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Jafari-Giv Z, Vajhi A, Farzad-Mohajeri S, Hassankhani M, Alian Samakkhah S, Hemmati A, Mohammadzade-Akbari A, Noroozzadegan M. Positive correlation between echocardiographic tricuspid E peak velocity and central venous pressure in dogs: A preliminary study. Vet Radiol Ultrasound 2024; 65:294-302. [PMID: 38513141 DOI: 10.1111/vru.13357] [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: 09/16/2023] [Revised: 01/29/2024] [Accepted: 03/04/2024] [Indexed: 03/23/2024] Open
Abstract
In the absence of vascular obstruction, central venous pressure (CVP) is a hydrostatic pressure in the cranial and caudal vena cava, providing valuable information about cardiac function and intravascular volume status. It is also a component in evaluating volume resuscitation in patients with septic shock and monitoring patients with right heart disease, pericardial disease, or volume depletion. Central venous pressure is calculated in dogs by invasive central venous catheterization, which is considered high-risk and impractical in critically ill patients. This study aimed to investigate the feasibility of using echocardiographic tricuspid E/E' as a noninvasive method to estimate CVP in anesthetized healthy dogs under controlled hypovolemic conditions. Ten male mixed-breed dogs were included in the study after a thorough health assessment. For hypovolemia induction, blood withdrawal was performed, and echocardiographic factors of the tricuspid valve, including peak E and E' velocities, were measured during CVP reduction. Repeated measures analysis of variance and Bonferroni post hoc tests were employed to compare the average difference between measured echocardiographic indices and CVP values derived from catheterization and intermittent measurement methods. Spearman's ρ correlation coefficient was used to evaluate the correlation between echocardiographic indices and CVP. E peak velocity had a significant negative correlation with venous blood pressure phases (r = -0.44, P = .001), indicating a decrease in peak E velocity with progressive CVP reduction. However, tricuspid valve E' peak velocity and E/E' did not correlate with CVP, suggesting that these parameters are not reliable for CVP estimation in dogs.
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Affiliation(s)
- Zahra Jafari-Giv
- Department of Surgery and Radiology, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
| | - Alireza Vajhi
- Department of Surgery and Radiology, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
| | - Saeed Farzad-Mohajeri
- Department of Surgery and Radiology, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
- Department of Regenerative Medicine, Institute of Biomedical Research, University of Tehran, Tehran, Iran
| | - Mahdi Hassankhani
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
| | - Shohreh Alian Samakkhah
- Department of Food Hygiene, Faculty of Veterinary Medicine, Amol University of Special Modern Technologies (AUSMT), Amol, Iran
| | - Amin Hemmati
- Department of Surgery and Radiology, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
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Anakmeteeprugsa S, Gonzalez-Fiol A, Vychodil R, Shelley K, Alian A. Assessment of changes in blood volume during lower body negative pressure-induced hypovolemia using bioelectrical impedance analysis. J Clin Monit Comput 2024; 38:293-299. [PMID: 37966562 DOI: 10.1007/s10877-023-01098-y] [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: 08/02/2023] [Accepted: 10/21/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Lower body negative Pressure (LBNP)-induced hypovolemia is simulating acute hemorrhage by sequestrating blood into lower extremities. Bioelectrical Impedance Analysis (BIA) is based on the electrical properties of biological tissues, as electrical current flows along highly conductive body tissues (such as blood). Changes in blood volume will lead to changes in bioimpedance. This study aims to study changes in upper (UL) and lower (LL) extremities bioimpedance during LBNP-induced hypovolemia. METHODS This was a prospective observational study of healthy volunteers who underwent gradual LBNP protocol which consisted of 3-minute intervals: at baseline, -15, -30, -45, -60 mmHg, then recovery phases at -30 mmHg and baseline. The UL&LL extremities bioimpedance were measured and recorded at each phase of LBNP and the percentage changes of bioimpedance from baseline were calculated and compared using student's t-test. A P-value of < 0.05 was considered significant. Correlation between relative changes in UL&LL bioimpedance and estimated blood loss (EBL) from LBNP was calculated using Pearson correlation. RESULTS 26 healthy volunteers were enrolled. As LBNP-induced hypovolemia progressed, there were a significant increase in UL bioimpedance and a significant decrease in LL bioimpedance. During recovery phases (where blood was shifted from the legs to the body), there were a significant increase in LL bioimpedance and a reduction in UL bioimpedance. There were significant correlations between estimated blood loss from LBNP model with UL (R = 0.97) and LL bioimpedance (R = - 0.97). CONCLUSION During LBNP-induced hypovolemia, there were reciprocal changes in UL&LL bioimpedance. These changes reflected hemodynamic compensatory mechanisms to hypovolemia.
