Hemodynamic Status Research Articles

Circulating Angiopoietin-2 (Angpt2) levels predict diagnosis of Chronic Thromboembolic Pulmonary Hypertension (CTEPH)

Abstract Background Vascular remodeling following incomplete thrombus resolution is considered to be a key factor in the progression to chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). Recent data demonstrated that Angpt2, which controls signaling via the Tie2 receptor, could interfere with the normal process of thrombus resolution. Our prior findings have shown that patients presenting with acute PE and having plasma levels of Angt-2 ≥5.5 ng/ml at admission are at a significantly increased risk (93 times higher) of being diagnosed with CTEPH in subsequent assessments. Purpose To externally validate the prognostic performance of Angpt2 for the development of CTEPH. Methods In a prospective cohort study of unselected consecutive all-comers with PE, survivors of the index acute event underwent 3-, 12- and 24-month follow-up with venous blood sampling for subsequent biomarker measurements. Angpt2 was measured on admission using specific enzyme linked immunosorbent assays (ELISA) detecting both the endogenous and the recombinant protein, according to the manufacturer (R&D Systems). Results Overall, 319 patients with acute PE (median age: 62 [IQR, 50-73]; females: 55.2%) were included in the analysis with a median Angpt2 plasma level of 2.6 ng/ml (IQR, 1.8-3.7) (Figure 1). Patients with PE and Angpt-2 plasma levels above the median had more often comorbidities, such as chronic heart failure (24.2% and 11.0.%; p=0.045), chronic kidney disease (33.3% vs 14.0%; p=0.010), or diabetes (27.3% vs. 12.9%; p=0.032). Angpt2 plasma levels correlated with haemodynamic status and parameters indicating severe PE (right ventricle dysfunction, r=0.129 [p=0.021) and troponin, r=0.246 [p<0.001]). In total, post-PE impairment (PPEI) was diagnosed in 33 (10.3%) and CTEPH in four (1.3%) patients during follow-up. Angpt2 plasma levels were higher on admission in patients developing PPEI or CTEPH during follow-up compared to patients without PPEI or CTEPH (PPEI vs non-PPEI: median, 3.2 [2.3-4.1] ng/ml vs. 2.5 [1-3.4] ng/ml, p=0.035; CTEPH vs. non-CTEPH: median, 5.1 [2.9-10.5] ng/ml vs. 2.5 [1.7-3.6] ng/ml, p=0.055). Regarding the diagnosis of CTEPH during follow-up, ROC analysis illustrated an AUC for Angpt2 (0.779 [95% CI 0.56–0.99]; p=0.055]) (Figure 2). By using univariate logistic regression analysis, the calculated predefined Angpt2 cut-off value of ≥5.5 ng/ml was associated with a 9.2-fold increased risk (1.3–67.4, p=0.030) for a diagnosis of CTEPH during follow-up. Conclusion We were able to validate in a different patient cohort the usefulness of Angpt2 as a novel biomarker to identify patients at risk for CTEPH.

Effect of Propofol and Isoflurane on Hemodynamic changes during Spinal Surgery Under General Anesthesia

