1
|
Manavi T, Zafar H, Sharif F. An Era of Digital Healthcare-A Comprehensive Review of Sensor Technologies and Telehealth Advancements in Chronic Heart Failure Management. Sensors (Basel) 2024; 24:2546. [PMID: 38676163 PMCID: PMC11053658 DOI: 10.3390/s24082546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/21/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024]
Abstract
Heart failure (HF) is a multi-faceted, complex clinical syndrome characterized by significant morbidity, high mortality rate, reduced quality of life, and rapidly increasing healthcare costs. A larger proportion of these costs comprise both ambulatory and emergency department visits, as well as hospital admissions. Despite the methods used by telehealth (TH) to improve self-care and quality of life, patient outcomes remain poor. HF management is associated with numerous challenges, such as conflicting evidence from clinical trials, heterogeneity of TH devices, variability in patient inclusion and exclusion criteria, and discrepancies between healthcare systems. A growing body of evidence suggests there is an unmet need for increased individualization of in-hospital management, continuous remote monitoring of patients pre and post-hospital admission, and continuation of treatment post-discharge in order to reduce re-hospitalizations and improve long-term outcomes. This review summarizes the current state-of-the-art for HF and associated novel technologies and advancements in the most frequently used types of TH (implantable sensors), categorizing devices in their preclinical and clinical stage, bench-to-bedside implementation challenges, and future perspectives on remote HF management to improve long-term outcomes of HF patients. The Review also highlights recent advancements in non-invasive remote monitoring technologies demonstrated by a few pilot observational prospective cohort studies.
Collapse
Affiliation(s)
- Tejaswini Manavi
- Cardiovascular Translational Research & Innovation Centre, University of Galway, H91 TK33 Galway, Ireland; (T.M.); (F.S.)
- Lambe Institute for Translational Research, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Haroon Zafar
- Cardiovascular Translational Research & Innovation Centre, University of Galway, H91 TK33 Galway, Ireland; (T.M.); (F.S.)
- Lambe Institute for Translational Research, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
- College of Science and Engineering, University of Galway, H91 TK33 Galway, Ireland
| | - Faisal Sharif
- Cardiovascular Translational Research & Innovation Centre, University of Galway, H91 TK33 Galway, Ireland; (T.M.); (F.S.)
- Lambe Institute for Translational Research, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
- Department of Cardiology, University Hospital Galway, H91 YR71 Galway, Ireland
| |
Collapse
|
2
|
Pražetina M, Šribar A, Sokolović Jurinjak I, Matošević J, Peršec J. Effect of machine learning-guided haemodynamic optimization on postoperative free flap perfusion in reconstructive maxillofacial surgery: A study protocol. Br J Clin Pharmacol 2024; 90:684-690. [PMID: 37876305 DOI: 10.1111/bcp.15942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/14/2023] [Accepted: 10/15/2023] [Indexed: 10/26/2023] Open
Abstract
AIMS Intraoperative hypotension and liberal fluid haemodynamic therapy are associated with postoperative medical and surgical complications in maxillofacial free flap surgery. The novel haemodynamic parameter hypotension prediction index (HPI) has shown good performance in predicting hypotension by analysing arterial pressure waveform in various types of surgery. HPI-based haemodynamic protocols were able to reduce the duration and depth of hypotension. We will try to determine whether haemodynamic therapy based on HPI can improve postoperative flap perfusion and tissue oxygenation by improving intraoperative mean arterial pressure and reducing fluid infusion. METHODS We present here a study protocol for a single centre, randomized, controlled trial (n = 42) in maxillofacial patients undergoing free flap surgery. Patients will be randomized into an intervention or a control group. In the intervention, group haemodynamic optimization will be guided by machine learning algorithm and functional haemodynamic parameters presented by the HemoSphere platform (Edwards Lifesciences, Irvine, CA, USA), most importantly, HPI. Tissue oxygen saturation of the free flap will be monitored noninvasively by near-infrared spectroscopy during the first 24 h postoperatively. The primary outcome will be the average value of tissue oxygen saturation in the first 24 h postoperatively.
Collapse
Affiliation(s)
- Marko Pražetina
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Andrej Šribar
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
- School of Dental Medicine, Zagreb University, Zagreb, Croatia
| | - Irena Sokolović Jurinjak
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Jelena Matošević
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Jasminka Peršec
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
- School of Dental Medicine, Zagreb University, Zagreb, Croatia
| |
Collapse
|
3
|
Myatra SN, Jagiasi BG, Singh NP, Divatia JV. Role of artificial intelligence in haemodynamic monitoring. Indian J Anaesth 2024; 68:93-99. [PMID: 38406336 PMCID: PMC10893816 DOI: 10.4103/ija.ija_1260_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 12/28/2023] [Accepted: 01/08/2024] [Indexed: 02/27/2024] Open
Abstract
This narrative review explores the evolving role of artificial intelligence (AI) in haemodynamic monitoring, emphasising its potential to revolutionise patient care. The historical reliance on invasive procedures for haemodynamic assessments is contrasted with the emerging non-invasive AI-driven approaches that address limitations and risks associated with traditional methods. Developing the hypotension prediction index and introducing CircEWSTM and CircEWS-lite TM showcase AI's effectiveness in predicting and managing circulatory failure. The crucial aspects include the balance between AI and healthcare professionals, ethical considerations, and the need for regulatory frameworks. The use of AI in haemodynamic monitoring will keep growing with ongoing research, better technology, and teamwork. As we navigate these advancements, it is crucial to balance AI's power and healthcare professionals' essential role. Clinicians must continue to use their clinical acumen to ensure that patient outliers or system problems do not compromise the treatment of the condition and patient safety.
Collapse
Affiliation(s)
- Sheila N. Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Bharat G. Jagiasi
- Director of Critical Care Department, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai, Maharashtra, India
| | - Neeraj P. Singh
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jigeeshu V. Divatia
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| |
Collapse
|
4
|
Flick M, Hilty MP, Duranteau J, Saugel B. The microcirculation in perioperative medicine: a narrative review. Br J Anaesth 2024; 132:25-34. [PMID: 38030549 DOI: 10.1016/j.bja.2023.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/25/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
The microcirculation describes the network of the smallest vessels in our cardiovascular system. On a microcirculatory level, oxygen delivery is determined by the flow of oxygen-carrying red blood cells in a given single capillary (capillary red blood cell flow) and the density of the capillary network in a given tissue volume (capillary vessel density). Handheld vital videomicroscopy enables visualisation of the capillary bed on the surface of organs and tissues but currently is only used for research. Measurements are generally possible on all organ surfaces but are most often performed in the sublingual area. In patients presenting for elective surgery, the sublingual microcirculation is usually intact and functional. Induction of general anaesthesia slightly decreases capillary red blood cell flow and increases capillary vessel density. During elective, even major, noncardiac surgery, the sublingual microcirculation is preserved and remains functional, presumably because elective noncardiac surgery is scheduled trauma and haemodynamic alterations are immediately treated by anaesthesiologists, usually restoring the macrocirculation before the microcirculation is substantially impaired. Additionally, surgery is regional trauma and thus likely causes regional, rather than systemic, impairment of the microcirculation. Whether or not the sublingual microcirculation is impaired after noncardiac surgery remains a subject of ongoing research. Similarly, it remains unclear if cardiac surgery, especially with cardiopulmonary bypass, impairs the sublingual microcirculation. The effects of therapeutic interventions specifically targeting the microcirculation remain to be elucidated and tested. Future research should focus on further improving microcirculation monitoring methods and investigating how regional microcirculation monitoring can inform clinical decision-making and treatment.
Collapse
Affiliation(s)
- Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA
| |
Collapse
|
5
|
Kouz K, Scheeren TW, van den Boom T, Saugel B. Hypotension Prediction Index software alarms during major noncardiac surgery: a post hoc secondary analysis of the EU-HYPROTECT registry. BJA Open 2023; 8:100232. [PMID: 37869057 PMCID: PMC10589371 DOI: 10.1016/j.bjao.2023.100232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/25/2023] [Indexed: 10/24/2023]
Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Thomas W.L. Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Edwards Lifesciences, Garching, Germany
| | | | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| |
Collapse
|
6
|
Heringlake M, Kouz K, Saugel B. A classification system for pulmonary artery catheters. Br J Anaesth 2023; 131:971-974. [PMID: 37714751 DOI: 10.1016/j.bja.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 09/17/2023] Open
Abstract
Flow-directed, balloon-tipped pulmonary artery catheters allow measuring cardiac output and other haemodynamic variables including intracardiac pressures. We propose classifying pulmonary artery catheters by generations and specifying additional measurement modalities. Based on the method used to measure cardiac output, pulmonary artery catheters can be classified into three generations: first-generation using intermittent pulmonary artery thermodilution; second-generation using a thermal filament for automated pulmonary artery thermodilution; and third-generation combining thermal filament-based automated pulmonary artery thermodilution and pulmonary artery pulse wave analysis. Each of these pulmonary artery catheter generations can include additional measurements, such as continuous mixed venous oxygen saturation, right ventricular ejection fraction and end-diastolic volume, and right ventricular pressure. This classification should help define indications for pulmonary artery catheters in clinical practice and research.
Collapse
Affiliation(s)
- Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, Heart- and Diabetes Center Mecklenburg - Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
7
|
Michard F, Joosten A, Futier E. Intraoperative blood pressure: could less be more? Br J Anaesth 2023; 131:810-812. [PMID: 37778938 DOI: 10.1016/j.bja.2023.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/03/2023] Open
Abstract
Retrospective observational studies have reported a significant association between intraoperative hypotension and postoperative morbidity. However, association does not imply causation, and whether preventing intraoperative hypotension can improve patient outcome remains to be demonstrated. In this issue of the British Journal of Anaesthesia, D'Amico and colleagues meta-analysed 10 prospective randomised trials comparing low (≤60 mm Hg) and higher mean arterial pressure targets during anaesthesia and surgery. They did not observe an increase in postoperative morbidity and mortality in the low target group. In contrast, they reported a statistically significant (but not clinically relevant) reduction in postoperative cardiac arrhythmia and hospital length of stay when targeting mean arterial pressure ≤60 mm Hg. These findings suggest that during most surgical cases, intraoperative hypotension is a marker of the severity, frailty, or both rather than a mediator of postoperative complications.
