Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study

PURPOSE

Early postoperative mobilization can be hindered by orthostatic intolerance (OI). Postoperative OI has multifactorial pathogenesis, possibly involving both postoperative hypovolemia and autonomic dysfunction. We aimed to investigate the effect of mild acute blood loss from blood donation simulating postoperative hypovolemia, on both autonomic function and OI, thus eliminating confounding perioperative factors such as inflammation, residual anesthesia, pain, and opioids.

METHODS

This prospective observational cohort study included 26 blood donors. Continuous electrocardiogram data were collected during mobilization and night sleep, both before and after blood donation. A Valsalva maneuver and a standardized mobilization procedure were performed immediately before and after blood donation, during which cardiovascular and tissue oxygenation variables were continuously measured by LiDCOrapid™ and Massimo Root™, respectively. The incidence of OI, hemodynamic responses during mobilization and Valsalva maneuver, as well as heart rate variability (HRV) responses during mobilization and sleep were compared before and 15 min after blood donation.

RESULTS

Prior to blood donation, no donors experienced OI during mobilization. After blood donation, 6/26 (23%; 95% CI, 9 to 44) donors experienced at least one OI symptom. Three out of 26 donors (12%; 95% CI, 2 to 30) terminated the mobilization procedure prematurely because of severe OI symptoms. Cardiovascular and cerebral tissue oxygenation responses were reduced in patients with severe OI. After blood loss, HRV indices of total autonomic power remained unchanged but increased sympathetic and decreased parasympathetic outflow was observed during mobilization, but also during sleep, indicating a prolonged autonomic effect of hypovolemia.

CONCLUSION

We describe a specific hypovolemic component of postoperative OI, independent of postoperative autonomic dysfunction, inflammation, opioids, and pain.

STUDY REGISTRATION

ClinicalTrials.gov (NCT04499664); registered 5 August 2020.

Hyponatraemia in patients with community-acquired pneumonia; prevalence and aetiology, and natural history of SIAD

OBJECTIVE

Hyponatraemia is common in community-acquired pneumonia (CAP) and is associated with increased mortality. The mechanism of hyponatraemia in CAP is not completely understood and treatment is therefore ill-defined. We aimed to define the causation of hyponatraemia in CAP.

DESIGN

Prospective, single-centre, observational study of all patients with CAP and hyponatraemia (≤ 130 mmol/L) during a 9-month period.

PATIENTS

The prevalence of each subtype of hyponatraemia, and the associated mortality, was determined in 143 admissions with CAP (Study 1). A sub-cohort of patients with SIAD (n = 10) was prospectively followed, to document the natural history of SIAD associated with CAP (Study 2).

MEASUREMENTS

In Study 2, blood and urine were collected on day 1, 3, 5 and 7 following admission for measurement of plasma vasopressin, sodium, osmolality and urine osmolality.

RESULTS

In study 1, 143/1723(8.3%) of CAP patients had hyponatraemia (≤130 mmol/L). About 66 had SIAD (46%), 60(42%) had hypovolaemic hyponatraemia (HON), 13(9%) had hypervolaemic hyponatraemia (HEN) and 4(3%) patients had hyponatraemia due to glucocorticoid hormone deficiency. Mortality was higher in the HEN than in the HON, SIAD or normonatraemic groups (P < 0.01). In Study 2, plasma sodium concentration normalized in 8/10 (80%) by day 7. Two patients with persistent hyponatraemia were discovered to have underlying bronchiectasis.

CONCLUSIONS

Hyponatraemia in CAP is most commonly secondary to SIAD or hypovolaemia. HEN is less common, but has worse prognosis. Prospective observation demonstrates that in SIAD, plasma AVP and sodium concentrations normalize with antimicrobials; failure of reversal of suggests underlying lung disease, such as bronchiectasis.

Novel Insights into the Pathogenesis and Prevention of Intradialytic Hypotension

BACKGROUND

Intradialytic hypotension (IDH) is a common complication of haemodialysis (HD) and associated with adverse outcomes, especially when a nadir definition (systolic blood pressure <90 mm Hg) is used. The pathogenesis of IDH is directly linked to the discontinuous nature of the HD treatment, in combination with patient-related factors such as age, diabetes mellitus and cardiac failure.

