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Ji JY, Seo YH, Jung HS, Chun HR, Park JS, Kim WJ, Ahn JM, Park YJ, Shin YE, Park CH. Coronary Artery Occlusion with Sharp Blood Pressure Drop during General Anesthesia Induction: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:232. [PMID: 38399520 PMCID: PMC10890261 DOI: 10.3390/medicina60020232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024]
Abstract
Most anesthetics reduce cardiac functions and lower blood pressure (BP), potentially causing excessive BP reduction in dehydrated patients or those with heart conditions, such as coronary artery disease (CAD). Considering the increased prevalence of cardiovascular disease with age, anesthesiologists must be cautious about BP reduction during general anesthesia in older adults. In the present case, a 76-year-old male patient with undiagnosed CAD in a hypovolemic state experienced a significant drop in systolic BP to the fifties during propofol and sevoflurane anesthesia. Despite the use of vasopressors, excessive hypotension persisted, leading to anesthesia suspension. Subsequent cardiac examinations, including computed tomography heart angio and calcium score, and coronary angiogram, revealed a near total occlusion of the proximal left anterior descending coronary artery (pLAD) and the formation of collateral circulation. After 5 days of hydration and anticoagulation medications and confirmation of normovolemic state, general anesthesia was attempted again and successfully induced; a normal BP was maintained throughout the surgery. Thus, it is important to conduct a thorough cardiac evaluation and maintain normovolemia for general anesthesia in older adults.
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Affiliation(s)
- Jae Young Ji
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Yong Han Seo
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Ho Soon Jung
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Hea Rim Chun
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Jin Soo Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Woo Jong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea;
| | - Jae Min Ahn
- Department of Neurosurgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea;
| | - Yu Jun Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Ye Eun Shin
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (J.Y.J.); (H.S.J.); (H.R.C.); (J.S.P.); (Y.J.P.); (Y.E.S.)
| | - Chan Ho Park
- Department of Radiology, Soonchunhyang University Hospital Cheonan, 31, Sooncheonhyang 6-gil, Donam-gu, Cheonan 31151, Republic of Korea;
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Lambert TP, Chan M, Sanchez-Perez JA, Nikbakht M, Lin DJ, Nawar A, Bashar SK, Kimball JP, Zia JS, Gazi AH, Cestero GI, Corporan D, Padala M, Hahn JO, Inan OT. A Comparison of Normalization Techniques for Individual Baseline-Free Estimation of Absolute Hypovolemic Status Using a Porcine Model. BIOSENSORS 2024; 14:61. [PMID: 38391980 PMCID: PMC10886994 DOI: 10.3390/bios14020061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/07/2024] [Accepted: 01/16/2024] [Indexed: 02/24/2024]
Abstract
Hypovolemic shock is one of the leading causes of death in the military. The current methods of assessing hypovolemia in field settings rely on a clinician assessment of vital signs, which is an unreliable assessment of hypovolemia severity. These methods often detect hypovolemia when interventional methods are ineffective. Therefore, there is a need to develop real-time sensing methods for the early detection of hypovolemia. Previously, our group developed a random-forest model that successfully estimated absolute blood-volume status (ABVS) from noninvasive wearable sensor data for a porcine model (n = 6). However, this model required normalizing ABVS data using individual baseline data, which may not be present in crisis situations where a wearable sensor might be placed on a patient by the attending clinician. We address this barrier by examining seven individual baseline-free normalization techniques. Using a feature-specific global mean from the ABVS and an external dataset for normalization demonstrated similar performance metrics compared to no normalization (normalization: R2 = 0.82 ± 0.025|0.80 ± 0.032, AUC = 0.86 ± 5.5 × 10-3|0.86 ± 0.013, RMSE = 28.30 ± 0.63%|27.68 ± 0.80%; no normalization: R2 = 0.81 ± 0.045, AUC = 0.86 ± 8.9 × 10-3, RMSE = 28.89 ± 0.84%). This demonstrates that normalization may not be required and develops a foundation for individual baseline-free ABVS prediction.
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Affiliation(s)
- Tamara P. Lambert
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (M.C.); (O.T.I.)
| | - Michael Chan
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (M.C.); (O.T.I.)
| | - Jesus Antonio Sanchez-Perez
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
| | - Mohammad Nikbakht
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
| | - David J. Lin
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
| | - Afra Nawar
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
| | - Syed Khairul Bashar
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
| | - Jacob P. Kimball
- The Donald P. Shiley School of Engineering, University of Portland, Portland, OR 97203, USA;
| | - Jonathan S. Zia
- Division of Neurology & Neurological Sciences, Stanford School of Medicine, Palo Alto, CA 94304, USA;
| | - Asim H. Gazi
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Allston, MA 02134, USA;
| | - Gabriela I. Cestero
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
| | - Daniella Corporan
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, GA 30308, USA; (D.C.); (M.P.)
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, GA 30308, USA; (D.C.); (M.P.)
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jin-Oh Hahn
- Department of Mechanical Engineering, University of Maryland, College Park, MD 20742, USA;
| | - Omer T. Inan
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (M.C.); (O.T.I.)
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; (J.A.S.-P.); (M.N.); (D.J.L.); (A.N.); (S.K.B.); (G.I.C.)