Collapse
Affiliation(s)
| | - Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Villejuif, France
| | - Emmanuel Futier
- Department of Anesthesia and Critical Care, Université Clermont Auvergne, Hopital d'Estaing, Clermont-Ferrand, France
| |
Collapse
|
8
|
Solanki SL, Maurya I, Sharma J. Impact of fluid and haemodynamic management in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy on postoperative outcomes - A systematic review. Indian J Anaesth 2023; 67:866-879. [PMID: 38044912 PMCID: PMC10691611 DOI: 10.4103/ija.ija_367_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 12/05/2023] Open
Abstract
Background and Aims Cytoreduction surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an extensive surgery associated with significant fluid shift and blood loss. The haemodynamic management and fluid therapy protocol may impact postoperative outcomes. This systematic review was conducted to find the effect of haemodynamic monitoring and perioperative fluid therapy in CRS-HIPEC on postoperative outcomes. Methods We searched PubMed, Scopus and Google Scholar. All studies published between 2010 and 2022 involving CRS-HIPEC surgeries that compared the effect of fluid therapy and haemodynamic monitoring on postoperative outcomes were included. Keywords for database searches included a combination of Medical Subject Headings terms and plain text related to the CRS-HIPEC procedure. The risk of bias and the certainty assessment were done by Risk of Bias-2 and the methodological index for non-randomised studies. Results The review included 16 published studies out of 388 articles. The studies were heterogeneous concerning the design type and parameter measures. The studies with goal-directed fluid therapy protocol had a duration of intensive care unit (ICU) stay that varied from 1 to 20 days, while mortality varied from 0% to 9.5%. The choice of fluid, crystalloid versus colloid, remains inconclusive. The studies that compared crystalloids and colloids for perioperative fluid management did not show a difference in clinical outcomes. Conclusion The interpretation of the available literature is challenging because the definitions of various fluid regimens and haemodynamic goals are not uniform among studies. An individualised approach to perioperative fluid therapy and a justified dynamic index cut-off for haemodynamic monitoring seem reasonable for CRS-HIPEC procedures.
Collapse
Affiliation(s)
- Sohan Lal Solanki
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Indubala Maurya
- Department of Anaesthesiology, Kalyan Singh Super Specialty Cancer Institute, Lucknow, Uttar Pradesh, India
| | - Jyoti Sharma
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Bathinda, Punjab, India
| |
Collapse
|
9
|
Miegoń J, Zacha S, Skonieczna-Żydecka K, Wiczk-Bratkowska A, Andrzejewska A, Jarosz K, Deptuła-Jarosz M, Biernawska J. Optimising Intraoperative Fluid Management in Patients Treated with Adolescent Idiopathic Scoliosis-A Novel Strategy for Improving Outcomes. Children (Basel) 2023; 10:1371. [PMID: 37628370 PMCID: PMC10453073 DOI: 10.3390/children10081371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023]
Abstract
Scoliosis surgery is a challenge for the entire team in terms of safety, and its accomplishment requires the utilization of advanced monitoring technologies. A prospective, single centre, non-randomised controlled cohort study, was designed to assess the efficacy of protocolised intraoperative haemodynamic monitoring and goal-directed therapy in relation to patient outcomes following posterior fusion surgery for adolescent idiopathic scoliosis (AIS). The control group (n = 35, mean age: 15 years) received standard blood pressure management during the surgical procedure, whereas the intervention group (n = 35, mean age: 14 years) underwent minimally invasive haemodynamic monitoring. Arterial pulse contour analysis (APCO) devices were employed, along with goal-directed therapy protocol centered on achieving target mean arterial pressure and stroke volume. This was facilitated through the application of crystalloid boluses, ephedrine, and noradrenaline. The intervention group was subjected to a comprehensive protocol following Enhanced Recovery After Surgery (ERAS) principles. Remarkably, the intervention group exhibited notable advantages (p < 0.05), including reduced hospital stay durations (median 7 days vs. 10), shorter episodes of hypotension (mean arterial pressure < 60 mmHg-median 8 vs. 40 min), lesser declines in postoperative haemoglobin levels (-2.36 g/dl vs. -3.83 g/dl), and quicker extubation times. These compelling findings strongly imply that the integration of targeted interventions during the intraoperative care of AIS patients undergoing posterior fusion enhance a set of treatment outcomes.
Collapse
Affiliation(s)
- Jakub Miegoń
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Sławomir Zacha
- Department of Paediatric Orthopaedics and Oncology of the Musculoskeletal System, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | | | - Agata Wiczk-Bratkowska
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Agata Andrzejewska
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Konrad Jarosz
- Department of Clinical Nursing, Pomeranian Medical University in Szczecin, 71-210 Szczecin, Poland
| | - Monika Deptuła-Jarosz
- Department of Neurosurgery and Paediatric Neurosurgery, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| | - Jowita Biernawska
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
| |
Collapse
|
10
|
Michard F, Futier E. Predicting intraoperative hypotension: from hope to hype and back to reality. Br J Anaesth 2023; 131:199-201. [PMID: 36997473 DOI: 10.1016/j.bja.2023.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/30/2023] Open
Abstract
The analysis of arterial pressure waveforms with machine learning algorithms has been proposed to predict intraoperative hypotension. The ability to forecast arterial hypotension 5-15 min ahead of the fall in blood pressure allows clinicians to be pro-active instead of reactive, and could potentially decrease postoperative morbidity. However, the predictive value of machine learning algorithms has been overestimated due to selection bias in several clinical studies, and they might not be superior to mere observation of arterial pressure. Continuous blood pressure monitoring enables immediate detection of hypotension, and giving fluid, vasopressors or inotropes to patients who are not yet (and might never become) hypotensive based on an algorithm is questionable. Finally, recent prospective interventional studies suggest that reducing intraoperative hypotension does not improve postoperative outcomes.
Collapse
Affiliation(s)
| | - Emmanuel Futier
- Department of Anesthesia and Critical Care, Université Clermont Auvergne, Hopital d'Estaing, Clermont-Ferrand, France
| |
Collapse
|
11
|
Andrzejewska A, Miegoń J, Zacha S, Skonieczna-Żydecka K, Jarosz K, Zacha W, Biernawska J. The Impact of Intraoperative Haemodynamic Monitoring, Prediction of Hypotension and Goal-Directed Therapy on the Outcomes of Patients Treated with Posterior Fusion Due to Adolescent Idiopathic Scoliosis. J Clin Med 2023; 12:4571. [PMID: 37510686 PMCID: PMC10380250 DOI: 10.3390/jcm12144571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/04/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
A prospective, single-centre, non-randomised, case-control study aimed to evaluate the effectiveness of intraoperative haemodynamic monitoring, prediction of hypotension and goal-directed therapy on the outcomes of patients undergoing posterior fusion for adolescent idiopathic scoliosis (AIS). The control group (n = 35, mean age: 15 years) received standard blood pressure control during surgery, while the intervention group (n = 24, mean age: 14 years) underwent minimally invasive haemodynamic monitoring and goal-directed therapy. The intervention group showed significantly shorter durations of hypotension (mean arterial pressure < 60 mmHg), reduced hospital stays and smaller decreases in post-surgery haemoglobin levels. Additionally, the intervention group experienced shorter times from the end of surgery to extubation. These findings suggest that incorporating targeted interventions during intraoperative care for AIS patients undergoing posterior fusion can lead to improved outcomes.
Collapse
Affiliation(s)
- Agata Andrzejewska
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Jakub Miegoń
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Sławomir Zacha
- Department of Paediatric Orthopaedics and Oncology of the Musculoskeletal System, Pomeranian Medical University, 71-252 Szczecin, Poland
| | | | - Konrad Jarosz
- Department of Clinical Nursing, Pomeranian Medical University, 71-210 Szczecin, Poland
| | - Wojciech Zacha
- Department of Paediatric Orthopaedics and Oncology of the Musculoskeletal System, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Jowita Biernawska
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University, 71-252 Szczecin, Poland
| |
Collapse
|
12
|
Kouz K, Monge García MI, Cerutti E, Lisanti I, Draisci G, Frassanito L, Sander M, Ali Akbari A, Frey UH, Grundmann CD, Davies SJ, Donati A, Ripolles-Melchor J, García-López D, Vojnar B, Gayat É, Noll E, Bramlage P, Saugel B. Intraoperative hypotension when using hypotension prediction index software during major noncardiac surgery: a European multicentre prospective observational registry (EU HYPROTECT). BJA Open 2023; 6:100140. [PMID: 37588176 PMCID: PMC10430826 DOI: 10.1016/j.bjao.2023.100140] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/19/2023] [Accepted: 03/28/2023] [Indexed: 08/18/2023]
Abstract
Background Intraoperative hypotension is associated with organ injury. Current intraoperative arterial pressure management is mainly reactive. Predictive haemodynamic monitoring may help clinicians reduce intraoperative hypotension. The Acumen™ Hypotension Prediction Index software (HPI-software) (Edwards Lifesciences, Irvine, CA, USA) was developed to predict hypotension. We built up the European multicentre, prospective, observational EU HYPROTECT Registry to describe the incidence, duration, and severity of intraoperative hypotension when using HPI-software monitoring in patients having noncardiac surgery. Methods We enrolled 749 patients having elective major noncardiac surgery in 12 medical centres in five European countries. Patients were monitored using the HPI-software. We quantified hypotension using the time-weighted average MAP <65 mm Hg (primary endpoint), the proportion of patients with at least one ≥1 min episode of a MAP <65 mm Hg, the number of ≥1 min episodes of a MAP <65 mm Hg, and duration patients spent below a MAP of 65 mm Hg. Results We included 702 patients in the final analysis. The median time-weighted average MAP <65 mm Hg was 0.03 (0.00-0.20) mm Hg. In addition, 285 patients (41%) had no ≥1 min episode of a MAP <65 mm Hg; 417 patients (59%) had at least one. The median number of ≥1 min episodes of a MAP <65 mm Hg was 1 (0-3). Patients spent a median of 2 (0-9) min below a MAP of 65 mm Hg. Conclusions The median time-weighted average MAP <65 mm Hg was very low in patients in this registry. This suggests that using HPI-software monitoring may help reduce the duration and severity of intraoperative hypotension in patients having noncardiac surgery.
