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Guinot PG, Longrois D. Challenging ICU dogmas: a new perspective on venous congestion and preload dependency. Crit Care 2024; 28:167. [PMID: 38760871 PMCID: PMC11102296 DOI: 10.1186/s13054-024-04897-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 03/30/2024] [Indexed: 05/19/2024] Open
Affiliation(s)
- Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France.
- University of Burgundy, LNC UMR1231, 21000, Dijon, France.
| | - Dan Longrois
- Anesthesiology and Intensive Care Department, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, Paris, France
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Joyner MJ. Reflections on physiology and modelling. Exp Physiol 2024. [PMID: 38224249 DOI: 10.1113/ep091711] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 01/16/2024]
Affiliation(s)
- Michael J Joyner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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3
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Furst B, González-Alonso J. The heart, a secondary organ in the control of blood circulation. Exp Physiol 2023. [PMID: 38126953 DOI: 10.1113/ep091387] [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: 08/29/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023]
Abstract
Circulation of the blood is a fundamental physiological function traditionally ascribed to the pressure-generating function of the heart. However, over the past century the 'cardiocentric' view has been challenged by August Krogh, Ernst Starling, Arthur Guyton and others, based on haemodynamic data obtained from isolated heart preparations and organ perfusion. Their research brought forth experimental evidence and phenomenological observations supporting the concept that cardiac output occurs primarily in response to the metabolic demands of the tissues. The basic tenets of Guyton's venous return model are presented and juxtaposed with their critiques. Developmental biology of the cardiovascular system shows that the blood circulates before the heart has achieved functional integrity and that its movement is intricately connected with the metabolic demands of the tissues. Long discovered, but as yet overlooked, negative interstitial pressure may play a role in assisting the flow returning to the heart. Based on these phenomena, an alternative circulation model has been proposed in which the heart functions like a hydraulic ram and maintains a dynamic equilibrium between the arterial (centrifugal) and venous (centripetal) forces which define the blood's circular movement. In this focused review we introduce some of the salient arguments in support of the proposed circulation model. Finally, we present evidence that exercising muscle blood flow is subject to local metabolic control which upholds optimal perfusion in the face of a substantive rise in muscle vascular conductance, thus lending further support to the permissive role of the heart in the overall control of blood circulation.
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Affiliation(s)
- Branko Furst
- Department of Anesthesiology, Albany Medical Center, Albany, New York, USA
| | - José González-Alonso
- Sport, Health and Exercise Sciences, Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK
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Kenny JES. A framework for heart-lung interaction and its application to prone position in the acute respiratory distress syndrome. Front Physiol 2023; 14:1230654. [PMID: 37614757 PMCID: PMC10443730 DOI: 10.3389/fphys.2023.1230654] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/24/2023] [Indexed: 08/25/2023] Open
Abstract
While both cardiac output (Qcirculatory) and right atrial pressure (PRA) are important measures in the intensive care unit (ICU), they are outputs of the system and not determinants. That is to say, in a model of the circulation wherein venous return and cardiac function find equilibrium at an 'operating point' (OP, defined by the PRA on the x-axis and Qcirculatory on the y-axis) both the PRA and Qcirculatory are, necessarily, dependent variables. A simplified geometrical approximation of Guyton's model is put forth to illustrate that the independent variables of the system are: 1) the mean systemic filling pressure (PMSF), 2) the pressure within the pericardium (PPC), 3) cardiac function and 4) the resistance to venous return. Classifying independent and dependent variables is clinically-important for therapeutic control of the circulation. Recent investigations in patients with acute respiratory distress syndrome (ARDS) have illuminated how PMSF, cardiac function and the resistance to venous return change when placing a patient in prone. Moreover, the location of the OP at baseline and the intimate physiological link between the heart and the lungs also mediate how the PRA and Qcirculatory respond to prone position. Whereas turning a patient from supine to prone is the focus of this discussion, the principles described within the framework apply equally-well to other more common ICU interventions including, but not limited to, ventilator management, initiating vasoactive medications and providing intravenous fluids.