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Affiliation(s)
- Suthawan Anakmeteeprugsa
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
- Department of Anesthesiology, Golden Jubilee Medical Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Antonio Gonzalez-Fiol
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Kirk Shelley
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Aymen Alian
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA.
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Abel B, Gerling KA, Mares JA, Hutzler J, Pierskalla I, Hays J, Propper B, White JM, Burmeister DM. Real-Time Measurements of Oral Mucosal Carbon Dioxide (POMCO2) Reveals an Inverse Correlation With Blood Pressure in a Porcine Model of Coagulopathic Junctional Hemorrhage. Mil Med 2024; 189:e612-e619. [PMID: 37632757 DOI: 10.1093/milmed/usad336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/28/2023] [Accepted: 08/11/2023] [Indexed: 08/28/2023] Open
Abstract
INTRODUCTION Shock states that occur during, for example, profound hemorrhage can cause global tissue hypoperfusion leading to organ failure. There is an unmet need for a reliable marker of tissue perfusion during hemorrhage that can be followed longitudinally. Herein, we investigated whether longitudinal POMCO2 tracks changes in hemodynamics in a swine model of coagulopathic uncontrolled junctional hemorrhage. MATERIALS AND METHODS Female Yorkshire-crossbreed swine (n = 7, 68.1 ± 0.7 kg) were anesthetized and instrumented for continuous measurement of mean arterial pressure (MAP). Coagulopathy was induced by the exchange of 50 to 60% of blood volume with 6% Hetastarch over 30 minutes to target a hematocrit of <15%. A 4.5-mm arteriotomy was made in the right common femoral artery with 30 seconds of free bleeding. POMCO2 was continuously measured from baseline through hemodilution, hemorrhage, and a subsequent 3-h intensive care unit period. Rotational thromboelastometry and blood gases were measured. RESULTS POMCO2 and MAP showed no significant changes during the hemodilution phase of the experiment, which produced coagulopathy evidenced by prolonged clot formation times. However, POMCO2 increased because of the uncontrolled hemorrhage by 11.3 ± 3.1 mmHg and was inversely correlated with the drop (17.9 ± 5.9 mmHg) in MAP (Y = -0.4122*X + 2.649, P = .02, r2 = 0.686). In contrast, lactate did not significantly correlate with the changes in MAP (P = .35) or POMCO2 (P = .37). CONCLUSIONS Despite the logical appeal of measuring noninvasive tissue CO2 measurement as a surrogate for gastrointestinal perfusion, prior studies have only reported snapshots of this readout. The present investigation shows real-time longitudinal measurement of POMCO2 to confirm that MAP inversely correlates to POMCO2 in the face of coagulopathy. The simplicity of measuring POMCO2 in real time can provide an additional practical option for military or civilian medics to monitor trends in hypoperfusion during hemorrhagic shock.
