Arterial Pressure Research Articles

Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study.

Patients with paraquat poisoning (PP) have a mortality rate comparable to that of advanced malignancies, yet palliative care is seldom considered in these patients. This audit aimed to identify triggers for early palliative care referral in critically ill patients with PP. Medical records of patients with PP were audited. Predictors of mortality within 48 hours of hospitalization and 24 hours of intensive care unit (ICU) admission were considered as triggers for palliative care referral. Among 108 patients, 84 complete records were analyzed, and 53 out of 84 (63.1%) expired. Within 48 hours after hospitalization, the lowest oxygen partial pressure in arterial blood to a fraction of inspired oxygen [the ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) (PaO2/FiO2)] was the independent predictor of mortality, cut-off ≤ 197; the area under the curve (AUC), 0.924; sensitivity, 97%; specificity, 78%; p <0.001; and 95% confidence interval (CI): 0.878-0.978. Kaplan-Meier survival plot showed that the mean survival time of patients with the lowest PaO2/FiO2, ≤197, was 4.64 days vs 17.20 days with PaO2/FiO2 >197 (log-rank p < 0.001). Sequential organ failure assessment (SOFA) score within 24 hours of ICU admission had a cut-off ≥9; AUC, 0.980; p < 0.001; 95% CI: 0.955-1.000; 91% sensitivity; and 90% specificity for mortality prediction. Out of the total of 84 patients with PP analyzed, there were 11 patients admitted to the high dependency units (13.1%) and 73 patients admitted to the ICU (86.9%). Out of the total of 84 patients of PP in whom data was analyzed, 53 (63.1%) patients required ventilator support. All the 53 patients who required ventilator support due to worsening hypoxemia, eventually expired. The lowest PaO2/FiO2 ≤ 197 within 48 hours of hospitalization, SOFA score ≥9 within 24 hours of ICU admission or need for mechanical ventilation are predictors of mortality in PP patients, who might benefit from early palliative care. Rao S, Maddani SS, Chaudhuri S, Bhatt MT, Karanth S, Damani A, et al. Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study. Indian J Crit Care Med 2024;28(5):453-460.

Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction.

Right ventricular dysfunction (RVD) is a complication following congenital cardiac surgery in children and can lead to systemic venous congestion, low cardiac output, and organ dysfunction. Venous congestion can be transmitted backwards and adversely affect encapsulated organs such as the kidneys. To investigate the association between systemic venous congestion, as estimated by Venous Excess Ultrasound (VExUS), and the occurrence of acute kidney injury (AKI) in children with RVD following congenital heart surgery. Secondary objectives included comparing changes in VExUS scores after initiating treatment for RVD and venous congestion. This was a prospective observational study in children with RVD. The VExUS study was performed on day 1, day 2, and day 3 and categorized as VExUS-1, VExUS-2, and VExUS-3. Among 43 patients with RVD and dilated inferior vena cava, 19/43 (44%), 10/43 (23%), and 12/43 (28%) were VExUS-2 and VExUS-3, respectively. There was an association between severe RVD and elevated pulmonary artery systolic pressures and a VExUS score >2. A significant association was observed between central venous pressure (CVP) measurements and VExUS. Among 31 patients with a high VExUS score >2, 18 (58%) had AKI. Additionally, improvement in CVP and fluid balance was associated with improving VExUS scores following targeted treatment for RVD. VExUS serves as a valuable bedside tool for diagnosing and grading venous congestion through ultrasound Doppler. An elevated VExUS score was associated with the occurrence of AKI, and among the components of VExUS, portal vein pulsatility may be useful as a predictor of AKI. Natraj R, Bhaskaran AK, Rola P, Haycock K, Siuba MTT, Ranjit S. Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction. Indian J Crit Care Med 2024;28(5):447-452.