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Cubeddu F, Masala G, Sotgiu G, Mollica A, Versace S, Careddu GM. Cardiorespiratory Effects and Desflurane Requirement in Dogs Undergoing Ovariectomy after Administration Maropitant or Methadone. Animals (Basel) 2023; 13:2388. [PMID: 37508165 PMCID: PMC10376119 DOI: 10.3390/ani13142388] [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: 06/19/2023] [Revised: 07/08/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
General anesthesia for ovariectomy in dogs is based on a balanced anesthesia protocol such as using analgesics along with an inhalant agent. While opioids such as fentanyl and methadone are commonly used for their analgesic potency, other drugs can also have analgesic effects. Maropitant, an antiemetic for dogs and cats, has also been shown to exert analgesic effects, especially on visceral pain. The aim of this study was to compare the cardiorespiratory effects and analgesic properties of maropitant and methadone combined with desflurane in dogs undergoing ovariectomy. Two groups of 20 healthy mixed-breeds bitches undergoing elective ovariectomy received intravenous either maropitant at antiemetic dose of 1 mg kg-1 or methadone at the dose of 0.3 mg kg-1. Cardiorespiratory variables were collected before premedication, 10 min after sedation and during surgery. Recovery quality and postoperative pain were evaluated 15, 30, 60, 120, 240 and 360 min postoperatively. Results showed that maropitant produced analgesia and reduced the requirement of desflurane in amounts similar to those determined by methadone (5.39 ± 0.20% and 4.91 ± 0.26%, respectively) without significant difference, while maintaining heart rate, arterial blood pressure, respiratory rate and carbon dioxide end-tidal partial pressure even at a more satisfactory level. Therefore, maropitant may be recommended as an analgesic drug for abdominal surgery not only in healthy dogs but also in those with reduced cardiorespiratory compensatory capacities or at risk of hypotension, especially when combined with a sedative such as dexmedetomidine.
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Affiliation(s)
- Francesca Cubeddu
- Department of Veterinary Medicine, University of Sassari, Via Vienna 2, 07100 Sassari, Italy
| | - Gerolamo Masala
- Department of Veterinary Medicine, University of Sassari, Via Vienna 2, 07100 Sassari, Italy
| | - Giovanni Sotgiu
- Department of Surgical and Experimental Medical Sciences Medicine, Surgery and Pharmacy, University of Sassari, Viale San Pietro 43, 07100 Sassari, Italy
| | - Alessandra Mollica
- Department of Veterinary Medicine, University of Sassari, Via Vienna 2, 07100 Sassari, Italy
| | - Sylvia Versace
- Department of Veterinary Medicine, University of Sassari, Via Vienna 2, 07100 Sassari, Italy
| | - Giovanni Mario Careddu
- Department of Veterinary Medicine, University of Sassari, Via Vienna 2, 07100 Sassari, Italy
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Wieser M, Beckmann KM, Kutter APN, Mauri N, Richter H, Zölch N, Bektas RN. Ketamine administration in idiopathic epileptic and healthy control dogs: Can we detect differences in brain metabolite response with spectroscopy? Front Vet Sci 2023; 9:1093267. [PMID: 36686158 PMCID: PMC9853535 DOI: 10.3389/fvets.2022.1093267] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction In recent years ketamine has increasingly become the focus of multimodal emergency management for epileptic seizures. However, little is known about the effect of ketamine on brain metabolites in epileptic patients. Magnetic resonance spectroscopy (MRS) is a non-invasive technique to estimate brain metabolites in vivo. Our aim was to measure the effect of ketamine on thalamic metabolites in idiopathic epileptic (IE) dogs using 3 Tesla MRS. We hypothesized that ketamine would increase the glutamine-glutamate (GLX)/creatine ratio in epileptic dogs with and without antiseizure drug treatment, but not in control dogs. Furthermore, we hypothesized that no different responses after ketamine administration in other measured brain metabolite ratios between the different groups would be detected. Methods In this controlled prospective experimental trial IE dogs with or without antiseizure drug treatment and healthy client-owned relatives of the breeds Border Collie and Greater Swiss Mountain Dog, were included. After sedation with butorphanol, induction with propofol and maintenance with sevoflurane in oxygen and air, a single voxel MRS at the level of the thalamus was performed before and 2 min after intravenous administration of 1 mg/kg ketamine. An automated data processing spectral fitting linear combination model algorithm was used to estimate all commonly measured metabolite ratios. A mixed ANOVA with the independent variables ketamine administration and group allocation was performed for all measured metabolites. A p < 0.05 was considered statistically significant. Results Twelve healthy control dogs, 10 untreated IE and 12 treated IE dogs were included. No significant effects for GLX/creatine were found. However, increased glucose/creatine ratios were found (p < 0.001) with no effect of group allocation. Furthermore, increases in the GABA/creatine ratio were found in IEU dogs. Discussion MRS was able to detect changes in metabolite/creatine ratios after intravenous administration of 1 mg/kg ketamine in dogs and no evidence was found that excitatory effects are induced in the thalamus. Although it is beyond the scope of this study to investigate the antiseizure potential of ketamine in dogs, results of this research suggest that the effect of ketamine on the brain metabolites could be dependent on the concentrations of brain metabolites before administration.
