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Savale L, Benazzo A, Corris P, Keshavjee S, Levine DJ, Mercier O, Davis RD, Granton JT. Transplantation, bridging, and support technologies in pulmonary hypertension. Eur Respir J 2024:2401193. [PMID: 39209471 DOI: 10.1183/13993003.01193-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 09/04/2024]
Abstract
Despite the progress made in medical therapies for treating pulmonary hypertension (PH), a subset of patients remain susceptible to developing a maladaptive right ventricular phenotype. The effective management of end-stage PH presents substantial challenges, necessitating a multidisciplinary approach and early identification of patients prone to acute decompensation. Identifying potential transplant candidates and assessing the feasibility of such a procedure are pivotal tasks that should be undertaken early in the treatment algorithm. Inclusion on the transplant list is contingent upon a comprehensive risk assessment, also considering the specific type of PH and various factors affecting waiting times, all of which should inform the decision-making process. While bilateral lung transplantation is the preferred option, it demands expert intra- and post-operative management to mitigate the heightened risks of pulmonary oedema and primary graft dysfunction in PH patients.Despite the availability of risk assessment tools, the occurrence of acute PH decompensation episodes can be unpredictable, potentially leading to refractory right ventricular failure even with optimal medical intervention, necessitating the use of rescue therapies. Advancements in right ventricular assist techniques and adjustments to graft allocation protocols for the most critically ill patients have significantly enhanced the survival in intensive care, affording the opportunity to endure while awaiting an urgent transplant. Given the breadth of therapeutic options available, specialised centres capable of delivering comprehensive care have become indispensable for optimising patient outcomes. These centres are instrumental in providing holistic support and management tailored to the complex needs of PH patients, ultimately enhancing their chances of a successful transplant and improved long-term prognosis.
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Affiliation(s)
- Laurent Savale
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, HPPIT, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Alberto Benazzo
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Paul Corris
- Newcastle University and Institute of Transplantation, Freeman Hospital, Newcastle, UK
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Deborah Jo Levine
- Division of Pulmonary, Critical Care and Allergy, Stanford University, Palo Alto, CA, USA
| | - Olaf Mercier
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, HPPIT, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Le Kremlin-Bicêtre, France
- Marie Lannelongue Hospital, Dept of Thoracic Surgery and Heart-Lung Transplantation, Le lessis Robinson, France
| | - R Duane Davis
- Thoracic and Cardiac Surgery, AdventHealth Transplant Institute, Orlando, FL, USA
| | - John T Granton
- Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada
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Alkhunaizi FA, Smith N, Brusca SB, Furfaro D. The Management of Cardiogenic Shock From Diagnosis to Devices: A Narrative Review. CHEST CRITICAL CARE 2024; 2:100071. [PMID: 38993934 PMCID: PMC11238736 DOI: 10.1016/j.chstcc.2024.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
Cardiogenic shock (CS) is a heterogenous syndrome broadly characterized by inadequate cardiac output leading to tissue hypoperfusion and multisystem organ dysfunction that carries an ongoing high mortality burden. The management of CS has advanced rapidly, especially with the incorporation of temporary mechanical circulatory support (tMCS) devices. A thorough understanding of how to approach a patient with CS and to select appropriate monitoring and treatment paradigms is essential in modern ICUs. Timely characterization of CS severity and hemodynamics is necessary to optimize outcomes, and this may be performed best by multidisciplinary shock-focused teams. In this article, we provide a review of CS aimed to inform both the cardiology-trained and non-cardiology-trained intensivist provider. We briefly describe the causes, pathophysiologic features, diagnosis, and severity staging of CS, focusing on gathering key information that is necessary for making management decisions. We go on to provide a more detailed review of CS management principles and practical applications, with a focus on tMCS. Medical management focuses on appropriate medication therapy to optimize perfusion-by enhancing contractility and minimizing afterload-and to facilitate decongestion. For more severe CS, or for patients with decompensating hemodynamic status despite medical therapy, initiation of the appropriate tMCS increasingly is common. We discuss the most common devices currently used for patients with CS-phenotyping patients as having left ventricular failure, right ventricular failure, or biventricular failure-and highlight key available data and particular points of consideration that inform tMCS device selection. Finally, we highlight core components of sedation and respiratory failure management for patients with CS.
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Affiliation(s)
- Fatimah A Alkhunaizi
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nikolhaus Smith
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC
| | - Samuel B Brusca
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - David Furfaro
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Isha S, Narra SA, Batool H, Jonna S, Giri A, Herrmann O, Dyson A, Nichols MD, Hannon R, Pham S, Moreno Franco P, Baz M, Sanghavi D, Kiley S, Waldron N, Pandompatam G, Bohman JKK, Chaudhary S, Rosenbaum DN, Guru PK, Bhattacharyya A. Assessing Right Ventricle Over Time in Patients on Veno-Venous Extracorporeal Membrane Oxygenation: Insights From Serial Echocardiography. ASAIO J 2024:00002480-990000000-00488. [PMID: 38819317 DOI: 10.1097/mat.0000000000002235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is often used in acute respiratory distress syndrome (ARDS) with refractory hypoxemia. There is limited literature highlighting the development of right ventricular (RV) failure while on ECMO. We conducted a retrospective multicenter observational study including 70 patients who were placed on veno-venous (VV)-ECMO for respiratory failure at Mayo Clinic, Jacksonville, and Mayo Clinic, Rochester, between January 2018 and June 2022 and had at least two post-ECMO transthoracic echoes. The primary outcomes were the incidence and progression of RV dysfunction and dilatation. The secondary outcome was in-patient mortality. Among 70 patients in our cohort, 60.6% had a normal RV function at the time of ECMO placement, whereas only 42% had a normal RV function at the second post-ECMO echo. On multinomial regression, a moderate decrease in RV function was associated with ECMO flow (odds ratio [OR] = 2.32, p = 0.001) and ECMO duration (OR = 1.01, p = 0.01). A moderately dilated RV size was also associated with ECMO flow (OR = 2.62, p < 0.001) and ECMO duration (OR = 1.02, p = 0.02). An increasing degree of RV dysfunction was associated with worse outcomes. Our study showed that the increasing duration and flow of VV-ECMO correlated with progressive RV dilatation and dysfunction, which were associated with poor survival.
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Affiliation(s)
- Shahin Isha
- From the Department of Internal Medicine, Ascension Saint Joseph Hospital, Chicago, Illinois
| | - Sai Abhishek Narra
- Department of Internal Medicine, Mercy Fitzgerald Hospital, Philadelphia, Pennsylvania
| | - Humera Batool
- Department of Internal Medicine, Mercy Fitzgerald Hospital, Philadelphia, Pennsylvania
| | - Sadhana Jonna
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Abhishek Giri
- Department of Internal Medicine, Fairview Hospital, Cleveland, Ohio
| | - Olivia Herrmann
- Cope Lab, Department of Biomedical Engineering, Georgia Institute of Technology,, Atlanta, Georgia
| | - Amari Dyson
- Florida State College, Jacksonville, Florida
| | - Mick D Nichols
- Department of Nursing, Mayo Clinic, Jacksonville, Florida
| | - Rachel Hannon
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Si Pham
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida
| | | | - Maher Baz
- Department of Transplant, Mayo Clinic, Jacksonville, Florida
| | - Devang Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Sean Kiley
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Nathan Waldron
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Govind Pandompatam
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - J Kyle K Bohman
- Department of Anesthesia, Mayo Clinic, Rochester, Minnesota; and
| | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Drew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
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Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med 2024; 79:1-11. [PMID: 38330877 DOI: 10.1016/j.ajem.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. OBJECTIVE This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. DISCUSSION High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. CONCLUSIONS Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.
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Affiliation(s)
- Samuel G Rouleau
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento, CA, United States of America.
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, United States of America.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
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5
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Meng L, Sun Y, Zhao X, Meng DM, Liu Z, Adams DC, McDonagh DL, Rasmussen M. Effects of phenylephrine on systemic and cerebral circulations in humans: a systematic review with mechanistic explanations. Anaesthesia 2024; 79:71-85. [PMID: 37948131 DOI: 10.1111/anae.16172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 11/12/2023]
Abstract
We conducted a systematic review of the literature reporting phenylephrine-induced changes in blood pressure, cardiac output, cerebral blood flow and cerebral tissue oxygen saturation as measured by near-infrared spectroscopy in humans. We used the proportion change of the group mean values reported by the original studies in our analysis. Phenylephrine elevates blood pressure whilst concurrently inducing a reduction in cardiac output. Furthermore, despite increasing cerebral blood flow, it decreases cerebral tissue oxygen saturation. The extent of phenylephrine's influence on cardiac output (r = -0.54 and p = 0.09 in awake humans; r = -0.55 and p = 0.007 in anaesthetised humans), cerebral blood flow (r = 0.65 and p = 0.002 in awake humans; r = 0.80 and p = 0.003 in anaesthetised humans) and cerebral tissue oxygen saturation (r = -0.72 and p = 0.03 in awake humans; r = -0.24 and p = 0.48 in anaesthetised humans) appears closely linked to the magnitude of phenylephrine-induced blood pressure changes. When comparing the effects of phenylephrine in awake and anaesthetised humans, we found no evidence of a significant difference in cardiac output, cerebral blood flow or cerebral tissue oxygen saturation. There was also no evidence of a significant difference in effect on systemic and cerebral circulations whether phenylephrine was given by bolus or infusion. We explore the underlying mechanisms driving the phenylephrine-induced cardiac output reduction, cerebral blood flow increase and cerebral tissue oxygen saturation decrease. Individualised treatment approaches, close monitoring and consideration of potential risks and benefits remain vital to the safe and effective use of phenylephrine in acute care.
