Careful Hemodynamic Monitoring Research Articles

Hemodynamic Support With the Impella 5.5 Acute Mechanical Circulatory Support Device.

The Impella 5.5 is increasingly used as a bridge to recovery or heart replacement therapies despite lack of clinical trial evidence. We report real-world outcomes and hemodynamic effects of 150 consecutive patients from a single, high-volume center. Primary outcome was incidence of recovery, durable left ventricular assist device (LVAD), or heart transplant compared with incidence of death at 90 days. Secondary outcomes included hemodynamic trends and upgrade to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The composite endpoint occurred in 59.3% and death in 18.8% of patients (incidence rate ratio: 8.1 [95% confidence interval {CI}: 5.4-12.2], p < 0.001). Decreases in pulmonary artery diastolic pressure (PADP) (p = 0.026), estimated pulmonary effective arterial elastance (Ea) (p < 0.001), and vasoactive-inotropic score (VIS) (p < 0.001) occurred during Impella 5.5 support. Pulmonary artery diastolic pressure correlated with estimated Ea (p < 0.001), suggesting improved right ventricle (RV) afterload with left ventricle (LV) unloading. Veno-arterial extracorporeal membrane oxygenation upgrade occurred in 11.3% of patients who had higher baseline right atrial pressure (RAP) (16.0 [9.0-20.5] vs. 9.0 [7.0-12.0], p = 0.022), PADP (28.5 [25.0-31.0] vs. 23.0 [18.0-28.0], p = 0.011), and lower pulmonary artery pulsatility index (PAPi) (1.45 [0.82-3.45] vs. 2.5 [1.65-3.86], p = 0.029). Upgrade patients had higher repeated measures trends in RAP (p < 0.001) and PADP (p = 0.015). The Impella 5.5 improved hemodynamics and effectively bridged to recovery or heart replacement therapies. Co-existing RV dysfunction can be supported on Impella 5.5 with careful hemodynamic trend monitoring.

Giant subcapsular hematoma of the liver — a rare complication after laparoscopic cholecystectomy

The article shows a clinical case of an extremely rare complication after laparoscopic cholecystectomy — a giant subcapsular hematoma of the liver. The clinical, laboratory and instrumental data of the patient and the results obtained were analyzed. Analysis of the data from the operated patient did not reveal the main reason that could have caused the development of a giant subcapsular hematoma of the liver. The patient had no bleeding disorders, had not previously suffered any bleeding, and did not take anticoagulants as an outpatient. During the operations, no source of bleeding or damage to the liver parenchyma was identified. In addition, there was no evidence of focal liver lesions according to the preoperative ultrasound scan. Outpatient use of a drug from the group of antiplatelet agents, as well as short-term irregular use of analgesics to relieve periodic pain could provoke the development of this complication. Treatment of subcapsular hematoma of the liver mainly depends on the clinical condition of the patient and the size of the hematoma. With conservative management, the condition of the formed hematoma should be more carefully monitored over time using radiation diagnostic methods. If necessary and according to indications, do not exclude possible repeated laparoscopic intervention, including conversion to laparotomy, taking into account the data of clinical, laboratory and radiological research methods. In most cases, this condition requires conservative treatment. Patients with such a complication require careful hemodynamic monitoring and visual monitoring of the complications development. Probably, preference should be given to magnetic resonance imaging, since this method is the most objective and does not carry a radiation load. The main task is not to miss the moment of hematoma rupture and the development of fatal bleeding.

The effect of block side on hemodynamic and respiratory parameters in patients who had interscalene block for upper limb surgery.