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Affiliation(s)
- Manuela Wieser
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, University of Zurich, Zurich, Switzerland,*Correspondence: Manuela Wieser ✉
| | | | - Annette P. N. Kutter
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, University of Zurich, Zurich, Switzerland
| | - Nico Mauri
- Department of Clinical Diagnostics and Services, Clinic for Diagnostic Imaging, University of Zurich, Zurich, Switzerland,Vetimage Diagnostik AG, Oberentfelden, Switzerland
| | - Henning Richter
- Department of Clinical Diagnostics and Services, Clinic for Diagnostic Imaging, University of Zurich, Zurich, Switzerland
| | - Niklaus Zölch
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Rima Nadine Bektas
- Section of Anesthesiology, Department of Clinical Diagnostics and Services, University of Zurich, Zurich, Switzerland
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The Impact of Individualized Hemodynamic Management on Intraoperative Fluid Balance and Hemodynamic Interventions during Spine Surgery in the Prone Position: A Prospective Randomized Trial. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58111683. [PMID: 36422222 PMCID: PMC9698539 DOI: 10.3390/medicina58111683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/07/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022]
Abstract
Background and Objectives: The effect of individualized hemodynamic management on the intraoperative use of fluids and other hemodynamic interventions in patients undergoing spinal surgery in the prone position is controversial. This study aimed to evaluate how the use of individualized hemodynamic management based on extended continuous non-invasive hemodynamic monitoring modifies intraoperative hemodynamic interventions compared to conventional hemodynamic monitoring with intermittent non-invasive blood pressure measurements. Methods: Fifty adult patients (American Society of Anesthesiologists physical status I−III) who underwent spinal procedures in the prone position and were then managed with a restrictive fluid strategy were prospectively randomized into intervention and control groups. In the intervention group, individualized hemodynamic management followed a goal-directed protocol based on continuously non-invasively measured blood pressure, heart rate, cardiac output, systemic vascular resistance, and stroke volume variation. In the control group, patients were monitored using intermittent non-invasive blood pressure monitoring, and the choice of hemodynamic intervention was left to the discretion of the attending anesthesiologist. Results: In the intervention group, more hypotensive episodes (3 (2−4) vs. 1 (0−2), p = 0.0001), higher intraoperative dose of ephedrine (0 (0−10) vs. 0 (0−0) mg, p = 0.0008), and more positive fluid balance (680 (510−937) vs. 270 (196−377) ml, p < 0.0001) were recorded. Intraoperative norepinephrine dose and postoperative outcomes did not differ between the groups. Conclusions: Individualized hemodynamic management based on data from extended non-invasive hemodynamic monitoring significantly modified intraoperative hemodynamic management and was associated with a higher number of hemodynamic interventions and a more positive fluid balance.
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Casoria V, Auckburally A, Rocchi A. Variable‐rate infusion of adrenaline to manage hypotension in an anaesthetised goat. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Uribe AA, Weaver TE, Echeverria-Villalobos M, Periel L, Shi H, Fiorda-Diaz J, Gonzalez-Zacarias A, Abdel-Rasoul M, Li L. Perioperative Morbidity and Complications in Patients With an Established Ileostomy Undergoing Major Abdominal Surgery: A Retrospective Study. Front Surg 2021; 8:757269. [PMID: 34957201 PMCID: PMC8692261 DOI: 10.3389/fsurg.2021.757269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Recently formed ileostomies may produce an average of 1,200 ml of watery stool per day, while an established ileostomy output varies between 600-800 ml per day. The reported incidence of renal impartment in patients with ileostomy is 8-20%, which could be caused by dehydration (up to 50%) or high output stoma (up to 40%). There is a lack of evidence if an ileostomy could influence perioperative fluid management and/or surgical outcomes. Methods: Subjects aged ≥18 years old with an established ileostomy scheduled to undergo an elective non-ileostomy-related major abdominal surgery under general anesthesia lasting more than 2 h and requiring hospitalization were included in the study. The primary outcome was to assess the incidence of perioperative complications within 30 days after surgery. Results: A total of 552 potential subjects who underwent non-ileostomy-related abdominal surgery were screened, but only 12 were included in the statistical analysis. In our study cohort, 66.7% of the subjects were men and the median age was 56 years old (interquartile range [IQR] 48-59). The median time from the creation of ileostomy to the qualifying surgery was 17.7 months (IQR: 8.3, 32.6). The most prevalent comorbidities in the study group were psychiatric disorders (58.3%), hypertension (50%), and cardiovascular disease (41.7%). The most predominant surgical approach was open (8 [67%]). The median surgical and anesthesia length was 3.4 h (IQR: 2.5, 5.7) and 4 h (IQR: 3, 6.5), respectively. The median post-anesthesia care unit (PACU) stay was 2 h (IQR:0.9, 3.1), while the median length of hospital stay (LOS) was 5.6 days (IQR: 4.1, 10.6). The overall incidence of postoperative complications was 50% (n = 6). Two subjects (16.7%) had a moderate surgical wound infection, and two subjects (16.7%) experienced a mild surgical wound infection. In addition, one subject (7.6%) developed a major postoperative complication with atrial fibrillation in conjunction with moderate hemorrhage. Conclusions: Our findings suggest that the presence of a well-established ileostomy might not represent a relevant risk factor for significant perioperative complications related to fluid management or hospital readmission. However, the presence of peristomal skin complications could trigger a higher incidence of surgical wound infections.
