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Yuriditsky E, Bakker J. What every intensivist should know about…Systolic arterial pressure targets in shock. J Crit Care 2024; 82:154790. [PMID: 38816174 DOI: 10.1016/j.jcrc.2024.154790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/10/2023] [Accepted: 12/17/2023] [Indexed: 06/01/2024]
Affiliation(s)
- Eugene Yuriditsky
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA.
| | - Jan Bakker
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, USA; Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, USA; Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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Hollo Z, McKenzie S, Kluger R, Peyton P, Melville A, Phan TD. The effect of restrictive compared to liberal intravenous fluid volume on hypotension in adults undergoing major abdominal surgery. Sci Rep 2024; 14:14401. [PMID: 38909131 PMCID: PMC11193751 DOI: 10.1038/s41598-024-65031-2] [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: 10/28/2023] [Accepted: 06/17/2024] [Indexed: 06/24/2024] Open
Abstract
In a cardiac output (CO) sub-study of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial, it was shown that restrictive fluid management was associated with lower cardiac index at the end of surgery. However, the association of the fluid protocol with intraoperative blood pressure was less clear. This paper primarily compares rates of hypotension between the two fluid regimens. The haemodynamic effects of these protocols may increase our understanding of perioperative fluid prescription. Using a data set of arterial pressure and cardiac output measurements, this observational cohort study primarily compares intraoperative hypotension rates defined by a mean arterial pressure < 65 mmHg between liberal and restrictive fluid protocols. Secondary analyses explore predictors of invasive mean arterial pressure and doppler-derived cardiac output, including fluid volume regimens and surgical duration. 105 patients had a combined total of 835 haemodynamic data capture events from the beginning to the end of the surgery. Here we report that a restrictive regimen is not associated with a greater proportion of participants who experience at least one episode of hypotension than the liberal regimen 64.1% vs. 61.5% (mean difference 2.6%, 95% CI - 15.9% to 21%, p = 0.78). Duration of surgery was associated with an increased risk of hypotension (OR 1.05, 1 to 1.1, p = 0.038). A fluid restriction protocol compared to liberal fluid administration is not associated with lower blood pressure.
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Affiliation(s)
- Zachary Hollo
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
- Deakin University, 75 Pigdons Road, Waurn Ponds, Geelong, VIC, Australia
| | | | - Roman Kluger
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
- University of Melbourne, Grattan Street, Parkville, VIC, Australia
| | - Philip Peyton
- Austin Health, 145 Studley Road, Heidelberg, VIC, Australia
- University of Melbourne, Grattan Street, Parkville, VIC, Australia
| | - Andrew Melville
- Alfred Health, 55 Commercial Road, Melbourne, VIC, Australia
| | - Tuong D Phan
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
- University of Melbourne, Grattan Street, Parkville, VIC, Australia.
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Hernández G, Valenzuela ED, Kattan E, Castro R, Guzmán C, Kraemer AE, Sarzosa N, Alegría L, Contreras R, Oviedo V, Bravo S, Soto D, Sáez C, Ait-Oufella H, Ospina-Tascón G, Bakker J. Capillary refill time response to a fluid challenge or a vasopressor test: an observational, proof-of-concept study. Ann Intensive Care 2024; 14:49. [PMID: 38558268 PMCID: PMC10984906 DOI: 10.1186/s13613-024-01275-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Several studies have validated capillary refill time (CRT) as a marker of tissue hypoperfusion, and recent guidelines recommend CRT monitoring during septic shock resuscitation. Therefore, it is relevant to further explore its kinetics of response to short-term hemodynamic interventions with fluids or vasopressors. A couple of previous studies explored the impact of a fluid bolus on CRT, but little is known about the impact of norepinephrine on CRT when aiming at a higher mean arterial pressure (MAP) target in septic shock. We designed this observational study to further evaluate the effect of a fluid challenge (FC) and a vasopressor test (VPT) on CRT in septic shock patients with abnormal CRT after initial resuscitation. Our purpose was to determine the effects of a FC in fluid-responsive patients, and of a VPT aimed at a higher MAP target in chronically hypertensive fluid-unresponsive patients on the direction and magnitude of CRT response. METHODS Thirty-four septic shock patients were included. Fluid responsiveness was assessed at baseline, and a FC (500 ml/30 mins) was administered in 9 fluid-responsive patients. A VPT was performed in 25 patients by increasing norepinephrine dose to reach a MAP to 80-85 mmHg for 30 min. Patients shared a multimodal perfusion and hemodynamic monitoring protocol with assessments at at least two time-points (baseline, and at the end of interventions). RESULTS CRT decreased significantly with both tests (from 5 [3.5-7.6] to 4 [2.4-5.1] sec, p = 0.008 after the FC; and from 4.0 [3.3-5.6] to 3 [2.6 -5] sec, p = 0.03 after the VPT. A CRT-response was observed in 7/9 patients after the FC, and in 14/25 pts after the VPT, but CRT deteriorated in 4 patients on this latter group, all of them receiving a concomitant low-dose vasopressin. CONCLUSIONS Our findings support that fluid boluses may improve CRT or produce neutral effects in fluid-responsive septic shock patients with persistent hypoperfusion. Conversely, raising NE doses to target a higher MAP in previously hypertensive patients elicits a more heterogeneous response, improving CRT in the majority, but deteriorating skin perfusion in some patients, a fact that deserves further research.
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Affiliation(s)
- Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile.
| | - Emilio Daniel Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Camila Guzmán
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Alicia Elzo Kraemer
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Nicolás Sarzosa
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Roberto Contreras
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Vanessa Oviedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Sebastián Bravo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Dagoberto Soto
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Claudia Sáez
- Departamento de Hematología Oncología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Hafid Ait-Oufella
- Medical Intensive Care Unit, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Gustavo Ospina-Tascón
- Cardiovascular Research Center, INSERM U970, Université de Paris, Paris, France
- Department of Intensive Care Medicine, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands
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Loomba RS, Farias JS, Villarreal EG, Flores S. Correlation of hepatic venous saturation and mixed venous saturation: pooled analyses. Minerva Pediatr (Torino) 2024; 76:253-258. [PMID: 38015430 DOI: 10.23736/s2724-5276.23.07208-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
INTRODUCTION In critical care, monitoring adequate tissue oxygenation is essential. Mixed venous oxygen saturation has traditionally been considered the gold standard for measuring cardiac output, which represents systemic oxygen delivery. Studies have shown that hepatic vein saturation is correlated with mixed venous oxygen saturation and mortality. The primary aim of this study was to determine the correlation between hepatic vein saturation and mixed venous saturation, and the impact of clinical characteristics on this correlation. EVIDENCE ACQUISITION A systematic review of the literature was performed to identify manuscripts. They must have included patients who received simultaneous mixed venous saturations and hepatic vein saturations, and the data for both must have been explicitly shared. Data were pooled from these studies to analyze the correlation between mixed venous saturation and the corresponding hepatic vein saturation. EVIDENCE SYNTHESIS A total of 13 studies with 333 patients were included in the final analyses. The average age across these studies was 60.3±5.2. The pooled correlation between the mixed venous saturation and hepatic vein saturation was 0.88, demonstrating a strong correlation between the two. The average mixed venous saturation was 73.3±5.0 while the average hepatic vein saturation was 59.5±11.1. CONCLUSIONS In these pooled analyses, hepatic vein saturation has a strong correlation with mixed venous saturation. This correlation is not significantly impacted by patient age, weight, or clinical setting. Nonetheless, further prospective studies are needed for confirmation.
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Affiliation(s)
- Rohit S Loomba
- Department of Pediatrics, Advocate Children's Hospital, Chicago, IL, USA
- Division of Pediatric Cardiac Critical Care, Chicago Medical School/Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
| | | | - Enrique G Villarreal
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Monterrey, Mexico
| | - Saul Flores
- Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Baylor College School of Medicine, Houston, TX, USA
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Foth PW, Gardner A, Pereira CR, Cooper E, Schroeder E, Mudge MC. Assessment and comparison of microcirculation and macrocirculation in horses undergoing emergency exploratory celiotomy versus elective surgical procedures. Vet Surg 2023; 52:1015-1023. [PMID: 37280741 DOI: 10.1111/vsu.13970] [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: 03/04/2022] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To assess oral buccal microcirculation by hand-held videomicroscopy in horses during colic surgery, comparing microcirculation values with macrocirculatory parameters and with those of healthy elective surgical horses. STUDY DESIGN Clinical prospective study. ANIMALS Client-owned horses (nine in the colic group; 11 in the elective group). METHODS In the colic group, buccal mucosal side stream dark-field microscopy (DFM) videos, cardiac output (CO), mean arterial pressure (MAP), and lactate were obtained at three timepoints under general anesthesia (30, 90, and 150 min after induction). Video analysis was used to determine total vessel density, proportion of perfused vessels, perfused vessel density, and heterogeneity index. Dark-field microscopy videos, MAP, and lactate were obtained at a single timepoint under general anesthesia (45 min after induction) in the elective group. RESULTS There were no differences in microcirculatory parameters between colic and elective horses, nor was there a difference across timepoints in the colic group. There was a weak negative correlation between microvascular parameters and CO (rho = -0.23). CONCLUSION The colic group did not have decreased microcirculation in comparison with the healthy elective group. Dark-field microscopy did not correlate well with macrocirculatory parameters in the colic group. IMPACT Dark-field microscopy may not be a sensitive enough indicator to detect differences in microcirculation between colic and elective groups. The lack of difference in microcirculation may be due to sample size, probe location, or variation in disease severity.
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Affiliation(s)
- Patrick W Foth
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Alison Gardner
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Carolina Ricco Pereira
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Edward Cooper
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Eric Schroeder
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Margaret C Mudge
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
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Lavillegrand JR, Blum L, Morin A, Urbina T, Gabarre P, Bonny V, Baudel JL, Guidet B, Maury E, Ait-Oufella H. Permissive Hypotension Has No Deleterious Impact on Fluid Balance or Kidney Function. Crit Care Explor 2023; 5:e0991. [PMID: 37868030 PMCID: PMC10586843 DOI: 10.1097/cce.0000000000000991] [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] [Indexed: 10/24/2023] Open
Abstract
OBJECTIVES Mean arterial hypotension between 55 and 65 mm Hg could be tolerated safely in the absence of tissue hypoperfusion, but the consequences on fluid balance and kidney function remain unknown. DESIGN During a 1-year period, we retrospectively collected data of consecutive septic patients admitted for sepsis with a mean arterial pressure (MAP) less than 65 mm Hg despite fluid resuscitation. SETTING Medical 18-bed ICU in a tertiary teaching hospital. PATIENTS Septic patients with a MAP less than 65 mm Hg despite initial resuscitation. INTERVENTIONS In our ICU, MAP between 55 and 65 mm Hg was tolerated in the absence of peripheral hypoperfusion (permissive hypotension) or corrected using norepinephrine (septic shock group) when peripheral tissue hypoperfusion was present. MEASUREMENTS AND MAIN RESULTS Ninety-four consecutive septic patients were included, 15 in the permissive hypotension group and 79 in the septic shock group. Median age was 66 years (57-77 yr) and 42% were women. The main sources of infection were respiratory (45%) and abdominal (18%). Severity was more important in septic shock group with higher Sequential Organ Failure Assessment score (7 [5-10] vs. 4 [1-6]; p < 0.0001), more frequent organ support therapy and ultimately higher mortality (38 vs. 0%; p < 0.01). The total volume of crystalloids infused before ICU admission was not different between groups (1930 ± 250 vs. 1850 ± 150 mL; p = 0.40). Within the 6 first hours of ICU stay, patients in the permissive hypotension group received less fluids (530 ± 170 vs. 1100 ± 110 mL; p = 0.03) and had higher urinary output (1.4 mL [0.88-2.34 mL] vs. 0.47 mL/kg/hr [0.08-1.25 mL/kg/hr]; p < 0.001). In addition, kidney injury evaluated using KDIGO score was lower in the permissive hypotension group at 48 hours (0 hr [0-1 hr] vs. 1 hr [0-2 hr]; p < 0.05). CONCLUSIONS In septic patients without clinical peripheral hypoperfusion, mean arterial hypotension between 55 and 65 mm Hg could be tolerated safely without vasopressor infusion and was not associated with excessive fluid administration or kidney damage.