The administration of interscalene block (ISB) may lead to several hemodynamic effects, likely due to the diffusion of local anesthetic to nearby structures such as carotid sinus baroreceptors. This study aimed to compare hemodynamic and respiratory changes resulting from right and left-sided ISB. A retrospective analysis was conducted on adults who had ultrasound-guided ISB for upper limb surgery between January 2020 and December 2021. All patients had ISB with bupivacaine 0.5% and lidocaine 2% mixture following premedication. Demographic data, arterial blood pressure, heart rate, and peripheral oxygen saturation (SpO2) were measured before and after the block at regular intervals. Block characteristics, surgical and post-anesthesia care unit (PACU) durations, intraoperative analgesic requirements, and side effects were analyzed. A total of 94 patients had ISB for upper limb surgery, 54 for the right and 40 for the left-sided surgeries. Patients' data were analyzed in two groups according to the block side. Increased arterial blood pressure was observed in both groups after the block compared to the control values. Systolic arterial pressure from 10 to 30 minutes, diastolic arterial pressure at the 25th minute, and mean arterial pressure at the 15th, 20th, and 25th minutes were significantly higher on the right-sided blocks. Heart rate, SpO2, analgesic requirements, block characteristics, and PACU durations did not differ between the groups. Ultrasound-guided ISB-applied patients demonstrated increased blood pressure compared to control values. This increase, without concurrent changes in heart rate, was more pronounced in right-sided ISB. These findings indicate that careful hemodynamic monitoring is necessary whenever hypertension should be avoided for the patients.

Comparison of mortality in emergency department patients with immediate versus delayed hypotension

BackgroundHypotension in the emergency department (ED) is known to be associated with increased mortality, however, the relationship between timing of hypotension and mortality has not been investigated. The objective of the study was to compare the mortality rate of patients presenting with hypotension with those who develop hypotension while in the ED. MethodsThis was a retrospective cohort study in a large academic medical center collected from January 2018–December 2021. Patients were included if they were ≥ 18 years old and had at least one recorded systolic blood pressure (SBP) ≤ 90 in the ED. Patients were separated into medical and trauma presentations by chief compliant. The primary outcome was in-hospital mortality, which included any deaths between ED arrival and hospital discharge. Further analysis examined the association of time to the first hypotensive SBP measurement with mortality. ResultsThere were 212,085 adult patients who presented to the ED during the study period, with 4053 (1.9%) patients having at least one hypotensive blood pressure measurement. The mortality rate was 0.8% for all patients and 10.0% for patients with hypotension. There were 676 unique chief complaints, of which 86 (12.7%) were determined to be trauma related. This grouping resulted in 176,947(83.4%) patients classified as medical and 35,138(16.6%) patients as trauma. For patients presenting with medical complaints, there was not a significant difference in mortality for patients who were hypotensive on arrival and those who developed hypotension during their ED stay (RR 1.19 [95% CI:0.97–1.39]). Similarly, there was no difference for patients with trauma (RR 0.6 [95% CI: 0.31–1.24]). However, for all patients, there was a significant trend toward decreased mortality for every hour after arrival until the development of hypotension, and increased mortality with increasing number of hypotensive measurements recorded. ConclusionThis study demonstrated hypotension in the ED was associated with a very significantly increased risk of in-hospital mortality. However, there was no significant increase in mortality between those patients with hypotension on arrival those who develop hypotension while in the ED. These finding underscore the importance of careful hemodynamic monitoring for patients in the ED throughout their stay.

Pediatric kidney transplantation, a technical update.

Pediatric kidney transplantation is the definitive therapy for infants and children suffering from renal failure. It is a distinct endeavor demanding specialized care for optimal results. This includes a dedicated preoperative workup accounting for unique predisposing urologic conditions, specialized surgical techniques, and careful hemodynamic monitoring and maintenance. Historically, size-matched renal allografts from pediatric donors to pediatric recipients suffered from poor outcomes. Advances in surgical technique performed at high volume centers have shown that these operations can be performed safely, helping expand the donor pool for these patients. Concurrently, transplantation of increasingly small for size infants with complex medical and surgical backgrounds has become a reality. On a policy front, efforts to expand access to size-matched organs, combined with advances in medical management and immunosuppression have seen pediatric renal transplantation reach new heights. Now, these breakthroughs are heightened by the ability to transplant such organs into the smallest infants. The net result will be diminished transplant waiting times and, accordingly, improved quality of life and longevity for children suffering from renal failure.

