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Gomes FKA, Fagundes AADP, Amorim FF. Cardiac Output and Stroke Volume Assessments by Transthoracic Echocardiography and Pulse index Continuous Cardiac Output Monitor in Critically ill Adult Patients: A Comparative Study. J Intensive Care Med 2024; 39:341-348. [PMID: 37769347 DOI: 10.1177/08850666231204787] [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] [Indexed: 09/30/2023]
Abstract
PURPOSE Bedside transthoracic echocardiography (TTEcho) is a noninvasive cardiac output (CO) monitoring method that has grown recently. However, there are questions regarding its accuracy compared to invasive methods. We aimed to evaluate the agreement and correlation of TTEcho and pulse index continuous CO (PiCCO) monitor measurements for CO and systolic volume (SV) in critically ill patients. METHODS This prospective experimental study included consecutive adult patients who required invasive hemodynamic monitoring admitted at an intensive care unit in the Federal District, Brazil, from January/2019 to January/2021. Correlation and agreement between SV and CO measurements by PiCCO and TTEcho were performed using the Spearman correlation and the Bland-Altman analysis. RESULTS The study enrolled 29 patients, with adequate TTEcho evaluations in all patients. There were very strong correlations between CO-TTEcho and CO-PiCCO (r = 0.845, P < .001) and SV-TTEcho and SV-PiCCO (r = 0.800, P < .001). TTEcho estimations for CO and SV were feasible within the limits of agreement in 96.6% (28/29) compared to PiCCO. The mean difference between CO-PiCCO and CO-TTEcho was 0.250 L/min (limits of agreement: -1.083 to 1.583 L/min, percentage error: 21.0%), and between SV-PiCCO and SV-TTEcho was 2.000 mL (limits of agreement: -16.960 to 20.960, percentage error: 24.3%). The reduced cardiac index (CI) measurements by TTEcho showed an accuracy of 89.7% (95% IC: 72.6%-97.8%) and an F1 score of 92.7% (95% IC: 75.0%-98.0%), considering the CI-PiCCO as the gold standard. CONCLUSION Echocardiographic measurements of CO and SV are comparable to measurements by PiCCO. These results reinforce echocardiography as a reliable tool to evaluate hemodynamics in critically ill patients.
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Affiliation(s)
- Flávia K A Gomes
- Graduate Program in Health Sciences, Higher Education School of Health Sciences (ESCS), Brasília, Federal District, Brazil
- Adult Intensive Care Unit, Hospital DF Star, Brasília, Federal District, Brazil
- Adult Intensive Care Unit, Hospital Home, Brasília, Federal District, Brazil
| | | | - Fábio F Amorim
- Graduate Program in Health Sciences, Higher Education School of Health Sciences (ESCS), Brasília, Federal District, Brazil
- Graduate Program in Health Sciences, University of Brasilia (UnB), Brasília, Federal District, Brazil
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2
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Jiang Z, Li S, Wang L, Yu F, Zeng Y, Li H, Li J, Zhang Z, Zuo J. A comparison of invasive arterial blood pressure measurement with oscillometric non-invasive blood pressure measurement in patients with sepsis. J Anesth 2024; 38:222-231. [PMID: 38305914 DOI: 10.1007/s00540-023-03304-2] [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: 09/30/2022] [Accepted: 12/25/2023] [Indexed: 02/03/2024]
Abstract
PURPOSE This study aimed to compare non-invasive oscillometric blood pressure (NIBP) measurement with invasive arterial blood pressure (IBP) measurement in patients with sepsis. METHODS We conducted a retrospective study to evaluate the agreement between IBP and NIBP using the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Paired blood pressure measurements of mean arterial pressure (MAP), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were compared using Bland-Altman analysis and paired Student's t test. We also focus on the effect of norepinephrine (NE) on the agreement between the two methods and the association between blood pressure and mortality during intensive care unit (ICU) stay. RESULTS A total of 96,673 paired blood pressure measurements from 6060 unique patients were analyzed in the study. In Bland-Altman analysis, the bias (± SD, 95% limits of agreement) was 6.21 mmHg (± 12.05 mmHg, - 17.41 to 29.83 mmHg) for MAP, 0.39 mmHg (± 19.25 mmHg, - 37.34 to 38.12 mmHg) for SBP, and 0.80 mmHg (± 12.92 mmHg, - 24.52 to 26.12 mmHg) for DBP between the two techniques. Similarly, large limits of agreement were shown in different groups of NE doses. NE doses significantly affected the agreement between IBP and NIBP. SBP between the two methods gave an inconsistent assessment of patients' risk of ICU mortality. CONCLUSION IBP and NIBP were not interchangeable in septic patients. Clinicians should be aware that non-invasive MAP was clinically and significantly underestimated invasive MAP.
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Affiliation(s)
- Ziqing Jiang
- Candidate of Master's Degree, The First Clinical Medical College, Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Shaoying Li
- Candidate of Master's Degree, The First Clinical Medical College, Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Lin Wang
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China
| | - Feng Yu
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China
| | - Yanping Zeng
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China
| | - Hongbo Li
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China
| | - Jun Li
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China
| | - Zhanfeng Zhang
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China
| | - Junling Zuo
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China.
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Gore P, Liu H, Bohringer C. Can Currently Available Non-invasive Continuous Blood Pressure Monitors Replace Invasive Measurement With an Arterial Catheter? Cureus 2024; 16:e54707. [PMID: 38529464 PMCID: PMC10961923 DOI: 10.7759/cureus.54707] [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] [Accepted: 02/21/2024] [Indexed: 03/27/2024] Open
Abstract
Deviations from normal blood pressure (BP) during general anesthesia have been clearly linked to several adverse outcomes. Measuring BP accurately is therefore critically important for producing excellent outcomes in health care. Normal BP does not necessarily guarantee adequate organ perfusion however and adverse events have occurred even when BP seemed adequate. Invasive blood pressure monitoring has recently evolved beyond merely measuring BP. Arterial line-derived pulse contour analysis is used now to assess both cardiac output and stroke volume variation as indices of adequate intravascular volume. Confirmation of acceptable cardiac output with data derived from invasive intra-arterial catheters has become very important when managing high-risk patients. Newer devices that measure BP continuously and non-invasively in the digital arteries via a finger cuff have also become available. Many clinicians contemplate now if these new devices are ready to replace invasive monitoring with an arterial catheter. Unlike non-invasive devices, intra-arterial catheters allow frequent blood sampling. This makes it possible to assess vital parameters like pH, hemoglobin concentration, ionized calcium, potassium, glucose, and arterial partial pressure of oxygen and carbon dioxide frequently. Non-invasive continuous BP measurement has been found to be unreliable in critically ill patients, the elderly, and patients with calcified arteries. Pulse contour-derived estimates of cardiac output and stroke volume variation have been validated better with data derived from arterial lines than that from the newer finger cuff monitors. Significant advances have been recently made with non-invasive continuous BP monitors. Invasive monitoring with an arterial line however remains the gold standard for measuring BP and assessing pulse contour analysis-derived hemodynamic variables in critically ill patients. In the future, non-invasive continuous BP monitors will likely replace intermittent oscillometers in the operating room and the postoperative period. They will however not eliminate the need for arterial catheterization in critically ill patients.