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Affiliation(s)
- L Meng
- Department of Anesthesia, Indiana University School of Medicine, IA, Indianapolis, USA
| | - Y Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - X Zhao
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - D M Meng
- Choate Rosemary Hall School, CT, Wallingford, USA
| | - Z Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, IA, Indianapolis, USA
| | - D C Adams
- Department of Anesthesia, Indiana University School of Medicine, IA, Indianapolis, USA
| | - D L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, Neurology and Neurotherapeutics, UT Southwestern Medical Center, TX, Dallas, USA
| | - M Rasmussen
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
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Torbic H, Tonelli AR. Sotatercept for Pulmonary Arterial Hypertension in the Inpatient Setting. J Cardiovasc Pharmacol Ther 2024; 29:10742484231225310. [PMID: 38361351 DOI: 10.1177/10742484231225310] [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] [Indexed: 02/17/2024]
Abstract
Patients with pulmonary arterial hypertension (PAH) who are admitted to the hospital pose a challenge to the multidisciplinary healthcare team due to the complexity of the pathophysiology of their disease state and PAH-specific medication considerations. Pulmonary arterial hypertension is a progressive disease that may lead to death as a result of right ventricular (RV) failure. During acute on chronic RV failure it is critical to decrease the pulmonary vascular resistance with the goal of improving RV function and prognosis; therefore, aggressive PAH-treatment based on disease risk stratification is essential. Pulmonary arterial hypertension treatment for acute on chronic RV failure can be impacted by end-organ damage, hemodynamic instability, drug interactions, and PAH medications dosage and delivery. Sotatercept, a first in class activin signaling inhibitor that works on the bone morphogenetic protein/activin pathway is on track for Food and Drug Administration approval for the treatment of PAH based on results of recent trials in where the medication led to clinical and hemodynamic improvements, even when added to traditional PAH-specific therapies. The purpose of this review is to highlight important considerations when starting or continuing sotatercept in patients admitted to the hospital with PAH.
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Affiliation(s)
- Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
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7
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Condliffe R, Newton R, Bauchmuller K, Bonnett T, Kerry R, Mannings A, Nair A, Selby K, Skinner PP, Wilson VJ, Kiely DG. Surgery and Anesthesia in Patients with Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:797-809. [PMID: 37729924 DOI: 10.1055/s-0043-1772753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Pulmonary hypertension is characterized by right ventricular impairment and a reduced ability to compensate for hemodynamic insults. Consequently, surgery can be challenging but is increasingly considered in view of available specific therapies and improved longer term survival. Optimal management requires a multidisciplinary patient-centered approach involving surgeons, anesthetists, pulmonary hypertension clinicians, and intensivists. The optimal pathway involves risk:benefit assessment for the proposed operation, optimization of pulmonary hypertension and any comorbidities, the appropriate anesthetic approach for the specific procedure and patient, and careful monitoring and management in the postoperative period. Where patients are carefully selected and meticulously managed, good outcomes can be achieved.
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Affiliation(s)
- Robin Condliffe
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Ruth Newton
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Kris Bauchmuller
- Department of Critical Care, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Tessa Bonnett
- Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Robert Kerry
- Department of Orthopaedics, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Alexa Mannings
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Amanda Nair
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Karen Selby
- Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Paul P Skinner
- Department of Surgery, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Victoria J Wilson
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - David G Kiely
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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Savale L, Kularatne M, Roche A, Pichon J, Baron A, Boucly A, Sitbon O, Humbert M. Management of Acutely Decompensated Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:762-770. [PMID: 37369216 DOI: 10.1055/s-0043-1770119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Pulmonary arterial hypertension is a severe life-threatening condition associated with increased pulmonary vascular resistance and resulting right heart dysfunction. Admission to intensive care unit with acutely decompensated right heart failure is a significant negative prognostic event with a high risk of multisystem organ dysfunction and death. Presentations are heterogenous and may combine signs of both diastolic and systolic dysfunction complicating management. Renal dysfunction is often present, but other organ systems can be involved resulting in findings such as acute hepatic dysfunction or bowel wall congestion and ischemia. The goals of therapy are to rapidly reverse ventriculo-arterial decoupling and reduce right ventricular afterload to prevent progression to refractory or irreversible right heart failure. Triggering events must be investigated for and addressed urgently if identified. Volume status management is critical and both noninvasive and invasive testing can aid in prognostication and guide management, including the use of inotropes and vasopressors. In cases of refractory right heart dysfunction, consideration of urgent lung transplantation and mechanical circulatory support is necessary. These patients should be managed at expert centers in an intensive care setting with a multidisciplinary team of practitioners experienced in the management of right heart dysfunction given the high short- and long-term mortality resulting from acute decompensated right heart failure.
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Affiliation(s)
- Laurent Savale
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Mithum Kularatne
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, Canada
| | - Anne Roche
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Jérémie Pichon
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Audrey Baron
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Athenaïs Boucly
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Olivier Sitbon
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Marc Humbert
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
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9
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Juhl-Olsen P, Berg-Hansen K, Nørskov J, Enevoldsen J, Hermansen JL. The haemodynamic effects of phenylephrine after cardiac surgery. Acta Anaesthesiol Scand 2023. [PMID: 37186094 DOI: 10.1111/aas.14256] [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: 01/06/2023] [Revised: 02/24/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Phenylephrine increases systemic- and pulmonary resistances and therefore may increase blood pressures at the expense of blood flow. Cardio-pulmonary bypass alters vasoreactivity and many patients exhibit chronotropic insufficiency after cardiac surgery. We aimed to describe the haemodynamic effects of phenylephrine infusion after cardiac surgery. METHODS Patients in steady state after low-risk cardiac surgery received incremental infusion rates of phenylephrine up to 1.0 μg/kg/min with the aim of increasing systemic mean arterial blood pressure 20 mmHg. Invasive haemodynamic parameters, including pulmonary wedge pressures, were captured along with echocardiographic measures of biventricular function before, during phenylephrine infusion at target systemic blood pressure, and 20 min after phenylephrine discontinuation. RESULTS Thirty patients were included. Phenylephrine increased mean arterial pressure increased from 78 (±9) mmHg to 98 (±10) mmHg with phenylephrine infusion. Also, pulmonary blood pressure as well as systemic- and pulmonary resistances increased. The ratio between systemic- and pulmonary artery resistances did not change statistically significantly (p = .59). Median cardiac output was 4.35 (interquartile range [IQR] 3.6-5.4) L/min at baseline and increased significantly with phenylephrine infusion (median Δcardiac output was 0.25 [IQR 0.1-0.6] L/min) (p = .012). Pulmonary artery wedge pressure increased from 10.2 (±3.0) mmHg to 11.9 (±3.4) mmHg (p < .001). This was accompanied by significant increases in central venous pressure. Phenylephrine infusion increased left ventricular end-diastolic volume from 105 (±46) mL to 119 (±44) mL (p < .001). All results of phenylephrine infusion were reversed with discontinuation. CONCLUSION In haemodynamically stable patients after cardiac surgery, phenylephrine increased PVR and SVR, but did not change the PVR/SVR ratio. Phenylephrine increased biventricular filling pressures and left ventricular end-diastolic area. Consequently, CO increased as ejection fraction was maintained. These findings do not discourage the use of phenylephrine after low-risk cardiac surgery. REGISTRATION clinicaltrial.gov (identifier NCT04419662).
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Affiliation(s)
- Peter Juhl-Olsen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kristoffer Berg-Hansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper Nørskov
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
| | - Johannes Enevoldsen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Johan Lyngklip Hermansen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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10
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Jha AK, Jha N, Malik V. Perioperative Decision-Making in Pulmonary Hypertension. Heart Lung Circ 2023; 32:454-466. [PMID: 36841637 DOI: 10.1016/j.hlc.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/03/2022] [Accepted: 01/03/2023] [Indexed: 02/27/2023]
Abstract
Pulmonary hypertension (PH) is a haemodynamic manifestation of cardiorespiratory and non-cardiorespiratory pathologies. Cardiorespiratory pathologies account for nearly three-fourths of patients with PH. It is now increasingly being recognised due to routine requests for transthoracic echocardiographic examination in the perioperative setting in patients undergoing intermediate- to high-risk non-cardiac surgery. The increased risks of perioperative morbidity and mortality attributed to PH have been widely acknowledged in the literature. The importance of PH in perioperative decision-making and postoperative outcomes has had little mention in all the guidelines. Understanding the complexity of the pathophysiology of PH may help in anaesthetic and surgical decision-making. Preoperative evaluation and risk assessment are guided by the nature, extent, invasiveness, and duration of surgery. Surgical decision-making and anaesthetic management involve preoperative risk stratification, understanding the interactions between surgical procedures and PH, and understanding the interactions between anaesthetic procedures, PH, and cardiopulmonary interactions. Intraoperative and postoperative monitoring is crucial for maintaining the haemodynamic parameters and helps titrate anaesthetic agents and medication. This narrative review focusses on all issues related to anaesthetic and surgical challenges in patients with PH. This review aimed to suggest a preoperative evaluation plan, surgical decision-making, anaesthetic plan, and anaesthetic management based on the evidence available in the literature.
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Affiliation(s)
- Ajay Kumar Jha
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.
| | - Nivedita Jha
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Vishwas Malik
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
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11
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Oshita K, Tokuyama S, Jotaki S, Yokomizo M, Hiraki T. Anesthetic management of a patient with methamphetamine-associated pulmonary arterial hypertension undergoing laparoscopic cholecystectomy. JA Clin Rep 2023; 9:10. [PMID: 36801985 PMCID: PMC9939558 DOI: 10.1186/s40981-023-00601-3] [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: 11/21/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Methamphetamine abuse is a serious public health concern and causes various life-threatening disorders including pulmonary arterial hypertension (PAH). Herein, we present the first case report describing the anesthetic management of a patient with methamphetamine-associated PAH (M-A PAH) undergoing laparoscopic cholecystectomy. CASE PRESENTATION A 34-year-old female with M-A PAH suffered from deterioration of right ventricular (RV) heart failure due to recurrent cholecystitis and was scheduled for laparoscopic cholecystectomy. Preoperative assessment of PA pressure showed 82/32 (mean, 50) mmHg, and transthoracic echocardiology revealed a slight reduction of RV function. General anesthesia was induced and maintained by thiopental, remifentanil, sevoflurane, and rocuronium. PA pressure gradually increased after peritoneal insufflation; therefore, we administered dobutamine and nitroglycerin to decrease pulmonary vascular resistance (PVR). The patient emerged from anesthesia smoothly. CONCLUSIONS Avoiding increased PVR by appropriate anesthesia and medical hemodynamic support is an important consideration for patients with M-A PAH.