Acute upper gastrointestinal bleeding due to portal hypertension in a patient with primary myelofibrosis: A case report

BACKGROUND Acute upper gastrointestinal bleeding is a common medical emergency that has a 10% hospital mortality rate. According to the etiology, this disease can be divided into acute varicose veins and nonvaricose veins. Bleeding from esophageal varices is a life-threatening complication of portal hypertension. Portal hypertension is a clinical syndrome defined as a portal venous pressure that exceeds 10 mmHg. Cirrhosis is the most common cause of portal hypertension, and thrombosis of the portal system not associated with liver cirrhosis is the second most common cause of portal hypertension in the Western world. Primary myeloproliferative disorders are the main cause of portal venous thrombosis, and somatic mutations in the Janus kinase 2 gene (JAK2 V617F ) can be found in approximately 90% of polycythemia vera, 50% of essential thrombocyrosis and 50% of primary myelofibrosis. CASE SUMMARY We present a rare case of primary myelofibrosis with gastrointestinal bleeding as the primary manifestation that presented as portal-superior-splenic mesenteric vein thrombosis. Peripheral blood tests revealed the presence of the JAK2 V617F mutation. Bone marrow biopsy ultimately confirmed the diagnosis of myelofibrosis (MF-2 grade). CONCLUSION In patients with acute esophageal variceal bleeding due to portal hypertension and vein thrombosis without cirrhosis, the possibility of myeloproliferative neoplasms should be considered, and the JAK2 mutation test should be performed.

Arterial oxygen pressure during veno-venous extracorporeal membrane oxygenation may be increased by advancing the tip of the drainage cannula into the superior vena cava: a case report.

A simple and robust method for veno-venous extracorporeal membrane oxygenation (V-V ECMO) involves a drainage cannula into the inferior vena cava via the femoral vein (FV) and a reinfusion cannula into the right atrium (RA) via the internal jugular vein (IJV) (F-J configuration). However, with this method, the arterial oxygen (PaO2) is said to remain below 100mmHg.Since recently, in our ICU, to prevent drainage failure, we apply a modification from the commonly practiced F-J configuration by advancing the tip of the drainage cannula inserted via the FV into the superior vena cava (SVC) and crossing the reinfusion cannula inserted via the IJV in the RA (F(SVC)-J(RA) configuration). We experienced that this modification can be associated with unexpectedly high PaO2 values, which here we investigated in detail.Veno-arteriovenous ECMO was induced in a 65-year-old male patient who suffered from repeated cardiac arrest due to acute respiratory distress syndrome. His chest X-ray images showed white-out after lung rest setting, consistent with near-absence of self-lung ventilation. Cardiac function recovered and the system was converted to F(SVC)-J(RA) configuration, after which both PaO2 and partial pressure of pulmonary arterial oxygen values remained high above 200mmHg. Transesophageal echocardiography could not detect right-to-left shunt, and more efficient drainage of the native venous return flow compared to common F-J configuration may explain the increased PaO2.Although the F(SVC)-J(RA) configuration is a small modification of the F-J configuration, it seems to provide a revolutionary improvement in the ECMO field by combining robustness/simplicity with high PaO2 values.

"What makes blood clots break off?" A Back-of-the-Envelope Computation Toward Explaining Clot Embolization.

One in four deaths worldwide is due to thromboembolic disease; that is, one in four people die from blood clots first forming and then breaking off or embolizing. Once broken off, clots travel downstream, where they occlude vital blood vessels such as those of the brain, heart, or lungs, leading to strokes, heart attacks, or pulmonary embolisms, respectively. Despite clots' obvious importance, much remains to be understood about clotting and clot embolization. In our work, we take a first step toward untangling the mystery behind clot embolization and try to answer the simple question: "What makes blood clots break off?" To this end, we conducted experimentally-informed, back-of-the-envelope computations combining fracture mechanics and phase-field modeling. We also focused on deep venous clots as our model problem. Here, we show that of the three general forces that act on venous blood clots-shear stress, blood pressure, and wall stretch-induced interfacial forces-the latter may be a critical embolization force in occlusive and non-occlusive clots, while blood pressure appears to play a determinant role only for occlusive clots. Contrary to intuition and prior reports, shear stress, even when severely elevated, appears unlikely to cause embolization. This first approach to understanding the source of blood clot bulk fracture may be a critical starting point for understanding blood clot embolization. We hope to inspire future work that will build on ours and overcome the limitations of theseback-of-the-envelope computations.

