Administration Of Catecholamines Research Articles

Impact of extracorporeal cardiopulmonary resuscitation with ECPELLA on improvement of short-term survival in patients with refractory cardiac arrest

Abstract Background Extracorporeal cardiopulmonary resuscitation (E-CPR) is considered for cardiac arrest (CA) patients when conventional CPR is ineffective. While veno-arterial extracorporeal membrane oxygenation (VA-ECMO) robustly maintains systemic perfusion, it also increases left ventricular (LV) afterload. Recently, the transcatheter LV assist device Impella has been introduced, and the potential benefits of its combined use with VA-ECMO (ECPELLA) are anticipated. However, the utility and effective management of ECPELLA remain unclear. Purpose This single-site cohort study aimed to assess the impact of ECPELLA compared to VA-ECMO with or without intra-aortic balloon pump (IABP) in patients with refractory CA who received E-CPR. Methods We retrospectively reviewed 207 consecutive patients who underwent E-CPR between January 2012 and September 2023 at our institute. The patients were divided into two groups, ECEPLLA (n = 65) and VA-ECMO with or without IABP (n = 141). A propensity score analysis was conducted, utilizing 1:1 score matching based on variables including age, the rate of male gender, acute coronary syndrome, out-of-hospital CA (OHCA), in-hospital CA, shockable rhythm, and the time from collapse to VA-ECMO initiation, known as low flow time (LFT). We evaluated 180-day survival rates, hemodynamic data, and safety profiles. Result After propensity score matching, 57 ECPELLA patients and 57 VA-ECMO patients were included for analysis. No significant differences in the adjusted factors and comorbidities were found between the two groups. In the VA-ECMO group, 42 patients (74%) received concomitant use of IABP. During the first 72 hours following the initiation of VA-ECMO, the ECPELLA group received significantly higher total mechanical circulatory support flow compared to the VA-ECMO group, correspondingly received less catecholamine administration, and had more patients started on vasodilators and cardioprotective medications. There were no statistical differences in safety profiles, except for hemolysis and embolic cerebral infarction, between the two groups. Kaplan-Meier analysis demonstrated that the 180-day survival rates were significantly higher in the ECPELLA group than in the VA-ECMO group. In a multivariate Cox proportional hazard analysis that included age, shockable rhythm, OHCA, initial lactate levels, LFT, and ECPELLA, it was found that age (hazard ratio [HR], 1.28 [for 10-year increase]; 95% confidence interval [CI], 1.09–1.51; p = 0.002), initial lactate level (HR, 1.06; 95% CI, 1.01-1.11; p = 0.04), and ECPELLA (HR, 0.55; 95% CI, 0.36–0.85; p = 0.007) were significantly associated with 180-day mortality. Conclusion ECPELLA was associated with improvement of 180-day mortality in patient who received E-CPR. The results suggest that not only the choice of ECPELLA but also sufficient circulatory support during the acute phase, along with modulating catecholamines and vasodilators, may have influenced the prognosis.

Intraoperative hypotension in children-Measurement and treatment

Intraoperative hypotension is acommon perioperative complication in pediatric anesthesia. Oscillometric blood pressure measurement is therefore an essential part of standard perioperative monitoring in pediatric anesthesia. The optimum measurement site is the upper arm. Attention must be paid to the correct cuff size. Blood pressure should be measured before induction. In children undergoing major surgery or in critically ill children, invasive blood pressure measurement is still the gold standard. Continuous noninvasive measurement methods could be an alternative in the future.Threshold values to define hypotension remain unknown, even in awake children. There are also little data on hypotension thresholds in the perioperative setting. The most reliable measurement parameter for estimating hypotension is the mean arterial pressure. The threshold values for intraoperative hypotension are 40 mm Hg in newborns, 45 mm Hg in infants, 50 mm Hg in young children and 65 mm Hg in adolescents. Treatment should be initiated at adeviation of 10% and intensified at adeviation of 20%.Bolus administration of isotonic balanced crystalloid solutions, vasopressors and/or catecholamines are used as treatment options. Consistent and rapid intervention in the event of hypotension appears to be crucial. So far there is no evidence as to whether this leads to an improvement in outcome parameters.