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Affiliation(s)
- Jon-Emile S. Kenny
- Health Sciences North Research Institute, Sudbury, ON, Canada
- Flosonics Medical, Toronto, ON, Canada
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5
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How to end the 'venous return' controversy. Eur J Anaesthesiol 2022; 39:629-630. [PMID: 35759296 DOI: 10.1097/eja.0000000000001689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Chalkias A, Laou E, Papagiannakis N, Spyropoulos V, Kouskouni E, Theodoraki K, Xanthos T. Assessment of Dynamic Changes in Stressed Volume and Venous Return during Hyperdynamic Septic Shock. J Pers Med 2022; 12:jpm12050724. [PMID: 35629145 PMCID: PMC9146182 DOI: 10.3390/jpm12050724] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/19/2022] [Accepted: 04/28/2022] [Indexed: 02/04/2023] Open
Abstract
The present work investigated the dynamic changes in stressed volume (Vs) and other determinants of venous return using a porcine model of hyperdynamic septic shock. Septicemia was induced in 10 anesthetized swine, and fluid challenges were started after the diagnosis of sepsis-induced arterial hypotension and/or tissue hypoperfusion. Norepinephrine infusion targeting a mean arterial pressure (MAP) of 65 mmHg was started after three consecutive fluid challenges. After septic shock was confirmed, norepinephrine infusion was discontinued, and the animals were left untreated until cardiac arrest occurred. Baseline Vs decreased by 7% for each mmHg decrease in MAP during progression of septic shock. Mean circulatory filling pressure (Pmcf) analogue (Pmca), right atrial pressure, resistance to venous return, and efficiency of the heart decreased with time (p < 0.001 for all). Fluid challenges did not improve hemodynamics, but noradrenaline increased Vs from 107 mL to 257 mL (140%) and MAP from 45 mmHg to 66 mmHg (47%). Baseline Pmca and post-cardiac arrest Pmcf did not differ significantly (14.3 ± 1.23 mmHg vs. 14.75 ± 1.5 mmHg, p = 0.24), but the difference between pre-arrest Pmca and post-cardiac arrest Pmcf was statistically significant (9.5 ± 0.57 mmHg vs. 14.75 ± 1.5 mmHg, p < 0.001). In conclusion, the baseline Vs decreased by 7% for each mmHg decrease in MAP during progression of hyperdynamic septic shock. Significant changes were also observed in other determinants of venous return. A new physiological intravascular volume existing at zero transmural distending pressure was identified, termed as the rest volume (Vr).
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Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece;
- Outcomes Research Consortium, Cleveland, OH 44195, USA
- Hellenic Society of Cardiopulmonary Resuscitation, 11528 Athens, Greece
- Correspondence:
| | - Eleni Laou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece;
| | - Nikolaos Papagiannakis
- First Department of Neurology, Eginition University Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | | | - Evaggelia Kouskouni
- Department of Biopathology, Aretaieion University Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 15772 Athens, Greece;
| | - Theodoros Xanthos
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus;
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8
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Driving forces of venous return. Eur J Anaesthesiol 2022; 39:393-394. [PMID: 35232939 DOI: 10.1097/eja.0000000000001661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Reply to: vasopressor effects on venous return in septic patients: a review. Ugeskr Laeger 2022; 39:289-291. [PMID: 35115461 DOI: 10.1097/eja.0000000000001631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Werner-Moller P, Heinisch PP, Hana A, Bachmann KF, Sondergaard S, Jakob SM, Takala J, Berger D. Experimental validation of a mean systemic pressure analog against zero-flow measurements in porcine VA-ECMO. J Appl Physiol (1985) 2022; 132:726-736. [PMID: 35085032 DOI: 10.1152/japplphysiol.00804.2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/24/2022] [Indexed: 11/22/2022] Open
Abstract