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Affiliation(s)
- Alberto A. Uribe
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Tristan E. Weaver
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | | | - Luis Periel
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Haixia Shi
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Alicia Gonzalez-Zacarias
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Medical Center, Columbus, OH, United States
| | - Lin Li
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
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Liu S, Su L, Liu X, Zhang X, Chen Z, Liu C, Hong N, Li Y, Long Y. Recognizing blood pressure patterns in sedated critically ill patients on mechanical ventilation by spectral clustering. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1404. [PMID: 34733956 PMCID: PMC8506777 DOI: 10.21037/atm-21-2806] [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] [Received: 05/29/2021] [Accepted: 08/06/2021] [Indexed: 11/10/2022]
Abstract
Background Blood pressure is a critical therapeutic goal in intensive care unit (ICU). One important factor influencing blood pressure are analgesia and sedation. Analgesic and sedative drugs are commonly used in critically ill patients. These drugs affect blood pressure by reducing the tension of the venous system, the cardiac preload, and cardiac output and inhibiting cardiac functions. Consequently, vasoactive agents are commonly used to increase blood pressure. The indications for the usage of vasoactive agents are unequivocal. However, opinions on when to stop raising blood pressure vary. This study explored the relationship between blood pressure and sedation. Methods Patients in the Multiparameter Intelligent Monitoring in Intensive Care-III (MIMIC) database who had received mechanical ventilation, had been administered sedative analgesics during their ICU stay, and met the inclusion criteria were included in this study. The mean arterial pressure (MAP) tendency patterns were identified using spectral clustering and visualized using the t-distributed Stochastic Neighbor Embedding (t-SNE) algorithm. The 28-day mortality rates of patients with different MAP patterns during their first 24 hours in the ICU and their sedation levels were calculated in the crosstab. Results Fourteen thousand seven hundred and eighty-five patients from the MIMIC-III database were included in this study. Three MAP patterns were identified by spectral clustering. The median MAP of the low, moderate, and high MAP groups was 71.2, 80.4, and 97.6 mmHg, respectively. The 28-day mortality rate of patients in the moderate MAP group (13.0%) was lower than that of patients in the low (16.6%) and high (15.6%) MAP groups. No difference was found in the 28-day mortality rate between the low and high MAP groups. Dynamic changes in blood pressure at different sedation depths were also examined. Notably, compared with light and moderate sedation level, patients in the deep sedation group, especially those in the high MAP group (48.5%), had a higher 28-day mortality rate (36.5%). Conclusions Low MAP in the first 24 hours in ICU indicates a high possibility of poor prognosis for critically ill patients on mechanical ventilation. For patients under deep sedation, maintaining a high mean arterial pressure also indicates poor prognosis. A personalized MAP target should be determined according to the severity of illness and level of sedation for each patient.
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Affiliation(s)
- Shengjun Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xin Liu
- Department of Electronic Engineering, Tsinghua University, Beijing, China
| | - Xueqian Zhang
- Department of Electronic Engineering, Tsinghua University, Beijing, China
| | - Zuyu Chen
- Department of Electronic Engineering, Tsinghua University, Beijing, China
| | - Chun Liu
- Digital Health China Technologies Co., Ltd., Beijing, China
| | - Na Hong
- Digital Health China Technologies Co., Ltd., Beijing, China
| | - Yali Li
- Department of Electronic Engineering, Tsinghua University, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
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Burkhoff D, Rich S, Pollesello P, Papp Z. Levosimendan-induced venodilation is mediated by opening of potassium channels. ESC Heart Fail 2021; 8:4454-4464. [PMID: 34716759 PMCID: PMC8712848 DOI: 10.1002/ehf2.13669] [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: 08/27/2021] [Accepted: 09/27/2021] [Indexed: 02/01/2023] Open
Abstract
Unique vascular responses adhere to the cardiovascular efficacy of the inodilator levosimendan. In particular, selective venodilation appears to explain its clinical benefit during pulmonary hypertension complicated by heart failure with preserved ejection fraction. Vasodilators increase vessel diameter in various parts of the vascular system to different degrees and thereby influence blood pressure, its distribution, and organ perfusion depending on their mechanisms of action. Levosimendan and its long‐lived active metabolite OR‐1896 mobilize a set of vasodilatory mechanisms, that is, the opening of the ATP‐sensitive K+ channels and other K+ channels on top of a highly selective inhibition of the phosphodiesterase III enzyme. A vessel‐specific combination of the above vasodilator mechanisms—in concert with cardiac effects and cardiovascular reflex regulations—illustrates the pharmacological profile of levosimendan in various cardiovascular disorders. While levosimendan has been known to be an inotrope, its properties as an activator of ATP‐sensitive K+ channels have gone largely ignored with respect to clinical applications. Here, we provide a summary of what is known about the ATP‐sensitive K+ channel properties in preclinical studies and now for the first time, its ATP‐sensitive K+ channel properties in a clinical trial.
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Affiliation(s)
| | - Stuart Rich
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond Str., Debrecen, H-4032, Hungary.,HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Budapest, Hungary
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10
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Sun J, Yuan J, Li B. SBP Is Superior to MAP to Reflect Tissue Perfusion and Hemodynamic Abnormality Perioperatively. Front Physiol 2021; 12:705558. [PMID: 34594235 PMCID: PMC8476970 DOI: 10.3389/fphys.2021.705558] [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: 05/05/2021] [Accepted: 08/11/2021] [Indexed: 11/15/2022] Open
Abstract
Many articles have reported that intraoperative low mean artery pressure (MAP) or low systolic blood pressure (SBP) impacts on organs’ function and patients’ outcomes perioperatively. On the contrary, what type of blood pressure should be obtained still needs to be clarified. In our paper, we compared the influencing factors of MAP and SBP, and mathematical formula, arterial pulse contour calculation, and cardiovascular physiological knowledge were adopted to discuss how blood pressure can effectively reflect tissue perfusion and hemodynamic abnormality perioperatively. We concluded that MAP can reflect cardiac output change sensitively and SBP can reflect stroke volume change sensitively. Moreover, SBP can reflect the early hemodynamic changes, organs’ perfusion, and heart systolic function. Compared with MAP, perioperative monitoring of SBP and timely detection and treatment of abnormal SBP are very important for the early detection of hemodynamic abnormalities.