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Affiliation(s)
- Biebele Abel
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
- Department of Surgery, Uniformed Services University of the Health Science, Bethesda, MD 20814, USA
| | | | - John A Mares
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
- Department of Surgery, Uniformed Services University of the Health Science, Bethesda, MD 20814, USA
| | - Justin Hutzler
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
- Department of Surgery, Uniformed Services University of the Health Science, Bethesda, MD 20814, USA
| | | | - Jim Hays
- ExoStat Medical, Inc., Prior Lake, MN 55372, USA
| | - Brandon Propper
- Department of Surgery, Uniformed Services University of the Health Science, Bethesda, MD 20814, USA
- Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Joseph M White
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - David M Burmeister
- Department of Surgery, Uniformed Services University of the Health Science, Bethesda, MD 20814, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Lambert TP, Chan M, Sanchez-Perez JA, Nikbakht M, Lin DJ, Nawar A, Bashar SK, Kimball JP, Zia JS, Gazi AH, Cestero GI, Corporan D, Padala M, Hahn JO, Inan OT. A Comparison of Normalization Techniques for Individual Baseline-Free Estimation of Absolute Hypovolemic Status Using a Porcine Model. BIOSENSORS 2024; 14:61. [PMID: 38391980 PMCID: PMC10886994 DOI: 10.3390/bios14020061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/07/2024] [Accepted: 01/16/2024] [Indexed: 02/24/2024]
Abstract
Hypovolemic shock is one of the leading causes of death in the military. The current methods of assessing hypovolemia in field settings rely on a clinician assessment of vital signs, which is an unreliable assessment of hypovolemia severity. These methods often detect hypovolemia when interventional methods are ineffective. Therefore, there is a need to develop real-time sensing methods for the early detection of hypovolemia. Previously, our group developed a random-forest model that successfully estimated absolute blood-volume status (ABVS) from noninvasive wearable sensor data for a porcine model (n = 6). However, this model required normalizing ABVS data using individual baseline data, which may not be present in crisis situations where a wearable sensor might be placed on a patient by the attending clinician. We address this barrier by examining seven individual baseline-free normalization techniques. Using a feature-specific global mean from the ABVS and an external dataset for normalization demonstrated similar performance metrics compared to no normalization (normalization: R2 = 0.82 ± 0.025|0.80 ± 0.032, AUC = 0.86 ± 5.5 × 10-3|0.86 ± 0.013, RMSE = 28.30 ± 0.63%|27.68 ± 0.80%; no normalization: R2 = 0.81 ± 0.045, AUC = 0.86 ± 8.9 × 10-3, RMSE = 28.89 ± 0.84%). This demonstrates that normalization may not be required and develops a foundation for individual baseline-free ABVS prediction.
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Affiliation(s)
- Tamara P. Lambert
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (M.C.); (O.T.I.)
| | - Michael Chan
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (M.C.); (O.T.I.)
| | - Jesus Antonio Sanchez-Perez
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
| | - Mohammad Nikbakht
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
| | - David J. Lin
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
| | - Afra Nawar
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
| | - Syed Khairul Bashar
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
| | - Jacob P. Kimball
- The Donald P. Shiley School of Engineering, University of Portland, Portland, OR 97203, USA;
| | - Jonathan S. Zia
- Division of Neurology & Neurological Sciences, Stanford School of Medicine, Palo Alto, CA 94304, USA;
| | - Asim H. Gazi
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Allston, MA 02134, USA;
| | - Gabriela I. Cestero
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
| | - Daniella Corporan
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, GA 30308, USA; (D.C.); (M.P.)
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, GA 30308, USA; (D.C.); (M.P.)
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jin-Oh Hahn
- Department of Mechanical Engineering, University of Maryland, College Park, MD 20742, USA;
| | - Omer T. Inan
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (M.C.); (O.T.I.)
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
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Wang L, Fu X, He M, Shi L, Wan D, Wang Y, Wu Q, Yang J, Cai B, Xia H, Chen H, Zhang G, Lei X, Zhang W, Feng Z, Wang B, Zhang Z. Risk Factor Analysis and Nomogram for Predicting In-Hospital Mortality in ICU Patients with Heat Stroke: A National Multicenter Study. J Multidiscip Healthc 2023; 16:3189-3201. [PMID: 37915977 PMCID: PMC10617527 DOI: 10.2147/jmdh.s428617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/19/2023] [Indexed: 11/03/2023] Open
Abstract
Objective The aim of this nationwide multicenter study was to ascertain the risk factors associated with in-hospital mortality in patients with heat stroke admitted to intensive care units (ICUs) and to develop a nomogram for prognostic prediction. Methods A retrospective analysis was conducted on clinical data collected from ICU patients diagnosed with heat stroke across multiple centers nationwide. Univariate and multivariate logistic regression analyses were performed to identify significant risk factors for in-hospital mortality. Based on the results of the multivariate analysis, a nomogram was constructed to estimate the individualized probability of mortality. Internal validation of the nomogram was performed, and its performance was assessed using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). Results A total of 292 ICU patients with heat stroke were included in this study. Three risk factors, namely Cr (creatinine), AST (aspartate aminotransferase), and SBP (systolic blood pressure), were found to be significantly associated with in-hospital mortality. These risk factors were incorporated into the nomogram, which exhibited good discriminative ability (area under the ROC curve of the training and validation cohorts were 0.763 and 0.739, respectively) and calibration. Internal validation and decision curve analysis confirmed the stability and reliability of the nomogram. Conclusion This nationwide multicenter study identified key risk factors for in-hospital mortality in ICU patients with heat stroke. The developed nomogram provides an individualized prediction of mortality risk and can serve as a valuable tool for clinicians in the assessment and management of ICU patients with heat stroke.