Background: Hemodynamic stability are vital requirements of up-to-date anesthesia. Both propofol and isoflurane meet these criteria though the clinical effects like postoperative nausea vomiting after administering propofol and isoflurane have been studied in various surgeries but have not been much evaluated or studied in patients undergoing major surgical procedures like spine surgeries, There’ is definite advantage of one technique over the other. Isoflurane has a low blood gas partition coefficient, which contributes to rapid induction and emergence from anaesthesia than with other volatile anesthetics in current clinical use. Propofol has been established as the intravenous agent that provides faster and smoother recovery & peri operative hemodynamic stability. Objective: To compare the effects of isoflurane and propofol regarding hemodynamic status in spinal surgery under general anaesthesia. Methods: After getting ethical approval, a randomized controlled trial study design was performed where patients were selected in the pre-anesthetic checkup room based on inclusion and exclusion criteria for those who were scheduled for spine surgeries under general anesthesia is admitted in the Department of Neurosurgery in East West Medical College from January 2023 – December 2024. A total number of 40 patients were selected. 20 patients were enrolled each in group A and group B by lottery method in a sealed envelope. They were divided into two groups by randomization; Group A and Group B. A written informed consent was taken from all selected patients. Patients were advised to fast for at least 8 hours before intervention. In Group A, anesthesia is maintained with propofol infusion, nitrous oxide (66%), and oxygen (33%) while in Group B, anesthesia is maintained with Isoflurane, nitrous oxide (66%), and oxygen (33%). All patients were given N2O in oxygen and 1.25% inspired concentration of Isoflurane (MAC -1.15). In Group A propofol infusion at rate of 80 μg/kg/min (fixed from the beginning). All data was collected at –Just after starting, 15 minutes, 30-minute, 1 hour, and >1 hour interval per operatively. Data was compiled, edited and plotted in tabular and figure form. P value was determined as significant when it was <0.05. Results: 40 patients yielded the following results. The mean age of Group A and B were 32.56±12.55 years and 34.6±12.5 years. Mean difference of heart rate was lower in Group A than that of Group B. Other parameters in both groups were confined to good and acceptable categories. But interestingly, there was a statistically significant difference found between Group A and Group B in Systolic Blood Pressure (SBP) & Diastolic Blood Pressure (DBP). The scoring was far better in Group A than Group B. Mean SBP was higher in Group B than Group A (p= >0.05). Similarly, mean DBP was also higher in Group B than Group A (p = >0.05). Conclusion: Propofol is better for maintaining hemodynamic status than Isoflurane for Spine surgery under General anaesthesia. EWMCJ Vol. 12, No. 1&2, January-July 2024: 21-26

Comparison of direct and indirect admission to a cardiac arrest centre for intubated out-of-hospital cardiac arrest patients in the Northwest England: an audit

Abstract Background Despite concerted global efforts to enhance cardio-pulmonary resuscitation (CPR) and post-resuscitation care, out-of-hospital cardiac arrest (OHCA) remains a significant cause of mortality. Current guidelines promote the concept of Cardiac Arrest Center (CAC), offering advanced post-resuscitation management with the aim of improving survival rates. However, it remains uncertain whether directly transporting OHCA patients from the scene to these centers would enhance their prognosis. Purpose This study aimed to assess whether direct transport of intubated OHCA patients to a higher-level cardiac arrest center in the Northwest of England yielded better outcomes compared to initial resuscitation in smaller local emergency departments followed by transfer. Methods Conducted as a retrospective analysis, the audit examined OHCA patients presenting at a single cardiac arrest center between October 2018 and April 2022. Only intubated patients were included. The study compared two groups based on the route of admission: direct admission to the cardiac arrest center from the field by emergency medical service providers versus indirect admission via inter-hospital transfer to the center. The primary outcomes assessed were inpatient survival and 30-day survival. Statistical analysis employed Student's T-test and Chi-square test for clinical significance. Results The audit included 214 patients, with 112 (52.34%) in the direct group and 102 (47.66%) in the indirect group. Baseline characteristics between the groups were similar, including age, gender, downtime, bystander CPR, haemodynamic status, initial presenting rhythm (VT/VF), post-arrest ECG (STEMI), comorbidities, and procedural outcomes (Table 1). However, the direct group exhibited significantly shorter average arrival times at the cardiac arrest center (72 minutes vs. 190 minutes, p=0.017), along with improved in-hospital survival (52.68% vs. 41.18%, p=0.009) and 30-day survival rates (52.68% vs. 37.25%, p=0.002). Conclusion The direct admission of intubated OHCA patients to a cardiac arrest center, as observed in this audit, was associated with improved outcomes attributed to expedited admission times. The study’s design limitations, including its non-randomized nature and single-center approach, underscore the need for further research.