Apelin-13 administration allows for norepinephrine sparing in a rat model of cecal ligation and puncture-induced septic shock

BackgroundInfusion of exogenous catecholamines (i.e., norepinephrine [NE] and dobutamine) is a recommended treatment for septic shock with myocardial dysfunction. However, sustained catecholamine infusion is linked to cardiac toxicity and impaired responsiveness. Several pre-clinical and clinical studies have investigated the use of alternative vasopressors in the treatment of septic shock, with limited benefits and generally no effect on mortality. Apelin-13 (APL-13) is an endogenous positive inotrope and vasoactive peptide and has been demonstrated cardioprotective with vasomodulator and sparing life effects in animal models of septic shock. A primary objective of this study was to evaluate the NE-sparing effect of APL-13 infusion in an experimental sepsis-induced hypotension.MethodsFor this goal, sepsis was induced by cecal ligation and puncture (CLP) in male rats and the arterial blood pressure (BP) monitored continuously via a carotid catheter. Monitoring, fluid resuscitation and experimental treatments were performed on conscious animals. Based on pilot assays, normal saline fluid resuscitation (2.5 mL/Kg/h) was initiated 3 h post-CLP and maintained up to the endpoint. Thus, titrated doses of NE, with or without fixed-doses of APL-13 or the apelin receptor antagonist F13A co-infusion were started when 20% decrease of systolic BP (SBP) from baseline was achieved, to restore SBP values ≥ 115 ± 1.5 mmHg (baseline average ± SEM).ResultsA reduction in mean NE dose was observed with APL-13 but not F13A co-infusion at pre-determined treatment time of 4.5 ± 0.5 h (17.37 ± 1.74 µg/Kg/h [APL-13] vs. 25.64 ± 2.61 µg/Kg/h [Control NE] vs. 28.60 ± 4.79 µg/Kg/min [F13A], P = 0.0491). A 60% decrease in NE infusion rate over time was observed with APL-13 co-infusion, (p = 0.008 vs NE alone), while F13A co-infusion increased the NE infusion rate over time by 218% (p = 0.003 vs NE + APL-13). Associated improvements in cardiac function are likely mediated by (i) enhanced left ventricular end-diastolic volume (0.18 ± 0.02 mL [Control NE] vs. 0.30 ± 0.03 mL [APL-13], P = 0.0051), stroke volume (0.11 ± 0.01 mL [Control NE] vs. 0.21 ± 0.01 mL [APL-13], P < 0.001) and cardiac output (67.57 ± 8.63 mL/min [Control NE] vs. 112.20 ± 8.53 mL/min [APL-13], P = 0.0036), and (ii) a reduced effective arterial elastance (920.6 ± 81.4 mmHg/mL/min [Control NE] vs. 497.633.44 mmHg/mL/min. [APL-13], P = 0.0002). APL-13 administration was also associated with a decrease in lactate levels compared to animals only receiving NE (7.08 ± 0.40 [Control NE] vs. 4.78 ± 0.60 [APL-13], P < 0.01).ConclusionAPL-13 exhibits NE-sparing benefits in the treatment of sepsis-induced shock, potentially reducing deleterious effects of prolonged exogenous catecholamine administration.

Treatment outcomes in non-occlusive mesenteric ischemia and post-treatment return to social activities.

To investigate the treatment outcomes of patients with non-occlusive mesenteric ischemia (NOMI) at our institution, we focused on their post-treatment return to social activities. This study included patients with suspected NOMI who were referred to our department between 2011 and 2023. In-hospital mortality was also investigated as a prognostic factor. The Glasgow-Pittsburgh Outcome Categories (GPOC) score was used to evaluate the return to social activities. The relationship between in-hospital mortality and GPOC scores and patient background and treatment factors was examined. Eighty-two patients were included in the study. Among them, 54 (65.9%) died during hospitalization. Only 9 patients (11%) returned to their social activities. In the multivariate analysis, non-surgical management was found to be the only independent factor for in-hospital mortality. Positive portal venous gas on computed tomography, no open abdomen, no pre-onset catecholamine administration, platelet count < 100,000/µL, lactate level < 5mmol/L, APTT < 46s, and Sequential Organ Failure Assessment score < 11 were factors significantly associated with an increased likelihood of return to social activities. This is the first study to assess the post-treatment return to social activities among patients with NOMI. Our findings highlight the concerning reality that survivors may face prolonged dependence on medical care.