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Affiliation(s)
- Lietao Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Xin Fu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Min He
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Lvyuan Shi
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Dingyuan Wan
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Yucong Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Qin Wu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Jing Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Bayuan Cai
- Department of Critical Care Medicine, The People’s Hospital of Jiajiang, Leshan, People’s Republic of China
| | - Hongtao Xia
- Department of Critical Care Medicine, Suining Central Hospital, Suining, People’s Republic of China
| | - Hongxu Chen
- Department of Critical Care Medicine, The Hospital of Traditional Chinese Medicine of Leshan, Leshan, People’s Republic of China
| | - Ge Zhang
- Department of Critical Care Medicine, The First People’s Hospital of Longquanyi District, Chengdu, People’s Republic of China
| | - Xianying Lei
- Department of Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, People’s Republic of China
| | - Wei Zhang
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, People’s Republic of China
| | - Zhongxue Feng
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, People’s Republic of China
| | - Bo Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Zhongwei Zhang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - On behalf of Heat Stroke Research Group in Southwestern China
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
- Department of Critical Care Medicine, The People’s Hospital of Jiajiang, Leshan, People’s Republic of China
- Department of Critical Care Medicine, Suining Central Hospital, Suining, People’s Republic of China
- Department of Critical Care Medicine, The Hospital of Traditional Chinese Medicine of Leshan, Leshan, People’s Republic of China
- Department of Critical Care Medicine, The First People’s Hospital of Longquanyi District, Chengdu, People’s Republic of China
- Department of Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, People’s Republic of China
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, People’s Republic of China
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Lord MG, Gould AJ, Clark MA, Rouse DJ, Lewkowitz AK. The AccuFlow sensor: a novel digital health tool to assess intrapartum blood loss at cesarean delivery. J Perinat Med 2023; 51:997-1005. [PMID: 37155696 PMCID: PMC11170087 DOI: 10.1515/jpm-2023-0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 04/02/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVES During obstetric hemorrhage, peripheral vasoconstriction maintains heart rate and blood pressure until compensatory mechanisms are overwhelmed and patients deteriorate rapidly. Real-time perfusion measurements could quantify vasoconstriction, improving early recognition of hemorrhage and facilitating early intervention to reduce morbidity and mortality. The AccuFlow device makes rapid, non-invasive, quantitative measurements of perfusion, but has not been studied for hemorrhage detection or used in surgical settings. This study evaluated feasibility, tolerability, and preliminary efficacy of the AccuFlow for assessment of blood loss at cesarean delivery (CD). METHODS In this pilot study, sensors were applied to the wrist, forearm, bicep, and chest wall of 25 patients undergoing scheduled CD. Postoperatively, sensors were removed and patients rated the AccuFlow and the standard anesthesia monitoring equipment on a validated comfort rating scale for wearable computers (CRS). Blood loss was estimated by the surgical team (EBL) and calculated from change in hematocrit, weight, and height (CBL). CRS scores were compared via Wilcoxon signed ranks tests. Coefficients of correlation between sensor readings and CBL, and between EBL and CBL, were compared using Fisher's R-to-z transformation. RESULTS There were no safety events; no participants requested device removal. CRS ratings of the AccuFlow and the standard monitoring equipment were similar (7.2 vs. 8.8, p=0.25). Change in wrist perfusion from delivery to dressing placement was more strongly correlated with CBL than was EBL (R=-0.48 vs. R=0.087, p=0.03). CONCLUSIONS The AccuFlow sensor is well-tolerated and shows promise in detecting intrapartum hemorrhage, though larger studies are needed.