The mean systemic pressure analog (Pmsa), calculated from running hemodynamic data, estimates mean systemic filling pressure (MSFP). This post hoc study used data from a porcine veno-arterial extracorporeal membrane oxygenation (ECMO) model [n = 9; Sus scrofa domesticus; ES breed (Schweizer Edelschwein)] with eight experimental conditions; Euvolemia [a volume state where ECMO flow produced normal mixed venous saturation (SVO2) without vascular collapse]; three levels of increasing norepinephrine infusion (Vasoconstriction 1-3); status after stopping norepinephrine (Post Vasoconstriction); and three steps of volume expansion (10 mL/kg crystalloid bolus) (Volume Expansion 1-3). In each condition, Pmsa and a "reduced-pump-speed-Pmsa" (Pmsared) were calculated from baseline and briefly reduced pump speeds, respectively. We calculated agreement for absolute values (per condition) and changes (between consecutive conditions) of Pmsa and Pmsared, against MSFP at zero ECMO flow. Euvolemia venous return driving pressure was 5.1 ± 2.0 mmHg. Bland-Altman analysis for Pmsa vs. MSFP (all conditions; 72 data pairs) showed bias (confidence interval) 0.5 (0.1-0.9) mmHg; limits of agreement (LoA) -2.7 to 3.8 mmHg. Bias for ΔPmsa vs. ΔMSFP (63 data pairs): 0.2 (-0.2 to 0.6) mmHg, LoA -3.2 to 3.6 mmHg. Bias for Pmsared vs. MSFP (72 data pairs): 0.0 (-0.3 to -0.3) mmHg; LoA -2.3 to 2.4 mmHg. Bias for ΔPmsared vs. ΔMSFP (63 data pairs) was 0.2 (-0.1 to 0.4) mmHg; LoA -1.8 to 2.1 mmHg. In conclusion, during veno-arterial ECMO, under clinically relevant levels of vasoconstriction and volume expansion, Pmsa accurately estimated absolute and changing values of MSFP, with low between-method precision. The within-method precision of Pmsa was excellent, with a least significant change of 0.15 mmHg.NEW & NOTEWORTHY This is the first study ever to validate the mean systemic pressure analog (Pmsa) against the reference mean systemic filling pressure (MSFP) determined at full arterio-venous pressure equilibrium. Using a porcine ECMO model with clinically relevant levels of vasoconstriction and volume expansion, we showed that Pmsa accurately estimated absolute and changing values of MSFP, with a poor between-method precision. The within-method precision of Pmsa was excellent.
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Affiliation(s)
- Per Werner-Moller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anesthesia, Surgery and Intensive Care, SV Hospital Group, Alingsas, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Paul Philipp Heinisch
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Anisa Hana
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Intensive Care Medicine, Laurentius Hospital, Roermond, The Netherlands
| | - Kaspar F Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centre for Intensive Care Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Soren Sondergaard
- Department of Intensive Care and Neurointensive Stepdown Unit, Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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12
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The venous system during pregnancy. Part 1: physiologic considerations on the venous system. Int J Obstet Anesth 2022; 50:103273. [DOI: 10.1016/j.ijoa.2022.103273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/13/2022] [Accepted: 02/17/2022] [Indexed: 12/20/2022]
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Mesin L, Albani S, Policastro P, Pasquero P, Porta M, Melchiorri C, Leonardi G, Albera C, Scacciatella P, Pellicori P, Stolfo D, Grillo A, Fabris B, Bini R, Giannoni A, Pepe A, Ermini L, Seddone S, Sinagra G, Antonini-Canterin F, Roatta S. Assessment of Phasic Changes of Vascular Size by Automated Edge Tracking-State of the Art and Clinical Perspectives. Front Cardiovasc Med 2022; 8:775635. [PMID: 35127855 PMCID: PMC8814097 DOI: 10.3389/fcvm.2021.775635] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/14/2021] [Indexed: 12/25/2022] Open
Abstract
Assessment of vascular size and of its phasic changes by ultrasound is important for the management of many clinical conditions. For example, a dilated and stiff inferior vena cava reflects increased intravascular volume and identifies patients with heart failure at greater risk of an early death. However, lack of standardization and sub-optimal intra- and inter- operator reproducibility limit the use of these techniques. To overcome these limitations, we developed two image-processing algorithms that quantify phasic vascular deformation by tracking wall movements, either in long or in short axis. Prospective studies will verify the clinical applicability and utility of these methods in different settings, vessels and medical conditions.
