Cardiovascular Instability Research Articles

Solutions to technical challenges during therapeutic plasma exchange using the Spectra Optia on a 4 kilogram neonate

Therapeutic plasma exchange (TPE) on severely ill neonates poses many technical challenges, including obtaining adequate vascular access. In addition, clinical challenges such as risk of hypotension and cardiovascular instability are more pronounced in these patients. We report an approach to successfully managing these challenges while performing TPE on a 4 kilogram neonate using the Spectra Optia and 22 G venous access.

Temporal requirements for ISL1 in sympathetic neuron proliferation, differentiation, and diversification

Malformations of the sympathetic nervous system have been associated with cardiovascular instability, gastrointestinal dysfunction, and neuroblastoma. A better understanding of the factors regulating sympathetic nervous system development is critical to the development of potential therapies. Here, we have uncovered a temporal requirement for the LIM homeodomain transcription factor ISL1 during sympathetic nervous system development by the analysis of two mutant mouse lines: an Isl1 hypomorphic line and mice with Isl1 ablated in neural crest lineages. During early development, ISL1 is required for sympathetic neuronal fate determination, differentiation, and repression of glial differentiation, although it is dispensable for initial noradrenergic differentiation. ISL1 also plays an essential role in sympathetic neuron proliferation by controlling cell cycle gene expression. During later development, ISL1 is required for axon growth and sympathetic neuron diversification by maintaining noradrenergic differentiation, but repressing cholinergic differentiation. RNA-seq analyses of sympathetic ganglia from Isl1 mutant and control embryos, together with ISL1 ChIP-seq analysis on sympathetic ganglia, demonstrated that ISL1 regulates directly or indirectly several distinct signaling pathways that orchestrate sympathetic neurogenesis. A number of genes implicated in neuroblastoma pathogenesis are direct downstream targets of ISL1. Our study revealed a temporal requirement for ISL1 in multiple aspects of sympathetic neuron development, and suggested Isl1 as a candidate gene for neuroblastoma.

Very-low-dose ketamine for the management of pain and sedation in the ICU

Management of pain in critically ill patients can be very difficult. In the attempt to provide comfort with adequate levels of opioids and sedatives, respiratory depression and cardiovascular instability may become difficult to control in patients with labile hemodynamics and poor cardiopulmonary reserve. The use of medications like ketamine, an anesthetic agent that in subanesthetic doses has been reported to be effective in preventing opioid-induced tolerance and to have analgesic properties, may be of help, especially in patients who develop tolerance, leading to rapidly escalating doses of opioids and sedatives. The case report presented here shows how a very low dose of ketamine can be helpful for the management of pain and sedation in critically ill patients, especially when they are ready to be weaned from mechanical ventilation, and very high doses of opiods and sedatives do not permit it.

Cardiac autonomic neuropathy: Risk factors, diagnosis and treatment.