A proof of concept for microcirculation monitoring using machine learning based hyperspectral imaging in critically ill patients: a monocentric observational study

BackgroundImpaired microcirculation is a cornerstone of sepsis development and leads to reduced tissue oxygenation, influenced by fluid and catecholamine administration during treatment. Hyperspectral imaging (HSI) is a non-invasive bedside technology for visualizing physicochemical tissue characteristics. Machine learning (ML) for skin HSI might offer an automated approach for bedside microcirculation assessment, providing an individualized tissue fingerprint of critically ill patients in intensive care. The study aimed to determine if machine learning could be utilized to automatically identify regions of interest (ROIs) in the hand, thereby distinguishing between healthy individuals and critically ill patients with sepsis using HSI.MethodsHSI raw data from 75 critically ill sepsis patients and from 30 healthy controls were recorded using TIVITA® Tissue System and analyzed using an automated ML approach. Additionally, patients were divided into two groups based on their SOFA scores for further subanalysis: less severely ill (SOFA ≤ 5) and severely ill (SOFA > 5). The analysis of the HSI raw data was fully-automated using MediaPipe for ROI detection (palm and fingertips) and feature extraction. HSI Features were statistically analyzed to highlight relevant wavelength combinations using Mann–Whitney-U test and Benjamini, Krieger, and Yekutieli (BKY) correction. In addition, Random Forest models were trained using bootstrapping, and feature importances were determined to gain insights regarding the wavelength importance for a model decision.ResultsAn automated pipeline for generating ROIs and HSI feature extraction was successfully established. HSI raw data analysis accurately distinguished healthy controls from sepsis patients. Wavelengths at the fingertips differed in the ranges of 575–695 nm and 840–1000 nm. For the palm, significant differences were observed in the range of 925–1000 nm. Feature importance plots indicated relevant information in the same wavelength ranges. Combining palm and fingertip analysis provided the highest reliability, with an AUC of 0.92 to distinguish between sepsis patients and healthy controls.ConclusionBased on this proof of concept, the integration of automated and standardized ROIs along with automated skin HSI analyzes, was able to differentiate between healthy individuals and patients with sepsis. This approach offers a reliable and objective assessment of skin microcirculation, facilitating the rapid identification of critically ill patients.

Low Stroke Volume Predicts Deterioration in Intermediate-Risk Pulmonary Embolism: Prospective Study.

Prognosis and management of patients with intermediate-risk pulmonary embolism (PE) is challenging. We investigated whether stroke volume may be used to identify the subset of this population at increased risk of clinical deterioration or PE-related death. Our secondary objective was to compare echocardiographic measurements of patients who received escalated interventions vs anticoagulation monotherapy. We selected patients with intermediate-risk PE, who had comprehensive echocardiography within 18 hours of PE diagnosis and before any escalated interventions, from a PE registry populated by 11 emergency departments. Echocardiographers measured right ventricle (RV) size, tricuspid annular plane systolic excursion (TAPSE), and stroke volume (SV) using velocity time integral (VTI) by left ventricular (LV) outflow tract Doppler or two-dimensional method of discs (MOD). The primary outcome was a composite of PE-related death, cardiac arrest, catecholamine administration for sustained hypotension, or emergency respiratory intervention during the index hospitalization. Secondary outcome was escalated intervention with reperfusion or extracorporeal membrane oxygenation therapy. Of 370 intermediate-risk PE patients (mean age 64.0 ± 15.5years, 38.1% male), 39 (10.5%) had the primary outcome. These 39 patients had lower mean SV regardless of measurement method than those without the primary outcome: SV MOD 36.2 vs 49.9 milliliters (mL), P < 0.001; SV Doppler 41.7 vs 57.2mL, P = 0.003; VTI 13.6 vs 17.9 centimeters [cm], P = 0.003. Patients with primary outcome also had lower mean TAPSE than those without (1.54 vs 1.81cm, P = 0.003). Multivariable models, selecting SV as predictor, had area under the receiver operating curve of 0.8 and Brier score 0.08. The best echocardiographic predictor of our primary outcome was SV MOD (odds ratio 0.72 [0.53, 0.94], P = 0.02). Patients who received escalated interventions had significantly lower SV or surrogate measurements, greater RV dilatation, and lower RV systolic function than patients who received anticoagulation monotherapy. Low stroke volume was a predictor of clinical deterioration and PE-related death. Low SV may be used to identify a subset of intermediate-risk PE patients, who are higher risk (intermediate-high risk), and for whom escalated interventions should be considered.