C-reactive protein to albumin ratio and risk of incident metabolic syndrome in community-dwelling adults: longitudinal findings over a 12-year follow-up period.

The C-reactive protein to albumin (CRP/Alb) ratio has emerged as a novel biomarker for various inflammatory diseases. This study aimed to evaluate the association between the CRP/Alb ratio and incident metabolic syndrome (MetS) with a large-sample, community-based Korean cohort over a 12-year follow-up period. Among 10,030 participants, a total of 6205 participants aged 40-69 years without MetS were selected from the Korean Genome and Epidemiology Study (KoGES). The baseline CRP/Alb ratio was divided into quartiles. The definition of newly developed MetS was the one proposed by the 2009 Joint Interim Statement of Circulation. Hazard ratios (HRs) with 95% confidence intervals (CIs) for incident MetS were calculated using multivariable Cox proportional hazards regression models after adjusting for potentially confounding variables. During the 12-year follow-up period, MetS developed in 2535 subjects (40.9%, 2535/6205) with an incidence rate of 5.6-11.9 (over 2 years). Compared to the reference first quartiles, the HRs (95% CIs) of incident MetS in the second, third, and fourth quartiles increased in a dose-response manner. Compared to the reference quartile, the HRs (95% CIs) of the incidence of MetS for the second, third, and fourth quartiles of CRP/Alb ratio were 1.12 (0.99-1.27), 1.24 (1.11-1.40), and 1.51 (1.34-1.69) after adjusting for age, sex, smoking status, alcohol intake, physical activity, total cholesterol, mean arterial pressure, HOMA-IR, and total energy intake. High CRP/Alb ratio at baseline may be a useful surrogate indicator of future incident MetS.

Cardiac and Liver Fibrosis Assessed by Multiparametric MRI in Patients with Fontan Circulation.

The abnormal hemodynamics in Fontan circulation due to persistently increased systemic venous pressure results in hepatic venous congestion and Fontan-associated liver disease. Combined assessment of cardiac and liver fibrosis and cardiac remodeling using multiparametric MRI in this context have not been fully explored. To evaluate cardiac and liver fibrosis and cardiac remodeling using multiparametric MRI in patients who have undergone Fontan procedures. Thirty-eight patients and 23 controls underwent cardiac and liver MRI examinations in a 3.0-T scanner. Mann-Whitney, Fisher exact test, and Spearman's correlation were applied to evaluate myocardial volumes, function, native cardiac and liver T1 mapping, ECVs and liver stiffness. The mean native cardiac T1 value (p = 0.018), cardiac ECV (p < 0.001), liver native T1 (p < 0.001), liver ECV (p < 0.001), and liver stiffness (p < 0.001) were higher in patients than controls. The indexed end-diastolic volume (EDVi) correlated with the myocardial ECV (r = 0.356; p = 0.033), native liver T1 (r = 0.571; p < 0.001), and with liver stiffness (r = 0.391; p = 0.015). In addition, liver stiffness correlated with liver ECV (r = 0.361; p = 0.031) and native liver T1 (r = 0.458; p = 0.004). An association between cardiac remodeling and cardiac and liver fibrosis were found in this population. The usefulness of MRI to follow cardiac and liver involvement in these patients is critical to improve treatment strategies and to prevent the need for combined liver and heart transplantation.

Material strengths of shear-induced platelet aggregation clots and coagulation clots

Arterial occlusion by thrombosis is the immediate cause of some strokes, heart attacks, and peripheral artery disease. Most prior studies assume that coagulation creates the thrombus. However, a contradiction arises as whole blood (WB) clots from coagulation are too weak to stop arterial blood pressures (> 150 mmHg). We measure the material mechanical properties of elasticity and ultimate strength for Shear-Induced Platelet Aggregation (SIPA) type clots, that form under stenotic arterial hemodynamics in comparison with coagulation clots. The ultimate strength of SIPA clots averaged 4.6 ± 1.3 kPa, while WB coagulation clots had a strength of 0.63 ± 0.3 kPa (p < 0.05). The elastic modulus of SIPA clots was 3.8 ± 1.5 kPa at 1 Hz and 0.5 mm displacement, or 2.8 times higher than WB coagulation clots (1.3 ± 1.2 kPa, p < 0.0001). This study shows that the SIPA thrombi, formed quickly under high shear hemodynamics, is seven-fold stronger and three-fold stiffer compared to WB coagulation clots. A force balance calculation shows a SIPA clot has the strength to resist arterial pressure with a short length of less than 2 mm, consistent with coronary pathology.