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Affiliation(s)
- Megan G. Lord
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Providence, RI, USA; Alpert Medical School of Brown University, Providence, RI, USA; and c/o Maternal Fetal Medicine101 Plain St, Providence, RI, USA
| | | | - Melissa A. Clark
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Providence, RI, USA; and Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Dwight J. Rouse
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Providence, RI, USA; and Alpert Medical School of Brown University, Providence, RI, USA
| | - Adam K. Lewkowitz
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Providence, RI, USA; and Alpert Medical School of Brown University, Providence, RI, USA
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Martín-Rodríguez F, Ortega GJ, Castro Villamor MA, Del Pozo Vegas C, Delgado Benito JF, Martín-Conty JL, Sanz-García A, López-Izquierdo R. Development of a prehospital lactic acidosis score for early-mortality. A prospective, multicenter, ambulance-based, cohort study. Am J Emerg Med 2023; 65:16-23. [PMID: 36580696 DOI: 10.1016/j.ajem.2022.12.030] [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: 07/01/2022] [Revised: 12/02/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Lactic acidosis is a clinical status related to clinical worsening. Actually, higher levels of lactate is a well-established trigger of emergency situations. The aim of this work is to build-up a prehospital early warning score to predict 2-day mortality and intensive care unit (ICU) admission, constructed with other components of the lactic acidosis besides the lactate. METHODS Prospective, multicenter, observational, derivation-validation cohort study of adults evacuated by ambulance and admitted to emergency department with acute diseases, between January 1st, 2020 and December 31st, 2021. Including six advanced life support, thirty-eight basic life support units, referring to four hospitals (Spain). The primary and secondary outcome of the study were 2-day all-cause mortality and ICU-admission. The prehospital lactic acidosis (PLA) score was derived from the analysis of prehospital blood parameters associated with the outcome using a logistic regression. The calibration, clinical utility, and discrimination of PLA were determined and compared to the performance of each component of the score alone. RESULTS A total of 3334 patients were enrolled. The final PLA score included: lactate, pCO2, and pH. For 2-day mortality, the PLA showed an AUC of 0.941 (95%CI: 0.914-0.967), a better performance in calibration, and a higher net benefit as compared to the other score components alone. For the ICU admission, the PLA only showed a better performance for AUC: 0.75 (95%CI: 0.706-0.794). CONCLUSIONS Our results showed that PLA predicts 2-day mortality better than other lactic acidosis components alone. Including PLA score in prehospital setting could improve emergency services decision-making.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain; Prehospital early warning scoring-system investigation group, Valladolid, Spain
| | - Guillermo J Ortega
- Health Research Institute, Hospital de la Princesa, Madrid (IIS-IP), Spain; CONICET, Argentina
| | - Miguel A Castro Villamor
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Prehospital early warning scoring-system investigation group, Valladolid, Spain
| | - Carlos Del Pozo Vegas
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Prehospital early warning scoring-system investigation group, Valladolid, Spain; Emergency Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Juan F Delgado Benito
- Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain; Prehospital early warning scoring-system investigation group, Valladolid, Spain
| | - José L Martín-Conty
- Faculty of Health Sciences, Universidad de Castilla la Mancha, Talavera de la Reina, Spain
| | - Ancor Sanz-García
- Prehospital early warning scoring-system investigation group, Valladolid, Spain; Health Research Institute, Hospital de la Princesa, Madrid (IIS-IP), Spain.
| | - Raúl López-Izquierdo
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Prehospital early warning scoring-system investigation group, Valladolid, Spain; Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
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Iyengar KP, Venkatesan AS, Jain VK, Shashidhara MK, Elbana H, Botchu R. Risks in the Management of Polytrauma Patients: Clinical Insights. Orthop Res Rev 2023; 15:27-38. [PMID: 36974036 PMCID: PMC10039633 DOI: 10.2147/orr.s340532] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 03/16/2023] [Indexed: 03/29/2023] Open
Abstract
Polytrauma, a patient's condition with multiple injuries that involve multiple organs or systems, is the leading cause of mortality in young adults. Trauma-related injuries are a major public health concern due to their associated morbidity, high disability, associated death, and socioeconomic consequences. Management of polytrauma patients has evolved over the last few decades due to the development of trauma systems, improved pre-hospital assessment, transport and in-hospital care supported by complementary investigations. Recognising the mortality patterns in trauma has led to significant changes in the approach to managing these patients. A structured approach with application of advanced trauma life support (ATLS) algorithms and optimisation of care based on clinical and physiological parameters has led to the development of early appropriate care (EAC) guidelines to treat these patients, with subsequent improved outcomes in such patients. The journey of a polytrauma patient through the stages of pre-hospital care, emergency resuscitation, in-hospital stabilization and rehabilitation pathway can be associated with risks at any of these phases. We describe the various risks that can be anticipated during the management of polytrauma patients at different stages and provide clinical insights into early recognition and effective treatment of these to improve clinical outcomes.
