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Hong A, Boukthir S, Levé C, Joachim J, Mateo J, Le Gall A, Mebazaa A, Gayat E, Cartailler J, Vallée F. "Association of velocity-pressure loop-derived values recorded during neurosurgical procedures with postoperative organ failure biomarkers: a retrospective single-center study". Anaesth Crit Care Pain Med 2024:101405. [PMID: 38997007 DOI: 10.1016/j.accpm.2024.101405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 05/24/2024] [Accepted: 06/02/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND Perioperative renal and myocardial protection primarily depends on preoperative prediction tools, along with intraoperative optimization of cardiac output (CO) and mean arterial pressure (MAP). We hypothesise that monitoring the intraoperative global afterload angle (GALA), a proxy of ventricular afterload derived from the velocity pressure (VP) loop, could better predict changes in postoperative biomarkers than the recommended traditional MAP and CO. METHOD This retrospective monocentric study included patients programmed for neurosurgery with continuous VP loop monitoring. Patients with hemodynamic instability were excluded. Those presenting a 1-day post-surgery increase in creatinine, B-type natriuretic peptide, or troponin Ic us were labelled Bio+, Bio- otherwise. Demographics, intra-operative data and comorbidities were considered as covariates. The study aimed to determine if intraoperative GALA monitoring could predict early postoperative biomarker disruption. RESULT From November 2018 to November 2020, 86 patients were analysed (Bio+/Bio- = 47/39). Bio + patients were significantly older (62[54-69] versus 42[34-57] years, p < 0.0001), More often hypertensive (25% vs. 9%, p = 0.009), and more frequently treated with antihypertensive drugs (31.9% vs. 7.7%, p = 0.013). GALA was significantly larger in Bio+ patients (40[31-56] vs. 23[19-29] °, p < 0.0001), while CO, MAP, and cumulative time spent <65mmHg were similar between groups. GALA exhibited strong predictive performances for postoperative biological deterioration (AUC=0.88[0.80-0.95]), significantly outperforming MAP (MAP AUC=0.55[0.43-0.68], p < 0.0001). CONCLUSION GALA under general anaesthesia prove more effective in detecting patients at risk of early cardiac or renal biological deterioration, compared to classical hemodynamic parameters.
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Affiliation(s)
- Alex Hong
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Cambodia China friendship preah kossamak hospital 316d St 150, Phnom Penh, Cambodia
| | - Sonia Boukthir
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.
| | - Charlotte Levé
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jona Joachim
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Joaquim Mateo
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Arthur Le Gall
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Alexandre Mebazaa
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Inserm, UMRS-942, Paris. France
| | - Etienne Gayat
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Inserm, UMRS-942, Paris. France
| | - Jérôme Cartailler
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Inserm, UMRS-942, Paris. France
| | - Fabrice Vallée
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Inserm, UMRS-942, Paris. France; Laboratoire de Mécanique des Solides (LMS), Ecole Polytechnique, CNRS, Palaiseau, France
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Højlund J, Cihoric M, Foss NB. Vasoconstriction with phenylephrine increases cardiac output in preload dependent patients. J Clin Monit Comput 2024:10.1007/s10877-024-01186-7. [PMID: 38907106 DOI: 10.1007/s10877-024-01186-7] [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: 04/16/2024] [Accepted: 06/02/2024] [Indexed: 06/23/2024]
Abstract
General Anaesthesia (GA) is accompanied by a marked decrease in sympathetic outflow and thus loss of vasomotor control of cardiac preload. The use of vasoconstriction during GA has mainly focused on maintaining blood pressure. Phenylephrine (PE) is a pure α1-agonist without inotropic effects widely used to correct intraoperative hypotension. The potential of PE for augmenting cardiac stroke volume (SV) and -output (CO) by venous recruitment is controversial and no human studies have explored the effects of PE in preload dependent circulation using indicator dilution technique. We hypothesized that PE-infusion in patients with cardiac stroke volume limited by reduced preload would restore preload and thus augment SV and CO. 20 patients undergoing GA for gastrointestinal surgery were monitored with arterial catheter and LiDCO unity monitor. Upon stable haemodynamics after induction patients were placed in head-up tilt (HUT). All patients became preload responsive as verified by a stroke volume variation (SVV) of > 12%. PE-infusion was then started at 15-20mikrg/min and adjusted until preload was restored (SVV < 12%). Li-dilution cardiac output (CO) was initially measured after induction (baseline), again with HUT in the preload responsive phase, and finally when preload was restored with infusion of PE.At baseline SVV was 10 ± 3% (mean ± st.dev.), CI was 2,6 ± 0,4 L/min*m2, and SVI 43 ± 7mL/m2. With HUT SVV was 19 ± 4%, CI was 2,2 ± 0,4 L/min*m2, SVI 35 ± 7mL/m2. During PE-infusion SVV was reduced to 6 ± 3%, CI increased to 2,6 ± 0,5 L/min*m2, and SVI increased to 49 ± 11mL/m2. All differences p < 0,001. In conclusion: Infusion of phenylephrine during preload dependency increased venous return abolishing preload dependency as evaluated by SVV and increased cardiac stroke volume and -output as measured by indicator-dilution technique. (ClinicalTrials.gov NCT05193097).
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Affiliation(s)
- Jakob Højlund
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark.
| | - Mirjana Cihoric
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark
| | - Nicolai Bang Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark
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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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Chen S, Luo F, Lin Y, Yu G, Luo J, Xu J. Effect of intravenous low-dose norepinephrine on blood loss in non-tourniquet total knee arthroplasty under general anesthesia: a randomized, double-blind, controlled, single-center trial. J Orthop Surg Res 2023; 18:933. [PMID: 38057870 DOI: 10.1186/s13018-023-04360-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/08/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVE This prospective trial aimed to evaluate the effects of low-dose intravenous norepinephrine (NE) on intraoperative blood loss and bleeding from osteotomy sites during non-tourniquet total knee arthroplasty (TKA) under general anesthesia. METHODS A total of 120 patients who underwent TKA between December 2020 and May 2022 were enrolled and randomly assigned to the intravenous low-dose NE Group (NE Group) or the control group (C Group). During surgery, NE Group received 0.05-0.1 μg/(kg min) of NE intravenously to raise and maintain the patient's mean arterial pressure (MAP). C Group received the same dose of saline as placebo. Intraoperative blood loss, bleeding score at osteotomy sites, Δlactate levels (Lac), postoperative complications, and transfusion rate during hospitalization were compared between groups. RESULTS Intraoperative and osteotomy blood loss was significantly lower in the NE Group than in the C Group (P < 0.001). No significant difference was observed in ΔLac between groups (P > 0.05). There was no significant difference in complications between the groups 3 days after surgery (P > 0.05). In addition, there was no significant difference in blood transfusion rates between the two groups during hospitalization (P > 0.05). CONCLUSION In non-tourniquet TKA under general anesthesia, low-dose intravenous NE safely and effectively reduced intraoperative blood loss and provided a satisfactory osteotomy site while maintaining a higher MAP.
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Affiliation(s)
- Shijie Chen
- Shengli Clinical College of Fujian Medical University, No. 134 East Street, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, No. 134 East Street, Fuzhou, Fujian, China
| | - Fenqi Luo
- Shengli Clinical College of Fujian Medical University, No. 134 East Street, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, No. 134 East Street, Fuzhou, Fujian, China
| | - Yuan Lin
- Shengli Clinical College of Fujian Medical University, No. 134 East Street, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, No. 134 East Street, Fuzhou, Fujian, China
| | - Guoyu Yu
- Shengli Clinical College of Fujian Medical University, No. 134 East Street, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, No. 134 East Street, Fuzhou, Fujian, China
| | - Jun Luo
- Shengli Clinical College of Fujian Medical University, No. 134 East Street, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, No. 134 East Street, Fuzhou, Fujian, China
| | - Jie Xu
- Shengli Clinical College of Fujian Medical University, No. 134 East Street, Fuzhou, Fujian, China.
- Department of Orthopedic, Fujian Provincial Hospital, No. 134 East Street, Fuzhou, Fujian, China.