Abstract PO2-22-09: The impact of blood loss and blood pressure management in DIEP flap surgery– a retrospective analysis of 206 patients

Abstract Introduction: Autologous breast reconstruction using the deep inferior epigastric perforator flap has excellent success rates and a natural aesthetic result. Therefore, this method and its management are of great importance in modern oncoplastic surgery. In particular, women who have undergone radiation therapy after mastectomy benefit from this satisfactory and usually uncomplicated method of breast reconstruction. To achieve a desirable outcome, the effects of blood loss and blood pressure management may play an important role. In this analysis, we hypothesize that neither postoperative blood pressure management (using catecholamines) nor the amount of blood loss (defined by the median hemoglobin level difference) will worsen the surgical outcome or increase the complication rate. Patients and Methods: We performed a multicenter, multisurgeon retrospective analysis with the following primary end points: intraoperative blood loss and postoperative blood pressure management. Secondary endpoints included serious complications including flap loss and minor complications. Patients (n=194) were included from 2014-2018 at St. Antonius Hospital in Eschweiler and from 2016 to July 2018 at the Cologne Municipal Breast Cancer Center in Holweide. Patients underwent either unilateral (n=180) or bilateral (n=13) breast reconstructions with DIEP flaps, resulting in a total of n=206 cases. The subgroup regarding blood pressure management was defined by cohorts with or without catecholamine administration and included all n=206 cases. Blood loss was defined by median hemoglobin level difference and could be calculated in n=199 cases. The cohorts of the two subgroups were comparable. Results: Six flap losses were detected in a total of 206 cases (2.9%). The distribution of flap losses in the blood pressure management subgroup was not statistically significant (p=.67), while the test was not available for the blood loss subgroup. Furthermore, the analysis showed that there were no significant differences in the rates of overall complications related to the amount of blood loss intraoperatively (p= .06) or blood pressure management postoperatively (p= .19). Conclusion: DIEP flap surgery is a safe method for autologous breast reconstruction, independent of blood loss and blood pressure management. Citation Format: Hanna Fritsch, Cosima Schreiber, Wolfram Malter, Matthias Warm, Max Zinser, Alexander Bach, Christian Eichler. The impact of blood loss and blood pressure management in DIEP flap surgery– a retrospective analysis of 206 patients [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-22-09.

Pulmonary CT perfusion robustly measures cardiac output in the context of multilevel pulmonary occlusion: a porcine study

BackgroundTo validate pulmonary computed tomography (CT) perfusion in a porcine model by invasive monitoring of cardiac output (CO) using thermodilution method.MethodsAnimals were studied at a single center, using a Swan-Ganz catheter for invasive CO monitoring as a reference. Fifteen pigs were included. Contrast-enhanced CT perfusion of the descending aorta and right and left pulmonary artery was performed. For variation purposes, a balloon catheter was inserted to block the contralateral pulmonary vascular bed; additionally, two increased CO settings were created by intravenous administration of catecholamines. Finally, stepwise capillary occlusion was performed by intrapulmonary arterial injection of 75-μm microspheres in four stages. A semiautomatic selection of AFs and a recirculation-aware tracer-kinetics model to extract the first-pass of AFs, estimating blood flow with the Stewart-Hamilton method, was implemented. Linear mixed models (LMM) were developed to calibrate blood flow calculations accounting with individual- and cohort-level effects.ResultsNine of 15 pigs had complete datasets. Strong correlations were observed between calibrated pulmonary (0.73, 95% confidence interval [CI] 0.6–0.82) and aortic blood flow measurements (0.82, 95% CI, 0.73–0.88) and the reference as well as agreements (± 2.24 L/min and ± 1.86 L/min, respectively) comparable to the state of the art, on a relatively wide range of right ventricle-CO measurements.ConclusionsCT perfusion validly measures CO using LMMs at both individual and cohort levels, as demonstrated by referencing the invasive CO.Relevance statementPossible clinical applications of CT perfusion for measuring CO could be in acute pulmonary thromboembolism or to assess right ventricular function to show impairment or mismatch to the left ventricle.Key points• CT perfusion measures flow in vessels.• CT perfusion measures cumulative cardiac output in the aorta and pulmonary vessels.• CT perfusion validly measures CO using LMMs at both individual and cohort levels, as demonstrated by using the invasive CO as a reference standard.Graphical

Efficacy and safety of ketamine for pediatric and adolescent super-refractory status epilepticus and the effect of cerebral inflammatory conditions

