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Liu X, Zhang P, Liu MX, Ma JL, Wei XC, Fan D. Preoperative carbohydrate loading and intraoperative goal-directed fluid therapy for elderly patients undergoing open gastrointestinal surgery: a prospective randomized controlled trial. BMC Anesthesiol 2021; 21:157. [PMID: 34020596 PMCID: PMC8139051 DOI: 10.1186/s12871-021-01377-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 05/12/2021] [Indexed: 11/05/2022] Open
Abstract
Background The effect of a combination of a goal-directed fluid protocol and preoperative carbohydrate loading on postoperative complications in elderly patients still remains unknown. Therefore, we designed this trial to evaluate the relative impact of preoperative carbohydrate loading and intraoperative goal-directed fluid therapy versus conventional fluid therapy (CFT) on clinical outcomes in elderly patients following gastrointestinal surgery. Methods This prospective randomized controlled trial with 120 patients over 65years undergoing gastrointestinal surgery were randomized into a CFT group (n=60) with traditional methods of fasting and water-deprivation, and a GDFT group (n=60) with carbohydrate (200ml) loading 2h before surgery. The CFT group underwent routine monitoring during surgery, however, the GDFT group was conducted by a Vigileo/FloTrac monitor with cardiac index (CI), stroke volume variation (SVV), and mean arterial pressure (MAP). For all patients, demographic data, intraoperative parameters and postoperative outcomes were recorded. Results Patients in the GDFT group received significantly less crystalloids fluid (1111442.9ml vs 1411412.6ml; p<0.001) and produced significantly less urine output (200ml [150300] vs 400ml [290500]; p<0.001) as compared to the CFT group. Moreover, GDFT was associated with a shorter average time to first flatus (5614.1h vs 6422.3h; p=0.002) and oral intake (7216.9h vs 8526.8h; p=0.011), as well as a reduction in the rate of postoperative complications (15 (25.0%) vs 29 (48.3%) patients; p=0.013). However, postoperative hospitalization or hospitalization expenses were similar between groups (p>0.05). Conclusions Focused on elderly patients undergoing open gastrointestinal surgery, we found perioperative fluid optimisation may be associated with improvement of bowel function and a lower incidence of postoperative complications. Trial registration ChiCTR, ChiCTR1800018227. Registered 6 September 2018 - Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01377-8.
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Affiliation(s)
- Xia Liu
- Department of Anesthesiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, No. 32 West Second Section, First Ring Road, Chengdu, Sichuan, China.,North Sichuan Medical College, Nanchong, Sichuan, China
| | - Peng Zhang
- Department of Anesthesiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, No. 32 West Second Section, First Ring Road, Chengdu, Sichuan, China
| | - Meng Xue Liu
- North Sichuan Medical College, Nanchong, Sichuan, China
| | - Jun Li Ma
- North Sichuan Medical College, Nanchong, Sichuan, China
| | - Xin Chuan Wei
- Department of Anesthesiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, No. 32 West Second Section, First Ring Road, Chengdu, Sichuan, China
| | - Dan Fan
- Department of Anesthesiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, No. 32 West Second Section, First Ring Road, Chengdu, Sichuan, China.
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Jun JH, Chung RK, Baik HJ, Chung MH, Hyeon JS, Lee YG, Park SH. The tidal volume challenge improves the reliability of dynamic preload indices during robot-assisted laparoscopic surgery in the Trendelenburg position with lung-protective ventilation. BMC Anesthesiol 2019; 19:142. [PMID: 31390982 PMCID: PMC6686427 DOI: 10.1186/s12871-019-0807-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/18/2019] [Indexed: 12/12/2022] Open
Abstract
Background The reliability of pulse pressure variation (PPV) and stroke volume variation (SVV) is controversial under pneumoperitoneum. In addition, the usefulness of these indices is being called into question with the increasing adoption of lung-protective ventilation using low tidal volume (VT) in surgical patients. A recent study indicated that changes in PPV or SVV obtained by transiently increasing VT (VT challenge) accurately predicted fluid responsiveness even in critically ill patients receiving low VT. We evaluated whether the changes in PPV and SVV induced by a VT challenge predicted fluid responsiveness during pneumoperitoneum. Methods We performed an interventional prospective study in patients undergoing robot-assisted laparoscopic surgery in the Trendelenburg position under lung-protective ventilation. PPV, SVV, and the stroke volume index (SVI) were measured at a VT of 6 mL/kg and 3 min after increasing the VT to 8 mL/kg. The VT was reduced to 6 mL/kg, and measurements were performed before and 5 min after volume expansion (infusing 6% hydroxyethyl starch 6 ml/kg over 10 min). Fluid responsiveness was defined as ≥15% increase in the SVI. Results Twenty-four of the 38 patients enrolled in the study were responders. In the receiver operating characteristic curve analysis, an increase in PPV > 1% after the VT challenge showed excellent predictive capability for fluid responsiveness, with an area under the curve (AUC) of 0.95 [95% confidence interval (CI), 0.83–0.99, P < 0.0001; sensitivity 92%, specificity 86%]. An increase in SVV > 2% after the VT challenge predicted fluid responsiveness, but showed only fair predictive capability, with an AUC of 0.76 (95% CI, 0.60–0.89, P < 0.0006; sensitivity 46%, specificity 100%). The augmented values of PPV and SVV following VT challenge also showed the improved predictability of fluid responsiveness compared to PPV and SVV values (as measured by VT) of 6 ml/kg. Conclusions The change in PPV following the VT challenge has excellent reliability in predicting fluid responsiveness in our surgical population. The change in SVV and augmented values of PPV and SVV following this test are also reliable. Trial registration This trial was registered with Clinicaltrials.gov, NCT03467711, 10th March 2018.
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Affiliation(s)
- Joo-Hyun Jun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, South Korea
| | - Rack Kyung Chung
- Department of Anesthesiology and Pain Medicine, Ewha Womans University, College of Medicine, Anyangcheon-ro, Yangcheon-gu, Seoul, 1071, South Korea.
| | - Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, Ewha Womans University, College of Medicine, Anyangcheon-ro, Yangcheon-gu, Seoul, 1071, South Korea
| | - Mi Hwa Chung
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, South Korea
| | - Joon-Sang Hyeon
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, South Korea
| | - Young-Goo Lee
- Department of Urology, Kangnam Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, South Korea
| | - Sung-Ho Park
- Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, South Korea
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Spinelli E, Mauri T, Fogagnolo A, Scaramuzzo G, Rundo A, Grieco DL, Grasselli G, Volta CA, Spadaro S. Electrical impedance tomography in perioperative medicine: careful respiratory monitoring for tailored interventions. BMC Anesthesiol 2019; 19:140. [PMID: 31390977 PMCID: PMC6686519 DOI: 10.1186/s12871-019-0814-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/29/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Electrical impedance tomography (EIT) is a non-invasive radiation-free monitoring technique that provides images based on tissue electrical conductivity of the chest. Several investigations applied EIT in the context of perioperative medicine, which is not confined to the intraoperative period but begins with the preoperative assessment and extends to postoperative follow-up. MAIN BODY EIT could provide careful respiratory monitoring in the preoperative assessment to improve preparation for surgery, during anaesthesia to guide optimal ventilation strategies and to monitor the hemodynamic status and in the postoperative period for early detection of respiratory complications. Moreover, EIT could further enhance care of patients undergoing perioperative diagnostic procedures. This narrative review summarizes the latest evidence on the application of this technique to the surgical patient, focusing also on possible future perspectives. CONCLUSIONS EIT is a promising technique for the perioperative assessment of surgical patients, providing tailored adaptive respiratory and haemodynamic monitoring. Further studies are needed to address the current technological limitations, confirm the findings and evaluate which patients can benefit more from this technology.
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Affiliation(s)
- Elena Spinelli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli studi di Milano, Milan, Italy
| | - Tommaso Mauri
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli studi di Milano, Milan, Italy
| | - Alberto Fogagnolo
- Department Morphology, Surgery and Experimental medicine, Anesthesia and Intensive care section, University of Ferrara, Azienda Ospedaliera- Universitaria Sant'Anna, 8, Aldo Moro, Ferrara, Italy
| | - Gaetano Scaramuzzo
- Department Morphology, Surgery and Experimental medicine, Anesthesia and Intensive care section, University of Ferrara, Azienda Ospedaliera- Universitaria Sant'Anna, 8, Aldo Moro, Ferrara, Italy
| | - Annalisa Rundo
- UOC Anestesia e Rianimazione, Polo ospedaliero Belcolle ASL, Viterbo, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - Giacomo Grasselli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli studi di Milano, Milan, Italy
| | - Carlo Alberto Volta
- Department Morphology, Surgery and Experimental medicine, Anesthesia and Intensive care section, University of Ferrara, Azienda Ospedaliera- Universitaria Sant'Anna, 8, Aldo Moro, Ferrara, Italy
| | - Savino Spadaro
- Department Morphology, Surgery and Experimental medicine, Anesthesia and Intensive care section, University of Ferrara, Azienda Ospedaliera- Universitaria Sant'Anna, 8, Aldo Moro, Ferrara, Italy.
