation. These data show that it is feasible to perform the noninvasive transcutaneous Doppler ultrasound using the pulmonary approach in the semirecumbent position for patients unable to maintain the supine position. The aortic approach in the sitting and semirecumbent positions is not suitable as it is not sufficiently reliable.
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Affiliation(s)
- Cangel Pui-Yee Chan
- Accident and Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong New Territories, Hong Kong
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Kweon TD, Jung CW, Park JW, Jeon YS, Bahk JH. Hemodynamic effect of full flexion of the hips and knees in the supine position: a comparison with straight leg raising. Korean J Anesthesiol 2012; 62:317-21. [PMID: 22558496 PMCID: PMC3337376 DOI: 10.4097/kjae.2012.62.4.317] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 07/20/2011] [Accepted: 07/26/2011] [Indexed: 11/18/2022] Open
Abstract
Background Straight raising of the legs in the supine position or Trendelenburg positioning has been used to treat hypotension or shock, but the advantages of these positions are not clear and under debate. We performed a crossover study to evaluate the circulatory effect of full flexion of the hips and knees in the supine position (exaggerated lithotomy), and compare it with straight leg raising. Methods This study was a prospective randomized crossover study from the tertiary care unit at our university hospital. Twenty-two patients scheduled for off-pump coronary artery bypass surgery were enrolled. Induction and maintenance of anesthesia were standardized. Exaggerated lithotomy position or straight leg raising were randomly selected in the supine position. Hemodynamic variables were measured in the following sequence: 10 min after induction, 1, 5, and 10 min following the designated position, and 1 and 5 min after returning to the supine position. Ten min later, the other position was applied to measure the same hemodynamic variables. Results During the exaggerated lithotomy position, cerebral and coronary perfusion pressure increased significantly (P < 0.01) without a change in cardiac output. During straight leg raising, cardiac output increased at 5 min (P < 0.05) and cerebral and coronary perfusion pressures did not increase except for cerebral perfusion pressure at 1 min. However, the difference between the two groups at each time point in terms of cerebral perfusion pressure was clinically insignificant. Conclusions Full flexion of the hips and knees in the supine position did not increase cardiac output but may be more beneficial than straight leg raising in terms of coronary perfusion pressure.
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Affiliation(s)
- Tae Dong Kweon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
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Sinha R, Garg R. Anesthetic management for laparoscopy surgery in a patient with residual coarctation of aorta and mild aortic stenosis. J Anaesthesiol Clin Pharmacol 2011; 27:412-3. [PMID: 21897524 PMCID: PMC3161478 DOI: 10.4103/0970-9185.83698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Perioperative management of patients with congenital heart disease is a challenge for the anesthesiologist. We present successful anesthetic management for diagnostic laparoscopy and cystectomy for tubo-ovarian mass in a case of residual coarctation of the aorta along with bicuspid aortic valve and mild aortic stenosis.
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Affiliation(s)
- Renu Sinha
- Department of Anesthesiology and Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Rakesh Garg
- Department of Anesthesiology and Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
- Address for correspondence: Dr. Rakesh Garg, Department of Anesthesiology and Intensive Care, 58-E, Kavita Colony, Nangloi, Delhi - 110 041, India. E-mail:
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Influence of body position on hemodynamics in patients with ischemic heart disease undergoing cardiac surgery. Wien Klin Wochenschr 2010; 122 Suppl 2:59-62. [PMID: 20517674 DOI: 10.1007/s00508-010-1346-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The cardiovascular response to decreased or increased preload in high-risk patients with ischemic heart disease enables us to understand the physiologic response to hemorrhage and its treatment. Although numerous studies have failed to show its effectiveness, the head-down position is still widely used to treat patients with hypotension and shock. The aim of our study was to evaluate the influence of body position on hemodynamics in high-risk patients undergoing coronary artery bypass graft surgery. METHODS In 16 patients with ischemic hearth disease and poor left ventricular function undergoing coronary artery bypass graft surgery, we measured cardiac output with thermodilution, arterial pressure, central venous pressure (CVP), pulmonary artery wedge pressure (PAWP) and heart rate in three different body positions: the horizontal position, 20 degrees head-up position, 20 degrees head-down position and back in the horizontal position. The measurements were made before and after cardiac surgery. RESULTS Before skin incision the change from horizontal to 20 degrees head-up position led to a nonsignificant decrease in cardiac output and a significant decrease in mean arterial pressure, CVP and PAWP. The change from 20 degrees head-up to 20 degrees head-down position led to a significant increase in cardiac output, mean arterial pressure, CVP and PAWP. After skin closure the change from horizontal to 20 degrees head-up position led to a nonsignificant decrease in cardiac output and mean arterial pressure and a significant decrease CVP and PAWP. The change from 20 degrees head-up to 20 degrees head-down position led to a nonsignificant increase in cardiac output and a significant increase in mean arterial pressure, CVP and PAWP. There were no significant changes in heart rate during the changes in position before or after surgery. CONCLUSIONS The results of our study showed a hemodynamic response similar to hemorrhage after placing the patients in a 20 degrees head-up position and improving hemodynamics in the head-down position in mechanically ventilated patients undergoing coronary artery bypass graft surgery.
