Adequate Tissue Perfusion Research Articles

Vasopressors: Do they have any role in hemorrhagic shock?

The priority in the management of patients with traumatic hemorrhagic shock is to control the bleeding with simultaneous volume resuscitation to maintain adequate tissue perfusion. Fluid replacement remains the mainstay of initial resuscitation in hemorrhagic shock. Traditionally, vasopressors are contraindicated in the early management of hemorrhagic shock due to their deleterious consequences, although vasopressors may have a role in resuscitation when vasoplegic shock ensues and blood pressure cannot be maintained by fluids alone. Use of vasopressors is not recommended according to the Advanced Trauma Life SupportR management principles. The role of vasopressors remains controversial with no clear guidelines on the timing, type, and dose of these drugs in hemorrhagic shock. Among vasopressors, norepinephrine and vasopressin have been used in the majority of the trials, although not many studies compare the effect of these two on long-term survival in trauma patients. This article reviews the pathophysiology of hemorrhagic shock, adverse effects of fluid resuscitation, and the various experimental and clinical studies on the use of vasopressors in the early phase of resuscitation in hemorrhagic shock.

Lactate levels and hemodynamic coherence in acute circulatory failure.

In this review, the relationship between changes in macrohemodynamics during the development and treatment of acute circulatory failure is discussed in the context of coherence with microcirculation and changes in lactate. In models of circulatory failure, coherence between changes in macrocirculatory and microcirculatory perfusion and coherence with subsequent changes in lactate levels are more or less preserved. However, in patients, particularly those with septic shock, these relationships are much less clear. As many factors influence the effect of circulatory failure and infection on microcirculation and on lactate levels, this should not be surprising. Resuscitation should therefore aim at adequate tissue perfusion where systemic hemodynamics, microcirculatory perfusion parameters, and lactate levels should be used in their relevant context. This results in treating the individual patient as an n=1 experiment.

Percutaneous mechanical circulatory support: current concepts and future directions

### Learning objectives Percutaneous mechanical circulatory support (MCS) strategies have been in the clinical arena for approximately half a century, with the main aim of providing adequate systemic tissue perfusion,...

The Secret Stories of Sodium How Infants, Athletes, Psychotics, And Otherwise Healthy People Die from Sodium Imbalance

1. Tamara Hew-Butler, DPM, PhD, FACSM[⇑][1] 1. School of Health Science, Oakland University, Rochester MI 2. Kevin Weisz, BS 1. William Beaumont School of Medicine, Oakland University, Rochester MI 1. Address for Correspondence: Tamara Hew-Butler, DPM, PhD, FACSM, School of Health Science, 3157 HHB, Oakland University, 2200 N. Squirrel Rd, Rochester, MI 49309; hew{at}oakland.edu 1. Define the normal blood sodium concentration and the definitions of hypo- and hypernatremia. 2. Summarize how extracellular sodium and intracellular potassium drive tonicity balance 3. Describe the roles of hormones in sodium balance. 4. Explain how plasma osmolality and plasma volume are monitored within the body. INTRODUCTION Every number tells a story. As such, clinical laboratory science empowers modern medicine with a vast yet growing repertoire of analytes, which subsequently guide the diagnosis, treatment and prognosis of most – if not all - medical conditions. The body's integrated response to dynamic perturbations in homeostasis creates an elusive trail of biochemical footprints, each providing clues to where pathophysiology began and how far the body has strayed off course (i.e. severity of the insult and appropriateness of the response). The ubiquitous cation, sodium, is one of the main markers of whole body homeostasis. The sodium concentration ([Na+]) within the extracellular fluid space is essential for maintaining cellular size and adequate tissue perfusion. As such, the inherent regulation of water and sodium balance is strict, precise, and fiercely protected by the body. Therefore, when blood sodium levels venture outside of the heavily guarded trails of normonatremia (normal blood [Na+]), into hyponatremia (low blood [Na+]) or hypernatremia (high blood [Na+]), each deviation foretells tales of health and disease - and in rare cases, of abuse and neglect. Water and sodium within the exterior milieu is essential to life. However, within the interior milieu, it is the balance between the two that is critical for individual human survival. We refer to this balance, between water and sodium within the internal milieu, as “fluid homeostasis.” The physiological mechanisms that govern fluid intake (thirst) and output (urine), as well as sodium intake (sodium palatability) and output (urine) have been well-described.1-3 Of historical note,… ABBREVIATIONS: [Na+] – sodium concentration, ADH - anti-diuretic hormone, AVP – arginine vasopressin, CVO - circumventricular organs, ECF – extracellular fluid, ICF – intracellular fluid, IV – intravenous, K+ - potassium, RAAS - renin-angiotensin-aldosterone system 1. Define the normal blood sodium concentration and the definitions of hypo- and hypernatremia. 2. Summarize how extracellular sodium and intracellular potassium drive tonicity balance 3. Describe the roles of hormones in sodium balance. 4. Explain how plasma osmolality and plasma volume are monitored within the body. [1]: #corresp-1