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Affiliation(s)
- Payton Gore
- Anesthesiology, University of California Davis Medical Center, Sacramento, USA
| | - Hong Liu
- Anesthesiology, University of California Davis Medical Center, Sacramento, USA
| | - Christian Bohringer
- Anesthesiology, University of California Davis Medical Center, Sacramento, USA
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Maruhashi T, Oi M, Hattori J, Asari Y. Distal radial approach for arterial pressure monitoring with a long catheter provides safe and stable monitoring in the intensive care unit: A single-center retrospective study. J Vasc Access 2023:11297298231212393. [PMID: 37997045 DOI: 10.1177/11297298231212393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND To compare the distal radial artery approach (DRA) with a longer catheter to DRA with a shorter catheter in arterial catheter (AC) placement in the intensive care unit (ICU). METHODS This was a single-center retrospective cohort study of DRA with a long catheter (60 mm) for arterial catheterization in the ICU. DRA with a short catheter (25-30 mm) was used in the control group, and the groups were compared using multivariate regression analysis. The primary study endpoint was the incidence of unplanned AC removal. The secondary endpoint was the incidence of other inappropriate events, namely loss of arterial pressure waveforms, bleeding, catheter-related infection, pressure ulcer, and other complications associated with the AC. RESULTS In this study, the DRA with a long catheter was used in 50 patients. No unplanned AC removals or other inappropriate events occurred, and there were no complications associated with the DRA. The DRA procedural success rate was 100%. There was no significant difference in hemostasis times between the groups. Loss of arterial waveforms was an early predictor of unplanned AC removal. CONCLUSIONS The DRA with a long catheter provided stable monitoring and was associated with a low unplanned removal rate. This method has the advantages of fewer complications and shorter hemostasis time compared with the DRA with a short catheter, and may become a new AC option in the ICU.
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Affiliation(s)
- Takaaki Maruhashi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Marina Oi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Jun Hattori
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Yasushi Asari
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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Orellana G, Josef V, Parchim NF, Mitchell JA. Current state of sepsis resuscitation in critical care. Int Anesthesiol Clin 2023; 61:43-54. [PMID: 37622346 DOI: 10.1097/aia.0000000000000416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Gabriela Orellana
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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Zhang X, Mao B, Che Y, Kang J, Luo M, Qiao A, Liu Y, Anzai H, Ohta M, Guo Y, Li G. Physics-informed neural networks (PINNs) for 4D hemodynamics prediction: An investigation of optimal framework based on vascular morphology. Comput Biol Med 2023; 164:107287. [PMID: 37536096 DOI: 10.1016/j.compbiomed.2023.107287] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/06/2023] [Accepted: 07/28/2023] [Indexed: 08/05/2023]
Abstract
Hemodynamic parameters are of great significance in the clinical diagnosis and treatment of cardiovascular diseases. However, noninvasive, real-time and accurate acquisition of hemodynamics remains a challenge for current invasive detection and simulation algorithms. Here, we integrate computational fluid dynamics with our customized analysis framework based on a multi-attribute point cloud dataset and physics-informed neural networks (PINNs)-aided deep learning modules. This combination is implemented by our workflow that generates flow field datasets within two types of patient personalized models - aorta with fine coronary branches and abdominal aorta. Deep learning modules with or without an antecedent hierarchical structure model the flow field development and complete the mapping from spatial and temporal dimensions to 4D hemodynamics. 88,000 cases on 4 randomized partitions in 16 controlled trials reveal the hemodynamic landscape of spatio-temporal anisotropy within two types of personalized models, which demonstrates the effectiveness of PINN in predicting the space-time behavior of flow fields and gives the optimal deep learning framework for different blood vessels in terms of balancing the training cost and accuracy dimensions. The proposed framework shows intentional performance in computational cost, accuracy and visualization compared to currently prevalent methods, and has the potential for generalization to model flow fields and corresponding clinical metrics within vessels at different locations. We expect our framework to push the 4D hemodynamic predictions to the real-time level, and in statistically significant fashion, applicable to morphologically variable vessels.
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Affiliation(s)
- Xuelan Zhang
- School of Mathematics and Physics, University of Science and Technology Beijing, Beijing, 100083, China
| | - Baoyan Mao
- Beijing University of Chinese Medicine, Beijing 100029, China
| | - Yue Che
- School of Mathematics and Physics, University of Science and Technology Beijing, Beijing, 100083, China
| | - Jiaheng Kang
- School of Mathematics and Physics, University of Science and Technology Beijing, Beijing, 100083, China
| | - Mingyao Luo
- Department of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, 100037, China; Department of Vascular Surgery, Fuwai Yunnan Cardiovascular Hospital, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, 650102, China
| | - Aike Qiao
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Youjun Liu
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Hitomi Anzai
- Institute of Fluid Science, Tohoku University, 2-1-1 Katahira, Aoba-ku, Sendai, 980-8577, Japan
| | - Makoto Ohta
- Institute of Fluid Science, Tohoku University, 2-1-1 Katahira, Aoba-ku, Sendai, 980-8577, Japan
| | - Yuting Guo
- Department of Mechanical Engineering and Science, Kyoto University, Kyoto, 615-8540, Japan
| | - Gaoyang Li
- Institute of Fluid Science, Tohoku University, 2-1-1 Katahira, Aoba-ku, Sendai, 980-8577, Japan.
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Caccamo M, Harrell FE, Hemnes AR. Evolution and optimization of clinical trial endpoints and design in pulmonary arterial hypertension. Pulm Circ 2023; 13:e12271. [PMID: 37554146 PMCID: PMC10405062 DOI: 10.1002/pul2.12271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023] Open
Abstract
Selection of endpoints for clinical trials in pulmonary arterial hypertension (PAH) is challenging because of the small numbers of patients and the changing expectations of patients, clinicians, and regulators in this evolving therapy area. The most commonly used primary endpoint in PAH trials has been 6-min walk distance (6MWD), leading to the approval of several targeted therapies. However, single surrogate endpoints such as 6MWD or hemodynamic parameters may not correlate with clinical outcomes. Composite endpoints of clinical worsening have been developed to reflect patients' overall condition more accurately, although there is no standard definition of worsening. Recently there has been a shift to composite endpoints assessing clinical improvement, and risk scores developed from registry data are increasingly being used. Biomarkers are another area of interest, although brain natriuretic peptide and its N-terminal prohormone are the only markers used for risk assessment or as endpoints in PAH. A range of other genetic, metabolic, and immunologic markers is currently under investigation, along with conventional and novel imaging modalities. Patient-reported outcomes are an increasingly important part of evaluating new therapies, and several PAH-specific tools are now available. In the future, alternative statistical techniques and trial designs, such as patient enrichment strategies, will play a role in evaluating PAH-targeted therapies. In addition, modern sequencing techniques, imaging analyses, and high-dimensional statistical modeling/machine learning may reveal novel markers that can play a role in the diagnosis and monitoring of PAH.