SUMMARY

Although the decline in blood volume due to removal of fluid by ultrafiltration is the prime mover, thermally induced reflex vasodilation compromises the haemodynamic response to hypovolemia. Recent studies have stressed the relevance of changes in tissue perfusion during HD, which may translate in long-term organ damage. Monitoring changes in tissue perfusion, for which emerging evidence becomes available, appears to have great promise in the fine-tuning of the dialysis procedure. Key Messages: While it is unlikely that IDH can be completely prevented, reduction in inter-dialytic weight gain, prevention of an increase in core temperature by adjusting the dialysate temperature and more frequent or prolonged dialysis treatment remain cornerstones in providing a more comfortable and safe treatment.

Management and outcome of hepatocellular adenoma with massive bleeding at presentation

AIM

To evaluate outcome of acute management and risk of rebleeding in patients with massive hemorrhage due to hepatocellular adenoma (HCA).

METHODS

This retrospective cohort study included all consecutive patients who presented to our hospital with massive hemorrhage (grade II or III) due to ruptured HCA and were admitted for observation and/or intervention between 1999-2016. The diagnosis of HCA was based on radiological findings from contrast-enhanced magnetic resonance imaging (MRI) or pathological findings from biopsy or resection of the HCA. Hemorrhage was diagnosed based on findings from computed tomography or MRI. Medical records were reviewed for demographic features, clinical presentation, tumor features, initial and subsequent management, short- and long-term complications and patient and lesion follow-up.

RESULTS

All patients were female (n = 23). Treatment in the acute phase consisted of embolization (n = 9, 39.1%), conservative therapy (n = 13, 56.5%), and other intervention (n = 1, 4.3%). Median hemoglobin level decreased significantly more on days 0-3 in the intervention group than in the patients initially treated conservatively (0.9 mmol/L vs 2.4 mmol/L respectively, P = 0.006). In total, 4 patients suffered severe short-term complications, which included hypovolemic shock, acute liver failure and abscess formation. After a median follow-up of 36 mo, tumor regression in non-surgically treated patients occurred with a median reduction of 76 mm down to 25 mm. Four patients underwent secondary (elective) treatment (i.e., tumor resection) to address HCA size of > 5 cm and/or desire for future pregnancy. One case of rebleeding was documented (4.3%). None of the patients experienced long-term complication (mean follow-up time: 36 mo).

CONCLUSION

With a 4.3% risk of rebleeding, secondary (elective) treatment of HCA after massive hemorrhage may only be considered in patients with persistent HCA > 5 cm.

[Postural orthostatic tachycardia syndrome (POTS)--pathophysiology, diagnostics, and treatment]

Postural orthostatic tachycardia syndrome (POTS) is one of the most common presentation of orthostatic intolerance. The syndrome is described as a multifactorial affliction. Main symptoms consist of persistent orthostatic tachycardia (heart rate increase at least 30 beats/min, lasting at least 10 min after assumic vertical position) with high noradrenalin serum concentration (measured in stand-up position). Additionally patients with POTS tend to have lover total blood volume. POTS is generally classified into dysatonomia disorders Symptoms in patients affected with POTS are chronic. The syndrome occurs predominantly in young women (approximately 80%). Due to complexity and variable intensity of symptoms POTS can severely impair daily activity and quality of life in otherwise healthy people. The correct diagnosis and identification of potential pathophysiological mechanisms of POTS is necessary before treatment administration. Adequate therapy can significantly reduce symptoms giving the patients a chance for a normal life.

Outbreak of epidemic dropsy in Ethiopia: the clinical and therapeutic observation

INTRODUCTION

Epidemic dropsy results from ingestion of argemone oil contaminated food staffs. The oil from Argemone Mexican seeds contains toxic alkaloids called sanguinarine and dehydrosangunarine. These cause wide spread capillary dilatation, proliferation and leakages. This leads to oedema, hypovolemia and hypotension.

OBJECTIVE

To describe the socio-demographic and clinical manifestations of the patients affected with epidemic dropsy in Tikur Anbessa specialized Hospital (TASH).

METHODS

A case series study was conducted in an outbreak with unusual cases which was later diagnosed to be epidemic dropsy. Clinical evaluation of suspects was done and optimal therapy given for the complications detected and information was filled in structured format by medical residents and medial chart records review was made for occurrence of new complications in the end of 9 months.