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Grupp K, Bonk S, Poppe A, Wodack K, Reeh M, Gocht A, Mann O, Izbicki JR, Bachmann K. Cholecystokinin-8 treatment reduces acinar necrosis and edema of pigs with induced pancreatitis. Asian J Surg 2019; 43:272-277. [PMID: 31171354 DOI: 10.1016/j.asjsur.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/11/2019] [Accepted: 05/07/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute pancreatitis is an inflammatory process of the pancreas and a leading cause of hospitalization amongst gastrointestinal disorders. Previously, cholecystokinin (CCK) has been described to play a role in regeneration of pancreas. The aim of this study was to analyse the function of cholecystokinin octapeptide (CCK-8) during induced pancreatitis in an animal model. METHODS Overall acute pancreatitis was induced in 38 pigs. After the induction of acute pancreatitis, half of the animals were treated with CCK-8. Intraoperative clinical data, postoperative blood parameters, 'Porcine Well-being' (PWB) and fitness score and post-mortal histopathological data were analysed. RESULTS At baseline, physiologically parameters of the pigs of both groups were comparable. No differences were observed regarding the overall survival of animals (p = 0.97). Postoperative PWB score were significantly enhanced in animals treated with CCK-8 as compared to the control group (p = 0.029). Moreover, histopathological analysis of the pancreatic tissue revealed that acinar necrosis and edema were significant reduced in the CCK-8 group in comparison to the control group (p = 0.016 and p = 0.019). CONCLUSIONS In conclusion, we found that CCK-8 treatment reduces acinar necrosis and edema of pancreatic tissue after induction of an acute pancreatitis in pigs.
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Affiliation(s)
- Katharina Grupp
- Department of General-, Visceral- and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
| | - Sarah Bonk
- Department of General-, Visceral- and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Annika Poppe
- Centre of Anesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Karin Wodack
- Centre of Anesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Reeh
- Department of General-, Visceral- and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Gocht
- Institute of Anatomy and Experimental Morphology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver Mann
- Department of General-, Visceral- and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General-, Visceral- and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kai Bachmann
- Department of General-, Visceral- and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Grupp K, Erbes J, Poppe A, Wodack K, Gocht A, Trepte C, Havel J, Mann O, Izbicki JR, Bachmann K. Melatonin treatment of pigs with acute pancreatitis reduces inflammatory reaction of pancreatic tissue and enhances fitness score of pigs: experimental research. World J Emerg Surg 2019; 14:18. [PMID: 31007709 PMCID: PMC6458612 DOI: 10.1186/s13017-019-0237-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 03/25/2019] [Indexed: 12/27/2022] Open
Abstract
Background Severe acute pancreatitis is associated with high morbidity and mortality. Melatonin is known as the activator of antioxidant enzymes. The main purpose of this study was to evaluate the clinical effect of melatonin treatment in a pig model with induced acute pancreatitis. Methods In this study, acute pancreatitis was induced in 38 German domestic pigs (German Hybrid). After induction of acute pancreatitis, 18 animals were treated with melatonin. Intraoperative clinical data, postoperative blood parameters, fitness, and Porcine Well-being (PWB) score, and post-mortal histopathological data were analyzed in both study groups. Results The matching procedure created two groups (melatonin group and control group) which were very similar. The fitness and PWB score were postoperative significantly enhanced in the melatonin group as compared to the control group (p = 0.005 and p = 0.003). Additionally, histological analysis revealed that acinar necrosis, fat tissue necrosis, and edema were significantly reduced in the melatonin group as compared to the non-melatonin group (p = 0.025, p = 0.003, and p = 0.028). Conclusions Pigs, which were treated with melatonin, were characterized by higher fitness and PWB scores than those of the control group. Moreover, melatonin treatment reduces the acinar necrosis, fat tissue necrosis, and edema of pancreatic tissue. Thus, melatonin might be a useful therapeutic option in severe acute pancreatitis.
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Affiliation(s)
- Katharina Grupp
- 1Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Erbes
- 1Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Annika Poppe
- 2Centre of Anesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Karin Wodack
- 2Centre of Anesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Gocht
- 3Institute of Anatomy and Experimental Morphology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Constantin Trepte
- 2Centre of Anesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Havel
- 1Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver Mann
- 1Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- 1Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kai Bachmann
- 1Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Trepte CJC, Phillips C, Solà J, Adler A, Saugel B, Haas S, Bohm SH, Reuter DA. Electrical impedance tomography for non-invasive assessment of stroke volume variation in health and experimental lung injury. Br J Anaesth 2018; 118:68-76. [PMID: 28039243 DOI: 10.1093/bja/aew341] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Functional imaging by thoracic electrical impedance tomography (EIT) is a non-invasive approach to continuously assess central stroke volume variation (SVV) for guiding fluid therapy. The early available data were from healthy lungs without injury-related changes in thoracic impedance as a potentially influencing factor. The aim of this study was to evaluate SVV measured by EIT (SVVEIT) against SVV from pulse contour analysis (SVVPC) in an experimental animal model of acute lung injury at different lung volumes. METHODS We conducted a randomized controlled trial in 30 anaesthetized domestic pigs. SVVEIT was calculated automatically analysing heart-lung interactions in a set of pixels representing the aorta. Each initial analysis was performed automatically and unsupervised using predefined frequency domain algorithms that had not previously been used in the study population. After baseline measurements in normal lung conditions, lung injury was induced either by repeated broncho-alveolar lavage (n=15) or by intravenous administration of oleic acid (n=15) and SVVEIT was remeasured. RESULTS The protocol was completed in 28 animals. A total of 123 pairs of SVV measurements were acquired. Correlation coefficients (r) between SVVEIT and SVVPC were 0.77 in healthy lungs, 0.84 after broncho-alveolar lavage, and 0.48 after lung injury from oleic acid. CONCLUSIONS EIT provides automated calculation of a dynamic preload index of fluid responsiveness (SVVEIT) that is non-invasively derived from a central haemodynamic signal. However, alterations in thoracic impedance induced by lung injury influence this method.
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Affiliation(s)
- C J C Trepte
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, Hamburg D-20246, Germany
| | - C Phillips
- Department of Pulmonary and Critical Care, Oregon Health and Science University, Portland, OR, USA
| | - J Solà
- Centre Suisse d'Electronique et de Microtechnique, Neuchatel, Switzerland
| | - A Adler
- Department of Systems and Computer Engineering, Carleton University, Ottawa, Canada
| | - B Saugel
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, Hamburg D-20246, Germany
| | - S Haas
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, Hamburg D-20246, Germany
| | - S H Bohm
- Swisstom AG, Landquart, Switzerland
| | - D A Reuter
- Department of Anaesthesiology, Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, Hamburg D-20246, Germany
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Wodack KH, Graessler MF, Nishimoto SA, Behem CR, Pinnschmidt HO, Punke MA, Monge-García MI, Trepte CJC, Reuter DA. Assessment of central hemodynamic effects of phenylephrine: an animal experiment. J Clin Monit Comput 2018; 33:377-384. [DOI: 10.1007/s10877-018-0204-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/26/2018] [Indexed: 12/17/2022]
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Kellermann S, Janssen C, Münch F, Koch A, Schneider-Stock R, Cesnjevar RA, Rüffer A. Deep hypothermic circulatory arrest or tepid regional cerebral perfusion: impact on haemodynamics and myocardial integrity in a randomized experimental trial. Interact Cardiovasc Thorac Surg 2018; 26:667-672. [PMID: 29272381 DOI: 10.1093/icvts/ivx393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/18/2017] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Organ protective management during aortic arch surgery comprises deep hypothermic (18°C) circulatory arrest (DHCA), or moderate hypothermia (28°C/ 'tepid') with regional cerebral perfusion (TRCP). The aim of this experimental study was to evaluate the effect of distinct organ protective management on hemodynamic performance and myocardial integrity. METHODS Ten male piglets were randomized to group DHCA (n = 5) or TRCP (n = 5) group and operated on cardiopulmonary bypass (CPB) with 60 min of aortic cross-clamping. Blood gas analysis was performed throughout the experiment. Haemodynamic assessment was performed using a thermodilution technique before and after CPB. Myocardial biopsies were taken 2 h after CPB and evaluated using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end labelling assay and western blot analysis. RESULTS At reperfusion, levels of central venous saturation were significantly higher (P = 0.016) and levels of lactate significantly lower (P = 0.029) in the DHCA group. After CPB, thermodilution measurements revealed higher stroke volume and lower peripheral resistance in the TRCP group (P = 0.012 and 0.037). At the end of the experiment, no significant differences regarding laboratory and haemodynamic parameters were evident. All specimens showed enrichment of terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end labelling-positive cells exclusively at the left ventricular subendocardium with no difference between groups and equal concentrations of cyclo-oxygenase-2. CONCLUSIONS TRCP is associated with decreased peripheral resistance and higher stroke volume immediately after CPB. However, this beneficial effect is contrasted by signs of lower body hypoperfusion, which is expressed by lower central venous saturations and higher lactate levels. Distinct strategies of organ protection did not seem to affect apoptotic/necrotic and inflammatory changes in the left ventricular myocardium.