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Affiliation(s)
- Karthikeyan P Iyengar
- Department of Orthopaedics, Southport and Ormskirk NHS Trust, Southport, UK
- Correspondence: Karthikeyan P Iyengar, Trauma and Orthopaedic Surgeon, Southport and Ormskirk NHS Trust, Southport, UK, PR8 6PN, Tel +44-1704-704926, Email
| | | | - Vijay K Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | | | - Husam Elbana
- Department of Orthopaedics, Royal Lancaster Infirmary, Lancaster, UK
| | - Rajesh Botchu
- Department of Musculoskeletal Radiology, Royal Orthopaedic Hospital, Birmingham, UK
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9
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Convertino VA, Wagner AR, Akers KS, VanFosson CA, Cancio LC. Early identification of sepsis in burn patients using compensatory reserve measurement: A prospective case series study. BURNS OPEN 2022. [DOI: 10.1016/j.burnso.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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10
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Suresh MR. The Early Detection of Hypovolemic Shock and Shifting the Focus to Compensation. J Intensive Care Med 2022; 37:1673-1675. [PMID: 35850608 DOI: 10.1177/08850666221114267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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11
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van der Ster BJP, Kim YS, Westerhof BE, van Lieshout JJ. Central Hypovolemia Detection During Environmental Stress-A Role for Artificial Intelligence? Front Physiol 2021; 12:784413. [PMID: 34975538 PMCID: PMC8715014 DOI: 10.3389/fphys.2021.784413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/18/2021] [Indexed: 11/19/2022] Open
Abstract
The first step to exercise is preceded by the required assumption of the upright body position, which itself involves physical activity. The gravitational displacement of blood from the chest to the lower parts of the body elicits a fall in central blood volume (CBV), which corresponds to the fraction of thoracic blood volume directly available to the left ventricle. The reduction in CBV and stroke volume (SV) in response to postural stress, post-exercise, or to blood loss results in reduced left ventricular filling, which may manifest as orthostatic intolerance. When termination of exercise removes the leg muscle pump function, CBV is no longer maintained. The resulting imbalance between a reduced cardiac output (CO) and a still enhanced peripheral vascular conductance may provoke post-exercise hypotension (PEH). Instruments that quantify CBV are not readily available and to express which magnitude of the CBV in a healthy subject should remains difficult. In the physiological laboratory, the CBV can be modified by making use of postural stressors, such as lower body "negative" or sub-atmospheric pressure (LBNP) or passive head-up tilt (HUT), while quantifying relevant biomedical parameters of blood flow and oxygenation. Several approaches, such as wearable sensors and advanced machine-learning techniques, have been followed in an attempt to improve methodologies for better prediction of outcomes and to guide treatment in civil patients and on the battlefield. In the recent decade, efforts have been made to develop algorithms and apply artificial intelligence (AI) in the field of hemodynamic monitoring. Advances in quantifying and monitoring CBV during environmental stress from exercise to hemorrhage and understanding the analogy between postural stress and central hypovolemia during anesthesia offer great relevance for healthy subjects and clinical populations.
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Affiliation(s)
- Björn J. P. van der Ster
- Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Yu-Sok Kim
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Internal Medicine, Medisch Centrum Leeuwarden, Leeuwarden, Netherlands
| | - Berend E. Westerhof
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Pulmonary Medicine, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Johannes J. van Lieshout
- Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Medical Research Council Versus Arthritis Centre for Musculoskeletal Ageing Research, Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, The Medical School, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, United Kingdom
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12
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Lee E, Song YJ, Jeon S, Lee J, Lee E, Lee JY, Lee E, Han MK, Jeong HG. Risk Factors for Intravenous Propacetamol-Induced Blood Pressure Drop in the Neurointensive Care Unit: A Retrospective Observational Study. Neurocrit Care 2021; 36:888-896. [PMID: 34791593 DOI: 10.1007/s12028-021-01390-2] [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: 07/17/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Intravenous propacetamol is commonly used to control fever and pain in neurocritically ill patients in whom oral administration is often difficult. However, several studies reported that intravenous propacetamol may cause blood pressure drop. Thus, we aimed to investigate the occurrence and risk factors for intravenous propacetamol-induced blood pressure drop in neurocritically ill patients. METHODS This retrospective study included consecutive patients who were administered intravenous propacetamol in a neurointensive care unit at a single tertiary academic hospital between April 2013 and June 2020. The exact timing of intravenous propacetamol administration was collected from a database of the electronic barcode medication administration system. Blood pressure drop was defined as a systolic blood pressure below 90 mm Hg or a decrease by 30 mm Hg or more. Blood pressure, pulse rate, and body temperature were collected at baseline and within 2 h after intravenous propacetamol administration. The incidence of blood pressure drop was evaluated, and multivariable logistic regression analysis was performed to identify risk factors for blood pressure drop events. RESULTS A total of 16,586 instances of intravenous propacetamol administration in 4916 patients were eligible for this study. Intravenous propacetamol resulted in a significant decrease in systolic blood pressure (baseline 131.1 ± 17.8 mm Hg; within 1 h 124.6 ± 17.3 mm Hg; between 1 and 2 h 123.4 ± 17.4 mm Hg; P < 0.01). The incidence of blood pressure drop events was 13.5% within 2 h after intravenous propacetamol. Older age, lower or higher baseline systolic blood pressure, fever, higher Acute Physiology and Chronic Health Evaluation II score, and concomitant administration of vasopressors/inotropes or analgesics/sedatives were significant factors associated with the occurrence of blood pressure drop events after intravenous propacetamol administration. CONCLUSIONS Intravenous propacetamol can induce hemodynamic changes and blood pressure drop events in neurocritically ill patients. This study identified the risk factors for blood pressure drop events. On the basis of our results, judicious use of intravenous propacetamol is warranted for neurocritically ill patients with risk factors that make them more susceptible to hemodynamic changes.