Tissue Oxygenation Monitoring as a Guide for Trauma Resuscitation.

Hypoperfusion is the most common event preceding the onset of multiple organ dysfunction syndrome during trauma resuscitation. Detecting subtle changes in perfusion is crucial to ensure adequate tissue oxygenation and perfusion. Traditional methods of detecting physiological changes include measurements of blood pressure, heart rate, urine output, serum levels of lactate, mixed venous oxygen saturation, and central venous oxygen saturation. Continuous noninvasive monitoring of tissue oxygen saturation in muscle has the potential to indicate severity of shock, detect occult hypoperfusion, guide resuscitation, and be predictive of the need for interventions to prevent multiple organ dysfunction syndrome. Tissue oxygen saturation is being used in emergency departments, trauma rooms, operating rooms, and emergency medical services. Tissue oxygen saturation technology is just as effective as mixed venous oxygen saturation, central venous oxygen saturation, serum lactate, and Stewart approach with strong ion gap, yet tissue oxygen saturation assessment is also a direct, noninvasive microcirculatory measurement of oxygen saturation.

Perioperative bleeding management in pediatric patients.

Managing the bleeding pediatric patient perioperatively can be extremely challenging. The primary goals include avoiding hypotension, maintaining adequate tissue perfusion and oxygenation, and maintaining hemostasis. Traditional bleeding management has consisted of transfusion of autologous blood products, however, there is strong evidence that transfusion-related side-effects are associated with increased morbidity and mortality in children. Especially concerning is the increased reported incidence of noninfectious adverse events such as transfusion-related acute lung injury, transfusion-related circulatory overload and transfusion-related immunomodulation. The current approach in perioperative bleeding management of the pediatric patient should focus on the diagnosis and treatment of anemia and coagulopathy with the transfusion of blood products only when clinically indicated and guided by goal-directed strategies. Current guidelines recommend that a comprehensive multimodal patient blood management strategy is critical in optimizing patient care, avoiding unnecessary transfusion of blood and blood product and limiting transfusion-related side-effects. This article will highlight current guidelines in perioperative bleeding management for our most vulnerable pediatric patients with emphasis on individualized targeted intervention using point-of-care testing and specific coagulation products.

Laser speckle contrast imaging identifies ischemic areas on gastric tube reconstructions following esophagectomy.

Gastric tube reconstruction (GTR) is a high-risk surgical procedure with substantial perioperative morbidity. Compromised arterial blood supply and venous congestion are believed to be the main etiologic factors associated with early and late anastomotic complications. Identifying low blood perfusion areas may provide information on the risks of future anastomotic leakage and could be essential for improving surgical techniques. The aim of this study was to generate a method for gastric microvascular perfusion analysis using laser speckle contrast imaging (LSCI) and to test the hypothesis that LSCI is able to identify ischemic regions on GTRs.Patients requiring elective laparoscopy-assisted GTR participated in this single-center observational investigation. A method for intraoperative evaluation of blood perfusion and postoperative analysis was generated and validated for reproducibility. Laser speckle measurements were performed at 3 different time pointes, baseline (devascularized) stomach (T0), after GTR (T1), and GTR at 20° reverse Trendelenburg (T2).Blood perfusion analysis inter-rater reliability was high, with intraclass correlation coefficients for each time point approximating 1 (P < 0.0001). Baseline (T0) and GTR (T1) mean blood perfusion profiles were highest at the base of the stomach and then progressively declined towards significant ischemia at the most cranial point or anastomotic tip (P < 0.01). After GTR, a statistically significant improvement in mean blood perfusion was observed in the cranial gastric regions of interest (P < 0.05). A generalized significant decrease in mean blood perfusion was observed across all GTR regions of interest during 20° reverse Trendelenburg (P < 0.05).It was feasible to implement LSCI intraoperatively to produce blood perfusion assessments on intact and reconstructed whole stomachs. The analytical design presented in this study resulted in good reproducibility of gastric perfusion measurements between different investigators. LSCI provides spatial and temporal information on the location of adequate tissue perfusion and may thus be an important aid in optimizing surgical and anesthesiological procedures for strategically selecting anastomotic site in patients undergoing esophagectomy with GTR.