Collapse
Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Elisabetta Cerutti
- Department of Anesthesia, Transplant and Surgical Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Ivana Lisanti
- Department of Anesthesia, Transplant and Surgical Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Gaetano Draisci
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Luciano Frassanito
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Michael Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Amir Ali Akbari
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Ulrich H. Frey
- Department of Anesthesiology, Intensive Care, Pain and Palliative Care, Marien Hospital Herne, Ruhr-University Bochum, Bochum, Germany
| | - Carla Davina Grundmann
- Department of Anesthesiology, Intensive Care, Pain and Palliative Care, Marien Hospital Herne, Ruhr-University Bochum, Bochum, Germany
| | - Simon James Davies
- York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
- Centre for Health and Population Sciences, Hull York Medical School, York, UK
| | - Abele Donati
- Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Ancona, Italy
| | - Javier Ripolles-Melchor
- Anesthesia and Critical Care Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Daniel García-López
- Department of Anaesthesiology and Reanimation, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Benjamin Vojnar
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany
| | - Étienne Gayat
- Université Paris Cité, INSERM, Paris, France
- Department of Anesthesia and Critical Care Medicine, Hôpital Lariboisière, Paris, France
| | - Eric Noll
- Department of Anesthesiology and Intensive Care, Hôpital de Hautepierre, Les Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| |
Collapse
|
13
|
Saugel B, Thomsen KK, Maheshwari K. Goal-directed haemodynamic therapy: an imprecise umbrella term to avoid. Br J Anaesth 2023; 130:390-393. [PMID: 36732140 DOI: 10.1016/j.bja.2022.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/30/2022] [Accepted: 12/31/2022] [Indexed: 02/04/2023] Open
Abstract
'Goal-directed haemodynamic therapy' describes various haemodynamic treatment strategies that have in common that interventions are titrated to achieve predefined haemodynamic targets. However, the treatment strategies differ substantially regarding the underlying haemodynamic target variables and target values, and thus presumably have different effects on outcome. It is an over-simplifying approach to lump complex and substantially differing haemodynamic treatment strategies together under the term 'goal-directed haemodynamic therapy', an imprecise umbrella term that we should thus stop using.
Collapse
Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Kristen K Thomsen
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kamal Maheshwari
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
14
|
Yoo HJ, Shim J. The impact of family care visitation programme on patients and caregivers in the intensive care unit: A mixed methods study. J Clin Nurs 2023. [PMID: 36876455 DOI: 10.1111/jocn.16650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 01/12/2023] [Accepted: 01/26/2023] [Indexed: 03/07/2023]
Abstract
AIMS To track changes in the haemodynamic and respiratory indicators of patients and evaluate families' caring experiences via the visitation programme in the intensive care unit (ICU). BACKGROUND Although most people recognise the importance of family care visitation programme in the ICU, objective research results on the effect on patients and caregivers are still insufficient. DESIGN Mixed methods. METHODS In this a quasi-experimental investigation and qualitative study, after executing the programme with families of ICU patients in a general hospital in South Korea from June to July 2019, changes in haemodynamic and respiratory indicators for control (n = 28) and experimental groups (n = 28) were analysed; the experimental group families' experiences were analysed through in-depth interviews; the qualitative study's reporting rigour was checked against the COREQ guidelines and TREND checklist for a quasi-experimental study. Qualitative and quantitative data were examined using content analysis and repeated-measures analysis of variance, respectively. RESULTS There was a significant change in systolic and diastolic blood pressure in the haemodynamic indicator, and the respiratory indicator in both groups increased slightly over time and then gradually stabilised; there were no significant differences or interactions between groups regarding time of systolic blood pressure. The respiratory rate significantly decreased only in the experimental group. There was a significant increase in oxygen saturation over time, as well as interactions between time and group and between groups. Four themes were extracted from families' experiences. CONCLUSION The haemodynamic and respiratory indicators of the group using patient- and family-centred care (PFCC) showed a stable effect on critically ill patients, which increased families' satisfaction. In future, interventions should encourage family participation in the ICU for successful PFCC. RELEVANCE TO CLINICAL PRACTICE The findings provided evidence for the importance of PFCC through changes in objective haemodynamic and respiratory indicators.
Collapse
Affiliation(s)
- Hye Jin Yoo
- College of Nursing, Dankook University, Cheonan, South Korea
| | - JaeLan Shim
- College of Nursing, Dongguk University, Gyeongju, South Korea
| |
Collapse
|
15
|
Kouz K, Brockmann L, Timmermann LM, Bergholz A, Flick M, Maheshwari K, Sessler DI, Krause L, Saugel B. Endotypes of intraoperative hypotension during major abdominal surgery: a retrospective machine learning analysis of an observational cohort study. Br J Anaesth 2023; 130:253-261. [PMID: 36526483 DOI: 10.1016/j.bja.2022.07.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 07/27/2022] [Accepted: 07/30/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Intraoperative hypotension is associated with myocardial injury, acute kidney injury, and death. In routine practice, specific causes of intraoperative hypotension are often unclear. A more detailed understanding of underlying haemodynamic alterations of intraoperative hypotension may identify specific treatments. We thus aimed to use machine learning - specifically, hierarchical clustering - to identify underlying haemodynamic alterations causing intraoperative hypotension in major abdominal surgery patients. Specifically, we tested the hypothesis that there are distinct endotypes of intraoperative hypotension, which may help refine therapeutic interventions. METHODS We conducted a secondary analysis of intraoperative haemodynamic measurements from a prospective observational study in 100 patients who had major abdominal surgery under general anaesthesia. We used stroke volume index, heart rate, cardiac index, systemic vascular resistance index, and pulse pressure variation measurements. Intraoperative hypotension was defined as any mean arterial pressure ≤65 mm Hg or a mean arterial pressure between 66 and 75 mm Hg requiring a norepinephrine infusion rate exceeding 0.1 μg kg-1 min-1. To identify endotypes of intraoperative hypotension, we used hierarchical clustering (Ward's method). RESULTS A total of 615 episodes of intraoperative hypotension occurred in 82 patients (46 [56%] female; median age: 64 [57, 73] yr) who had surgery of a median duration of 270 (195, 335) min. Hierarchical clustering revealed six distinct intraoperative hypotension endotypes. Based on their clinical characteristics, we labelled these endotypes as (1) myocardial depression, (2) bradycardia, (3) vasodilation with cardiac index increase, (4) vasodilation without cardiac index increase, (5) hypovolaemia, and (6) mixed type. CONCLUSION Hierarchical clustering identified six endotypes of intraoperative hypotension. If validated, considering these intraoperative hypotension endotypes may enable causal treatment of intraoperative hypotension.
Collapse
Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lennart Brockmann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lea Malin Timmermann
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| |
Collapse
|
16
|
Persona P, Tonetti T, Valeri I, Pivetta E, Zarantonello F, Pettenuzzo T, De Cassai A, Navalesi P. Dynamic Arterial Elastance to Predict Mean Arterial Pressure Decrease after Reduction of Vasopressor in Septic Shock Patients. Life (Basel) 2022; 13. [PMID: 36675977 DOI: 10.3390/life13010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022] Open
Abstract
After fluid status optimization, norepinephrine infusion represents the cornerstone of septic shock treatment. De-escalation of vasopressors should be considered with caution, as hypotension increases the risk of mortality. In this prospective observational study including 42 patients, we assess the role of dynamic elastance (EaDyn), i.e., the ratio between pulse pressure variation and stroke volume variation, which can be measured noninvasively by the MostCare monitoring system, to predict a mean arterial pressure (MAP) drop > 10% 30 min after norepinephrine reduction. Patients were divided into responders (MAP falling > 10%) and non-responders (MAP falling < 10%). The receiver-operating-characteristic curve identified an area under the curve of the EaDyn value to predict a MAP decrease > 10% of 0.84. An EaDyn cut-off of 0.84 predicted a MAP drop > 10% with a sensitivity of 0.71 and a specificity of 0.89. In a multivariate logistic regression, EaDyn was significantly and independently associated with MAP decrease (OR 0.001, 95% confidence interval 0.00001−0.081, p < 0.001). The nomogram model for the probability of MAP decrease > 10% showed a C-index of 0.90. In conclusion, in a septic shock cohort, EaDyn correlates well with the risk of decrease of MAP > 10% after norepinephrine reduction.
Collapse
|
17
|
Russo A, Cascarano L, Dell'Anna AM, Grieco DL, Menga LS, Romanò B, Papanice D, Cataldo A, Foschi N, Russo P, Bassi P, Sollazzi L. Correlation of in-target time for mean arterial pressure and stroke volume with tissue perfusion during major urological surgery: an observational pilot study. Br J Anaesth 2022; 129:e128-e131. [PMID: 36058724 DOI: 10.1016/j.bja.2022.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Andrea Russo
- Department of Anesthesia and Intensive Care Medicine, Università Cattolica Del Sacro Cuore (UCSC), Rome, Italy
| | - Laura Cascarano
- Department of Anesthesia and Intensive Care Medicine, Università Cattolica Del Sacro Cuore (UCSC), Rome, Italy
| | - Antonio M Dell'Anna
- Department of Anesthesia and Intensive Care Medicine, Università Cattolica Del Sacro Cuore (UCSC), Rome, Italy.
| | - Domenico L Grieco
- Department of Anesthesia and Intensive Care Medicine, Università Cattolica Del Sacro Cuore (UCSC), Rome, Italy
| | - Luca S Menga
- Department of Anesthesia and Intensive Care Medicine, Università Cattolica Del Sacro Cuore (UCSC), Rome, Italy
| | - Bruno Romanò
- Department of Anesthesia and Intensive Care Medicine, Università Cattolica Del Sacro Cuore (UCSC), Rome, Italy
| | - Domenico Papanice
- Department of Anesthesia and Intensive Care Medicine, Università Cattolica Del Sacro Cuore (UCSC), Rome, Italy
| | - Andrea Cataldo
- Department of Anesthesia and Intensive Care Medicine, Università Cattolica Del Sacro Cuore (UCSC), Rome, Italy
| | - Nazario Foschi
- Department of Clinical Urology, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica Del Sacro Cuore (UCSC), Rome, Italy
| | - Pierluigi Russo
- Department of Clinical Urology, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica Del Sacro Cuore (UCSC), Rome, Italy
| | - Pierfrancesco Bassi
- Department of Clinical Urology, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica Del Sacro Cuore (UCSC), Rome, Italy
| | - Liliana Sollazzi
- Department of Anesthesia and Intensive Care Medicine, Università Cattolica Del Sacro Cuore (UCSC), Rome, Italy
| |
Collapse
|
18
|
Kouz K, Wegge M, Flick M, Bergholz A, Moll-Khosrawi P, Nitzschke R, Trepte CJC, Krause L, Sessler DI, Zöllner C, Saugel B. Continuous intra-arterial versus intermittent oscillometric arterial pressure monitoring and hypotension during induction of anaesthesia: the AWAKE randomised trial. Br J Anaesth 2022; 129:478-486. [PMID: 36008202 DOI: 10.1016/j.bja.2022.06.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Hypotension during induction of anaesthesia is associated with organ injury. Continuous arterial pressure monitoring might help reduce hypotension. We tested the hypothesis that continuous intra-arterial compared with intermittent oscillometric arterial pressure monitoring reduces hypotension during induction of anaesthesia in noncardiac surgery patients. METHODS In this single-centre randomised trial, 242 noncardiac surgery patients in whom intra-arterial arterial pressure monitoring was planned were randomised to unblinded continuous intra-arterial or to intermittent oscillometric arterial pressure monitoring (with blinded intra-arterial arterial pressure monitoring) during induction of anaesthesia. The primary endpoint was the area under a mean arterial pressure (MAP) of 65 mm Hg within the first 15 min of induction of anaesthesia. Secondary endpoints included areas under MAP values of 60, 50, and 40 mm Hg and durations of MAP values <65, <60, <50, and <40 mm Hg. RESULTS There were 224 subjects available for analysis. The median (25th-75th percentile) area under a MAP of 65 mm Hg was 15 (2-36) mm Hg • min in subjects assigned to continuous intra-arterial monitoring and 46 (7-111) mm Hg • min in subjects assigned to intermittent oscillometric monitoring (P<0.001). Subjects assigned to continuous intra-arterial monitoring had smaller areas under MAP values of 60, 50, and 40 mm Hg and shorter durations of MAP values <65, <60, <50, and <40 mm Hg than subjects assigned to intermittent oscillometric monitoring. CONCLUSION Continuous intra-arterial arterial pressure monitoring reduces hypotension during induction of anaesthesia compared with intermittent oscillometric arterial pressure monitoring in noncardiac surgery patients. In patients for whom an arterial catheter is planned, clinicians might therefore consider inserting the arterial catheter before rather than after induction of anaesthesia. CLINICAL TRIALS REGISTRATION NCT04894019.