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Affiliation(s)
- Eunah Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seoungnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Young Joo Song
- Department of Pharmacy, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seoungnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Sujeong Jeon
- Department of Pharmacy, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seoungnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Junghwa Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seoungnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Eunsook Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seoungnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea
| | - Euni Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, 08826, Republic of Korea
| | - Han-Gil Jeong
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, 08826, Republic of Korea. .,Division of Neurocritical Care, Department of Neurosurgery and Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.
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13
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Kimball JP, Zia JS, An S, Rolfes C, Hahn JO, Sawka MN, Inan OT. Unifying the Estimation of Blood Volume Decompensation Status in a Porcine Model of Relative and Absolute Hypovolemia Via Wearable Sensing. IEEE J Biomed Health Inform 2021; 25:3351-3360. [PMID: 33760744 DOI: 10.1109/jbhi.2021.3068619] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hypovolemia remains the leading cause of preventable death in trauma cases. Recent research has demonstrated that using noninvasive continuous waveforms rather than traditional vital signs improves accuracy in early detection of hypovolemia to assist in triage and resuscitation. This work evaluates random forest models trained on different subsets of data from a pig model (n = 6) of absolute (bleeding) and relative (nitroglycerin-induced vasodilation) progressive hypovolemia (to 20% decrease in mean arterial pressure) and resuscitation. Features for the models were derived from a multi-modal set of wearable sensors, comprised of the electrocardiogram (ECG), seismocardiogram (SCG) and reflective photoplethysmogram (RPPG) and were normalized to each subject.s baseline. The median RMSE between predicted and actual percent progression towards cardiovascular decompensation for the best model was 30.5% during the relative period, 16.8% during absolute and 22.1% during resuscitation. The least squares best fit line over the mean aggregated predictions had a slope of 0.65 and intercept of 12.3, with an R2 value of 0.93. When transitioned to a binary classification problem to identify decompensation, this model achieved an AUROC of 0.80. This study: a) developed a global model incorporating ECG, SCG and RPPG features for estimating individual-specific decompensation from progressive relative and absolute hypovolemia and resuscitation; b) demonstrated SCG as the most important modality to predict decompensation; c) demonstrated efficacy of random forest models trained on different data subsets; and d) demonstrated adding training data from two discrete forms of hypovolemia increases prediction accuracy for the other form of hypovolemia and resuscitation.