Hemodynamic effects of intra-aortic balloon pump in patients with advanced heart failure and cardiogenic shock waiting heart transplant

Abstract Background The use of intra-aortic ballon pump (IABP) as a bridge therapy in patients with advanced heart failure (HF) and cardiogenic shock (CS) waiting heart transplant (HTx) remains under debate. IABP can be an available device to improve hemodynamic conditions of these patients until HTx. Purpose Evaluate the hemodynamic effects of IABP and its efficacy in patients with advanced HF and CS waiting HTx. Methods We retrospectively analyzed from a single center intensive care unit, between 2009 and 2020, patients with advanced HF with optimized intravenous drugs that required IABP placement before HTx. Changes in oxygen central venous saturation (ScvO2), arterial lactate, renal function, and use of vasoactive drugs before and 96 hours after IABP insertion were evaluated. Patients with acute myocardial infarction and implant of ventricular assist device before HTx were excluded. Results A total of 199 patients (mean age 46,5 ± 12 years) were included. Median time of IABP onset to HTx was 20 days. Mean left ventricle ejection fraction was 23,5 ± 5,9%, 53,7% of patients had moderate to severe right ventricular dysfunction and the most frequent etiology was Chagas disease (47,2%, n=94). Before the IABP placement, 97,47% of patients were using dobutamine, 19,29% milrinone, 58,08% nitroprusside and 17,7% norepinephrine. Clinical and laboratory data were compared before and 96 hours after IABP therapy. ScvO2 increased from 49,9% to 66,85% (p<0,001), lactate decreased from 21,91 mg/dl to 12,6 mg/dl (p<0,001), creatinine decreased from 2,04 mg/dL to 1,72 mg/dL (p=0,301) and urine output increased from 1690,12 mL/24h to 2193,12 mL/24h (p<0,001). These differences were maintained until the day before HTx. Use of nitroprusside increased from 58,08 to 63,59% (p=0,154), and the use of norepinephrine decreased from 17,7% to 6,63% (p<0,001). Conclusion IABP improves tissue perfusion, renal function, and hemodynamic status in patients with advanced HF and CS and can be an effective method of circulatory support as a bridge therapy to HTx.Laboratory data pre and post-IABPVasoactive Drugs pre and post-IABP

SUCCESSFUL MANAGEMENT OF SHARP ABDOMINAL TRAUMA WITH DIAGNOSTIC LAPAROSCOPY AT DR. ZAINOEL ABIDIN ACEH HOSPITAL

Abdominal trauma is injury that occurs to organs in the abdomen, such as the stomach, intestines, liver, spleen, pancreas, bile and kidneys, damage to the structures located between the diaphragm and pelvis. Abdominal trauma is divided into two types, namely blunt abdominal trauma and stab abdominal trauma. Injuries to the intestines and liver are the most common in penetrating trauma to the abdomen. Case report: a 35 year-old man came to the Emergency Room at the Dr. Zainoel Abidin Regional General Hospital in Banda Aceh with the main complaint of a wooden stab wound (foreign body) on the right side of the abdomen which had penetrated to the back. The patient underwent diagnostic laparoscopy, it was found that a piece of wood (foreign body) was stuck in the liver segment V-VI which had penetrated to the right flank and a hematoma was found around the body and about 100 cc of hemorrhagic fluid originating from the liver due to contact with wood friction but the bleeding was not active. Based on the primary and secondary survey evaluations, the hemodynamic condition was stable. In the evaluation, there were no intra-abdominal organ injury. Extraction of the foreign body wood could be performed well after identification of being free from intra-abdominal organ injury. Conclusion: Abdominal trauma is an injury that occurs to organs in the stomach, such as the stomach, intestines, liver, spleen, pancreas, gallbladder, and kidneys. In this case, it was a penetrating stab wound with stable hemodynamics and no small intestine and omental protruding from the stomach, so this patient underwent diagnostic laparoscopic surgery. The operation with diagnostic laparoscopic in this case was successful and minimally invasive.