Collapse
Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mirja Wegge
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Parisa Moll-Khosrawi
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Nitzschke
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Constantin J C Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Krause
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| |
Collapse
|
19
|
Jasińska-Gniadzik K, Szwed P, Gasecka A, Zawadka M, Grabowski M, Pietrasik A. Haemodynamic monitoring in acute heart failure - what you need to know. Adv Cardiol 2022; 18:90-100. [PMID: 36051835 DOI: 10.5114/aic.2022.118524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/05/2022] [Indexed: 12/03/2022]
Abstract
Acute heart failure (AHF) is a sudden, life-threatening condition, defined as a gradual or rapid onset of symptoms and/or signs of HF. AHF requires urgent medical attention, being the most frequent cause of unplanned hospital admission in patients above 65 years of age. AHF is associated with a 4–12% in-hospital mortality rate and a 21–35% 1-year mortality rate post-discharge. Considering the serious prognosis in AHF patients, it is very important to understand the mechanisms and haemodynamic status in an individual AHF patient, thus preventing end-organ failure and death. Haemodynamic monitoring is a serial assessment of cardiovascular function, intended to detect physiologic abnormalities at the earliest stages, determine which interventions could be most effective, and provide the basis for initiating the most appropriate therapy and evaluate its effects. Over the past decades, haemodynamic monitoring techniques have evolved greatly. Nowadays, they range from very invasive to non-invasive, from intermittent to continuous, and in terms of the provided parameters. Invasive techniques contain pulmonary artery catheterization and transpulmonary thermodilution. Minimally invasive techniques include oesophageal Doppler and noncalibrated pulse wave analysis. Non-invasive techniques contain echocardiography, bioimpedance, and bioreactance techniques as well as non-invasive pulse contour methods. Each of these techniques has specific indications and limitations. In this article, we aimed to provide a pathophysiological explanation of the physical terms and parameters used for haemodynamic monitoring in AHF and to summarize the working principles, advantages, and disadvantages of the currently used methods of haemodynamic monitoring.
Collapse
|
20
|
Coverdale G, Patteril M. Do pulmonary artery catheters have a role in the 21 st century intensive care unit? Br J Anaesth 2022; 129:3-7. [PMID: 35331542 DOI: 10.1016/j.bja.2022.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 11/16/2022] Open
Abstract
Use of pulmonary artery catheters on general intensive care units has declined. Reasons for this decline are explored and the evidence for and against their use is re-examined. We conclude that the growing consensus for a lack of benefit is not justified, and use of pulmonary artery catheters can still be appropriate.
Collapse
Affiliation(s)
- Giles Coverdale
- Department of Anaesthesia and Critical Care, University Hospital Coventry and Warwickshire, Coventry, UK.
| | - Mathew Patteril
- Department of Anaesthesia and Critical Care, University Hospital Coventry and Warwickshire, Coventry, UK
| |
Collapse
|
21
|
Liang S, Zou W. Effect of the intraoperative use of the hypotension prediction index on postoperative hypotension in the postanaesthesia care unit. Comment on Br J Anaesth 2021; 127: 681-8. Br J Anaesth 2022; 128:e340-e341. [PMID: 35331545 DOI: 10.1016/j.bja.2022.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/29/2022] [Accepted: 02/21/2022] [Indexed: 11/02/2022] Open
Affiliation(s)
- Shuang Liang
- Department of Anaesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Wangyuan Zou
- Department of Anaesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan Province, China.
| |
Collapse
|
22
|
Atti V, Narayanan MA, Patel B, Balla S, Siddique A, Lundgren S, Velagapudi P. A Comprehensive Review of Mechanical Circulatory Support Devices. Heart Int 2022; 16:37-48. [PMID: 36275352 PMCID: PMC9524665 DOI: 10.17925/hi.2022.16.1.37] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/07/2021] [Indexed: 08/08/2023] Open
Abstract
Treatment strategies to combat cardiogenic shock (CS) have remained stagnant over the past decade. Mortality rates among patients who suffer CS after acute myocardial infarction (AMI) remain high at 50%. Mechanical circulatory support (MCS) devices have evolved as novel treatment strategies to restore systemic perfusion to allow cardiac recovery in the short term, or as durable support devices in refractory heart failure in the long term. Haemodynamic parameters derived from right heart catheterization assist in the selection of an appropriate MCS device and escalation of mechanical support where needed. Evidence favouring the use of one MCS device over another is scant. An intra-aortic balloon pump is the most commonly used short-term MCS device, despite providing only modest haemodynamic support. Impella CP® has been increasingly used for CS in recent times and remains an important focus of research for patients with AMI-CS. Among durable devices, Heartmate® 3 is the most widely used in the USA. Adequately powered randomized controlled trials are needed to compare these MCS devices and to guide the operator for their use in CS. This article provides a brief overview of the types of currently available MCS devices and the indications for their use.
Collapse
Affiliation(s)
- Varunsiri Atti
- Division of Cardiovascular Diseases, West Virginia University Heart and Vascular Institute, Morgantown, WV, USA
| | | | - Brijesh Patel
- Division of Cardiovascular Diseases, West Virginia University Heart and Vascular Institute, Morgantown, WV, USA
| | - Sudarshan Balla
- Division of Cardiovascular Diseases, West Virginia University Heart and Vascular Institute, Morgantown, WV, USA
| | - Aleem Siddique
- Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Scott Lundgren
- Division of Cardiovascular Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Poonam Velagapudi
- Division of Cardiovascular Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| |
Collapse
|
23
|
Flick M, Saugel B. Continuous ward monitoring: the selection, monitoring, alarms, response, treatment (SMART) road map. Br J Anaesth 2021; 127:675-677. [PMID: 34454711 DOI: 10.1016/j.bja.2021.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| |
Collapse
|
24
|
Morelli A, Sanfilippo F, Romano SM, Vieillard-Baron A. Assessment of ventriculo-arterial coupling from peripheral waveform analysis in septic shock. Reply to Br J Anaesth 2021; 126: e101-2. Br J Anaesth 2021; 127:e17-e19. [PMID: 33931172 DOI: 10.1016/j.bja.2021.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/25/2021] [Accepted: 03/02/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Andrea Morelli
- Department of Internal Clinical, Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Rome, Italy.
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, Policlinico-Vittorio Emanuele University Hospital, Catania, Italy
| | - Salvatore M Romano
- Department of Experimental and Clinical Medicine, Unit of Internal Medicine and Cardiology, University of Florence, Florence, Italy
| | - Antoine Vieillard-Baron
- Intensive Care Medicine Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise, Boulogne-Billancourt, France; INSERM UMR-1018, CESP, Team Kidney and Heart, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| |
Collapse
|
25
|
Insom G, Marinari E, Scolari AF, Garisto C, Vitale V, Di Chiara L, Ricci Z. Veno-arterial CO(2) difference and cardiac index in children after cardiac surgery. Cardiol Young 2021; 31:597-601. [PMID: 33292893 DOI: 10.1017/S1047951120004357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Veno-arterial CO2 difference has been considered as a marker of low cardiac output. This study aimed to evaluate the correlation between veno-arterial CO2 difference and cardiac index estimated by MostCareTM in children after cardiac surgery and its association with other indirect perfusion parameters and the complex clinical course (vasoactive inotropic score above 15 or length of stay above 5 days).Data from 40 patients and 127 arterial and venous CO2 measurements for gap calculation taken 0-5 days postoperatively were available. The median (range) veno-arterial CO2 difference value was 9 (1-25 mmHg). The correlation between veno-arterial CO2 difference and cardiac index was not significant (r: -0.16, p = 0.08). However, there was a significant correlation between veno-arterial CO2 difference and vasoactive inotropic score (r: 0.21, p = 0.02), systolic arterial pressure (r: -0.43, p = 0.0001), dP/dtMAX (r: 0.26, p = 0.004), and arterio-venous O2 difference (r: 0.63, p = 0.0001). Systolic arterial pressure (OR 0.95, 95% CI 0.90-0.99), dP/dtMAX (OR 0.00, 95% CI 0.00-0.06), lactates (OR 1.87, 95% CI 1.21-3.31), and veno-arterial CO2 difference (OR 1.13, 95% CI 1.01-1.35) showed a significant univariate association with the complex clinical course. In conclusion, veno-arterial CO2 difference did not correlate with cardiac index estimated by MostCareTM in our cohort of post-cardiosurgical children, but it identified patients with the complex clinical course, especially when combined with other direct and indirect variables of perfusion.
Collapse
|
26
|
Nweze K, Ribeiro CS, Kelly J, Cevallos Morales J. Successful Intraosseous Thrombolysis in the Management of a Massive Pulmonary Embolism With Cardiac Arrest. Cureus 2020; 12:e12105. [PMID: 33489522 PMCID: PMC7805517 DOI: 10.7759/cureus.12105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We describe the successful cardiopulmonary resuscitation of a patient with massive pulmonary embolism who received thrombolysis via the intraosseous route. This case also demonstrates survival without apparent long-term sequelae despite extreme metabolic acidosis. In the context of pulmonary embolism, this has not been widely reported in the existing literature. A 22-year-old woman suffered a prolonged cardiac arrest secondary to pulmonary embolism in a hospital corridor following short hospital admission for medical termination of pregnancy. A point-of-care echocardiogram showed a grossly dilated right ventricle indicative of pulmonary embolism. Due to severe peripheral vasoconstriction, intravenous access proved difficult, and the decision was made to deliver intraosseous thrombolysis. Initial blood gas analysis showed a profound acidosis due to alternating return of spontaneous circulation and further loss of output. Because of her prolonged "low-flow" state, she was deemed unsuitable for extracorporeal membrane oxygenation. Despite the poor prognosis, the decision was made to continue with resuscitation in light of a reversible pathology. She was successfully discharged from the hospital after a short intensive care stay with no long-term complications. This case demonstrates successful thrombolysis through an intraosseous route, with a good outcome despite poor prognostic factors. Early thrombolysis and continuous cardiopulmonary resuscitation in massive pulmonary embolism are imperative to survival in cardiac arrest.