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Affiliation(s)
- Kensuke Oshita
- Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka, 830-0011, Japan.
| | - Shin Tokuyama
- grid.410781.b0000 0001 0706 0776Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka 830-0011 Japan
| | - Shosaburo Jotaki
- grid.410781.b0000 0001 0706 0776Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka 830-0011 Japan
| | - Michiko Yokomizo
- grid.410781.b0000 0001 0706 0776Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka 830-0011 Japan
| | - Teruyuki Hiraki
- grid.410781.b0000 0001 0706 0776Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-Machi, Kurume, Fukuoka 830-0011 Japan
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12
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McGlothlin D, Granton J, Klepetko W, Beghetti M, Rosenzweig EB, Corris P, Horn E, Kanwar M, McRae K, Roman A, Tedford R, Badagliacca R, Bartolome S, Benza R, Caccamo M, Cogswell R, Dewachter C, Donahoe L, Fadel E, Farber HW, Feinstein J, Franco V, Frantz R, Gatzoulis M, Hwa (Anne) Goh C, Guazzi M, Hansmann G, Hastings S, Heerdt P, Hemnes A, Herpain A, Hsu CH, Kerr K, Kolaitis N, Kukreja J, Madani M, McCluskey S, McCulloch M, Moser B, Navaratnam M, Radegran G, Reimer C, Savale L, Shlobin O, Svetlichnaya J, Swetz K, Tashjian J, Thenappan T, Vizza CD, West S, Zuckerman W, Zuckermann A, De Marco T. ISHLT CONSENSUS STATEMENT: Peri-operative Management of Patients with Pulmonary Hypertension and Right Heart Failure Undergoing Surgery. J Heart Lung Transplant 2022; 41:1135-1194. [DOI: 10.1016/j.healun.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
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13
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Zochios V, Yusuff H, Conway H, Lau G, Schmidt M. The Right Ventricle During Veno-Venous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome: Can We Protect the Injured Ventricle? ASAIO J 2022; 68:456-460. [PMID: 35349520 DOI: 10.1097/mat.0000000000001655] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Vasileios Zochios
- From the Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
| | - Hakeem Yusuff
- From the Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
- University of Leicester, Leicester, United Kingdom
| | - Hannah Conway
- From the Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
| | - Gary Lau
- From the Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, RESPIRE, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
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14
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Zochios V, Charlesworth M. Protecting the right ventricle in COVID-19 pneumonitis: a missing piece of the puzzle? Anaesthesia 2022; 77:739-742. [PMID: 35315056 PMCID: PMC9111229 DOI: 10.1111/anae.15720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Affiliation(s)
- V Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, University of Leicester, UK
| | - M Charlesworth
- Department of Cardiothoracic Critical Care Medicine and ECMO, Wythenshawe Hospital, Manchester, UK
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15
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Cambruzzi M, Borgeat K, MacFarlane P. Anaesthetic management of a dog with severe pulmonary stenosis and R2A right coronary artery anomaly undergoing placement of a hybrid transventricular pulmonary stent. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Martina Cambruzzi
- Small Animal Hospital Langford Vets University of Bristol Langford UK
| | - Kieran Borgeat
- Small Animal Hospital Langford Vets University of Bristol Langford UK
| | - Paul MacFarlane
- Small Animal Hospital Langford Vets University of Bristol Langford UK
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16
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Adie SK, Abdul-Aziz AA, Ketcham SW, Moles VM. Considerations for Inotrope and Vasopressor Use in Critically Ill Patients With Pulmonary Arterial Hypertension. J Cardiovasc Pharmacol 2022; 79:e11-e17. [PMID: 34654789 DOI: 10.1097/fjc.0000000000001155] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/21/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Pulmonary arterial hypertension (PAH) is a rare and progressive cardiopulmonary disease, characterized by pulmonary vasculopathy. The disease can lead to increase pulmonary arterial pressures and eventual right ventricle failure due to elevated afterload. The prevalence of PAH in patients admitted to the intensive care unit (ICU) is unknown, and pulmonary hypertension (PH) in the ICU is more commonly the result of left heart disease or hypoxic lung injury (PH due to left heart disease and PH due to lung diseases and/or hypoxia, respectively), as opposed to PAH. Management of patients with PAH in the ICU is complex as it requires a careful balance to maintain perfusion while optimizing right-sided heart function. A comprehensive understanding of the underlying physiology and underlying hemodynamics is crucial for the management of this population. In this review, we summarized the evidence for use of vasopressors and inotropes in the management of PH and extrapolated the data to patients with PAH. We strongly believe that the understanding of the hemodynamic consequences of inotropes and vasopressors, especially from data in the PH population, can lead to better management of this complex patient population.
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Affiliation(s)
- Sarah K Adie
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, MI
| | - Ahmad A Abdul-Aziz
- Division of Critical Care, Department of Internal Medicine, Stanford University, Palo Alto, CA; and
| | - Scott W Ketcham
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Victor M Moles
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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In-silico analysis of closed-loop vasopressor control of phenylephrine versus norepinephrine. J Clin Monit Comput 2021; 36:1305-1313. [PMID: 34599736 DOI: 10.1007/s10877-021-00761-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/23/2021] [Indexed: 10/20/2022]
Abstract
We have previously demonstrated in in-silico, pre-clinical animal models, and finally human clinical studies the ability of a novel closed-loop vasopressor titration system to manage norepinephrine infusion rates to keep mean arterial blood pressure in a very tight range, reduce hypotension time and severity, and reduce overtreatment. We hypothesized that the same controller could, with modification for pharmacologic differences, suitably titrate a lower-potency longer duration of action agent like phenylephrine. Using the same physiologic simulation model as was used previously for in-silico testing of our controller for norepinephrine, we first updated the model to include a new vasopressor agent modeled after phenylephrine. A series of simulation tests patterned after our previous norepinephrine study was then conducted, this time using phenylephrine for management, in order to both test the system with the new agent and allow for comparisons between the two. Hundreds of simulation trials were conducted across a range of patient and environmental variances. The controller performance was characterized based on time in target, time above and below target, coefficient of variation, and using Varvel's criteria. The controller kept the simulated patients' MAP in target for 94% of management time in the simple scenarios and more than 85% of time in the most challenging scenarios. Varvel criteria were all under 1% error for expected pharmacologic responses and were consistent with those established for norepinephrine in our previous studies. The controller was able to acceptably titrate phenylephrine in this simulated patient model consistent with performance previously seen for norepinephrine after adjusting for the anticipated differences between the two agents.
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18
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Vahdatpour CA, Ryan JJ, Zimmerman JM, MacCormick SJ, Palevsky HI, Alnuaimat H, Ataya A. Advanced airway management and respiratory care in decompensated pulmonary hypertension. Heart Fail Rev 2021; 27:1807-1817. [PMID: 34476657 PMCID: PMC8412384 DOI: 10.1007/s10741-021-10168-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 12/19/2022]
Abstract
Meticulous risk stratification is essential when considering intubation of a patient with decompensated pulmonary hypertension (dPH). It is paramount to understand both the pathophysiology of dPH (and associated right ventricular failure) and the complications related to a high-risk intubation before attempting the procedure. There are few recommendations in this area and the literature, guiding these recommendations, is limited to expert opinion and very few case reports/case series. This review will discuss the complex pathophysiology of dPH, the complications associated with intubation, the debates surrounding induction agents, and the available options for the intubation procedure, with specific emphasis on the emerging role for awake fiberoptic intubation. All patients should be evaluated for candidacy for veno-arterial extracorporeal membrane oxygen as a bridge to recovery, lung transplantation, or pulmonary endarterectomy prior to intubation. Only an experienced proceduralist who is both comfortable with high-risk intubations and the pathophysiology of dPH should perform these intubations.
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Affiliation(s)
- Cyrus A Vahdatpour
- Department of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, P.O Box 100225 JHMHC, Gainesville, FL, 32610-0225, USA.
| | - John J Ryan
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA
| | - Joshua M Zimmerman
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Samuel J MacCormick
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Harold I Palevsky
- Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Hassan Alnuaimat
- Department of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, P.O Box 100225 JHMHC, Gainesville, FL, 32610-0225, USA
| | - Ali Ataya
- Department of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, P.O Box 100225 JHMHC, Gainesville, FL, 32610-0225, USA
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Jasinski T, Migon D, Sporysz K, Kamysz W, Owczuk R. The Density of Different Local Anesthetic Solutions, Opioid Adjuvants and Their Clinically Used Combinations: An Experimental Study. Pharmaceuticals (Basel) 2021; 14:801. [PMID: 34451898 PMCID: PMC8401070 DOI: 10.3390/ph14080801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/31/2021] [Accepted: 08/13/2021] [Indexed: 11/20/2022] Open
Abstract
Various opioids are added to local anesthetic solutions for spinal anesthesia. This may change the final density of the local anestetic (LA) mixture. This effect regarding current concepts in spinal anesthesia needs to be re-evaluated. In order to re-evaluate such effects, hyperbaric and isobaric local anesthetic (LA) solutions were mixed with opioid adjuvants (A) using the equipment available in the operating room. Ten density measurements for each composition (LA-A) were performed. The density change of 0.0006 g/mL was regarded as significant. Measured densities were also compared with theoretical values calculated using Hare's. As a result, the addition of an opioid adjuvant caused a significant reduction in the final density of the LA-A solution. In hyperbaric LA mixtures, it did not change the baricity from hyperbaric to isobaric. However, the addition of highly hypobaric fentanyl 0.99360 g/mL (SD ± 0.00004) changes all isobaric LA solutions baricity to hypobaric. The comparison of measured and theoretical densities revealed significant differences (p > 0.05). However, the absolute reduction reached 0.0006 g/mL in only two LA-A compositions. We conclude that the addition of fentanyl to isobaric LA results in a hypobaric solution that may affect the distribution of the block. The inadequacy of LA-A in a clinical setting is unlikely to influence block characteristics.