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Kindermans M, Joachim J, Manquat E, Levé C, Hong A, Mateo J, Mebazaa A, Gayat E, De Backer D, Vallée F. Micro- and macrocirculatory effects of norepinephrine on anaesthesia-induced hypotension: a prospective preliminary study. BMC Anesthesiol 2023; 23:374. [PMID: 37974084 PMCID: PMC10652607 DOI: 10.1186/s12871-023-02342-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 11/06/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Intraoperative arterial hypotension (IOH) leads to increased postoperative morbidity. Norepinephrine is often use to treat IOH. The question regarding the mode of administration in either a bolus or continuous infusion remains unanswered. The aim of the present study was to describe and compare the effects on macrocirculation and microcirculation of a bolus and a continuous infusion of norepinephrine to treat IOH. METHODS We conducted a prospective observational study with adult patients who underwent neurosurgery. Patients with invasive arterial blood pressure and cardiac output (CO) monitoring were screened for inclusion. All patients underwent microcirculation monitoring by video-capillaroscopy, laser doppler, near-infrared spectroscopy technology, and tissular CO2. In case of IOH, the patient could receive either a bolus of 10 µg or a continuous infusion of 200 µg/h of norepinephrine. Time analysis for comparison between bolus and continuous infusion were at peak of MAP. The primary outcome was MFI by videocapillaroscopy. RESULTS Thirty-five patients were included, with 41 boluses and 33 continuous infusion. Bolus and continuous infusion induced an maximal increase in mean arterial pressure of +30[20-45] and +23[12-34] %, respectively (P=0,07). For macrocirculatory parameters, continuous infusion was associated with a smaller decrease in CO and stroke volume (p<0.05). For microcirculatory parameters, microvascular flow index (-0,1 vs. + 0,3, p=0,03), perfusion index (-12 vs. +12%, p=0,008), total vessel density (-0,2 vs. +2,3 mm2/mm2, p=0,002), showed significant opposite variations with bolus and continuous infusion, respectively. CONCLUSIONS These results on macro and microcirculation enlighten the potential benefits of a continuous infusion of norepinephrine rather than a bolus to treat anaesthesia-induced hypotension. TRIAL REGISTRATION (NOR-PHARM: 1-17-42 Clinical Trials: NCT03454204), 05/03/2018.
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Affiliation(s)
- Manuel Kindermans
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France.
| | - Jona Joachim
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
- Inserm, UMRS-942, Paris Diderot University, 02, rue Ambroise Paré, 75010, Paris, France
| | - Elsa Manquat
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
- Inserm, UMRS-942, Paris Diderot University, 02, rue Ambroise Paré, 75010, Paris, France
| | - Charlotte Levé
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Alex Hong
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Joachim Mateo
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Alexandre Mebazaa
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
- Inserm, UMRS-942, Paris Diderot University, 02, rue Ambroise Paré, 75010, Paris, France
| | - Etienne Gayat
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
- Inserm, UMRS-942, Paris Diderot University, 02, rue Ambroise Paré, 75010, Paris, France
| | - Daniel De Backer
- CHIREC, Brussels, Belgium
- Intensive Care Department, CHIREC Hospitals, Brussels, Belgium
| | - Fabrice Vallée
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
- Inserm, UMRS-942, Paris Diderot University, 02, rue Ambroise Paré, 75010, Paris, France
- Inria Saclay Ile-de-France, Palaiseau, France
- LMS, École Polytechnique, CNRS, Paris, France
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6
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Coombs GB, Al-Khazraji BK, Suskin N, Shoemaker JK. Impact of ischemic heart disease and cardiac rehabilitation on cerebrovascular compliance. J Appl Physiol (1985) 2023; 135:753-762. [PMID: 37616337 DOI: 10.1152/japplphysiol.00654.2022] [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: 10/31/2022] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 08/26/2023] Open
Abstract
We aimed to determine the influence of ischemic heart disease (IHD) and cardiac rehabilitation (CR) on cerebrovascular compliance index (Ci). Eleven (one female) patients with IHD (mean[SD]: 61[11] yr, 29[4] kg/m2) underwent 6 mo of CR, which consisted of ≥3 sessions/wk of aerobic and resistance training (20-60 min each). Ten (three female) similarly aged controls (CON) were tested at baseline as a comparator group. Middle cerebral artery velocity (MCAv) and mean arterial pressure were monitored continuously using transcranial Doppler ultrasound and finger photoplethysmography, respectively, during a rapid sit-to-stand maneuver. A Windkessel model was used to estimate cerebrovascular Ci every five cardiac cycles for a duration of 30 s. Cerebrovascular resistance was calculated as the quotient of MAP and MCAv. Two-way ANOVAs were used to determine whether cerebrovascular variables differ during postural transitions between groups and after CR. Baseline MCAv was higher in CON versus IHD (P = 0.014) and a time × group interaction was observed (P = 0.045) where MCAv decreased more in CON after standing. Compared with the precondition, CR had no effect on MCAv (condition P = 0.950) but a main effect of time indicated that MCAv decreased from the seated position in both conditions (time P = 0.013). Baseline cerebrovascular Ci was greater in IHD versus CON (P = 0.049) and the peak cerebrovascular Ci during the transition to standing was significantly higher in IHD compared with CON (interaction P = 0.047). CR did not affect cerebrovascular compliance (P = 0.452) and no time-by-condition interaction upon standing was present (P = 0.174). Baseline cerebrovascular Ci is higher in IHD at baseline compared with CON, but 6 mo of CR did not modify the transient increase in cerebrovascular Ci during sit-to-stand maneuvers.NEW & NOTEWORTHY Post-cardiac event cognitive impairment is common and exercise-based rehabilitation may be an effective intervention to mitigate cognitive decline. Microvascular damage due to high blood pressure pulsatility entering the brain is the putative mechanism of vascular dementia. Whether patients with ischemic heart disease exhibit lower cerebrovascular compliance, and if cardiac rehabilitation can improve cerebrovascular compliance is unknown. We observed that patients with ischemic heart disease have paradoxically higher cerebrovascular compliance, which is not affected by cardiac rehabilitation.
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Affiliation(s)
- Geoff B Coombs
- School of Kinesiology, University of Western Ontario, London, Ontario, Canada
| | - Baraa K Al-Khazraji
- School of Kinesiology, University of Western Ontario, London, Ontario, Canada
- Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Neville Suskin
- Division of Cardiology, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - J Kevin Shoemaker
- School of Kinesiology, University of Western Ontario, London, Ontario, Canada
- Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario, Canada
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Karamchandani K, Dave S, Hoffmann U, Khanna AK, Saugel B. Intraoperative arterial pressure management: knowns and unknowns. Br J Anaesth 2023; 131:445-451. [PMID: 37419749 DOI: 10.1016/j.bja.2023.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/16/2023] [Accepted: 05/29/2023] [Indexed: 07/09/2023] Open
Abstract
Preventing postoperative organ dysfunction is integral to the practice of anaesthesia. Although intraoperative hypotension is associated with postoperative end organ dysfunction, there remains ambiguity with regards to its definition, targets, thresholds for initiating treatment, and ideal treatment modalities.