Kidney and Liver Injuries After Major Burns in Rats Are Prevented by Resolvin D2.

Innate immune dysfunction after major burn injuries increases the susceptibility to organ failure. Lipid mediators of inflammation resolution, e.g., resolvin D2, have been shown recently to restore neutrophil functionality and reduce mortality rate in a rat model of major burn injury. However, the physiological mechanisms responsible for the benefic activity of resolvin D2 are not well understood. Prospective randomized animal investigation. Academic research setting. Wistar male rats. Animals were subjected to a full-thickness burn of 30% total body surface area. Two hours after burn, 25 ng/kg resolvin D2 was administered IV and repeated every day, for 8 days. At day 10 post burn, 2 mg/kg of lipopolysaccharide was administered IV, and the presence of renal and hepatic injuries was evaluated at day 11 post burn by histology, immunohistochemistry, and relevant blood chemistry. In untreated animals, we found significant tissue damage in the kidneys and liver, consistent with acute tubular necrosis and multifocal necrosis, and changes in blood chemistry, reflecting the deterioration of renal and hepatic functions. We detected less tissue damage and significantly lower values of blood urea nitrogen (26.4 ± 2.1 vs 36.0 ± 9.3 mg/dL; p ≤ 0.001), alanine aminotransferase (266.5 ± 295.2 vs 861.8 ± 813.7 U/L; p ≤ 0.01), and total bilirubin (0.13 ± 0.05 vs 0.30 ± 0.14 mg/dL; p ≤ 0.01) in resolvin D2-treated rats than in untreated animals. The mean blood pressure of all animals was above 65 mm Hg, indicating adequate tissue perfusion throughout the experiments. We measured significantly larger amounts of chromatin in the circulation of untreated than of resolvin D2-treated rats (575.1 ± 331.0 vs 264.1 ± 122.4 ng/mL; p ≤ 0.05) and identified neutrophil extracellular traps in kidney and liver tissues from untreated rats, consistent with the tissue damage. Pathologic changes in kidney and liver tissues in a rat model of major burn and endotoxin insults are ameliorated by resolvin D2.

Goal directed fluid therapy reduces major complications in elective surgery for abdominal aortic aneurysm: liberal versus restrictive strategies

BackgroundOptimal fluid management is crucial for patients undergoing surgical repair of abdominal aortic aneurysm (AAA). Persistent hypovolemia is associated with complications but fluid overload is also harmful.AimThis study evaluates that perioperative fluid restriction would reduce complications and improve outcome through goal-directed strategies in patients undergoing AAA.MethodsFifty patients, aged from 60 to 75 years undergoing elective surgical repair of AAA were included in this randomized study. Patients were divided into two groups, 25 for each: liberal group (L) receives 12 ml/kg/h and restrictive group (R) receives 4 ml/kg/h. Goal-directed-therapy approach was concerning assessment of tissue oxygenation. Dobutamine and fluid challenges were used to maintain adequate tissue perfusion during surgery.ResultsThe patients of the (L) group received a significant greater amount of Lactated Ringer’s solution (3586.76 ± 473.21) than the (R) group (1219 ± 140.6). The (R) group had 50% lower rate of major postoperative complications than the (L) group (24% vs 48%) and less hospital stay.ConclusionA restrictive strategy of fluid maintenance during optimization of oxygen delivery with early treatment directed to maintain oxygen extraction ratio estimate (O2ERe) at <27% reduces major complications and hospital stay of surgical patients undergo abdominal aortic aneurysm.