ObjectiveTo investigate the short-term benefits and adverse effects of ketamine in the treatment of pediatric and adolescent super-refractory status epilepticus (SRSE), with a focus on the inflammatory etiology. MethodsThis retrospective observational cohort study included a consecutive series of 18 pediatric to adolescent patients with SRSE admitted between 2008 and 2023 and treated with ketamine. Seizure frequency per hour before and after ketamine administration and response rate were calculated. Neurological decline, catecholamine administration, and adverse effects were also assessed. The patients were divided into inflammatory and non-inflammatory etiology groups. ResultsThe median age at SRSE onset was 1 year 5 months (range: 11 days-24 years), and 78% of the patients were male individuals. The median duration of treatment was 7.5 days (interquartile range: 2.8–15.5 days). Fifteen (83%) patients achieved >50% seizure reduction. The median seizure frequency before and after ketamine treatment was 5.9 and 0.9, respectively, showing a significant reduction in seizure frequency (p < 0.0001). Ten patients had inflammatory etiologies including bacterial meningitis (n = 2), viral encephalitis (n = 3), and febrile infection related epilepsy syndrome (n = 5). The inflammatory etiology group required a longer treatment duration (p = 0.0453) and showed lower seizure reduction (p = 0.0264), lower response rate (p = 0.0044), and higher neurological decline (p = 0.0003) than the non-inflammatory etiology group. Three (17%) patients experienced transient adverse events requiring intervention within 24 h of initiating ketamine administration. ConclusionsKetamine administration was associated with fewer serious adverse events and a reduced seizure frequency. Additionally, inflammatory conditions may weaken the efficacy of ketamine in patients with SRSE.

Mechanical support for bridge to transplant in an infant with post-cardiotomy end-stage heart failure and complete heart block: report of a case.

The patient was diagnosed with perimembranous ventricular septal defect (VSD). She underwent VSD closure and muscle bundle resection across right ventricular outflow tract at the age of 3 months. Since then, she had suffered from severe heart failure and complete heart block. Permanent pacemaker generator was implanted in the left hypochondrium. She was depended on continuous catecholamine administration, so transferred to our hospital for further management. On arrival, her body weight was 5686g (- 2.7 SD). She underwent Excor pediatric left ventricular assist device implantation at the age of 9 months. Because the position of the left ventricular assist device cannula interfered with the pacemaker, herein, the pacemaker pocket was newly created in the left thoracic cavity. An 1mm in thickness of expanded polytetrafluoroethylene sheet was trimmed and sutured under the anterolateral wall of left thoracic cavity as a pacemaker pocket. Bipolar ventricular lead was sutured on left ventricular apex and basal wall to face each other, mimicking cardiac regeneration therapy. Even though she unfortunately required right diaphragmatic plication for iatrogenic phrenic nerve palsy, her respiratory function was well maintained; therefore, secondary right heart failure was not observed. Her cardiopulmonary function was quite stable until post-operative day 275 when the patient was transferred to another hospital for heart transplantation.

Predicting the need for pre-transport adjustments in neonatal intensive care depending on the level of initial medical organization

Introduction. The need for intensive care adjustments to be made by the transport team at the originating medical organization remains an important element of pre-transport preparation, being an indirect indicator that the level of care does not match the needs of the patient. The aim of the study is to identify factors associated with the need for therapy adjustments depending on the level of initial medical organization. Materials and methods. The one-stage, cross-sectional study included the data of visits of the neonatal transport team of the resuscitation and consultative centre of the Regional Children’s Clinical Hospital (Ekaterinburg) in the period 01. 07. 2014–31. 12. 2018 (n = 2029). The sample was divided into groups: the first group – patients from level 1 organizations (22.8 %, n = 462), the second group – patients from level 2 organizations without paediatric intensive care units (34.9 %, n = 709), the third group – patients from level 2 organizations with paediatric intensive care units (32.5 %, n = 659), the fourth group – patients from level 3 institutions (9.8 %, n = 199). Results. The need for therapy adjustment at baseline was dependent on the level of the institution, with a maximum in level 1 organizations and a minimum in level 3 organizations. The odds ratio of need for therapy correction for level 1 organizations compared to level 2 organizations with paediatric intensive care units was 1.4, 95 % CI [1.2–1.7], p = 0.002, and compared to level 3 organizations was 1.6, 95 % CI [1.2–2.3], p = 0.003. Multivariate analysis identified the following factors associated with the need to adjust therapy at the original facility: for level 1 facilities, respiratory support, dopamine administration; for level 2 facilities without paediatric intensive care units, respiratory support, dopamine and epinephrine infusion, sedation; for level 2 facilities with paediatric intensive care units, respiratory support, dopamine infusion; for level 2 facilities with paediatric intensive care units, respiratory support, dopamine infusion; for level 2 facilities with paediatric intensive care units, respiratory support, dopamine infusion; for level 2 facilities with paediatric intensive care units, respiratory support, dopamine infusion; for level 2 facilities with paediatric intensive care units, respiratory support, dopamine infusion; and for level 3 facilities with paediatric intensive care units, respiratory support, dopamine infusion. Discussion. The need for respiratory support and administration of catecholamines are indicators of the severity of the patient’s condition. Patients in low-acuity healthcare organizations require an increased level of care, regardless of the birth weight and gestational age of the newborn. Conclusion. Logistic regression analysis revealed factors associated with the need for therapy correction in patients in the initial medical organizations depending on their level. The following factors played a statistically significant role: respiratory support, sedation, intravenous infusion of catecholamines, patient weight.