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Affiliation(s)
- Jean-Rémi Lavillegrand
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Sorbonne Université, Paris, France
| | - Laurene Blum
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Alexandra Morin
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Tomas Urbina
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Paul Gabarre
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Sorbonne Université, Paris, France
| | - Vincent Bonny
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jean-Luc Baudel
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Bertrand Guidet
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Sorbonne Université, Paris, France
| | - Eric Maury
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Sorbonne Université, Paris, France
- Inserm UMR 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
| | - Hafid Ait-Oufella
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Sorbonne Université, Paris, France
- Inserm UMR 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
- Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France
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Barka ND, Smith JW, Shoyama FM, Howard BT. Intracardiac Induced Ventricular Fibrillation for the Euthanasia of Sheep. JOURNAL OF THE AMERICAN ASSOCIATION FOR LABORATORY ANIMAL SCIENCE : JAALAS 2023; 62:464-469. [PMID: 37673664 PMCID: PMC10597332 DOI: 10.30802/aalas-jaalas-23-000062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 09/08/2023]
Abstract
Euthanasia is the humane termination of an animal's life and an important consideration for scientists, veterinarians, regulators, and others contemplating investigations involving animals. Techniques for euthanasia must induce the most rapid, painless, and distress-free death possible. This study investigated the effectiveness of direct current induction of ventricular fibrillation for the euthanasia of sheep after a primary study in which artifacts or chemical contamination from injectable euthanasia agents were undesirable. Female crossbred adult sheep (Ovis aries; n = 12) under deep isoflurane general anesthesia were instrumented with electrophysiology catheters to induce ventricular fibrillation for euthanasia. Data regarding invasive arterial blood pressure, expired airway gases, limb lead electrocardiograms, and pulse oximetry were collected and assessed just prior to, immediately after, and at 5, 10, 15, and 20min after energy delivery. In all animals, a single 10-s application of 9V of direct current to the right ventricular endocardium via the electrophysiology catheter induced persistent ventricular fibrillation. Arterial blood pressure (mean ± 1 SD) immediately after fibrillation induction was 22.9±4.5mmHg, with negligible difference between systolic and diastolic pressures. The lack of differential pressure continued through the end of the monitoring period. Arterial blood pressure reached an initial nadir at 1??0.5min after fibrillation induction, peaked (40.8±11.1mmHg) due to a vasoconstrictive reflex at 3min after induction, and returned to a static uniform pressure (20.4±17.8mmHg) with mildly increased variability due to reflexive diaphragmatic contractions at 10min after induction. The use of 9V direct current for the induction of ventricular fibrillation via an electrophysiology catheter is a reliable method of euthanasia in sheep.
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Putowski Z, Gołdyn M, Pluta MP, Krzych ŁJ, Hernández G, Kattan E. Correlation Between Mean Arterial Pressure and Capillary Refill Time in Patients with Septic Shock: A Systematic Review and Meta-analysis. J Intensive Care Med 2023; 38:838-846. [PMID: 37042043 DOI: 10.1177/08850666231168038] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Background: The initial hemodynamic goal during septic shock resuscitation is to achieve a mean arterial pressure (MAP) above 65 mm Hg, although this does not assure a normal tissue perfusion. Capillary refill time (CRT), a marker of skin blood flow, has been validated as a marker of the reperfusion process. The aim of the study was to explore the relationship between MAP and CRT in patients in septic shock. Methods: We systematically reviewed studies which reported CRT and MAP in septic shock patients. Authors of eligible studies were asked to provide necessary data for performing a meta-correlation of Spearman's rank correlation coefficients. Subgroup analyses were performed, including studies of good quality and studies with higher/lower norepinephrine doses. Results: We identified 10 studies, comprising 917 patients. There were 5 studies considered to be of good quality. A meta-correlation showed a statistically significant but poor negative correlation between MAP and CRT (R = -0.158, range -0.221 to -0.093, P < .001, I2 = 0.0%). Subgroup analysis of best-quality studies gave similar results (R = -0.201, range -0.282 to -0.116, P < .001, I2 = 0.0%). In subanalysis concerning norepinephrine doses, no significant correlations were found. Conclusions: In patients with septic shock, there is poor inverse correlation between MAP and CRT. MAP > 65 mm Hg does not guarantee normalization of CRT.Registration code: PROSPERO: CRD42022355996. Registered on 5 September 2022.
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Affiliation(s)
- Zbigniew Putowski
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz Gołdyn
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Michał P Pluta
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Łukasz J Krzych
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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9
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Zhou Y, He H, Cui N, Wang X, Long Y, Liu D. Elevation of the head of bed reduces splanchnic blood flow in patients with intra-abdominal hypertension. BMC Anesthesiol 2023; 23:133. [PMID: 37087427 PMCID: PMC10122394 DOI: 10.1186/s12871-023-02046-8] [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: 07/03/2022] [Accepted: 03/14/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Elevation of the head of bed (HOB) increases intra-abdominal pressure (IAP), but the effect of body position on abdominal splanchnic perfusion is not clear. The current study aimed to evaluate the effect of body position on the superior mesenteric artery (SMA) and the celiac artery (CA) blood flow by Doppler ultrasound in mechanically ventilated patients with intra-abdominal hypertension (IAH). METHODS This prospective cohort study included 53 mechanically ventilated patients with IAH. IAP, hemodynamic variables, and Doppler parameters of the SMA and CA were measured in the supine position. The measurements were repeated after the HOB angle was raised to 15° for 5 min and similarly at HOB angles of 30° and 45°. Finally, the patient was returned to the supine and these variables were re-measured. RESULTS The median (interquartile range, IQR) superior mesenteric artery blood flow (SMABF) decreased from 269 (244-322) to 204 (183-234) mL/min and the median (IQR) celiac artery blood flow (CABF) from 424 (368-483) to 376 (332-472) mL/min (both p<0.0001) while median (IQR) IAP increased from 14(13-16) to 16(14-18) mmHg (p<0.0001) when the HOB angle was changed from 0° to 15°. However, SMABF and CABF were maintained at similar levels from 15° to 30°, despite median (IQR) IAP increased to 17(15-18) mmHg (p = 0.0002). Elevation from 30° to 45° further reduced median (IQR) SMABF from 200(169-244) to 164(139-212) mL/min and CABF from 389(310-438) to 291(241-383) mL/min (both p<0.0001), Meanwhile, median (IQR) IAP increased to 19(18-21) mmHg (p<0.0001). CONCLUSIONS In mechanically ventilated patients with IAH, progressive elevation of the HOB from a supine to semi-recumbent position was associated with a gradual reduction in splanchnic blood flow. However, the results indicate that splanchnic blood flow is not further reduced when the HOB is elevated from 15° to 30°.This study confirms the influence of head-up angle on blood flow of the splanchnic organs and may contribute to the selection of the optimal position in patients with abdominal hypertension.
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Affiliation(s)
- Yuankai Zhou
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Na Cui
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Dawei Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
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10
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de Miranda AC, Stefani FDCD, Vesco BCD, Carraro Júnior H, Assreuy J, Morello LG, de Menezes IAC. Relationship between peripheral ischemic microvascular reserve, persistent hyperlactatemia, and its temporal dynamics in sepsis: a post hoc study. CRITICAL CARE SCIENCE 2023; 35:177-186. [PMID: 37712807 PMCID: PMC10406409 DOI: 10.5935/2965-2774.20230348-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/25/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE To measure the prognostic value of peripheral ischemic microvascular reserve in the context of persistent sepsis-induced hyperlactatemia and measure its influence on the temporal dynamics of lactate and the strength of association between these variables. METHODS This post hoc analysis of the peripheral perfusion index/postocclusive reactive hyperemia trial, an observational cohort study that enrolled patients with sepsis who persisted with lactate levels ≥ 2mmol/L after fluid resuscitation (with or without shock). Peripheral ischemic microvascular reserve was evaluated using the association of the peripheral perfusion index and postocclusive reactive hyperemia techniques. The cutoff point of ∆ peripheral perfusion index peak values (%) defined the groups with low (≤ 62%) and high peripheral ischemic microvascular reserve (> 62%). RESULTS A total of 108 consecutive patients with persistent sepsis-induced hyperlactatemia were studied. The high peripheral ischemic microvascular reserve group showed higher 28-day mortality than the low peripheral ischemic microvascular reserve group (p < 0.01). The temporal dynamics of lactate within the first 48 hours showed a rapid decrease in lactate levels in the low peripheral ischemic microvascular reserve group (p < 0.01). However, this result was not reproduced in the linear mixed effects model. A weak correlation between peripheral ischemic microvascular reserve (%) and lactate level (mmol/L) was observed within the first 24 hours (r = 0.23; p < 0.05). CONCLUSION The prognostic value of high peripheral ischemic microvascular reserve was confirmed in the context of persistent sepsis-induced hyperlactatemia. Although there was a weak positive correlation between peripheral ischemic microvascular reserve value and lactate level within the first 24 hours of sepsis diagnosis, the low peripheral ischemic microvascular reserve group appeared to have a faster decrease in lactate over the 48 hours of follow-up.
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Affiliation(s)
- Ana Carolina de Miranda
- Department of Internal Medicine, Hospital de Clínicas,
Universidade Federal do Paraná - Curitiba (PR), Brazil
| | | | - Bruna Cassia Dal Vesco
- Intensive Care Unit, Hospital de Clínicas, Universidade
Federal do Paraná - Curitiba (PR), Brazil
| | - Hipólito Carraro Júnior
- Intensive Care Unit, Hospital de Clínicas, Universidade
Federal do Paraná - Curitiba (PR), Brazil
| | - Jamil Assreuy
- Department of Pharmacology, Universidade Federal de Santa Catarina
- Florianópolis (SC), Brazil
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11
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Does the age of packed red blood cells, donor sex or sex mismatch affect the sublingual microcirculation in critically ill intensive care unit patients? A secondary interpretation of a retrospective analysis. J Clin Monit Comput 2023; 37:179-188. [PMID: 35665876 PMCID: PMC9852146 DOI: 10.1007/s10877-022-00877-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 05/05/2022] [Indexed: 01/24/2023]
Abstract
In vitro studies have thoroughly documented age-dependent impact of storage lesions in packed red blood cells (pRBC) on erythrocyte oxygen carrying capacity. While studies have examined the effect of pRBC age on patient outcome only few data exist on the microcirculation as their primary site of action. In this secondary analysis we examined the relationship between age of pRBC and changes of microcirculatory flow (MCF) in 54 patients based on data from the Basel Bedside assessment Microcirculation Transfusion Limit study (Ba2MiTraL) on effects of pRBC on sublingual MCF. Mean change from pre- to post-transfusion proportion of perfused vessels (∆PPV) was + 8.8% (IQR - 0.5 to 22.5), 5.5% (IQR 0.1 to 10.1), and + 4.7% (IQR - 2.1 to 6.5) after transfusion of fresh (≤ 14 days old), medium (15 to 34 days old), and old (≥ 35 days old) pRBC, respectively. Values for the microcirculatory flow index (MFI) were + 0.22 (IQR - 0.1 to 0.6), + 0.22 (IQR 0.0 to 0.3), and + 0.06 (IQR - 0.1 to 0.3) for the fresh, medium, and old pRBC age groups, respectively. Lower ∆PPV and transfusion of older blood correlated with a higher Sequential Organ Failure Assessment (SOFA) score of patients upon admission to the intensive care unit (ICU) (p = 0.01). However, regression models showed no overall significant correlation between pRBC age and ∆PPV (p = 0.2). Donor or recipient sex had no influence. We detected no significant effect of pRBC on microcirculation. Patients with a higher SOFA score upon ICU admission might experience a negative effect on the ∆PPV after transfusion of older blood.