Emanuel Sendromlu Çocuk Hastada Anestezik Yaklaşım

Emanuel syndrome is a very rare recessive hereditary disorder characterized by multiple congenital anomalies, craniofacial dysmorphism, significant developmental delay and mental retardation. In this case report, we discussed our anesthetic management of a pediatric patient with Emanuel Syndrome undergoing isolated cleft palate repair operation. General anesthesia was maintained with total intravenous anesthetic techniques. Videolaryngoscopy was used for endotracheal intubation. The patient was extubated at the operating room following an uneventful intraoperative period, however she developed respiratory distress and was reintubated and transferred to pediatric intensive care unit. Anesthesiologists should be prepared for difficult airway management because of concomitant micro-retrognathia, as in our patient. Most of the problems regarding anesthetic management of this extremely rare syndrome can be reduced by a detailed preoperative assesment, preparation for diffucult airway and a careful hemodynamic monitoring.

VOLEMIC AND HEMODYNAMIC STATUS OF PATIENTS WITH COMORBIDITY OF CORONARY HEART DISEASE AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE BEFORE AND AFTER MYOCARDIAL REVASCULARIZATION

Introduction . The comorbidity of chronic obstructive pulmonary disease (COPD) and coronary heart disease (CHD) significantly worsens the clinical course of these pathologies, which determines the need for careful hemodynamic monitoring during coronary artery bypass grafting (CABG). Aim. To evaluate the parameters of central and pulmonary hemodynamics during the performance of CABG under conditions of cardiopulmonary bypass (CPB) in patients with comorbidity of IHD and COPD. Materials and methods. Two groups of patients with IHD before and after CABG were examined. The first group included 11 patients with coronary heart disease in combination with COPD II-III severity without exacerbation, the second group included 29 patients with coronary heart disease without pulmonary pathology. Volumetric and hemodynamic parameters were measured by transpulmonary thermodilution using a Drager Delta XL monitor and the Pulsion PiCCO Plus module (Germany) at three stages of the study: after the start of artificial lung ventilation; completion of the CPB procedure; 24 hours after IR. Results. For patients with comorbidity of coronary heart disease and COPD, a specific set of volumic and hemodynamic parameters was characteristic that distinguishes them from persons with coronary artery disease without pulmonary pathology. In the early postoperative period, this was manifested by the formation of a hypokinetic type of blood circulation, an increase in systemic vascular resistance, a less noticeable decrease in the global final diastolic volume, intrathoracic and pulmonary blood volumes. In addition, in patients with cardio-respiratory comorbidity, the maximum values of the indices of extravascular water in the lungs and permeability of the pulmonary vessels were recorded. Timely diagnosis of these disorders contributed to the restoration of pulmonary hemodynamics and water balance. Conclusion. When conducting CABG in patients with comorbidity of IHD and COPD, it is advisable to use the method of transpulmonary thermodilution, which provides more accurate control of hemodynamics and a personalized approach to correcting its disorders.

Cardiovascular Collapse with Intravenous Amiodarone in Children: A Multi-Center Retrospective Cohort Study.