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Affiliation(s)
- Stephanie Kellermann
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carina Janssen
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Frank Münch
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Adrian Koch
- Experimental Tumorpathology, Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Regine Schneider-Stock
- Experimental Tumorpathology, Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Robert Anton Cesnjevar
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - André Rüffer
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Preload dependency determines the effects of phenylephrine on cardiac output in anaesthetised patients: A prospective observational study. Eur J Anaesthesiol 2018; 33:638-44. [PMID: 27164015 DOI: 10.1097/eja.0000000000000470] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Although phenylephrine is widely used in the operating room to control arterial pressure, its haemodynamic effects remain controversial. OBJECTIVE We hypothesised that the effect of phenylephrine on cardiac output is affected by preload dependency. DESIGN A prospective observational study. SETTING Single-centre, University Hospital of Caen, France. PATIENTS Fifty ventilated patients undergoing surgery were studied during hypotension before and after administration of phenylephrine. MAIN OUTCOME MEASURES Cardiac index (CI), stroke volume (SV), corrected flow time, mean arterial pressure, pulse pressure variations (PPV) and systemic vascular resistance index were used to assess effects of changes in preload dependency. RESULTS Twenty seven (54%) patients were included in the preload-dependent group (PPV ≥ 13%) and 23 (46%) in the preload-independent group (PPV < 13%) before administration of phenylephrine. For the whole cohort, phenylephrine increased mean arterial pressure [58 (±8) mmHg vs. 79 (±13) mmHg; P < 0.0001] and calculated systemic vascular resistance index [2010 (1338; 2481) dyn s cm m vs. 2989 (2155; 3870) dyn s cm m; P < 0.0001]. However, CI and SV decreased in the preload-independent group [2.3 (1.9; 3.7) l min m vs. 1.8 (1.5; 2.7) l min m; P < 0.0001 and 65 (44; 81) ml vs. 56 (39; 66) ml; P < 0.0001 for both] but not in the preload-dependent group [respectively 2.1 (1.8; 3.5) l min m vs. 2.1 (1.8; 3.3) l min m; P = 0.168 and 49 (41; 67) ml vs. 53 (41; 69) ml; P = 0.191]. Corrected flow time increased [294 (47) ms vs. 306 (56) ms; P = 0.031], and PPV decreased [17 (15; 19) % vs.12 (14; 16) %; P < 0.0003] only in the PPV at least 13% group. CONCLUSION The effects of phenylephrine on CI and SV depend on preload. CI and SV decreased in preload-independent patients through increase in afterload, but were unchanged in those preload-dependent through increased venous return.
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Zlicar M, Novak-Jankovic V, Blagus R, Cecconi M. Predictive values of pulse pressure variation and stroke volume variation for fluid responsiveness in patients with pneumoperitoneum. J Clin Monit Comput 2017; 32:825-832. [PMID: 29149433 DOI: 10.1007/s10877-017-0081-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022]
Abstract
Animal studies suggest that dynamic predictors remain useful in patients with pneumoperitoneum, but human data is conflicting. Our aim was to determine predictive values of pulse pressure variation (PPV) and stroke volume variation (SVV) in patients with pneumoperitoneum using LiDCORapid™ haemodynamic monitor. Standardised fluid challenges of colloid were administered to patients undergoing laparoscopic procedures, one fluid challenge per patient. Intra-abdominal pressure was automatically held at 12 mmHg. Fluid responsiveness was defined as an increase in nominal stroke index (nSI) ≥ 10%. Linear regression was used to assess the ability of PPV and SVV to track the changes of nSI and logistic regression and area under the receiver operating curve (AUROC) to assess the predictive value of PPV and SVV for fluid responsiveness. Threshold values for PPV and SVV were obtained using the "gray zone" approach. A p < 0.05 was considered as statistically significant. 56 patients were included in analysis. 41 patients (73%) responded to fluids. Both PPV and SVV tracked changes in nSI (Spearman correlation coefficients 0.34 for PPV and 0.53 for SVV). Odds ratio for fluid responsiveness for PPV was 1.163 (95% CI 1.01-1.34) and for SVV 1.341 (95% CI 1.10-1.63). PPV achieved an AUROC of 0.674 (95% CI 0.518-0.830) and SVV 0.80 (95% CI 0.668-0.932). The gray zone of PPV ranged between 6.5 and 20.5% and that of SVV between 7.5 and 13%. During pneumoperitoneum, as measured by LiDCORapid™, PPV and SVV can predict fluid responsiveness, however their sensitivity is lower than the one reported in conditions without pneumoperitoneum. Trial registry number: (with the Australian New Zealand Clinical Trials Registry): ACTRN12612000456853.
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Affiliation(s)
- Marko Zlicar
- Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Zaloska 2, Ljubljana, Slovenia.
| | - Vesna Novak-Jankovic
- Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Zaloska 2, Ljubljana, Slovenia
| | - Rok Blagus
- Institute for Biostatistics and Medical Informatics, Medical Faculty, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia
| | - Maurizio Cecconi
- Adult Critical Care, St. George's Healthcare NHS Trust, London, SW170QT, UK
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Arterial Pressure Variation in Elective Noncardiac Surgery: Identifying Reference Distributions and Modifying Factors. Anesthesiology 2017; 126:249-259. [PMID: 27906705 DOI: 10.1097/aln.0000000000001460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Assessment of need for intravascular volume resuscitation remains challenging for anesthesiologists. Dynamic waveform indices, including systolic and pulse pressure variation, are demonstrated as reliable measures of fluid responsiveness for mechanically ventilated patients. Despite widespread use, real-world reference distributions for systolic and pulse pressure variation values have not been established for euvolemic intraoperative patients. The authors sought to establish systolic and pulse pressure variation reference distributions and assess the impact of modifying factors. METHODS The authors evaluated adult patients undergoing general anesthetics for elective noncardiac surgery. Median systolic and pulse pressure variations during a 50-min postinduction period were noted for each case. Modifying factors including body mass index, age, ventilator settings, positioning, and hemodynamic management were studied via univariate and multivariable analyses. For systolic pressure variation values, effects of data entry method (manually entered vs. automated recorded) were similarly studied. RESULTS Among 1,791 cases, per-case median systolic and pulse pressure variation values formed nonparametric distributions. For each distribution, median values, interquartile ranges, and reference intervals (2.5th to 97.5th percentile) were, respectively, noted: these included manually entered systolic pressure variation (6.0, 5.0 to 7.0, and 3.0 to 11.0 mmHg), automated systolic pressure variation (4.7, 3.9 to 6.0, and 2.2 to 10.4 mmHg), and automated pulse pressure variation (7.0, 5.0 to 9.0, and 2.0 to 16.0%). Nonsupine positioning and preoperative β blocker were independently associated with altered systolic and pulse pressure variations, whereas ventilator tidal volume more than 8 ml/kg ideal body weight and peak inspiratory pressure more than 16 cm H2O demonstrated independent associations for systolic pressure variation only. CONCLUSIONS This study establishes real-world systolic and pulse pressure variation reference distributions absent in the current literature. Through a consideration of reference distributions and modifying factors, the authors' study provides further evidence for assessing intraoperative volume status and fluid management therapies.