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12
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Gatica S, Aravena D, Echeverría C, Santibanez JF, Riedel CA, Simon F. Effects of Adrenergic Receptor Stimulation on Human Hemostasis: A Systematic Review. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1408:49-63. [PMID: 37093421 DOI: 10.1007/978-3-031-26163-3_3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Catecholamine stimulation over adrenergic receptors results in a state of hypercoagulability. Chronic stress involves the release and increase in circulation of catecholamines and other stress related hormones. Numerous observational studies in human have related stressful scenarios to several coagulation variables, but controlled stimulation with agonists or antagonists to adrenergic receptors are scarce. This systematic review is aimed at presenting an updated appraisal of the effect of adrenergic receptor modulation on variables related to human hemostasis by systematically reviewing the effect of adrenergic receptor-targeting drugs on scale variables related to hemostasis. By searching 3 databases for articles published between January 1st 2011 and February 16th, 2022 reporting effects on coagulation parameters from stimulation with α- or β-adrenergic receptor targeting drugs in humans regardless of baseline condition, excluding records different from original research and those not addressing the main aim of this systematic review. Risk of bias assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB 2). Tables describing a pro-thrombotic anti-fibrinolytic state induced after β-adrenergic receptor agonist stimulation and the opposite after α1-, β-adrenergic receptor antagonist stimulation were synthesized from 4 eligible records by comparing hemostasis-related variables to their baseline. Notwithstanding this low number of records, experimental interventions included were sound and mostly unbiased, results were coherent, and outcomes were biologically plausible. In summary, this systematic review provides a critical systematic assessment and an updated elaboration, and its shortcomings highlight the need for further investigation in the field of hematology.
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Affiliation(s)
- Sebastian Gatica
- Laboratory of Integrative Physiopathology, Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile.
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile.
| | - Diego Aravena
- Laboratory of Integrative Physiopathology, Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Cesar Echeverría
- Laboratory of Molecular Biology, Nanomedicine and Genomics, Faculty of Medicine, University of Atacama, Copiapo, Chile
| | - Juan F Santibanez
- Institute for Medical Research, National Institute of the Republic of Serbia, University of Belgrade, Belgrade, Serbia
- Integrative Center for Biology and Applied Chemistry (CIBQA), Bernardo O'Higgins University, Santiago, Chile
| | - Claudia A Riedel
- Laboratory of Integrative Physiopathology, Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Felipe Simon
- Laboratory of Integrative Physiopathology, Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile.
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile.
- Millennium Nucleus of Ion Channel-Associated Diseases, Universidad de Chile, Santiago, Chile.
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13
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Kallab R, Sudy R, Dos Santos Rocha A, Diaper J, Petak F, Keli Barcelos G, Habre W. Invasive and non-invasive assessment of macro- and micro-circulatory effects of vasopressors during sevoflurane anesthesia in a pediatric experimental model: A randomized trial. Paediatr Anaesth 2022; 32:1129-1137. [PMID: 35662322 DOI: 10.1111/pan.14506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND While non-invasive assessment of macro- and micro-circulation has the promise to optimize anesthesia management, evidence is lacking for the relationship between invasive and non-invasive measurements of cardiac output and microcirculatory indices. AIMS We aimed to compare the abilities of non-invasive techniques to detect changes in macro- and micro-circulation following deep anesthesia and subsequent restoration of the compromised hemodynamic by routinely used vasopressors in a randomized experimental study. METHODS A 20%-25% drop in mean arterial pressure was induced by sevoflurane in anesthetized mechanically ventilated just-weaned piglets (n = 12) prior to the administration of vasopressors in random order (dopamine, ephedrine, noradrenaline, and phenylephrine). Simultaneous transpulmonary thermodilution cardiac output assessment with the invasive pulse index continuous contour (PiCCO) method was compared with non-invasive estimates obtained with electrical conductivity (ICON) and echo Doppler (Cardio Q). Changes in microcirculation were characterized by sublingual red blood cell velocity, jugular cerebral venous oxygen saturation, and arterial lactate. MAIN OUTCOME MEASURES Cardiac output indices obtained by invasive and non-invasive methods. RESULTS Changes in cardiac output measured invasively and non-invasively correlated significantly after sevoflurane (r = .78, p = .003 and r = .76, p = .006 between PiCCO and ICON or Cardio Q, respectively). Following the administration of vasopressors, invasive and non-invasive cardiac output assessments were unrelated with significant correlations observed only between PiCCO and ICON after dopamine and ephedrine. Sevoflurane-induced hypotension decreased jugular cerebral venous oxygen saturation significantly and was recovered by all vasopressors. Sevoflurane and vasopressors had no effect on red blood cell velocity, which increased only after dopamine. No consistent changes in lactate were observed during the study period. CONCLUSIONS The results of this study suggest that non-invasive cardiac output measurements may not accurately reflect changes in macrocirculation after hemodynamic optimization by vasopressors. Due to the incoherence between macro- and micro-circulation, monitoring microcirculation is essential to guide patient management.
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Affiliation(s)
- Rita Kallab
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.,Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Roberta Sudy
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Andre Dos Santos Rocha
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.,Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - John Diaper
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Ferenc Petak
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Gleicy Keli Barcelos
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Walid Habre
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.,Paediatric Anesthesia Unit, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
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14
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Chiscano-Camón L, Plata-Menchaca E, Ruiz-Rodríguez JC, Ferrer R. Fisiopatología del shock séptico. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.03.017] [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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15
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Caballer A, Nogales S, Gruartmoner G, Mesquida J. Monitorización hemodinámica en la sepsis y el shock séptico. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.02.010] [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]
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16
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Agerskov M, Sørensen H, Højlund J, Secher NH, Foss NB. Fluid-responsiveness, blood volume and perfusion in preoperative haemodynamic optimisation of hip fracture patients; a prospective observational study. Acta Anaesthesiol Scand 2022; 66:660-673. [PMID: 35396854 DOI: 10.1111/aas.14070] [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: 11/25/2021] [Revised: 03/27/2022] [Accepted: 04/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preoperative resuscitation strategies in patients with hip fracture (HF) are lacking. We aimed to investigate fluid-responsiveness, peripheral perfusion index (PPI) and blood volume (BV)-status in patients with HF undergoing resuscitation in the preoperative phase. METHODS In a prospective observational study, we evaluated preoperative fluid-responsiveness, indices of perfusion and BV before and after lumbar epidural analgesia in 50 patients with HF shortly after admittance. RESULTS Initially, 18 (36%) patients were fluid-responsive (≥10% increased SV in response to 250 ml fluid bolus) and 13 (26%) presented hypovolaemia (deviation of measured BV from estimated BV ≤ 0.9). According to fluid-responsiveness, no difference in absolute values of cardiac index (CI) (2.7 L [2.1-3.3] vs. 2.8 L [2.3-3.4], p = .5) was seen, but cardiac output (CO) rose significantly in the hypovolaemic patients: 9% [5-18] vs. 1% [-3-7], p = .004. After epidural analgesia, 26 (52%) patients were again fluid-responsive and 15 (30%) were hypovolaemic. CI was now significantly lower in fluid-responsive patients (2.2 L [1.7-2.7] vs. 2.9 L [2.3-3.5], p = .001). Prior to epidural analgesia, no significant trend towards hypovolaemic patients having lower indices of perfusion was seen. After epidural analgesia, more patients with hypovolaemia presented with PPI≤1.5 (8 (53%) vs. 3 (9%), p = .001) and absolute values of PPI were also significantly lower if IBV was low (1.4 [0.9-3.2] vs. 3.2 [2.4-4.8], p = .01). PPI correlated with hypovolaemia after epidural analgesia (rho 0.4 [0.1-0.7], p = .007). CONCLUSIONS Preoperative fluid-responsivity in HF patients might be attributable to elements of hypovolaemia and sympathetic compensatory ability conjointly, confounding the use of SV-guided resuscitation. PPI could be associated with BV, which may support clinicians during perioperative haemodynamic optimisation.
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Affiliation(s)
- Marianne Agerskov
- Department of Anesthesiology and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
| | - Henrik Sørensen
- Department of Anaesthesiology Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
| | - Niels H. Secher
- Department of Anaesthesiology Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Nicolai Bang Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
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17
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Caballer A, Nogales S, Gruartmoner G, Mesquida J. [Haemodynamic monitoring in sepsis and septic shock]. Med Intensiva 2022; 46 Suppl 1:38-48. [PMID: 38341259 DOI: 10.1016/j.medine.2022.02.026] [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: 12/29/2021] [Revised: 02/23/2022] [Accepted: 02/26/2022] [Indexed: 02/12/2024]
Abstract
Cardiovascular disturbances associated with sepsis cause hypoperfusion situations, which will negatively impact these patients' prognosis. The aim of haemodynamic monitoring is to guide the detection and correction of this hypoperfusion, and assist in decision making in optimising oxygen transport to tissues, primarily by manipulating cardiac output. This review seeks to summarise the different parameters of haemodynamic monitoring, the objectives of resuscitation, the physiological parameters, and the tools available to us for appropriate cardiac output manipulation.
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Affiliation(s)
- Alba Caballer
- Àrea de Crítics, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España.
| | - Sara Nogales
- Àrea de Crítics, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - Guillem Gruartmoner
- Àrea de Crítics, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - Jaume Mesquida
- Àrea de Crítics, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
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18
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Chiscano-Camón L, Plata-Menchaca E, Ruiz-Rodríguez JC, Ferrer R. [Pathophysiology of septic shock]. Med Intensiva 2022; 46 Suppl 1:1-13. [PMID: 38341256 DOI: 10.1016/j.medine.2022.03.010] [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: 02/01/2022] [Accepted: 03/20/2022] [Indexed: 02/12/2024]
Abstract
Sepsis and septic shock result from an inadequate host response to an infection, which causes organ dysfunction. The progression of this condition is manifested by the occurrence of successive clinical stages, resulting from the systemic inflammatory response secondary to the activation of different inflammatory mediators, leading to organ dysfunction. There is a high burden of evidence on the role of endotoxin in the pathogenesis of sepsis and its crucial role in triggering the inflammatory response in sepsis caused by gram-negative bacteria. The coagulation cascade activation in sepsis patients is part of the host's adaptive immune response to infection. The endothelium is the main target in sepsis, which is metabolically active and can.