The interplay between coronary microvascular resistance, arterial reservoir function and coronary flow reserve: unravelling the significance of high microvascular resistance

Abstract Background Beyond the observation that patients with low CFR indicating presence of coronary microvascular dysfunction (CMD) have an unfavourable prognosis compared to patients with preserved CFR, recent large multicentre trials [1-2] have shown that increased minimal hyperaemic microvascular resistance (HMR or IMR) ,neither on top of the low CFR nor alone, does not play a role as a prognostic factor for ischemia in nonobstructive coronary artery disease (INOCA) patients. Purpose This study investigates the pathophysiological interactive processes in CMD and no-CMD groups with high and low HMR taking into account potential adaptive mechanisms that alter arterial reservoir function [3] associated with microvascular resistance and systemic vasomotor response in INOCA patients. Methods Analysis was conducted on 312 unique unobstructed vessels (FFR>0.80) from 258 patients (73% male) enrolled in the DEFINE-FLOW [4] study. CFR and HMR were quantified using intracoronary Doppler and pressure measurements. Vessels were categorized into four groups based on high and low CFR and HMR using the best available cut-off values (2.5 for both). Arterial reservoir capacity (ARC) and related parameters [3] were quantified using reservoir-excess pressure (Preservoir and Pexcess) analysis of averaged aortic and distal coronary pressure waveforms in CMD (CFR<2.5) and no-CMD (CFR≥2.5) subgroups. (Figure 1-2) Results Compared to vessels without CMD, functional and structural CMD have increased Pexcess (p:0.007) and a rapid decline in diastolic pressure (DRCcoronary p<0.001, DRCaortic, p<0.05), indicating the ongoing systemic hemodynamic superfluous state despite locally suppressed resting blood flow in the structural CMD. Higher baseline microvascular resistance (BMR) was associated with increased reservoir pressure (r:0.302, p<0.001). The vessels with preserved CFR despite high HMR are characterised by uniquely increased ARC (p:0.014), effectively diminished Pexcess (p:0.010), which parallels the local (highest BMR p<0.001) and global (lowest DRCaortic, p<0.05) vasomotor response, that normalizes the systemic and local hyperperfusion, and ultimately regains an adequate flow reserve (CFR) (p<0.001). The high HMR in this group was mainly due to increased resting tonus unlike structural CMD, evident by the highest RRR (BMR/HMR).(p<0.001) (Figure 1-2) Conclusion(s) The high HMR despite preserved CFR vessels form a unique-adaptive group, characterised by substantially increased arterial reservoir capacity and effectively diminished Pexcess, by means of an adaptive vasomotor response which manifests locally in the coronary bed as pronouncedly augmented BMR & RRR, and globally as reduced DRC in the aortic pressure waveform. This adaptive myogenic response normalising resting flow and ongoing systemic and local hyperperfusion ultimately regains an adequate flow reserve (CFR).Figure 1.Methods and Main FindingsFigure 2.Visual Abstract

Acute echocardiographic assessment of patients with ST-elevation myocardial infarction in detecting clinically hidden hemodynamic deterioration