Collapse
Affiliation(s)
- Kirsty Nweze
- Intensive Care Unit, Newham University Hospital, London, GBR
| | | | - James Kelly
- Intensive Care Unit, Newham University Hospital, London, GBR
| | | |
Collapse
|
27
|
Saugel B, Kouz K, Scheeren TWL, Greiwe G, Hoppe P, Romagnoli S, de Backer D. Cardiac output estimation using pulse wave analysis-physiology, algorithms, and technologies: a narrative review. Br J Anaesth 2020; 126:67-76. [PMID: 33246581 DOI: 10.1016/j.bja.2020.09.049] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/23/2020] [Accepted: 09/10/2020] [Indexed: 01/18/2023] Open
Abstract
Pulse wave analysis (PWA) allows estimation of cardiac output (CO) based on continuous analysis of the arterial blood pressure (AP) waveform. We describe the physiology of the AP waveform, basic principles of PWA algorithms for CO estimation, and PWA technologies available for clinical practice. The AP waveform is a complex physiological signal that is determined by interplay of left ventricular stroke volume, systemic vascular resistance, and vascular compliance. Numerous PWA algorithms are available to estimate CO, including Windkessel models, long time interval or multi-beat analysis, pulse power analysis, or the pressure recording analytical method. Invasive, minimally-invasive, and noninvasive PWA monitoring systems can be classified according to the method they use to calibrate estimated CO values in externally calibrated systems, internally calibrated systems, and uncalibrated systems.
Collapse
Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gillis Greiwe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy; Department of Anesthesia and Critical Care, Careggi University Hospital, Florence, Italy
| | - Daniel de Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
28
|
Terada T, Ochiai R. Comparison of the ability of two continuous cardiac output monitors to detect stroke volume index: Estimated continuous cardiac output estimated by modified pulse wave transit time and measured by an arterial pulse contour-based cardiac output device. Technol Health Care 2020; 29:499-504. [PMID: 32925120 DOI: 10.3233/thc-202332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Estimated continuous cardiac output (esCCO), a non-invasive technique for continuously measuring cardiac output (CO), is based on modified pulse wave transit time, which is determined by pulse oximetry and electrocardiography. OBJECTIVE We examined the ability of esCCO to detect stroke volume index (SVI) and changes in SVI compared with currently available arterial waveform analysis methods. METHODS We retrospectively reanalysed 15 of the cases from our previous study on esCCO measurement. SVI was calculated using an esCCO system, measured using the arterial pressure-based CO (APCO) method, and compared with a corresponding intermittent bolus thermodilution CO (ICO) method. Percentage error measurement and statistical methods, including concordance analysis and polar plot analysis, were performed. RESULTS The difference in the SVI values between esCCO and ICO was -3.0 ± 8.8 ml (percentage error, 33.5%). The mean angular bias was 0.8 and the radial limits of agreement were ± 27.3. The difference in the SVI values between APCO and ICO was 0.9 ± 11.2 ml (percentage error, 42.6%). The mean angular bias was -6.8 and the radial limits of agreement were ± 44.1. CONCLUSION This study demonstrated that the accuracy, precision, and dynamic trend of esCCO are better than those of APCO.
Collapse
|
29
|
Nicklas JY, Diener O, Leistenschneider M, Sellhorn C, Schön G, Winkler M, Daum G, Schwedhelm E, Schröder J, Fisch M, Schmalfeldt B, Izbicki JR, Bauer M, Coldewey SM, Reuter DA, Saugel B. Personalised haemodynamic management targeting baseline cardiac index in high-risk patients undergoing major abdominal surgery: a randomised single-centre clinical trial. Br J Anaesth 2020; 125:122-32. [PMID: 32711724 DOI: 10.1016/j.bja.2020.04.094] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite several clinical trials on haemodynamic therapy, the optimal intraoperative haemodynamic management for high-risk patients undergoing major abdominal surgery remains unclear. We tested the hypothesis that personalised haemodynamic management targeting each individual's baseline cardiac index at rest reduces postoperative morbidity. METHODS In this single-centre trial, 188 high-risk patients undergoing major abdominal surgery were randomised to either routine management or personalised haemodynamic management requiring clinicians to maintain personal baseline cardiac index (determined at rest preoperatively) using an algorithm that guided intraoperative i.v. fluid and/or dobutamine administration. The primary outcome was a composite of major complications (European Perioperative Clinical Outcome definitions) or death within 30 days of surgery. Secondary outcomes included postoperative morbidity (assessed by a postoperative morbidity survey), hospital length of stay, mortality within 90 days of surgery, and neurocognitive function assessed after postoperative Day 3. RESULTS The primary outcome occurred in 29.8% (28/94) of patients in the personalised management group, compared with 55.3% (52/94) of patients in the routine management group (relative risk: 0.54, 95% confidence interval [CI]: 0.38 to 0.77; absolute risk reduction: -25.5%, 95% CI: -39.2% to -11.9%; P<0.001). One patient assigned to the personalised management group, compared with five assigned to the routine management group, died within 30 days after surgery (P=0.097). There were no clinically relevant differences between the two groups for secondary outcomes. CONCLUSIONS In high-risk patients undergoing major abdominal surgery, personalised haemodynamic management reduces a composite outcome of major postoperative complications or death within 30 days after surgery compared with routine care. CLINICAL TRIAL REGISTRATION NCT02834377.
Collapse
|
30
|
Molnar Z, Benes J, Saugel B. Intraoperative hypotension is just the tip of the iceberg: a call for multimodal, individualised, contextualised management of intraoperative cardiovascular dynamics. Br J Anaesth 2020; 125:419-423. [PMID: 32690244 DOI: 10.1016/j.bja.2020.05.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/16/2020] [Accepted: 05/16/2020] [Indexed: 01/25/2023] Open
Affiliation(s)
- Zsolt Molnar
- Department of Translational Medicine, Medical School, University of Pecs, Pecs, Hungary; Department of Anaesthesiology and Intensive Therapy, Poznan University for Medical Sciences, Poznan, Poland
| | - Jan Benes
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Pilsen, Pilsen, Czech Republic; Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| |
Collapse
|
31
|
Brezeanu LN, Brezeanu RC, Diculescu M, Droc G. Anaesthesia for Liver Transplantation: An Update. ACTA ACUST UNITED AC 2020; 6:91-100. [PMID: 32426515 DOI: 10.2478/jccm-2020-0011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 01/30/2020] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) is a challenging surgery performed on patients with complex physiology profiles, complicated by multi-system dysfunction. It represents the treatment of choice for end-stage liver disease. The procedure is performed under general anaesthesia, and a successful procedure requires an excellent understanding of the patho-physiology of liver failure and its implications. Despite advances in knowledge and technical skills and innovations in immunosuppression, the anaesthetic management for LT can be complicated and represent a real challenge. Monitoring devices offer crucial information for the successful management of patients. Hemodynamic instability is typical during surgery, requiring sophisticated invasive monitoring. Arterial pulse contour analysis and thermo-dilution techniques (PiCCO), rotational thromboelastometry (RO-TEM), transcranial doppler (TCD), trans-oesophageal echocardiography (TEE) and bispectral index (BIS) have been proven to be reliable monitoring techniques playing a significant role in decision making. Anaesthetic management is specific according to the three critical phases of surgery: pre-anhepatic, anhepatic and neo-hepatic phase. Surgical techniques such as total or partial clamping of the inferior vena cava (IVC), use of venovenous bypass (VVBP) or portocaval shunts have a significant impact on cardiovascular stability. Post reperfusion syndrome (PRS) is a significant event and can lead to arrhythmias and even cardiac arrest.
Collapse
|
32
|
Abstract
Burn-injured patients provide unique challenges to those providing anaesthesia and pain management. This review aims to update both the regular burn anaesthetist and the anaesthetist only occasionally involved with burn patients in emergency settings. It addresses some aspects of care that are perhaps contentious in terms of airway management, fluid resuscitation, transfusion practices and pharmacology. Recognition of pain management failures and the lack of mechanism-specific analgesics are discussed along with the opioid crisis as it relates to burns and nonpharmacological methods in the management of distressed patients.
Collapse
Affiliation(s)
- Francois Stapelberg
- Department of Anaesthesia and Pain Medicine, New Zealand National Burn Centre, Auckland, New Zealand.,Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| |
Collapse
|
33
|
Beurskens DMH, Bol ME, Delhaas T, van de Poll MCG, Reutelingsperger CPM, Nicolaes GAF, Sels JWEM. Decreased endothelial glycocalyx thickness is an early predictor of mortality in sepsis. Anaesth Intensive Care 2020; 48:221-228. [PMID: 32486831 PMCID: PMC7328096 DOI: 10.1177/0310057x20916471] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Microcirculatory alterations play an important role in the early phase of sepsis. Shedding of the endothelial glycocalyx is regarded as a central pathophysiological mechanism causing microvascular dysfunction, contributing to multiple organ failure and death in sepsis. The objective of this study was to investigate whether endothelial glycocalyx thickness at an early stage in septic patients relates to clinical outcome. We measured the perfused boundary region (PBR), which is inversely proportional to glycocalyx thickness, of sublingual microvessels (5-25 µm) using sidestream dark field imaging. The PBR in 21 patients with sepsis was measured within 24 h of admission to the intensive care unit (ICU). In addition, we determined plasma markers of microcirculatory dysfunction and studied their correlation with PBR and mortality. Endothelial glycocalyx thickness in sepsis was significantly lower for non-survivors as compared with survivors, indicated by a higher PBR of 1.97 [1.85, 2.19]µm compared with 1.76 [1.59, 1.97] µm, P=0.03. Admission PBR was associated with hospital mortality with an area under the curve of 0.778 based on the receiver operating characteristic curve. Furthermore, PBR correlated positively with angiopoietin-2 (rho=0.532, P=0.03), indicative of impaired barrier function. PBR did not correlate with Acute Physiology and Chronic Health Evaluation IV (APACHE IV), Sequential Organ Failure Assessment score (SOFA score), lactate, syndecan-1, angiopoietin-1 or heparin-binding protein. An increased PBR within the first 24 h after ICU admission is associated with mortality in sepsis. Further research should be aimed at the pathophysiological importance of glycocalyx shedding in the development of multi-organ failure and at therapies attempting to preserve glycocalyx integrity.