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Affiliation(s)
- Jie Sun
- Department of Anesthesiology, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jing Yuan
- Department of Anesthesiology, Zhongda Hospital, Southeast University, Nanjing, China
| | - Bin Li
- Department of Anesthesiology, Zhongda Hospital, Southeast University, Nanjing, China
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11
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Navarro KL, Huss M, Smith JC, Sharp P, Marx JO, Pacharinsak C. Mouse Anesthesia: The Art and Science. ILAR J 2021; 62:238-273. [PMID: 34180990 PMCID: PMC9236661 DOI: 10.1093/ilar/ilab016] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/04/2021] [Accepted: 12/01/2020] [Indexed: 12/15/2022] Open
Abstract
There is an art and science to performing mouse anesthesia, which is a significant component to animal research. Frequently, anesthesia is one vital step of many over the course of a research project spanning weeks, months, or beyond. It is critical to perform anesthesia according to the approved research protocol using appropriately handled and administered pharmaceutical-grade compounds whenever possible. Sufficient documentation of the anesthetic event and procedure should also be performed to meet the legal, ethical, and research reproducibility obligations. However, this regulatory and documentation process may lead to the use of a few possibly oversimplified anesthetic protocols used for mouse procedures and anesthesia. Although a frequently used anesthetic protocol may work perfectly for each mouse anesthetized, sometimes unexpected complications will arise, and quick adjustments to the anesthetic depth and support provided will be required. As an old saying goes, anesthesia is 99% boredom and 1% sheer terror. The purpose of this review article is to discuss the science of mouse anesthesia together with the art of applying these anesthetic techniques to provide readers with the knowledge needed for successful anesthetic procedures. The authors include experiences in mouse inhalant and injectable anesthesia, peri-anesthetic monitoring, specific procedures, and treating common complications. This article utilizes key points for easy access of important messages and authors’ recommendation based on the authors’ clinical experiences.
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Affiliation(s)
- Kaela L Navarro
- Department of Comparative Medicine, Stanford University, Stanford, California, USA
| | - Monika Huss
- Department of Comparative Medicine, Stanford University, Stanford, California, USA
| | - Jennifer C Smith
- Bioresources Department, Henry Ford Health System, Detroit, Michigan, USA
| | - Patrick Sharp
- Office of Research and Economic Development, University of California, Merced, California, USA
- Animal Resources Authority, Murdoch, Australia
- School of Veterinary and Life Sciences, Murdoch University, Murdoch, Western Australia, Australia
| | - James O Marx
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cholawat Pacharinsak
- Corresponding Author: Cholawat Pacharinsak, DVM, PhD, DACVAA, Stanford University, Department of Comparative Medicine, 287 Campus Drive, Stanford, CA 94305-5410, USA. E-mail:
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12
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Moreno‐Martinez F, Mosing M, Senior M. Controlled mechanical ventilation in equine anaesthesia: Physiological background and basic considerations (Part 1). EQUINE VET EDUC 2021. [DOI: 10.1111/eve.13476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- F. Moreno‐Martinez
- School of Veterinary and Life Sciences Murdoch University Perth Western Australia Australia
| | - M. Mosing
- School of Veterinary and Life Sciences Murdoch University Perth Western Australia Australia
| | - M. Senior
- Department of Equine Clinical Science Institute of Veterinary Science University of Liverpool Neston, Cheshire UK
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13
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Intraoperative Assessment of Fluid Responsiveness in Normotensive Dogs under Isoflurane Anaesthesia. Vet Sci 2021; 8:vetsci8020026. [PMID: 33670144 PMCID: PMC7916826 DOI: 10.3390/vetsci8020026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/31/2021] [Accepted: 02/07/2021] [Indexed: 12/17/2022] Open
Abstract
The aim of this study was to evaluate the incidence of fluid responsiveness (FR) to a fluid challenge (FC) in normotensive dogs under anaesthesia. The accuracy of pulse pressure variation (PPV), systolic pressure variation (SPV), stroke volume variation (SVV), and plethysmographic variability index (PVI) for predicting FR was also evaluated. Dogs were anaesthetised with methadone, propofol, and inhaled isoflurane in oxygen, under volume-controlled mechanical ventilation. FC was performed by the administration of 5 mL/kg of Ringer's lactate within 5 min. Cardiac index (CI; L/min/m2), PPV, (%), SVV (%), SPV (%), and PVI (%) were registered before and after FC. Data were analysed with ANOVA and ROC tests (p < 0.05). Fluid responsiveness was defined as 15% increase in CI. Eighty dogs completed the study. Fifty (62.5%) were responders and 30 (37.5%) were nonresponders. The PPV, PVI, SPV, and SVV cut-off values (AUC, p) for discriminating responders from nonresponders were PPV >13.8% (0.979, <0.001), PVI >14% (0.956, <0.001), SPV >4.1% (0.793, <0.001), and SVV >14.7% (0.729, <0.001), respectively. Up to 62.5% of normotensive dogs under inhalant anaesthesia may be fluid responders. PPV and PVI have better diagnostic accuracy to predict FR, compared to SPV and SVV.