Abstract Background Transthoracic echocardiography (TTE) offers an immediate non-invasive assessment of cardiac morphology and function that can be performed bedside. Acute TTE in the catheterization laboratory (cath.lab.) may be helpful to identify markers of subsequent development of cardiogenic shock (CS) in patients with ST-elevation myocardial infarction (STEMI) in addition to the previously validated ORBI risk score. This relationship has not been investigated thoroughly previously. Purpose To investigate the association between acute TTE estimates of left ventricular (LV) function prior to primary percutaneous coronary intervention (pPCI) in STEMI patients and pro-B-type natriuretic peptide (proBNP) as a proxy associated with of CS development. Method From September 2023 all non-CS STEMI patients at one tertiary heart center underwent acute bedside TTE in the cath.lab. and ORBI risk score assessing the risk of CS development aiming for inclusion of 500 patients. The 5 minutes TTE-protocol consisted of LV ejection fraction (EF), LV outflow tract velocity time integral (LVOT VTI), mitral inflow (E and E/A), mitral deceleration time, and mitral annular early diastolic velocity é lateral. The primary endpoint was proBNP measured 24 hours (h) after pPCI (12-36h) stratified in quartiles (Q4 vs. Q1-3). The correlation between proBNP and TTE measurements and proBNP and ORBI risk score was examined using univariate linear regression models. Results Until now 153 STEMI patients (mean age 64 years, 25% female) were studied. Anterior STEMI was present in 36%, and median time from cath. lab. arrival to first wire over the culprit lesion was 28 minutes (IQR 24; 37). Patients with high proBNP level (Q4 vs. Q1-3) had significantly higher heart rate (median 84 bpm vs. 72 bpm) and Killip Class>1 (16% vs. 0%) at admission, but similar lactate levels (1.8mM vs. 1.5mM), systolic blood pressure (130 mmHg vs. 137 mmHg), and out-of-hospital cardiac arrest (11% vs. 12%). Patients with high proBNP levels (Q4 vs. Q1-3) had significantly lower LVEF (35% vs. 50%), higher E/é lateral (median 11.4 vs. 7.9), and higher ORBI risk score (median 8 vs. 4). LVEF, LVOT VTI, E/é lateral, and ORBI risk score were significantly associated with proBNP (Figure 1). Two patients developed CS after the pPCI; one with high proBNP level Q4, and one deceased prior to proBNP measurement. Conclusion Acute TTE is an easy tool for assessment of the acute hemodynamic status in STEMI patients bedside in the cath.lab., and it can be without delaying time to revascularization. LVEF, LVOT VTI, E/é lateral, and ORBI were all parameters associated with increased levels of the hemodynamic biomarker proBNP, and may together with the ORBI risk score improve the assessment and risk stratification of STEMI-patients at risk of CS-development.Figure 1.

Prognostic impact of the tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure ratio in acute pulmonary embolism

Abstract Background Currently available risk stratification models for acute pulmonary embolism (PE) include hemodynamic status, cardiac biomarkers, right ventricle (RV) dysfunction on imaging, and clinical scores. Focusing on length-tension relationship of the ventricle might have a superior predictive capability over RV dysfunction in terms of mortality and classification of patients with acute PE. In this study, our hypothesis suggests that tricuspid annular plane systolic excursion (TAPSE)/systolic pulmonary artery pressure (sPAP) ratio has superior predictive capability for in-hospital mortality in patients with acute PE compared to TAPSE or sPAP as distinct measures. Methods This single-center study comprised retrospectively evaluated 703 patients referred to our tertiary cardiovascular center with acute PE. We divided patients into quartiles by TAPSE/sPAP ratio. Different models were developed to quantify the predictive relationship between in-hospital death and echocardiographic measurements. A base model was created with variables including risk status and RV/LV ratio >1. Then, to evaluate the predictive contribution of each measurement; TAPSE/sPAP, TAPSE, and sPAP were sequentially added to the base model. After that, the performance of each model was evaluated. Results Predictive and discriminative power was the highest in model containing TAPSE/sPAP. There was still a significant inverse association between TAPSE/sPAP and risk of in-hospital death even after adjusting by risk status and RV/LV ratio >1. ROC curve analysis for TAPSE/sPAP revealed the best cut-off value as 0.34. Conclusion The outcomes of our study reveals that the ratio of TAPSE/sPAP serves as a more potent predictor of mortality than either of the two measurements taken separately. The interpretation and utilization of the TAPSE/sPAP cut-off value in acute PE can assist in identifying patients at risk of deterioration and guide the consideration of more intensive treatment options across all risk groups.