To determine the incidence of cardiovascular collapse in children receiving intravenous (IV) amiodarone and to identify the population at risk. A multicenter study of patients ≤18years of age who received intravenous amiodarone between January 2005 and December 2015. A retrospective analysis was performed to identify patients who developed cardiovascular collapse (bradycardia and/or hypotension). Of 456 patients who received amiodarone, cardiovascular collapse occurred in 47 patients (10%). Patient risk factors for collapse in a univariate analysis were as follows: age < 3 months (p = 0.04), depressed cardiac function (p < 0.001), blood pressure below 3rd percentile (p < 0.001), high lactate at baseline (p < 0.001). Administration risk factors included bolus administration (p = 0.04), and bolus administration over ≤ 20min (p = 0.04). In multivariate analysis, age, baseline blood pressure less than 3rd percentile, and rapid bolus delivery were independent risk factors for cardiovascular collapse in the study group. The mortality rate was significantly higher in the collapse group (28% versus 8%). We found an association between IV amiodarone administration and the risk of developing cardiovascular collapse in a significant subset of children. Extreme caution and careful hemodynamic monitoring is recommended when using IV amiodarone in this population, especially in young infants, hemodynamically compromised patients, and in patients receiving rapid amiodarone bolus administration.

High risk of heart failure associated with desmoglein-2 mutations compared to plakophilin-2 mutations in arrhythmogenic right ventricular cardiomyopathy/dysplasia.

Previous studies suggested that genetic status affects the clinical course of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) patients. The aim of this study was to compare the outcome of desmoglein-2 (DSG2) mutation carriers to those who carry the plakophilin-2 (PKP2) mutation, the most common ARVC/D-associated gene. Consecutive ARVC/D patients carrying a pathogenic mutation in PKP2 or DSG2 were selected from a national ARVC/D registry. The cumulative freedom from sustained ventricular arrhythmia and cardiac transplantation/death from heart failure (HF) during follow-up was assessed, compared between PKP2 and DSG2, and predictors for ventricular arrhythmia and HF events determined. Overall, 118 patients from 78 families were included: 27 (23%) carried a DSG2 mutation and 91 (77%) a PKP2 mutation. There were no significant differences between DSG2 and PKP2 mutation carriers concerning gender, proband status, age at diagnosis, T-wave inversion, or right ventricular dysfunction at baseline. DSG2 patients displayed more frequent epsilon wave (37% vs. 17%, P = 0.048) and left ventricular dysfunction at diagnosis (54% vs. 10%, P < 0.001). During a median follow-up of 5.6 years (2.5-16), DSG2 and PKP2 mutation carriers displayed a similar risk of sustained ventricular arrhythmia (log-rank P = 0.20), but DSG2 mutation carriers were at higher risk of transplantation/HF-related death (log-rank P < 0.001). The presence of a DSG2 mutation vs. PKP2 mutation was a predictor of transplantation/HF-related death in univariate Cox analysis (P = 0.0005). In this multicentre cohort, DSG2 mutation carriers were found to be at high risk of end-stage HF compared to PKP2 mutation carriers, supporting careful haemodynamic monitoring of these patients. The benefit of early HF treatment needs to be assessed in DSG2 carriers.

Non-intubated thoracic epidural anesthesia for modified radical mastectomy as an alternative to general anaesthesia

Purpose : We provide the application of modified radial mastectomy in perioperative treatment under awake thoracic epidural block in breast cancer operations. Methods : Twelve women who underwent modified radical mastectomy in elective breast cancer surgery were included in the study. All patients were treated without tracheal intubation using thoracic epidural anesthesia and sedation. The epidural catheter was placed in the T 4-5 level and the mixture of 0.5% bupivacaine and fentanyl was gradually administered with careful haemodynamic monitoring. Target-controlled propofol infusion was used. Pain intensity was evaluated by using a 10 cm VAS, where zero represented no pain and 10 cm represented worst possible pain. The primary endpoint was pain. A VAS score of 4 cm or less was considered to be an acceptable level of pain. The sedation situation was focused and calm in Wilson 2 level and in cooperation with sedation. Preoperative comorbidity and perioperative therapy were recorded. Results : We observed 4 hypotensive patients treated by increasing intravenous fluid infusion rate and initiating dopamine infusion. One patient had bradycardia, one patient had nausea and three patients had vomiting. There were no respiratory complications or pruritus. The mean duration of hospitalization is 5 days postoperatively. The patient had no intraoperative or postoperative complications. Conclusion : Epidural block in axillary lymph node dissection and oncologic mastectomy may be considered as a safe anesthetic option.