Collapse
Affiliation(s)
- Daniëlle MH Beurskens
- Department of Biochemistry, Maastricht University, the
Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht
University, the Netherlands
| | - Martine E Bol
- Department of Intensive Care Medicine, Maastricht University
Medical Center, the Netherlands
- School of Nutrition and Translational Research in Metabolism,
Maastricht University, the Netherlands
| | - Tammo Delhaas
- Cardiovascular Research Institute Maastricht, Maastricht
University, the Netherlands
- Department of Biomedical Engineering, Maastricht University, the
Netherlands
| | - Marcel CG van de Poll
- Department of Intensive Care Medicine, Maastricht University
Medical Center, the Netherlands
- School of Nutrition and Translational Research in Metabolism,
Maastricht University, the Netherlands
- Department of Surgery, Maastricht University Medical Center, the
Netherlands
| | - Chris PM Reutelingsperger
- Department of Biochemistry, Maastricht University, the
Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht
University, the Netherlands
| | - Gerry AF Nicolaes
- Department of Biochemistry, Maastricht University, the
Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht
University, the Netherlands
| | - Jan-Willem EM Sels
- Department of Intensive Care Medicine, Maastricht University
Medical Center, the Netherlands
- Department of Cardiology, Maastricht University Medical Center,
the Netherlands
| |
Collapse
|
34
|
Kouz K, Hoppe P, Briesenick L, Saugel B. Intraoperative hypotension: Pathophysiology, clinical relevance, and therapeutic approaches. Indian J Anaesth 2020; 64:90-96. [PMID: 32139925 PMCID: PMC7017666 DOI: 10.4103/ija.ija_939_19] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 12/20/2022] Open
Abstract
Intraoperative hypotension (IOH) i.e., low arterial blood pressure (AP) during surgery is common in patients having non-cardiac surgery under general anaesthesia. It has a multifactorial aetiology, and is associated with major postoperative complications including acute kidney injury, myocardial injury and death. Therefore, IOH may be a modifiable risk factor for postoperative complications. However, there is no uniform definition for IOH. IOH not only occurs during surgery but also after the induction of general anaesthesia before surgical incision. However, the optimal therapeutic approach to IOH remains elusive. There is evidence from one small randomised controlled trial that individualising AP targets may reduce the risk of postoperative organ dysfunction compared with standard care. More research is needed to define individual AP harm thresholds, to develop therapeutic strategies to treat and avoid IOH, and to integrate new technologies for continuous AP monitoring.
Collapse
Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Luisa Briesenick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Outcomes Research Consortium, Cleveland, Ohio, USA
| |
Collapse
|
35
|
Alan N, Khorshid L. The effects of different positions on saturation and vital signs in patients. Nurs Crit Care 2019; 26:28-34. [PMID: 31659840 DOI: 10.1111/nicc.12477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 08/27/2019] [Accepted: 09/04/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patient positioning is an independent nursing intervention and may increase peripheral oxygenation for patients with lung disease. Few studies have been conducted on the effect of body positions on oxygenation in patients with lung disease. AIMS AND OBJECTIVES To investigate the effects of five different positions on peripheral oxygen saturation (SpO2 ) and vital signs in patients with lung disease. DESIGN A semi-experimental study was conducted. METHODS Consecutive samples were recorded from critical care patients followed in the chest clinic of a university hospital. A total of 109 patients with lung disease were recruited. Patients who were able to lie in all positions, and who had unilateral or bilateral lung disease documented by a medical diagnosis by a physician were included in this study. The SpO2 and vital signs were measured at each position three times. RESULTS For patients with right, left, and bilateral lung disease, lying on the right side of the body at 45 in bed, the SpO2 was higher, but this difference was not statistically significant. There was a significant difference at 40 minutes between the pulse rate in patients with left and bilateral lung disease, but not in patients with right lung disease. No significant differences were found between respiratory rates and body temperature in patients in any of the three groups at 10, 25, and 40 minutes. CONCLUSIONS Although this difference was not statistically significant, lying on the right side of the body at 45 in bed can be an effective position for improving oxygenation in all patients with lung disease. RELEVANCE TO CLINICAL PRACTICE As there is insufficient evidence to suggest a specific position, further studies are needed. This study provides evidence that the best oxygenation in patients with unilateral and bilateral lung disease can be obtained by determining the appropriate position for critical care nurses.
Collapse
Affiliation(s)
- Nurten Alan
- Dokuz Eylül University Nursing Faculty, İnciraltı, İzmir, Turkey
| | | |
Collapse
|
36
|
Vistisen ST, Enevoldsen JN, Greisen J, Juhl-Olsen P. What the anaesthesiologist needs to know about heart-lung interactions. Best Pract Res Clin Anaesthesiol 2019; 33:165-177. [PMID: 31582096 DOI: 10.1016/j.bpa.2019.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The impact of positive pressure ventilation extends the effect on lungs and gas exchange because the altered intra-thoracic pressure conditions influence determinants of cardiovascular function. These mechanisms are called heart-lung interactions, which conceptually can be divided into two components (1) The effect of positive airway pressure on the cardiovascular system, which may be more or less pronounced under various pathologic cardiac conditions, and (2) The effect of cyclic airway pressure swing on the cardiovascular system, which can be useful in the interpretation of the individual patient's current haemodynamic state. It is imperative for the anaesthesiologist to understand the fundamental mechanisms of heart-lung interactions, as they are a foundation for the understanding of optimal, personalised cardiovascular treatment of patients undergoing surgery in general anaesthesia. The aim of this review is thus to describe what the anaesthesiologist needs to know about heart-lung interactions.
Collapse
Affiliation(s)
- Simon T Vistisen
- Institute of Clinical Medicine, Aarhus University, Denmark; Department of Anaesthesiology & Intensive Care, Aarhus University Hospital, Denmark.
| | - Johannes N Enevoldsen
- Institute of Clinical Medicine, Aarhus University, Denmark; Department of Anaesthesiology & Intensive Care, Aarhus University Hospital, Denmark.
| | - Jacob Greisen
- Department of Anaesthesiology & Intensive Care, Aarhus University Hospital, Denmark; Institute of Clinical Medicine, Aarhus University, Denmark.
| | - Peter Juhl-Olsen
- Department of Anaesthesiology & Intensive Care, Aarhus University Hospital, Denmark; Institute of Clinical Medicine, Aarhus University, Denmark.
| |
Collapse
|
37
|
Terada T, Kessoku S, Suzuki A, Kurosawa A, Nakagomi S, Oiwa A, Arai M, Sakamoto N, Idemitsu W, Ochiai R. Comparison of the Pulse Wave Transit Time Method and an Arterial Pressure-Based Cardiac Output System for Measuring Cardiac Output Trends During Laparotomy Without Postural Change. Asian J Anesthesiol 2019; 57:85-92. [PMID: 31722470 DOI: 10.6859/aja.201909_57(3).0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective Perioperative intravascular volume can be optimised by identifying predictors of fluid responsiveness. This study compared the estimated continuous cardiac output (esCCO) system for non- invasive measurement and an arterial pressure-based cardiac output (APCO) system for detecting exact changes in cardiac output (CO) among patients undergoing laparotomy without postural change. Methods This study was performed at Toho University Omori Medical Centre in Japan from April 2016 to July 2016 and included 26 adult patients undergoing elective laparotomy lasting > 2 h without postural change. We evaluated both interchangeability and dynamic trend. After entering the biometric data (age, sex, height, weight, heart rate, pulse wave transit time, and blood pressure), the esCCO device was calibrated. All patients were also monitored with the APCO system. Data were analysed and compared for 12 adult patients using Bland–Altman analysis and polar plots. Results The CO value obtained with esCCO was 0.75 ± 0.86 L/min (percentage error: 41%) lower than that obtained with the APCO system. Polar plotting revealed that the mean angular bias was 3.5°, and the radial limit of agreement was 28.3°. Conclusion This study demonstrated that data obtained using esCCO are not interchangeable with those obtained using the APCO system. The trending ability of the esCCO device was deemed good among patients undergoing laparotomy without postural change.
Collapse
|
38
|
Bein B, Renner J. Best practice & research clinical anaesthesiology: Advances in haemodynamic monitoring for the perioperative patient: Perioperative cardiac output monitoring. Best Pract Res Clin Anaesthesiol 2019; 33:139-53. [PMID: 31582094 DOI: 10.1016/j.bpa.2019.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/01/2019] [Accepted: 05/16/2019] [Indexed: 12/15/2022]
Abstract
Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. Even established, invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution have still an evidence-based place in the perioperative setting, albeit only in special patient populations. Accumulating evidence suggests to use continuous haemodynamic monitoring, especially flow-based variables such as stroke volume or cardiac output to prevent occult hypoperfusion and, consequently, decrease morbidity and mortality perioperatively. However, there is still a substantial gap between evidence provided by randomised trials and the implementation of haemodynamic monitoring in daily clinical routine. Given the fact that perioperative morbidity and mortality are higher than anticipated and anaesthesiologists are in charge to deal with this problem, the recent advances in minimally invasive and non-invasive monitoring technologies may facilitate more widespread use in the operating theatre, as in addition to costs, the degree of invasiveness of any monitoring tool determines the frequency of its application, at least perioperatively. This review covers the currently available invasive, non-invasive and minimally invasive techniques and devices and addresses their indications and limitations.
Collapse
|
39
|
Jackevičiūtė J, Kraujalytė G, Jaremko I, Stremaitytė V, Gudaitytė J. Comparison of two continuous non-invasive haemodynamic monitoring techniques in the perioperative setting. Acta Med Litu 2019; 26:31-37. [PMID: 31281214 PMCID: PMC6586383 DOI: 10.6001/actamedica.v26i1.3953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 03/26/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The aim of the study was to identify the accuracy of and agreement between two non-invasive haemodynamic monitoring techniques in the perioperative setting - thoracic electrical bioimpedance (TEB) and Edwards Lifesciences ClearSight system (CS). MATERIALS AND METHODS The study included ten patients. Parametric quantitative data were expressed as mean ± SD. The Shapiro-Wilk test was used to test the normality of the distributions. A linear regression model was used to measure the strength of the linear relationship between TEB and CS. Bland-Altman analysis was performed to assess the mean difference, precision, and the limits of agreements (LOA). The Critchley and Critchley method was used to calculate the percentage error (PE), and if <30%, it was considered clinically acceptable. RESULTS Ten patients were involved in our study. The mean cardiac output (CO) with TEB was 6.15 ± 1.14 L/min vs. 4.78 ± 1.40 L/min with CS (p < 0.01). The relationship was significant (n = 144; r 2 = 0.7; p < 0.01). The mean bias, LOA, and PE were 1.37 ± 1.01 L/min, 3.35 L/min and -0.61 L/min and 36.22%, respectively. The mean stroke volume index (SVI) with TEB was 48.64 ± 9.8 ml/beat/m2 vs. 37.12 ± 9.14 ml/beat/m2 with CS (p < 0.01). The relationship was significant (n = 144; r 2 = 0.65; p < 0.01). The mean bias, LOA, and PE were 11.52 ± 7.92 ml/beat/m2, 27.04 ml/beat/m2 and -4 ml/beat/m2 and 36.19%. CONCLUSIONS The two methods of non-invasive haemodynamic monitoring are not compatible in the perioperative setting. However, the CS system has more advantages in terms of continuity and simplicity of monitoring, while measurements of TEB are interrupted by electrocautery.