Cardiac autonomic neuropathy (CAN) is a serious complication of diabetes mellitus (DM) that is strongly associated with approximately five-fold increased risk of cardiovascular mortality. CAN manifests in a spectrum of things, ranging from resting tachycardia and fixed heart rate (HR) to development of “silent” myocardial infarction. Clinical correlates or risk markers for CAN are age, DM duration, glycemic control, hypertension, and dyslipidemia (DLP), development of other microvascular complications. Established risk factors for CAN are poor glycemic control in type 1 DM and a combination of hypertension, DLP, obesity, and unsatisfactory glycemic control in type 2 DM. Symptomatic manifestations of CAN include sinus tachycardia, exercise intolerance, orthostatic hypotension (OH), abnormal blood pressure (BP) regulation, dizziness, presyncope and syncope, intraoperative cardiovascular instability, asymptomatic myocardial ischemia and infarction. Methods of CAN assessment in clinical practice include assessment of symptoms and signs, cardiovascular reflex tests based on HR and BP, short-term electrocardiography (ECG), QT interval prolongation, HR variability (24 h, classic 24 h Holter ECG), ambulatory BP monitoring, HR turbulence, baroreflex sensitivity, muscle sympathetic nerve activity, catecholamine assessment and cardiovascular sympathetic tests, heart sympathetic imaging. Although it is common complication, the significance of CAN has not been fully appreciated and there are no unified treatment algorithms for today. Treatment is based on early diagnosis, life style changes, optimization of glycemic control and management of cardiovascular risk factors. Pathogenetic treatment of CAN includes: Balanced diet and physical activity; optimization of glycemic control; treatment of DLP; antioxidants, first of all α-lipoic acid (ALA), aldose reductase inhibitors, acetyl-L-carnitine; vitamins, first of all fat-soluble vitamin B1; correction of vascular endothelial dysfunction; prevention and treatment of thrombosis; in severe cases-treatment of OH. The promising methods include prescription of prostacyclin analogues, thromboxane A2 blockers and drugs that contribute into strengthening and/or normalization of Na+, K+-ATPase (phosphodiesterase inhibitor), ALA, dihomo-γ-linolenic acid (DGLA), ω-3 polyunsaturated fatty acids (ω-3 PUFAs), and the simultaneous prescription of ALA, ω-3 PUFAs and DGLA, but the future investigations are needed. Development of OH is associated with severe or advanced CAN and prescription of nonpharmacological and pharmacological, in the foreground midodrine and fludrocortisone acetate, treatment methods are necessary.

Pre-hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental?

The benefits of pre-hospital emergency anaesthesia (PHEA) are controversial. Patients who are hypovolaemic prior to induction of anaesthesia are at risk of severe cardiovascular instability post-induction. This study compared mortality for hypovolaemic trauma patients (without major neurological injury) undergoing PHEA with a patient cohort with similar physiology transported to hospital without PHEA. A retrospective database review was performed to identify patients who were hypotensive on scene [systolic blood pressure (SBP) < 90 mmHg], and GCS 13-15. Patient records were reviewed independently by two pre-hospital clinicians to identify the likelihood of hypovolaemia. Primary outcome measure was mortality defined as death before hospital discharge. Two hundred and thirty-six patients were included; 101 patients underwent PHEA. Fifteen PHEA patients died (14.9%) compared with six non-PHEA patients (4.4%), P = 0.01; unadjusted OR for death was 3.73 (1.30-12.21; P = 0.01). This association remained after adjustment for age, injury mechanism, heart rate and hypovolaemia (adjusted odds ratio 3.07 (1.03-9.14) P = 0.04). Fifty-eight PHEA patients (57.4%) were hypovolaemic prior to induction of anaesthesia, 14 died (24%). Of 43 PHEA patients (42.6%) not meeting hypovolaemia criteria, one died (2%); unadjusted OR for mortality was 13.12 (1.84-578.21). After adjustment for age, injury mechanism and initial heart rate, the odds ratio for mortality remained significant at 9.99 (1.69-58.98); P = 0.01. Our results suggest an association between PHEA and in-hospital mortality in awake hypotensive trauma patients, which is strengthened when hypotension is due to hypovolaemia. If patients are hypovolaemic and awake on scene it might, where possible, be appropriate to delay induction of anaesthesia until hospital arrival.

Evaluation of Physiologic Alterations during Prehospital Paramedic-Performed Rapid Sequence Intubation