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Affiliation(s)
- Marco Caccamo
- Division of CardiologyWVU Heart and Vascular InstituteMorgantownWest VirginiaUSA
| | - Frank E. Harrell
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
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Loreto M, Pisanti M, Celentani M, Pasta G, Erman A, Santangelo C, Giaccari LG, Sansone P, Villani R. Non invasive hemodynamic monitoring for fluids and blood resuscitation during placenta praevia accreta cesarean delivery: a retrospective observational study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:54. [PMID: 37386677 DOI: 10.1186/s44158-022-00083-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/06/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND We carry out a retrospective observational analysis of clinical records of patients with major placenta praevia who underwent cesarean section surgery over a period of 20 months in our hospital. Out of a total of 40 patients, 20 were subjected to Goal-Directed Therapy (GDT) implemented with non-invasive hemodynamic monitoring using the EV1000 ClearSight system (Group I) and 20 to standard hemodynamic monitoring (Group II). Given the risk of conspicuous blood loss, this study evaluate the impact on maternal and fetal health of GDT relative to standard hemodynamic monitoring. RESULTS Average total infusion of fluids was 1600 +/- 350 ml. Use of blood products occurred in 29 patients (72,5%), of which 11 had a hysterectomy and 8 were treated with Bakri Balloons. For 2 patients > 1000 mL of concentrated red blood cells were used. When stroke volume index SVI dropped below 35 mL/m2/beat, it responded well to the infusion of at least 2 crystalloid boluses (5 ml/kg) in 7 patients. Cardiac index (CI) increased in 8 patients in concomitance with a reduction in medium arterial pressure (MAP), but the use of ephedrine (10 mg iv) re-established acceptable baseline values. Group I means are higher than Group II means for MAP, lower for RBC usage, end-of-surgery maternal lactates and fetal pH, and for LOS. Statistical analysis determines that the null hypotheses of equalities between Groups I and II can be rejected for all measures apart from MAP at baseline and induction. Proportions of serious complications in Groups I and II are respectively 10% and 32% and Boschloo's test rejects the null of equality of proportions against the alternative hypothesis of lower proportion of occurrence in Group I than in Group II. CONCLUSIONS Hypovolemia can lead to vasoconstriction and inadequate perfusion with decreased oxygen delivery to organs and peripheral tissues and ultimately cause organ dysfunction. Despite the small sample size due to the rarity of the pathology, our statistical analysis finds evidence in favor of more favorable clinical outcomes for patients who received GDT implemented with non-invasive hemodynamic monitoring infusion relative to patients who received standard hemodynamic monitoring.
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Affiliation(s)
- Maria Loreto
- Hospital of National Relevance "A. Cardarelli", Naples, Italy
| | - Massimo Pisanti
- Hospital of National Relevance "A. Cardarelli", Naples, Italy
| | - Marco Celentani
- Department of Economics, Universidad Carlos III de Madrid, Madrid, Spain
| | - Gilda Pasta
- National Cancer Institute IRCCS - "G. Pascale" Foundation, Naples, Italy
| | - Alfredo Erman
- Fatebenefratelli "S. Giovanni di Dio" Hospital, Naples, Italy
| | | | | | | | - Romolo Villani
- Hospital of National Relevance "A. Cardarelli", Naples, Italy
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Hupp NJ, Talavera B, Melius S, Lacuey N, Lhatoo SD. Protocols for multimodal polygraphy for cardiorespiratory monitoring in the epilepsy monitoring unit. Part II - Research acquisition. Epilepsy Res 2022; 185:106987. [PMID: 35843018 DOI: 10.1016/j.eplepsyres.2022.106987] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 11/30/2022]
Abstract
Multimodal polygraphy including cardiorespiratory monitoring is a valuable tool for epilepsy and sudden unexpected death in epilepsy (SUDEP) research. Broader applications in research into stress, anxiety, mood and other domains exist. Polygraphy techniques used during video electroencephalogram (EEG) recordings provide information on cardiac and respiratory changes in the peri-ictal period. In addition, such monitoring in brain mapping during chronic intracranial EEG evaluations has helped the understanding of pathomechanisms that lead to seizure induced cardiorespiratory dysfunction. Our aim here is to provide protocols and information on devices that may be used in the Epilepsy Monitoring Unit, in addition to proposed standard of care data acquisition. These devices include oronasal thermistors, oronasal pressure transducers, capnography, transcutaneous CO2 sensors, and continuous noninvasive blood pressure monitoring. Standard protocols for cardiorespiratory monitoring simultaneously with video EEG recording, may be useful in the study of cardiorespiratory phenomena in persons with epilepsy.
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Affiliation(s)
- Norma J Hupp
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, TX, USA
| | - Blanca Talavera
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, TX, USA.
| | - Stephen Melius
- Memorial Hermann. Texas Medical Center, Houston, TX, USA
| | - Nuria Lacuey
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, TX, USA
| | - Samden D Lhatoo
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, TX, USA
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Rali AS, Butcher A, Tedford RJ, Sinha SS, Mekki P, Van Spall HGC, Sauer AJ. Contemporary Review of Hemodynamic Monitoring in the Critical Care Setting. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hemodynamic assessment remains the most valuable adjunct to physical examination and laboratory assessment in the diagnosis and management of shock. Through the years, multiple modalities to measure and trend hemodynamic indices have evolved with varying degrees of invasiveness. Pulmonary artery catheter (PAC) has long been considered the gold standard of hemodynamic assessment in critically ill patients and in recent years has been shown to improve clinical outcomes among patients in cardiogenic shock. The invasive nature of PAC is often cited as its major limitation and has encouraged development of less invasive technologies. In this review, the authors summarize the literature on the mechanism and validation of several minimally invasive and noninvasive modalities available in the contemporary intensive care unit. They also provide an update on the use of focused bedside echocardiography.
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Amy Butcher
- Department of Cardiovascular Anesthesia and Critical Care, Baylor College of Medicine, Houston, TX
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Shashank S Sinha
- Division of Cardiology, Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | - Pakinam Mekki
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Harriette GC Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Andrew J Sauer
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS
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Comparing Cardiac Output Measurements Using a Wearable, Wireless, Noninvasive Photoplethysmography-Based Device to Pulse Contour Cardiac Output in the General ICU: A Brief Report. Crit Care Explor 2022; 4:e0624. [PMID: 35128457 PMCID: PMC8812679 DOI: 10.1097/cce.0000000000000624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Nam K, Jeon Y. Microcirculation during surgery. Anesth Pain Med (Seoul) 2022; 17:24-34. [PMID: 35139609 PMCID: PMC8841265 DOI: 10.17085/apm.22127] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 01/13/2022] [Indexed: 11/17/2022] Open
Abstract
Throughout the long history of surgery, there has been great advancement in the hemodynamic management of surgical patients. Traditionally, hemodynamic management has focused on macrocirculatory monitoring and intervention to maintain appropriate oxygen delivery. However, even after optimization of macro-hemodynamic parameters, microcirculatory dysfunction, which is related to higher postoperative complications, occurs in some patients. Although the clinical significance of microcirculatory dysfunction has been well reported, little is known about interventions to recover microcirculation and prevent microcirculatory dysfunction. This may be at least partly caused by the fact that the feasibility of monitoring tools to evaluate microcirculation is still insufficient for use in routine clinical practice. However, considering recent advancements in these research fields, with more popular use of microcirculation monitoring and more clinical trials, clinicians may better understand and manage microcirculation in surgical patients in the future. In this review, we describe currently available methods for microcirculatory evaluation. The current knowledge on the clinical relevance of microcirculatory alterations has been summarized based on previous studies in various clinical settings. In the latter part, pharmacological and clinical interventions to improve or restore microcirculation are also presented.