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Broch O, Renner J, Meybohm P, Albrecht M, Höcker J, Haneya A, Steinfath M, Bein B, Gruenewald M. Dynamic Variables Fail to Predict Fluid Responsiveness in an Animal Model With Pericardial Effusion. J Cardiothorac Vasc Anesth 2016; 30:1205-11. [PMID: 27499343 DOI: 10.1053/j.jvca.2016.03.151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The reliability of dynamic and volumetric variables of fluid responsiveness in the presence of pericardial effusion is still elusive. The aim of the present study was to investigate their predictive power in a porcine model with hemodynamic relevant pericardial effusion. DESIGN A single-center animal investigation. PARTICIPANTS Twelve German domestic pigs. INTERVENTIONS Pigs were studied before and during pericardial effusion. Instrumentation included a pulmonary artery catheter and a transpulmonary thermodilution catheter in the femoral artery. Hemodynamic variables like cardiac output (COPAC) and stroke volume (SVPAC) derived from pulmonary artery catheter, global end-diastolic volume (GEDV), stroke volume variation (SVV), and pulse-pressure variation (PPV) were obtained. MEASUREMENTS AND MAIN RESULTS At baseline, SVV, PPV, GEDV, COPAC, and SVPAC reliably predicted fluid responsiveness (area under the curve 0.81 [p = 0.02], 0.82 [p = 0.02], 0.74 [p = 0.07], 0.74 [p = 0.07], 0.82 [p = 0.02]). After establishment of pericardial effusion the predictive power of dynamic variables was impaired and only COPAC and SVPAC and GEDV allowed significant prediction of fluid responsiveness (area under the curve 0.77 [p = 0.04], 0.76 [p = 0.05], 0.83 [p = 0.01]) with clinically relevant changes in threshold values. CONCLUSIONS In this porcine model, hemodynamic relevant pericardial effusion abolished the ability of dynamic variables to predict fluid responsiveness. COPAC, SVPAC, and GEDV enabled prediction, but their threshold values were significantly changed.
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Affiliation(s)
- Ole Broch
- Departments of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany.
| | - Jochen Renner
- Departments of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Patrick Meybohm
- Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital, Frankfurt, Germany
| | - Martin Albrecht
- Experimental Anesthesiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Jan Höcker
- Departments of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Assad Haneya
- Cardiothoracic and Vascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Markus Steinfath
- Departments of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Berthold Bein
- Anesthesiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Matthias Gruenewald
- Departments of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany
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Lee SH, Chun YM, Oh YJ, Shin S, Park SJ, Kim SY, Choi YS. Prediction of fluid responsiveness in the beach chair position using dynamic preload indices. J Clin Monit Comput 2015; 30:995-1002. [PMID: 26719298 DOI: 10.1007/s10877-015-9821-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 12/22/2015] [Indexed: 11/29/2022]
Abstract
Hemodynamic instability in the beach chair position (BCP) may lead to adverse outcomes. Cardiac preload optimization is a prerequisite to improve hemodynamics. We evaluated the clinical usefulness of dynamic indices for the prediction of fluid responsiveness in BCP patients under general anesthesia. Forty-two patients in the BCP under mechanical ventilation received colloids at 6 ml/kg for 10 min. Stroke volume variation (SVV), pulse pressure variation (PPV), pleth variability index (PVI), and hemodynamic data were measured before and after the fluid challenge. Patients were considered responders to volume expansion if the stroke volume index increased by ≥15 %. The areas under receiver operating characteristic curves for SVV, PPV and PVI were 0.83, 0.81 and 0.74, respectively (p < 0.05), with the corresponding optimal cut-off values of 12, 15 and 10 %. SVV, PPV and PVI can be used to predict fluid responsiveness in the BCP under mechanical ventilation.
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Affiliation(s)
- Su Hyun Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Min Chun
- Department of Orthopedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Jun Oh
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seokyung Shin
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Jun Park
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Young Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea. .,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Kawazoe Y, Nakashima T, Iseri T, Yonetani C, Ueda K, Fujimoto Y, Kato S. The impact of inspiratory pressure on stroke volume variation and the evaluation of indexing stroke volume variation to inspiratory pressure under various preload conditions in experimental animals. J Anesth 2015; 29:515-21. [PMID: 25771761 PMCID: PMC4543412 DOI: 10.1007/s00540-015-1995-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 02/26/2015] [Indexed: 12/29/2022]
Abstract
Purpose Stroke volume variation (SVV) measures fluid responsiveness, enabling optimal fluid management under positive pressure ventilation. We aimed to investigate the effect of peak inspiratory pressure (PIP) on SVV under various preload conditions in experimental animals and to ascertain whether SVV indexed to PIP decreases the effect. Methods Mild and moderate hemorrhage models were created in nine anesthetized, mechanically ventilated beagle dogs by sequentially removing 10 and then an additional 10 ml/kg of blood, respectively. In all the animals, PIP was incrementally increased by 4 cmH2O, from 5 to 21 cmH2O. SVV was measured by arterial pulse contour analysis. Stroke volume was derived using a thermodilution method, and central venous pressure and mean arterial pressure were also measured. Results SVV increased according to PIP with significant correlation at baseline, with mild hemorrhage and moderate hemorrhage. PIP regression coefficients at baseline and in the mild and moderate hemorrhage models were 0.59, 0.86, and 1.4, respectively. Two-way repeated-measures analysis of variance showed that PIP and the degree of hemorrhage had a significant interaction effect on SVV (p = 0.0016). SVV indexed to PIP reflected the hemorrhage status regardless of PIP changes ≥9 cmH2O. Conclusions PIP is significantly correlated with SVV, even under hypovolemia, and the effect is enhanced with decreasing preload volumes. Compared with SVV, the indexed SVV was less susceptible to higher inspiratory pressures.
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Affiliation(s)
- Yu Kawazoe
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan,
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Individualized early goal-directed therapy in systemic inflammation: is full utilization of preload reserve the optimal strategy? Crit Care Med 2015; 42:e741-51. [PMID: 25402295 DOI: 10.1097/ccm.0000000000000657] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES In severe acute pancreatitis, the administration of fluids in the presence of positive fluid responsiveness is associated with better outcome when compared to guiding therapy on central venous pressure. We compared the effects of such consequent maximization of stroke volume index with a regime using individual values of stroke volume index assessed prior to severe acute pancreatitis induction as therapeutic hemodynamic goals. DESIGN Prospective, randomized animal study. SETTING University animal research laboratory. SUBJECTS Thirty domestic pigs. INTERVENTIONS After randomization, fluid resuscitation was started 2 hours after severe acute pancreatitis induction and continued for 6 hours according to the respective treatment algorithms. In the control group, fluid therapy was directed by maximizing stroke volume index, and in the study group, stroke volume index assessed prior to severe acute pancreatitis served as primary hemodynamic goal. MEASUREMENTS AND MAIN RESULTS Within the first 6 hours of severe acute pancreatitis, the study group received a total of 1,935.8 ± 540.7 mL of fluids compared with 3,462.8 ± 828.2 mL in the control group (p < 0.001). Pancreatic tissue oxygenation did not differ significantly between both groups. Vascular endothelial function, measured by flow-mediated vasodilation before and 6 hours after severe acute pancreatitis induction, revealed less impairment in the study group after treatment interval (-90.76% [study group] vs -130.89% [control group]; p = 0.046). Further, lower levels of heparan sulfate (3.41 ± 5.6 pg/mL [study group] vs 43.67 ± 46.61 pg/mL [control group]; p = 0.032) and interleukin 6 (32.18 ± 8.81 pg/mL [study group] vs 77.76 ± 56.86 pg/mL [control group]; p = 0.021) were found in the study group compared with control group. Histopathological examination of the pancreatic head and corpus at day 7 revealed less edema for the study group compared with the control group (1.82 ± 0.87 [study group] vs 2.89 ± 0.33 [control group, pancreatic head]; p = 0.03; 2.2 ± 0.92 [study group] vs 2.91 ± 0.3 [control group, pancreatic corpus]; p = 0.025). CONCLUSIONS Individualized optimization of intravascular fluid status during the early course of severe acute pancreatitis, compared with a treatment strategy of maximizing stroke volume by fluid loading, leads to less vascular endothelial damage, pancreatic edema, and inflammatory response.