Comparison of hemodynamic changes between old and very old patients undergoing cemented bipolar hemiarthroplasty under spinal anesthesia.

BackgroundThe old age population, including the very old aged (≥ 85 years), is rapidly increasing, and femur neck fracture from accidents is commonly seen in the elderly. Use of bone cement during bipolar hemiarthroplasty can cause bone cement implantation syndrome.MethodsThis study was prospectively conducted on the elderly who were scheduled to undergo elective cemented bipolar hemiarthroplasty under spinal anesthesia. Patients were divided into 2 groups: the old age (65-84 years) and very old age groups (≥ 85 years). Hemodynamic parameters were recorded at the following time points: the start of the operation, femoral reaming, cement insertion, every 2 minutes after cement insertion for 10 minutes, femoral joint reduction, and the end of operation. When hypotension occurred, ephedrine was given.ResultsSixty-five patients in the old age group and 32 patients in the very old age group were enrolled. Mean ages were 78.9 and 89.4 years, respectively, in the old age and very old age groups. The very old age group showed constantly decreased levels of cardiac index and stroke volume from cementing until the end of the operation compared to the old age group. To maintain hemodynamic stability after cement insertion, the requirement of ephedrine was higher in the very old age group than in the old age group (13.52 ± 7.76 vs 8.65 ± 6.38 mg, P = 0.001).ConclusionsBone cement implantation during bipolar hemiarthroplasty may cause more prominent hemodynamic changes in very elderly patients. Careful hemodynamic monitoring and management are warranted in very elderly patients undergoing cemented bipolar hemiarthroplasty.

Factors Influencing Blood Loss and Postoperative Morbidity in Children Undergoing Craniosynostosis Surgery: A Retrospective Study

Background: Craniosynostosis is a condition resulting from the premature fusion of cranial sutures. Corrective surgery is often associated with a large amount of blood loss, with transfusion of red blood cells (RBC) and fresh frozen plasma (FFP). The aims of this study were to determine the variables associated with increased blood loss and postoperative complications. Methods: A retrospective analysis was performed of 42 pediatric patients who underwent craniosynostosis surgery. We analyzed the following: demographic parameters, duration of surgery, intraoperative blood loss, RBC, FFP and fluid transfusion, urine output, and hemodynamic parameters. In addition, we recorded the postoperative length of stay in the intensive care unit and hospital, postoperative blood loss and early complications. Results: The mean age, weight and surgical duration were 9.2 ± 3.2 months, 9.3 ± 2.0 kg and 255.8 ± 46.7 min, respectively. Intraoperative blood loss was 61.2 ± 15.3 ml/kg and RBC, FFP and fluid transfusion were 27.3 ± 7.1 ml/kg, 16.5 ± 4.7 ml/kg and 21.7 ± 4.6 ml/kg/h, respectively. Greater intraoperative blood loss was associated with longer surgical duration (p = 0.001, correlation coefficient = 0.495, R² = 0.245) and lower patient weight (p < 0.001, correlation coefficient = -0.557, R² = 0.311). Longer hospital stay was associated with greater intraoperative blood loss (p < 0.001, correlation coefficient = 0.754, R² = 0.568) and greater intraoperative RBC transfusion (p < 0.001, correlation coefficient = 0.795, R² = 0.632). Conclusion: Severe blood loss occurred in all children who underwent craniosynostotic corrections. Furthermore, the duration of surgery, patient weight and certain surgical procedures correlated with greater blood loss. Careful hemodynamic monitoring and evaluation of a patient's hematocrit value and volume status together may be helpful in maintaining the balance between insufficient and excessive blood product transfusion.