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14
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Chow RS. Terms, Definitions, Nomenclature, and Routes of Fluid Administration. Front Vet Sci 2021; 7:591218. [PMID: 33521077 PMCID: PMC7844884 DOI: 10.3389/fvets.2020.591218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/02/2020] [Indexed: 12/14/2022] Open
Abstract
Fluid therapy is administered to veterinary patients in order to improve hemodynamics, replace deficits, and maintain hydration. The gradual expansion of medical knowledge and research in this field has led to a proliferation of terms related to fluid products, fluid delivery and body fluid distribution. Consistency in the use of terminology enables precise and effective communication in clinical and research settings. This article provides an alphabetical glossary of important terms and common definitions in the human and veterinary literature. It also summarizes the common routes of fluid administration in small and large animal species.
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Affiliation(s)
- Rosalind S Chow
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MI, United States
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15
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Sasaki K, Yamamoto S, Mutoh T. Noninvasive assessment of fluid responsiveness for emergency abdominal surgery in dogs with pulmonary hypertension: Insights into high-risk companion animal anesthesia. PLoS One 2020; 15:e0241234. [PMID: 33095826 PMCID: PMC7584187 DOI: 10.1371/journal.pone.0241234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 10/11/2020] [Indexed: 11/19/2022] Open
Abstract
Objective Optimizing cardiac stroke volume during high-risk surgical anesthesia is of particular interest with regard to a therapeutic target to reduce the incidence of postoperative complications. However, intensive fluid management in critically ill small animals with pulmonary hypertension (PH) has been empirically performed, and thus it can be challenging. Stroke volume variation (SVV) has been used as a dynamic preload predictor of fluid responsiveness. We hypothesized that if SVV exhibited robust reliability in the setting of hemodynamically unstable condition, it would provide more precise information on fluid resuscitation to translate it into veterinary anesthesia. Thus the aim of this study was to investigate the utility of SVV measured by the electrical velocimetry (EV) method for predicting fluid responsiveness in dogs with PH. Methods Sixteen dogs undergoing emergency abdominal surgery and diagnosed with PH secondary to myxomatous mitral valve disease (MMVD) on preoperative transthoracic echocardiogram were included. Dogs were randomly assigned to 2 groups with and without inotropic cardiac support with dobutamine. Hemodynamic measurements including stroke volume and SVV derived from the EV device were performed under general anesthesia before (baseline) and after surgery (fluid challenge with a colloid solution defined by a SV increase of ≥ 10%). Results In both groups, SVV elevated significantly after abdominal surgery compared with baseline. In dobutamine infused group, the SVV values decreased significantly after fluid challenge (P < 0.05) with a greater number of responders than saline infused control group (P < 0.01). Receiver operating curve analysis of SVV confirmed high positive predictive value for dogs during dobutamine infusion (P < 0.05; cut-off value of 15%; specificity 90%, sensitivity 82%). Conclusions Noninvasive EV monitoring may be useful for the prediction of fluid responsiveness in critically ill dogs with left-sided heart failure-related PH. This normalization of dynamic preload indices, which could be achieved more precisely under inotropic support, may prevent further detrimental consequence of fluid loading.
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Affiliation(s)
- Kazumasu Sasaki
- Small Animal Emergency and Critical Care Service, Sendai Animal Care and Research Center, Sendai, Japan
- Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Shuzo Yamamoto
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Tatsushi Mutoh
- Small Animal Emergency and Critical Care Service, Sendai Animal Care and Research Center, Sendai, Japan
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
- * E-mail:
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Solanki SL, Jhingan MAK, Saklani AP. Rebound hypothermia after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) and cardiac arrest in immediate postoperative period: a report of two cases and review of literature. Pleura Peritoneum 2020; 5:20200126. [PMID: 33364341 PMCID: PMC7746889 DOI: 10.1515/pp-2020-0126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/29/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS-HIPEC) for peritoneal malignancies are complex surgeries marked with hemodynamic perturbations, temperature fluctuations, blood loss and metabolic disturbances in the intra-operative and post-operative period. In this report, we highlighted perioperative factors which may have led to cardiac arrest in immediate postoperative period and subsequent successful resuscitation in two patients with high volume peritoneal cancers who underwent CRS-HIPEC. CASE PRESENTATION Both patients had a similar clinical course, characterized by massive blood and fluid loss, metabolic derangement, hemodynamic instability, long duration of surgery, post HIPEC rebound hypothermia and hypokalemia which need to be anticipated. CONCLUSIONS We reviewed the literature related to postoperative hypothermia and other major complications after CRS-HIPEC and correlated the available literature with our findings.