Airway pressure release ventilation (APRV) versus pressure support ventilation (PSV)-A prospective intervention trial comparing haemodynamic parameters in intensive care patients.

Assisted mechanical ventilation may alter the pressure profile in the thorax compared to normal breathing, which can affect the blood flow to and from the heart. Studies suggest that in patients with severe lung disease, airway pressure release ventilation (APRV) may be haemodynamically beneficial compared to other ventilator settings. The primary aim of this study was to investigate if APRV affects cardiac index in intubated intensive care patients without severe lung disease when compared to pressure support ventilation (PSV). The secondary aim comprised potential changes in other haemodynamic and ventilatory parameters. Twenty patients were enrolled in the intensive care unit (ICU) at Sahlgrenska University Hospital. Eligible patients met the inclusion criteria; 18 years of age or above, intubated and mechanically ventilated, triggering and stable on PSV mode, with indwelling haemodynamic monitoring via a pulse-induced continuous cardiac output (PiCCO) catheter. The study protocol started with a 30-min interval on PSV mode, followed by a 30-min interval on APRV mode, and finally a 30-min interval back on PSV mode. At the end of each interval, PiCCO outputs, ventilator outputs, arterial and venous blood gas analyses, heart rate and central venous pressure were recorded and compared between modes. There was no significant difference in cardiac index (3.42 vs. 3.39 L/min/m2) between PSV and APRV, but a significant increase in central venous pressure (+1.0 mmHg, p = .027). Furthermore, we found a significant reduction in peak airway pressure (-3.16 cmH2O, p < .01) and an increase in mean airway pressure (+2.1 cmH2O, p < .01). No statistically significant change was found in oxygenation index (partial pressure of O2 [pO2]/fraction of inspired oxygen) nor in other secondary outcomes when comparing PSV and APRV. There was no significant association between global end-diastolic volume index and cardiac index (R2 = 0.0089) or central venous pressure (R2 = 0.278). All parameters returned to baseline after switching the ventilator mode back to PSV. We could not detect any changes in cardiac index in ICU patients without severe lung disease during APRV compared to PSV mode, despite lower peak airwaypressure and increasedmean airway pressure.

Anaesthetic Management for a Dilated Cardiomyopathy Patient, Scheduled for Lumbar Spine Surgery

Background: Dilated cardiomyopathy (DCM) is characterized by dilatation and impaired contraction of left or both ventricles. Diagnostic criteria are left ventricular ejection fraction less than 40% or fractional shortening less than 25%. Perioperative anesthetic management of these patients are very challenging for anesthesiologists and intensive care team. Case presentation: A 55-year-old female, presented with complaints of severe low-back ache with bilateral lower limb involvement without involvement of bladder and bowel. Severe cord compression at the L4-5 level and severe lumbar canal stenosis were detected by magnetic resonance imaging. Echocardiography showed that the left ventricle (LV) had global hypokinesia, with an ejection fraction of 25% to 30%. The planed surgical procedures were L4 lumbar laminectomy and L4-5 microdiscectomy. Conclusion: Continuous monitoring and control of hemodynamic parameters as well as central venous pressure guided fluid therapy is the cornerstone in improving outcome in patients with dilated cardiomyopathy for non-cardiac surgery.