Prise en charge du rétrécissement aortique en préopératoire d’une chirurgie non cardiaque

There is a significant risk of cardiovascular morbidity and mortality in patients with severe aortic stenosis (valve area <1cm(2) or 0.6cm(2)/m(2) body surface area, and maximum jet velocity ≥4m/sec, and mean aortic pressure gradient ≥40mmHg) undergoing non-cardiac surgery, especially in patients with symptoms (dyspnoea, angina, syncope, or heart failure). Before any surgery, clinical assessment should search for signs of aortic stenosis which justifies echocardiographic examination, particularly in the elderly. A systematic rest echocardiography with searching aortic stenosis should be considered in patients undergoing high risk surgery. The key points of pre-operative cardiac risk assessment are: assessment of the severity of aortic stenosis, measurement of the functional capacity, evaluation of the left ventricular systolic function, search of associated coronary artery disease, estimate of the surgical risk of cardiac events, and achievement of risk indices. In symptomatic patients with severe aortic stenosis, only urgent non-cardiac surgery should be performed under careful haemodynamic monitoring. Aortic valve replacement should be considered before elective non-cardiac surgery. In asymptomatic patients with severe aortic stenosis, aortic valve replacement should be considered before non-cardiac high risk surgery. Non-cardiac surgery at low/intermediate risk can be performed provided an adapted anaesthetic technique.

Delayed bleeding and pelvic haematoma after low-energy osteoporotic pubic rami fracture in a warfarin patient: an unusual cause of abdominal pain.

Introduction. Acute abdominal pain may be the presenting symptom in a wide range of diseases in the elderly. Acute abdominal pain related to a delayed bleeding and pelvic haematoma after a low-energy pubic rami fracture is rare and can have important consequences; to the best of our knowledge, only one case has been previously described. Case Report. We present an unusual case of an 83-year-old woman taking warfarin for atrial fibrillation, admitted to the Emergency Department (ED) with acute abdominal pain and progressive anemia related to a delayed bleeding and pelvic haematoma 72 hours after a low-energy osteoporotic pubic rami fracture. Warfarin was withheld, anticoagulation was reversed by using fresh frozen plasma and vitamin K, and concentrated red blood cells were given. Haemoglobin level gradually returned to normal with a progressive resorption of the haematoma. Conclusion. Delayed bleeding and pelvic haematoma after osteoporotic pubic rami fracture should be considered in the differential diagnosis of acute abdominal pain in the elderly. This case indicates the need for hospital admission, careful haemodynamic monitoring, and early identification of bleeding in patients with “benign” osteoporotic pubic rami fracture, especially those receiving anticoagulants, to provide an adequate management and prevent severe complications.

Anesthetic management of a patient with Marfan syndrome and severe aortic root dilatation undergoing cholecystectomy and partial hepatic resection

Due to high mortality associated with aortic dissection, anesthetic management of patients with Marfan syndrome with severe aortic root dilation is a challenging situation. We describe the anesthetic management of a patient with Marfan syndrome with severe aortic root dilation, who required major surgery like cholecystectomy with partial liver resection under general anesthesia. A 47-year-old female presented to pre-anesthetic clinic for cholecystectomy with partial hepatic resection for gall bladder carcinoma. Clinical features, transthoracic echocardiography and computed tomography of thorax supported a diagnosis of Marfan syndrome with severely dilated aortic root. Aortic dissection in patients with Marfan syndrome and severely dilated aortic root can be precipitated by major hemodynamic changes under anesthesia. Careful hemodynamic monitoring and avoidance of hemodynamic swings can prevent this life-threatening event.