RESULTS

A total of 164 patients were seen at TASH from 26 households, in 8 sub-cities of Addis Ababa. A wide range of age group was affected with 70% from 16 to 40 years of age. There was no case among less than 5 years of age. Females were affected more than threefold as compared to males. All the patients manifested with bilateral leg swelling and pitting oedema. It was tender in 50 (30.4%) of them while 43 (26.2%) had erythema. Tachycardia was the next common manifestation occurring in 135 (82.3%), followed by cough in 123 (75%), anaemia in 59 (36%), headache in 58 (35.4%), shortness of breathing in 52 (31.2%), hair loss in 44 (26.8%) and respiratory distress in 35 (21.3%). Abdominal pain, hepatomegally, nausea and vomiting were also seen. There was abnormality in the chest X-ray of 31 (27.2%). Hair loss, tingling and burning extremities, difficulty of standing, hyperpigmentation, pruritic rash and eye symptoms were observed lately during follow up. Five of the patients died while in hospital care due to acute respiratory distress syndrome (ARDS).

CONCLUSIONS

The commonest clinical manifestation in our patients is bilateral leg swelling which is similar to other outbreaks of epidemic dropsy elsewhere. The mortality rate is also comparable with other series but all cases died by ARDS in our series which is unusual in other reports. As this is the first reported epidemics in Ethiopia the findings will create awareness of clinical features of epidemic dropsy among clinicians, and therefore, helps for diagnoses of similar problems in the future.

[Acute kidney injury in cancer patients]

Acute kidney injury is a common and serious complication of cancer. We analyzed medical records of 335 cancer patients who were treated in Internal Diseases and Nephrology Department with Dialysis Center at St. Lucas Hospital in Tarnow in years 2009 and 2010. AKI was diagnosed according to the RIFLE classification in 91 cases (43 woman and 48 men). The average age was 68.7 years (from 18 to 93 years). 54 patients were classified as category F, 23 as category I and 14 as category R of the RIFLE classification. 60.4% of the patients were diagnosed with metastatic cancer, 12.1% with a regionally developed disease, 18.7% with cancer limited to one organ and in 8.8% the stage of the disease could not be established. The highest incidence of AKI was observed in patients with cancer of the cervix, ovary, prostate, breast, stomach and of unknown primary site. The most common risk factor of AKI was hypovolemia diagnosed in 35% of cases. Obstruction of the urinary tract, the second most frequent risk factor was observed in 26% of cases. 14.5% of the patients required hemodialysis. In the group of dialysed patients 38.5% of them died, 61.5% were discharged from hospital after improvement of renal function. In the group of non-dialysed patients mortality rate was 25.6%; survivors in that group presented improvement in renal function. Evaluation of the renal function in patients with cancer is essential.

[Systemic hemodynamic disorders in critically ill patients with intracranial hemorrhages]

The paper analyzes systemic hemodynamic disorders in 45 victims of severe brain injury and patients with nontraumatic intracranial hemorrhages. The incidence of hypovolemia in patients with nontraumatic intracranial hemorrhages and victims of severe brain injury is 65.4% and 73.7%, respectively. Infusion therapy based on the estimation of routine hemodynamic parameters (blood pressure, heart rate, central venous pressure, daily fluid balance) could not prevent hypovolemia in the examinees and caused a high rate of sympathomimetic use in uncorrected volemic states.

[The results of pulsed compression therapy by pneumatic massage in patients with chronic venous insufficiency]

An open prospective observational study was conducted in 68 patients (aged from 32 to 78) with chronic venous insufficiency (CVI) treated with pulsed compression therapy (PCT) by means of Air Massage Slimmer, SB-432 (Seo Hung Mechatec Co., Ltd, South Korea). Outcome parameters included rheoplethysmography measurements of limb volume, limb circumference at different level, ultrasonic features of subcutaneous tissue and patient's subjective assessment of treatment success during and one month after PCT course. PCT was shown to decrease effectively limb volume, venous congestion, and intracellular component of edema syndrome in patients with CVI. Patient subjective feelings normalized in short time, the therapeutic effect of PCT maintained for a month in 83.8% of patients.

Severe malaria: lessons learned from the management of critical illness in children

Two hypotheses have recently been raised to explain the metabolic acidosis (increased blood acidity) of severe malaria, and both are relevant to treatment. The first suggests that a decreased blood volume (hypovolaemia) has an important role in severe malaria; following this, treatment should be based on the current standard paediatric management of acidosis in children with features of cardiovascular compromise. The second hypothesis contends that acidosis in malaria has a metabolic cause and proposes treatment with dichloroacetate. Both hypotheses are plausible and are not mutually exclusive. In truth, the risks and benefits of either treatment are uncertain, and will remain so until large multicentre, randomised controlled trials provide appropriate supportive evidence. As both views involve complex physiological rationales, beyond the usual scope of this journal, I attempt here to present the largely academic aspects of these hypotheses within the practical and contextual aspects of childhood severe malaria.