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Affiliation(s)
| | - Yunseok Jeon
- Corresponding author: Yunseok Jeon, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: 82-2-2072-3108, Fax: 82-2-747-8363 E-mail:
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Ramsingh D, Staab J, Flynn B. Application of perioperative hemodynamics today and potentials for tomorrow. Best Pract Res Clin Anaesthesiol 2021; 35:551-564. [PMID: 34801217 DOI: 10.1016/j.bpa.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 11/18/2022]
Abstract
Hemodynamic (HD) monitoring remains integral to the assessment and management of perioperative and critical care patients. This review article seeks to provide an update on the different types of flow-guided HD monitoring technologies available, highlight their limitations, and review the therapies associated with the application of these technologies. Additionally, we will also comment on the expanding roles of HD monitoring in the future.
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Affiliation(s)
- Davinder Ramsingh
- Department of Anesthesiology Loma Linda University Medical Center, Loma Linda, CA, USA; VP for Clinical and Medical Affairs, Edwards Lifesciences Critical Care Division, USA.
| | - Jared Staab
- Director of Perioperative Ultrasound, Program Director Critical Care Anesthesiology Fellowship, Department of Anesthesiology, University of Kansas Medical Center, USA.
| | - Brigid Flynn
- Chief, Division of Critical Care, Co-Director Cardiothoracic ICUChair Anesthesia Research Committee, Department of Anesthesiology, University of Kansas Medical, USA.
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Bodys-Pełka A, Kusztal M, Boszko M, Główczyńska R, Grabowski M. Non-Invasive Continuous Measurement of Haemodynamic Parameters-Clinical Utility. J Clin Med 2021; 10:jcm10214929. [PMID: 34768449 PMCID: PMC8584279 DOI: 10.3390/jcm10214929] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/15/2021] [Accepted: 10/20/2021] [Indexed: 11/16/2022] Open
Abstract
The evaluation and monitoring of patients’ haemodynamic parameters are essential in everyday clinical practice. The application of continuous, non-invasive measurement methods is a relatively recent solution. CNAP, ClearSight and many other technologies have been introduced to the market. The use of these techniques for assessing patient eligibility before cardiac procedures, as well as for intraoperative monitoring is currently being widely investigated. Their numerous advantages, including the simplicity of application, time- and cost-effectiveness, and the limited risk of infection, could enforce their further development and potential utility. However, some limitations and contradictions should also be discussed. The aim of this paper is to briefly describe the new findings, give practical examples of the clinical utility of these methods, compare them with invasive techniques, and review the literature on this subject.
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Affiliation(s)
- Aleksandra Bodys-Pełka
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.B.-P.); (M.K.); (M.B.); (M.G.)
- Doctoral School, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Maciej Kusztal
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.B.-P.); (M.K.); (M.B.); (M.G.)
| | - Maria Boszko
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.B.-P.); (M.K.); (M.B.); (M.G.)
| | - Renata Główczyńska
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.B.-P.); (M.K.); (M.B.); (M.G.)
- Correspondence: ; Tel.: +48-5992-616
| | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.B.-P.); (M.K.); (M.B.); (M.G.)
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15
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Lam S, Liu H, Jian Z, Settels J, Bohringer C. Intraoperative Invasive Blood Pressure Monitoring and the Potential Pitfalls of Invasively Measured Systolic Blood Pressure. Cureus 2021; 13:e17610. [PMID: 34646661 PMCID: PMC8483407 DOI: 10.7759/cureus.17610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 11/17/2022] Open
Abstract
Invasive intraarterial blood pressure measurement is currently the gold standard for intraoperative hemodynamic monitoring but accurate systolic blood pressure (SBP) measurement is difficult in everyday clinical practice, mostly because of problems with hyper-resonance or damping within the measurement system, which can lead to erroneous treatment decisions if these phenomena are not recognized. A hyper-resonant blood pressure trace significantly overestimates true systolic blood pressure while underestimating the diastolic pressure. Invasively measured systolic blood pressure is also significantly more affected than mean blood pressure by the site of measurement within the arterial system. Patients in the intraoperative period should be treated based on the invasively measured mean blood pressure rather than the systolic blood pressure. In this review, we discuss the pros/cons, mechanisms of invasive blood pressure measurements, and the interpretation of the invasively measured systolic blood pressure value.
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Affiliation(s)
- Sean Lam
- Anesthesiology, University of California, Davis Medical Center, Sacramento, USA
| | - Hong Liu
- Anesthesiology, University of California, Davis Medical Center, Sacramento, USA
| | | | - Jos Settels
- Bioengineering, Edwards Lifesciences, Irvine, USA
| | - Christian Bohringer
- Anesthesiology, University of California, Davis Medical Center, Sacramento, USA
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16
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Kachel E, Constantini K, Nachman D, Carasso S, Littman R, Eisenkraft A, Gepner Y. A Pilot Study of Blood Pressure Monitoring After Cardiac Surgery Using a Wearable, Non-invasive Sensor. Front Med (Lausanne) 2021; 8:693926. [PMID: 34422859 PMCID: PMC8375406 DOI: 10.3389/fmed.2021.693926] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Continuous blood pressure (BP) measurement in intensive care units is based on arterial line (AL) transducers, sometimes associated with clinical complications. Our objective was to evaluate continuous BP measurements obtained from a non-invasive, wireless photoplethysmography (PPG)-based device using two distinct configurations (wristwatch and chest-patch monitors) compared to an AL. Methods: In this prospective evaluation study, comparison of the PPG-based devices to the AL was conducted in 10 patients immediately following cardiac surgery. Pulse rate (PR), systolic BP (SBP), diastolic BP (DBP), and mean arterial pressure (MAP) were recorded using both the AL and the PPG-based devices simultaneously for an average of 432 ± 290 min starting immediately after cardiac surgery. Bland-Altman plots and Pearson's correlations were used to assess the accuracy and degree of agreement between techniques. Results: A total of ~4,000 data points were included in the final analysis. AL measurements for PR, SBP, DBP and MAP were significantly (p < 0.001) and strongly correlated with both the wristwatch (r = 0.99, r = 0.94, r = 0.93 and r = 0.96, respectively) and the chest-patch (r = 0.99, r = 0.95, r = 0.93 and r = 0.95, respectively) monitors. Both configurations showed a marginal bias of <1 mmHg for BP measurements and <1 beat/min for PR [95% limits of agreement -3,3 beat/min; BP measurements: (-6)-(-10), 6-10 mmHg] compared to AL measurements. Conclusion: The PPG-based devices offer a high level of accuracy for cardiac-related parameters compared to an AL in post-cardiac surgery patients. Such devices could provide advanced monitoring capabilities in a variety of clinical settings, including immediate post-operative and intensive care unit settings. Clinical Trial Registration:www.clinicaltrials.gov, NCT03603860.