Objective: Physiologic alterations during rapid sequence intubation (RSI) have been studied in several emergency airway management settings, but few data exist to describe physiologic alterations during prehospital RSI performed by ground-based paramedics. To address this evidence gap and provide guidance for future quality improvement initiatives in our EMS system, we collected electronic monitoring data to evaluate peri-intubation vital signs changes occurring during prehospital RSI. Methods: Electronic patient monitor data files from cases in which paramedic RSI was attempted were prospectively collected over a 15-month study period to supplement the standard EMS patient care documentation. Cases were analyzed to identify peri-intubation changes in oxygen saturation, heart rate, and blood pressure. Results: Data from 134 RSI cases were available for analysis. Paramedic-assigned prehospital diagnostic impression categories included neurologic (42%), respiratory (26%), toxicologic (22%), trauma (9%), and cardiac (1%). The overall intubation success rate (95%) and first-attempt success rate (82%) did not differ across diagnostic impression categories. Peri-intubation desaturation (SpO2 decrease to below 90%) occurred in 43% of cases, and 70% of desaturation episodes occurred on first-attempt success. The incidence of desaturation varied among patient categories, with a respiratory diagnostic impression associated with more frequent, more severe, and more prolonged desaturations, as well as a higher incidence of accompanying cardiovascular instability. Bradycardia (HR decrease to below 60 bpm) occurred in 13% of cases, and 60% of bradycardia episodes occurred on first-attempt success. Hypotension (systolic blood pressure decrease to below 90 mmHg) occurred in 7% of cases, and 63% of hypotension episodes occurred on first-attempt success. Peri-intubation cardiac arrest occurred in 2 cases, one of which was on first-attempt success. Only 11% of desaturations and no instances of bradycardia were reflected in the standard EMS patient care documentation. Conclusions: In this study, the majority of peri-intubation physiologic alterations occurred on first-attempt success, highlighting that first-attempt success is an incomplete and potentially deceptive measure of intubation quality. Supplementing the standard patient care documentation with electronic monitoring data can identify unrecognized physiologic instability during prehospital RSI and provide valuable guidance for quality improvement interventions.

Early mobilization practices of mechanically ventilated patients: a 1-day point-prevalence study in southern Brazil

OBJECTIVES:To assess early mobilization practices of mechanically ventilated patients in southern Brazilian intensive care units (ICUs) and to identify barriers associated with early mobilization and possible complications.METHODS:A prospective, observational, multicenter, 1-day point-prevalence study was conducted across 11 ICUs and included all mechanically ventilated adult patients. Hospital and ICU characteristics and patients' demographic data, the highest level of mobilization achieved in the 24 hours prior to the survey and related barriers, and complications that occurred during mobilization were collected in the hospital and the ICU.RESULTS:A total of 140 patients were included with a mean age of 57±17 years. The median and interquartile range was 7 (3-17) days for the length of ICU stay to the day of the survey and 7 (3-16) days for the duration of mechanical ventilation (MV). The 8-level mobilization scale was classified into two categories: 126 patients (90%) remained in bed (level 1–3) and 14 (10%) were mobilized out of bed (level 4–8). Among patients with an endotracheal tube, tracheostomy, and noninvasive ventilation, 2%, 23%, and 50% were mobilized out of bed, respectively (p<0.001 for differences among the three groups). Weakness (20%), cardiovascular instability (19%), and sedation (18%) were the most commonly observed barriers to achieving a higher level of mobilization. No complications were reported.CONCLUSIONS:In southern Brazilian ICUs, the prevalence of patient mobilization was low, with only 10% of all mechanically ventilated patients and only 2% of patients with an endotracheal tube mobilized out of bed as part of routine care.

Pathophysiologic Implications of Cytokines Secretion during Liver Transplantation Surgery.

We introduce the following issues of the cytokines secretion during liver transplantation surgery in this review article; 1) the aspect of cytokines secretion during liver transplantation surgery, 2) the evidences of association of cytokines concentration with post-transplantation graft survival, 3) a variety of factors that may influence the secretion of cytokines during liver transplantation, 4) pro-inflammatory and anti-inflammatory cytokine balance during the surgery, and 5) the issues of T helper 1 and T helper 2, and T helper 17 and regulatory T cell signature cytokines secretion and their ratio during liver transplantation surgery. Primary failure of the liver is associated with the secondary dysfunction of virtually all other organ systems, including the cardiovascular, pulmonary, renal, coagulation and central nervous systems. In addition, liver transplantation surgery itself is a major surgical procedure with accompanying life-threatening hemorrhage, massive transfusion, clamping and unclamping of great vessels and resulting ischemia-reperfusion injury and cardiovascular instability. Both the underlying liver failure and the surgical events act as stressors and promote the secretion of various cytokines. So it is clinically important to understand above issues regarding the cytokines secretion during liver transplantation surgery. As cytokines secretion has clear relationship with post-transplantation clinical outcomes, future study directions for artificially manipulating cytokines secretion is also suggested for enhancing outcomes of the patients.