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Affiliation(s)
- Kunal Karamchandani
- Department of Anesthesiology and Pain Management, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Siddharth Dave
- Department of Anesthesiology and Pain Management, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ulrike Hoffmann
- Department of Anesthesiology and Pain Management, Division of Neuroanesthesia, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Perioperative Outcomes and Informatics Collaborative (POIC), Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Bernd Saugel
- Outcomes Research Consortium, Cleveland, OH, USA; Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Vojnar B, Geldner G, Huljic-Lankinen S, Murst M, Keller T, Weber S, Gaik C, Koch T, Weyland A, Kranke P, Kreuer S, Chappell D, Eberhart L. A randomized open label, parallel-group study to evaluate the hemodynamic effects of Cafedrine/Theodrenaline vs Noradrenaline in the treatment of intraoperative hypotension after induction of general anesthesia: the "HERO" study design and rationale. Curr Med Res Opin 2023; 39:803-810. [PMID: 37211772 DOI: 10.1080/03007995.2023.2213124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/24/2023] [Accepted: 05/09/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Intraoperative arterial hypotension (IOH) is associated with poor patient outcome. This study aims to compare the hemodynamic effects of Cafedrine/Theodrenaline (C/T) and Noradrenaline (NA) for the treatment of hypotension in patients who develop IOH after anesthesia induction. RESEARCH DESIGN AND METHODS This is a national, randomized, parallel-group, multicenter, and open-label study. Adult patients (≥50 years, ASA-classification III-IV) who undergo elective surgery will be included. When IOH (MAP <70 mmHg) develops, C/T or NA will be given as a bolus injection ("bolus phase", 0-20 min after initial application) and subsequently as continuous infusion ("infusion phase", 21-40 min after initial application) to achieve MAP = 90 mmHg. Hemodynamic data are captured in real time by advanced hemodynamic monitoring. RESULTS Primary endpoints, i.e. the treatment-related difference in average mean arterial pressure (MAP) during the "infusion phase" and the treatment-related difference in average cardiac index during the "bolus phase" are assessed (fixed-sequence method). Non-inferiority of C/T compared to NA in achieving 90 mmHg (MAP) when applied as continuous infusion is hypothesized. In addition, superiority of C/T over NA, applied as bolus injection, in increasing cardiac index is postulated. It is estimated that 172 patients are required to establish statistical significance with a power of 90%. After adjusting for ineligibility and dropout rate, 220 patients will be screened. CONCLUSION This clinical trial will yield evidence for marketing authorization of C/T applied as continuous infusion. Additionally, the effects of C/T compared to NA on cardiac index will be assessed. First results of the "HERO"-study are expected in 2024. DRKS identifier: DRKS00028589. EudraCT identifier: 2021-001954-76.
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Affiliation(s)
- Benjamin Vojnar
- Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Marburg, Germany
| | - Götz Geldner
- Clinic for Intensive Care, Emergency Medicine and Pain Therapy, Hospital Ludwigsburg, Ludwigsburg, Germany
| | | | | | | | | | - Christine Gaik
- Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Marburg, Germany
| | - Tilo Koch
- Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Marburg, Germany
| | - Andreas Weyland
- Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Peter Kranke
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Sascha Kreuer
- Department of Anesthesiology, Intensive Care and Pain Therapy, Saarland University Faculty of Medicine, Homburg, Germany
| | - Daniel Chappell
- Department of Anesthesiology and Intensive Care, Varisano Hospital Frankfurt-Höchst, Frankfurt, Germany
| | - Leopold Eberhart
- Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Marburg, Germany
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Legrand M, Kothari R, Fong N, Palaniappa N, Boldt D, Chen LL, Kurien P, Gabel E, Sturgess-DaPrato J, Harhay MO, Pirracchio R, Bokoch MP. Norepinephrine versus phenylephrine for treating hypotension during general anaesthesia in adult patients undergoing major noncardiac surgery: a multicentre, open-label, cluster-randomised, crossover, feasibility, and pilot trial. Br J Anaesth 2023; 130:519-527. [PMID: 36925330 DOI: 10.1016/j.bja.2023.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Intraoperative hypotension is associated with postoperative complications. The use of vasopressors is often required to correct hypotension but the best vasopressor is unknown. METHODS A multicentre, cluster-randomised, crossover, feasibility and pilot trial was conducted across five hospitals in California. Phenylephrine (PE) vs norepinephrine (NE) infusion as the first-line vasopressor in patients under general anaesthesia alternated monthly at each hospital for 6 months. The primary endpoint was first-line vasopressor administration compliance of 80% or higher. Secondary endpoints were acute kidney injury (AKI), 30-day mortality, myocardial injury after noncardiac surgery (MINS), hospital length of stay, and rehospitalisation within 30 days. RESULTS A total of 3626 patients were enrolled over 6 months; 1809 patients were randomised in the NE group, 1817 in the PE group. Overall, 88.2% received the assigned first-line vasopressor. No drug infiltrations requiring treatment were reported in either group. Patients were median 63 yr old, 50% female, and 58% white. Randomisation in the NE group vs PE group did not reduce readmission within 30 days (adjusted odds ratio=0.92; 95% confidence interval, 0.6-1.39), 30-day mortality (1.01; 0.48-2.09), AKI (1.1; 0.92-1.31), or MINS (1.63; 0.84-3.16). CONCLUSIONS A large and diverse population undergoing major surgery under general anaesthesia was successfully enrolled and randomised to receive NE or PE infusion. This pilot and feasibility trial was not powered for adverse postoperative outcomes and a follow-up multicentre effectiveness trial is planned. CLINICAL TRIAL REGISTRATION NCT04789330 (ClinicalTrials.gov).
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA; INI-CRCT Network, Nancy, France.
| | - Rishi Kothari
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA; Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas Fong
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA; School of Medicine, University of California, San Francisco, CA, USA
| | - Nandini Palaniappa
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - David Boldt
- Department of Anesthesia and Perioperative Care, University of California, Los Angeles, USA
| | - Lee-Lynn Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Philip Kurien
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Eilon Gabel
- Department of Anesthesia and Perioperative Care, University of California, Los Angeles, USA
| | - Jillene Sturgess-DaPrato
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Michael O Harhay
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Romain Pirracchio
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Michael P Bokoch
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
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10
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Laou E, Papagiannakis N, Sarchosi S, Kleisiaris K, Apostolopoulou A, Syngelou V, Kakagianni M, Christopoulos A, Ntalarizou N, Chalkias A. The use of mean circulatory filling pressure analogue for monitoring hemodynamic coherence: A post-hoc analysis of the SPARSE data and proof-of-concept study. Clin Hemorheol Microcirc 2023:CH221563. [PMID: 36846992 DOI: 10.3233/ch-221563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Dissociation between macrocirculation and microcirculation is often observed in surgical patients. OBJECTIVE To test the hypothesis that the analogue of mean circulatory filling pressure (Pmca) can monitor hemodynamic coherence during major non-cardiac surgery. METHODS In this post-hoc analysis and proof-of-concept study, we used the central venous pressure (CVP), mean arterial pressure (MAP), and cardiac output (CO) to calculate Pmca. Efficiency of the heart (Eh), arterial resistance (Rart), effective arterial elastance (Ea), venous compartment resistance (Rven), oxygen delivery (DO2), and oxygen extraction ratio (O2ER) were also calculated. Sublingual microcirculation was assessed using SDF + imaging, and the De Backer score, Consensus Proportion of Perfused Vessels (Consensus PPV), and Consensus PPV (small) were determined. RESULTS Thirteen patients were included, with a median age of 66 years. Median Pmca was 16 (14.9-18) mmHg and was positively associated with CO [p < 0.001; a 1 mmHg increase in Pmca increases CO by 0.73 L min - 1 (p < 0.001)], Eh (p < 0.001), Rart (p = 0.01), Ea (p = 0.03), Rven (p = 0.005), DO2 (p = 0.03), and O2ER (p = 0.02). A significant correlation was observed between Pmca and Consensus PPV (p = 0.02), but not with De Backer Score (p = 0.34) or Consensus PPV (small) (p = 0.1). CONCLUSION Significant associations exist between Pmca and several hemodynamic and metabolic variables including Consensus PPV. Adequately powered studies should determine whether Pmca can provide real-time information on hemodynamic coherence.