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Affiliation(s)
- Erez Kachel
- Division of Cardiac Surgery, Cardiovascular Center, Padeh-Poriya Hospital, Tiberias, Israel.,Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel
| | - Keren Constantini
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine and Sylvan Adams Sports Institute, Tel Aviv University, Tel Aviv, Israel
| | - Dean Nachman
- Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel.,Israel Defense Force Medical Corps, Tel Aviv, Israel.,Heart Institute, Hadassah Ein Kerem Medical Center, Jerusalem, Israel
| | - Shemy Carasso
- Division of Cardiac Surgery, Cardiovascular Center, Padeh-Poriya Hospital, Tiberias, Israel.,Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel
| | | | - Arik Eisenkraft
- Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel.,Israel Defense Force Medical Corps, Tel Aviv, Israel.,Biobeat Technologies Ltd., Petah Tikva, Israel
| | - Yftach Gepner
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine and Sylvan Adams Sports Institute, Tel Aviv University, Tel Aviv, Israel
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17
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Pal A, Martinez F, Aguila AP, Akey MA, Chatterjee R, Conserman MGE, Aysola RS, Henderson LA, Macey PM. Beat-to-beat blood pressure variability in patients with obstructive sleep apnea. J Clin Sleep Med 2021; 17:381-392. [PMID: 33089774 DOI: 10.5664/jcsm.8866] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
STUDY OBJECTIVES Cardiovascular comorbidities in obstructive sleep apnea (OSA) are difficult to treat, perhaps due to autonomic dysfunction. We assessed beat-to-beat blood pressure (BP) variability (BPV) in OSA while considering other markers derived from electrocardiogram and continuous BP signals. METHODS We studied 66 participants (33 participants with OSA: respiratory event index [mean ± SEM]: 21.1 ± 2.7 events/h; 12 females, aged 51.5 ± 2.4 years; body mass index: 32.8 ± 1.4 kg/m²; 33 healthy controls: 20 females; aged 45.3 ± 2.4 years; body mass index: 26.3 ± 0.7 kg/m²). We collected 5-minute resting noninvasive beat-to-beat BP and electrocardiogram values. From BP, we derived systolic, diastolic, and mean BP values, and calculated variability as standard deviations (systolic BPV, diastolic BPV, BPV). We also calculated diastole-to-systole time (time to peak). From the electrocardiogram, we derived QRS markers and calculated heart rate and heart rate variability. We performed a multivariate analysis of variance based on sex and group (OSA vs control), with Bonferroni-corrected post hoc comparisons (P ≤ .05) between groups. We calculated correlations of BPV with biological variables. RESULTS Multivariate analysis of variance showed effects of diastolic BPV and BPV in OSA; post hoc comparisons revealed high diastolic BPV and BPV only in female participants with OSA vs controls. QRS duration was higher in OSA, with post hoc comparisons showing the effect only in males. BPV correlated positively with heart rate variability in controls but not in participants with OSA. BPV correlated positively with time to peak in females with OSA and OSA combined, whereas there was no BPV-time-to-peak correlation in healthy participants. CONCLUSIONS The findings show sex-specific autonomic dysfunction reflected in beat-to-beat BP in OSA. The higher BPV may reflect poor baroreflex control or vascular damage in OSA, which are potential precursors to cardiovascular complications.
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Affiliation(s)
- Amrita Pal
- UCLA School of Nursing, Los Angeles, California
| | | | | | | | | | | | - Ravi S Aysola
- Division of Pulmonary and Critical Care, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California
| | - Luke A Henderson
- Department of Anatomy and Histology, Sydney Medical School, University of Sydney, Sydney, Australia
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18
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Sivakorn C, Schultz MJ, Dondorp AM. How to monitor cardiovascular function in critical illness in resource-limited settings. Curr Opin Crit Care 2021; 27:274-281. [PMID: 33899817 PMCID: PMC8240644 DOI: 10.1097/mcc.0000000000000830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Hemodynamic monitoring is an essential component in the care for critically ill patients. A range of tools are available and new approaches have been developed. This review summarizes their availability, affordability and feasibility for hospital settings in resource-limited settings. RECENT FINDINGS Evidence for the performance of specific hemodynamic monitoring tools or strategies in low-income and middle-income countries (LMICs) is limited. Repeated physical examination and basic observations remain a cornerstone for patient monitoring and have a high sensitivity for detecting organ hypoperfusion, but with a low specificity. Additional feasible approaches for hemodynamic monitoring in LMICs include: for tissue perfusion monitoring: urine output, skin mottling score, capillary refill time, skin temperature gradients, and blood lactate measurements; for cardiovascular monitoring: echocardiography and noninvasive or minimally invasive cardiac output measurements; and for fluid status monitoring: inferior vena cava distensibility index, mini-fluid challenge test, passive leg raising test, end-expiratory occlusion test and lung ultrasound. Tools with currently limited applicability in LMICs include microcirculatory monitoring devices and pulmonary artery catheterization, because of costs and limited added value. Especially ultrasound is a promising and affordable monitoring device for LMICs, and is increasingly available. SUMMARY A set of basic tools and approaches is available for adequate hemodynamic monitoring in resource-limited settings. Future research should focus on the development and trialing of robust and context-appropriate monitoring technologies.
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Affiliation(s)
| | - Marcus J. Schultz
- Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine Mahidol University, Bangkok, Thailand
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Arjen M. Dondorp
- Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine Mahidol University, Bangkok, Thailand
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
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19
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Dhiman A, Fenton E, Whitridge J, Belanski J, Petersen W, Macaraeg S, Rangrass G, Shergill A, Micic D, Eng OS, Turaga K. Guide to Enhanced Recovery for Cancer Patients Undergoing Surgery: ERAS for Patients Undergoing Cytoreductive Surgery with or Without HIPEC. Ann Surg Oncol 2021; 28:6955-6964. [PMID: 33954868 DOI: 10.1245/s10434-021-09973-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/19/2021] [Indexed: 12/22/2022]
Abstract
ERAS protocols may reduce length of stay and return to full functional recovery after cytoreductive surgery and HIPEC. Prehabilitation programs and post-operative goal directed pathways, along with other essential components of ERAS are discussed with supporting evidence.
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Affiliation(s)
- Ankit Dhiman
- Department of Surgery, University of Chicago, 5841 S. Maryland Ave, MC 5094, Chicago, IL, 60637, USA
| | - Emily Fenton
- Department of Surgery, University of Chicago, 5841 S. Maryland Ave, MC 5094, Chicago, IL, 60637, USA
| | - Jeffrey Whitridge
- University of Chicago Comprehensive Cancer Center, University of Chicago, Chicago, IL, USA
| | - Jennifer Belanski
- University of Chicago Comprehensive Cancer Center, University of Chicago, Chicago, IL, USA
| | - Whitney Petersen
- Department of Surgery, University of Chicago, 5841 S. Maryland Ave, MC 5094, Chicago, IL, 60637, USA
| | - Sarah Macaraeg
- University of Chicago Comprehensive Cancer Center, University of Chicago, Chicago, IL, USA
| | - Govind Rangrass
- Department of Anesthesiology, University of Chicago, Chicago, IL, USA
| | | | - Dejan Micic
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Oliver S Eng
- Department of Surgery, University of Chicago, 5841 S. Maryland Ave, MC 5094, Chicago, IL, 60637, USA
| | - Kiran Turaga
- Department of Surgery, University of Chicago, 5841 S. Maryland Ave, MC 5094, Chicago, IL, 60637, USA.