Rapid Extracorporeal Membrane Oxygenation Overcomes Fulminant Myocarditis Induced by 5‑Fluorouracil

Fulminant myocarditis is a rare but potentially life-threatening illness caused by 5-fluorouracil cardiotoxicity. Data supporting the use of extracorporeal membrane oxygenation for the treatment of fulminant myocarditis are limited. A 49-year-old, previously healthy white man, recently diagnosed with anal squamous cell carcinoma, developed severe chest pain hours after completing his first 96-hour intravenous 5-fluorouracil treatment. Over a period of 3 days from onset of symptoms, the patient developed cardiogenic shock secondary to fulminant myocarditis induced by 5-fluorouracil cardiotoxicity. This required emergency initiation of extracorporeal membrane oxygenation. The patient's systolic function recovered by day 5, and on the 17th day he was discharged in hemodynamically stable condition, without symptoms of heart failure. This case shows the importance of prompt recognition of cardiogenic shock secondary to 5-fluorouracil-induced myocarditis and how the immediate initiation of extracorporeal membrane oxygenation can restore adequate tissue perfusion, leading to myocardial recovery and ultimately the survival of the patient.

The Role of Intraoperative Perfusion Assessment: What Is the Current State and How Can I Use It in My Practice?

Evolving intraoperative technology has an increased presence and usefulness in aiding surgeon clinical judgment. Many surgical devices are readily available as an adjunct to this gold standard assessment of adequate tissue perfusion. Intraoperative perfusion monitoring provides surgeons with the ability to interpret additional information that enhances surgical decision-making in real-time. Technologies include various dye-based and non-dye-based near-infrared angiography, tissue oximetry measurements, and ultrasound-based tools. This review summarizes the available intraoperative technologies for planning and assessment of tissue perfusion in plastic and reconstructive surgery. The authors discuss the available literature for the individual devices and supporting evidence for their use. The authors recommend the evidence-based use of these tools in indicated surgical cases to improve clinical outcomes.

Current management of sepsis and septic shock

Sepsis remains a leading cause of death in the intensive care unit. With no specific sepsis therapies available, management currently relies on infection control and hemodynamic stabilization. Rapid diag-nosis enabling early initiation of appropri-ate therapy is essential to maximize sur-vival rates. Effective antimicrobial therapy should be started as soon as possible after diagnosis, with empirical choices based on likely pathogens, local microbiologi-cal patterns, and any recent antimicrobial therapy. At the same time, fluids and va-sopressor agents should be commenced to restore and maintain hemodynamic stability and adequate tissue perfusion. No effective immunomodulatory therapies are available, but some candidates are un-dergoing clinical trials. Better techniques for characterization of the degree of sepsis response in individual patients are needed to help target such agents more appropri-ately as some patients may benefit from immunosuppressive agents while others may require an immune stimulating in-tervention. The management of patients with septic shock is often complex and the development of sepsis teams should be encouraged so that the multiple compo-nents of treatment, e.g., insertion of intra-vascular lines, blood sampling for culture and biochemistry, positioning of required monitoring devices, fluid, antibiotic and vasoactive drug administration, etc, can be carried out simultaneously.

Neuromonitoring during adult cardiac surgery.