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Affiliation(s)
- Eleni Laou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Nikolaos Papagiannakis
- First Department of Neurology, Eginition University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Smaragdi Sarchosi
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Konstantinos Kleisiaris
- Intermediate Care Unit, Cardiovascular Center, University Hospital of Bern, Bern, Switzerland
| | | | - Vasiliki Syngelou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Maria Kakagianni
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | | | - Nicoleta Ntalarizou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, Larisa, Greece.,Outcomes Research Consortium, Cleveland, OH, USA
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11
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Le Gall A, Vallée F, Joachim J, Hong A, Matéo J, Mebazaa A, Gayat E. Estimation of cardiac output variations induced by hemodynamic interventions using multi-beat analysis of arterial waveform: a comparative off-line study with transesophageal Doppler method during non-cardiac surgery. J Clin Monit Comput 2022; 36:501-510. [PMID: 33687601 PMCID: PMC9123019 DOI: 10.1007/s10877-021-00679-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 01/08/2021] [Indexed: 11/25/2022]
Abstract
Multi-beat analysis (MBA) of the radial arterial pressure (AP) waveform is a new method that may improve cardiac output (CO) estimation via modelling of the confounding arterial wave reflection. We evaluated the precision and accuracy using the trending ability of the MBA method to estimate absolute CO and variations (ΔCO) during hemodynamic challenges. We reviewed the hemodynamic challenges (fluid challenge or vasopressors) performed when intra-operative hypotension occurred during non-cardiac surgery. The CO was calculated offline using transesophageal Doppler (TED) waveform (COTED) or via application of the MBA algorithm onto the AP waveform (COMBA) before and after hemodynamic challenges. We evaluated the precision and the accuracy according to the Bland & Altman method. We also assessed the trending ability of the MBA by evaluating the percentage of concordance with 15% exclusion zone between ΔCOMBA and ΔCOTED. A non-inferiority margin was set at 87.5%. Among the 58 patients included, 23 (40%) received at least 1 fluid challenge, and 46 (81%) received at least 1 bolus of vasopressors. Before treatment, the COTED was 5.3 (IQR [4.1-8.1]) l min-1, and the COMBA was 4.1 (IQR [3-5.4]) l min-1. The agreement between COTED and COMBA was poor with a 70% percentage error. The bias and lower and upper limits of agreement between COTED and COMBA were 0.9 (CI95 = 0.82 to 1.07) l min-1, -2.8 (CI95 = -2.71 to-2.96) l min-1 and 4.7 (CI95 = 4.61 to 4.86) l min-1, respectively. After hemodynamic challenge, the percentage of concordance (PC) with 15% exclusion zone for ΔCO was 93 (CI97.5 = 90 to 97)%. In this retrospective offline analysis, the accuracy, limits of agreements and percentage error between TED and MBA for the absolute estimation of CO were poor, but the MBA could adequately track induced CO variations measured by TED. The MBA needs further evaluation in prospective studies to confirm those results in clinical practice conditions.
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Affiliation(s)
- Arthur Le Gall
- Inria Paris-Saclay, 01, avenue Honoré d'Estienne d'Orves, 91120, Palaiseau, France.
- LMS, École Polytechnique, 91128, Palaiseau Cedex, France.
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France.
- Université de Paris, 85 boulevard Saint-Germain, 75006, Paris, France.
| | - Fabrice Vallée
- Inria Paris-Saclay, 01, avenue Honoré d'Estienne d'Orves, 91120, Palaiseau, France
- LMS, École Polytechnique, 91128, Palaiseau Cedex, France
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France
- UMR-S 942, INSERM, 02 rue Ambroise Paré, 75010, Paris, France
| | - Jona Joachim
- Inria Paris-Saclay, 01, avenue Honoré d'Estienne d'Orves, 91120, Palaiseau, France
- LMS, École Polytechnique, 91128, Palaiseau Cedex, France
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France
- UMR-S 942, INSERM, 02 rue Ambroise Paré, 75010, Paris, France
| | - Alex Hong
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France
- Université de Paris, 85 boulevard Saint-Germain, 75006, Paris, France
| | - Joaquim Matéo
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France
| | - Alexandre Mebazaa
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France
- UMR-S 942, INSERM, 02 rue Ambroise Paré, 75010, Paris, France
- Université de Paris, 85 boulevard Saint-Germain, 75006, Paris, France
| | - Etienne Gayat
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France
- UMR-S 942, INSERM, 02 rue Ambroise Paré, 75010, Paris, France
- Université de Paris, 85 boulevard Saint-Germain, 75006, Paris, France
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12
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Aykanat VM, Myles PS, Weinberg L, Burrell A, Bellomo R. Low-Concentration Norepinephrine Infusion for Major Surgery: A Safety and Feasibility Pilot Randomized Controlled Trial. Anesth Analg 2021; 134:410-418. [PMID: 34872102 DOI: 10.1213/ane.0000000000005811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Prevention of hypotension during the intra- and postoperative period is an important goal. Peripheral administration of low-concentration norepinephrine may be a safe and effective strategy to reduce the risk of hypotension. METHODS We conducted a 2-center, randomized pilot feasibility trial, with a target of 60 adult patients undergoing major noncardiac surgery. We randomized patients to receive a peripheral low-concentration (10 µg/mL) norepinephrine or placebo (saline 0.9%) infusion. The study drug infusion was titrated to achieve a minimum systolic blood pressure target, preselected within 10% of baseline value and within the range limit 100 to 120 mm Hg during surgery and for up to 4 or 24 hours postoperatively. RESULTS We achieved a high consent rate (84%), successful study drug administration throughout surgery (98% of patients) and absence of unblinding. There were no important study drug-related adverse events. The average intraoperative systolic blood pressure was 120 ± 12.6 mm Hg in the norepinephrine group and 115 ± 14.9 mm Hg in the placebo group. The mean difference between the intraoperative systolic blood pressure achieved less the preselected minimum systolic blood pressure target was 10.0 ± 12.7 mm Hg in the norepinephrine group and 2.9 ± 14.7 mm Hg in the placebo group; difference in means, 7.1 (95% confidence interval, 0.2-14.0) mm Hg. CONCLUSIONS A future large trial evaluating the effectiveness and safety of peripheral administration of low-concentration norepinephrine during the perioperative period is feasible, and likely to achieve a minimum systolic blood pressure threshold.
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Affiliation(s)
- Verna M Aykanat
- From the Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - Paul S Myles
- From the Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | | | - Aidan Burrell
- Department of Intensive Care, Alfred Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Intensive Care Austin Hospital, Melbourne, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Australia
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13
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Kim NY, Kim KJ, Kim TL, Shin HJ, Oh C, Lee MH, Min JY, Kim SY. Prediction of hypotension after postural change in robot-assisted laparoscopic prostatectomy using esophageal Doppler monitoring: a prospective observational trial. Sci Rep 2021; 11:14589. [PMID: 34272425 PMCID: PMC8285389 DOI: 10.1038/s41598-021-93990-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/28/2021] [Indexed: 11/09/2022] Open
Abstract
Postural change from a steep Trendelenburg position to a supine position (T-off) during robot-assisted laparoscopic prostatectomy (RALP) induces a considerable abrupt decrease in the mean arterial pressure (MAP). We investigated the variables for predicting postural hypotension induced by T-off using esophageal Doppler monitoring (EDM). One hundred and twenty-five patients undergoing RALP were enrolled. Data on the MAP, heart rate, stroke volume index (SVI), cardiac index, peak velocity, corrected flow time, stroke volume variation, pulse pressure variation, arterial elastance (Ea), and dynamic arterial elastance were collected before T-off and at 1, 3, 5, 7, and 10 min after T-off using EDM. MAP < 60 mmHg within 10 min after T-off was considered to indicate hypotension, and 25 patients developed hypotension. The areas under the curves of the MAP, SVI, and Ea were 0.734 (95% confidence interval [CI] 0.623–0.846; P < 0.001), 0.712 (95% CI 0.598–0.825; P < 0.001), and 0.760 (95% CI 0.646–0.875; P < 0.001), respectively, with threshold values of ≤ 74 mmHg, ≥ 42.5 mL/m2, and ≤ 1.08 mmHg/mL, respectively. If patients have MAP < 75 mmHg with SVI ≥ 42.5 mL/m2 or Ea ≤ 1.08 mmHg/mL before postural change from T-off during RALP, prompt management for ensuing hypotension should be considered. Trial registration: NCT03882697 (ClinicalTrial.gov, March 20, 2019).