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Affiliation(s)
- Tomasz Jasinski
- Department of Anesthesiology and Intensive Therapy, Medical University of Gdansk, 80-214 Gdansk, Poland; (T.J.); (K.S.)
| | - Dorian Migon
- Department of Inorganic Chemistry, Medical University of Gdansk, 80-416 Gdansk, Poland; (D.M.); (W.K.)
| | - Krystian Sporysz
- Department of Anesthesiology and Intensive Therapy, Medical University of Gdansk, 80-214 Gdansk, Poland; (T.J.); (K.S.)
| | - Wojciech Kamysz
- Department of Inorganic Chemistry, Medical University of Gdansk, 80-416 Gdansk, Poland; (D.M.); (W.K.)
| | - Radoslaw Owczuk
- Department of Anesthesiology and Intensive Therapy, Medical University of Gdansk, 80-214 Gdansk, Poland; (T.J.); (K.S.)
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20
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Liao LM, Zhou L, Wang CR, Hu JY, Lu YJ, Huang S. Opposing responses of the rat pulmonary artery and vein to phenylephrine and other agents in vitro. BMC Pulm Med 2021; 21:189. [PMID: 34090386 PMCID: PMC8180060 DOI: 10.1186/s12890-021-01558-8] [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] [Received: 07/01/2020] [Accepted: 05/27/2021] [Indexed: 11/10/2022] Open
Abstract
Background Different from current cognition, our study demonstrated that adrenergic receptors agonist phenylephrine significantly relaxed isolated pulmonary artery but constricted pulmonary veins. Through comparing differences in the effects of commonly used vasoactive drugs on pulmonary artery and veins, the study aimed to improve efficiency and accuracy of isolated pulmonary vascular experiments, and to provide experimental basis for clinical drug use. Methods The contractile responses of pulmonary arteries and veins from twelve-week-old Male Sprague-Dawley rats to phenylephrine, arginine vasopressin (AVP), U46619, endothelin-1, and potassium chloride (KCl) were recorded, as well as the relaxation in response to phenylephrine, AVP, acetylcholine. To further explore the mechanism, some vessels was also pre-incubated with adrenergic receptors antagonists propranolol, prazosin and nitric oxide synthesis inhibitor N[gamma]-nitro-L-arginine methyl ester (L-NAME) before addition of the experimental drugs. Results Phenylephrine constricted pulmonary veins directly, but constricted pulmonary artery only after incubation with propranolol or/and L-NAME. The pulmonary artery exhibited significant relaxation to AVP with or without L-NAME incubation. AVP more clearly constricted the veins after incubation with L-NAME. Changes in vascular tension also varied from pulmonary artery to veins for KCl stimulation. Different from phenomena presented in veins, acetylcholine did not relax pulmonary artery preconstricted by KCl, U46619, and endothelin-1. Conclusions According to the results, phenylephrine, KCl, AVP, and acetylcholine could be used to distinguish pulmonary arteries and pulmonary veins in vitro. This also suggested that the pulmonary arteries and pulmonary veins have great differences in physiology and drug reactivity.
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Affiliation(s)
- Li-Mei Liao
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang road, Shanghai, 200090, China.,Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jinsui Road, Guangzhou, 510623, China
| | - Li Zhou
- Department of Physiology and Pathophysiology, School of Basic Medicine Science, Fudan University, 130 Dongan Road, Shanghai, 200032, China.
| | - Chen-Ran Wang
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang road, Shanghai, 200090, China
| | - Jian-Ying Hu
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang road, Shanghai, 200090, China
| | - Yao-Jun Lu
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang road, Shanghai, 200090, China
| | - Shaoqiang Huang
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang road, Shanghai, 200090, China.
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21
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Zochios V, Lau G, Conway H, Yusuff HO. Protecting the Injured Right Ventricle in COVID-19 Acute Respiratory Distress Syndrome: Can Clinicians Personalize Interventions and Reduce Mortality? J Cardiothorac Vasc Anesth 2021; 35:3325-3330. [PMID: 34247924 PMCID: PMC8178062 DOI: 10.1053/j.jvca.2021.05.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 05/30/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Vasileios Zochios
- Department of Critical Care Medicine, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK; Birmingham Acute Care Research, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK
| | - Gary Lau
- Department of Cardiac Anesthesia and Intensive Care, University Hospitals Leicester National Health Service Trust, Glenfield Hospital, Leicester, UK
| | - Hannah Conway
- Department of Cardiac Anesthesia and Intensive Care, University Hospitals Leicester National Health Service Trust, Glenfield Hospital, Leicester, UK
| | - Hakeem O Yusuff
- Department of Cardiac Anesthesia and Intensive Care, University Hospitals Leicester National Health Service Trust, Glenfield Hospital, Leicester, UK; University of Leicester, Leicester, UK
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22
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Bootsma IT, de Lange F, Scheeren TWL, Jainandunsing JS, Boerma EC. High Versus Normal Blood Pressure Targets in Relation to Right Ventricular Dysfunction After Cardiac Surgery: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2021; 35:2980-2990. [PMID: 33814247 DOI: 10.1053/j.jvca.2021.02.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Management of right ventricular (RV) dysfunction is challenging. Current practice predominantly is based on data from experimental and small uncontrolled studies and includes augmentation of blood pressure. However, whether such intervention is effective in the clinical setting of cardiac surgery is unknown. DESIGN Randomized controlled trial. SETTING Single-center study in a tertiary teaching hospital. PARTICIPANTS The study comprised 78 patients equipped with a pulmonary artery catheter (PAC), classified according to PAC-derived RV ejection fraction (RVEF); 44 patients had an RVEF of <20%, and 34 patients had an RVEF between ≥20% and <30%. INTERVENTIONS Patients randomly were assigned to either a normal target group (mean arterial pressure 65 mmHg) or a high target group [mean arterial pressure 85 mmHg]). The primary end- point was the change in RVEF over a one-hour study period. MEASUREMENTS AND MAIN RESULTS There was no significant between-group difference in change of RVEF <20% (-1% [-3.3 to 1.8] in the normal-target group v 0.5% [-1 to 4] in the high-target group; p = 0.159). There was no significant between-group difference in change in RVEF 20%-to-30% (-1% [-3 to 0] in the normal-target group v 1% [-1 to 3] in the high-target group; p = 0.074). These results were in line with the simultaneous observation that echocardiographic variables of RV and left ventricular function also remained unaltered over time, irrespective of either baseline RVEF or treatment protocol. CONCLUSION In a mixed cardiac surgery population with RV dysfunction, norepinephrine-mediated high blood pressure targets did not result in an increase in PAC-derived RVEF compared with normal blood pressure targets.
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Affiliation(s)
- Inge T Bootsma
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands.
| | - Fellery de Lange
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Thomas W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jayant S Jainandunsing
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
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23
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Steppan J, Heerdt PM. Preoperative Assessment and Perioperative Management of the Patient with Pulmonary Vascular Disease. Clin Chest Med 2021; 42:133-141. [PMID: 33541607 DOI: 10.1016/j.ccm.2020.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The incidence of pulmonary hypertension (PH) in patients undergoing noncardiac surgery has increased steadily over the past decade. Patients with known PH have significantly higher perioperative morbidity and mortality than those without PH. Moreover, a substantial number of patients may have occult disease. It, therefore, is of paramount importance for perioperative providers to recognize high-risk patients and treat them appropriately. This review first provides an overview of PH pathophysiology, then estimates the perioperative incidence of PH and its impact on surgical outcomes, and finally outlines a perioperative management strategy.
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Affiliation(s)
- Jochen Steppan
- Johns Hopkins University, School of Medicine, Department of Anesthesiology and Critical Care Medicine, Baltimore, MD, USA.
| | - Paul M Heerdt
- Department of Anesthesiology Yale School of Medicine, Division of Applied Hemodynamics, New Haven, CT, USA
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24
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Guarracino F, Habicher M, Treskatsch S, Sander M, Szekely A, Paternoster G, Salvi L, Lysenko L, Gaudard P, Giannakopoulos P, Kilger E, Rompola A, Häberle H, Knotzer J, Schirmer U, Fellahi JL, Hajjar LA, Kettner S, Groesdonk HV, Heringlake M. Vasopressor Therapy in Cardiac Surgery-An Experts' Consensus Statement. J Cardiothorac Vasc Anesth 2020; 35:1018-1029. [PMID: 33334651 DOI: 10.1053/j.jvca.2020.11.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 12/17/2022]
Abstract
Hemodynamic conditions with reduced systemic vascular resistance commonly are observed in patients undergoing cardiac surgery and may range from moderate reductions in vascular tone, as a side effect of general anesthetics, to a profound vasodilatory syndrome, often referred to as vasoplegic shock. Therapy with vasopressors is an important pillar in the treatment of these conditions. There is limited guidance on the appropriate choice of vasopressors to restore and optimize systemic vascular tone in patients undergoing cardiac surgery. A panel of experts in the field convened to develop statements and evidence-based recommendations on clinically relevant questions on the use of vasopressors in cardiac surgical patients, using a critical appraisal of the literature following the GRADE system and a modified Delphi process. The authors unanimously and strongly recommend the use of norepinephrine and/or vasopressin for restoration and maintenance of systemic perfusion pressure in cardiac surgical patients; despite that, the authors cannot recommend either of these drugs with respect to the risk of ischemic complications. The authors unanimously and strongly recommend against using dopamine for treating post-cardiac surgery vasoplegic shock and against using methylene blue for purposes other than a rescue therapy. The authors unanimously and weakly recommend that clinicians consider early addition of a second vasopressor (norepinephrine or vasopressin) if adequate vascular tone cannot be restored by a monotherapy with either norepinephrine or vasopressin and to consider using vasopressin as a first-line vasopressor or to add vasopressin to norepinephrine in cardiac surgical patients with pulmonary hypertension or right-sided heart dysfunction.