Pressure-adjusted venting eliminates start-up delays and compensates for vertical position of syringe infusion pumps used for microinfusion.

Microinfusions are commonly used for the administration of catecholamines, but start-up delays pose a problem for reliable and timely drug delivery. Recent findings show that venting of the syringe infusion pump with draining of fluid to ambient pressure before directing the flow towards the central venous catheter does not counteract start-up delays. With the aim to reduce start-up delays, this study compared fluid delivery during start-up of syringe infusion pumps without venting, with ambient pressure venting, and with central venous pressure (CVP)-adjusted venting. Start-up fluid delivery from syringe pumps using a microinfusion of 1mL/h was assessed by means of liquid flow measurement at 10, 60, 180 and 360s after opening the stopcock and starting the pump. Assessments were performed using no venting, ambient pressure venting or CVP-adjusted venting, with the pump placed either at zero, -43cm or + 43cm level and exposed to a simulated CVP of 10mmHg. Measured fluid delivery was closest to the calculated fluid delivery for CVP-adjusted venting (87% to 100% at the different timepoints). The largest deviations were found for ambient pressure venting (-1151% to + 82%). At 360s after start-up 72% to 92% of expected fluid volumes were delivered without venting, 46% to 82% with ambient pressure venting and 96% to 99% with CVP-adjusted venting. CVP-adjusted venting demonstrated consistent results across vertical pump placements (p = 0.485), whereas the other methods had significant variances (p < 0.001 for both). In conclusion, CVP-adjusted venting effectively eliminates imprecise drug delivery and start-up delays when using microinfusions.

Combined use of VA-ECMO and Impella (ECPELLA) improves short- and long-term mortality in patients with cardiogenic shock who received VA-ECMO

Abstract Introduction Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is beneficial for patients with refractory cardiac arrest and cardiogenic shock. Despite its benefits, VA-ECMO increases left ventricular (LV) afterload and causes pulmonary edema and LV distension. Recently, a transcatheter left ventricular assist device, Impella has been introduced and potential benefits of the concomitant use of VA-ECMO and Impella (ECPELLA) are expected. However, with the concomitant increase in complications, the utility of ECPELLA remains controversial and unsettled. Objective This single-site cohort study aimed to assess the impact of ECPELLA compared to VA-ECMO with or without intra-aortic balloon pump (IABP) in patients with refractory cardiogenic shock, including cardiac arrest, who received VA-ECMO treatment. Methods We retrospectively reviewed 245 consecutive patients, who underwent VA-ECMO treatment between January 2012 and December 2021 at our institute. Seventeen patients for difficult weaning from cardiopulmonary bypass (n = 15) and as a backup during high-risk transcatheter aortic valve implantation (n = 2) were excluded. The patients were divided into two groups, ECEPLLA (n = 64) and VA-ECMO with or without IABP (n = 164). We performed propensity score analysis with 1:1 score matching using dependent variables of age, the rate of male gender, acute coronary syndrome, out-of-hospital and in-hospital cardiac arrest, and extracorporeal cardiopulmonary resuscitation. We evaluated hemodynamic data, safety profiles, and mortality. Results Following matching, 58 ECPELLA and 58 VA-ECMO patients were included for analysis. No significant differences in the adjusted factors and comorbidities were found between the two groups, except for a significantly higher prevalence of chronic kidney disease in the VA-ECMO group compared to the ECPELLA group. Seventy-one percent of patients received concomitant use of IABP in the VA-ECMO group. During the first 72 hours following the initiation of VA-ECMO, the ECPELLA group received a significantly higher total mechanical circulatory support flow and correspondingly less administration of catecholamines compared with the VA-ECMO group. There were no statistical differences in safety profiles, except for hemolysis and embolic cerebral infarction, between the treatment groups. Kaplan-Meier analysis demonstrated that the 30-day and 1-year survival rates were significantly higher in the ECPELLA group than in the VA-ECMO group. Multivariate cox proportional hazard analysis revealed that age (hazard ratio [HR], 1.36 [10 years increase]; 95% confidence interval [CI], 1.15–1.62, p &amp;lt; 0.001), lactate level at ER (HR 1.07; 95% CI 1.03–1.12, p = 0.001), and ECPELLA (HR, 0.47, 95% CI, 0.30–0.73, p = 0.008) were significantly associated with the 1-year mortality. Conclusion ECPELLA was associated with improvement of short- and long-term mortality in patients with refractory cardiogenic shock who received VA-ECMO.Total MCS flow index and VISKaplan-Meier for 1-year mortality