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Affiliation(s)
- Luca Mesin
- Mathematical Biology and Physiology, Department of Electronics and Telecommunications, Politecnico di Torino, Turin, Italy
- *Correspondence: Luca Mesin
| | - Stefano Albani
- SC Cardiologia Ospedale Regionale U. Parini, Aosta, Italy
- Department of Medical, Surgical and Health Sciences, Universitá di Trieste, Trieste, Italy
| | - Piero Policastro
- Mathematical Biology and Physiology, Department of Electronics and Telecommunications, Politecnico di Torino, Turin, Italy
| | - Paolo Pasquero
- Department of Medical Sciences, Universitá di Torino, Turin, Italy
| | - Massimo Porta
- Department of Medical Sciences, Universitá di Torino, Turin, Italy
| | | | | | - Carlo Albera
- Department of Medical Sciences, Universitá di Torino, Turin, Italy
| | | | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics, Research Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Davide Stolfo
- Department of Medical, Surgical and Health Sciences, Universitá di Trieste, Trieste, Italy
| | - Andrea Grillo
- Department of Medical, Surgical and Health Sciences, Universitá di Trieste, Trieste, Italy
| | - Bruno Fabris
- Department of Medical, Surgical and Health Sciences, Universitá di Trieste, Trieste, Italy
| | - Roberto Bini
- Chirurgia Generale e Trauma Team GOM Niguarda, Milan, Italy
| | - Alberto Giannoni
- Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Antonio Pepe
- Highly Specialized in Rehabilitation Hospital-ORAS S.p.A., Motta di Livenza, Italy
- Ospedale Unico di Santorso, AULSS7 Pedemontana, Italy
| | - Leonardo Ermini
- Integrative Physiology Lab, Department of Neuroscience, Universitá di Torino, Turin, Italy
| | - Stefano Seddone
- Integrative Physiology Lab, Department of Neuroscience, Universitá di Torino, Turin, Italy
| | - Gianfranco Sinagra
- Robertson Centre for Biostatistics, Research Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | | | - Silvestro Roatta
- Integrative Physiology Lab, Department of Neuroscience, Universitá di Torino, Turin, Italy
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Keogh C, Drummond GB, Bates A, Mann J, Arvind DK. A conceptual model for changes in finger photoplethysmograph signals caused by hand posture and isothermic regulation. Physiol Meas 2022; 43. [PMID: 34986476 DOI: 10.1088/1361-6579/ac482e] [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: 12/02/2021] [Accepted: 01/05/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To observe changes in baseline and pulsatile light absorbance (photoplethysmograph, PPG) in the finger-tip, by raising the hand above the horizontal plane in recumbent subjects. We applied current knowledge of the circulation to the finger-tip, particularly arteriovenous anastomoses (AVAs), and the physiology of the venous circulation. APPROACH We studied healthy young volunteers in a quiet thermoneutral environment. A finger plethysmograph on the non-dominant hand recorded transmission of red and infra-red light, and the values were converted into absorbance to allow comparisons within and between subjects. Breathing movements were recorded unobtrusively to assess any effect on absorbance and the pulse amplitude of the signals. All body movements were passive: the study arm was elevated in a trough to about 40° above the horizontal plane. The following conditions were studied, each for 15 minutes, using the last 10 minutes for analysis: recumbent, study arm elevated, study arm horizontal, and both legs elevated by 40°. MAIN RESULTS There was a substantial time-related effect, and considerable variation between subjects. Arm elevation reduced red light absorbance and increased the range of amplitudes of the PPG waveform: only in subjects with large absorbances, did waveform amplitude increase. The other main effect was that spontaneous, thermoregulatory decreases in absorbance were associated with decreases in waveform amplitude. SIGNIFICANCE Finger-tip vessels distend with blood when AVAs open. The vessels pulsate more strongly if venous collapse allows the vessels to become more compliant. The postcapillary circulation is likely to be an important source of pulsation.