Collapse
Affiliation(s)
- Jonė Jackevičiūtė
- Department of Anaesthesiology, Medical Academy, Lithuanian University of Health Sciences, Lithuania
| | - Greta Kraujalytė
- Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Inna Jaremko
- Department of Anaesthesiology, Medical Academy, Lithuanian University of Health Sciences, Lithuania
| | - Vilija Stremaitytė
- Department of Anaesthesiology, Medical Academy, Lithuanian University of Health Sciences, Lithuania
| | - Jūratė Gudaitytė
- Department of Anaesthesiology, Medical Academy, Lithuanian University of Health Sciences, Lithuania
- Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| |
Collapse
|
40
|
Agerskov M, Sørensen H, Højlund J, Secher NH, Foss NB. Pre-operative haemodynamic monitoring and resuscitation in hip fracture patients: Protocol for a prospective observational study. Acta Anaesthesiol Scand 2018; 62:1314-1320. [PMID: 29851062 DOI: 10.1111/aas.13163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/05/2018] [Accepted: 04/29/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND In a frail patient group often suffering from dehydration, hip fracture is potentially fatal partly because of the blood loss and thus deteriorated circulation. An important goal for haemodynamic monitoring and resuscitation is early detection of insufficient tissue perfusion. "The peripheral perfusion index" reflects changes in peripheral perfusion and blood volume. We hypothesize that hip fracture patients are hypovolaemic with poor peripheral perfusion and accordingly respond to controlled fluid resuscitation. The peripheral perfusion index might reflect restricted tissue perfusion in spite of stable central haemodynamic variables. METHODS This prospective observational study assess to what extend hip fracture patients suffer from hypovolaemia and respond to a stroke volume-guided fluid challenge. The secondary objectives are to evaluate correlation between the non-invasive peripheral perfusion index and minimally invasive measures of stroke volume, changes in blood volume and near-infrared spectroscopy determined tissue- and cerebral oxygenation and to compare results to prevalence of post-operative complications including mortality. We will include 50 patients (>65 years) presenting a hip fracture and treated in a multimodal fast-track regimen when written informed consent is available. DISCUSSION This is likely the first study to address pre-operative haemodynamic monitoring and resuscitation in hip fracture patients where adequate resuscitation is easily missed. We aim to evaluate feasibility of pre-operative stroke volume-guided haemodynamic optimization in the context of minimally- and non-invasive monitoring of peripheral perfusion and measure of blood volume.
Collapse
Affiliation(s)
- M. Agerskov
- Department of Anaesthesiology; Hvidovre Hospital; University of Copenhagen; Hvidovre Denmark
| | - H. Sørensen
- Department of Anaesthesiology; Abdominal Centre; Rigshospitalet; University of Copenhagen; Kobenhavn Denmark
| | - J. Højlund
- Department of Anaesthesiology; Hvidovre Hospital; University of Copenhagen; Hvidovre Denmark
| | - N. H. Secher
- Department of Anaesthesiology; Abdominal Centre; Rigshospitalet; University of Copenhagen; Kobenhavn Denmark
| | - N. B. Foss
- Department of Anaesthesiology; Hvidovre Hospital; University of Copenhagen; Hvidovre Denmark
| |
Collapse
|
41
|
Affiliation(s)
- M A Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M R Edwards
- Department of Anaesthesia and Peri-operative Medicine, University Hospital Southampton NHS Foundation Trust, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, University of Southampton, Southampton, UK
| |
Collapse
|
42
|
Abstract
To describe the baseline hemodynamic variables and response time of hemodynamic changes associated with the Valsalva maneuver using noninvasive continuous cardiac output monitoring (Nexfin). Hemodynamic monitoring provides an integral component of advanced clinical care and the ability to monitor response to treatment interventions. The emergence of noninvasive hemodynamic monitoring provides clinicians with an opportunity to monitor and assess patients rapidly with ease of implementation. However, the responsiveness of this method in tracking dynamic changes that occur has not been fully elucidated. A prospective observational study was conducted involving 44 healthy volunteers (age = 38 ±12 years). Participants performed a Valsalva maneuvers to illicit dynamic changes in blood pressure, cardiac output, cardiac index, systemic vascular resistance index (SVRI), and stroke volume. Changes in these hemodynamic parameters were monitored while performing repeated standardized Valsalva maneuvers. Baseline hemodynamic values were obtained in all 44 participants, and showed an interaction with age, accompanying a significant decline in cardiac index (r = -.66, p < .05) and stroke volume (r = -.68,p < .05), and an increase in SVRI (r = .67, p < .05) with increasing age. The Valsalva maneuver, performed in 20 participants, resulted in a change of 10% from baseline blood pressure and cardiac index, which was detected within 4.53 s (SD = 4.36) and 3.31 s (SD = 2.21), respectively. Noninvasive continuous cardiac monitoring demonstrated the ability to rapidly detect logical and predictable hemodynamic changes. These observations suggest that such Nexfin technology may have useful clinical applications.
Collapse
Affiliation(s)
- L J Delaney
- University of Canberra, Australian Capital Territory, Australia.,Australian National University, Canberra, Australian Capital Territory, Australia
| | - R Bellomo
- Melbourne University, Victoria, Australia.,Austin Hospital, Heidelberg, Victoria, Australia
| | - F van Haren
- Australian National University, Canberra, Australian Capital Territory, Australia.,Canberra Hospital, Australian Capital Territory, Australia
| |
Collapse
|
43
|
Abstract
Central venous pressure (CVP) monitoring is used to assess the fluid status of patients in critical care settings. This article explains CVP monitoring, discussing the rationale for its use, the ways CVP can be measured, and the physiological factors that can affect the reliability and validity of CVP measurement. It also discusses the complications associated with CVP monitoring and the nursing responsibilities in relation to this activity.
Collapse
Affiliation(s)
- Barry Thomas Hill
- Faculty of Health and Life Science, Northumbria University, Newcastle upon Tyne, England
| |
Collapse
|
44
|
Byrne L, Obonyo NG, Diab S, Dunster K, Passmore M, Boon AC, Hoe LS, Hay K, Van Haren F, Tung JP, Cullen L, Shekar K, Maitland K, Fraser JF. An Ovine Model of Hyperdynamic Endotoxemia and Vital Organ Metabolism. Shock 2018; 49:99-107. [PMID: 28520696 PMCID: PMC7004818 DOI: 10.1097/shk.0000000000000904] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Animal models of endotoxemia are frequently used to understand the pathophysiology of sepsis and test new therapies. However, important differences exist between commonly used experimental models of endotoxemia and clinical sepsis. Animal models of endotoxemia frequently produce hypodynamic shock in contrast to clinical hyperdynamic shock. This difference may exaggerate the importance of hypoperfusion as a causative factor in organ dysfunction. This study sought to develop an ovine model of hyperdynamic endotoxemia and assess if there is evidence of impaired oxidative metabolism in the vital organs. METHODS Eight sheep had microdialysis catheters implanted into the brain, heart, liver, kidney, and arterial circulation. Shock was induced with a 4 h escalating dose infusion of endotoxin. After 3 h vasopressor support was initiated with noradrenaline and vasopressin. Animals were monitored for 12 h after endotoxemia. Blood samples were recovered for hemoglobin, white blood cell count, creatinine, and proinflammatory cytokines (IL-1Beta, IL-6, and IL-8). RESULTS The endotoxin infusion was successful in producing distributive shock with the mean arterial pressure decreasing from 84.5 ± 12.8 mm Hg to 49 ± 8.03 mm Hg (P < 0.001). Cardiac index remained within the normal range decreasing from 3.33 ± 0.56 L/min/m to 2.89l ± 0.36 L/min/m (P = 0.0845). Lactate/pyruvate ratios were not significantly abnormal in the heart, brain, kidney, or arterial circulation. Liver microdialysis samples demonstrated persistently high lactate/pyruvate ratios (mean 37.9 ± 3.3). CONCLUSIONS An escalating dose endotoxin infusion was successful in producing hyperdynamic shock. There was evidence of impaired oxidative metabolism in the liver suggesting impaired splanchnic perfusion. This may be a modifiable factor in the progression to multiple organ dysfunction and death.
Collapse
Affiliation(s)
- Liam Byrne
- The Critical Care Research Group, Chermside, Brisbane, Australia
- Australian National University, Canberra, ACT, Australia
- The Canberra Hospital Yamba Dr, Garran, ACT, Australia
| | | | - Sara Diab
- The Critical Care Research Group, Chermside, Brisbane, Australia
| | - Kimble Dunster
- The Critical Care Research Group, Chermside, Brisbane, Australia
- Queensland University of Technology, Brisbane City, Australia
| | - Margaret Passmore
- The Critical Care Research Group, Chermside, Brisbane, Australia
- University of Queensland, St Lucia, Australia
| | - Ai Ching Boon
- The Critical Care Research Group, Chermside, Brisbane, Australia
- University of Queensland, St Lucia, Australia
| | - Louise See Hoe
- The Critical Care Research Group, Chermside, Brisbane, Australia
- University of Queensland, St Lucia, Australia
| | - Karen Hay
- QIMR Berghofer Medical Research Institute, Herston, Brisbane, Australia
| | - Frank Van Haren
- Australian National University, Canberra, ACT, Australia
- The Canberra Hospital Yamba Dr, Garran, ACT, Australia
| | - John-Paul Tung
- The Critical Care Research Group, Chermside, Brisbane, Australia
- Australian Red Cross Blood Service, Kelvin Grove, Brisbane, Australia
| | - Louise Cullen
- Queensland University of Technology, Brisbane City, Australia
- The Emergency Department Royal Brisbane Women and Children’s Hospital Brisbane, Australia
| | - Kiran Shekar
- The Critical Care Research Group, Chermside, Brisbane, Australia
- The Adult Intensive Care, The Prince Charles Hospital, Chermside, Brisbane, Australia
| | - Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, Imperial College London, United Kingdom
| | - John F. Fraser
- The Critical Care Research Group, Chermside, Brisbane, Australia
- University of Queensland, St Lucia, Australia
- The Adult Intensive Care, The Prince Charles Hospital, Chermside, Brisbane, Australia
| |
Collapse
|
45
|
Hall DP, Jordan H, Alam S, Gillies MA. The impact of focused echocardiography using the Focused Intensive Care Echo protocol on the management of critically ill patients, and comparison with full echocardiographic studies by BSE-accredited sonographers. J Intensive Care Soc 2017; 18:206-211. [PMID: 29118832 DOI: 10.1177/1751143717700911] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Introduction Focused echocardiography is widely used to assist clinical decision-making in critically ill patients. In the UK, the Focused Intensive Care Echo protocol is recommended by the Intensive Care Society to ensure consistency of approach and guarantee training standards. Concerns remain about the reliability of information attained by non-expert clinicians in focused echocardiography, particularly when this is used to alter clinical management. Methods A prospective, observational evaluation of 60 consecutive patients undergoing Focused Intensive Care Echo studies in a single ICU. Results A complete Focused Intensive Care Echo study was possible in 43/60 scans (72%) and new diagnostic information obtained following 41/60 scans (68%), which lead to a change of clinical management in 28/60 (47%) of cases. In 24/60 (40%) of cases, a full transthoracic study was subsequently undertaken by a fully accredited sonographer. There were no cases where the results from the full study contradicted those from the limited Focused Intensive Care Echo study; additional diagnostic information was attained following 68% of full studies. Conclusion Focused echocardiography using the Focused Intensive Care Echo protocol is feasible and clinically useful in a high proportion of ICU patients. However, many still require additional expert echocardiographic assessment. Focused echocardiography delivered by non-experts is clinically useful in this setting but its limitations must be understood and access to expert assessment should be available.