Vipera Palaestinae Bite and Serum Sickness During Pregnancy

Vipera palaestinae is the most common venomous snake in Israel. We report a case of V. palaestinae bite and antivenom-induced serum sickness during pregnancy and discuss the unique considerations relevant to the treatment of a pregnant woman envenomated by a snake. A 46-year-old woman, G6P5, 14 weeks gestation, was admitted after a V. palaestinae bite on her right toe. On admission to the Emergency Department, physical examination included the following vital signs and findings: pulse 76 beats/min, blood pressure 90/60 mm Hg, nausea, vomiting, foot and distal leg swelling, and normal fetal monitoring. She was treated with intravenous fluids, analgesics, and V. palaestinae antivenom. Eight days later she developed serum sickness, was treated with prednisone, and fully recovered. A healthy baby was born at term, with normal examination at 2 months post-delivery. To our knowledge, this is the first reported case of V. palaestinae bite complicated by antivenom-induced serum sickness during pregnancy. No adverse pregnancy outcome due to the antivenom treatment or serum sickness was observed. Careful hemodynamic, hematologic, and obstetric monitoring (including ultrasound) of pregnant snakebite victims is warranted. Antivenom administration should be considered according to published indications to prevent maternal complications and fetal compromise. Patients treated with antivenom should be followed for possible development of serum sickness.

General anesthesia using remifentanil for Cesarean delivery in a parturient with Marfan’s syndrome

Due to cardiovascular and skeletal abnormalities, anesthetic management of parturients with Marfan's syndrome can be particularly challenging. Parturients with aortic root dilatation are at risk for aortic dissection. We describe the anesthetic management of a parturient with Marfan's syndrome and aortic root dilatation, who required general anesthesia for Cesarean delivery.At 26 weeks gestation, a nulliparous woman with Marfan's syndrome presented to the Anesthesia Clinic. Her history revealed asymptomatic aortic root dilatation of 41 mm, and partial correction of scoliosis with Harrington rods. Her cardiologist advised metoprolol, serial echocardiograms, and Cesarean delivery to decrease the risk of aortic dissection. At a multidisciplinary conference, a decision was made to proceed with Cesarean delivery, at term, at the cardiac surgery centre. After placement of arterial and central lines, general anesthesia was induced with remifentanil, propofol, and succinylcholine. Anesthesia was maintained with N(2)O, sevoflurane, and remifentanil (0.02-0.08 microg x kg(-1) x min(-1)). Transesophageal echocardiography examination confirmed stable aortic root dilatation. The patient remained hemodynamically stable. The baby's Apgars were 4 and 8, at one and five minutes, respectively. At the end of the procedure, the patient's trachea was extubated when she was awake. Initial postoperative care was in the intensive care unit. Both mother and baby recovered uneventfully.Peripartum hemodynamic changes can be life-threatening to the parturient with Marfan's syndrome and aortic dilatation. Anesthetic goals for delivery included preparation for possible aortic dissection, and avoidance of increased aortic root shear stress, through careful hemodynamic monitoring, and general anesthesia using remifentanil.

The haemodynamic responses to venesection and the effects of cardiovascular disease.

The haemodynamic effects of the venesection of one unit (450 ml) of blood over 9 min were measured using non-invasive techniques, in 14 healthy controls and 18 patients with coronary heart disease or hypertension. Venesection was associated with significant reductions in supine and standing systolic and diastolic blood pressure, stroke volume index and cardiac index, and increases in standing heart rate, in both patient groups. No significant differences were observed between the responses of subjects with and without cardiovascular disease. The authors conclude that, in contrast to established teaching, blood loss can be detected in its early stages by careful haemodynamic monitoring and that venesection can be performed safely without volume replacement in patients with stable cardiovascular disease.