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Saugel B, Reuter D. III. Are we ready for the age of non-invasive haemodynamic monitoring? Br J Anaesth 2014; 113:340-3. [DOI: 10.1093/bja/aeu145] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Cherpanath TGV, Smeding L, Lagrand WK, Hirsch A, Schultz MJ, Groeneveld JAB. Pulse pressure variation does not reflect stroke volume variation in mechanically ventilated rats with lipopolysaccharide-induced pneumonia. Clin Exp Pharmacol Physiol 2014; 41:98-104. [PMID: 24372424 DOI: 10.1111/1440-1681.12187] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Revised: 10/04/2013] [Accepted: 10/19/2013] [Indexed: 11/26/2022]
Abstract
1. The present study examined the relationship between centrally measured stroke volume variation (SVV) and peripherally derived pulse pressure variation (PPV) in the setting of increased total arterial compliance (CA rt ). 2. Ten male Wistar rats were anaesthetized, paralysed and mechanically ventilated before being randomized to receive intrapulmonary lipopolysaccharide (LPS) or no LPS. Pulse pressure (PP) was derived from the left carotid artery, whereas stroke volume (SV) was measured directly in the left ventricle. Values of SVV and PPV were calculated over three breaths. Balloon inflation of a catheter positioned in the inferior vena cava was used, for a maximum of 30 s, to decrease preload while the SVV and PPV measurements were repeated. Values of CA rt were calculated as SV/PP. 3. Intrapulmonary LPS increased CA rt and SV. Values of SVV and PPV increased in both LPS-treated and untreated rats during balloon inflation. There was a correlation between SVV and PPV in untreated rats before (r = 0.55; P = 0.005) and during (r = 0.69; P < 0.001) occlusion of the vena cava. There was no such correlation in LPS-treated rats either before (r = -0.08; P = 0.70) or during (r = 0.36; P = 0.08) vena cava occlusion. 4. In conclusion, under normovolaemic and hypovolaemic conditions, PPV does not reflect SVV during an increase in CA rt following LPS-induced pneumonia in mechanically ventilated rats. Our data caution against their interchangeability in human sepsis.
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Affiliation(s)
- Thomas G V Cherpanath
- Department of Intensive Care Medicine, Academic Medical Centre, Amsterdam, The Netherlands
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Pikkemaat R, Lundin S, Stenqvist O, Hilgers RD, Leonhardt S. Recent Advances in and Limitations of Cardiac Output Monitoring by Means of Electrical Impedance Tomography. Anesth Analg 2014; 119:76-83. [DOI: 10.1213/ane.0000000000000241] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Guinot PG, de Broca B, Bernard E, Arab OA, Lorne E, Dupont H. Respiratory stroke volume variation assessed by oesophageal Doppler monitoring predicts fluid responsiveness during laparoscopy. Br J Anaesth 2014; 112:660-4. [DOI: 10.1093/bja/aet430] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Pei S, Yuan W, Mai H, Wang M, Hao C, Mi W, Fu Q. Efficacy of dynamic indices in predicting fluid responsiveness in patients with obstructive jaundice. Physiol Meas 2014; 35:369-82. [PMID: 24499723 DOI: 10.1088/0967-3334/35/3/369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Previous studies have shown that the stroke volume variation (SVV), the pulse pressure variation (PPV) and the pleth variability index (PVI) could be successfully used for predicting fluid responsiveness (FR) in surgical patients. The aim of this study was to validate the ability of SVV, PPV and PVI to predict intraoperative FR in mechanically ventilated patients with obstructive jaundice (OJ). Thirty-two patients with OJ (mean serum total bilirubin 190.5 ± 95.3 µmol L(-1)) received intraoperative volume expansion (VE) with 250 ml colloids immediately after an exploratory laparotomy had been completed and after a 5 min period of hemodynamic stability. Hemodynamic variables were recorded before and after VE. FR was defined as an increase in stroke volume index > 10% after VE. The ability of SVV, PPV and PVI to predict FR was assessed by calculation of the area under the receiver operating characteristic curve. Eleven (34%) patients were responders and 21 patients were nonresponders to VE. The PPV was the unique dynamic index that had the moderate ability to predict FR during surgical procedures, the area under the curve was 0.71 (95% CI, 0.523 to 0.856; P = 0.039) and the threshold (sensitivity and specificity) discriminated responders was 7.5% (63.6%/71.4%). The present study concluded that SVV and PVI were not reliable predictors of FR, but PPV has some value predicting FR in patients with OJ intraoperatively.
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Affiliation(s)
- Shujun Pei
- Anesthesia and Operation Center, Chinese People's Liberation Army General Hospital & Medical School of Chinese People's Liberation Army, Beijing 100853, People's Republic of China. Department of Anesthesiology, 251 Hospital of Chinese People's Liberation Army, Zhangjiakou 075000, People's Republic of China
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Trepte CJC, Eichhorn V, Haas SA, Stahl K, Schmid F, Nitzschke R, Goetz AE, Reuter DA. Comparison of an automated respiratory systolic variation test with dynamic preload indicators to predict fluid responsiveness after major surgery. Br J Anaesth 2013; 111:736-42. [PMID: 23811425 DOI: 10.1093/bja/aet204] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Predicting the response of cardiac output to volume administration remains an ongoing clinical challenge. The objective of our study was to compare the ability to predict volume responsiveness of various functional measures of cardiac preload. These included pulse pressure variation (PPV), stroke volume variation (SVV), and the recently launched automated respiratory systolic variation test (RSVT) in patients after major surgery. METHODS In this prospective study, 24 mechanically ventilated patients after major surgery were enrolled. Three consecutive volume loading steps consisting of 300 ml 6% hydroxyethylstarch 130/0.4 were performed and cardiac index (CI) was assessed by transpulmonary thermodilution. Volume responsiveness was considered as positive if CI increased by >10%. RESULTS In total 72 volume loading steps were analysed, of which 41 showed a positive volume response. Receiver operating characteristic (ROC) curve analysis revealed an area under the curve (AUC) of 0.70 for PPV, 0.72 for SVV and 0.77 for RSVT. Areas under the curves of all variables did not differ significantly from each other (P>0.05). Suggested cut-off values were 9.9% for SVV, 10.1% for PPV, and 19.7° for RSVT as calculated by the Youden Index. CONCLUSION In predicting fluid responsiveness the new automated RSVT appears to be as accurate as established dynamic indicators of preload PPV and SVV in patients after major surgery. The automated RSVT is clinically easy to use and may be useful in guiding fluid therapy in ventilated patients.
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Affiliation(s)
- C J C Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
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Effect of pulse pressure on the predictability of stroke volume variation for fluid responsiveness in patients with coronary disease. J Crit Care 2013; 28:318.e1-7. [DOI: 10.1016/j.jcrc.2012.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 09/03/2012] [Accepted: 09/07/2012] [Indexed: 01/08/2023]
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Trepte CJC, Bachmann KA, Stork JH, Friedheim TJ, Hinsch A, Goepfert MS, Mann O, Izbicki JR, Goetz AE, Reuter DA. The impact of early goal-directed fluid management on survival in an experimental model of severe acute pancreatitis. Intensive Care Med 2013; 39:717-26. [PMID: 23287870 DOI: 10.1007/s00134-012-2775-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 10/01/2012] [Indexed: 12/16/2022]
Abstract
PURPOSE Severe acute pancreatitis (SAP) remains a life-threatening disease with classic etiology of systemic inflammatory response and mortality between 30 and 50 %. The aim of the present study is to compare two different treatment strategies of goal-directed hemodynamic management and evaluate their impact on survival, microcirculation, tissue oxygenation, and histopathologic damage in acute pancreatitis in a prospective animal study. METHODS Thirty-four domestic pigs were randomly assigned to two different treatment groups. After induction of acute pancreatitis, in group 1 volume administration was guided by central venous pressure (CVP >12 mmHg) and mean arterial pressure (MAP). In group 2, hemodynamic management was guided primarily by left-ventricular stroke volume variation (SVV <10 %), MAP, and cardiac output (CO). Treatment according to randomization was performed for 6 h, and tissue oxygen tension in the pancreas and pancreatic microcirculation were evaluated. Thereafter, animals were observed for 7 days and then sacrificed. Standardized tissue specimens were taken post mortem, and histopathologic scoring was performed. RESULTS Survival after 7 days was 29.4 % in group 2 versus 11.8 % in group 1 (p < 0.05). Pancreatic oxygen tension (138.0 ± 89.5 mmHg versus 71.1 ± 35.3 mmHg; p < 0.05) and pancreatic microcirculation (1,209.9 ± 630 AU versus 732 ± 315 AU; p < 0.05) were significantly higher in group 2. Significantly less histopathologic damage within the pancreas could be analyzed post mortem in group 2. CONCLUSIONS Goal-directed hemodynamic management guided by stroke volume variation led to improved survival, tissue oxygenation, and microcirculatory perfusion, as well as less histopathologic damage in an animal model of severe acute pancreatitis.