A Comparison of Different Doses Efficacy of Isobaric Ropivacaine 0.5% in Spinal Anesthesia in Cesarean Section

Background: Cesarean delivery is a standard surgical procedure in women. Thus, a practical, affordable, and low-risk anesthetic technique is essential for mother and infant safety. Spinal anesthesia is a popular and efficient technique for anesthesia during cesarean delivery. However, other local anesthesia drugs with negligible side effects should be considered. The most selective medication for this purpose is bupivacaine (marcaine), which creates optimal anesthesia at doses of 10 to 12 mg. Objectives: The most available medicine for spinal anesthesia during cesarean delivery is a 0.5% marine solution. However, ropivacaine for spinal anesthesia can occasionally be accessed as a long-acting amide local anesthetic agent used as an alternative to marcaine during the cesarean delivery. The ropivacaine's advantage over marcaine is its less neurotoxicity and cardiotoxicity, as well as the more stable hemodynamical condition of the patients. So far, no proper therapeutic dose of 0.5% isobaric ropivacaine has been proposed to be used during the cesarean delivery. Any increase in the dose may ensure the block performance, but, by contrast, some side effects may arise, including hypotension, bradycardia, vomiting, and nausea. Herewith, the likelihood of maximum block and most minor side effects was attempted to be assessed at the tiniest doses of this anesthetic agent. Methods: This randomized clinical trial was conducted on C-section candidates. Patients were categorized into three groups receiving 22.5, 25, and 20 mg of the 0.5% isobaric ropivacaine solution. Systolic and diastolic blood pressure, heartbeats, the level of sensational and sympathetic nerve block, duration to reach the maximum motor block, the rate of vasopressors and atropine consumption, rate of vomiting and nausea, the rate of using supplementary drugs, block breakdown, and the patient's satisfaction with the anesthesia were measured and recorded. The collected data were analyzed using IBM SPSS Statistics. Results: No significant difference was found between demographic characteristics. Likewise, there was no significant difference in systolic and diastolic blood pressure, heartbeats, the level of sensational and sympathetic nerve block, duration to reach the maximum motor block, the rate of vasopressors and atropine consumption, rate of vomiting and nausea, and the rate of using supplementary drugs between the three groups. The most significant block breakdown and use of supplementary drugs were found in the first group (20 mg), with a significant difference between the three groups. Conclusions: The three doses used did not result in meaningful differences between the three groups. However, the differences were significant for the block breakdown, with the higher block breakdown and supplementary drug use observed when using 20 mg of the 0.5 ropivacaine solution.

Microaxial Flow Pump Hemodynamic and Metabolic Effects in Infarct-Related Cardiogenic Shock: A Substudy of the DanGer Shock Randomized Clinical Trial.

Mechanical circulatory support with a microaxial flow pump (MAFP) has been shown to improve survival in ST-elevation myocardial infarction-induced cardiogenic shock (STEMI-CS). Understanding the impact on hemodynamic stability over time is crucial for optimizing patient treatment. To determine if an MAFP reduces the need for pharmacological circulatory support without compromising hemodynamics compared with standard care in STEMI-CS. This was a substudy of the Danish-German (DanGer) Shock trial, an international, multicenter, open-label randomized clinical trial. Patients from 14 heart centers across Denmark, Germany, and the UK were enrolled. Inclusion criteria for the trial were STEMI and systolic blood pressure less than 100 mm Hg or ongoing vasopressor treatment, left ventricular ejection fraction less than 45%, and arterial lactate level greater than 2.5 mmol/L. Of the enrolled patients, after exclusions from death in the catheterization laboratory or immediately on intensive care unit (ICU) admission, the remaining patients had serial recordings of hemodynamics, arterial lactate, and use of vasoactive drugs. Patients who were in comas after cardiac arrest and patients with mechanical complications or right ventricular failure were excluded. Data were analyzed from May to September 2024. MAFP and standard of care or standard of care alone. Hemodynamic status in terms of heart rate and blood pressure, metabolic status in terms of arterial lactate concentration, and vasoactive-inotropic score (VIS). The clinical events during the first 72 hours were as follows: death from all causes, escalation of mechanical circulatory support, and discharge alive from the ICU. From 355 enrolled patients, 324 (mean [IQR] age, 68 [58-75] years; 259 male [80%]) underwent ICU treatment (169 [52%] in the MAFP group, 155 [48%] in the standard-care group). Baseline characteristics were balanced. There was no difference in heart rate between groups, and mean arterial pressure was above the treatment target of 65 mm Hg in both groups but was achieved with a lower VIS in the MAFP group. No difference in arterial lactate level was found between groups at randomization, but on arrival to the ICU, the MAFP group had significantly lower arterial lactate levels compared with the standard-care group (mean difference, 1.3 mmol/L; 95% CI, 0.7-1.9 mmol/L), a difference that persisted throughout the first 24 hours of observation. The MAFP group achieved lactate normalization (<2 mmol/L) 12 hours (95% CI, 5-18 hours) before the standard-care group. Use of a MAFP reduces the use of vasopressors and inotropic medication while maintaining hemodynamic stability and achieving faster normalization of lactate level in patients with STEMI-CS. ClinicalTrials.gov Identifier: NCT01633502.