Pediatric Myxedema Coma – presenting as Surgical Abdomen

Myxedema com, also called myxedema crisis is a rare life threatening clinical condition that represents severe hypothyroidism. It may be the initial presentation in pediatric patients with prolonged untreated hypothyroidism. Myxedema coma should be suspected in pediatric patients with altered mental status, hypothermia and cardiovascular instability. This condition is fatal without treatment. Thyroid replacement should be initiated as early as possible. Early intervention in hypothyroid patients and in patients where hypothyroidism is suspected has shown to prevent morbidity and mortality associated with myxedema crisis.

Prognostic Value of Secretoneurin in Patients With Severe Sepsis and Septic Shock: Data From the Albumin Italian Outcome Sepsis Study.

Secretoneurin directly influences cardiomyocyte calcium handling, and circulating secretoneurin levels seem to improve risk prediction in patients with myocardial dysfunction by integrating information on systemic stress, myocardial function, and renal function. Accordingly, in this study, we hypothesized that secretoneurin would improve risk prediction in patients with sepsis and especially in patients with septic shock as these patients are more hemodynamically unstable. Multicenter, interventional randomized clinical trial. Multicenter, pragmatic, open-label, randomized, prospective clinical trial testing fluid administration with either 20% human albumin and crystalloids or crystalloid solutions alone in patients with severe sepsis or septic shock (The Albumin Italian Outcome Sepsis). In total, 540 patients with septic shock and 418 patients with severe sepsis. Either 20% human albumin and crystalloids or crystalloid solutions alone. We measured secretoneurin on days 1, 2, and 7 after randomization and compared the prognostic value of secretoneurin for ICU and 90-day mortality with established risk indices and cardiac biomarkers in septic shock and severe sepsis. High secretoneurin levels on day 1 were associated with age and serum concentrations of lactate, bilirubin, creatinine, and N-terminal pro-B-type natriuretic peptide. Adjusting for established risk factors and cardiovascular biomarkers, secretoneurin levels on day 1 were associated with ICU (odds ratio, 2.27 [95% CI, 1.05-4.93]; p = 0.04) and 90-day mortality (2.04 [1.02-4.10]; p = 0.04) in patients with septic shock, but not severe sepsis without shock. Secretoneurin levels on day 2 were also associated with ICU (3.11 [1.34-7.20]; p = 0.008) and 90-day mortality (2.69 [1.26-5.78]; p = 0.01) in multivariate regression analyses and improved reclassification in patients with septic shock, as assessed by the net reclassification index. Randomized albumin administration did not influence the associations between secretoneurin and outcomes. Secretoneurin provides early and potent prognostic information in septic patients with cardiovascular instability.

Ethylene glycol poisoning

Ethylene glycol poisoning

Detection of ventricular premature beats based on the pressure signals of a hemodialysis machine

Monitoring of ventricular premature beats (VPBs), being abundant in hemodialysis patients, can provide information on cardiovascular instability and electrolyte imbalance. In this paper, we describe a method for VPB detection which explores the signals acquired from the arterial and the venous pressure sensors, located in the extracorporeal blood circuit of a hemodialysis machine. The pressure signals are mainly composed of a pump component and a cardiac component. The cardiac component, severely overshadowed by the pump component, is estimated from the pressure signals using an earlier described iterative method. A set of simple features is extracted, and linear discriminant analysis is performed to classify beats as either normal or ventricular premature. Performance is evaluated on signals from nine hemodialysis treatments, using leave-one-out crossvalidation. The simultaneously recorded and annotated photoplethysmographic signal serves as the reference signal, with a total of 149,686 normal beats and 3574 VPBs. The results show that VPBs can be reliably detected, quantified by a Youden’s J statistic of 0.9, for average cardiac pulse pressures exceeding 1 mmHg; for lower pressures, the J statistic drops to 0.55. It is concluded that the cardiac pressure signal is suitable for VPB detection, provided that the average cardiac pulse pressure exceeds 1 mmHg.