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Affiliation(s)
- Luis Chiscano-Camón
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, España; Grupo de Investigación Sepsis Organ Dysfunction and Resuscitation (SODIR), Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, España; Departament de Medicina. Universitat Autònoma de Barcelona. Barcelona. España
| | - Erika Plata-Menchaca
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, España; Grupo de Investigación Sepsis Organ Dysfunction and Resuscitation (SODIR), Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Juan Carlos Ruiz-Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, España; Grupo de Investigación Sepsis Organ Dysfunction and Resuscitation (SODIR), Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, España; Departament de Medicina. Universitat Autònoma de Barcelona. Barcelona. España
| | - Ricard Ferrer
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, España; Grupo de Investigación Sepsis Organ Dysfunction and Resuscitation (SODIR), Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, España; Departament de Medicina. Universitat Autònoma de Barcelona. Barcelona. España.
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19
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA. .,Outcomes Research Consortium, Cleveland, OH, USA.
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20
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Mandigers L, Pooth JS, Wefers Bettink MA, den Uil CA, Damjanovic D, Mik EG, Brixius S, Gommers D, Trummer G, Dos Reis Miranda D. Monitoring Mitochondrial Partial Oxygen Pressure During Cardiac Arrest and Extracorporeal Cardiopulmonary Resuscitation. An Experimental Pilot Study in a Pig Model. Front Cardiovasc Med 2021; 8:754852. [PMID: 34760949 PMCID: PMC8572977 DOI: 10.3389/fcvm.2021.754852] [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: 08/07/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Ischemia and reperfusion are crucial in determining the outcome after cardiac arrest and can be influenced by extracorporeal cardiopulmonary resuscitation (ECPR). The effect of ECPR on the availability and level of oxygen in mitochondria remains unknown. The aim of this study was to find out if skin mitochondrial partial oxygen pressure (mitoPO2) measurements in cardiac arrest and ECPR are feasible and to investigate its course. Materials and Methods: We performed a feasibility test to determine if skin mitoPO2 measurements in a pig are possible. Next, we aimed to measure skin mitoPO2 in 10 experimental pigs. Measurements were performed using a cellular oxygen metabolism measurement monitor (COMET), at baseline, during cardiac arrest, and during ECPR using the controlled integrated resuscitation device (CIRD). Results: The feasibility test showed continuous mitoPO2 values. Nine experimental pigs could be measured. Measurements in six experimental pigs succeeded. Our results showed a delay until the initial spike of mitoPO2 after ECPR initiation in all six experimental tests. In two experiments (33%) mitoPO2 remained present after the initial spike. A correlation of mitoPO2 with mean arterial pressure (MAP) and arterial partial oxygen pressure measured by CIRD (CIRD-PaO2) seemed not present. One of the experimental pigs survived. Conclusions: This experimental pilot study shows that continuous measurements of skin mitoPO2 in pigs treated with ECPR are feasible. The delay in initial mitoPO2 and discrepancy of mitoPO2 and MAP in our small sample study could point to the possible value of additional measurements besides MAP to monitor the quality of tissue perfusion during cardiac arrest and ECPR.
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Affiliation(s)
- Loes Mandigers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jan-Steffen Pooth
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mark A Wefers Bettink
- Department of Anaesthesiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Corstiaan A den Uil
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Intensive Care, Maasstad Hospital, Rotterdam, Netherlands
| | - Domagoj Damjanovic
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Egbert G Mik
- Department of Anaesthesiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Sam Brixius
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Georg Trummer
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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21
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Petitjeans F, Geloen A, Pichot C, Leroy S, Ghignone M, Quintin L. Is the Sympathetic System Detrimental in the Setting of Septic Shock, with Antihypertensive Agents as a Counterintuitive Approach? A Clinical Proposition. J Clin Med 2021; 10:4569. [PMID: 34640590 PMCID: PMC8509206 DOI: 10.3390/jcm10194569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022] Open
Abstract
Mortality in the setting of septic shock varies between 20% and 100%. Refractory septic shock leads to early circulatory failure and carries the worst prognosis. The pathophysiology is poorly understood despite studies of the microcirculatory defects and the immuno-paralysis. The acute circulatory distress is treated with volume expansion, administration of vasopressors (usually noradrenaline: NA), and inotropes. Ventilation and anti-infectious strategy shall not be discussed here. When circulation is considered, the literature is segregated between interventions directed to the systemic circulation vs. interventions directed to the micro-circulation. Our thesis is that, after stabilization of the acute cardioventilatory distress, the prolonged sympathetic hyperactivity is detrimental in the setting of septic shock. Our hypothesis is that the sympathetic hyperactivity observed in septic shock being normalized towards baseline activity will improve the microcirculation by recoupling the capillaries and the systemic circulation. Therefore, counterintuitively, antihypertensive agents such as beta-blockers or alpha-2 adrenergic agonists (clonidine, dexmedetomidine) are useful. They would reduce the noradrenaline requirements. Adjuncts (vitamins, steroids, NO donors/inhibitors, etc.) proposed to normalize the sepsis-evoked vasodilation are not reviewed. This itemized approach (systemic vs. microcirculation) requires physiological and epidemiological studies to look for reduced mortality.
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Affiliation(s)
- Fabrice Petitjeans
- Critical Care, Hôpital d’Instruction des Armées Desgenettes, 69003 Lyon, France;
| | - Alain Geloen
- UMR Ecologie Microbienne Lyon (LEM), University of Lyon, 69100 Villeurbanne, France;
| | - Cyrille Pichot
- Critical Care, Hôpital Louis Pasteur, 39108 Dole, France;
| | | | - Marco Ghignone
- Critical Care, JF Kennedy Hospital North Campus, West Palm Beach, FL 33407, USA;
| | - Luc Quintin
- Critical Care, Hôpital d’Instruction des Armées Desgenettes, 69003 Lyon, France;
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22
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Valeanu L, Bubenek-Turconi SI, Ginghina C, Balan C. Hemodynamic Monitoring in Sepsis-A Conceptual Framework of Macro- and Microcirculatory Alterations. Diagnostics (Basel) 2021; 11:1559. [PMID: 34573901 PMCID: PMC8469937 DOI: 10.3390/diagnostics11091559] [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: 07/21/2021] [Revised: 08/22/2021] [Accepted: 08/26/2021] [Indexed: 12/29/2022] Open
Abstract
Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.
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Affiliation(s)
- Liana Valeanu
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Serban-Ion Bubenek-Turconi
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Carmen Ginghina
- 3rd Department of Cardiology, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania;
- Department of Cardiology, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Cosmin Balan
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
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Riessen R, Hellwege RS. [Pharmacological therapy of circulatory shock]. Med Klin Intensivmed Notfmed 2021; 116:541-553. [PMID: 34338810 DOI: 10.1007/s00063-021-00838-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 12/18/2022]
Abstract
Circulatory shock requires treatment of the underlying pathology in addition to supportive pharmacological therapy that is guided by hemodynamic monitoring. Based on the evaluation of the patient's volume, perfusion and cardiac status, the following therapeutic goals should be achieved: (1) Normalization of the intra- and extravascular fluid volume. (2) Provision of sufficient perfusion pressure and organ perfusion. (3) Optimization of cardiac function including protecting an ischemic and exhausted myocardium from overload. The most important therapeutic substances are balanced electrolyte solutions and the vasopressor noradrenaline. Because there is little scientific evidence for the use of alternative drugs, these should only be given if there is a good pathophysiologic rationale and if their effect is continuously monitored and re-evaluated.
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Affiliation(s)
- Reimer Riessen
- Internistische Intensivstation, Department für Innere Medizin, Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland.
| | - Rubi Stephani Hellwege
- Internistische Intensivstation, Department für Innere Medizin, Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland
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Abstract
BACKGROUND Circulatory shock is a life-threatening disorder that is associated with high mortality, with a state of systemic and tissue hypoperfusion that can lead to organ failure, including the brain, where altered mental state is often observed. We hypothesized that cerebral autoregulation (CA) is impaired in patients with circulatory shock. METHODS Adult patients with circulatory shock and healthy controls were included. Cerebral blood flow velocity (CBFV, transcranial Doppler ultrasound) and arterial blood pressure (BP, Finometer or intra-arterial line) were continuously recorded during 5 min in both groups. Autoregulation Index (ARI) was estimated from the CBFV response to a step change in BP, derived by transfer function analysis; ARI ≤ 4 was considered impaired CA. The relationship between organ dysfunction, assessed with the Sequential Organ Failure Assessment (SOFA) score and the ARI, was assessed with linear regression. RESULTS Twenty-five shock patients and 28 age-matched healthy volunteers were studied. The mean ± SD SOFA score was 10.8 ± 4.3. Shock patients compared with control subjects had lower ARI values (4.0 ± 2.1 vs. 5.9 ± 1.5, P = 0.001). Impaired CA was more common in shock patients (44.4% vs. 7.1%, P = 0.003). There was a significant inverse relationship between the ARI and the SOFA score (R = -0.63, P = 0.0008). CONCLUSIONS These results suggest that circulatory shock is often associated with impaired CA and that the severity of CA alterations is correlated with the degree of multiple organ failure, reinforcing the need to monitor cerebral hemodynamics in patients with circulatory shock.
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Pielmus AG, Mühlstef J, Bresch E, Glos M, Jungen C, Mieke S, Orglmeister R, Schulze A, Stender B, Voigt V, Zaunseder S. Surrogate based continuous noninvasive blood pressure measurement. ACTA ACUST UNITED AC 2021; 66:231-245. [PMID: 33565285 DOI: 10.1515/bmt-2020-0209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/28/2020] [Indexed: 11/15/2022]
Abstract
Arterial blood pressure is one of the most often measured vital parameters in clinical practice. State-of-the-art noninvasive ABP measurement technologies have noticeable limitations and are mainly based on uncomfortable techniques of complete or partial arterial occlusion by cuffs. Most commonplace devices provide only intermittent measurements, and continuous systems are bulky and difficult to apply correctly for nonprofessionals. Continuous cuffless ABP measurements are still an unmet clinical need and a topic of ongoing research, with only few commercially available devices. This paper discusses surrogate-based noninvasive blood pressure measurement techniques. It covers measurement methods of continuously and noninvasively inferring BP from surrogate signals without applying external pressures, except for reference or initialization purposes. The BP is estimated by processing signal features, so called surrogates, which are modulated by variations of BP. Discussed techniques include well-known approaches such as pulse transit time and pulse arrival time techniques, pulse wave analysis or combinations thereof. Despite a long research history, these methods have not found widespread use in clinical and ambulatory practice, in part due to technical limitations and the lack of a standardized regulatory framework. This work summarizes findings from an invited workshop of experts in the fields covering clinical expertise, engineering aspects, commercialization and standardization issues. The goal is to provide an application driven outlook, starting with clinical needs, and extending to technical actuality. It provides an outline of recommended research directions and includes a detailed overview of clinical use case scenarios for these technologies, opportunities, and limitations.