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Affiliation(s)
- Fabio Guarracino
- Department of Anesthesia and Intensive Care Medicine, University Hospital of Pisa, Pisa, Italy
| | - Marit Habicher
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Gieβen, Justus-Liebig University Gieβen, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Operative Intensive Care Medicine Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Gieβen, Justus-Liebig University Gieβen, Germany
| | - Andrea Szekely
- Department of Anesthesia, Semmelweis University Budapest, Budapest, Hungary
| | - Gianluca Paternoster
- Division of Cardiac Resuscitation, Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | - Luca Salvi
- IRCCS Centro Cardiologico Monzino, Milano, Italy
| | - Lidia Lysenko
- Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Phillipe Gaudard
- Department of Anaesthesiology and Critical Care Medicine Arnaud de Villeneuve, CHU Montpellier, University of Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | | | - Erich Kilger
- Department of Anesthesiology, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Amalia Rompola
- Department of Cardiac Surgery Intensive Care, Onassis Cardiac Center, Kallithea Athens, Greece
| | - Helene Häberle
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Johann Knotzer
- Department of Anaesthesiology and Critical Care Medicine, County Hospital Wels, Wels, Austria
| | - Uwe Schirmer
- Institute for Anesthesiology, Heart, and Diabetes Center, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care, Hôpital Cardiologique Louis Pradel, Lyon, France
| | - Ludhmila Abrahao Hajjar
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clínicas, Sao Paulo, Brazil
| | - Stephan Kettner
- Department of Anesthesiology and Intensive Care, Vienna Hospital Association, Vienna, Austria
| | | | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care, Heart- and Diabetes Center Mecklenburg - Western Pomerania, Karlsburg, Germany.
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Tian L, Xiong PY, Alizadeh E, Lima PDA, Potus F, Mewburn J, Martin A, Chen K, Archer SL. Supra-coronary aortic banding improves right ventricular function in experimental pulmonary arterial hypertension in rats by increasing systolic right coronary artery perfusion. Acta Physiol (Oxf) 2020; 229:e13483. [PMID: 32339403 DOI: 10.1111/apha.13483] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022]
Abstract
AIM Pulmonary arterial hypertension (PAH) results in right ventricular (RV) dysfunction owing, in part, to RV ischemia. The relative contribution of RV microvascular rarefaction vs reduced right coronary artery perfusion pressure (RCA-PP) to RV ischemia remains unknown. We hypothesize that increasing RCA-PP improves RV function in PAH by increasing RV systolic perfusion. METHODS Supra-coronary aortic banding (SAB) or sham surgery was performed on male Sprague-Dawley rats. Seven to ten days later, rats received either monocrotaline (MCT; 60 mg/kg) or saline. After 1 month, echocardiography, cardiac catheterization, 99m Tc-sestamibi single-photon emission computed tomography (SPECT) and microsphere infusion studies were performed. The RV was harvested for measurement of hypertrophy (RVH), fibrosis and immunoblotting, and the lung was harvested for pulmonary artery (PA) histology. RESULTS Supra-coronary aortic banding increased systolic pressures in proximal aorta and systolic RCA-PP in SAB + MCT vs MCT rats (114 ± 12 vs 5 ± 9 mm Hg), without altering diastolic RCA-PP. SAB + MCT rats had improved RV function vs MCT rats, evident from their significantly increased cardiac output (CO), RV free wall (RVFW) thickening, tricuspid annular plane systolic excursion (TAPSE) and RV-PA coupling indices. RV-PA coupling indices and CO correlated directly with systolic RCA-PP. RV perfusion was increased in SAB + MCT vs MCT rats and correlated well with CO; whereas microvascular rarefaction was unaltered. SAB + MCT rats had less RVH and fibrosis and lower PA pressures vs MCT rats. SAB + MCT rats had significantly lower RV pyruvate kinase muscle isoform 2/1 ratios than MCT rats, consistent with restoration of oxidative metabolism. CONCLUSION A SAB-induced increase in systolic RCA-PP improves RV perfusion and function in MCT rats. Maintaining systolic RCA perfusion can preserve RV function in PAH.
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Affiliation(s)
- Lian Tian
- Department of Medicine Queen's University Kingston ON Canada
| | - Ping Yu Xiong
- Department of Medicine Queen's University Kingston ON Canada
- Department of Biomedical and Molecular Sciences Queen's University Kingston ON Canada
| | | | | | - François Potus
- Department of Medicine Queen's University Kingston ON Canada
| | - Jeffrey Mewburn
- Department of Medicine Queen's University Kingston ON Canada
| | - Ashley Martin
- Department of Medicine Queen's University Kingston ON Canada
| | | | - Stephen L. Archer
- Department of Medicine Queen's University Kingston ON Canada
- Queen's CardioPulmonary Unit (QCPU) Kingston ON Canada
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Wang J, Lu J. Anesthesia for Pregnant Women with Pulmonary Hypertension. J Cardiothorac Vasc Anesth 2020; 35:2201-2211. [PMID: 32736999 DOI: 10.1053/j.jvca.2020.06.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 12/12/2022]
Abstract
Despite advances in the therapy for pulmonary hypertension over the past decades, the prognosis of pregnant patients with pulmonary hypertension remains poor, with high maternal mortality. This poses a particular challenge for the mother and her medical team. In the present review, the authors have updated the classification and definition of pulmonary hypertension, summarized the current knowledge with regard to perioperative management and anesthesia considerations for these patients, and stressed the importance of a "pregnancy heart team" to improve long-term outcomes of pregnant women with pulmonary hypertension.
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Affiliation(s)
- Jiawan Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jiakai Lu
- Department of Anesthesiology, Beijing An-Zhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China.
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27
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Mondal S, Sankova S, Lee K, Sorensen E, Kaczorowski D, Mazzeffi M. Intraoperative and Early Postoperative Management of Patients Undergoing Minimally Invasive Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2020; 35:616-630. [PMID: 32505605 DOI: 10.1053/j.jvca.2020.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/03/2020] [Accepted: 04/09/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Susan Sankova
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Khang Lee
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Erik Sorensen
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - David Kaczorowski
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
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Abstract
Acute right ventricular failure remains the leading cause of mortality associated with acute pulmonary embolism (PE). This article reviews the pathophysiology behind acute right ventricular failure and strategies for managing right ventricular failure in acute PE. Immediate clot reduction via systemic thrombolytics, catheter based procedures, or surgery is always advocated for unstable patients. While waiting to mobilize these resources, it often becomes necessary to support the RV with vasoactive medications. Clinicians should carefully assess volume status and use caution with volume resuscitation. Right ventricular assist devices may have an expanding role in the future.
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Affiliation(s)
- Steven Zhao
- Division of Pulmonary and Critical Care medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Room 6728, Los Angeles, CA 90048, USA
| | - Oren Friedman
- Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, Los Angeles, CA 90048, USA.
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29
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Jentzer JC, Hollenberg SM. Vasopressor and Inotrope Therapy in Cardiac Critical Care. J Intensive Care Med 2020; 36:843-856. [PMID: 32281470 DOI: 10.1177/0885066620917630] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients admitted to the cardiac intensive care unit (CICU) are often in shock and require hemodynamic support. Identifying and addressing the pathophysiology mechanisms operating in an individual patient is crucial to achieving a successful outcome, while initiating circulatory support therapy to restore adequate tissue perfusion. Vasopressors and inotropes are the cornerstone of supportive medical therapy for shock, in addition to fluid resuscitation when indicated. Timely initiation of optimal vasopressor and inotrope therapy is essential for patients with shock, with the ultimate goals of restoring effective tissue perfusion in order to normalize cellular metabolism. Use of vasoactive agents for hemodynamic support of patients with shock should take both arterial pressure and tissue perfusion into account when choosing therapeutic interventions. For most patients with shock, including cardiogenic or septic shock, norepinephrine (NE) is an appropriate choice as a first-line vasopressor titrated to achieve an adequate arterial pressure due to a lower risk of adverse events than other catecholamine vasopressors. If tissue and organ perfusion remain inadequate, an inotrope such as dobutamine may be added to increase cardiac output to a sufficient level that meets tissue demand. Low doses of epinephrine or dopamine may be used for inotropic support, but high doses of these drugs carry an excessive risk of adverse events when used for vasopressor support and should be avoided. When NE alone is inadequate to achieve an adequate arterial pressure, addition of a noncatecholamine vasopressor such as vasopressin or angiotensin-II is reasonable, in addition to rescue therapies that may improve vasopressor responsiveness. In this review, we discuss the pharmacology and evidence-based use of vasopressor and inotrope drugs in critically ill patients, with a focus on the CICU population.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, 4352Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Steven M Hollenberg
- Department of Cardiology, 3673Hackensack University Medical Center, Hackensack, NJ, USA
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30
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The Right Ventricle-You May Forget it, but It Will Not Forget You. J Clin Med 2020; 9:jcm9020432. [PMID: 32033368 PMCID: PMC7074056 DOI: 10.3390/jcm9020432] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 01/21/2023] Open
Abstract
Right ventricular (RV) dysfunction and failure are common and often overlooked causes of perioperative deterioration and adverse outcomes. Due to its unique pathophysiologic underpinnings, RV failure often does not respond to typical therapeutic measures such as volume resuscitation and often worsens when therapy is escalated and mechanical ventilation is begun, with a danger of irreversible cardiovascular collapse and death. The single most important factor in improving outcomes in the context of RV failure is anticipating and recognizing it. Once established, a vicious circle of systemic hypotension, and RV ischemia and dilation is set in motion, rapidly spiraling down into a state of shock culminating in multi-organ failure and ultimately death. Therapy of RV failure must focus on rapidly reestablishing RV coronary perfusion, lowering pulmonary vascular resistance and optimizing volemia. In parallel, underlying reversible causes should be sought and if possible treated. In all stages of diagnostics and therapy, echocardiography plays a central role. In severe cases of RV dysfunction there remains a role for the use of the pulmonary artery catheter. When these mostly simple measures are undertaken in a timely fashion, the spiral of death of RV failure can often be broken or even prevented altogether.