Available online at www.jbr-pub.org Open Access at PubMed Central The Journal of Biomedical Research, 2016, 30(3):171-173 Perspective Neuromonitoring during adult cardiac surgery Anna K. Kowalczyk, Bradlee J. Bachar, Hong Liu  Department of Anesthesiology and Pain Medicine, University of California Davis, Sacramento, CA 95817, USA. Introduction Cerebral oximetry The brain has been considered an index organ for global tissue perfusion because of the physiological processes aimed at flow preservation to vital organs of the body [1] .When cerebral perfusion is compromised, other organs are likely inadequately perfused as well. It would therefore be prudent to monitor cerebral perfu- sion based on the proposition that interventions aimed at its preservation will likely result in adequate tissue perfusion of the whole body and reduced complications related to ischemia of various organs. It is worth emphasizing the difference between tissue perfusion and tissue oxygen supply. It is a consensus that the normal oxygen supply/demand ratio is impor- tant to normal tissue metabolic physiology at the molec- ular level. Because oxygen demand is largely related to perfusion, it is perfusion that remains the main focus of all clinicians in the cardiac operating room [1] . Very brief periods of cerebral hypoperfusion occur fre- quently during cardiac surgery due to a multitude of fac- tors (reduced cardiac output, low pump flow, decreased perfusion pressure, etc.) but are of minute clinical sig- nificance. It is prolonged or cumulative hypoperfusion, particularly in watershed areas of the brain, undetected by standard monitors such as arterial blood pressure or pulse oximetry, that leads to brain tissue injury and adverse outcomes [2] . To date, no device has been devel- oped that can reliably, continuously and non-invasively monitor global cerebral tissue perfusion directly. A num- ber of existing monitors can indirectly assess regional cerebral perfusion and provide information useful in managing cerebral blood flow and oxygen supply. Cerebral tissue oximetry operates via measurement of hemoglobin saturation of the mixed arterial, cap- illary and venous blood in superficial frontal lobe being illuminated by near-infrared light. The number represents the ratio of the oxygenated hemoglob in to total hemoglobin, with the frequently reported range of 50-80 and bilateral (right and left) hemisphere difference of no more than 10 points. Desaturation below 50% or more than 20% below baseline, obtained in an awake, non-sedated patient breathing room air, has been used as the threshold of interven- tion in cardiac patients. Previous evidence shows that interventions aimed at maintaining cerebral sat- uration at baseline correlate with reduced neuropsy- chological complications and decreased length of hospital stay [2-4] . The benefit of the monitor is that it is non-invasive and as such poses virtually no known harm to the patient. It is portable, easy to apply and operate as well as interpret. The cost is moderate and can be jus- tified by the beneficial outcome it associates with. It is now considered by many experts in the field as a standard of monitoring during cardiac surgery [2] . Given that both hemispheres are monitored, it can differen- tiate between global and unilateral causes of hypop- erfusion, such as head position or unilateral vessel occlusion. Because the technology does not require pulsatile flow, it offers an advantage during cardio- pulmonary bypass or in patients with non-pulsatile arterial flow (e.g. patients with left ventricular assist devices). Corresponding author: Hong Liu, MD, Professor of Anesthesiology, Department of Anesthesiology and Pain Medicine,University of California Davis Health System, 4150 V Street, Sacramento, CA 95817, USA, Tel: 1-916-734-2413, email: hualiu@ucdavis.edu. Received 20 November 2015, Revised 08 December 2015, Accepted 03 February 2016, Epub 10 March 2016 CLC number: R614, Document code: B The authors reported no conflict of interests. © 2016 by the Journal of Biomedical Research. All rights reserved. doi: 10.7555/JBR.30.20150159

Efficacy of pleth variability index in guiding volume therapy in patients undergoing thoracoscopic surgery

Objective To evaluate the efficacy of pleth variability index (PVI) in guiding volume therapy in the patients undergoing thoracoscopic surgery. Methods Forty patients of both sexes, aged 18-64 yr, with body mass index<35 kg/m2, of American Society of Anesthesiologists physical statusⅠorⅡ, scheduled for elective thoracoscopic lobectomy, were randomized into 2 groups (n= 20 each): control group (group C) and PVI group.During induction of anesthesia, multiple electrolyte solution was infused rapidly as a bolus of 250 ml, followed by a 2-8 ml·kg-1·h-1 infusion.In group C, 6% hydroxyethyl starch 130/0.4 and sodium chloride injection 50 ml and metaraminol 0.5 mg were administered to maintain mean arterial pressure ≥ 65 mmHg.In group PVI, 6% hydroxyethyl starch 130/0.4 and sodium chloride injection 50 ml and metaraminol 0.5 mg were administered to maintain PVI ≤ 13% and mean arterial pressure ≥ 65 mmHg.Immediately after the beginning of one-lung ventilation (T1), immediately after the termination of one-lung ventilation (T2) and at 1 h after surgery (T3), arterial oxygen saturation were recorded, and arterial blood samples were collected for blood gas analysis, and for determination of lactic acid concentrations.The blood creatinine concentrations were measured at 24 h before and after surgery.The fulid balance was recorded. Results The amount of colloid solution infused, total volume of fluid infused and lactic acid concentrations at T3 were significantly lower in group C than in group PVI.There were no significant differences in the amount of crystralloid solution infused, urine volume, blood loss, arterial oxygen saturation at each time point, and blood creatinine concentrations at 24 h before and after surgery between the two groups. Conclusion PVI-guided volume therapy can not only maintain adequate blood volume and tissue perfusion, but also reduce the amount of fluid infused, and is helpful in mitigating lung water overload when used for the patients undergoing thoracoscopic surgery. Key words: Plethysmograp; Fluid therapy; Monitoring, intraoperative; Thoracoscopy

Increasing venoarterial extracorporeal membrane oxygenation flow negatively affects left ventricular performance in a porcine model of cardiogenic shock.