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20
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Koopmans NK, Stolmeijer R, Sijtsma BC, van Beest PA, Boerma CE, Veeger NJ, Ter Avest E. Non-invasive assessment of fluid responsiveness to guide fluid therapy in patients with sepsis in the emergency department: a prospective cohort study. Emerg Med J 2021; 38:416-422. [PMID: 33888514 PMCID: PMC8165141 DOI: 10.1136/emermed-2020-209771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 02/08/2021] [Accepted: 03/21/2021] [Indexed: 12/20/2022]
Abstract
Background Little is known about optimal fluid therapy for patients with sepsis without shock who present to the ED. In this study, we aimed to quantify the effect of a fluid challenge on non-invasively measured Cardiac Index (CI) in patients presenting with sepsis without shock. Methods In a prospective cohort study, CI, stroke volume (SV) and systemic vascular resistance (SVR) were measured non-invasively in 30 patients presenting with sepsis without shock to the ED of a large teaching hospital in the Netherlands between May 2018 and March 2019 using the ClearSight system. After baseline measurements were performed, a passive leg raise (PLR) was done to simulate a fluid bolus. Measurements were then repeated 30, 60, 90 and 120 s after PLR. Finally, a standardised 500 mL NaCl 0.9% intravenous bolus was administered after which final measurements were done. Fluid responsiveness was defined as >15% increase in CI after a standardised fluid challenge. Measurements and main results Seven out of 30 (23%) patients demonstrated a >15% increase in CI after PLR and after a 500 mL fluid bolus. Fluid responders had a higher estimated glomerular filtration rate (eGFR) (64 (44–78) vs 37 (23–47), p=0.009) but otherwise similar patient and treatment characteristics as non-responders. Baseline measurements of cardiac output (CO), CI, SV and SVR were unrelated to PLR fluid responsiveness. The change in CI after PLR was strongly positive correlated to the change in CI after a 500 mL NaCl 0.9% fluid bolus (r=0.88, p<0.001). Conclusion The results of the present study demonstrate that in patients with sepsis in the absence of shock, three out of four patients do not demonstrate a clinically relevant increase in CI after a standardised fluid challenge. Non-invasive CO monitoring in combination with a PLR test has the potential to identify patients who might benefit from fluid resuscitation and may contribute to a better tailored treatment of these patients.
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Affiliation(s)
- Nienke K Koopmans
- Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Renate Stolmeijer
- Emergency Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Ben C Sijtsma
- Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Paul A van Beest
- Anesthesiology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Christiaan E Boerma
- Intensive Care Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Nic J Veeger
- Epidemiology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.,Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ewoud Ter Avest
- Emergency Medicine, University Medical Centre Groningen, Groningen, The Netherlands .,Air Ambulance Kent, Surrey and Sussex, Redhill, UK
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21
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Lopez CN, Sulaica EM, Donahue KR, Wanat MA. Updates in Hemodynamic Monitoring: A Review for Pharmacists. J Pharm Pract 2021; 35:762-768. [PMID: 33769132 DOI: 10.1177/08971900211003436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Vital signs are regularly monitored in hospitalized patients. In the intensive care unit (ICU), traditional non-invasive blood pressure monitoring and telemetry may not provide enough information to determine the etiology of hemodynamic instability or guide intervention. Arterial catheters remain the gold-standard for continuous blood pressure monitoring and are commonly used in ICU patients. Pulmonary artery catheters and central venous catheters are beneficial in select patient populations and provide more advanced and specific information about a patient's hemodynamics. However, neither are benign and can increase risk of complications such as infection, arrhythmias, pneumothorax and vascular or valvular damage. In the past 10 years, the development of reliable non-invasive (NICOM), or minimally-invasive (MICOM), cardiac output monitoring devices has accelerated. The MICOM devices require an arterial catheter to obtain hemodynamic values, whereas NICOM devices do not require any arterial or venous access. These devices have emerged to be particularly useful in evaluating and managing patients with suspected mixed shock. As these devices become more prevalent, it is imperative that clinical pharmacists become familiar with interpreting this data as it may have a substantial impact on medication selection and optimization. This review will discuss the basics of NICOM and MICOM devices, limitations with these methods of monitoring, and clinical application for pharmacists.
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Affiliation(s)
- Chelsea N Lopez
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Elisabeth M Sulaica
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Kevin R Donahue
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Matthew A Wanat
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA.,Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
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22
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Dose requirement and cardiopulmonary effects of diluted and undiluted propofol for induction of anaesthesia in dogs. Vet Anaesth Analg 2020; 48:247-251. [PMID: 33423952 DOI: 10.1016/j.vaa.2020.10.008] [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: 12/29/2019] [Revised: 10/08/2020] [Accepted: 10/23/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the dose, cardiopulmonary effects and quality of anaesthetic induction in dogs using propofol (10 mg mL-1) and diluted propofol (5 mg mL-1). STUDY DESIGN Randomized, blinded, clinical study. ANIMALS A total of 28 client-owned dogs (12 males/16 females). METHODS Following intramuscular acepromazine (0.02 mg kg-1) and methadone (0.2 mg kg-1), propofol (UP, 10 mg mL-1) or diluted propofol (DP, 5 mg mL-1) was administered intravenously (0.2 mL kg-1 minute-1) by an anaesthetist unaware of the allocated group to achieve tracheal intubation. Sedation, intubation and induction quality were scored from 0 to 3. Pre- and post-induction pulse rate (PR), respiratory rate (fR) and systolic (SAP), mean (MAP) and diastolic (DAP) arterial blood pressure were compared. Time to first breath and induction dose were recorded. Data were analysed for normality and Mann-Whitney U or Student t tests were performed where appropriate. Significance was set at p < 0.05. Data are presented as mean ± standard deviation or median (range). RESULTS The propofol dose administered to achieve induction was lower in the DP group (2.62 ± 0.48 mg kg-1) than in the UP group (3.48 ± 1.17 mg kg-1) (p = 0.021). No difference was observed in pre- and post-induction PR, SAP, MAP, DAP and fR between groups. The differences between post-induction and pre-induction values of these variables were also similar between groups. Time to first breath did not differ between groups. Sedation scores were similar between groups. Quality of tracheal intubation was marginally better with UP 0 (0-1) than with DP 1 (0-2) (p = 0.036), but overall quality of induction was similar between groups [UP 0 (0-1) and DP 0 (0-1), p = 0.549]. CONCLUSION AND CLINICAL RELEVANCE Diluting propofol reduced the dose to induce anaesthesia without significantly altering the cardiopulmonary variables.