Ultrasound Guided Measurement of Inferior Vena Cava Diameter, Common Carotid Artery Diameter versus Central Venous Pressure for Estimation of Intravascular Volume Status in Septic Shock Patients

Background: In critically ill patients, the fluid resuscitation is crucial and is the first step in treatment protocol. Invasive CVP measurement was used to guide fluid resuscitation. However, it is time consuming and invasive maneuver. Ultrasound measurement of inferior vena cave and common carotid arteries are suggest to predict the fluid response as well as CVP or even better. The current work designed to compare inferior vena cava diameter and common carotid artery diameter with central venous pressure for estimation of intravascular volume status in septic shock. Patients and Methods: The study included 60 subjects with septic shock who received vasopressor support. CVP and ultrasound were performed before and after fluid challenge test. Values of inferior vena cava and common carotid arteries were documented and compared to CVP values. This was performed after full clinical assessment by detailed clinical examination and laboratory workup. Results: The MAP was significantly increased and HR decreased after than before procedure. In addition, CVP, (inferior vena cava), ICVmax, ICV min and common carotid artery diameter (CCAD) were significantly increased, IVC CI (%) was significantly reduced after procedure than basal values. There was significant decrease of IVCmax, IVCmin and CCAD while there was significant increase of IVC CI% with lower (&lt;8) than higher (&gt; 8) CVP values. CVP was positively and significantly correlated with IVCmax, IVCmin and CCAD, while it was inversely correlated with IVC CI%. The AUC was over 0.75 for IVCmax, IVCmin and CCAD for prediction of CVP while it was lower than 0.7 for IVC CI%. These data reflected the better predictive power of IVCmax, IVCmin and CCAD. The best cutoff value was 1.35, 1.25, 10.45 and 4.15 for IVCmax, IVCmin, IVC CI% and CCAD successively. Conclusion: IVC and CCA diameters measurement by US may replace CVP measurement for estimation of intravascular volume status in septic shock patients.

Speckle Plethysmograph-Based Blood Pressure Assessment

Continuous non-invasive blood pressure (CNBP) monitoring is of the utmost importance in detecting and managing hypertension, a leading cause of death in the United States. Extensive research has delved into pioneering methods for predicting systolic and diastolic blood pressure values by leveraging pulse arrival time (PAT), the time difference between the proximal and distal signal peaks. The most widely employed pairing involves electrocardiography (ECG) and photoplethysmography (PPG). Possessing similar characteristics in terms of measuring blood flow changes, a recently investigated optical signal known as speckleplethysmography (SPG) showed its stability and high signal-to-noise ratio compared with PPG. Thus, SPG is a potential surrogate to pair with ECG for CNBP estimation. The present study aims to unlock the untapped potential of SPG as a signal for non-invasive blood pressure monitoring based on PAT. To ascertain SPG’s capabilities, eight subjects were enrolled in multiple recording sessions. A third-party device was employed for ECG and PPG measurements, while a commercial device served as the reference for arterial blood pressure (ABP). SPG measurements were obtained using a prototype smartphone-based system. Following the completion of three scenarios—sitting, walking, and running—the subjects’ signals and ABP were recorded to investigate the predictive capacity of systolic blood pressure. The collected data were processed and prepared for machine learning models, including support vector regression and decision tree regression. The models’ effectiveness was evaluated using root-mean-square error and mean absolute percentage error. In most instances, predictions utilizing PATSPG exhibited comparable or superior performance to PATPPG (i.e., SPG Rest ± 12.4 mmHg vs. PPG Rest ± 13.7 mmHg for RSME, and SPG 8% vs. PPG 9% for MAPE). Furthermore, incorporating an additional feature, namely the previous SBP value, resulted in reduced prediction errors for both signals in multiple model configurations (i.e., SPG Rest ± 12.4 mmHg to ±3.7 mmHg for RSME, and SPG Rest 8% to 3% for MAPE). These preliminary tests of SPG underscore the remarkable potential of this novel signal in PAT-based blood pressure predictions. Subsequent studies involving a larger cohort of test subjects and advancements in the SPG acquisition system hold promise for further improving the effectiveness of this newly explored signal in blood pressure monitoring.