Bilateral multiple stroke, left upper extremity ischemia, and transient complete atrioventricular block in transcatheter aortic valve implantation: a case report

BackgroundTranscatheter aortic valve implantation (TAVI) is a minimally invasive surgery. However, there is a risk of surgical manipulation causing detachment of a lesion of the aortic valve, which can result in various embolisms.Case presentationAn 87-year-old woman with symptomatic severe aortic valve stenosis was scheduled for transfemoral TAVI under monitored anesthesia. Preoperative examination revealed severe calcification of the aortic valve, but there was no calcification in the ascending aorta. After a delivery catheter system passed the aortic valve, left radial arterial pressure dropped significantly, and complete atrioventricular block (CAVB) occurred. Catecholamine administration and ventricular pacing improved hemodynamics, and a self-expandable valve was implanted. CAVB resolved after surgery, but her state of consciousness was poor, and her left hand became ischemic. Imaging studies revealed multiple embolic infarcts in her bilateral cerebrum and cerebellum.ConclusionsIt should be noted that there is a risk of detachment of a calcified lesion of the aortic valve during TAVI, which can cause embolisms not only in the brain but also in the extremities and coronary arteries.

Distributive shock

In shock there is asignificant mismatch between oxygen supply and consumption. In recent years the classification of forms of shock has been established based on pathophysiological and clinical aspects. The term distributive shock includes septic, anaphylactic and neurogenic shock. All these forms share adistinct vasoplegia with a relative volume deficiency. The adequate treatment of patients with distributive shock includes a rapid diagnosis and a consistent emergency treatment consisting of volume and catecholamine administration as well as additional specific emergency procedures when necessary.

Takotsubo cardiomyopathy following envenomation: An updated review.

Takotsubo cardiomyopathy (TTC) can be diagnosed in patients presenting with clinical features of acute coronary syndrome (ACS) by using Mayo clinic criteria. Multiple precipitators have been attributed to causing TTC. Rarely it has been reported to occur following an acute envenomation. This review describes the various patterns, mechanisms, and outcomes of envenomation induced TTC. In this review, we included all studies on "TTC" and "envenomation "published in the various databases before June 2022. To be included in the review articles had to have a distinct diagnosis of TTC and an envenomation. A total of 20 patients with envenomation induced TTC were identified. Most episodes of envenomation induced TTC were reported following a bee sting, scorpion sting, and snake envenomation. Fear and anxiety related to the sting, direct catecholamine toxicity and administration of exogenous beta-adrenergic agents have been commonly postulated to precipitate TTC in these patients. 95% of these patients presented with a clinical picture of ACS. Most of these patients also fulfill at least 3 out of 4 criteria of Mayo clinic criteria for TTC. Echocardiographic evidence of Apical TTC was noted in 72% of patients. 94% of these patients had clinical improvement following optimal management and 35% of these patients were treated with guideline directed medications for heart failure. Envenomation following multiple insect stings and reptile bites can precipitate TTC. Most reported envenomation related TTC has been due to bee stings and scorpion bites. Common mechanisms causing TTC were fear, anxiety, and stress of envenomation. Most of these patients present with clinical presentation of ACS, ST elevation, and elevated troponin. The most common type of TTC in these patients is Apical, which improved following medical management.

The impact of nitroglycerine and volume on gastric tube microperfusion assessed by indocyanine green fluorescence imaging

The influence of hypervolemia and intraoperative administration of nitroglycerine on gastric tube microperfusion remains unclear The present study aimed to investigate the impact of different hemodynamic settings on gastric tube microperfusion quantified by fluorescence imaging with Indocyanine green (ICG-FI) as a promising tool for perfusion evaluation. Three groups with seven pigs each were formed using noradrenaline, nitroglycerin, and hypervolemia for hemodynamic management, respectively. ICG-FI, hemodynamic parameters, and transit-time flow measurement (TTFM) in the right gastroepiploic artery were continuously assessed. Fluorescent microspheres (FM) were administered, and the partial pressure of tissue oxygen was quantified. The administration of nitroglycerine and hypervolemia were both associated with significantly impaired microperfusion compared to the noradrenaline group quantified by ICG-FI. Even the most minor differences in microperfusion could be sufficiently predicted which, however, could not be represented by the mean arterial pressure measurement. Histopathological findings supported these results with a higher degree of epithelial damage in areas with impaired perfusion. The values measured by ICG-FI significantly correlated with the FM measurement. Using tissue oxygenation and TTFM for perfusion measurement, changes in microperfusion could not be comprehended. Our results support current clinical practice with restrictive volume and catecholamine administration in major surgery. Hypervolemia and continuous administration of nitroglycerine should be avoided.