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Affiliation(s)
- Cameron Keogh
- Anaesthesia Critical Care and Pain Medicine, The University of Edinburgh School of Clinical Sciences, Old College, South Bridge, Edinburgh, Edinburgh, EH8 9YL, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Gordon B Drummond
- Department of Anaesthesia, Critical Care and Pain Medicine, The University of Edinburgh Division of Health Sciences, Old College, South Bridge, Edinburgh, Edinburgh, EH8 9YL, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Andrew Bates
- Centre for Speckled Computing, University of Edinburgh College of Science and Engineering, Old College, South Bridge, Edinburgh, EH8 9YL, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Janek Mann
- Centre for Speckled Computing, University of Edinburgh College of Science & Engineering , Old College, South Bridge, Edinburgh, EH8 9YL, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - D K Arvind
- Centre for Speckled Computing, The University of Edinburgh College of Science and Engineering, Old College, South Bridge, Edinburgh, Edinburgh, EH8 9YL, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
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Muir WW, Hughes D, Silverstein DC. Editorial: Fluid Therapy in Animals: Physiologic Principles and Contemporary Fluid Resuscitation Considerations. Front Vet Sci 2021; 8:744080. [PMID: 34746284 PMCID: PMC8563835 DOI: 10.3389/fvets.2021.744080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- William W. Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | - Dez Hughes
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Deborah C. Silverstein
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Stiles TW, Morfin Rodriguez AE, Mohiuddin HS, Lee H, Dalal FA, Fuertes WW, Adams TH, Stewart RH, Quick CM. Algebraic formulas characterizing an alternative to Guyton's graphical analysis relevant for heart failure. Am J Physiol Regul Integr Comp Physiol 2021; 320:R851-R870. [PMID: 33596744 DOI: 10.1152/ajpregu.00260.2019] [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: 11/22/2022]
Abstract
Although Guyton's graphical analysis of cardiac output-venous return has become a ubiquitous tool for explaining how circulatory equilibrium emerges from heart-vascular interactions, this classical model relies on a formula for venous return that contains unphysiological assumptions. Furthermore, Guyton's graphical analysis does not predict pulmonary venous pressure, which is a critical variable for evaluating heart failure patients' risk of pulmonary edema. Therefore, the purpose of the present work was to use a minimal closed-loop mathematical model to develop an alternative to Guyton's analysis. Limitations inherent in Guyton's model were addressed by 1) partitioning the cardiovascular system differently to isolate left ventricular function and lump all blood volumes together, 2) linearizing end-diastolic pressure-volume relationships to obtain algebraic solutions, and 3) treating arterial pressures as constants. This approach yielded three advances. First, variables related to morbidities associated with left ventricular failure were predicted. Second, an algebraic formula predicting left ventricular function was derived in terms of ventricular properties. Third, an algebraic formula predicting flow through the portion of the system isolated from the left ventricle was derived in terms of mechanical properties without neglecting redistribution of blood between systemic and pulmonary circulations. Although complexities were neglected, approximations necessary to obtain algebraic formulas resulted in minimal error, and predicted variables were consistent with reported values.
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Affiliation(s)
- Thomas W Stiles
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | | | - Hanifa S Mohiuddin
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Hyunjin Lee
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Fazal A Dalal
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Wesley W Fuertes
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Thaddeus H Adams
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Randolph H Stewart
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
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Kamali Shahri SM, Contarino C, Chifari F, Mahmoudi M, Gelman S. Function of arteries and veins in conditions of simulated cardiac arrest. ACTA ACUST UNITED AC 2021; 11:157-164. [PMID: 33842286 PMCID: PMC8022231 DOI: 10.34172/bi.2021.13] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/17/2020] [Accepted: 10/20/2020] [Indexed: 12/24/2022]
Abstract
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Introduction: The study examined the behavior of vasculature in conditions of eliminated cardiac function using mathematical modeling. In addition, we addressed the question of whether the stretch-recoil capability of veins, at least in part accounts for the slower response to simulated cardiac arrest. Methods: In the first set of computational experiments, blood flow and pressure patterns in veins and arteries during the first few seconds after cardiac arrest were assessed via a validated multi-scale mathematical model of the whole cardiovascular system, comprising cardiac dynamics, arterial and venous blood flow dynamics, and microcirculation. In the second set of experiments, the effects of stretch-recoil zones of venous vessels with different diameters and velocities on blood velocity and dynamic pressure analyzed using computational fluid dynamics (CFD) modeling. Results: In the first set of experiments, measurement of changes in velocity, dynamic pressure, and fluid flow revealed that the venous system responded to cardiac arrest more slowly compared to the arteries. This disparity might be due to the intrinsic characteristics of the venous system, including stretch-recoil and elastic fiber composition. In the second set of experiments, we attempted to determine the role of the stretch-recoil capability of veins in the slower response to cardiac arrest. During the second set of experiments, we found that this recoil behavior increased dynamic pressure, velocity, and blood flow. The enhancement in dynamic pressure through combining the results from both experiments yielded a 15-40% increase in maximum dynamic pressure due to stretch-recoil, depending on vein diameter under normal conditions. Conclusion: In the situation of cardiac arrest, the vein geometry changes continue, promoting smooth responses of the venous system. Moreover, the importance of such vein behavior in blood displacement may grow as the pressure on the venous side gradually decreases with time. Our experiments suggest that the driving force for venous return is the pressure difference that remains within the venous system after the energy coming from every ventricular systole spent to overcome the resistance created by arterial and capillary systems.