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31
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Fredholm M, Jörgensen K, Houltz E, Ricksten S. Levosimendan or milrinone for right ventricular inotropic treatment?-A secondary analysis of a randomized trial. Acta Anaesthesiol Scand 2020; 64:193-201. [PMID: 31556095 DOI: 10.1111/aas.13486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND The aim of the present study was to compare the effects of milrinone and levosimendan on right ventricular (RV) inotropy and lusitropy in patients after aortic valve replacement (AVR) for aortic stenosis, a procedure in which an abnormal postoperative RV function may be seen. METHODS In a prospective, blinded trial, 31 patients were randomized to receive either milrinone (0.4 and 0.8 µg/kg/min, n = 16) or levosimendan (0.1 and 0.2 µg/kg/min, n = 15) after AVR for aortic stenosis. RV performance, afterload (pulmonary arterial elastance), RV strain, systolic (SR-S) and early diastolic (SR-E) strain rate were measured by pulmonary artery thermodilution catheterization and transoesophageal two-dimensional speckle tracking echocardiography. To circumvent the indirect effects of inodilator-induced hemodynamic changes on RV systolic and diastolic deformation, pulmonary arterial elastance, central venous pressure and heart rate were maintained constant by atrial pacing, plasma volume expansion with colloids and phenylephrine-induced vasoconstriction during treatment with the inotropes. RESULTS A dose-dependent increase in stroke volume index and cardiac index by approximately 20% were seen with both agents at the highest doses, with no difference between groups (P = .792 and 0.744, respectively). In both groups, RV strain and SR-S dose-dependently increased by 20% and 15%-19%, respectively, at the highest doses (P = .742 and 0.259, respectively) with no difference between groups. SR-E improved by both agents 20%-24% at the highest dose with no difference between groups (P = .714). CONCLUSIONS The direct RV inotropic and lusitropic effects of levosimendan and milrinone were comparable at clinically relevant infusion rates.
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Affiliation(s)
- Martin Fredholm
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| | - Kirsten Jörgensen
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| | - Erik Houltz
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| | - Sven‐Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
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Francis L, Whitener S, McKinnon J, Whitener G. Pulmonary Hypertension and Thoracic Surgery: Impact and Treatment Options. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00360-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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33
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Abstract
Patients with pulmonary arterial hypertension (PAH) who are admitted to the intensive care unit (ICU) pose a challenge to the multidisciplinary health-care team due to the complexity of the pathophysiology of their disease state and the medication considerations that must be made to appropriately manage them. PAH is a progressive disease with the majority of patients ultimately dying as a result of right ventricular (RV) failure. During an acute decompensation, patients must be appropriately managed to optimize volume status, RV function, cardiac output, and systemic perfusion, while treating the underlying cause of the exacerbation. During times of critical illness, the ability to administer medications approved for use in PAH can be impacted by end-organ damage, hemodynamic instability, new drug interactions, or available dosage forms. Balancing the multimodal treatment approach needed to manage an acute exacerbation and the pharmacokinetic and administration concerns impacting baseline PAH therapy as a result of critical illness requires an expert multiprofessional PAH team. The purpose of this review is to evaluate specific management considerations for critically ill patients with PAH in the ICU.
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Affiliation(s)
- Heather Torbic
- 1 Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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34
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Poidinger B, Kotzinger O, Rützler K, Kleinsasser A, Zierer A, Knotzer H. Intravenous Levosimendan and Vasopressin in New-Onset Acute Pulmonary Hypertension After Weaning from Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2019; 33:328-333. [DOI: 10.1053/j.jvca.2018.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Indexed: 11/11/2022]
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35
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Park J, Lee SH, Kim J, Park SJ, Park MS, Choi GS, Lee SK, Kim GS. Predictive Value of Intraoperative Pulmonary Vascular Resistance in Liver Transplantation. Liver Transpl 2018; 24:1680-1689. [PMID: 30240130 DOI: 10.1002/lt.25341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/04/2018] [Indexed: 01/13/2023]
Abstract
We aimed to evaluate the association between intraoperative pulmonary vascular resistance (PVR) and clinical outcome of liver transplantation (LT). Cardiovascular involvement of end-stage liver disease is relatively common, and hemodynamic instability during LT can be fatal to recipients. However, the clinical impact of intraoperative PVR in LT remains undetermined. A total of 363 adult recipients with intraoperative right heart catheterization from January 2011 to May 2016 were analyzed. Patients were divided into 2 groups according to PVR. Two separate analyses were performed according to the time point of measurement: at the beginning and at the end of LT. The primary outcome was all-cause death or graft failure during the follow-up period. Increased PVR was observed in 11.8% (43/363) of recipients at the beginning and 12.7% (46/363) of recipients at the end of LT. PVR at the beginning of LT had no significant effect on the rate of death or graft failure in the multivariate analysis (hazard ratio [HR], 1.24; 95% confidence interval [CI], 0.64-2.38; P = 0.52). In contrast, PVR at the end of LT was significantly associated with death or graft failure during the overall follow-up period (HR, 2.00; 95% CI, 1.13-3.54; P = 0.02). In conclusion, PVR at the end of LT, rather than the beginning, is associated with clinical outcome. Larger trials are needed to support this finding.
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Affiliation(s)
- Jungchan Park
- Departments of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Hwa Lee
- Division of Cardiology, Heart, Stroke and Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeayoun Kim
- Departments of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soo Jung Park
- Departments of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Myung Soo Park
- Department of Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Seoul, South Korea
| | - Gyu-Seong Choi
- Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Suk-Koo Lee
- Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gaab Soo Kim
- Department of Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Seoul, South Korea
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Rana M, Yusuff H, Zochios V. The Right Ventricle During Selective Lung Ventilation for Thoracic Surgery. J Cardiothorac Vasc Anesth 2018; 33:2007-2016. [PMID: 30595486 DOI: 10.1053/j.jvca.2018.11.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Indexed: 12/25/2022]
Abstract
The right ventricle (RV) has been an area of evolving interest after decades of being ignored and considered less important than the left ventricle. Right ventricular dysfunction/failure is an independent predictor of mortality and morbidity in cardiac surgery; however, very little is known about the incidence or impact of RV dysfunction/failure in thoracic surgery. The pathophysiology of RV dysfunction/failure has been studied in the context of acute respiratory distress syndrome (ARDS), cardiac surgery, pulmonary hypertension, and left ventricular failure, but limited data exist in literature addressing the issue of RV dysfunction/failure in the context of thoracic surgery and one-lung ventilation (OLV). Thoracic surgery and OLV present as a unique situation where the RV is faced with sudden changes in afterload, preload, and contractility throughout the perioperative period. The authors discuss the possible pathophysiologic mechanisms that can affect adversely the RV during OLV and introduce the term RV injury to the myocardium that is affected adversely by the various intraoperative factors, which then makes it predisposed to acute dysfunction. The most important of these mechanisms seems to be the role of intraoperative mechanical ventilation, which potentially could cause both ventilator-induced lung injury leading to ARDS and RV injury. Identification of at-risk patients in the perioperative period using focused imaging, particularly echocardiography, is paramount. The authors also discuss the various RV-protective strategies required to prevent RV dysfunction and management of established RV failure.
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Affiliation(s)
- Meenal Rana
- University Hospitals of Leicester National Health Service Trust, Department of Cardiothoracic Anesthesia and Critical Care Medicine, Glenfield Hospital, Leicester, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK
| | - Hakeem Yusuff
- University Hospitals of Leicester National Health Service Trust, Department of Cardiothoracic Anesthesia and Critical Care Medicine, Glenfield Hospital, Leicester, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK.
| | - Vasileios Zochios
- University Hospitals Birmingham National Health Service Foundation Trust, Department of Critical Care Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham, UK
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Monaco F, Di Prima AL, De Luca M, Barucco G, Zangrillo A. Periprocedural and perioperatory management of patients with tricuspid valve disease. Minerva Cardioangiol 2018; 66:691-699. [DOI: 10.23736/s0026-4725.18.04699-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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38
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Hassani V, Movaseghi G, Safaeeyan R, Masghati S, Ghorbani Yekta B, Farahmand Rad R. Comparison of Ephedrine vs. Norepinephrine in Treating Anesthesia-Induced Hypotension in Hypertensive Patients: Randomized Double-Blinded Study. Anesth Pain Med 2018; 8:e79626. [PMID: 30271750 PMCID: PMC6150924 DOI: 10.5812/aapm.79626] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/08/2018] [Accepted: 08/08/2018] [Indexed: 12/04/2022] Open
Abstract
Background Hypotension is a common problem in general anesthesia. Maintaining the mean arterial pressure by choosing a vasopressor with minimal complications is still discussed in various surgeries. Objectives The aim of this study is comparison of ephedrine versus norepinephrine in treating anesthesia-induced hypotension in hypertensive patients in spinal surgery in a randomized double-blinded study. Methods This randomized, double-blinded study was approved by Iran University of Medical Sciences, operating room of medical center. Data collection was completed between Jan to Dec 2017. Inclusion criteria included age between 20 and 75 years, history of high blood pressure (a patient who has been treated for maximum 5 years with a anti hypertensive medication), and patients under general anesthesia in spinal surgery. The exclusion criteria were based on American Society of Anesthesiologists physical status of 3 or higher, history of arrhythmia, heart valve disease, cerebrovascular disease, kidney failure, beta-blocker use and diabetes, as well as intra operative massive blood loss. After initiation of anesthesia, when the pressure reaches less than 60, the patient entered the protocol and simultaneously administration of 5 mL/kg serum crystalloid and vasopressor. Patients were randomized to the ephedrine group (n = 28) who received 5 mg ephedrine intravenous (i.v.) or norepinephrine Group (n = 28) who received 10 µg (i.v.) bolus norepinephrine at anesthesia-induced hypotension. The administration of 5 mL/kg serum crystalloid and vasopressor was simultaneous. If the mean arterial pressure (MAP) had not reached 60 mmHg, the same dose should be repeated at a maximum of three or more times at five-minute intervals in the ephedrine group and at two minutes intervals in the norepinephrine group. All parameters were collected before and at the end of administration anesthesia drug and during episodes of hypotension. Hemodynamic variables, frequency of hypotension, and total number of vasopressors doses during anesthesia were recorded and analyzed. Results The mean number of hypotension times, the number of vasopressors doses in the first hypotension, the total number of doses consumed during the anesthesia, and heart rate at the end of anesthesia were lower in the norepinephrine group (P) respectively. MAP, 5 minutes after the first episode of hypotension and MAP at the end of anesthesia were higher in norepinephrine group. Conclusions Norepinephrine is more effective than ephedrine in maintenance of MAP in hypertensive patients undergoing spinal surgery under general anesthesia.