English

Objectives: To identify the risk factors of delayed extubation after cardiac surgery.Study Design: Observational study. Setting: Cardiac surgery in CPE Institute of Cardiology.Period: 2 months from November-2016 to March-2017. Methods: Eighty-one (81) patients whounderwent cardiac surgery. In ICU we recorded extubation time of all patients. Patients withextubation time &lt;6 hours after labelled as early extubation group and those with extubationtime &gt;6 hours were labelled as delayed extubation group. We recorded their preoperative riskfactors and operative variables of surgery to identify the risk factors that leads to late extubationafter cardiac surgery (CS). Results: Prevalence of diabetes was significantly high in patientswith delayed extubation. There were 42.3% diabetic patients with delayed extubation and only12.7% diabetic patients with early extubation (p-value 0.003). Total pump time, cross clamptime and type of operation were similar between the groups. Cardiovascular instability wasthe most common cause of delayed extubation that occurred in 9 patients, reduced level ofconsciousness in 9 patients, post-op bleeding in 6 patients, while hypoxemia and increasedrespiratory rate occurred in 1, 1 patient respectively. Conclusion: Diabetes Mellitus is anindependent risk factor of delayed extubation after cardiac surgery. Cardiovascular instability,reduced level of consciousness and post-operative bleeding after surgery are the main factorsthat leads to delayed extubation after CS.

Inotrope-induced necrosis of facial skin and oral mucosa – a rare occurrence

Introduction: Inotropes alter cardiac muscular contractions and are often utilised in situations of cardiovascular instability such as acute heart failure and septic shock. Inotrope-induced necrosis of the extremities has been reported however there is no literature reporting necrosis of the facial skin and oral mucosa. This report demonstrates such a case.

CARDAIC SURGERY;

Objectives: To identify the risk factors of delayed extubation after cardiac surgery.Study Design: Observational study. Setting: Cardiac surgery in CPE Institute of Cardiology.Period: 2 months from November-2016 to March-2017. Methods: Eighty-one (81) patients whounderwent cardiac surgery. In ICU we recorded extubation time of all patients. Patients withextubation time &lt;6 hours after labelled as early extubation group and those with extubationtime &gt;6 hours were labelled as delayed extubation group. We recorded their preoperative riskfactors and operative variables of surgery to identify the risk factors that leads to late extubationafter cardiac surgery (CS). Results: Prevalence of diabetes was significantly high in patientswith delayed extubation. There were 42.3% diabetic patients with delayed extubation and only12.7% diabetic patients with early extubation (p-value 0.003). Total pump time, cross clamptime and type of operation were similar between the groups. Cardiovascular instability wasthe most common cause of delayed extubation that occurred in 9 patients, reduced level ofconsciousness in 9 patients, post-op bleeding in 6 patients, while hypoxemia and increasedrespiratory rate occurred in 1, 1 patient respectively. Conclusion: Diabetes Mellitus is anindependent risk factor of delayed extubation after cardiac surgery. Cardiovascular instability,reduced level of consciousness and post-operative bleeding after surgery are the main factorsthat leads to delayed extubation after CS.

Schizophrenia and anaesthesia

Administering anaesthesia for elderly patients with chronic schizophrenia has always been a great challenge to anaesthetists. These patients will usually be on multiple antipsychotic drugs for many years and may...