Comparison of cardiopulmonary hemodynamic changes according to different ethanol bolus injection doses in piglets: the applicability of the study of ethanol injection effects on cardiopulmonary hemodynamic changes in sclerotherapy of congenital arteriovenous malformations

Background: Ethanol injection during a sclerotherapy for the treatment of arteriovenous malformation, which performed under general anesthesia, can cause significant hemodynamic changes, even cardiovascular collapse. However, guideline for adequate management of hemodynamic change or preventing detrimental complication has still not been proposed. Methods: Twenty-two piglets were randomly allocated to one of two groups: a 2.5 ml and a 4.0 ml ethanol. After baseline hemodynamic measurements, 2.5 ml or 4.0 ml of absolute ethanol was repeatedly administered in distal portion of renal vein with 10 minute intervals, and hemodynamic parameters were measured immediately before and after bolus injection of absolute ethanol until 10 minutes after final injection. Results: Compared with 2.5 ml group, systolic, mean and diastolic pulmonary arterial pressures (PAP) and pulmonary vascular resistance (PVR) of 4.0 ml group showed significant differences from the first bolus injection of absolute ethanol. Hemodynamic parameters of 2.5 ml group did not show the increasing or decreasing tendency during a session, whereas, in 4.0 ml group, systolic, mean and diastolic PAP and PVR showed significantly increasing tendency. However, systemic arterial blood pressure, heart rate, central venous pressure, pulmonary capillary wedge pressure, cardiac output, and systemic vascular resistance did not show increasing or decreasing tendency in both groups. Conclusions: Based on the hemodynamic alterations observed from piglet model, the bolus injection of absolute ethanol during sclerotherapy in congenital arteriovenous malformation requires careful hemodynamic monitoring. We strongly recommend that anesthesiologist should carefully monitor the hemodynamic parameters after injection of relatively large amount of absolute ethanol.

Outcomes of Acute Respiratory Distress Syndrome (ARDS) in Elderly Patients

Elderly patients have become an increasingly prevalent proportion of the intensive care unit population. Outcomes of patients with acute respiratory distress syndrome (ARDS) have been improving in recent years, but studies of ARDS rarely include substantial numbers of elderly patients. Historically, the mortality rate for ARDS has been 69% to 80% among elderly patients. We reviewed our experience with ARDS to determine whether outcomes were improving over time, and in particular whether outcomes were equally favorable among our elderly patients aged 65 years or older. Patients who developed ARDS in a university surgical intensive care unit from 1993 to 2003 were identified and their data were collected prospectively. Data collected included age, gender, cause of ARDS, Acute Physiology and Chronic Health Evaluation (APACHE) III score (AIII), initial Pao2:FIO2, lung injury score (LIS), maximum positive end-expiratory pressure, multiple organ dysfunction pulmonary and nonpulmonary organ dysfunction scores (MODnp), vasopressor dependence, and development of ventilator-associated pneumonia. Outcomes of patients >65 years old with ARDS were compared with those of patients <65 years old. In the study period, 343 patients developed ARDS, 210 of whom were >65 years old. Overall, age was 65.2 +/- 0.2 years, with a mean APACHE III score of 83.4 +/- 2.0 points. Sixty-six percent were men. The initial Pao2:FIO2 for the entire group was 104.3 +/- 4.1, and was less in younger patients. Maximum positive end-expiratory pressure was 15.6 +/- 0.5 cm H2O, and mean LIS was 3.3 +/- 0.6 points; these values did not differ between cohorts. Elderly patients had a mortality of 51.9% when compared with 41.7% for younger patients (p = not significant). By logistic regression analysis, factors predicting mortality included APACHE III score (each point, odds ratio [OR], 1.022; 95% confidence interval [CI], 1.008-1.035; p < 0.01) and nonpulmonary multiple organ dysfunction score (each point, OR, 1.366; 95% CI, 1.223-1.526; p < 0.0001), but neither age (p = 0.37), LIS (p = 0.49), multiple organ dysfunction pulmonary (p = 0.90), nor year of treatment (p = 0.74) had any effect on mortality. The mortality rate for elderly patients with ARDS is lower in our experience when compared with historical series, even though illness severity may be higher, and comparable to that of other patients. Careful hemodynamic monitoring and resuscitation combined with other strategies to ameliorate nonpulmonary organ dysfunction achieved good outcomes in high-risk patients and could contribute in the future to further improved outcomes of elderly patients with ARDS.