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14
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Nadler R, Tsur AM, Lipsky AM, Lending G, Benov A, Ostffeld I, Shinar E, Yanovich R, Moser A, Levy D, Haiman N, Eliassen H, Bader T, Glassberg E, Chen J. Cognitive and physical performance are well preserved following standard blood donation: A noninferiority, randomized clinical trial. Transfusion 2020; 60 Suppl 3:S77-S86. [PMID: 32478913 DOI: 10.1111/trf.15624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/17/2019] [Accepted: 11/17/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND A walking blood bank (WBB) refers to the use of fellow combatants for battlefield blood donation. This requires pretesting combatants for infectious diseases and blood type. A fundamental prerequisite for this technique is that the donating soldier will suffer minimal physiological and mental impact. The purpose of the current study is to assess the effect of blood shedding on battlefield performance. METHODS This is a double-blind randomized control trial. Forty Israel Defense Forces combatants volunteered for the study. Participants underwent baseline evaluation, including repeated measurement of vital signs, cognitive evaluation, physical evaluation, and a strenuous shooting test. Three weeks after the baseline evaluation, subjects were randomized to either blood donation or the control group. For blinding purposes, all subjects underwent venous catheterization for the duration of a blood donation. Repeated vital signs and function evaluation were then performed. RESULTS Thirty-six patients were available for randomization. Baseline measurements were similar for both groups. Mean strenuous shooting score was 80.5 ± 9.5 for the control group and 82 ± 6.6 for the test group (p = 0.58). No clinically or statistically significant differences were found in tests designed to evaluate cognitive performance or physical functions. Vital signs taken multiple times were also similar between the test and control groups. CONCLUSIONS Executive, cognitive, and physical functions were well preserved after blood donation. This study supports the hypothesis that a WBB does not decrease donor combat performance. The categorical prohibition of physical exercise following blood donation might need to be reconsidered in both military and civilian populations.
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Affiliation(s)
- Roy Nadler
- Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel.,Department of Surgery and Transplantation B, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Avishai M Tsur
- Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Ari M Lipsky
- Department of Emergency Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Gadi Lending
- Bar-Ilan University Faculty of Medicine (G.E.), Safed, Israel
| | - Avi Benov
- Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel.,Bar-Ilan University Faculty of Medicine (G.E.), Safed, Israel
| | - Ishai Ostffeld
- Office of Medical Affairs, National Insurance Institute of Israel, Jerusalem, Israel
| | - Eilat Shinar
- National Blood Services, Magen David Adom, Ramat Gan, Israel
| | - Ran Yanovich
- Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Asher Moser
- National Blood Services, Magen David Adom, Ramat Gan, Israel
| | - Diana Levy
- Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Nikolai Haiman
- Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Hakon Eliassen
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Tarif Bader
- Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
| | - Elon Glassberg
- Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel.,Bar-Ilan University Faculty of Medicine (G.E.), Safed, Israel
| | - Jacob Chen
- Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
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15
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Convertino VA, Koons NJ. The compensatory reserve: potential for accurate individualized goal-directed whole blood resuscitation. Transfusion 2020; 60 Suppl 3:S150-S157. [PMID: 32478902 DOI: 10.1111/trf.15632] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 11/29/2022]
Abstract
Hemorrhagic shock can be mitigated by timely and accurate resuscitation designed to restore adequate delivery of oxygen (DO2 ). Current doctrine of using systolic blood pressure (SBP) as a guide for resuscitation can be associated with increased morbidity. The compensatory reserve measurement (CRM) is a novel vital sign based on the recognition that the sum of all mechanisms that contribute to the compensatory response to hemorrhage reside in features of the arterial pulse waveform. CRM can be assessed continuously and non-invasively in real time. Compared to standard vital signs, CRM provides an early, as well as more sensitive and specific, indicator of patient hemorrhagic status since the activation of compensatory mechanisms occurs immediately at the onset of blood loss. Recent data obtained from our laboratory experiments on non-human primates have demonstrated that CRM is linearly related to DO2 during controlled progressive hemorrhage and subsequent whole blood resuscitation. We used this relationship to determine that the time of hemodynamic decompensation (i.e., CRM = 0%) is defined by a critical DO2 at approximately 5.3 mL O2 ∙kg-1 ∙min-1 . We also demonstrated that a target CRM of 35% during whole blood resuscitation only required replacement of 40% of the total blood volume loss to adequately sustain a DO2 more than 50% (i.e., 8.1 mL O2 ∙kg-1 ∙min-1 ) above critical DO2 (i.e., threshold for decompensated shock) while maintaining hypotensive resuscitation (i.e., SBP at ~90 mmHg). Consistent with our hypothesis, specific values of CRM can be used to accurately maintain DO2 thresholds above critical DO2 , avoiding the onset of hemorrhagic shock with whole blood resuscitation.
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Affiliation(s)
- Victor A Convertino
- Battlefield Health & Trauma Center for Human Integrative Physiology, United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Natalie J Koons
- Battlefield Health & Trauma Center for Human Integrative Physiology, United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
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16
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Validating clinical threshold values for a dashboard view of the compensatory reserve measurement for hemorrhage detection. J Trauma Acute Care Surg 2020; 89:S169-S174. [DOI: 10.1097/ta.0000000000002586] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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