The effect of deep and awake extubation on emergence agitation after nasal surgery: a randomized controlled trial

BackgroundPost-anesthetic emergence agitation is common after general anesthesia and may cause adverse consequences, such as injury as well as respiratory and circulatory complications. Emergence agitation after general anesthesia occurs more frequently in nasal surgery than in other surgical procedures. This study aimed to assess the occurrence of emergence agitation in patients undergoing nasal surgery who were extubated under deep anesthesia or when fully awake.MethodsA total of 202 patients (18–60 years, American Society of Anesthesiologists classification: I–II) undergoing nasal surgery under general anesthesia were randomized 1:1 into two groups: a deep extubation group (group D) and an awake extubation group (group A). The primary outcome was the incidence of emergence agitation. The secondary outcomes included number of emergence agitations, sedation score, vital signs, and incidence of adverse events.ResultsThe incidence of emergence agitation was lower in group D than in group A (34.7% vs. 72.8%; p < 0.001). Compared to group A, patients in group D had lower Richmond Agitation-Sedation Scale scores, higher Ramsay sedation scores, fewer agitation episodes, and lower mean arterial pressure when extubated and 30 min after surgery, whereas these indicators did not differ 90 min after surgery. There was no difference in the incidence of adverse events between the two groups.ConclusionsExtubation under deep anesthesia can significantly reduce emergence agitation after nasal surgery under general anesthesia without increasing the incidence of adverse events.Trial registrationRegistered in Clinicaltrials.gov (NCT04844333) on 14/04/2021.

Post-anesthesia care unit hypotension in low-risk patients recovering from non-cardiac surgery: a prospective observational study.

Intraoperative hypotension is common and associated with organ injury. Hypotension can not only occur during surgery, but also thereafter. After surgery, most patients are treated in post-anesthesia care units (PACU). The incidence of PACU hypotension is largely unknown - presumably in part because arterial pressure is usually monitored intermittently in PACU patients. We therefore aimed to evaluate the incidence, duration, and severity of PACU hypotension in low-risk patients recovering from non-cardiac surgery. In this observational study, we performed blinded continuous non-invasive arterial pressure monitoring with finger-cuffs (ClearSight system; Edwards Lifesciences, Irvine,CA, USA) in 100 patients recovering from non-cardiac surgery in the PACU. We defined PACU hypotension as a mean arterial pressure (MAP) < 65 mmHg. Patients had continuous finger-cuff monitoring for a median (25th percentile, 75th percentile) of 64 (44 to 91) minutes. Only three patients (3%) had PACU hypotension for at least one consecutive minute. These three patients had 4, 4, and 2 cumulative minutes of PACU hypotension; areas under a MAP of 65 mmHg of 17, 9, and 9 mmHg x minute; and time-weighted averages MAP less than 65 mmHg of 0.5, 0.3, and 0.2 mmHg. The median volume of crystalloid fluid patients were given during PACU treatment was 200 (100 to 400) ml. None was given colloids or a vasopressor during PACU treatment. In low-risk patients recovering from non-cardiac surgery, the incidence of PACU hypotension was very low and the few episodes of PACU hypotension were short and of modest severity.

Relationship between Tryptase and Hypotension in Anaphylaxis during Anesthesia.

Hypotension is a cardiovascular symptom that appears at the onset of anaphylaxis. It is considered an important factor as it affects the severity of anaphylaxis; however, its details remain to be elucidated. In this study, we investigated the characteristics of hypotension at the onset of anaphylaxis during anesthesia, along with the relationship between hypotension, tryptase and histamine. The minimum systolic blood pressures of patients diagnosed with anaphylaxis using the clinical diagnostic criteria of the World Allergy Organization guidelines were extracted from electronic anesthesia records. We analyzed changes in tryptase and histamine that were measured after the onset of anaphylaxis. We analyzed the relationship of tryptase and histamine with the minimum systolic blood pressure and the severity of anaphylaxis. Of 55,996 patients, 25 were diagnosed with anaphylaxis during anesthesia (0.045%). Among these patients, the minimum systolic blood pressure was less than 90 mmHg. Furthermore, the minimum systolic blood pressure was inversely correlated with tryptase levels immediately to 1 hour, and 2 to 4 hours after the onset of anaphylaxis. The minimum systolic blood pressure was inversely correlated with the severity of anaphylaxis. The severity of anaphylaxis was positively correlated with tryptase levels immediately to 1 hour, and 2 to 4 hours after the onset of anaphylaxis. Hypotension tended to reflect the severity of anaphylaxis. Tryptase is an adjunct in the diagnosis of hypotension and may be a useful indicator of the severity of anaphylaxis. A larger-scale study is needed to validate these results.