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23
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Bonnemain J, Pegolotti L, Liaudet L, Deparis S. Implementation and Calibration of a Deep Neural Network to Predict Parameters of Left Ventricular Systolic Function Based on Pulmonary and Systemic Arterial Pressure Signals. Front Physiol 2020; 11:1086. [PMID: 33071803 PMCID: PMC7533610 DOI: 10.3389/fphys.2020.01086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 08/06/2020] [Indexed: 01/06/2023] Open
Abstract
The evaluation of cardiac contractility by the assessment of the ventricular systolic elastance function is clinically challenging and cannot be easily obtained at the bedside. In this work, we present a framework characterizing left ventricular systolic function from clinically readily available data, including systemic and pulmonary arterial pressure signals. We implemented and calibrated a deep neural network (DNN) consisting of a multi-layer perceptron with 4 fully connected hidden layers and with 16 neurons per layer, which was trained with data obtained from a lumped model of the cardiovascular system modeling different levels of cardiac function. The lumped model included a function of circulatory autoregulation from carotid baroreceptors in pulsatile conditions. Inputs for the DNN were systemic and pulmonary arterial pressure curves. Outputs from the DNN were parameters of the lumped model characterizing left ventricular systolic function, especially end-systolic elastance. The DNN adequately performed and accurately recovered the relevant hemodynamic parameters with a mean relative error of less than 2%. Therefore, our framework can easily provide complex physiological parameters of cardiac contractility, which could lead to the development of invaluable tools for the clinical evaluation of patients with severe cardiac dysfunction.
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Affiliation(s)
- Jean Bonnemain
- Adult Intensive Care and Burn Unit, University Hospital and University of Lausanne, Lausanne, Switzerland.,SCI-SB-SD, School of Basic Sciences, Ecole Polytechnique Fédérale de Lausanne, Institute of Mathematics, Lausanne, Switzerland
| | - Luca Pegolotti
- SCI-SB-SD, School of Basic Sciences, Ecole Polytechnique Fédérale de Lausanne, Institute of Mathematics, Lausanne, Switzerland
| | - Lucas Liaudet
- Adult Intensive Care and Burn Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Simone Deparis
- SCI-SB-SD, School of Basic Sciences, Ecole Polytechnique Fédérale de Lausanne, Institute of Mathematics, Lausanne, Switzerland
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24
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Sengupta SP, Mungulmare K, Okwose NC, MacGowan GA, Jakovljevic DG. Comparison of cardiac output estimates by echocardiography and bioreactance at rest and peak dobutamine stress test in heart failure patients with preserved ejection fraction. Echocardiography 2020; 37:1603-1609. [PMID: 32949037 DOI: 10.1111/echo.14836] [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: 06/15/2020] [Revised: 07/25/2020] [Accepted: 08/02/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To assess the agreement between cardiac output estimated by two-dimensional echocardiography and bioreactance methods at rest and during dobutamine stress test in heart failure patients with preserved left ventricular ejection fraction (HFpEF). METHODS Hemodynamic measurements were assessed in 20 stable HFpEF patients (12 females; aged 61 ± 7 years) using echocardiography and bioreactance methods during rest and dobutamine stress test at increment dosages of 5, 10, 15, and 20 μg/kg/min until maximal dose was achieved or symptoms and sign occurred, that is, chest pain, abnormal blood pressure elevation, breathlessness, ischemic changes, or arrhythmia. RESULTS Resting cardiac output and cardiac index estimated by bioreactance and echocardiography were not significantly different. At peak dobutamine stress test, cardiac output and cardiac index estimated by echocardiography and bioreactance were significantly different (7.06 ± 1.43 vs 5.71 ± 1.59 L/min, P < .01; and 4.27 ± 0.67 vs 3.43 ± 0.87 L/m2 /min; P < .01) due to the significant differences in stroke volume. There was a strong positive relationship between cardiac outputs obtained by the two methods at peak dobutamine stress (r = .79, P < .01). The mean difference (lower and upper limits of agreement) between bioreactance and echocardiography cardiac outputs at rest and peak dobutamine stress was -0.45 (1.71 to -2.62) L/min and -1.35 (0.60 to -3.31) L/min, respectively. CONCLUSION Bioreactance and echocardiography methods provide different cardiac output values at rest and during stress thus cannot be used interchangeably. Ability to continuously monitor key hemodynamic variables such as cardiac output, stroke volume, and heart rate is the major advantage of bioreactance method.
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Affiliation(s)
- Shantanu P Sengupta
- Cardiology, Sengupta Hospital and Research Institute, Ravinagar Nagpur, Maharashtra, India.,Faculty of Medical Sciences, Cardiovascular Research Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Kunda Mungulmare
- Cardiology, Sengupta Hospital and Research Institute, Ravinagar Nagpur, Maharashtra, India
| | - Nduka C Okwose
- Faculty of Medical Sciences, Cardiovascular Research Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Guy A MacGowan
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Faculty of Medical Sciences, Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Djordje G Jakovljevic
- Faculty of Medical Sciences, Cardiovascular Research Translational and Clinical Research Institute, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Faculty of Health and Life Sciences, Coventry University, Coventry, UK
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25
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Al-Qatatsheh A, Morsi Y, Zavabeti A, Zolfagharian A, Salim N, Z. Kouzani A, Mosadegh B, Gharaie S. Blood Pressure Sensors: Materials, Fabrication Methods, Performance Evaluations and Future Perspectives. SENSORS (BASEL, SWITZERLAND) 2020; 20:E4484. [PMID: 32796604 PMCID: PMC7474433 DOI: 10.3390/s20164484] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 12/14/2022]
Abstract
Advancements in materials science and fabrication techniques have contributed to the significant growing attention to a wide variety of sensors for digital healthcare. While the progress in this area is tremendously impressive, few wearable sensors with the capability of real-time blood pressure monitoring are approved for clinical use. One of the key obstacles in the further development of wearable sensors for medical applications is the lack of comprehensive technical evaluation of sensor materials against the expected clinical performance. Here, we present an extensive review and critical analysis of various materials applied in the design and fabrication of wearable sensors. In our unique transdisciplinary approach, we studied the fundamentals of blood pressure and examined its measuring modalities while focusing on their clinical use and sensing principles to identify material functionalities. Then, we carefully reviewed various categories of functional materials utilized in sensor building blocks allowing for comparative analysis of the performance of a wide range of materials throughout the sensor operational-life cycle. Not only this provides essential data to enhance the materials' properties and optimize their performance, but also, it highlights new perspectives and provides suggestions to develop the next generation pressure sensors for clinical use.
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Affiliation(s)
- Ahmed Al-Qatatsheh
- Faculty of Science, Engineering, and Technology (FSET), Swinburne University of Technology, Melbourne VIC 3122, Australia; (Y.M.); (N.S.)
| | - Yosry Morsi
- Faculty of Science, Engineering, and Technology (FSET), Swinburne University of Technology, Melbourne VIC 3122, Australia; (Y.M.); (N.S.)
| | - Ali Zavabeti
- Department of Chemical Engineering, The University of Melbourne, Parkville VIC 3010, Australia;
| | - Ali Zolfagharian
- Faculty of Science, Engineering and Built Environment, School of Engineering, Deakin University, Waurn Ponds VIC 3216, Australia; (A.Z.); (A.Z.K.)
| | - Nisa Salim
- Faculty of Science, Engineering, and Technology (FSET), Swinburne University of Technology, Melbourne VIC 3122, Australia; (Y.M.); (N.S.)
| | - Abbas Z. Kouzani
- Faculty of Science, Engineering and Built Environment, School of Engineering, Deakin University, Waurn Ponds VIC 3216, Australia; (A.Z.); (A.Z.K.)
| | - Bobak Mosadegh
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medicine, New York, NY 10065, USA;
| | - Saleh Gharaie
- Faculty of Science, Engineering and Built Environment, School of Engineering, Deakin University, Waurn Ponds VIC 3216, Australia; (A.Z.); (A.Z.K.)