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Affiliation(s)
- Na Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ki Jun Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Tae Lim Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hye Jung Shin
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chaerim Oh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Min Huiy Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ji Young Min
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 1021 Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea.
| | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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14
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Prophylactic Norepinephrine Infusion Reduces Postoperative Complications and Hospitalization Time in Elderly Patients Undergoing Posterior Lumbar Spinal Fusion. BIOMED RESEARCH INTERNATIONAL 2021; 2021:2161036. [PMID: 34189135 PMCID: PMC8195642 DOI: 10.1155/2021/2161036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 02/22/2021] [Accepted: 05/21/2021] [Indexed: 11/17/2022]
Abstract
This single-center prospective randomized controlled trial explores the effect of prophylactic norepinephrine infusion on the incidence of complications and hospitalization time in elderly patients (60-85 years old) undergoing posterior lumbar spinal fusion. In total, 129 elderly patients were randomized into two groups: a group that received norepinephrine during general anesthesia and a control group not receiving norepinephrine. The primary outcomes were in-hospital complications and 90-day postoperative complications and hospitalization time. The results show that in-hospital complications occurred in 24 of 60 patients (40%) in the control group versus 11 of 60 patients (18.3%) in the norepinephrine group (RR, 2.182; 95% CI, 1.177–4.045; P = 0.015). Cardiac events occurred significantly more frequently in the control than in the norepinephrine group. Total number of patients experiencing complications within 90 days postoperatively was lower in the norepinephrine (11 of 60; 18.3%) than in the control group (26 of 60; 43.3%; RR, 2.364; 95% CI, 1.288–4.339; P = 0.005). The median length of hospital stay was 17 days (11–27) in the control group and 15 days (10– 23) in the norepinephrine group (P = 0.01). The secondary outcomes were serum levels of syndecan-1, hyaluronic acid, heparan sulfate, and brain natriuretic peptide. Logistic regression analysis is used to describe the relationship between selected independent variables and in-hospital complications. Intraoperative total fluid, crystalloid, and colloid volumes were significantly higher in the control than in the norepinephrine group. The patients in the norepinephrine group had a higher MAP but a lower heart rate than those in the control group after the induction of anesthesia and intraoperatively. Syndecan-1, hyaluronic acid, and heparan sulfate serum levels showed a different course in the two groups. In conclusion, prophylactic norepinephrine infusion during posterior lumbar spinal fusion is preferable for elderly patients undergoing lumbar spinal fusion under general anesthesia. It can reduce postoperative complications and hospitalization time by reducing the injury to the vascular endothelium. This trial is registered with Clinical Trial Registration http://www.chictr.org.cn/showproj.aspx?proj=33660, identifier ChiCTR-1900021309.
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15
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Eberhart L, Geldner G, Kowark A, Zucker TP, Kreuer S, Przemeck M, Huljic S, Koch T, Keller T, Weber S, Kranke P. Treatment of intraoperative hypotension with cafedrine/theodrenaline versus ephedrine : A prospective, national, multicenter, non-interventional study-the HYPOTENS trial. Anaesthesist 2021; 70:298-307. [PMID: 33170310 PMCID: PMC8026467 DOI: 10.1007/s00101-020-00877-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sympathomimetic drugs are a therapeutic cornerstone for the management of hypotensive states like intraoperative hypotension (IOH). While cafedrine/theodrenaline (C/T) is widely used in Germany to restore blood pressure in patients with IOH, more research is required to compare its effectiveness with alternatives such as ephedrine (E) that are more commonly available internationally. METHODS HYPOTENS (NCT02893241, DRKS00010740) was a prospective, national, multicenter, open-label, two-armed, non-interventional study that compared C/T with E for treatment of IOH. We describe a prospectively defined cohort of patients ≥50 years old with comorbidities undergoing general anesthesia induced with propofol and fentanyl. Primary objectives were to examine treatment precision, rapidity of onset and the ability to restore blood pressure without relevant increases in heart rate. Secondary endpoints were treatment satisfaction and the number of required additional boluses or other accompanying measures. RESULTS A total of 1496 patients were included in the per protocol analysis. Overall, effective stabilization of blood pressure was achieved with both C/T and E. Post-hoc analysis showed that blood pressure increase from baseline was more pronounced with C/T. Fewer additional boluses or other accompanying measures were required in the C/T arm. The incidence of tachycardia was comparable between groups. Post-hoc analysis showed that E produced dose-dependent elevated heart rate values. By contrast, heart rate remained stable in patients treated with C/T. Physicians reported a higher level of treatment satisfaction with C/T, with a higher proportion of anesthetists rating treatment precision and rapidity of onset as good or very good when compared with E. CONCLUSION Neither drug was superior in restoring blood pressure levels; however, post-hoc analyses suggested that treatment is more goal-orientated and easier to control with C/T. Heart rate was shown to be more stable with C/T and fewer additional interventions were required to restore blood pressure, which could have contributed to the increased treatment satisfaction reported by anesthetists using C/T.
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Affiliation(s)
- L Eberhart
- Department of Anesthesiology & Intensive Care, Philipps University Marburg, Baldingerstraße 1, 35033, Marburg, Germany.
| | - G Geldner
- Clinic for Intensive Care, Emergency Medicine and Pain Therapy, Hospital Ludwigsburg, Ludwigsburg, Germany
| | - A Kowark
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - T-P Zucker
- Department of Anesthesiology, Intensive Care and Pain Therapy, Academic Teaching Hospital Traunstein, Traunstein, Germany
| | - S Kreuer
- Department of Anesthesiology, Intensive Care and Pain Therapy, University Hospital Saarland, Homburg, Germany
| | - M Przemeck
- Department of Anesthesiology and Intensive Care, DIAKOVERE Annastift, Hannover, Germany
| | | | - T Koch
- Department of Anesthesiology & Intensive Care, Philipps University Marburg, Baldingerstraße 1, 35033, Marburg, Germany
| | - T Keller
- ACOMED Statistik, Leipzig, Germany
| | - S Weber
- ACOMED Statistik, Leipzig, Germany
| | - P Kranke
- Department of Anesthesia and Critical Care, University Hospital Würzburg, Würzburg, Germany
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16
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Le Gall A, Gayat É, Joachim J, Cohen S, Hong A, Matéo J, Buxin C, Millasseau S, Mebazaa A, Vallée F. Velocity-pressure loops can estimate intrinsic and pharmacologically induced changes in cardiac afterload during non-cardiac surgery. An observational study. J Clin Monit Comput 2021; 36:545-555. [PMID: 33755846 DOI: 10.1007/s10877-021-00686-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 10/13/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Continuous measurement of aortic pressure and aortic flow velocity signals in the operating theatre allows us to draw velocity-pressure (Vel-Pre) loops. The global afterload angle (GALA), derived from the Vel-Pre loops, has been linked to cardiac afterload indicators. As age is the major determinant of constitutive arterial stiffness, we aimed to describe (1) the evolution of the GALA according to age in a large cohort of anesthetized patients and (2) GALA variations induced by haemodynamic interventions. METHODS We included patients for whom continuous monitoring of arterial pressure and cardiac output were indicated. Fluid challenges or vasopressors were administered to treat intra-operative hypotension. The primary endpoint was the comparison of the GALA values between young and old patients. The secondary endpoint was the difference in the GALA values before and after haemodynamic interventions. RESULTS We included 133 anaesthetized patients: 66 old and 67 young patients. At baseline, the GALA was higher in the old patients than in young patients (38 ± 6 vs. 25 ± 4 degrees; p < 0.001). The GALA was positively associated with age (p < 0.001), but the mean arterial pressure (MAP) and cardiac output were not. The GALA did not change after volume expansion, regardless of the fluid response, but it did increase after vasopressor administration. Furthermore, while a vasopressor bolus led to a similar increase in MAP, phenylephrine induced a more substantial increase in the GALA than noradrenaline (+ 12 ± 5° vs. + 8 ± 5°; p = 0.01). CONCLUSION In non-cardiac surgery, the GALA seems to be associated with both intrinsic rigidity (reflected by age) and pharmacologically induced vasoconstriction changes (by vasopressors). In addition, the GALA can discriminate the differential effects of phenylephrine and noradrenaline. These results should be confirmed in a prospective, ideally randomized, trial.
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Affiliation(s)
- Arthur Le Gall
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France.
- M3DISIM, Inria-Saclay, Palaiseau, France.