In Silico Evaluation of In Vivo Degradation Kinetics of Poly(Lactic Acid) Vascular Stent Devices

Biodegradable vascular stents (BVS) are deemed as great potential alternatives for overcoming the inherent limitations of permanent metallic stents in the treatment of coronary artery diseases. The current study aimed to comprehensively compare the mechanical behaviors of four poly(lactic acid) (PLA) BVS designs with varying geometries via numerical methods and to clarify the optimal BVS selection. Four PLA BVS (i.e., Absorb, DESolve, Igaki-Tamai, and Fantom) were first constructed. A degradation model was refined by simply including the fatigue effect induced by pulsatile blood pressures, and an explicit solver was employed to simulate the crimping and degradation behaviors of the four PLA BVS. The degradation dynamics here were characterized by four indices. The results indicated that the stent designs affected crimping and degradation behaviors. Compared to the other three stents, the DESolve stent had the greatest radial stiffness in the crimping simulation and the best diameter maintenance ability despite its faster degradation; moreover, the stent was considered to perform better according to a pilot scoring system. The current work provides a theoretical method for studying and understanding the degradation dynamics of the PLA BVS, and it could be helpful for the design of next-generation BVS.

Upstroke time is a more useful marker of atherosclerosis than percentage of mean arterial pressure for detecting coronary artery disease in subjects with a normal ankle-brachial index.

Upstroke time (UT) and percentage of mean arterial pressure (%MAP) at the ankle have been shown to serve as atherosclerotic markers. The purpose of this study was to directly compare the diagnostic accuracy of UT with that of %MAP for clinical coronary artery disease (CAD) in subjects with a normal ankle-brachial index (ABI) in both legs. We measured UT and %MAP in 1953 subjects with a normal ABI. The optimal cutoff values of UT and %MAP derived from a receiver operating characteristic (ROC) curve to diagnose CAD were 148 ms and 40.4%, respectively. Multivariable analyses revealed that both UT ≥ 148 ms (odds ratio [OR], 2.72; p < 0.001) and %MAP ≥ 40.4% (OR, 1.28; p = 0.003) were significantly associated with CAD. When the subjects were divided into four groups according to the cutoff values of UT and %MAP, there was no significant difference in the risk of CAD between subjects with UT ≥ 148 ms and %MAP < 40.4% and those with UT ≥ 148 ms and %MAP ≥ 40.4% (OR, 1.45; p = 0.09). ROC curve analyses revealed that the area under the curve value of UT was significantly higher than that of %MAP (0.69 vs. 0.53, p < 0.001). The addition of UT to traditional risk factors significantly improved the diagnostic accuracy for CAD (0.82 to 0.84, p = 0.004), whereas the addition of %MAP to traditional risk factors did not improve the diagnostic accuracy for CAD (0.82 to 0.82, p = 0.84). UT is more useful than %MAP for identifying individuals with CAD among those with a normal ABI.

Obstructive Sleep Apnea and Pulmonary Hypertension: A Chicken-and-Egg Relationship

Obstructive sleep apnea (OSA) is characterized by repeated episodes of upper airway obstruction during sleep, and it is closely linked to several cardiovascular issues due to intermittent hypoxia, nocturnal hypoxemia, and disrupted sleep patterns. Pulmonary hypertension (PH), identified by elevated pulmonary arterial pressure, shares a complex interplay with OSA, contributing to cardiovascular complications and morbidity. The prevalence of OSA is alarmingly high, with studies indicating rates of 20–30% in males and 10–15% in females, escalating significantly with age and obesity. OSA’s impact on cardiovascular health is profound, particularly in exacerbating conditions like systemic hypertension and heart failure. The pivotal role of hypoxemia increases intrathoracic pressure, inflammation, and autonomic nervous system dysregulation in this interplay, which all contribute to PH’s pathogenesis. The prevalence of PH among OSA patients varies widely, with studies reporting rates from 15% to 80%, highlighting the variability in diagnostic criteria and methodologies. Conversely, OSA prevalence among PH patients also remains high, often exceeding 25%, stressing the need for careful screening and diagnosis. Treatment strategies like continuous positive airway pressure (CPAP) therapy show promise in mitigating PH progression in OSA patients. However, this review underscores the need for further research into long-term outcomes and the efficacy of these treatments. This review provides comprehensive insights into the epidemiology, pathophysiology, and treatment of the intricate interplay between OSA and PH, calling for integrated, personalized approaches in diagnosis and management. The future landscape of OSA and PH management hinges on continued research, technological advancements, and a holistic approach to improving patient outcomes.