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Affiliation(s)
- Seyed Mehdi Kamali Shahri
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, MA, USA
| | | | | | - Morteza Mahmoudi
- Precision Health Program and Department of Radiology, Michigan State University, MI, USA
| | - Simon Gelman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, MA, USA
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Schulz L, Geri G, Vieillard‐Baron A, Vignon P, Parkin G, Aneman A. Volume status and volume responsiveness in postoperative cardiac surgical patients: An observational, multicentre cohort study. Acta Anaesthesiol Scand 2021; 65:320-328. [PMID: 33169357 DOI: 10.1111/aas.13735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The best strategy to identify patients in whom fluid loading increases cardiac output (CO) following cardiac surgery remains debated. This study examined the utility of a calculated mean systemic filling pressure analogue (Pmsa ) and derived variables to explain the response to a fluid bolus. METHODS The Pmsa was calculated using retrospective, observational cohort data in the early postoperative period between admission to the intensive care unit and extubation within 6 hours. The venous return pressure gradient (VRdP) was calculated as Pmsa - central venous pressure. Concurrent changes induced by a fluid bolus in the ratio of the VRdP over Pmsa , the volume efficiency (Evol ), were studied to assess fluid responsiveness. Changes between Pmsa and derived variables and CO were analysed by Wilcoxon rank-sum test, hierarchial clustering and multiple linear regression. RESULTS Data were analysed for 235 patients who received 489 fluid boluses. The Pmsa increased with consecutive fluid boluses (median difference [range] 1.3 [0.5-2.4] mm Hg, P = .03) with a corresponding increase in VRdP (median difference 0.4 [0.2-0.6] mm Hg, P = .04). Hierarchical cluster analysis only identified Evol and the change in CO within one cluster. The multiple linear regression between Pmsa and its derived variables and the change in CO (overall r2 = .48, P < .001) demonstrated the best partial regression between the continuous change in CO and the concurrent Evol (r = .55, P < .001). CONCLUSION The mean systemic filling Pmsa enabled a comprehensive interpretation of fluid responsiveness with volume efficiency useful to explain the change in CO as a continuous phenomenon.