- LMS, École Polytechnique, CNRS, Palaiseau, France.
| | - Étienne Gayat
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
- Inserm, UMRS-942, Paris Diderot University, 02, rue Ambroise Paré, 75010, Paris, France
| | - Jona Joachim
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Samuel Cohen
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Alex Hong
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Joaquim Matéo
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Cédric Buxin
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
| | - Sandrine Millasseau
- Pulse Wave Consulting, 72 B rue de Montignon, 95320, Saint Leu La Foret, France
| | - Alexandre Mebazaa
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
- Inserm, UMRS-942, Paris Diderot University, 02, rue Ambroise Paré, 75010, Paris, France
| | - Fabrice Vallée
- Department of Anaesthesiology and Intensive Care, Lariboisière - Saint Louis Hospitals, 02 rue Ambroise Paré, 75010, Paris, France
- Inserm, UMRS-942, Paris Diderot University, 02, rue Ambroise Paré, 75010, Paris, France
- M3DISIM, Inria-Saclay, Palaiseau, France
- LMS, École Polytechnique, CNRS, Palaiseau, France
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17
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Saugel B, Bebert EJ, Briesenick L, Hoppe P, Greiwe G, Yang D, Ma C, Mascha EJ, Sessler DI, Rogge DE. Mechanisms contributing to hypotension after anesthetic induction with sufentanil, propofol, and rocuronium: a prospective observational study. J Clin Monit Comput 2021; 36:341-347. [PMID: 33523352 PMCID: PMC9122881 DOI: 10.1007/s10877-021-00653-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/07/2021] [Indexed: 11/30/2022]
Abstract
It remains unclear whether reduced myocardial contractility, venous dilation with decreased venous return, or arterial dilation with reduced systemic vascular resistance contribute most to hypotension after induction of general anesthesia. We sought to assess the relative contribution of various hemodynamic mechanisms to hypotension after induction of general anesthesia with sufentanil, propofol, and rocuronium. In this prospective observational study, we continuously recorded hemodynamic variables during anesthetic induction using a finger-cuff method in 92 non-cardiac surgery patients. After sufentanil administration, there was no clinically important change in arterial pressure, but heart rate increased from baseline by 11 (99.89% confidence interval: 7 to 16) bpm (P < 0.001). After administration of propofol, mean arterial pressure decreased by 23 (17 to 28) mmHg and systemic vascular resistance index decreased by 565 (419 to 712) dyn*s*cm−5*m2 (P values < 0.001). Mean arterial pressure was < 65 mmHg in 27 patients (29%). After propofol administration, heart rate returned to baseline, and stroke volume index and cardiac index remained stable. After tracheal intubation, there were no clinically important differences compared to baseline in heart rate, stroke volume index, and cardiac index, but arterial pressure and systemic vascular resistance index remained markedly decreased. Anesthetic induction with sufentanil, propofol, and rocuronium reduced arterial pressure and systemic vascular resistance index. Heart rate, stroke volume index, and cardiac index remained stable. Post-induction hypotension therefore appears to result from arterial dilation with reduced systemic vascular resistance rather than venous dilation or reduced myocardial contractility.
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. .,Outcomes Research Consortium, Cleveland, OH, USA.
| | - Elisa-Johanna Bebert
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Luisa Briesenick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Gillis Greiwe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Dongsheng Yang
- Departments of Quantitative Health Sciences and Outcomes Research, Lerner Research Institute and Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Chao Ma
- Departments of Quantitative Health Sciences and Outcomes Research, Lerner Research Institute and Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Edward J Mascha
- Departments of Quantitative Health Sciences and Outcomes Research, Lerner Research Institute and Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Dorothea E Rogge
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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18
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Influence of noninvasive central blood pressure devices for afterload monitoring with aortic velocity-pressure Loop in anesthetized patients. Blood Press Monit 2020; 25:184-194. [PMID: 32433117 DOI: 10.1097/mbp.0000000000000445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Global afterload angle (GALA) is a parameter derived from velocity-pressure loop (VP Loop), for continuous assessment of cardiac afterload in the operating room. It has been validated with invasive measure of central pressure. The aim of this study was to evaluate the feasibility of noninvasive VP Loop obtained with central pressure measured with two different noninvasive tonometers. METHODS A prospective, observational, monocentric study was conducted in 51 patients under general anesthesia. Invasive central pressure (cPINV) was measured with a fulfilled intravascular catheter, and noninvasive central pressure signals were obtained with two applanation tonometry devices: radial artery tonometry (cPSHYG: Sphygmocor tonometer) and carotid tonometry (cPCOMP: Complior tonometer). Three VP Loops were built: VP LoopINV, VP LoopSPHYG and VP LoopCOMP. Patients were separated according to cardiovascular risk factors. RESULTS In the 51 patients under general anesthesia, cPSHYG was adequately obtained in 48 patients (89%) but, compared to cPINV, SBP was underestimated (-4 ± 6 mmHg, P < 0.0001), augmentation index (AIXSPHYG) and a GALASPHYG were overestimated (+13 ± 19%, P = 0.0077 and +4 ± 8°, P = 0.0024, respectively) with large limit of agreement (LOA) (-21 to 47% and -13 to 21° for AIXSPHYG and GALASPHYG, respectively). With the Complior, the failure rate of measurement for cPCOMP was 41%. SBP was similar (3 ± 17 mmHg, P = 0.32), AIXCOMP was underestimated (-11 ± 19%, P = 0.0046) and GALACOMP was similar but with large LOA (-50 to 26% and -20 to 18° for AIXCOMP and GALACOMP, respectively). CONCLUSION In anesthetized patient, the reliability of noninvasive central pressure monitoring by tonometry seems too limited to monitor cardiac afterload with VP Loop.
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19
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Mostafa M, Hasanin A, Mostafa M, Taha MY, Elsayad M, Haggag FA, Taalab O, Rady A, Abdelhamid B. Hemodynamic effects of norepinephrine versus phenylephrine infusion for prophylaxis against spinal anesthesia-induced hypotension in the elderly population undergoing hip fracture surgery: a randomized controlled trial. Korean J Anesthesiol 2020; 74:308-316. [PMID: 33121228 PMCID: PMC8342837 DOI: 10.4097/kja.20519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background Elderly population are at increased risk of spinal anesthesia-induced hypotension increasing their risk for postoperative morbidity and mortality. This study aimed to compare the hemodynamic effects of prophylactic infusion of norepinephrine (NE) versus phenylephrine (PE) in elderly patients undergoing hip fracture surgery under spinal anesthesia. Methods Elderly patients scheduled for hip fracture surgery were randomized to receive either NE infusion (8 µg/min) (NE group, n = 31) or PE infusion (100 µg/min) (PE group, n = 31) after spinal anesthesia. Outcomes included mean heart rate, mean blood pressure, cardiac output, incidence of spinal anesthesia-induced hypotension, incidence of bradycardia, and incidence of hypertension. Results Sixty-two patients with a mean age of 71 ± 6 years were included in the final analysis (31 patients in each group). The NE group showed a higher mean heart rate and cardiac output than the PE group. The NE group had a lower incidence of reactive bradycardia (10% vs. 36%, P = 0.031) and hypertension (3% vs. 36%, P = 0.003) than the PE group. No study participant developed hypotension, and the mean blood pressure was comparable between the two groups. Conclusions Both NE and PE infusions effectively prevented spinal anesthesia-induced hypotension in elderly patients undergoing hip fracture surgery. However, NE provided more hemodynamic stability than PE; maintaining the heart rate, higher cardiac output, less reactive bradycardia, and hypertension.
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Affiliation(s)
- Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mahmoud Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mai Y Taha
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Elsayad
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | | | - Omar Taalab
- Department of Orthopedic Surgery, Cairo University, Cairo, Egypt
| | - Ashraf Rady
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Bassant Abdelhamid
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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20
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Propofol/Remifentanil Anesthesia Might Not Alter the Middle Cerebral Artery Diameter by Digital Subtraction Angiography. Neurocrit Care 2020; 31:338-345. [PMID: 30877554 DOI: 10.1007/s12028-019-00699-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Transcranial Doppler (TCD) of the middle cerebral artery (MCA) enables the measurement of the mean blood velocity (MCAVm) and the estimation of the cerebral blood flow (CBF), provided that no significant changes occur in the MCA diameter (MCADiam). Previous studies described a decrease in the MCAVm associated with the induction of total intravenous anesthesia (TIVA) by propofol and remifentanil. This decrease in blood velocity might be interpreted as a decrease in the CBF only where the MCADiam is not modified across TCD examinations. METHODS In this observational study, we measured the MCADiam of 24 subjects (almost exclusively females) on digital subtraction angiography under awake and TIVA conditions. RESULTS Across the two phases, we observed a decrease in the mean arterial blood pressure (from 84 ± 9 to 71 ± 6 mmHg; p < 0.001) and heart rate (76 ± 10 vs. 65 ± 8 beats/min; p < 0.001), and a concomitant decrease in the MCAVm (61 vs. 42 cm/s; p < 0.001). In contrast, the MCADiam did not vary in association with TIVA (2.3 ± 0.2 vs. 2.3 ± 0.2 mm; p = 0.52). CONCLUSIONS Those results suggested that in this population, no significant changes in the MCADiam are associated with TIVA.