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Affiliation(s)
| | - Jens Mühlstef
- Research Group 'Patient Care Solutions', Philips Research Europe, Eindhoven, The Netherlands
| | - Erik Bresch
- Research Group 'Patient Care Solutions', Philips Research Europe, Eindhoven, The Netherlands
| | - Martin Glos
- Interdisciplinary Center of Sleep Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christiane Jungen
- Klinik und Poliklinik für Kardiologie, Universitäres Herz- und Gefäßzentrum UKE Hamburg, Hamburg, Germany
| | - Stefan Mieke
- Physikalisch-Technische Bundesanstalt, Berlin, Germany
| | - Reinhold Orglmeister
- Electronics and Medical Signal Processing, Technical University of Berlin, Berlin, Germany
| | - Andreas Schulze
- Research Group 'Patient Care Solutions', Philips Research Europe, Eindhoven, The Netherlands
| | | | - Verena Voigt
- Klinik für Anästhesiologie, Sektion Medizintechnik, Uniklinik RWTH Aachen, Aachen, Germany
| | - Sebastian Zaunseder
- Technical University of Dresden, Dresden, Germany.,Fachhochschule Dortmund, Dortmund, Germany
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Sarathy S, Nino MA, Ghanim AH, Rajagopal S, Mubeen S, Raghavan ML. Electrochemical Approach to Measure Physiological Fluid Flow Rates. Front Chem 2021; 9:680099. [PMID: 34235135 PMCID: PMC8256275 DOI: 10.3389/fchem.2021.680099] [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: 03/13/2021] [Accepted: 05/26/2021] [Indexed: 11/13/2022] Open
Abstract
In vivo measurement of the flow rate of physiological fluids such as the blood flow rate in the heart is vital in critically ill patients and for those undergoing surgical procedures. The reliability of these measurements is therefore quite crucial. However, current methods in practice for measuring flow rates of physiological fluids suffer from poor repeatability and reliability. Here, we assessed the feasibility of a flow rate measurement method that leverages time transient electrochemical behavior of a tracer that is injected directly into a medium (the electrochemical signal caused due to the tracer injectate will be diluted by the continued flow of the medium and the time response of the current-the electrodilution curve-will depend on the flow rate of the medium). In an experimental flow loop apparatus equipped with an electrochemical cell, we used the AC voltammetry technique and tested the feasibility of electrodilution-based measurement of the flow rate using two mediums-pure water and anticoagulated blood-with 0.9 wt% saline as the injectate. The electrodilution curve was quantified using three metrics-change in current amplitude, total time, and change in the total charge for a range of AC voltammetry settings (peak voltages and frequencies). All three metrics showed an inverse relationship with the flow rate of water and blood, with the strongest negative correlation obtained for change in current amplitude. The findings are a proof of concept for the electrodilution method of the flow rate measurement and offer the potential for physiological fluid flow rate measurement in vivo.
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Affiliation(s)
- Srivats Sarathy
- Roy J Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA, United States
| | - Marco A Nino
- Roy J Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA, United States
| | - Abdulsattar H Ghanim
- Department of Chemical and Biochemical Engineering, University of Iowa, Iowa City, IA, United States
| | - Srinivasan Rajagopal
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Syed Mubeen
- Department of Chemical and Biochemical Engineering, University of Iowa, Iowa City, IA, United States
| | - M L Raghavan
- Roy J Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA, United States
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Abstract
PURPOSE OF REVIEW Current goals of resuscitation in septic shock are mainly a fixed volume of fluids and vasopressors to correct hypotension and improve tissue perfusion indicated by decreasing lactate levels. RECENT FINDINGS Abnormal peripheral perfusion by objective and subjective parameters are associated with increased mortality in various phases of the treatment of critically ill patients including patients with septic shock. Ongoing resuscitation in septic shock patients with normal peripheral perfusion is not associated with improved outcome, rather with increased mortality. Mitigation of fluid resuscitation by using parameters of peripheral perfusion in septic shock seems to be safe. SUMMARY Septic shock patients with normal peripheral perfusion represent a different clinical phenotype of patients that might benefit from limited resuscitation efforts. Parameters of peripheral perfusion could be used to guide the individualization of patients with septic shock.
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Effect of mean arterial pressure change by norepinephrine on peripheral perfusion index in septic shock patients after early resuscitation. Chin Med J (Engl) 2021; 133:2146-2152. [PMID: 32842018 PMCID: PMC7508439 DOI: 10.1097/cm9.0000000000001017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background The peripheral perfusion index (PI), as a real-time bedside indicator of peripheral tissue perfusion, may be useful for determining mean arterial pressure (MAP) after early resuscitation of septic shock patients. The aim of this study was to explore the response of PI to norepinephrine (NE)-induced changes in MAP. Methods Twenty septic shock patients with pulse-induced contour cardiac output catheter, who had usual MAP under NE infusion after early resuscitation, were enrolled in this prospective, open-label study. Three MAP levels (usual MAP −10 mmHg, usual MAP, and usual MAP +10 mmHg) were obtained by NE titration, and the corresponding global hemodynamic parameters and PI were recorded. The general linear model with repeated measures was used for analysis of variance of related parameters at three MAP levels. Results With increasing NE infusion, significant changes were found in MAP (F = 502.46, P < 0.001) and central venous pressure (F = 27.45, P < 0.001) during NE titration. However, there was not a significant and consistent change in continuous cardiac output (CO) (F = 0.41, P = 0.720) and PI (F = 0.73, P = 0.482) at different MAP levels. Of the 20 patients enrolled, seven reached the maximum PI value at usual MAP −10 mmHg, three reached the maximum PI value at usual MAP, and ten reached the maximum PI value at usual MAP +10 mmHg. The change in PI was not significantly correlated with the change in CO (r = 0.260, P = 0.269) from usual MAP −10 mmHg to usual MAP. There was also no significant correlation between the change in PI and change in CO (r = 0.084, P = 0.726) from usual MAP to usual MAP +10 mmHg. Conclusions Differing MAP levels by NE infusion induced diverse PI responses in septic shock patients, and these PI responses may be independent of the change in CO. PI may have potential applications for MAP optimization based on changes in peripheral tissue perfusion.
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Godoy DA, Badenes R, Murillo-Cabezas F. Ten physiological commandments for severe head injury. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:280-292. [PMID: 34140125 DOI: 10.1016/j.redare.2020.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 09/07/2020] [Indexed: 06/12/2023]
Abstract
Advances in multiparametric brain monitoring have allowed us to deepen our knowledge of the physiopathology of head injury and how it can be treated using the therapies available today. It is essential to understand and interpret a series of basic physiological and physiopathological principles that, on the one hand, provide an adequate metabolic environment to prevent worsening of the primary brain injury and favour its recovery, and on the other hand, allow therapeutic resources to be individually adapted to the specific needs of the patient. Based on these notions, this article presents a decalogue of the physiological objectives to be achieved in brain injury, together with a series of diagnostic and therapeutic recommendations for achieving these goals. We emphasise the importance of considering and analysing the physiological variables involved in the transport of oxygen to the brain, such as cardiac output and arterial oxygen content, together with their conditioning factors and possible alterations. Special attention is paid to the basic elements of physiological neuroprotection, and we describe the multiple causes of cerebral hypoxia, how to approach them, and how to correct them. We also examine the increase in intracranial pressure as a physiopathological element, focussing on the significance of thoracic and abdominal pressure in the interpretation of intracranial pressure. Treatment of intracranial pressure should be based on a step-wise model, the first stage of which should be based on a physiopathological reflection combined with information on the tomographic lesions rather than on rigid numerical values.
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Affiliation(s)
- D A Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, Catamarca, Argentina; Unidad de Terapia Intensiva, Hospital San Juan Bautista, Catamarca, Argentina.
| | - R Badenes
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, Spain; Departamento de Cirugía, Universitat de València, Valencia, Spain; Instituto de Investigación Sanitaria de Valencia (INCLIVA), Valencia, Spain
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Biventricular Unloading with Impella and Venoarterial Extracorporeal Membrane Oxygenation in Severe Refractory Cardiogenic Shock: Implications from the Combined Use of the Devices and Prognostic Risk Factors of Survival. J Clin Med 2021; 10:jcm10040747. [PMID: 33668590 PMCID: PMC7918629 DOI: 10.3390/jcm10040747] [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: 01/22/2021] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 12/01/2022] Open
Abstract
Since mechanical circulatory support (MCS) devices have become integral component in the therapy of refractory cardiogenic shock (RCS), we identified 67 patients in biventricular support with Impella and venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) for RCS between February 2013 and December 2019 and evaluated the risk factors of mortality in this setting. Mean age was 61.07 ± 10.7 and 54 (80.6%) patients were male. Main cause of RCS was acute myocardial infarction (AMI) (74.6%), while 44 (65.7%) were resuscitated prior to admission. The mean Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment Score (SOFA) score on admission was 73.54 ± 16.03 and 12.25 ± 2.71, respectively, corresponding to an expected mortality of higher than 80%. Vasopressor doses and lactate levels were significantly decreased within 72 h on biventricular support (p < 0.05 for both). Overall, 17 (25.4%) patients were discharged to cardiac rehabilitation and 5 patients (7.5%) were bridged successfully to ventricular assist device implantation, leading to a total of 32.8% survival on hospital discharge. The 6-month survival was 31.3%. Lactate > 6 mmol/L, vasoactive score > 100 and pH < 7.26 on initiation of biventricular support, as well as Charlson comorbity index > 3 and prior resuscitation were independent predictors of survival. In conclusion, biventricular support with Impella and VA-ECMO in patients with RCS is feasible and efficient leading to a better survival than predicted through traditional risk scores, mainly via significant hemodynamic improvement and reduction in lactate levels.
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Godoy DA, Badenes R, Murillo-Cabezas F. Ten physiological commandments for severe head injury. ACTA ACUST UNITED AC 2021; 68:280-292. [PMID: 33487456 DOI: 10.1016/j.redar.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 09/05/2020] [Accepted: 09/07/2020] [Indexed: 11/17/2022]
Abstract
Advances in multiparametric brain monitoring have allowed us to deepen our knowledge of the physiopathology of head injury and how it can be treated using the therapies available today. It is essential to understand and interpret a series of basic physiological and physiopathological principles that, on the one hand, provide an adequate metabolic environment to prevent worsening of the primary brain injury and favour its recovery, and on the other hand, allow therapeutic resources to be individually adapted to the specific needs of the patient. Based on these notions, this article presents a decalogue of the physiological objectives to be achieved in brain injury, together with a series of diagnostic and therapeutic recommendations for achieving these goals. We emphasise the importance of considering and analysing the physiological variables involved in the transport of oxygen to the brain, such as cardiac output and arterial oxygen content, together with their conditioning factors and possible alterations. Special attention is paid to the basic elements of physiological neuroprotection, and we describe the multiple causes of cerebral hypoxia, how to approach them, and how to correct them. We also examine the increase in intracranial pressure as a physiopathological element, focussing on the significance of thoracic and abdominal pressure in the interpretation of intracranial pressure. Treatment of intracranial pressure should be based on a step-wise model, the first stage of which should be based on a physiopathological reflection combined with information on the tomographic lesions rather than on rigid numerical values.