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Affiliation(s)
- Constantin J C Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Indraratna K. To give or not to give fluid challenges! TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Trepte C, Haas S, Meyer N, Gebhardt M, Goepfert M, Goetz A, Reuter D. Effects of one-lung ventilation on thermodilution-derived assessment of cardiac output. Br J Anaesth 2012; 108:922-8. [DOI: 10.1093/bja/aes032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hemodynamic effects of orally administered delta-ALA during radical prostatectomy. World J Urol 2011; 31:371-6. [PMID: 22120180 DOI: 10.1007/s00345-011-0788-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 10/12/2011] [Indexed: 10/15/2022] Open
Abstract
PURPOSE We investigated hemodynamics in patients receiving delta-Aminolevulinic acid (delta-ALA) to visualize tumor margins prior to radical retro pubic prostatectomy. PATIENTS Twenty patients undergoing elective open radical retro pubic prostatectomy (RRP). METHODS Cohort observational study. Ten patients receiving 20 mg/kg of delta-ALA orally prior to surgery (delta-ALA) and 10 patients undergoing RRP without the application of delta-ALA served as a retrospectively matched cohort (CONTROL). MEASUREMENTS Changes in heart rate (HR), mean arterial blood pressure (MAP), and functional hemodynamic parameters were assessed by electrocardiogram, non-invasive and invasive blood pressure monitoring plus transcardiopulmonary thermodilution. RESULTS Patients of both groups did not differ in means of age, body mass index, or ASA classification. During surgery, HR and MAP did not differ significantly between both groups. Also, the amount of IV crystalloids and colloids did not differ significantly. In contrast, the amount of vasopressor necessary to maintain MAP within the target range of 70-90 mmHg was significantly higher in delta-ALA when compared to CONTROL (0.08 ± 0.04 μg/kg/min (delta-ALA) vs. 0.03 ± 0.02 μg/kg/min (CONTROL); P < 0.01). Immediately after surgery, patients of delta-ALA showed a significantly higher heart rate (82 ± 18 min(-1) vs. 67 ± 9 min(-1); P < 0.05) compared to patients of CONTROL. Cardiac index, global end-diastolic volume index, and extravascular lung water index were significantly higher after surgery, when compared to baseline values (P < 0.05). CONCLUSIONS Orally administered delta-ALA prior to open radical prostatectomy induces hemodynamic instability in the perioperative period requiring vasopressor support. Further, an increase of extravascular lung water points toward an increased vascular permeability induced by delta-ALA.
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Minimally- and non-invasive assessment of maternal cardiac output: go with the flow! Int J Obstet Anesth 2011; 20:330-40. [DOI: 10.1016/j.ijoa.2011.07.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 06/29/2011] [Accepted: 07/05/2011] [Indexed: 10/17/2022]
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Kronas N, Kubitz JC, Forkl S, Kemming GI, Goetz AE, Reuter DA. Functional Hemodynamic Parameters Do Not Reflect Volume Responsiveness in the Immediate Phase After Acute Myocardial Ischemia and Reperfusion. J Cardiothorac Vasc Anesth 2011; 25:780-3. [DOI: 10.1053/j.jvca.2010.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Indexed: 11/11/2022]
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Hofer CK, Cannesson M. Monitoring fluid responsiveness. ACTA ACUST UNITED AC 2011; 49:59-65. [DOI: 10.1016/j.aat.2011.05.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Revised: 12/27/2010] [Accepted: 12/30/2010] [Indexed: 12/11/2022]
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Beattie C, Moores C, Thomson AJ, Nimmo AF. The effect of anaesthesia and aortic clamping on cardiac output measurement using arterial pulse power analysis during aortic aneurysm repair. Anaesthesia 2011; 65:1194-9. [PMID: 21182600 DOI: 10.1111/j.1365-2044.2010.06558.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The LiDCO plus monitor (LiDCO Ltd, Cambridge, UK) uses pulse contour analysis of the arterial pressure waveform to indicate changes in stroke volume and cardiac output. Calibration against a lithium indicator dilution method is required to permit display of absolute values in addition to trends. The effect of haemodynamic changes during anaesthesia and surgery on this calibration factor has not previously been studied. Therefore, we investigated whether it remained constant during elective abdominal aortic aneurysm surgery in 15 patients. Comparison between the calibration factor values at different time points was made by repeated recalibration throughout the peri-operative period. Calibration factor increased by a mean of 53% after anaesthesia (epidural plus general) (p = 0.03) and decreased by a mean of 40% after aortic clamping (p = 0.0001). Recalibration should be undertaken after induction of anaesthesia and after aortic clamping if absolute values of cardiac output and stroke volume are required.
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Affiliation(s)
- C Beattie
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.
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Respiratory variation in aortic blood flow velocity as a predictor of fluid responsiveness in children after repair of ventricular septal defect. Pediatr Cardiol 2010; 31:1166-70. [PMID: 20703453 DOI: 10.1007/s00246-010-9776-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Accepted: 07/27/2010] [Indexed: 10/19/2022]
Abstract
This study aimed to compare respiratory variation in transthoracic echo-derived aortic blood flow velocity (∆Vpeak) and inferior vena cava diameter (∆IVCD) with central venous pressure (CVP) as predictors of fluid responsiveness in children after repair of ventricular septal defect (VSD). A prospective study conducted in pediatric intensive care unit investigated 21 mechanically ventilated children who had undergone repair of VSD. Standardized volume replacement (VR) was the intervention used. Hemodynamic measurements including CVP, heart rate, mean arterial pressure, transthoracic echo-derived stroke volume (SV), cardiac output, ∆Vpeak, and ∆IVCD were performed 1 h after patient arrival in the intensive care unit. Hemodynamic measurements were repeated 10 min after VR by an infusion of 6% hydroxyethyl starch 130/0.4 (10 ml/kg) over 20 min. The volume-induced increase in the SV was 15% or more in 11 patients (responders) and less than 15% in 10 patients (nonresponders). Before volume replacement, the ∆Vpeak (23.1 ± 5.7% vs. 14.0 ± 7.7%; p = 0.006) and ∆IVCD (26.5 ± 16.2% vs. 9.2 ± 9.1%; p = 0.008) was higher in the responders than in the nonresponders, whereas CVP did not significantly differ between the two groups. The prediction of fluid responsiveness was higher with the ΔVpeak, as shown by a receiver operating characteristic curve area of 0.83 (95% confidence interval [CI], 0.61-1.00; p = 0.01), a ΔIVCD of 0.85 (95% CI, 0.69-1.00; p = 0.01), and a CVP of 0.48 (95% CI, 0.22-0.73; nonsignificant difference). The ∆Vpeak and ∆IVCD measured by transthoracic echocardiography can predict the response of SV after volume expansion in mechanically ventilated children at completion of VSD repair.