OP.7A.02] SUSTAINED REDUCTION OF BLOOD PRESSURE WITH BARORECEPTOR ACTIVATION THERAPY

Objective: Baroreflex Activation Therapy (BAT) is a novel technique for treating patients with resistant hypertension. Although short-term studies have demonstrated that BAT lowers blood pressure, long-term results have not yet been reported. The aim of the present study is to assess the long-term efficacy and safety of BAT. Design and method: Long-term follow-up data on blood pressure and heart rate were analyzed from all patients who have been included in one of the three BAT trials that focused on treatment-resistant hypertensive patients. These trials were the US feasibility study, the DEBut-HT trial and the pivotal trial. The first two were non-randomized, observational trials in the US and Europe respectively. In the pivotal trial patients were randomized to either immediate BAT or deferred BAT (six months after implantation). All patients who have received an implant were followed with regular visits. Results: Altogether, 383 patients were available for analysis: 143 of these had completed five years of follow-up and 48 patients had completed six years of follow-up. In the entire cohort, systolic blood pressure fell from 179+24 mmHg to 144+28 mmHg (p < 0.0001) while diastolic pressure dropped from 103+16 mmHg to 85+18 mmHg (p < 0.0001). The data further demonstrate that the greatest fall in pressure already occurs within 6 months following device implant. The blood pressure lowering effect of BAT is greater than average in patients with signs of heart failure, and less than average in patients with isolated systolic hypertension. The percentage of patients in whom systolic blood pressure at the end of follow-up had fallen below 140 mmHg was greatest in those with unilateral right-sided stimulation. In about 25% of patients it was possible to reduce the number of medications from a median of 6 to a median of 3. Temporary side effects, related to either the surgical procedure or to cardiovascular instability, do occur, but they do not require specific measures and resolve over time. Conclusions: After a follow-up of 5 years, BAT is safe and maintains its efficacy for persistent reduction of blood pressure in patients with resistant hypertension.

Perfusion monitoring and intraventricular hemorrhage in preterm infants.

Cardiovascular instability in preterm infants during the early postnatal period correlates with the development of intraventricular hemorrhage (IVH). Due to the correlation between hypotension and fluctuation of blood pressure, treatment was targeted specifically at hypotension to prevent IVH, but this was not successful. Recently, several novel perfusion markers have been found to be correlated with the development of IVH, and they are of current interest in cardiovascular management. In this review, the correlation between IVH and conventional, as well as novel, perfusion markers is examined.

Acute Idiopathic Gastric Distension Causing Atrioventricular Block and Cardiogenic Shock

BackgroundWe report a rare case of acute idiopathic gastric dilatation with associated severe bradycardia and shock. Case ReportA 69-year-old woman presented to the emergency department (ED) with complaint of chest pain and dyspnea. The patient required transvenous cardiac pacing for profound bradycardia and cardiogenic shock. After a negative emergent cardiac catheterization, a flat plate abdominal x-ray study demonstrated massive gastric dilatation, prompting nasogastric tube placement, with subsequent rapid improvement of the patient's cardiovascular and metabolic instability. Why Should an Emergency Physician Be Aware of This?This case highlights the rare though potentially catastrophic complications of acute gastric dilatation, and benefits of early intervention with gastric decompression.

Sustained Reduction of Blood Pressure With Baroreceptor Activation Therapy: Results of the 6-Year Open Follow-Up.

Baroreflex activation therapy is a novel technique for treating patients with resistant hypertension. Although short-term studies have demonstrated that it lowers blood pressure, long-term results have not yet been reported. The aim of the present study is to assess the long-term efficacy and safety of baroreflex activation therapy. Long-term follow-up data were analyzed from all patients who had been included in 1 of the 3 trials that focused on treatment-resistant hypertensive patients. Altogether, 383 patients were available for analysis: 143 of these had completed 5 years of follow-up and 48 patients had completed 6 years of follow-up. In the entire cohort, office systolic blood pressure fell from 179±24 mm Hg to 144±28 mm Hg (P<0.0001), whereas office diastolic pressure dropped from 103±16 mm Hg to 85±18 mm Hg (P<0.0001). Heart rate fell from 74±15 beats per minute to 71±13 beats per minute (P<0.02). The effect of baroreflex activation therapy is greater than average in patients with signs of heart failure and less than average in patients with isolated systolic hypertension. In ≈25% of patients, it was possible to reduce the number of medications from a median of 6 to a median of 3. Temporary side effects, related to either the surgical procedure or the cardiovascular instability, do occur, but they do not require specific measures and resolve over time.After a follow-up of 6 years, baroreflex activation therapy maintains its efficacy for persistent reduction of office blood pressure in patients with resistant hypertension without major safety issues.