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21
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Acute psychological stress, autonomic function, and arterial stiffness among women. Int J Psychophysiol 2020; 155:219-226. [PMID: 32619458 DOI: 10.1016/j.ijpsycho.2020.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/20/2020] [Accepted: 06/26/2020] [Indexed: 11/23/2022]
Abstract
This study aimed to investigate the effect of acute psychological stress on autonomic function and arterial stiffness, and to test a mediating role of changes in autonomic function between acute stress and arterial stiffness. Eighty-five healthy female adults were randomized into either an experimental or control group. The Trier Social Stress Test (TSST) was used to induce acute psychological stress. Autonomic function (measured by pre-ejection period [PEP] from cardiac impedance and high frequency [HF] of heart rate variability [HRV]) and arterial stiffness (measured by carotid and femoral pulse wave velocity [cfPWV] and augmentation index [AIx]) were assessed before and after the TSST. The mean age of the participants was 28.78 (±9.84) years old. Experimental group participants had a significant increase in cfPWV (p = .025) and AIx (p = .017) following the stressor, compared with those in the control group, after controlling for age, body mass index, and systolic blood pressure. However, no significant group differences were observed in changes in PEP (p = .181) and HF (p = .058). Changes in PEP and HF were neither associated with changes in cfPWV (p = .975 and p = .654, respectively), nor in AIx (p = .376 and p = .323, respectively). The results suggest that even a brief period of mild to moderate stress, which does not cause sustainable changes in autonomic function, may still exert significant adverse effects on arterial stiffness. The changes in arterial stiffness were not related to changes in autonomic function. Future experimental studies with several measurement points are recommended to identify distinct effects of stress on autonomic function and arterial stiffness.
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22
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Le Gall A, Vallée F, Pushparajah K, Hussain T, Mebazaa A, Chapelle D, Gayat É, Chabiniok R. Monitoring of cardiovascular physiology augmented by a patient-specific biomechanical model during general anesthesia. A proof of concept study. PLoS One 2020; 15:e0232830. [PMID: 32407353 PMCID: PMC7224549 DOI: 10.1371/journal.pone.0232830] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/22/2020] [Indexed: 12/29/2022] Open
Abstract
During general anesthesia (GA), direct analysis of arterial pressure or aortic flow waveforms may be inconclusive in complex situations. Patient-specific biomechanical models, based on data obtained during GA and capable to perform fast simulations of cardiac cycles, have the potential to augment hemodynamic monitoring. Such models allow to simulate Pressure-Volume (PV) loops and estimate functional indicators of cardiovascular (CV) system, e.g. ventricular-arterial coupling (Vva), cardiac efficiency (CE) or myocardial contractility, evolving throughout GA. In this prospective observational study, we created patient-specific biomechanical models of heart and vasculature of a reduced geometric complexity for n = 45 patients undergoing GA, while using transthoracic echocardiography and aortic pressure and flow signals acquired in the beginning of GA (baseline condition). If intraoperative hypotension (IOH) appeared, diluted norepinephrine (NOR) was administered and the model readjusted according to the measured aortic pressure and flow signals. Such patients were a posteriori assigned into a so-called hypotensive group. The accuracy of simulated mean aortic pressure (MAP) and stroke volume (SV) at baseline were in accordance with the guidelines for the validation of new devices or reference measurement methods in all patients. After NOR administration in the hypotensive group, the percentage of concordance with 10% exclusion zone between measurement and simulation was >95% for both MAP and SV. The modeling results showed a decreased Vva (0.64±0.37 vs 0.88±0.43; p = 0.039) and an increased CE (0.8±0.1 vs 0.73±0.11; p = 0.042) in hypotensive vs normotensive patients. Furthermore, Vva increased by 92±101%, CE decreased by 13±11% (p < 0.001 for both) and contractility increased by 14±11% (p = 0.002) in the hypotensive group post-NOR administration. In this work we demonstrated the application of fast-running patient-specific biophysical models to estimate PV loops and functional indicators of CV system using clinical data available during GA. The work paves the way for model-augmented hemodynamic monitoring at operating theatres or intensive care units to enhance the information on patient-specific physiology.
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Affiliation(s)
- Arthur Le Gall
- Inria, Paris, France
- LMS, École Polytechnique, CNRS, Institut Polytechnique de Paris, Paris, France
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, Paris, France
- INSERM, Paris, France
| | - Fabrice Vallée
- Inria, Paris, France
- LMS, École Polytechnique, CNRS, Institut Polytechnique de Paris, Paris, France
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, Paris, France
- INSERM, Paris, France
| | - Kuberan Pushparajah
- School of Biomedical Engineering & Imaging Sciences, St Thomas’ Hospital, King’s College London, London, United Kingdom
| | - Tarique Hussain
- Department of Pediatrics, Division of Pediatric Cardiology, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Alexandre Mebazaa
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, Paris, France
- INSERM, Paris, France
| | - Dominique Chapelle
- Inria, Paris, France
- LMS, École Polytechnique, CNRS, Institut Polytechnique de Paris, Paris, France
| | - Étienne Gayat
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, Paris, France
- INSERM, Paris, France
| | - Radomír Chabiniok
- Inria, Paris, France
- LMS, École Polytechnique, CNRS, Institut Polytechnique de Paris, Paris, France
- School of Biomedical Engineering & Imaging Sciences, St Thomas’ Hospital, King’s College London, London, United Kingdom
- Department of Mathematics, Faculty of Nuclear Sciences and Physical Engineering, Czech Technical University in Prague, Prague, Czech Republic
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23
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Chaix I, Manquat E, Liu N, Casadio MC, Ludes P, Tantot A, Lopes J, Touchard C, Mateo J, Mebazaa A, Gayat E, Vallée F. Impact of hypotension on cerebral perfusion during general anesthesia induction: A prospective observational study in adults. Acta Anaesthesiol Scand 2020; 64:592-601. [PMID: 31883375 DOI: 10.1111/aas.13537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/02/2019] [Accepted: 12/10/2019] [Indexed: 01/01/2023]
Abstract
INTRODUCTION During anesthesia, decreases in mean arterial pressure (MAP) are common but the impact on possible cerebral hypoperfusion remains a matter of debate. We evaluated cerebral perfusion in patients with or without cardiovascular comorbidities (Hi-risk vs Lo-risk) during induction of general anesthesia and during hypotensive episodes. METHODS Patients scheduled for neuroradiology procedure using standardized target-controlled Propofol-Remifentanil infusion were prospectively included. Monitoring included Transcranial Doppler (TCD) measuring mean blood velocity of the middle cerebral artery (Vm), Bispectral Index with burst suppression ratio (SR) and cerebral Near-Infrared Spectroscopy (NIRS). Hypotensive episodes were treated with a 10 µg bolus of Norepinephrine. RESULTS Eighty-one patients were included, 37 Hi-risk and 44 Lo-risk. During induction of anesthesia, MAP and Vm decreased in all patients, with greater changes observed in Hi-risk patients compared to Lo-risk patients (-34 [38-29]% vs -17 [25-8]%, P < .001 and -39 [45-29]% vs -28 [34-19]%, P < .01 respectively). In Hi-risk patients, the MAP-decrease correlated with the Vm-decrease (r = .48, P < .01), and was associated with more frequent occurrences of SR (21 vs 5 patients, P < .01 for Hi-risk vs Lo-risk). For the MAP-increase induced by norepinephrine, the Vm-increase was greater in Hi-risk than in Lo-risk patients (+15 [8-21]% vs +4 [1-11]%, P < .01). During induction and norepinephrine boluses, NIRS values did not follow acute changes of Vm. CONCLUSION Our results showed that Hi-risk patients had a higher decrease in MAP and Vm, and a higher occurrence of SR during induction of anesthesia than Lo-risk patients. Correction of MAP with norepinephrine increased Vm mainly in Hi-rik patients.