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Affiliation(s)
- Luis Schulz
- Intensive Care Unit Liverpool Hospital South Western Sydney Local Health District Liverpool NSW Australia
| | - Guillaume Geri
- Intensive Care Unit Assistance Publique‐Hôpitaux de Paris University Hospital Ambroise Paré Boulogne‐Billancourt France
- INSERM U‐1018 CESP Team 5 University of Versailles Saint‐Quentin en Yvelines Villejuif France
- Faculty of Medicine Paris Ile‐de‐France Ouest University of Versailles Saint‐Quentin en Yvelines Villejuif France
| | - Antoine Vieillard‐Baron
- Intensive Care Unit Assistance Publique‐Hôpitaux de Paris University Hospital Ambroise Paré Boulogne‐Billancourt France
- INSERM U‐1018 CESP Team 5 University of Versailles Saint‐Quentin en Yvelines Villejuif France
- Faculty of Medicine Paris Ile‐de‐France Ouest University of Versailles Saint‐Quentin en Yvelines Villejuif France
| | - Philippe Vignon
- Medical‐surgical Intensive Care Unit Limoges University Hospital Limoges France
- INSERM CIC 1435 Limoges University Hospital Limoges France
- Faculty of Medicine University of Limoges Limoges France
| | - Geoffrey Parkin
- Intensive Care Unit Monash Medical Centre Clayton Vic. Australia
| | - Anders Aneman
- Intensive Care Unit Liverpool Hospital South Western Sydney Local Health District Liverpool NSW Australia
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia
- Faculty of Medicine and Health Sciences Macquarie University Sydney NSW Australia
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Reply to: goal-directed haemodynamic therapy is in need of a new paradigm to survive. Eur J Anaesthesiol 2021; 38:91. [PMID: 33273384 DOI: 10.1097/eja.0000000000001293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Reply to: stressed volume and fluid responsiveness. Eur J Anaesthesiol 2021; 38:88-89. [PMID: 33273382 DOI: 10.1097/eja.0000000000001282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kenny JES. Letter to the editor: The venous circulation actively alters flow: a brief evolutionary perspective. Am J Physiol Heart Circ Physiol 2021; 320:H469-H470. [PMID: 33448258 DOI: 10.1152/ajpheart.00862.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jon-Emile S Kenny
- Health Sciences North Research Institute, Sudbury, Ontario, Canada.,Flosonics Medical, Sudbury, Ontario, Canada
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van Loon LM, van der Hoeven H, Veltink PH, Lemson J. The inspiration hold maneuver is a reliable method to assess mean systemic filling pressure but its clinical value remains unclear. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1390. [PMID: 33313135 PMCID: PMC7723632 DOI: 10.21037/atm-20-3540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background The upstream pressure for venous return (VR) is considered to be a combined conceptual blood pressure of the systemic vessels: the mean systemic filling pressure (MSFP). The relevance of estimating the MSFP during dynamic changes of the circulation at the bedside is controversial. Herein, we studied the effect of high ventilatory pressures on the relationship between VR and central venous pressure (CVP). Methods In 9 healthy pigs under anaesthesia and mechanically ventilated, MSFP was estimated from extrapolated VR versus CVP relationships during inspiratory hold maneuvers (IHMs) with different levels of ventilatory pressure (Pvent). MSFP was measure 3 times per animal during euvolemia and hypovolemia. Hypovolemia was induced by bleeding with 10 mL/kg. The estimated MSFP values were compared to the blood pressure recording after induced ventricle fibrillation (i.e., mean circulatory filling pressure). Results Our results revealed a strong linear correlation between VR and CVP [R2 of 0.92 (range, 0.67–0.99)], during IHMs with different levels of Pvent. Volume status significantly alters the resulting MSFP, 20±1 and 16±2 mmHg for euvolemia and hypovolemia respectively. This estimation of the MSFP was strongly correlated—but not interchangeable—to the blood pressure recording after induced ventricle fibrillation (R2=0.8 and P=0.045). Conclusions In conclusion, we showed a strong linear correlation between VR and CVP—when applying IHMs with high levels of Pvent—however the clinical applicability of this method to guide volume therapy in its current form is improbable.