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Affiliation(s)
- D A Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, Catamarca, Argentina; Unidad de Terapia Intensiva, Hospital San Juan Bautista, Catamarca, Argentina.
| | - R Badenes
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, España; Departamento de Cirugía, Universitat de València, Valencia, España; Instituto de Investigación Sanitaria de Valencia (INCLIVA), Valencia, España
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Khanna AK, Karamchandani K. Macrocirculation and Microcirculation: The "Batman and Superman" Story of Critical Care Resuscitation. Anesth Analg 2021; 132:280-283. [PMID: 33177325 DOI: 10.1213/ane.0000000000005272] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Ashish K Khanna
- From the Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Health Network, Winston-Salem, North Carolina.,Outcomes Research Consortium, Cleveland, Ohio
| | - Kunal Karamchandani
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Lupu F, Kinasewitz G, Dormer K. The role of endothelial shear stress on haemodynamics, inflammation, coagulation and glycocalyx during sepsis. J Cell Mol Med 2020; 24:12258-12271. [PMID: 32951280 PMCID: PMC7687012 DOI: 10.1111/jcmm.15895] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/27/2020] [Accepted: 08/28/2020] [Indexed: 12/11/2022] Open
Abstract
Sepsis is a multifactorial syndrome primarily determined by the host response to an invading pathogen. It is common, with over 48 million cases worldwide in 2017, and often lethal. The sequence of events in sepsis begins with the damage of endothelium within the microvasculature, as a consequence of the inflammatory and coagulopathic responses to the pathogen that can progress to multiple organ failure and death. Most therapeutic interventions target the inflammation and coagulation pathways that act as an auto-amplified vicious cycle, which, if unchecked can be fatal. Normal blood flow and shear stress acting on a healthy endothelium and intact glycocalyx have anti-inflammatory, anticoagulant and self-repairing effects. During early stages of sepsis, the vascular endothelium and its glycocalyx become dysfunctional, yet they are essential components of resuscitation and recovery from sepsis. The effects of shear forces on sepsis-induced endothelial dysfunction, including inflammation, coagulation, complement activation and microcirculatory breakdown are reviewed. It is suggested that early therapeutic strategies should prioritize on the restoration of shear forces and endothelial function and on the preservation of the endothelial-glycocalyx barrier.
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Affiliation(s)
- Florea Lupu
- Cardiovascular Biology Research ProgramOklahoma Medical Research FoundationOklahoma CityOKUSA
| | - Gary Kinasewitz
- Cardiovascular Biology Research ProgramOklahoma Medical Research FoundationOklahoma CityOKUSA
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Bogatu LI, Turco S, Mischi M, Woerlee P, Bouwman A, Korsten EHHM, Muehlsteff J. A modelling framework for assessment of arterial compliance by fusion of oscillometry and pulse wave velocity information. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 196:105492. [PMID: 32603986 DOI: 10.1016/j.cmpb.2020.105492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND AND OBJECTIVES Measurement of arterial compliance is recognized as important for clinical use and for enabling better understanding of circulatory system regulation mechanisms. Estimation of arterial compliance involves either a direct measure of the ratio between arterial volume and pressure changes or an inference from the pulse wave velocity (PWV). In this study we demonstrate an approach to assess arterial compliance by fusion of these two information sources. The approach is based on combining oscillometry as used for blood pressure inference and PWV measurements based on ECG/PPG. Enabling reliable arterial compliance measurements will contribute to the understanding of regulation mechanisms of the arterial tree, possibly establishing arterial compliance as a key measure relevant in hemodynamic monitoring. METHODS A measurement strategy, a physiological model, and a framework based on Bayesian principles are developed for measuring changes in arterial compliance based on combining oscillometry and PWV data. A simulation framework is used to study and validate the algorithm and measurement principle in detail, motivated by previous experimental findings. RESULTS Simulations demonstrate the possibility of inferring arterial compliance via fusion of simultaneously acquired volume/pressure relationships and PWV data. In addition, the simulation framework demonstrates how Bayesian principles can be used to handle low signal - to - noise ratio and partial information loss. CONCLUSIONS The developed simulation framework shows the feasibility of the proposed approach for assessment of arterial compliance by combining multiple data sources. This represents a first step towards integration of arterial compliance measurements in hemodynamic monitoring using existing clinical technology. The Bayesian approach is of particular relevance for such patient monitoring settings, where measurements are repeated frequently, context is relevant, and data is affected by artefacts. In addition, the simulation framework is necessary for future clinical-study design, in order to determine device specifications and the extent to which noise affects the inference process.
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Affiliation(s)
- Laura I Bogatu
- Patient Care and Measurements, Philips Research, Eindhoven, 5656 AE, Netherlands; Biomedical Diagnostics, Eindhoven University of Technology, Eindhoven, 5612 AZ, Netherlands.
| | - Simona Turco
- Biomedical Diagnostics, Eindhoven University of Technology, Eindhoven, 5612 AZ, Netherlands.
| | - Massimo Mischi
- Biomedical Diagnostics, Eindhoven University of Technology, Eindhoven, 5612 AZ, Netherlands.
| | - Pierre Woerlee
- Biomedical Diagnostics, Eindhoven University of Technology, Eindhoven, 5612 AZ, Netherlands.
| | | | | | - Jens Muehlsteff
- Patient Care and Measurements, Philips Research, Eindhoven, 5656 AE, Netherlands.
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Schött U, Kander T. NOMI after cardiac arrest. Could refined diagnostics improve outcome? Resuscitation 2020; 157:266-268. [PMID: 33091535 DOI: 10.1016/j.resuscitation.2020.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/11/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Ulf Schött
- Department of Anesthesia and Intensive Care, Skåne University Hospital, Lund S-22185, Sweden; Department of Anesthesia and Intensive Care, Institution of Clinical Sciences, Medical Faculty, Lund University, Lund, Sweden.
| | - Thomas Kander
- Department of Anesthesia and Intensive Care, Skåne University Hospital, Lund S-22185, Sweden; Department of Anesthesia and Intensive Care, Institution of Clinical Sciences, Medical Faculty, Lund University, Lund, Sweden
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Endo Y, Miyasho T, Imahase H, Kawamura Y, Sakamoto Y, Yamashita K. Use of perfusion index to detect hemodynamic changes in endotoxemic pigs. J Vet Emerg Crit Care (San Antonio) 2020; 30:534-542. [PMID: 32652875 DOI: 10.1111/vec.12985] [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: 08/09/2017] [Revised: 12/23/2018] [Accepted: 01/30/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The perfusion index (PI) derived from plethysmographic signals provides a noninvasive indication of peripheral perfusion. This study aimed to investigate changes in PI and other hemodynamic variables in pigs subjected to endotoxemia. DESIGN Prospective experimental study. SETTING University teaching hospital. ANIMALS Twelve healthy pigs weighing a mean (± standard deviation [SD]) of 31.7 ± 2.0 kg. INTERVENTIONS Pigs were divided into control and endotoxin groups (n = 6 each). Endotoxemia was induced by IV infusion of lipopolysaccharide. Heart rate, mean arterial pressure, cardiac index (CI), central venous pressure, systemic vascular resistance index (SVRI), extravascular lung water index (ELWI), Global end-diastolic volume (GEDV) index, and pulmonary permeability index were measured using a transpulmonary thermodilution monitor in all pigs. PI was measured using a pulse oximeter probe attached to the tail. Pao2 , Paco2 , and plasma lactate concentration were measured by blood gas analysis. Measurements were taken at baseline (T0 ). Saline or lipopolysaccharide was then administered for 30 min to all pigs (control or endotoxemia group, respectively), and each parameter was measured every 30 min up to 270 min. Data were analyzed by analysis of variance and Student's t-tests. MEASUREMENTS AND MAIN RESULTS There were no significant changes in any variables in the control group, but CI, SVRI, PI, ELWI, blood lactate concentration, and Pao2 changed significantly from baseline in the endotoxin group (P < 0.001, P = 0.0048, P < 0.001, P = 0.0064, P < 0.001, and P = 0.0220, respectively). In the endotoxin group, mean (± SD) %PI increased from T0 to 154 ± 34% at T60 (P = .001) and 135 ± 50% at T90 (P =0 .004), which mirrored significant changes in %CI and %SVRI. CONCLUSION The PI may be useful to detect changes in CI and SVRI.
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Affiliation(s)
- Yusuke Endo
- Departments of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Japan
| | - Taku Miyasho
- Departments of Veterinary Science, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Japan
| | - Hisashi Imahase
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Yoshio Kawamura
- Department of Veterinary Pathobiology, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Japan
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Kazuto Yamashita
- Departments of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Japan
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Abstract
PURPOSE OF REVIEW Despite restoration of adequate systemic blood flow in patients with shock, single organs may remain hypoperfused. In this review, we summarize the results of a literature research on methods to monitor single organ perfusion in shock. We focused on methods to measure heart, brain, kidney, and/or visceral organ perfusion. Furthermore, only methods that can be used in real-time and at the bedside were included. RECENT FINDINGS We identified studies on physical examination techniques, electrocardiography, echocardiography, contrast-enhanced ultrasound, near-infrared spectroscopy, and Doppler sonography to assess single organ perfusion. SUMMARY Physical examination techniques have a reasonable negative predictive value to exclude single organ hypoperfusion but are nonspecific to detect it. Technical methods to indirectly measure myocardial perfusion include ECG and echocardiography. Contrast-enhanced ultrasound can quantify myocardial perfusion but has so far only been used to detect regional myocardial hypoperfusion. Near-infrared spectroscopy and transcranial Doppler sonography can be used to assess cerebral perfusion and determine autoregulation thresholds of the brain. Both Doppler and contrast-enhanced ultrasound techniques are novel methods to evaluate renal and visceral organ perfusion. A key limitation of most techniques is the inability to determine adequacy of organ blood flow to meet the organs' metabolic demands.
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Gazmuri RJ, de Gomez CA. Septic shock patients with adequate tissue perfusion parameters still need the recommended minimal Mean Arterial Pressure: Not really. J Crit Care 2020; 56:308-310. [PMID: 32178832 DOI: 10.1016/j.jcrc.2020.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/08/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Raúl J Gazmuri
- Medicine, Physiology & Biophysics, Resuscitation Institute at Rosalind Franklin University of Medicine and Science, Critical Care Medicine, Captain James A. Lovell Federal Health Care Center, United States of America.
| | - Cristina Añez de Gomez
- Internal Medicine Physician, Northwestern Medicine Lake Forest Hospital, United States of America
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Leibner E, Andreae M, Galvagno SM, Scalea T. Damage control resuscitation. Clin Exp Emerg Med 2020; 7:5-13. [PMID: 32252128 PMCID: PMC7141982 DOI: 10.15441/ceem.19.089] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 12/10/2019] [Indexed: 01/24/2023] Open
Abstract
The United States Navy originally utilized the concept of damage control to describe the process of prioritizing the critical repairs needed to return a ship safely to shore during a maritime emergency. To pursue a completed repair would detract from the goal of saving the ship. This concept of damage control management in crisis is well suited to the care of the critically ill trauma patient, and has evolved into the standard of care. Damage control resuscitation is not one technique, but, rather, a group of strategies which address the lethal triad of coagulopathy, acidosis, and hypothermia. In this article, we describe this approach to trauma resuscitation and the supporting evidence base.