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Affiliation(s)
- Sohan Lal Solanki
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Mrida A. K. Jhingan
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Avanish P. Saklani
- Gastro-Intestinal Services, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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17
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Gómez Fernández L, Niimura Del Barrio MC, Loughran C. Use of adrenaline continuous infusion to treat hypotension during general anaesthesia in a cow and a calf. Ir Vet J 2020; 73:13. [PMID: 32637073 PMCID: PMC7333263 DOI: 10.1186/s13620-020-00164-0] [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: 01/28/2020] [Accepted: 06/17/2020] [Indexed: 12/22/2022] Open
Abstract
Background Hypotension is one of the most common complications observed during inhalation anaesthesia in veterinary patients. Treatment of hypotension in cattle is more challenging than in other species, owing to the limited number of drugs licensed in food producing animals. The use of adrenaline as an infusion to support blood pressure has not been described previously in bovines. Case presentation A cow and a calf presented to University College Dublin Veterinary Hospital for bilateral mandibular fracture repair and bladder rupture repair respectively, developed severe anaesthetic related hypotension unresponsive to conventional treatments. In both cases an adrenaline infusion was started and slowly increased to effect, with infusion rates ranging from 0.01 to 0.25 μg/kg/min. Blood pressure increased as the adrenaline infusion rate increased, but clinically significant improvements in blood pressure were only observed with infusion rates exceeding 0.05 μg/kg/min. The side effect observed with adrenaline infusion was an increase in plasma lactate levels in both cases. Both animals were euthanised due to non-anaesthetic related complications. Conclusions Maintenance of normotension is important during bovine anaesthesia to prevent the development of post-anaesthetic complications. In the cases described here, adrenaline was effective as an additional treatment of anaesthetic related hypotension. Further research is required to establish the recommended infusion rates, cardiovascular effects and possible side effects of adrenaline infusion administration as a treatment for hypotension in bovines.
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Affiliation(s)
- Laura Gómez Fernández
- UCD Veterinary Hospital, University College Dublin, Belfield, Dublin 4, Eircode: D04 V1W8 Ireland
| | | | - Claire Loughran
- UCD Veterinary Hospital, University College Dublin, Belfield, Dublin 4, Eircode: D04 V1W8 Ireland
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18
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Chi TT, Hay Kraus BL. The effect of intravenous maropitant on blood pressure in healthy awake and anesthetized dogs. PLoS One 2020; 15:e0229736. [PMID: 32108177 PMCID: PMC7046230 DOI: 10.1371/journal.pone.0229736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 02/13/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To evaluate the effects of intravenous maropitant on arterial blood pressure in healthy dogs while awake and under general anesthesia. DESIGN Experimental crossover study. ANIMALS Eight healthy adult Beagle dogs. PROCEDURE All dogs received maropitant (1 mg kg-1) intravenously under the following conditions: 1) awake with non-invasive blood pressure monitoring (AwNIBP), 2) awake with invasive blood pressure monitoring (AwIBP), 3) premedication with acepromazine (0.005 mg kg-1) and butorphanol (0.2 mg kg-1) intramuscularly followed by propofol induction and isoflurane anesthesia (GaAB), and 4) premedication with dexmedetomidine (0.005 mg kg-1) and butorphanol (0.2 mg kg-1) intramuscularly followed by propofol induction and isoflurane anesthesia (GaDB). Heart rate (HR), systolic (SAP), diastolic (DAP), and mean blood pressures (MAP) were recorded before injection of maropitant (baseline), during the first 60 seconds of injection, during the second 60 seconds of injection, at the completion of injection and every 2 minutes post injection for 18 minutes. The data were compared over time using a Generalized Linear Model with mixed effects and then with simple effect comparison with Bonferroni adjustments (p <0.05). RESULTS There were significant decreases from baseline in SAP in the GaAB group (p < 0.01) and in MAP and DAP in the AwIBP and GaAB (p < 0.001) groups during injection. A significant decrease in SAP (p < 0.05), DAP (p < 0.05), and MAP (p < 0.05) occurred at 16 minutes post injection in GaDB group. There was also a significant increase in HR in the AwIBP group (p < 0.01) during injection. Clinically significant hypotension occurred in the GaAB group with a mean MAP at 54 ± 6 mmHg during injection. CONCLUSION Intravenous maropitant administration significantly decreases arterial blood pressure during inhalant anesthesia. Patients premedicated with acepromazine prior to isoflurane anesthesia may develop clinically significant hypotension.
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Affiliation(s)
- Ting-Ting Chi
- Department of Veterinary Clinical Sciences, Iowa State University College of Veterinary Medicine, Ames, Iowa, United States of America
| | - Bonnie L. Hay Kraus
- Department of Veterinary Clinical Sciences, Iowa State University College of Veterinary Medicine, Ames, Iowa, United States of America
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19
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Sars B, van der Sande FM, Kooman JP. Intradialytic Hypotension: Mechanisms and Outcome. Blood Purif 2019; 49:158-167. [PMID: 31851975 DOI: 10.1159/000503776] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/28/2019] [Indexed: 12/14/2022]
Abstract
Intradialytic hypotension (IDH) occurs in approximately 10-12% of treatments. Whereas several definitions for IDH are available, a nadir systolic blood pressure carries the strongest relation with outcome. Whereas the relation between IDH may partly be based on patient characteristics, it is likely that also impaired organ perfusion leading to permanent damage, plays a role in this relationship. The pathogenesis of IDH is multifactorial and is based on a combination of a decline in blood volume (BV) and impaired vascular resistance at a background of a reduced cardiovascular reserve. Measurements of absolute BV based on an on-line dilution method appear more promising than relative BV measurements in the prediction of IDH. Also, feedback treatments in which ultrafiltration rate is automatically adjusted based on changes in relative BV have not yet resulted in improvement. Frequent assessment of dry weight, attempting to reduce interdialytic weight gain and prescribing more frequent or longer dialysis treatments may aid in preventing IDH. The impaired vascular response can be improved using isothermic or cool dialysis treatment which has also been associated with a reduction in end organ damage, although their effect on mortality has not yet been assessed. For the future, identification of vulnerable patients based on artificial intelligence and on-line assessment of markers of organ perfusion may aid in individualizing treatment prescription, which will always remain dependent on the clinical context of the patient.