BackgroundThe aim of this study was to assess the relationship between extracorporeal blood flow (EBF) and left ventricular (LV) performance during venoarterial extracorporeal membrane oxygenation (VA ECMO) therapy.MethodsFive swine (body weight 45 kg) underwent VA ECMO implantation under general anesthesia and artificial ventilation. Subsequently, acute cardiogenic shock with signs of tissue hypoxia was induced. Hemodynamic and cardiac performance parameters were then measured at different levels of EBF (ranging from 1 to 5 L/min) using arterial and venous catheters, a pulmonary artery catheter and a pressure–volume loop catheter introduced into the left ventricle.ResultsMyocardial hypoxia resulted in a decline in mean (±SEM) cardiac output to 2.8 ± 0.3 L/min and systolic blood pressure (SBP) to 60 ± 7 mmHg. With an increase in EBF from 1 to 5 L/min, SBP increased to 97 ± 8 mmHg (P < 0.001); however, increasing EBF from 1 to 5 L/min significantly negatively influences several cardiac performance parameters: cardiac output decreased form 2.8 ± 0.3 L/min to 1.86 ± 0.53 L/min (P < 0.001), LV end-systolic volume increased from 64 ± 11 mL to 83 ± 14 mL (P < 0.001), LV stroke volume decreased from 48 ± 9 mL to 40 ± 8 mL (P = 0.045), LV ejection fraction decreased from 43 ± 3 % to 32 ± 3 % (P < 0.001) and stroke work increased from 2096 ± 342 mmHg mL to 3031 ± 404 mmHg mL (P < 0.001). LV end-diastolic pressure and volume were not significantly affected.ConclusionsThe results of the present study indicate that higher levels of VA ECMO blood flow in cardiogenic shock may negatively affect LV function. Therefore, it appears that to mitigate negative effects on LV function, optimal VA ECMO blood flow should be set as low as possible to allow adequate tissue perfusion.

Early hyperlactatemia predicts pancreatic fistula after surgery.

BackgroundPostoperative pancreatic fistula (POPF) is a major complication after pancreatic surgery and results from an impaired healing of the pancreatic enteric anastomosis. Whether perioperative hemodynamic fluid management aiming to provide an adequate tissue perfusion could influence the occurrence of POPF is unknown. Serum lactate level is a well-recognized marker of decreased tissue perfusion and is known to be associated with higher morbidity and mortality in various postoperative settings. We aimed to determine in a retrospective high-volume center’s cohort whether postoperative hyperlactatemia could predict POPF occurrence.MethodWe conducted a retrospective analysis of 96 consecutive patients admitted in the intensive care unit (ICU) after pancreaticoduodenectomy or distal pancreatectomy. Univariate analysis was conducted to compare lactate levels at 6 h between patients evolving with versus without POPF. A logistic regression model was developed and included potential confounding factors.ResultsPOPF occurred in 28 patients (29 %). Serum lactate level 6 h after admission was significantly higher in the POPF group (2.8 mmol/L [95 % confidence interval (CI): 2.1–3.5] versus 1.8 mmol/L [95 % CI: 1.8–2.4], p-value = 0.04) whereas it did not differ at ICU admission or at 12 h. Despite similar cumulative fluid balance, fluid intake and vasopressor use, hyperlactatemia > 2.5 mmol/L (Odds ratio (OR): 3.58; 95 % CI: 1.22–10.48; p-value = 0.020) and red blood cells transfusion (OR: 1.24; 95 % CI: 1.03–1.49; p-value = 0.022) were found to be independent predictive factors of POPF occurrence.ConclusionIn patients undergoing partial pancreatectomy, hyperlactatemia measured 6 h after ICU admission is a predictive factor for the occurrence of POPF. Inflammatory changes after surgery may account for this observation and should be further evaluated.

EFFECTS OF HYPERTONIC SALINE (7.5%) ON LACTATE CLEARANCE COMPARED WITH NORMAL SALINE (0.9%) AFTER ON PUMP CARDIOVASCULAR SURGERY. A RANDOMIZED CONTROLLED TRIAL

Cardiovascular care after the CPB pump often require an exhaustive reanimation,because reduces the intravascular oncotic pressure and increases the capillary permeability.The crystalloids might increase edema and is well known that fluid overload increases mortality.The colloids have not proved a better outcome.A option is to use hypertonic solutions.Lactate is reliable for monitoring adequate tissue perfusion during extracorporeal life support and is strongly predictive of mortality.