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Benes J, Chytra I, Altmann P, Hluchy M, Kasal E, Svitak R, Pradl R, Stepan M. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R118. [PMID: 20553586 PMCID: PMC2911766 DOI: 10.1186/cc9070] [Citation(s) in RCA: 300] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 05/04/2010] [Accepted: 06/16/2010] [Indexed: 12/16/2022]
Abstract
Introduction Stroke volume variation (SVV) is a good and easily obtainable predictor of fluid responsiveness, which can be used to guide fluid therapy in mechanically ventilated patients. During major abdominal surgery, inappropriate fluid management may result in occult organ hypoperfusion or fluid overload in patients with compromised cardiovascular reserves and thus increase postoperative morbidity. The aim of our study was to evaluate the influence of SVV guided fluid optimization on organ functions and postoperative morbidity in high risk patients undergoing major abdominal surgery. Methods Patients undergoing elective intraabdominal surgery were randomly assigned to a Control group (n = 60) with routine intraoperative care and a Vigileo group (n = 60), where fluid management was guided by SVV (Vigileo/FloTrac system). The aim was to maintain the SVV below 10% using colloid boluses of 3 ml/kg. The laboratory parameters of organ hypoperfusion in perioperative period, the number of infectious and organ complications on day 30 after the operation, and the hospital and ICU length of stay and mortality were evaluated. The local ethics committee approved the study. Results The patients in the Vigileo group received more colloid (1425 ml [1000-1500] vs. 1000 ml [540-1250]; P = 0.0028) intraoperatively and a lower number of hypotensive events were observed (2[1-2] Vigileo vs. 3.5[2-6] in Control; P = 0.0001). Lactate levels at the end of surgery were lower in Vigileo (1.78 ± 0.83 mmol/l vs. 2.25 ± 1.12 mmol/l; P = 0.0252). Fewer Vigileo patients developed complications (18 (30%) vs. 35 (58.3%) patients; P = 0.0033) and the overall number of complications was also reduced (34 vs. 77 complications in Vigileo and Control respectively; P = 0.0066). A difference in hospital length of stay was found only in per protocol analysis of patients receiving optimization (9 [8-12] vs. 10 [8-19] days; P = 0.0421). No difference in mortality (1 (1.7%) vs. 2 (3.3%); P = 1.0) and ICU length of stay (3 [2-5] vs. 3 [0.5-5]; P = 0.789) was found. Conclusions In this study, fluid optimization guided by SVV during major abdominal surgery is associated with better intraoperative hemodynamic stability, decrease in serum lactate at the end of surgery and lower incidence of postoperative organ complications. Trial registration Current Controlled Trials ISRCTN95085011.
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Affiliation(s)
- Jan Benes
- Department of Anesthesiology and Intensive Care, Charles University teaching hospital, alej Svobody 80, Plzen 304 60, Czech Republic.
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Haas S, Kiefmann R, Eichhorn V, Goetz AE, Reuter DA. [Hemodynamic monitoring in one-lung ventilation]. Anaesthesist 2010; 58:1085-96. [PMID: 19915882 DOI: 10.1007/s00101-009-1632-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
One-lung ventilation causes adverse effects in pulmonary gas exchange and cardiocirculatory function. These adverse effects become particularly important for patients with underlying cardiopulmonary comorbidities. Alterations in pulmonary gas exchange have been investigated in several experimental and clinical trials. However, the hemodynamic consequences of one-lung ventilation are to a great extent unknown. Furthermore, no conclusive recommendations exist as to which kind of hemodynamic monitoring should be preferred in the situation of one-lung ventilation. Many issues regarding hemodynamic monitoring in one-lung ventilation remain unacknowledged. This article will review the current literature on hemodynamic monitoring in one-lung ventilation in order to derive recommendations for the application of hemodynamic monitoring in this specific peri-operative situation.
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Affiliation(s)
- S Haas
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Emerging trends in minimally invasive haemodynamic monitoring and optimization of fluid therapy. Eur J Anaesthesiol 2010; 26:893-905. [PMID: 19667998 DOI: 10.1097/eja.0b013e3283308e50] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND For decades the pulmonary artery catheter has been the mainstay of cardiac output monitoring in critically ill patients, and pressure-based indices of ventricular filling have been used to gauge fluid requirements with acknowledged limitations. In recent years, alternative technologies have become available which are minimally invasive, allow beat-to-beat cardiac output monitoring and permit assessment of fluid requirements by volumetric means and by allowing assessment of heart-lung interaction in mechanically ventilated patients. METHODS A qualitative review of the basic science behind the transpulmonary dilution technique used in the measurement of cardiac output, global end-diastolic volume and extravascular lung water; the basic science and validation of pulse contour analysis methods of real-time cardiac output monitoring; the application and limitations of these technologies to guide rational fluid therapy in surgical and critically ill patients. RESULTS Transpulmonary dilution techniques correlate well with pulmonary artery catheter-derived measurement of cardiac output. Volumetric measures of preload appear to be superior to central venous and pulmonary artery occlusion pressures. Dynamic indices of preload responsiveness such as stroke volume variation are more useful than static measures in mechanically ventilated patients. CONCLUSION In fully mechanically ventilated patients, dynamic measurements of heart-lung interaction such as stroke volume variation are superior to static measures of preload in assessing whether a patient is volume-responsive (i.e. will increase stroke volume in response to a fluid challenge). For patients who are not fully mechanically ventilated, pulse contour analysis allows real-time assessment of increases in cardiac output in response to passive leg-raising.
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Less invasive indicators of changes in thermodilution cardiac output by ventilatory changes after cardiac surgery. Eur J Anaesthesiol 2009; 26:863-7. [PMID: 19390444 DOI: 10.1097/eja.0b013e32832ac5fe] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE We studied whether changes in less invasive, noncalibrated pulse-contour cardiac output (by modified ModelFlow, COmf) and derived stroke volume variations (SVV), as well as systolic and pulse pressure variations, predict changes in bolus thermodilution cardiac output (COtd), evoked by continuous and cyclic increases in intrathoracic pressure by increases in positive end-expiratory pressure (PEEP) and tidal volume (Vt), respectively. METHODS Prospective study on 17 critically ill postcardiac surgery patients on full mechanical ventilatory support, in the intensive care unit. RESULTS In contrast to systolic pressure variation and pulse pressure variation, SVV increased from (mean +/- SD) 6.2 +/- 4.4 to 8.1 +/- 5.6 at PEEP 10 cmH2O (P = 0.064) and to 7.8 +/- 3.5% at PEEP 15 cmH2O (P = 0.031), concomitantly with a 12 +/- 7 and 11 +/- 8% decrease in COmf and COtd (P < 0.001), respectively. For pooled data, changes in COmf correlated with those in COtd (r = 0.55, P = 0.002), but changes in SVV did not. Variables did not change when Vt was increased up to 50%. CONCLUSION A fall in COmf is more sensitive than a rise in SVV, which is more sensitive than systolic pressure variation and pulse pressure variation, in tracking a fall in COtd during continuous (and not cyclic) increases in intrathoracic pressure, in mechanically ventilated patients after cardiac surgery. This suggests a reduction in biventricular preload as the main factor in decreasing cardiac output and increasing SVV with PEEP.
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Lahner D, Kabon B, Marschalek C, Chiari A, Pestel G, Kaider A, Fleischmann E, Hetz H. Evaluation of stroke volume variation obtained by arterial pulse contour analysis to predict fluid responsiveness intraoperatively. Br J Anaesth 2009; 103:346-51. [DOI: 10.1093/bja/aep200] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Effects of changes in blood pressure and airway pressures on parameters of fluid responsiveness. Eur J Anaesthesiol 2009; 26:322-7. [PMID: 19401662 DOI: 10.1097/eja.0b013e32831ac31b] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Systolic pressure variation (SPV) and stroke volume variation (SVV) are clinical indicators of fluid responsiveness. However, several factors may influence these parameters and thereby limit their usefulness. In this clinical study, we analysed SPV and SVV in comparison with static preload parameters during an increase in arterial blood pressure (BP) and airway pressure. METHODS We studied 16 postoperative cardiac surgical and mechanically ventilated patients who, for clinical reasons, underwent haemodynamic monitoring by transpulmonary thermodilution (PiCCO, Pulsion Medical Systems, Munich, Germany) and continuously received norepinephrine. After baseline, the systolic BP was increased (from 105 +/- 10 to 135 +/- 14 mmHg) by briefly increasing the norepinephrine dosage and, after a return to baseline level, the tidal volume was increased from 6 to 10 ml kg(-1). Final measurements were again taken at baseline airway pressures. At each time point, three boluses of 15 ml of 0.9% saline solution (<8 degrees C) were injected into a central vein. Fluid status and sedation remained unchanged. Friedman ANOVA on ranks for repeated measurements was used for statistical analysis. RESULTS Heart rate (HR), cardiac index, intrathoracic blood volume and extravascular lung water remained constant throughout. However, the SPV (6 +/- 3 versus 5 +/- 2 mmHg) remained unchanged and the SVV decreased (12 +/- 5 versus 10 +/- 4%) with higher BP, whereas both parameters, in contrast to central venous and left atrial pressure, significantly increased with higher tidal volume. CONCLUSION In cardiac surgical patients with preserved cardiac index, SVV, but not SPV, decreased during an acute increase in BP, whereas both parameters, in contrast to cardiac filling pressures, significantly increased with higher tidal volume.