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Su Y, Liu K, Zheng JL, Li X, Zhu DM, Zhang Y, Zhang YJ, Wang CS, SHI TT, Luo Z, Tu GW. Hemodynamic monitoring in patients with venoarterial extracorporeal membrane oxygenation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:792. [PMID: 32647717 PMCID: PMC7333156 DOI: 10.21037/atm.2020.03.186] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective mechanical circulatory support modality that rapidly restores systemic perfusion for circulatory failure in patients. Given the huge increase in VA-ECMO use, its optimal management depends on continuous and discrete hemodynamic monitoring. This article provides an overview of VA-ECMO pathophysiology, and the current state of the art in hemodynamic monitoring in patients with VA-ECMO.
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Affiliation(s)
- Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ji-Li Zheng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xin Li
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Du-Ming Zhu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ying Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yi-Jie Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Chun-Sheng Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Tian-Tian SHI
- Department of medicine, Yale New Haven Health/Bridgeport Hospital, Bridgeport, USA
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen 361015, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Hou JY, Zheng JL, Ma GG, Lin XM, Hao GW, Su Y, Luo JC, Liu K, Luo Z, Tu GW. Evaluation of radial artery pulse pressure effects on detection of stroke volume changes after volume loading maneuvers in cardiac surgical patients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:787. [PMID: 32647712 PMCID: PMC7333092 DOI: 10.21037/atm-20-847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fluid responsiveness is defined as an increase in cardiac output (CO) or stroke volume (SV) of >10-15% after fluid challenge (FC). However, CO or SV monitoring is often not available in clinical practice. The aim of this study was to evaluate whether changes in radial artery pulse pressure (rPP) induced by FC or passive leg raising (PLR) correlates with changes in SV in patients after cardiac surgery. METHODS This prospective observational study included 102 patients undergoing cardiac surgery, in which rPP and SV were recorded before and immediately after a PLR test and FC with 250 mL of Gelofusine for 10 min. SV was measured using pulse contour analysis. Patients were divided into responders (≥15% increase in SV after FC) and non-responders. The hemodynamic variables between responders and non-responders were analyzed to assess the ability of rPP to track SV changes. RESULTS A total of 52% patients were fluid responders in this study. An rPP increase induced by FC was significantly correlated with SV changes after a FC (ΔSV-FC, r=0.62, P<0.01). A fluid-induced increase in rPP (ΔrPP-FC) of >16% detected a fluid-induced increase in SV of >15%, with a sensitivity of 91% and a specificity of 73%. The area under the receiver operating characteristic curve (AUROC) for the fluid-induced changes in rPP identified fluid responsiveness was 0.881 (95% CI: 0.802-0.937). A grey zone of 16-34% included 30% of patients for ΔrPP-FC. The ΔrPP-PLR was weakly correlated with ΔSV-FC (r=0.30, P<0.01). An increase in rPP induced by PLR (ΔrPP-PLR) predicted fluid responsiveness with an AUROC of 0.734 (95% CI: 0.637-0.816). A grey zone of 10-23% included 52% of patients for ΔrPP-PLR. CONCLUSIONS Changes in rPP might be used to detect changes in SV via FC in mechanically ventilated patients after cardiac surgery. In contrast, changes in rPP induced by PLR are unreliable predictors of fluid responsiveness.
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Affiliation(s)
- Jun-Yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji-Li Zheng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Guang Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao-Ming Lin
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Guang-Wei Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
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Vazquez Martinez JL. Volume load during major abdominal surgery: focusing on the fluid responsiveness. Minerva Anestesiol 2020; 86:473-475. [PMID: 32100516 DOI: 10.23736/s0375-9393.20.14328-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Jose L Vazquez Martinez
- Pediatric Intensive Care Unit, Pediatrics Department, University Hospital Ramón y Cajal, Madrid, Spain -
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29
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Wagner M, Anzinger E, Hey F, Reiter K, Wermelt JZ, Pastor-Villaescusa B, Genzel-Boroviczény O, Nussbaum C. Monitoring of the microcirculation in children undergoing major abdominal and thoracic surgery: A pilot study. Clin Hemorheol Microcirc 2017; 83:217-229. [PMID: 36502307 PMCID: PMC10116146 DOI: 10.3233/ch-221617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND: Monitoring of the macrocirculation during surgery provides limited information on the quality of organ perfusion. OBJECTIVE: We investigated the feasibility of perioperative microcirculatory measurements in children. METHODS: Sublingual microvessels were visualized by handheld videomicroscopy in 11 children (19 mo – 10 yrs) undergoing surgery > 120 min at four time points: T0) after induction of anesthesia; T1) before end of anesthesia, T2) 6 h post surgery and T3) 24 h post surgery. RESULTS: Measurements were feasible in all children at T0 and T1. At T2 and T3, imaging was restricted to 6 and 4 infants, respectively, due to respiratory compromise and missing cooperation. The capillary density was reduced at T1 compared to T0 (8.1 mm/mm2 [4.0-17.0] vs. 10.6 mm/mm2 [5.1-19.3]; p = 0.01), and inversely related to norepinephrine dose (Pearson r = -0.65; p = 0.04). Microvascular flow and serum glycocalyx makers Syndecan-1 and Hyaluronan increased significantly from T0 to T1. CONCLUSION: Perioperative microcirculatory monitoring in children requires a high amount of personal and logistic resources still limiting its routine use. Major surgery is associated with microvascular alterations and glycocalyx perturbation. The possible consequences on patient outcome need further evaluation. Efforts should concentrate on the development of next generation devices designed to facilitate microcirculatory monitoring in children.
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Affiliation(s)
- Marie Wagner
- Department of Pediatrics, Division of Neonatology, Dr von Hauner Children’s Hospital, University Hospital, LMU Munich, Germany
| | - Eveline Anzinger
- Department of Pediatrics, Division of Neonatology, Dr von Hauner Children’s Hospital, University Hospital, LMU Munich, Germany
| | - Florian Hey
- Department of Pediatrics, Pediatric Intensive Care Unit, Dr von Hauner Children’s Hospital, University Hospital, LMU, Munich, Germany
| | - Karl Reiter
- Department of Pediatrics, Pediatric Intensive Care Unit, Dr von Hauner Children’s Hospital, University Hospital, LMU, Munich, Germany
| | - Julius Z. Wermelt
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
- Department of Anesthesiology, Bürgerhospital und Clementine Kinderhospital gGmbH, Teaching Hospital of the University Frankfurt, Frankfurt, Germany
| | - Belén Pastor-Villaescusa
- Metabolism in Childhood Research Group, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Córdoba, Spain
| | - Orsolya Genzel-Boroviczény
- Department of Pediatrics, Division of Neonatology, Dr von Hauner Children’s Hospital, University Hospital, LMU Munich, Germany
| | - Claudia Nussbaum
- Department of Pediatrics, Division of Neonatology, Dr von Hauner Children’s Hospital, University Hospital, LMU Munich, Germany
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