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Affiliation(s)
- Lex M van Loon
- Cardiovascular and Respiratory Physiology Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Hans van der Hoeven
- Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Nijmegen, The Netherlands
| | - Peter H Veltink
- Biomedical Signals and Systems, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Joris Lemson
- Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, The Netherlands
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Yastrebov K, Brunel L, Williams ZA, Paterson HS, Yata M, Burrows CS, Wise IK, Robinson BM, Bannon PG. Comparison of dynamic changes in stressed intravascular volume, mean systemic filling pressure and cardiovascular compliance: Pilot investigation and study protocol. PLoS One 2020; 15:e0238045. [PMID: 32857803 PMCID: PMC7454998 DOI: 10.1371/journal.pone.0238045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/07/2020] [Indexed: 11/18/2022] Open
Abstract
The mean systemic filling pressure (MSFP) represents an interaction between intravascular volume and global cardiovascular compliance (GCC). Intravascular volume expansion using fluid resuscitation is the most frequent intervention in intensive care and emergency medicine for patients in shock and with haemodynamic compromise. The relationship between dynamic changes in MSFP, GCC and left ventricular compliance is unknown. We conducted prospective interventional pilot study following euthanasia in post cardiotomy adult sheep, investigating the relationships between changes in MSFP induced by rapid intravascular filling with fluids, global cardiovascular compliance and left ventricular compliance. This pilot investigation suggested a robust correlation between a gradual increase in the intravascular stressed volume from 0 to 40 ml/kg and the MSFP r = 0.708 95% CI 0.435 to 0.862, making feasible future prospective interventional studies. Based on the statistical modelling from the pilot results, we expect to identify a strong correlation of 0.71 ± 0.1 (95% CI) between the MSFP and the stressed intravascular volume in a future study.
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Affiliation(s)
- Konstantin Yastrebov
- Department of Intensive Care, Prince of Wales Hospital, Sydney, Australia
- The University of New South Wales, Sydney, Australia
| | | | | | | | - Mariko Yata
- Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Innes K. Wise
- DVC Research, University of Sydney, Sydney, Australia
| | - Benjamin M. Robinson
- DVC Research, University of Sydney, Sydney, Australia
- Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul G. Bannon
- DVC Research, University of Sydney, Sydney, Australia
- Royal Prince Alfred Hospital, Sydney, Australia
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Affiliation(s)
- Rafael Dalmau
- Department of Anesthesiology, Hospital Español de Rosario, S2001SBL Rosario, Argentina
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Abstract
In the 1950s, Arthur C. Guyton removed the heart from its pedestal in cardiovascular physiology by arguing that cardiac output is primarily regulated by the peripheral vasculature. This is counterintuitive, as modulating heart rate would appear to be the most obvious means of regulating cardiac output. In this Review, we visit recent and classic advances in comparative physiology in light of this concept. Although most vertebrates increase heart rate when oxygen demands rise (e.g. during activity or warming), experimental evidence suggests that this tachycardia is neither necessary nor sufficient to drive a change in cardiac output (i.e. systemic blood flow, Q̇ sys) under most circumstances. Instead, Q̇ sys is determined by the interplay between vascular conductance (resistance) and capacitance (which is mainly determined by the venous circulation), with a limited and variable contribution from heart function (myocardial inotropy). This pattern prevails across vertebrates; however, we also highlight the unique adaptations that have evolved in certain vertebrate groups to regulate venous return during diving bradycardia (i.e. inferior caval sphincters in diving mammals and atrial smooth muscle in turtles). Going forward, future investigation of cardiovascular responses to altered metabolic rate should pay equal consideration to the factors influencing venous return and cardiac filling as to the factors dictating cardiac function and heart rate.
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Affiliation(s)
- William Joyce
- Zoophysiology, Department of Bioscience, Aarhus University, 8000 Aarhus C, Denmark .,Department of Biology, University of Ottawa, 30 Marie Curie, Ottawa, ON K1N 6N5, Canada
| | - Tobias Wang
- Zoophysiology, Department of Bioscience, Aarhus University, 8000 Aarhus C, Denmark
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Werner-Moller P, Berger D, Takala J. Letter to the Editor: Venous return and the physical connection between distribution of segmental pressures and volumes. Am J Physiol Heart Circ Physiol 2020; 318:H203-H204. [PMID: 31910359 DOI: 10.1152/ajpheart.00698.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Per Werner-Moller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Anaesthesiology, Alingsas Hospital, Alingsas, Sweden
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Brengelmann GL. Reply to "Letter to the Editor: Venous return and the physical connection between distribution of segmental pressures and volumes". Am J Physiol Heart Circ Physiol 2020; 318:H205-H206. [PMID: 31910360 DOI: 10.1152/ajpheart.00730.2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- George L Brengelmann
- Department of Physiology and Biophysics, University of Washington, Seattle, Washington
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Affiliation(s)
- Rafael Dalmau
- Department of Anesthesiology, Hospital Español de Rosario, Rosario, Santa Fe, Argentina
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