Postoperative fluid management.

Postoperative care units are run by an anesthesiologist or a surgeon, or a team formed of both. Management of postoperative fluid therapy should be done considering both patients' status and intraoperative events. Types of the fluids, amount of the fluid given and timing of the administration are the main topics that determine the fluid management strategy. The main goal of fluid resuscitation is to provide adequate tissue perfusion without harming the patient. The endothelial glycocalyx dysfunction and fluid shift to extracellular compartment should be considered wisely. Fluid management must be done based on patient's body fluid status. Patients who are responsive to fluids can benefit from fluid resuscitation, whereas patients who are not fluid responsive are more likely to suffer complications of over-hydration. Therefore, common use of central venous pressure measurement, which is proved to be inefficient to predict fluid responsiveness, should be avoided. Goal directed strategy is the most rational approach to assess the patient and maintain optimum fluid balance. However, accessible and applicable monitoring tools for determining patient's actual fluid need should be further studied and universalized. The debate around colloids and crystalloids should also be considered with goal directed therapies. Advantages and disadvantages of each solution must be evaluated with the patient's specific condition.

Fluid therapy for septic shock resuscitation: which fluid should be used?

Early resuscitation of septic shock patients reduces the sepsis-related morbidity and mortality. The main goals of septic shock resuscitation include volemic expansion, maintenance of adequate tissue perfusion and oxygen delivery, guided by central venous pressure, mean arterial pressure, mixed or central venous oxygen saturation and arterial lactate levels. An aggressive fluid resuscitation, possibly in association with vasopressors, inotropes and red blood cell concentrate transfusion may be necessary to achieve those hemodynamic goals. Nonetheless, even though fluid administration is one of the most common interventions offered to critically ill patients, the most appropriate type of fluid to be used remains controversial. According to recently published clinical trials, crystalloid solutions seem to be the most appropriate type of fluids for initial resuscitation of septic shock patients. Balanced crystalloids have theoretical advantages over the classic solutions, but there is not enough evidence to indicate it as first-line treatment. Additionally, when large amounts of fluids are necessary to restore the hemodynamic stability, albumin solutions may be a safe and effective alternative. Hydroxyethyl starches solutions must be avoided in septic patients due to the increased risk of acute renal failure, increased need for renal replacement therapy and increased mortality. Our objective was to present a narrative review of the literature regarding the major types of fluids and their main drawbacks in the initial resuscitation of the septic shock patients.

Effect of phase one cardiac rehabilitation on occurrence of early complications Among acute myocardial infarction patients with st segment-elevation

AbstractPhase one cardiac rehabilitation is important for patients with acute myocardial infarction .Critical care nurses play an important role on relieving pain, improving respiratory distress , maintaining adequate tissue perfusion by decreasing the heart work load, and early recognition of complications. Aim: to evaluate the effect of phase one cardiac rehabilitation on occurrence of early complications among acute myocardial infarction patients with ST segment- elevation. Patient and methods. Design: a quasi-experimental research design is used in this study. Setting: this study is conducted in the coronary care unit, Assiut University Hospital. Sample: a convenience sample of 60 patients (control and study) 30 each .Tools: Three tools are used for data collection. I –Acute myocardial infarction patient assessment, II- modified Borg's rating perceived exertion Scale , III -Hospital anxiety and depression scale . Methods: training the patient up to a heart rate of 120 beats / minute or peak heart rate, guided by symptoms of chest pain and dyspnea (Borg’s rating of perceived exertion < 10 ) for the study group were performed for 5-days during phase one cardiac rehabilitation, Hospital anxiety and depression scale was applied tool for both groups. Results: findings of the present study show significant difference recurrence of chest pain was between both groups in 4th day .Also the duration of chest pain per hr in the 2 nd day & 3 rd day between both groups indicates highly statistical significant difference ( p < 0.05) ,and improve Heart rate, respiratory rate & decrease anxiety from 3 rd to 5 th day in the study group than control group, also shows Borg's (RPE) scale shows highly significant increased in study group during exercise from admission to 5th day. Conclusion: phase one cardiac rehabilitation is associated with significant improvement of the study group versus control group regarding for dyspnea, heart rate, chest pain, anxiety and depression.