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Funk DJ, Moretti EW, Gan TJ. Minimally invasive cardiac output monitoring in the perioperative setting. Anesth Analg 2009; 108:887-97. [PMID: 19224798 DOI: 10.1213/ane.0b013e31818ffd99] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
With advancing age and increased co-morbidities in patients, the need for monitoring devices during the perioperative period that allow clinicians to track physiologic variables, such as cardiac output (CO), fluid responsiveness and tissue perfusion, is increasing. Until recently, the only tool available to anesthesiologists to monitor CO was either a pulmonary artery catheter or transesophageal echocardiograph. These devices have their limitations and potential for morbidity. Several new devices (including esophageal Doppler monitors, pulse contour analysis, indicator dilution, thoracic bioimpedance and partial non-rebreathing systems) have recently been marketed which have the ability to monitor CO noninvasively and, in some cases, assess the patient's ability to respond to fluid challenges. In this review, we will describe these new devices including the technology, studies on their efficacy and the limitations of their use.
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Affiliation(s)
- Duane J Funk
- Department of Anesthesiology, Division of Critical Care, Duke University Medical Center, Durham, NC 27710, USA
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Influence of increased intra-abdominal pressure on fluid responsiveness predicted by pulse pressure variation and stroke volume variation in a porcine model*. Crit Care Med 2009; 37:650-8. [DOI: 10.1097/ccm.0b013e3181959864] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ability of pulse power, esophageal Doppler, and arterial pulse pressure to estimate rapid changes in stroke volume in humans. Crit Care Med 2008; 36:3001-7. [PMID: 18824912 DOI: 10.1097/ccm.0b013e31818b31f0] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Measures of arterial pulse pressure variation and left ventricular stroke volume variation induced by positive-pressure breathing vary in proportion to preload responsiveness. However, the accuracy of commercially available devices to report dynamic left ventricular stroke volume variation has never been validated. METHODS We compared the accuracy of measured arterial pulse pressure and estimated left ventricular stroke volume reported from two Food and Drug Administration-approved aortic flow monitoring devices, one using arterial pulse power (LiDCOplus) and the other esophageal Doppler monitor (HemoSonic). We compared estimated left ventricular stroke volume and their changes during a venous occlusion and release maneuver to a calibrated aortic flow probe placed around the aortic root on a beat-to-beat basis in seven anesthetized open-chested cardiac surgery patients. RESULTS Dynamic changes in arterial pulse pressure closely tracked left ventricular stroke volume changes (mean r .96). Both devices showed good agreement with steady-state apneic left ventricular stroke volume values and moderate agreement with dynamic changes in left ventricular stroke volume (esophageal Doppler monitor -1 +/- 22 mL, and pulse power -7 +/- 12 mL, bias +/- 2 sd). In general, the pulse power signals tended to underestimate left ventricular stroke volume at higher left ventricular stroke volume values. CONCLUSION Arterial pulse pressure, as well as, left ventricular stroke volume estimated from esophageal Doppler monitor and pulse power reflects short-term steady-state left ventricular stroke volume values and tract dynamic changes in left ventricular stroke volume moderately well in humans.
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Archer T, Knape K, Liles D, Wheeler A, Carter B. The hemodynamics of oxytocin and other vasoactive agents during neuraxial anesthesia for cesarean delivery: findings in six cases. Int J Obstet Anesth 2008; 17:247-54. [DOI: 10.1016/j.ijoa.2008.03.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2008] [Indexed: 12/01/2022]
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Ryan KL, Cooke WH, Rickards CA, Lurie KG, Convertino VA. Breathing through an inspiratory threshold device improves stroke volume during central hypovolemia in humans. J Appl Physiol (1985) 2008; 104:1402-9. [DOI: 10.1152/japplphysiol.00439.2007] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Inspiratory resistance induced by breathing through an impedance threshold device (ITD) reduces intrathoracic pressure and increases stroke volume (SV) in supine normovolemic humans. We hypothesized that breathing through an ITD would also be associated with a protection of SV and a subsequent increase in the tolerance to progressive central hypovolemia. Eight volunteers (5 men, 3 women) were instrumented to record ECG and beat-by-beat arterial pressure and SV (Finometer). Tolerance to progressive lower body negative pressure (LBNP) was assessed while subjects breathed against either 0 (sham ITD) or −7 cmH2O inspiratory resistance (active ITD); experiments were performed on separate days. Because the active ITD increased LBNP tolerance time from 2,014 ± 106 to 2,259 ± 138 s ( P = 0.006), data were analyzed (time and frequency domains) under both conditions at the time at which cardiovascular collapse occurred during the sham experiment to determine the mechanisms underlying this protective effect. At this time point, arterial blood pressure, SV, and cardiac output were higher ( P ≤ 0.005) when breathing on the active ITD rather than the sham ITD, whereas indirect indicators of autonomic activity (low- and high-frequency oscillations of the R-to-R interval) were not altered. ITD breathing did not alter the transfer function between systolic arterial pressure and R-to-R interval, indicating that integrated baroreflex sensitivity was similar between the two conditions. These data show that breathing against inspiratory resistance increases tolerance to progressive central hypovolemia by better maintaining SV, cardiac output, and arterial blood pressures via primarily mechanical rather than neural mechanisms.
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Kubitz JC, Forkl S, Annecke T, Kronas N, Goetz AE, Reuter DA. Systolic pressure variation and pulse pressure variation during modifications of arterial pressure. Intensive Care Med 2008; 34:1520-4. [PMID: 18427779 DOI: 10.1007/s00134-008-1114-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Accepted: 03/24/2008] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study was performed to investigate the effect of vasopressor therapy on systolic pressure variation (SPV) and pulse pressure variation (PPV) compared to experimentally measured left ventricular stroke volume variation (SVV). DESIGN AND SETTING Prospective study in a university laboratory. SUBJECTS Twelve anesthetized and mechanically ventilated pigs. INTERVENTIONS Increase in mean arterial pressure (by 100%) using phenylephrine and decrease (by 38%) using adenosine. MEASUREMENTS AND RESULTS SPV and PPV were calculated and compared to SVV derived from aortic blood flow measurements. SPV was significantly affected by changes in arterial pressure [4.6% (1.5) vs. 6.3% (2.1), p < 0.05, increased vs. decreased arterial pressure], whereas PPV did not change during modifications of arterial pressure. During baseline conditions and decreased afterload, correlation with SVV was good both for SPV (r =0.892 and r = 0.859, respectively) and for PPV (r = 0.870 and r = 0.871, respectively) (all p < 0.001). Correlation with SVV was only moderate during increased arterial pressure (r = 0.683 for SPV and r = 0.732 for PPV, p < 0.05). CONCLUSION For guiding fluid therapy in patients under vasopressor support, PPV seems superior to SPV.
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Affiliation(s)
- Jens C Kubitz
- Department of Anesthesiology, University of Hamburg, Hamburg-Eppendorf University Hospital, Hamburg, Germany.
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Effects of changes in vascular tone on the agreement between pulse contour and transpulmonary thermodilution cardiac output measurements within an up to 6-hour calibration-free period*. Crit Care Med 2008; 36:434-40. [DOI: 10.1097/01.ccm.ob013e318161fec4] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Bein B, Renner J, Meybohm P, Scholz J. Validation of pulse contour derived stroke volume variation. Br J Anaesth 2007; 99:745-6; author reply 746. [DOI: 10.1093/bja/aem284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
PURPOSE OF REVIEW In the ICU only half of the patients are volume responsive - that is, they respond to fluid administration by increasing their cardiac output. We aim to summarize the methods available for predicting volume responsiveness, focusing on recent findings in patients with spontaneous breathing activity. RECENT FINDINGS New information mainly comes from studies that have attempted to find accurate predictors of volume responsiveness in cases of spontaneous breathing activity when heart-lung interaction indices cannot be reliably used. Passive leg raising has emerged as a reliable test for this purpose. The hemodynamic response to this maneuver, which induces a transient increase in cardiac preload, has been shown to provide a robust prediction of volume responsiveness. Assessment of the effects of passive leg raising requires real-time measurement of cardiac output/stroke volume or their surrogates. SUMMARY Predicting the hemodynamic response to fluid administration in patients with acute circulatory failure is of major importance and numerous methods are now available. While the respiratory variations of stroke volume (or its surrogates) can be used in patients fully adapted to their ventilator, the passive leg-raising test has become a reliable predictive method in patients with spontaneous breathing activity.
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Affiliation(s)
- Xavier Monnet
- Medical Intensive Care Unit, Bicêtre University Hospital, Paris-11 University, Le Kremlin-Bicêtre, France
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