The management of goal-directed fluid therapy during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Cytoreductive surgery is a surgical treatment approach that has been applied over the last 3 decades in patients with peritoneal metastases originating from intraabdominal organs. Goal-directed fluid therapy (GDFT) is an approach in which a patient fluid therapy during a medical procedure or surgery is carefully managed based on a specific goal. In this study, we aimed to present the results of GDFT in patients who underwent cytoreductive surgery for peritoneal carcinomatosis (PC) during the perioperative period. This retrospective study included 398 patients patient who underwent cytoreductive surgery + hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) due to PC originating from intraabdominal malignancies. Of the cases, 233 (58.6%) were female, and 165 (41.4%) were male patients. The mean age was 58.9. Perioperative findings revealed an average PC score of 12 (3-24), average lactate levels of 3 (2-7) mmol/L, Pao2/fio2 of 3.3 (2.4-4.1) mm Hg, mean arterial pressure (MAP) of 60 (55-70), average surgery duration of 6.5 hours (3-14), and average blood loss of 400 (200-4000) cc. The mean intraoperative fluid rate was 6.4 mL/kg/h (IQR 5.8-7.1). Sixteen (16.3%) patients experienced Clavien-Dindo Grade 3-4 adverse events. Within 30 days, 25 patients (6.3%) died. CRS + HIPEC procedures utilizing perioperative GDFT along with advanced anesthesia monitoring devices have shown successful application, offering an alternative to traditional and restrictive fluid management approaches.

Perioperative outcomes of utilizing infrahepatic inferior vena cava clamping and Pringle maneuver duringhepatectomy: a meta-analysis.

Intraoperative bleeding during hepatectomy is primarily controlled through anaesthesiological interventions or surgical techniques such as Pringle maneuver (PM). Infrahepatic IVC clamping (IIVCC) is an alternative surgical technique to reduce central venous pressure and prevent retrograde hepatic venous bleeding. The aim of the meta-analysis was to compare IIVCC+PM with PMalone in terms of intraoperative outcomes and perioperative complications. Medline, Cochrane Library, Scopus, Web of Science, and EMBASE were searched for comparative studies till 16.04.2024, resulting in 679 articles, of which eight studies met inclusion criteria. Data on patient demographics, surgical technique, and perioperative outcomes was assessed. Cochrane Risk of Bias 2.0 (RoB 2.0) Tool and Newcastle-Ottawa Scale (NOS) were used for risk of bias assessment. Two randomized controlled trials, one prospective, and five retrospective cohort studies with 358 patients in IIVCC+PM and 397 patients in PMalone group were included. IIVCC+PM resulted in significantly greater CVP reduction, less intraoperative blood loss (MD (95% CI) = - 233.03 (- 360.48 to - 105.58), P < 0.001), and less intraoperative blood transfusion (OR (95% CI) = 0.38 (0.25 to 0.57), P < 0.001) compared to PMalone. The two groups had comparable total operative time, transection time and total intraoperative fluid infusion. Patients undergoing IIVCC+PM had significantly shorter length of stay (MD (95% CI) = - 0.63 days (- 1.21 to - 0.05 days), P = 0.03) and overall complication rates (OR (95% CI) = 0.63 (0.43-0.92), P = 0.02) compared to PMalone group. The utilization of IIVCC along with PM during liver resection may be beneficial in reducing intraoperative bleeding and blood transfusion without adversely influencing operative times or perioperative outcomes compared to PMalone.