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Affiliation(s)
- Benedict Sars
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frank M van der Sande
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jeroen P Kooman
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,
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20
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Brengelmann GL. Venous return and the physical connection between distribution of segmental pressures and volumes. Am J Physiol Heart Circ Physiol 2019; 317:H939-H953. [PMID: 31518160 DOI: 10.1152/ajpheart.00381.2019] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
More than sixty years ago, Guyton and coworkers related their observations of venous return to a mathematical model. Showing steady-state flow (F) as proportional to the difference between mean systemic pressure (Pms) and right atrial pressure (Pra), the model fit their data. The parameter defined by the ratio (Pms - Pra)/F, first called an "impedance," came to be called the "resistance to venous return." The interpretation that Pra opposes Pms and that, to increase output, the heart must act to reduce back pressure at the right atrium was widely accepted. Today, the perceived importance of Pms is evident in the efforts to find reliable ways to estimate it in patients. This article reviews concepts about venous return, criticizing some as inconsistent with elementary physical principles. After review of basic background topics-the steady-state vascular compliance; stressed versus unstressed volume-simulations from a multicompartment model based on data and definitions from Rothe's classical review of the venous system are presented. They illustrate the obligatory connection between flow-dependent compartment pressures and the distribution of volume among vascular compartments. An appendix shows that the pressure profile can be expressed either as decrements relative to arterial pressure or as increments relative to Pra (the option taken in the original model). Conclusion: The (Pms - Pra)/F formulation was never about Pms physically driving venous return; it was about how intravascular volume distributes among compliant compartments in accordance with their flow-dependent distending pressures, arbitrarily expressed relative to Pra rather than arterial pressure.
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Affiliation(s)
- George L Brengelmann
- Department of Physiology and Biophysics, University of Washington, Seattle, Washington
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21
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Araos J, Kenny JES, Rousseau-Blass F, Pang DS. Dynamic prediction of fluid responsiveness during positive pressure ventilation: a review of the physiology underlying heart-lung interactions and a critical interpretation. Vet Anaesth Analg 2019; 47:3-14. [PMID: 31831334 DOI: 10.1016/j.vaa.2019.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 07/10/2019] [Accepted: 08/17/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Cardiovascular responses to hypovolemia and hypotension are depressed during general anesthesia. A considerable number of anesthetized and critically ill animals may not benefit hemodynamically from a fluid bolus; therefore, it is important to have measures for accurate prediction of fluid responsiveness. Static measures of preload, such as central venous pressure, do not provide accurate prediction of fluid responsiveness, whereas dynamic measures of cardiovascular function, obtained during positive pressure ventilation, are highly predictive. This review describes key physiological concepts behind heart-lung interactions during positive pressure ventilation, factors that can modify this relationship and provides the basis for a rational interpretation of the information obtained from dynamic measurements, with a focus on pulse pressure variation (PPV). DATABASE USED PubMed. Search items used were: heart-lung interaction, positive pressure ventilation, pulse pressure variation, dynamic index of fluid therapy, goal-directed hemodynamic therapy, dogs, cats, pigs, horses and rabbits. CONCLUSIONS The veterinary literature suggests that targeting specific PPV thresholds should guide fluid therapy in lieu of conventional assessments. Understanding the physiology of heart-lung interactions during intermittent positive pressure ventilation provides a rational basis for interpreting the literature on dynamic indices of fluid responsiveness, including PPV. Clinical trials are needed to evaluate whether goal-directed fluid therapy based on PPV results in improved outcomes in veterinary patient populations.
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Affiliation(s)
- Joaquin Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA.
| | | | - Frederik Rousseau-Blass
- Centre Hospitalier Universitaire Veterinaire, Faculte de Medecine Veterinaire, Universite de Montreal, Saint-Hyacinthe, QC, Canada
| | - Daniel Sj Pang
- Centre Hospitalier Universitaire Veterinaire, Faculte de Medecine Veterinaire, Universite de Montreal, Saint-Hyacinthe, QC, Canada; Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, AB, Canada
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22
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Jacobs R, Lochy S, Malbrain MLNG. Phenylephrine-induced recruitable preload from the venous side. J Clin Monit Comput 2018; 33:373-376. [PMID: 30478524 PMCID: PMC6499741 DOI: 10.1007/s10877-018-0225-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 01/27/2023]
Affiliation(s)
- Rita Jacobs
- Intensive Care Department, University Hospital Brussels (UZB), Laarbeeklaan 101, 1090, Jette, Belgium
| | - Stijn Lochy
- Intensive Care Department, University Hospital Brussels (UZB), Laarbeeklaan 101, 1090, Jette, Belgium.,Cardiology Department, University Hospital Brussels (UZB), Jette, Belgium
| | - Manu L N G Malbrain
- Intensive Care Department, University Hospital Brussels (UZB), Laarbeeklaan 101, 1090, Jette, Belgium. .,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
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