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Affiliation(s)
- Evan Leibner
- Department of Emergency Medicine, Institute of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mark Andreae
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Samuel M Galvagno
- Program in Trauma, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas Scalea
- Program in Trauma, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Udesen NLJ, Helgestad OKL, Banke ABS, Frederiksen PH, Josiassen J, Jensen LO, Schmidt H, Edelman ER, Chang BY, Ravn HB, Møller JE. Impact of concomitant vasoactive treatment and mechanical left ventricular unloading in a porcine model of profound cardiogenic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:95. [PMID: 32188462 PMCID: PMC7079533 DOI: 10.1186/s13054-020-2816-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/04/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Concomitant vasoactive drugs are often required to maintain adequate perfusion pressure in patients with acute myocardial infarction (AMI) and cardiogenic shock (CS) receiving hemodynamic support with an axial flow pump (Impella CP). OBJECTIVE To compare the effect of equipotent dosages of epinephrine, dopamine, norepinephrine, and phenylephrine on cardiac work and end-organ perfusion in a porcine model of profound ischemic CS supported with an Impella CP. METHODS CS was induced in 10 pigs by stepwise intracoronary injection of polyvinyl microspheres. Hemodynamic support with Impella CP was initiated followed by blinded crossover to vasoactive treatment with norepinephrine (0.10 μg/kg/min), epinephrine (0.10 μg/kg/min), or dopamine (10 μg/kg/min) for 30 min each. At the end of the study, phenylephrine (10 μg/kg/min) was administered for 20 min. The primary outcome was cardiac workload, a product of pressure-volume area (PVA) and heart rate (HR), measured using the conductance catheter technique. End-organ perfusion was assessed by measuring venous oxygen saturation from the pulmonary artery (SvO2), jugular bulb, and renal vein. Treatment effects were evaluated using multilevel mixed-effects linear regression. RESULTS All catecholamines significantly increased LV stroke work and cardiac work, dopamine to the greatest extend by 341.8 × 103 (mmHg × mL)/min [95% CI (174.1, 509.5), p < 0.0001], and SvO2 significantly improved during all catecholamines. Phenylephrine, a vasoconstrictor, caused a significant increase in cardiac work by 437.8 × 103 (mmHg × mL)/min [95% CI (297.9, 577.6), p < 0.0001] due to increase in potential energy (p = 0.001), but no significant change in LV stroke work. Also, phenylephrine tended to decrease SvO2 (p = 0.063) and increased arterial lactate levels (p = 0.002). CONCLUSION Catecholamines increased end-organ perfusion at the expense of increased cardiac work, most by dopamine. However, phenylephrine increased cardiac work with no increase in end-organ perfusion.
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Affiliation(s)
- Nanna L J Udesen
- Department of Cardiology, Odense University Hospital, J. B. Winsløwsvej 4, Odense C, Denmark.
| | - Ole K L Helgestad
- Department of Cardiology, Odense University Hospital, J. B. Winsløwsvej 4, Odense C, Denmark
| | - Ann B S Banke
- Department of Cardiology, Odense University Hospital, J. B. Winsløwsvej 4, Odense C, Denmark
| | - Peter H Frederiksen
- Department of Cardiology, Odense University Hospital, J. B. Winsløwsvej 4, Odense C, Denmark
| | - Jakob Josiassen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lisette O Jensen
- Department of Cardiology, Odense University Hospital, J. B. Winsløwsvej 4, Odense C, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.,Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian Y Chang
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Hanne B Ravn
- Department of Cardiothoracic Anaesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology, Odense University Hospital, J. B. Winsløwsvej 4, Odense C, Denmark.,Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Szasz J, Noitz M, Dünser M. [Diagnosing acute organ ischemia : A practical guide for the emergency and intensive care physician]. Med Klin Intensivmed Notfmed 2020; 115:159-172. [PMID: 32086542 DOI: 10.1007/s00063-020-00655-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 02/07/2023]
Abstract
Ischemia refers to a reduction or interruption of the blood flow to one or more organs. Early recognition of shock, a global ischemic state of the body, is of key importance in emergency and intensive care medicine. The physical examination and point-of-care laboratory diagnostics (i.e. lactate, base deficit, central/mixed venous oxygen saturation, venous-arterial carbon dioxide partial tension) are the methods of choice to diagnose shock in clinical practice. Importantly, a state of shock can also be present in patients with normo- or hypertensive arterial blood pressures. In shock, hypoperfusion of vital and visceral organs occurs. In the second part of this article, physical examination techniques, laboratory and diagnostic methods to detect shock-related hypoperfusion of the brain, heart, kidney and gastrointestinal tract are reviewed.
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Affiliation(s)
- Johannes Szasz
- Universitätsklinik für Anästhesiologie und Operative Intensivmedizin, Kepler Universitätsklinikum GmbH, Krankenhausstraße 9, 4020, Linz, Österreich
| | - Matthias Noitz
- Universitätsklinik für Anästhesiologie und Operative Intensivmedizin, Kepler Universitätsklinikum GmbH, Krankenhausstraße 9, 4020, Linz, Österreich
- Johannes Kepler Universität Linz, Altenberger Straße 69, 4040, Linz, Österreich
| | - Martin Dünser
- Universitätsklinik für Anästhesiologie und Operative Intensivmedizin, Kepler Universitätsklinikum GmbH, Krankenhausstraße 9, 4020, Linz, Österreich.
- Johannes Kepler Universität Linz, Altenberger Straße 69, 4040, Linz, Österreich.
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Sublingual microcirculation does not reflect red blood cell transfusion thresholds in the intensive care unit-a prospective observational study in the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:18. [PMID: 31952555 PMCID: PMC6969438 DOI: 10.1186/s13054-020-2728-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/01/2020] [Indexed: 01/28/2023]
Abstract
Purpose Hemoglobin (Hb) transfusion thresholds are established in intensive care units. A restrictive transfusion threshold (Hb 70–75 g/l) is recommended in septic patients, and a liberal transfusion threshold (Hb 90 g/l) for cardiogenic shock. It is unclear whether these historically adopted transfusion thresholds meet the challenges of individual patients. Methods We evaluated microvascular flow index (MFI) and proportion of perfused vessels (PPV) in the sublingual microcirculation with CytoCam-IDF microscopy and near-infrared spectroscopy (NIRS). A study team-independent, treating intensivist assigned a total of 64 patients to 1 of 2 two transfusion thresholds, 43 patients to the Hb 75 g/l threshold and 21 patients to the Hb 90 g/l threshold, at a surgical intensive care unit. We performed microcirculatory measurements 1 h before and 1 h after transfusion of 1 unit of red blood cells. Results Microcirculatory flow variables correlated negatively with pre-transfusion flow variables (ΔMFI: ρ = − 0.821, p < 0.001; ΔPPV: ρ = − 0.778, p < 0.001). Patients with good initial microcirculation (cutoffs: MFI > 2.84, PPV > 88%) showed a deteriorated microcirculation after red blood cell transfusion. An impaired microcirculation improved after transfusion. At both transfusion thresholds, approximately one third of the patients showed an initially impaired microcirculation. In contrast, one third in every group had good microcirculation above the cutoff variables and did not profit from the transfusion. Conclusion The data suggest that the established transfusion thresholds and other hemodynamic variables do not reflect microcirculatory perfusion of patients. Blood transfusion at both thresholds 75 g/l and 90 g/l hemoglobin can either improve or harm the microcirculatory blood flow, questioning the concept of arbitrary transfusion thresholds.
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Gazmuri RJ, de Gomez CA. From a pressure-guided to a perfusion-centered resuscitation strategy in septic shock: Critical literature review and illustrative case. J Crit Care 2020; 56:294-304. [PMID: 31926637 DOI: 10.1016/j.jcrc.2019.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 07/28/2019] [Accepted: 11/13/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE To support a paradigm shift in the management of septic shock from pressure-guided to perfusion-centered, expected to improve outcome while reducing adverse effects from vasopressor therapy and aggressive fluid resuscitation. MATERIAL AND METHODS Critical review of the literature cited in support of vasopressor use to achieve a predefined mean arterial pressure (MAP) of 65 mmHg and review of pertinent clinical trials and studies enabling deeper understanding of the hemodynamic pathophysiology supportive of a perfusion-centered approach, accompanied by an illustrative case. RESULTS Review of the literature cited by the Surviving Sepsis Campaign revealed lack of controlled clinical trials supporting outcome benefits from vasopressors. Additional literature review revealed adverse effects associated with vasopressors and worsened outcome in some studies. Vasopressors increase MAP primarily by peripheral vasoconstriction and in occasions by a modest increase in cardiac output when using norepinephrine. Thus, achieving the recommended MAP of 65 mmHg using vasopressors should not be presumed indicative that organ perfusion has been restored. It may instead create a false sense of hemodynamic stability hampering shock resolution. CONCLUSIONS We propose focusing the hemodynamic management of septic shock on reversing organ hypoperfusion instead of attaining a predefined MAP target as the key strategy for improving outcome.
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Affiliation(s)
- Raúl J Gazmuri
- Medicine, Physiology & Biophysics, Resuscitation Institute at Rosalind Franklin University of Medicine and Science, Critical Care Medicine and ICU, Captain James A. Lovell Federal Health Care Center, USA.
| | - Cristina Añez de Gomez
- Internal Medicine Physician, Northwestern Medical Group, Northwestern Medicine Lake Forrest Hospital, USA
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Jakobsen RP, Nielsen TH, Mølstrøm S, Nordström CH, Granfeldt A, Toft P. Moderately prolonged permissive hypotension results in reversible metabolic perturbation evaluated by intracerebral microdialysis - an experimental animal study. Intensive Care Med Exp 2019; 7:67. [PMID: 31802303 PMCID: PMC6892994 DOI: 10.1186/s40635-019-0282-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/13/2019] [Indexed: 12/28/2022] Open
Abstract
Background Damage control resuscitation (DCR) and damage control surgery (DCS) is the main strategy in patients with uncontrollable hemorrhagic shock. One aspect of DCR is permissive hypotension. However, the duration of hypotension that can be tolerated without affecting the brain is unknown. In the present study we investigate the effect of 60 min severe hypotension on the brain’s energy metabolism and seek to verify earlier findings that venous cerebral blood can be used as a marker of global cerebral energy state. Material and methods Ten pigs were anaesthetized, and vital parameters recorded. Microdialysis catheters were placed in the left parietal lobe, femoral artery, and superior sagittal sinus for analysis of lactate, pyruvate, glucose, glycerol, and glutamate. Hemorrhagic shock was induced by bleeding the animal until mean arterial pressure (MAP) of 40 mmHg was achieved. After 60 min the pigs were resuscitated with autologous blood and observed for 3 h. Results At baseline the lactate to pyruvate ratios (LP ratio) in the hemisphere, artery, and sagittal sinus were (median (interquartile range)) 13 (8–16), 21 (18–24), and 9 (6–22), respectively. After induction of hemorrhagic shock, the LP ratio from the left hemisphere in 9 pigs increased to levels indicating a reversible perturbation of cerebral energy metabolism 19 (12–30). The same pattern was seen in LP measurements from the femoral artery 28 (20–35) and sagittal sinus 22 (19–26). At the end of the experiment hemisphere, artery and sinus LP ratios were 16 (10–23), 17 (15–25), and 17 (10–27), respectively. Although hemisphere and sinus LP ratios decreased, they did not reach baseline levels (p < 0.05). In one pig hemisphere LP ratio increased to a level indicating irreversible metabolic perturbation (LP ratio > 200). Conclusion During 60 min of severe hypotension intracerebral microdialysis shows signs of perturbations of cerebral energy metabolism, and these changes trend towards baseline values after resuscitation. Sagittal sinus microdialysis values followed hemisphere values but were not distinguishable from systemic arterial values. Venous (jugular bulb) microdialysis might have a place in monitoring conditions where global cerebral ischemia is a risk.