Optimized definition of right ventricular dysfunction on computed tomography for risk stratification of pulmonary embolism

ObjectivesThere is an ongoing discussion on the optimal right to left (RV/LV) diameter ratio threshold and the best definition of RV dysfunction on computed tomography pulmonary angiography (CTPA) for risk assessment of pulmonary embolism (PE). MethodsOn routine diagnostic CTPA, volumetric and diameter measurements (axial and reconstructed views) of the ventricles and reflux of contrast medium into the inferior vena cava (IVC) and hepatic veins were assessed in consecutive PE patients enrolled in a prospective single-center registry. In-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration. ResultsOf 609 patients (median age, 69 [IQR, 56–77] years; 47 % male) included in the analysis, 68 patients (11.2 %) had an adverse outcome and 35 (5.7 %) died. While neither a RV/LV volume ratio ≥1.0 nor RV/LV diameter ratios ≥1.0 were able to predict an adverse outcome, higher thresholds increased specificity. Further, neither volumetric measurements nor reconstruction of images provided superior prognostic information compared to RV/LV ratios measured in axial planes. The combination of an axial RV/LV diameter ratio ≥1.5 with substantial reflux of contrast medium was present in 134 patients (22 %) and associated with the best prognostic performance to predict an adverse outcome in unselected (OR 3.7 [95 % CI, 2.0–6.6]) and normotensive (OR 2.8 [95 % CI, 1.1–6.7]) patients. ConclusionA new definition of RV dysfunction (axial RV/LV diameter ratio ≥1.5 and substantial reflux of contrast medium to the IVC and hepatic veins) allows an optimized CTPA-based prediction of PE-related adverse outcome.

Use of remimazolam in living donor liver transplantation: a case report

BackgroundRemimazolam is an intravenous ultra-short-acting benzodiazepine with the benefit of hemodynamic stability, including blood pressure and pulse rate. We report a case in which remimazolam was used in living donor liver transplantation with stable hemodynamics.Case presentationA 19-year-old woman underwent living donor liver transplantation due to end-stage liver disease, which is associated with a hyperdynamic state and hemodynamic instability. The patient’s sister had a history of malignant hyperthermia, so we chose total intravenous anesthesia with remimazolam. Intraoperative bleeding of seven liters occurred, but she had mild intraoperative blood pressure changes, and continuous catecholamine administration was not necessary. The patient had no memories or discomfort during the surgery.ConclusionsWe maintained stable hemodynamics using remimazolam for anesthetic management of a patient undergoing a liver transplantation, which is characterized by a hyperdynamic state and circulatory instability.

Impaired myocellular Ca2+ cycling in protein phosphatase PP2A-B56α KO mice is normalized by β-adrenergic stimulation

The activity of protein phosphatase 2A (PP2A) is determined by the expression and localization of the regulatory B-subunits. PP2A-B56α is the dominant isoform of the B′-family in the heart. Its role in regulating the cardiac response to β-adrenergic stimulation is not yet fully understood. We therefore generated mice deficient in B56α to test the functional cardiac effects in response to catecholamine administration versus corresponding WT mice. We found the decrease in basal PP2A activity in hearts of KO mice was accompanied by a counter-regulatory increase in the expression of B′ subunits (β and γ) and higher phosphorylation of sarcoplasmic reticulum Ca2+ regulatory and myofilament proteins. The higher phosphorylation levels were associated with enhanced intraventricular pressure and relaxation in catheterized KO mice. In contrast, at the cellular level, we detected depressed Ca2+ transient and sarcomere shortening parameters in KO mice at basal conditions. Consistently, the peak amplitude of the L-type Ca2+ current was reduced and the inactivation kinetics of ICaL were prolonged in KO cardiomyocytes. However, we show β-adrenergic stimulation resulted in a comparable peak amplitude of Ca2+ transients and myocellular contraction between KO and WT cardiomyocytes. Therefore, we propose higher isoprenaline-induced Ca2+ spark frequencies might facilitate the normalized Ca2+ signaling in KO cardiomyocytes. In addition, the application of isoprenaline was associated with unchanged L-type Ca2+ current parameters between both groups. Our data suggest an important influence of PP2A-B56α on the regulation of Ca2+ signaling and contractility in response to β-adrenergic stimulation in the myocardium.