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Affiliation(s)
- Isabelle Chaix
- Department of Anesthesiology and Critical Care Lariboisière University Hospital, DMU Parabol, AP-HP Nord & University of ParisParis France
- UMR-S 942 "MASCOT" Inserm Paris France
| | - Elsa Manquat
- Department of Anesthesiology and Critical Care Lariboisière University Hospital, DMU Parabol, AP-HP Nord & University of ParisParis France
- UMR-S 942 "MASCOT" Inserm Paris France
| | - Ngai Liu
- Department of Anesthesiology Hopital Foch Suresnes France
- Outcomes Research Consortium Cleveland Clinic Cleveland OH USA
| | - Maria Chiara Casadio
- Department of Anesthesiology and Critical Care Lariboisière University Hospital, DMU Parabol, AP-HP Nord & University of ParisParis France
- UMR-S 942 "MASCOT" Inserm Paris France
| | - Pierre‐Olivier Ludes
- Department of Anesthesiology and Critical Care Lariboisière University Hospital, DMU Parabol, AP-HP Nord & University of ParisParis France
- UMR-S 942 "MASCOT" Inserm Paris France
| | - Audrey Tantot
- Department of Anesthesiology and Critical Care Lariboisière University Hospital, DMU Parabol, AP-HP Nord & University of ParisParis France
- UMR-S 942 "MASCOT" Inserm Paris France
| | - Jean‐Paul Lopes
- Department of Anesthesiology and Critical Care Lariboisière University Hospital, DMU Parabol, AP-HP Nord & University of ParisParis France
- UMR-S 942 "MASCOT" Inserm Paris France
| | - Cyril Touchard
- Department of Anesthesiology and Critical Care Lariboisière University Hospital, DMU Parabol, AP-HP Nord & University of ParisParis France
- UMR-S 942 "MASCOT" Inserm Paris France
| | - Joaquim Mateo
- Department of Anesthesiology and Critical Care Lariboisière University Hospital, DMU Parabol, AP-HP Nord & University of ParisParis France
- UMR-S 942 "MASCOT" Inserm Paris France
- Inria Paris France
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care Lariboisière University Hospital, DMU Parabol, AP-HP Nord & University of ParisParis France
- UMR-S 942 "MASCOT" Inserm Paris France
- Inria Paris France
| | - Etienne Gayat
- Department of Anesthesiology and Critical Care Lariboisière University Hospital, DMU Parabol, AP-HP Nord & University of ParisParis France
- UMR-S 942 "MASCOT" Inserm Paris France
- Inria Paris France
| | - Fabrice Vallée
- Department of Anesthesiology and Critical Care Lariboisière University Hospital, DMU Parabol, AP-HP Nord & University of ParisParis France
- UMR-S 942 "MASCOT" Inserm Paris France
- Inria Paris France
- LMS, CNRS Institut Polytechnique de ParisEcole Polytechnique Palaiseau France
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24
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Dépret F, Coutrot M. Commentary: Posterior Reversible Encephalopathy Syndrome as a Complication of Induced Hypertension in Subarachnoid Hemorrhage: A Case-Control Study. Neurosurgery 2020; 85:E243-E244. [PMID: 29889252 DOI: 10.1093/neuros/nyy244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 05/10/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- François Dépret
- AP-HP, GH St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France.,University Paris Diderot, Paris, France.,UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), F-CRIN INICRCT network, Paris, France
| | - Maxime Coutrot
- AP-HP, GH St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France.,University Paris Diderot, Paris, France.,UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), F-CRIN INICRCT network, Paris, France
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25
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Hong A, Joachim J, Buxin C, Levé C, Le Gall A, Millasseau S, Mateo J, Civelli V, Serrano J, Mebazaa A, Gayat E, Vallée F. Using velocity-pressure loops in the operating room: a new approach of arterial mechanics for cardiac afterload monitoring under general anesthesia. Am J Physiol Heart Circ Physiol 2019; 317:H1354-H1362. [PMID: 31674813 DOI: 10.1152/ajpheart.00362.2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cardiac afterload is usually assessed in the ascending aorta and can be defined by the association of peripheral vascular resistance (PVR), total arterial compliance (Ctot), and aortic wave reflection (WR). We recently proposed the global afterload angle (GALA) and β-angle derived from the aortic velocity-pressure (VP) loop as continuous cardiac afterload monitoring in the descending thoracic aorta. The aim of this study was to 1) describe the arterial mechanic properties by studying the velocity-pressure relations according to cardiovascular risk (low-risk and high-risk patients) in the ascending and descending thoracic aorta and 2) analyze the association between the VP loop (GALA and β-angle) and cardiac afterload parameters (PVR, Ctot, and WR). PVR, Ctot, WR, and VP loop parameters were measured in the ascending and descending thoracic aorta in 50 anesthetized patients. At each aortic level, the mean arterial pressure (MAP), cardiac output (CO), and PVR were similar between low-risk and high-risk patients. In contrast, Ctot, WR, GALA, and β-angle were strongly influenced by cardiovascular risk factors regardless of the site of measurement along the aorta. The GALA angle was inversely related to aortic compliance, and the β-angle reflected the magnitude of wave reflection in both the ascending and descending aortas (P < 0.001). Under general anesthesia, the VP loop can provide new visual insights into arterial mechanical properties compared with the traditional MAP and CO for the assessment of cardiac afterload. Further studies are necessary to demonstrate the clinical utility of the VP loop in the operating room.NEW & NOTEWORTHY Our team recently proposed the global afterload angle (GALA) and β-angle derived from the aortic velocity-pressure (VP) loop as continuous cardiac afterload monitoring in the descending thoracic aorta under general anesthesia. However, the evaluation of cardiac afterload at this location is unusual. The present study shows that VP loop parameters can describe the components of cardiac afterload both in the ascending and descending thoracic aorta in the operating room. Aging and cardiovascular risk factors strongly influence VP loop parameters. The VP loop could provide continuous visual additional information on the arterial system than the traditional mean arterial pressure and cardiac output during the general anesthesia.
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Affiliation(s)
- A Hong
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France.,Inserm, UMRS-942, Paris Diderot University, Paris, France
| | - J Joachim
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France.,Inserm, UMRS-942, Paris Diderot University, Paris, France
| | - C Buxin
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France
| | - C Levé
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France
| | - A Le Gall
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France.,Mathematical and Mechanical Modeling with Data Interaction in Simulations for Medicine, Inria, Université Paris-Saclay, Palaiseau, France.,Solid Mechanics Laboratory, Ecole Polytechnique, Centre National de la Recherche Scientifique, Palaiseau, France
| | - S Millasseau
- Pulse Wave Consulting, Saint-Leu-La-Forêt, France
| | - J Mateo
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France
| | - V Civelli
- Department of Neuroradiology, Lariboisière Hospital, Paris, France
| | - J Serrano
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France
| | - A Mebazaa
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France.,Inserm, UMRS-942, Paris Diderot University, Paris, France
| | - E Gayat
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France.,Inserm, UMRS-942, Paris Diderot University, Paris, France
| | - F Vallée
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France.,Inserm, UMRS-942, Paris Diderot University, Paris, France.,Mathematical and Mechanical Modeling with Data Interaction in Simulations for Medicine, Inria, Université Paris-Saclay, Palaiseau, France.,Solid Mechanics Laboratory, Ecole Polytechnique, Centre National de la Recherche Scientifique, Palaiseau, France
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26
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Abou Arab O, Fischer MO, Carpentier A, Beyls C, Huette P, Hchikat A, Benammar A, Labont B, Mahjoub Y, Bar S, Guinot PG, Lorne E. Etomidate-induced hypotension: a pathophysiological approach using arterial elastance. Anaesth Crit Care Pain Med 2019; 38:347-352. [DOI: 10.1016/j.accpm.2018.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/17/2018] [Accepted: 12/18/2018] [Indexed: 11/26/2022]
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27
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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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