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Saugel B, Umgelter A, Schuster T, Phillip V, Schmid RM, Huber W. Transpulmonary thermodilution using femoral indicator injection: a prospective trial in patients with a femoral and a jugular central venous catheter. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R95. [PMID: 20500825 PMCID: PMC2911732 DOI: 10.1186/cc9030] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 03/25/2010] [Accepted: 05/25/2010] [Indexed: 12/22/2022]
Abstract
Introduction Advanced hemodynamic monitoring using transpulmonary thermodilution (TPTD) is established for measurement of cardiac index (CI), global end-diastolic volume index (GEDVI) and extra-vascular lung water index (EVLWI). TPTD requires indicator injection via a central venous catheter (usually placed via the jugular or subclavian vein). However, superior vena cava access is often not feasible due to the clinical situation. This study investigates the conformity of TPTD using femoral access. Methods This prospective study involved an 18-month trial at a medical intensive care unit at a university hospital. Twenty-four patients with both a superior and an inferior vena cava catheter at the same time were enrolled in the study. Results TPTD-variables were calculated from TPTD curves after injection of the indicator bolus via jugular access (TPTDjug) and femoral access (TPTDfem). GEDVIfem and GEDVIjug were significantly correlated (rm = 0.88; P < 0.001), but significantly different (1,034 ± 275 vs. 793 ± 180 mL/m2; P < 0.001). Bland-Altman analysis demonstrated a bias of +241 mL/m2 (limits of agreement: -9 and +491 mL/m2). GEDVIfem, CIfem and ideal body weight were independently associated with the bias (GEDVIfem-GEDVIjug). A correction formula of GEDVIjug after femoral TPTD, was calculated. EVLWIfem and EVLWIjug were significantly correlated (rm = 0.93; P < 0.001). Bland-Altman analysis revealed a bias of +0.83 mL/kg (limits of agreement: -2.61 and +4.28 mL/kg). Furthermore, CIfem and CIjug were significantly correlated (rm = 0.95; P < 0.001). Bland-Altman analysis demonstrated a bias of +0.29 L/min/m2 (limits of agreement -0.40 and +0.97 L/min/m2; percentage-error 16%). Conclusions TPTD after femoral injection of the thermo-bolus provides precise data on GEDVI with a high correlation, but a self-evident significant bias related to the augmented TPTD-volume. After correction of GEDVIfem using a correction formula, GEDVIfem shows high predictive capabilities for GEDVIjug. Regarding CI and EVLWI, accurate TPTD-data is obtained using femoral access.
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Affiliation(s)
- Bernd Saugel
- II Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str 22, 81675 München, Germany.
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Kardos A, Földesi C, Nagy A, Sáringer A, Kiss A, Kiss G, Marschalkó P, Szabó M. Trendelenburg positioning does not prevent a decrease in cardiac output after induction of anaesthesia with propofol in children. Acta Anaesthesiol Scand 2006; 50:869-74. [PMID: 16879471 DOI: 10.1111/j.1399-6576.2006.01073.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE Induction of anaesthesia may cause decreased cardiac output and blood pressure. Head-down tilt is often the first clinical step to treat hypotension. The objective of this randomized single centre study was to determine, with the use of impedance cardiography (ICG), whether Trendelenburg positioning modifies the haemodynamic response to propofol/fentanyl induction of anaesthesia in ASA I children. METHODS Thirty ASA I children aged between 7 and 16 years scheduled for elective minor orthopaedic surgery were included. After intravenous induction with propofol and fentanyl in the head-down group (HDG, n = 15), 5 min of 20 degrees head-down tilt was applied. In the supine group (SG, n = 15), no change in the supine position was made. Heart rate (HR), mean arterial blood pressure (MABP), end-tidal carbon dioxide (ETCO(2)), stroke volume index (SVI), cardiac index (CI), systemic vascular resistance index (SVRI) and Heather index (HI) were recorded before (B), at 3 (A(3)), 5 (A(5)) and 8 (A(8)) minutes after induction in each group. RESULTS After induction, a significant decrease in CI, MABP, HR and HI was recorded in both groups. In the study group, significantly lower values of HR (66 vs. 78 beat/min) and higher values of SVI (42.9 vs. 40.6 ml/min/m(2)) were measured at A(3) compared with the control group. After induction, no difference in CI and SVRI was found between the two groups. CONCLUSION The present study shows that cardiac performance is not improved by Trendelenburg positioning after propofol/fentanyl induction of anaesthesia in children.
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Affiliation(s)
- A Kardos
- Paediatric Intensive Care Unit, Heim Pál Children's Hospital, Ullöi Str. 89, 1086 Budapest, Hungary.
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