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Affiliation(s)
- Rasmus Peter Jakobsen
- Department of Anesthesia and Intensive Care, Odense University Hospital, J.B. Winsløws Vej 4, Indgang 8, 20, 201, 5000, Odense C, Denmark.
| | - Troels Halfeld Nielsen
- Department of Neurosurgery, Odense University Hospital, Kløvervænget 47, Indgang 44, 1. etage, 5000, Odense C, Denmark
| | - Simon Mølstrøm
- Department of Anesthesia and Intensive Care, Odense University Hospital, J.B. Winsløws Vej 4, Indgang 8, 20, 201, 5000, Odense C, Denmark
| | - Carl-Henrik Nordström
- Department of Neurosurgery, Odense University Hospital, Kløvervænget 47, Indgang 44, 1. etage, 5000, Odense C, Denmark
| | - Asger Granfeldt
- Department of Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99 G304, 8200, Aarhus, Denmark
| | - Palle Toft
- Department of Anesthesia and Intensive Care, Odense University Hospital, J.B. Winsløws Vej 4, Indgang 8, 20, 201, 5000, Odense C, Denmark
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Significance of Early Postoperative Arterial Lactic Acid, Inferior Vena Cava Variability, and Central Venous Pressure in Hypovolemic Shock. Emerg Med Int 2019; 2019:6504916. [PMID: 31827930 PMCID: PMC6881569 DOI: 10.1155/2019/6504916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 10/18/2019] [Accepted: 10/25/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Up to one-third of patients admitted to the ICU are in circulatory shock, and early recognition of the condition is vital if subsequent tissue injuries are to be avoided. We would like to know what role the arterial lactic acid, inferior vena cava variability, and CVP (central venous pressure) play in the early stages of shock. Methods This is a retrospective study of patients who underwent surgical resuscitation in the Department of Critical Care Medicine. We use the ROC (receiver-operating characteristic) curve to evaluate the significance of each indicator in the diagnosis. For correlation analysis between groups, we first use linear regression for processing and then analysis with correlation. Results The ROC curve analysis shows that the area under the curve of the lactic acid group was 0.9272, the area under the curve of the inferior vena cava variability group was 0.8652, and the area under the curve of the CVP group was 0.633. Correlation analysis shows that the inferior vena cava variability and arterial lactic acid Pearson's r = 0.2863 and CVP and arterial lactic acid Pearson's r = 0.0729. Conclusion The diagnostic value of arterial lactate is still very high and can still be used as an early warning indicator to help clinicians be alert to the microcirculatory disorders that have emerged quietly. The degree of inferior vena cava variability is linearly related to arterial lactic acid and can also be used as a reference indicator for early evaluation of shock. The diagnostic value of CVP is obviously lower.
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Mu TS, Becker AM, Clark AJ, Batts SG, Murata LAM, Uyehara CFT. ECMO with vasopressor use during early endotoxic shock: Can it improve circulatory support and regional microcirculatory blood flow? PLoS One 2019; 14:e0223604. [PMID: 31600278 PMCID: PMC6786553 DOI: 10.1371/journal.pone.0223604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/24/2019] [Indexed: 11/24/2022] Open
Abstract
Introduction While extracorporeal membrane oxygenation (ECMO) is effective in preventing further hypoxemia and maintains blood flow in endotoxin-induced shock, ECMO alone does not reverse the hypotension. In this study, we tested whether concurrent vasopressor use with ECMO would provide increased circulatory support and blood flow, and characterized regional blood flow distribution to vital organs. Methods Endotoxic shock was induced in piglets to achieve a 30% decrease in mean arterial pressure (MAP). Measurements of untreated pigs were compared to pigs treated with ECMO alone or ECMO and vasopressors. Results ECMO provided cardiac support during vasodilatory endotoxic shock and improved oxygen delivery, but vasopressor therapy was required to return MAP to normotensive levels. Increased blood pressure with vasopressors did not alter oxygen consumption or extraction compared to ECMO alone. Regional microcirculatory blood flow (RBF) to the brain, kidney, and liver were maintained or increased during ECMO with and without vasopressors. Conclusion ECMO support and concurrent vasopressor use improve regional blood flow and oxygen delivery even in the absence of full blood pressure restoration. Vasopressor-induced selective distribution of blood flow to vital organs is retained when vasopressors are administered with ECMO.
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Affiliation(s)
- Thornton S. Mu
- Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas, United States of America
- * E-mail:
| | - Amy M. Becker
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, United States of America
| | - Aaron J. Clark
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, United States of America
| | - Sherreen G. Batts
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, United States of America
| | - Lee-Ann M. Murata
- Department of Clinical Investigation, Tripler Army Medical Center, Honolulu, HI, United States of America
| | - Catherine F. T. Uyehara
- Department of Clinical Investigation, Tripler Army Medical Center, Honolulu, HI, United States of America
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Jacquet-Lagrèze M, Bouhamri N, Portran P, Schweizer R, Baudin F, Lilot M, Fornier W, Fellahi JL. Capillary refill time variation induced by passive leg raising predicts capillary refill time response to volume expansion. Crit Care 2019; 23:281. [PMID: 31420052 PMCID: PMC6697974 DOI: 10.1186/s13054-019-2560-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/31/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND A peripheral perfusion-targeted resuscitation during early septic shock has shown encouraging results. Capillary refill time, which has a prognostic value, was used. Adding accuracy and predictability on capillary refill time (CRT) measurement, if feasible, would benefit to peripheral perfusion-targeted resuscitation. We assessed whether a reduction of capillary refill time during passive leg raising (ΔCRT-PLR) predicted volume-induced peripheral perfusion improvement defined as a significant decrease of capillary refill time following volume expansion. METHODS Thirty-four patients with acute circulatory failure were selected. Haemodynamic variables, metabolic variables (PCO2gap), and four capillary refill time measurements were recorded before and during a passive leg raising test and after a 500-mL volume expansion over 20 min. Receiver operating characteristic curves were built, and areas under the curves were calculated (ROCAUC). Confidence intervals (CI) were performed using a bootstrap analysis. We recorded mortality at day 90. RESULTS The least significant change in the capillary refill time was 25% [95% CI, 18-30]. We defined CRT responders as patients showing a reduction of at least 25% of capillary refill time after volume expansion. A decrease of 27% in ΔCRT-PLR predicted peripheral perfusion improvement with a sensitivity of 87% [95% CI, 73-100] and a specificity of 100% [95% CI, 74-100]. The ROCAUC of ΔCRT-PLR was 0.94 [95% CI, 0.87-1.0]. The ROCAUC of baseline capillary refill time was 0.73 [95% CI, 0.54-0.90] and of baseline PCO2gap was 0.79 [0.61-0.93]. Capillary refill time was significantly longer in non-survivors than in survivors at day 90. CONCLUSION ΔCRT-PLR predicted peripheral perfusion response following volume expansion. This simple low-cost and non-invasive diagnostic method could be used in peripheral perfusion-targeted resuscitation protocols. TRIAL REGISTRATION CPP Lyon Sud-Est II ANSM: 2014-A01034-43 Clinicaltrial.gov, NCT02248025 , registered 13th of September 2014.
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Affiliation(s)
- Matthias Jacquet-Lagrèze
- Département d’Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
- Université Claude-Bernard, Lyon 1, Campus Lyon Santé Est, 8 avenue Rockefeller, 69008 Lyon, France
| | - Nourredine Bouhamri
- Département d’Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
| | - Philippe Portran
- Département d’Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
- Université Claude-Bernard, Lyon 1, Campus Lyon Santé Est, 8 avenue Rockefeller, 69008 Lyon, France
| | - Rémi Schweizer
- Département d’Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
- Université Claude-Bernard, Lyon 1, Campus Lyon Santé Est, 8 avenue Rockefeller, 69008 Lyon, France
| | - Florent Baudin
- Université Claude-Bernard, Lyon 1, Campus Lyon Santé Est, 8 avenue Rockefeller, 69008 Lyon, France
- Département de Réanimation Pédiatrique, Centre Hospitalier Femme mère enfant, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
| | - Marc Lilot
- Département d’Anesthésie Pédiatrique, Centre Hospitalier Femme Mère Enfant, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
- Centre Lyonnais d’Enseignement par Simulation en Santé, SAMSEI, Université Claude Bernard Lyon 1, Lyon, France
- Health Services and Performance Research Lab (EA 7425 HESPER), Université Claude Bernard Lyon 1, Lyon, France
- EPICIME-CIC 1407 de Lyon, Inserm, Hospices Civils de Lyon, F-69677 Bron, France
| | - William Fornier
- Département d’Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
- Université Claude-Bernard, Lyon 1, Campus Lyon Santé Est, 8 avenue Rockefeller, 69008 Lyon, France
| | - Jean-Luc Fellahi
- Département d’Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500 Bron, France
- Université Claude-Bernard, Lyon 1, Campus Lyon Santé Est, 8 avenue Rockefeller, 69008 Lyon, France
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Reconsidering Vasopressors for Cardiogenic Shock. Chest 2019; 156:392-401. [DOI: 10.1016/j.chest.2019.03.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/13/2019] [Accepted: 03/15/2019] [Indexed: 12/27/2022] Open
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Scheuzger JD, Zehnder A, Yeginsoy D, Siegemund M. Sublingual microcirculation: a case report. J Med Case Rep 2019; 13:179. [PMID: 31186057 PMCID: PMC6560767 DOI: 10.1186/s13256-019-2118-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/09/2019] [Indexed: 11/20/2022] Open
Abstract
Introduction Sublingual microcirculation monitoring is suitable for bedside use in critically ill patients. We present a case in which severely impaired sublingual microcirculation was the first alarming sign of an early deterioration of the patient’s medical situation. Case presentation This is the case of a 58-year-old white woman admitted to our intensive care unit after the removal of parts of her small intestine due to a volvulus. Her microcirculation was checked the day after surgery in terms of an ongoing study and predicted a massive deterioration of her clinical situation. Conclusions This case highlights the potential value of monitoring the microcirculation in critically ill patients. Two full hours could have been saved for diagnostic workup and earlier treatment had we considered the impaired microcirculation alone as a warning sign. Regardless of the supposed cause, impaired microcirculation should alert the responsible physician and should be followed by a diagnostic workup. Sublingual microcirculation monitoring can be useful in intensive care units to detect a deteriorated microcirculation earlier than with standard monitoring. Electronic supplementary material The online version of this article (10.1186/s13256-019-2118-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jonas D Scheuzger
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland.
| | - Anna Zehnder
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
| | - Desirée Yeginsoy
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
| | - Martin Siegemund
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland.
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Ackland GL, Brudney CS, Cecconi M, Ince C, Irwin MG, Lacey J, Pinsky MR, Grocott MPW, Mythen MG, Edwards MR, Miller TE, Miller TE, Mythen MG, Grocott MPW, Edwards MR, Ackland GL, Brudney CS, Cecconi M, Ince C, Irwin MG, Lacey J, Pinsky MR, Sanders R, Hughes F, Bader A, Thompson A, Hoeft A, Williams D, Shaw AD, Sessler DI, Aronson S, Berry C, Gan TJ, Kellum J, Plumb J, Bloomstone J, McEvoy MD, Thacker JK, Gupta R, Koepke E, Feldheiser A, Levett D, Michard F, Hamilton M. Perioperative Quality Initiative consensus statement on the physiology of arterial blood pressure control in perioperative medicine. Br J Anaesth 2019; 122:542-551. [DOI: 10.1016/j.bja.2019.01.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 12/10/2018] [Accepted: 01/02/2019] [Indexed: 01/19/2023] Open
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