Collapse
Affiliation(s)
- David P Hall
- Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine ICT Centre, Birmingham, UK
| | - Helen Jordan
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Shirjel Alam
- Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael A Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| |
Collapse
|
46
|
Sasaki K, Mutoh T, Mutoh T, Kawashima R, Tsubone H. Electrical velocimetry for noninvasive cardiac output and stroke volume variation measurements in dogs undergoing cardiovascular surgery. Vet Anaesth Analg 2017; 44:7-16. [PMID: 27159382 DOI: 10.1111/vaa.12380] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 02/25/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To compare electrical velocimetry (EV) noninvasive measures of cardiac output (CO) and stroke volume variation (SVV) in dogs undergoing cardiovascular surgery with those obtained with the conventional thermodilution technique using a pulmonary artery catheter. STUDY DESIGN Prospective experimental trial. ANIMALS Seven adult Beagle dogs with a median weight of 13.6 kg. METHODS Simultaneous, coupled cardiac index (CI; CO indexed to body surface area) measurements by EV (CIEV) and the reference pulmonary artery catheter thermodilution method (CIPAC) were obtained in seven sevoflurane-anaesthetized, mechanically ventilated dogs undergoing experimental open-chest cardiovascular surgery for isolated right ventricular failure. Relationships between SVV or central venous pressure (CVP) and stroke volume (SV) were analysed to estimate fluid responsiveness. Haemodynamic data were recorded intraoperatively and before and after fluid challenge. RESULTS Bland-Altman analysis of 332 matched sets of CI data revealed an overall bias and precision of - 0.22 ± 0.52 L minute-1 m-2 for CIEV and CIPAC (percentage error: 30.4%). Trend analysis showed a concordance of 88% for CIEV. SVV showed a significant positive correlation (r2 = 0.442, p < 0.0001) with SV changes to a volume loading of 200 mL, but CVP did not (r2 = 0.0002, p = 0.94). Better prediction of SV responsiveness (rise of SV index of ≥ 10%) was observed for SVV (0.74 ± 0.09; p = 0.014) with a significant area under the receiver operating characteristic curve in comparison with CVP (0.53 ± 0.98; p = 0.78), with a cut-off value of 14.5% (60% specificity and 83% sensitivity). CONCLUSIONS AND CLINICAL RELEVANCE In dogs undergoing cardiovascular surgery, EV provided accurate CO measurements compared with CIPAC, although its trending ability was poor. Further, SVV by EV, but not CVP, reliably predicted fluid responsiveness during mechanical ventilation in dogs.
Collapse
Affiliation(s)
- Kazumasu Sasaki
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan; Sendai Animal Care and Research Center, Sendai, Japan
| | - Tatsushi Mutoh
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan.
| | - Tomoko Mutoh
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Ryuta Kawashima
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Hirokazu Tsubone
- Research Center for Food Safety, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
47
|
Sasaki K, Mutoh T, Mutoh T, Taki Y, Kawashima R. Noninvasive stroke volume variation using electrical velocimetry for predicting fluid responsiveness in dogs undergoing cardiac surgery. Vet Anaesth Analg 2017; 44:719-726. [PMID: 28803717 DOI: 10.1016/j.vaa.2016.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 10/29/2016] [Accepted: 11/06/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the ability of a noninvasive cardiac output monitoring system with electrical velocimetry (EV) for predicting fluid responsiveness in dogs undergoing cardiac surgery. STUDY DESIGN Prospective experimental trial. ANIMALS A total of 30 adult Beagle dogs. METHODS Stroke volume (SV), stroke volume variation (SVV) and cardiac index were measured using the EV device in sevoflurane-anaesthetized, mechanically ventilated dogs undergoing thoracotomies for experimental creation of right ventricular failure. The dogs were considered fluid responsive if stroke volume (SVI; indexed to body weight), measured using pulmonary artery thermodilution, increased by 10% or more after volume loading (10 mL kg-1). Relationships of SVV, central venous pressure (CVP) and pulmonary artery occlusion pressure (PAOP) with SVI were analysed to estimate fluid responsiveness. RESULTS Better prediction of fluid responsiveness, with a significant area under the receiver operating characteristic curve, was observed for SVV (0.85±0.07; p=0.0016) in comparison with CVP (0.65±0.11; p=0.17) or PAOP (0.60±0.12; p=0.35), with a cut-off value of 13.5% (84% specificity and 73% sensitivity). CONCLUSIONS AND CLINICAL RELEVANCE SVV derived from EV is useful for identification of dogs that are likely to respond to fluids, providing valuable information on volume status under cardiothoracic anaesthesia.
Collapse
Affiliation(s)
- Kazumasu Sasaki
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan; Sendai Animal Care and Research Center, Sendai, Japan
| | - Tatsushi Mutoh
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan.
| | - Tomoko Mutoh
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Yasuyuki Taki
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Ryuta Kawashima
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| |
Collapse
|
48
|
Abstract
With advances in cardiology and cardiothoracic surgery, several newer implantable cardiac devices have become common in the surgical population. Multichamber pacemakers, implanted cardiac defibrillators and ventricular assist devices are frequent in current day practice. Many of the newer implantable cardiac electronic devices are targeted at managing heart failure. While managing such patients for non-cardiac surgeries, specific issues related to equipment characteristics and troubleshooting should be a priority for the anaesthesiologists. There is a possibility of malfunction of the devices resulting in catastrophic outcomes. Therefore, it is imperative to understand the pathophysiology, device characteristics and troubleshooting before embarking on anaesthetising patients with implantable cardiac electronic devices.
Collapse
Affiliation(s)
- Murali Chakravarthy
- Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India
| | - Dattatreya Prabhakumar
- Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India
| | - Antony George
- Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India
| |
Collapse
|
49
|
Carsetti A, Watson X, Cecconi M. Haemodynamic coherence in perioperative setting. Best Pract Res Clin Anaesthesiol 2016; 30:445-52. [PMID: 27931648 DOI: 10.1016/j.bpa.2016.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 10/21/2016] [Accepted: 10/27/2016] [Indexed: 11/23/2022]
Abstract
Over the last decade, there has been an increased interest in the use of goal-directed therapy (GDT) in patients undergoing high-risk surgery, and various haemodynamic monitoring tools have been developed to guide perioperative care. Both the complexity of the patient and surgical procedure need to be considered when deciding whether GDT will be beneficial. Ensuring optimum tissue perfusion is paramount in the perioperative period and relies on the coherence between both macrovascular and microvascular circulations. Although global haemodynamic parameters may be optimised with the use of GDT, microvascular impairment can still persist. This review will provide an overview of both haemodynamic optimisation and microvascular assessment in the perioperative period.
Collapse
|
50
|
Grensemann J, Defosse JM, Wieland C, Wild UW, Wappler F, Sakka SG. Comparison of PulsioFlex® uncalibrated pulse contour method and a modified Fick principle with transpulmonary thermodilution measurements in critically ill patients. Anaesth Intensive Care 2016; 44:484-90. [PMID: 27456179 DOI: 10.1177/0310057x1604400407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Monitoring of cardiac index (CI) by uncalibrated pulse contour (PC) methods has been shown to be inaccurate in critically ill patients. We tested accuracy and trending of a new pulse contour method and a modified Fick method using central venous oxygen saturation. We studied 21 critically ill and mechanically ventilated patients (age 20-86 years) monitored by PC (PulsioFlex®) and transpulmonary thermodilution (TPTD, PiCCO2®) as reference. At baseline, reference and PC-derived CI (CIPC) were recorded and CI obtained by Fick's method (FM, CIFICK). After four hours, measurements were performed analogously for trending analysis. CI are given in l/min/m2 as mean±standard deviation. At baseline CITPTD was 3.7±0.7, CIPC 3.8±0.7 and CIFICK 5.2±1.8. After 4 hours, CITPTD was 3.5±0.6, CIPC 3.8±1.2 and CIFICK 4.8±1.7. Mean bias for PC at baseline was -0.1 (limits of agreement [LOA] -1.4 to 1.2) and -0.4 (LOA -2.6 to 1.9) after four hours. Percentage errors (PE) were 34% and 60% respectively. FM revealed a bias of -1.5 (LOA -4.8 to 1.8, PE 74%) at baseline and -1.5 (LOA -4.5 to 1.4, PE 68%) at four hours. With an exclusion window of 10% of mean cardiac index, trending analysis by polar plots showed an angular bias of 5° (radial LOA±57°) for PC and 16° (radial LOA±51°) for FM. Although PC values at baseline were marginally acceptable, both methods fail to yield clinically acceptable absolute values. Likewise, trending ability is not adequate for both methods to be used in critically ill patients.
Collapse
Affiliation(s)
- J Grensemann
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Witten/Herdecke, Medical Center Cologne-Merheim, Köln; Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J M Defosse
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Witten/Herdecke, Medical Center Cologne-Merheim, Köln, Germany
| | - C Wieland
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Witten/Herdecke, Medical Center Cologne-Merheim, Köln, Germany
| | - U W Wild
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Köln, Germany
| | - F Wappler
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Köln, Germany
| | - S G Sakka
- Professor and Head of the Operative Intensive Care Unit, Department of Anaesthesiology and Operative Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Köln, Germany
| |
Collapse
|