Fluid resuscitation and nutritional support during severe acute pancreatitis in the past: what have we learned and how can we do better?

BACKGROUND/AIMS

Severe acute pancreatitis is associated with microcirculatory impairment, increased gut permeability and metabolic changes. The aim of the present study was to evaluate initial fluid resuscitation and nutritional support versus outcome in patients with severe acute pancreatitis.

METHODS

All cases of acute pancreatitis admitted 1994-2003 were analyzed retrospectively. The inclusion criteria of severe acute pancreatitis were organ failure and/or local complications according to the Atlanta classification system. Mortality was used as outcome measure.

RESULTS

Ninty-nine patients were included in the study. The hospital mortality was 17%. Hypovolemia at arrival was found in 13% (13/99) and correlated with increased hospital mortality (P=0.009). During the first three days in average 11000+/-4100 ml of fluids and 1470+/-820 calories were administered. Total parental nutrition was given to 73% (69/95) and enteral nutrition served as a complement in 29% (28/95) of the patients. Hyperglycemia was seen in 61% (55/90) of the patients and insulin was administered to 53% (29/55) at an average glucose level of 19+/-3 mmol/l. The intake of oral food was reintroduced in average 15+/-9 days after admission and was interrupted in 17% (13/75) because of pain relapse.

CONCLUSION

A nutritional treatment regime in severe acute pancreatitis including a moderate and hypocaloric initial fluid resuscitation, parental nutrition as the preferred route for nutritional support and a non-strict glucose control, with an associated mortality of 17%, indicates several modes of improving outcome.

Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data

OBJECTIVE

Menorrhagia is defined as blood loss of >80 mL, but in routine clinical practice measurement is seldom undertaken. Our aim was to identify the features of the clinical history that best predict menorrhagic blood loss.

STUDY DESIGN

A questionnaire survey of 952 menstrual complaint referrals at 3 hospital gynecology clinics in Glasgow and Edinburgh included 226 women with putatively heavy periods who also had consented to the measurement of their blood loss.

RESULTS

Only 34% (95% CI, 28%-40%) of women had blood loss volume of >80 mL, but the volume was associated with subjective heaviness of period. Logistic regression with ferritin status, clots, and changing rate during full flow correctly predicts a loss of >80 mL for 76% of women (n=161 patients; sensitivity, 60%; specificity, 86%). Diagnosis and treatment of patients seem unrelated to the volume of blood loss.

CONCLUSION

The subjective judgment of the volume of blood loss is better than has been believed. Clinical features can be combined to predict losses of >80 mL.

Menorrhagia II: is the 80-mL blood loss criterion useful in management of complaint of menorrhagia?

OBJECTIVE

Menorrhagia is defined in terms of statistical"abnormality"as blood loss of >80 mL. We examined the usefulness of this definition in women who were referred to gynecology clinics with heavy periods.

STUDY DESIGN

A questionnaire survey of 952 menstrual complaint referrals at 3 hospital gynaecology clinics in Glasgow and Edinburgh included 226 women with heavy periods who had also consented to the measurement of their blood loss.

RESULTS

Women reported a range of problems with their periods, but absolute volume (31.2%) was less prevalent than period pain (37.5%), mood change (35.7%), and change in the amount (volume) of the period (33.8%). Although there were associations with volume, these associations were due to the heaviest and lightest of the loss groups, whereas the 2 groups with loss either side of 80 mL were virtually indistinguishable.

CONCLUSION

The 80-mL criterion for menorrhagia is of limited clinical usefulness because it is prognostic neither for problems nor iron status and apparently does not guide management.

[Types and variants of cerebral circulation in healthy young people in clino-stasis and anti-orthostasis]

This paper presents the results of investigations of 199 apparently healthy individuals aged 18-22 years. Analysis of the findings yielded concepts of the types of cerebral circulation--the types of cerebral microcirculation and the variants brain volumia--the variants of summarized pulse blood filling of this organ. To define the types and variants of cerebral hemodynamics makes it possible to predict the magnitude and direction of brain vasomotor responses aimed at optimizing arterial blood stream into the region and venous blood outflow under antiorthostasis. The types and variants of cerebral circulation that most and least favourable as to a risk for regional venous congestion. The views of the types and variants of cerebral circulation open up fresh opportunities for in-depth study of the most important parameters of cardiovascular performance. A typological analysis of cerebral circulation can find a wide application in clinical practice for "the passportization" of the most important physiological parameters of regional blood flow.