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Affiliation(s)
- Valiollah Hassani
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Movaseghi
- Department of Anesthesiology, Hasheminezhad Hospital, Iran University of Medical Sciences, Tehran,
Iran
| | - Reza Safaeeyan
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Sahar Masghati
- Iran University of Medical Sciences (IUMS), Tehran, Iran
- Corresponding Author: Iran University of Medical Sciences (IUMS), Tehran, Iran. Tel: +98-9111931972,
| | - Batool Ghorbani Yekta
- Young Researchers and Elite Club, Tehran Medical Sciences Branch, Islamic Azad University, Tehran,
Iran
- Herbal Pharmacology Research Center, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
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Morozowich ST, Murray AW, Ramakrishna H. Pulmonary Hypertension in Patients for Transcatheter and Surgical Aortic Valve Replacement: A Focus on Outcomes and Perioperative Management. J Cardiothorac Vasc Anesth 2018; 32:2005-2018. [DOI: 10.1053/j.jvca.2017.09.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Indexed: 01/03/2023]
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Musuku SR, Pani S, Cagino J. Acute Right Ventricular Failure Postintubation in a Mitral Stenosis Patient. J Cardiovasc Echogr 2018; 28:48-50. [PMID: 29629260 PMCID: PMC5875136 DOI: 10.4103/jcecho.jcecho_27_17] [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] [Indexed: 11/29/2022] Open
Abstract
Mitral stenosis (MS) is prevalent in 0.02-0.2% of the population in developed countries. The pathophysiology of MS results in elevated left atrial pressures and over-time results in pulmonary hypertension (HTN) which ultimately affects the right ventricle. In addition, MS restricts the diastolic filling of the left ventricle. Therefore, during induction patients with MS are limited by their ability to increase cardiac output by increasing stroke volume. Anesthesia goals in severe MS are to avoid sudden changes in heart rate, as well as systemic and pulmonary artery pressures. We report a patient who sustained severe hypotension upon induction and intubation which was resistant to conventional medications. Intraoperative transesophageal echocardiography displayed unique right atrial and right ventricular dilatation. In addition, the leftward inter-ventricular, inter-atrial septal shift and septal bounce were noted as the characteristic findings. Intravenous epinephrine bolus was administered to achieve normo-tension and normal chamber dimensions and interventricular septal position.
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Affiliation(s)
| | - Saroj Pani
- Department of Anesthesiology, Albany Medical Center, Albany, NY, USA
| | - John Cagino
- Department of Anesthesiology, Albany Medical Center, Albany, NY, USA
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Maslow A, Joyce MF, Chen TH, Gorgone M, Dinardo J. Hypoxemia After Percutaneous Mitral Valve Replacement: Management. J Cardiothorac Vasc Anesth 2018. [PMID: 29526445 DOI: 10.1053/j.jvca.2018.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI.
| | - Maurice F Joyce
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Tzong-Huei Chen
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Michelle Gorgone
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - James Dinardo
- Department of Anesthesiology, Children's Hospital, Boston, MA
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42
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Coz Yataco A, Aguinaga Meza M, Buch KP, Disselkamp MA. Hospital and intensive care unit management of decompensated pulmonary hypertension and right ventricular failure. Heart Fail Rev 2018; 21:323-46. [PMID: 26486799 PMCID: PMC7102249 DOI: 10.1007/s10741-015-9514-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pulmonary hypertension and concomitant right ventricular failure present a diagnostic and therapeutic challenge in the intensive care unit and have been associated with a high mortality. Significant co-morbidities and hemodynamic instability are often present, and routine critical care unit resuscitation may worsen hemodynamics and limit the chances of survival in patients with an already underlying poor prognosis. Right ventricular failure results from structural or functional processes that limit the right ventricle’s ability to maintain adequate cardiac output. It is commonly seen as the result of left heart failure, acute pulmonary embolism, progression or decompensation of pulmonary hypertension, sepsis, acute lung injury, or in the perioperative setting. Prompt recognition of the underlying cause and institution of treatment with a thorough understanding of the elements necessary to optimize preload, cardiac contractility, enhance systemic arterial perfusion, and reduce right ventricular afterload are of paramount importance. Moreover, the emergence of previously uncommon entities in patients with pulmonary hypertension (pregnancy, sepsis, liver disease, etc.) and the availability of modern devices to provide support pose additional challenges that must be addressed with an in-depth knowledge of this disease.
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Affiliation(s)
- Angel Coz Yataco
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, 740 S. Limestone, KY Clinic L543, Lexington, KY, 40536, USA.
| | - Melina Aguinaga Meza
- Department of Internal Medicine, Division of Cardiovascular Medicine - Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Ketan P Buch
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, 740 S. Limestone, KY Clinic L543, Lexington, KY, 40536, USA
| | - Margaret A Disselkamp
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, 740 S. Limestone, KY Clinic L543, Lexington, KY, 40536, USA
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Steppan J, Diaz-Rodriguez N, Barodka VM, Nyhan D, Pullins E, Housten T, Damico RL, Mathai SC, Hassoun PM, Berkowitz DE, Maxwell BG, Kolb TM. Focused Review of Perioperative Care of Patients with Pulmonary Hypertension and Proposal of a Perioperative Pathway. Cureus 2018; 10:e2072. [PMID: 29552434 PMCID: PMC5854330 DOI: 10.7759/cureus.2072] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Morbidity and mortality risk increase considerably for patients with pulmonary hypertension (PH) undergoing non-cardiac surgery. Unfortunately, there are no comprehensive, evidence-based guidelines for perioperative evaluation and management of these patients. We present a brief review of the literature on perioperative outcomes for patients with PH and describe the implementation of a collaborative perioperative management program for these high-risk patients at a tertiary academic center.
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Affiliation(s)
- Jochen Steppan
- Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine
| | | | - Viachaslau M Barodka
- Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine
| | - Daniel Nyhan
- Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine
| | - Erica Pullins
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine
| | - Traci Housten
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine
| | - Rachel L Damico
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine
| | - Dan E Berkowitz
- Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine
| | | | - Todd M Kolb
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine
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Acute Right Ventricular Dysfunction in Intensive Care Unit. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8217105. [PMID: 29201914 PMCID: PMC5671685 DOI: 10.1155/2017/8217105] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/13/2017] [Accepted: 09/18/2017] [Indexed: 02/07/2023]
Abstract
The role of the left ventricle in ICU patients with circulatory shock has long been considered. However, acute right ventricle (RV) dysfunction causes and aggravates many common critical diseases (acute respiratory distress syndrome, pulmonary embolism, acute myocardial infarction, and postoperative cardiac surgery). Several supportive therapies, including mechanical ventilation and fluid management, can make RV dysfunction worse, potentially exacerbating shock. We briefly review the epidemiology, pathophysiology, diagnosis, and recommendations to guide management of acute RV dysfunction in ICU patients. Our aim is to clarify the complex effects of mechanical ventilation, fluid therapy, vasoactive drug infusions, and other therapies to resuscitate the critical patient optimally.
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Yaung J, Arabia FA, Nurok M. Perioperative Care of the Patient With the Total Artificial Heart. Anesth Analg 2017; 124:1412-1422. [PMID: 28107271 DOI: 10.1213/ane.0000000000001851] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Advanced heart failure continues to be a leading cause of morbidity and mortality despite improvements in pharmacologic therapy. High demand for cardiac transplantation and shortage of donor organs have led to an increase in the utilization of mechanical circulatory support devices. The total artificial heart is an effective biventricular assist device that may be used as a bridge to transplant and that is being studied for destination therapy. This review discusses the history, indications, and perioperative management of the total artificial heart with emphasis on the postoperative concerns.
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Affiliation(s)
- Jill Yaung
- From the *Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California; and †Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Vallée F, Passouant O, Le Gall A, Joachim J, Mateo J, Mebazaa A, Gayat E. Norepinephrine reduces arterial compliance less than phenylephrine when treating general anesthesia-induced arterial hypotension. Acta Anaesthesiol Scand 2017; 61:590-600. [PMID: 28543052 DOI: 10.1111/aas.12905] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 04/22/2017] [Indexed: 12/15/2022]
Abstract
INTRODUCTION During general anesthesia, arterial hypotension is frequent and may be an important contributor to perioperative morbidity. We assessed the effect of a 5 μg bolus of Norepinephrine (NA) when compared with 50 μg bolus of Phenylephrine (PE) administered to treat hypotension during maintenance anesthesia, on MAP, derived cardiac output and arterial stiffness parameters. METHODS Patients scheduled for a neurosurgical procedure under general anesthesia were prospectively included. Monitoring included invasive blood pressure, esophageal Doppler, and arterial tonometer used to estimate central aortic pressure with arterial stiffness parameters, such as augmentation index (Aix). After initial resuscitation, hypotensive episodes were corrected by a bolus administration of NA or PE in a peripheral venous line. RESULTS There were 269 bolus administrations of vasopressors (149 NA, 120 PE) in 47 patients with no adverse effects detected. A decrease in stroke volume (SV) was observed with PE compared with NA (-18 ± 9% vs. -14 ± 7%, P < 0.001). This decrease was associated with an increase in Aix, which was greater for PE than for NA (+10 ± 8% vs. +6 ± 6%, P < 0.0001), and a decrease in total arterial compliance greater for PE compared to NA (Ctot = SV/Central Pulse Pressure) (-35 ± 9% vs. -29 ± 10%, P < 0.001). DISCUSSION This study suggests that 5 μg of NA administered as a bolus in a peripheral venous line could treat general anesthesia-induced arterial hypotension with a smaller decrease in SV and arterial compliance when compared to PE.
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Affiliation(s)
- F. Vallée
- Département d'Anesthésie - Réanimation - SMUR; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
- Université Paris Diderot; Paris France
- UMR-S 942; INSERM; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
- LMS; Ecole Polytechnique; CNRS; Université Paris-Saclay; Palaiseau France
- M3DISIM; Inria; Université Paris-Saclay; Palaiseau France
| | - O. Passouant
- Département d'Anesthésie - Réanimation - SMUR; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
- Université Paris Diderot; Paris France
- UMR-S 942; INSERM; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
- Réanimation Polyvalente; CHU REIMS; Hôpital Robert Debré; Reims France
| | - A. Le Gall
- Département d'Anesthésie - Réanimation - SMUR; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
- Université Paris Diderot; Paris France
- UMR-S 942; INSERM; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
- LMS; Ecole Polytechnique; CNRS; Université Paris-Saclay; Palaiseau France
- M3DISIM; Inria; Université Paris-Saclay; Palaiseau France
| | - J. Joachim
- Département d'Anesthésie - Réanimation - SMUR; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
- Université Paris Diderot; Paris France
- UMR-S 942; INSERM; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
- LMS; Ecole Polytechnique; CNRS; Université Paris-Saclay; Palaiseau France
- M3DISIM; Inria; Université Paris-Saclay; Palaiseau France
| | - J. Mateo
- Département d'Anesthésie - Réanimation - SMUR; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
- Université Paris Diderot; Paris France
- UMR-S 942; INSERM; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
| | - A. Mebazaa
- Département d'Anesthésie - Réanimation - SMUR; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
- Université Paris Diderot; Paris France
- UMR-S 942; INSERM; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
| | - E. Gayat
- Département d'Anesthésie - Réanimation - SMUR; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
- Université Paris Diderot; Paris France
- UMR-S 942; INSERM; Assistance Publique - Hôpitaux de Paris; Hôpitaux Universitaires Saint Louis - Lariboisière; Paris France
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Zochios V, Parhar K, Tunnicliffe W, Roscoe A, Gao F. The Right Ventricle in ARDS. Chest 2017; 152:181-193. [PMID: 28267435 DOI: 10.1016/j.chest.2017.02.019] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 02/15/2017] [Accepted: 02/17/2017] [Indexed: 02/08/2023] Open
Abstract
ARDS is associated with poor clinical outcomes, with a pooled mortality rate of approximately 40% despite best standards of care. Current therapeutic strategies are based on improving oxygenation and pulmonary compliance while minimizing ventilator-induced lung injury. It has been demonstrated that relative hypoxemia can be well tolerated, and improvements in oxygenation do not necessarily translate into survival benefit. Cardiac failure, in particular right ventricular dysfunction (RVD), is commonly encountered in moderate to severe ARDS and is reported to be one of the major determinants of mortality. The prevalence rate of echocardiographically evident RVD in ARDS varies across studies, ranging from 22% to 50%. Although there is no definitive causal relationship between RVD and mortality, severe RVD is associated with increased mortality. Factors that can adversely affect RV function include hypoxic pulmonary vasoconstriction, hypercapnia, and invasive ventilation with high driving pressure. It might be expected that early diagnosis of RVD would be of benefit; however, echocardiographic markers (qualitative and quantitative) used to prospectively evaluate the right ventricle in ARDS have not been tested in adequately powered studies. In this review, we examine the prognostic implications and pathophysiology of RVD in ARDS and discuss available diagnostic modalities and treatment options. We aim to identify gaps in knowledge and directions for future research that could potentially improve clinical outcomes in this patient population.
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Affiliation(s)
- Vasileios Zochios
- Department of Critical Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Edgbaston; Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham.
| | - Ken Parhar
- Department of Critical Care Medicine, the University of Calgary, Calgary, AB, Canada
| | - William Tunnicliffe
- Department of Critical Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Edgbaston
| | - Andrew Roscoe
- Department of Cardiothoracic Anesthesia and Critical Care Medicine, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge
| | - Fang Gao
- Institute of Inflammation and Ageing, Centre of Translational Inflammation Research, University of Birmingham, Birmingham; Academic Department of Anesthesia, Critical Care, Pain and Resuscitation, Heart of England NHS Foundation Trust, Birmingham, England, and The 2nd Affiliated Hospital and Yuying Children's Hospital Wenzhou Medical University, Wenzhou, China
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48
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Vasopressors induce passive pulmonary hypertension by blood redistribution from systemic to pulmonary circulation. Basic Res Cardiol 2017; 112:21. [PMID: 28258299 DOI: 10.1007/s00395-017-0611-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 02/28/2017] [Indexed: 02/05/2023]
Abstract
Vasopressors are widely used in resuscitation, ventricular failure, and sepsis, and often induce pulmonary hypertension with undefined mechanisms. We hypothesize that vasopressor-induced pulmonary hypertension is caused by increased pulmonary blood volume and tested this hypothesis in dogs under general anesthesia. In normal hearts (model 1), phenylephrine (2.5 μg/kg/min) transiently increased right but decreased left cardiac output, associated with increased pulmonary blood volume (63% ± 11.8, P = 0.007) and pressures in the left atrium, pulmonary capillary, and pulmonary artery. However, the trans-pulmonary gradient and pulmonary vascular resistance remained stable. These changes were absent after decreasing blood volume or during right cardiac dysfunction to reduce pulmonary blood volume (model 2). During double-ventricle bypass (model 3), phenylephrine (1, 2.5 and 10 μg/kg/min) only slightly induced pulmonary vasoconstriction. Vasopressin (1U and 2U) dose-dependently increased pulmonary artery pressure (52 ± 8.4 and 71 ± 10.3%), but did not cause pulmonary vasoconstriction in normally beating hearts (model 1). Pulmonary artery and left atrial pressures increased during left ventricle dysfunction (model 4), and further increased after phenylephrine injection by 31 ± 5.6 and 43 ± 7.5%, respectively. In conclusion, vasopressors increased blood volume in the lung with minimal pulmonary vasoconstriction. Thus, this pulmonary hypertension is similar to the hemodynamic pattern observed in left heart diseases and is passive, due to redistribution of blood from systemic to pulmonary circulation. Understanding the underlying mechanisms may improve clinical management of patients who are taking vasopressors, especially those with coexisting heart disease.
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Subramaniam K, Yared JP. Management of Pulmonary Hypertension in the Operating Room. Semin Cardiothorac Vasc Anesth 2016; 11:119-36. [PMID: 17536116 DOI: 10.1177/1089253207301733] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pulmonary artery hypertension is defined as persistent elevation of mean pulmonary artery pressure > 25 mm Hg with pulmonary capillary wedge pressure < 15 mm Hg or elevation of exercise mean pulmonary artery pressure > 35 mm Hg. Although mild pulmonary hypertension rarely impacts anesthetic management, severe pulmonary hypertension and exacerbation of moderate hypertension can lead to acute right ventricular failure and cardiogenic shock. Knowledge of anesthetic drug effects on the pulmonary circulation is essential for anesthesiologists. Intraoperative management should include prevention of exacerbating factors such as hypoxemia, hypercarbia, acidosis, hypothermia, hypervolemia, and increased intrathoracic pressure; monitoring and optimizing right ventricular function; and treatment with selective pulmonary vasodilators. Recent advances in pharmacology provide anesthesiologists with a wide variety of options for selective pulmonary vasodilatation. Pulmonary hypertension is a major determinant of perioperative morbidity and mortality in special situations such as heart and lung transplantation, pneumonectomy, and ventricular assist device placement.
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology, Presbyterian University Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
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50
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Ard JL, Kendale S. Searching for baseline blood pressure: A comparison of blood pressure at three different care points. J Clin Neurosci 2016; 34:59-62. [PMID: 27544232 DOI: 10.1016/j.jocn.2016.08.001] [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] [Received: 06/27/2016] [Accepted: 08/01/2016] [Indexed: 11/25/2022]
Abstract
A common approach to blood pressure management in the operating room is to keep the intraoperative, pressures within 20% of baseline blood pressure. One question that arises from this recommendation is; what is a patient's true baseline blood pressure? In order to get a more precise definition of baseline blood pressure, a comparison of the first operating room blood pressure was made with the blood pressure taken in a preoperative holding area before surgery, and the blood pressure taken in pre-surgical testing. (before day of surgery). A database of 2087 adult general anesthesia cases was generated, which contained the blood pressure (BP) in the pre-surgical testing clinic, the first BP in preoperative holding on the day of surgery, and the first BP in the operating room. Comparisons were made between the blood pressures taken at each phase of care. All components of BP taken in the OR were statistically significantly higher (p<0.001 for all comparisons) than in either PST or the holding area, while the BP in the latter locations were not significantly different. This blood pressure difference persists whether or not the patient is taking antihypertensive medications. The higher blood pressure measured in the operating rooms precludes using this measurement to determine baseline blood pressure. Blood pressures taken prior to arrival in the operating room are similar to blood pressures taken before the day of surgery. Blood pressure measurements taken prior to entrance in the operating room can be used to determine baseline blood pressure.
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Affiliation(s)
- John L Ard
- Department of Anesthesiology, New York University Langone Medical Center, 550 First Ave., New York, NY 10016, United States.
| | - Samir Kendale
- Department of Anesthesiology, New York University Langone Medical Center, 550 First Ave., New York, NY 10016, United States
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