Comparative evaluation of analgesic efficacy of buprenorphine transdermal patch and fentanyl transdermal patch in the management of postoperative pain after lower limb surgery

Background: Postoperative pain represents a significant medical issue that needs immediate attention. Despite advancements in pain management, managing postoperative pain remains challenging. Transdermal drug delivery systems (TDDS) offers a straightforward, reliable, non-invasive, and patient-friendly approach for alleviating post-surgical pain. Hence, this study was planned to evaluate the analgesic efficacy of buprenorphine and fentanyl transdermal patch in the management of post-operative pain after lower limb surgery. Methods: In this prospective, randomised study, 82 adult patients of either sex undergoing elective lower limb surgery were randomly allocated into two groups- Group A (Transdermal Buprenorphine 20 mg patch) and Group B (Transdermal Fentanyl 50 mcg patch). Postoperative pain was assessed by 10-point Visual Analogue Scale (VAS) every 6 hours following surgery on the first day and then daily for next 4 days. All patients were also monitored for total rescue analgesic requirement, drug-related adverse effect and haemodynamic status. Statistical analysis was carried out using student t-test and Chi-square test. A p-value &lt;0.05 was considered significant. Results: The mean pain intensity scores were found to be significantly different (p&lt;0.0001) between the two groups, with VAS scores consistently lower in Buprenorphine group as compared to Fentanyl group. Also, Buprenorphine group had the lowest demand for rescue analgesic, with 58.5% of patients requiring two administrations and 36.6% needing only one. Patients belonging to Fentanyl group exhibited higher occurrence of nausea (46.3%), vomiting (46.3%) and pruritus (31.7%). Conclusions: Our study concludes that transdermal patch of buprenorphine demonstrates superior efficacy and safety profile as compared to fentanyl patch for post-operative pain management in lower limb surgeries.

Posterior short ciliary arteries ischemia following embolization of anterior ethmoid artery to treat dural arteriovenous fistulas: a case report

BackgroundThe Onyx™ Liquid Embolic System is a non-adhesive liquid embolic agent, which has been proved by the US FDA for embolization of lesions in the peripheral and neurovasculature since 2005. We reported a case of ischemic optic neuropathy after using Onyx-18 to embolize the anterior ethmoid arteries that feeding dural arteriovenous fistulas (DAVF).Case presentationA 57-year-old Asian male presented with anterior cranial fossa DAVF underwent embolotherapy by delivering Onyx-18 through a microcatheter into the anterior ethmoid arteries under angiography guidance. The interventional procedure was successful and no clear evidence was found pointing to untargeted occlusive embolus. But after the surgery the patient experienced delayed painless vision loss in the right eye (RE). The fundoscopy showed unilateral papilledema with pale optic disc in RE, accompanied by significant edema and thickening in the retinal nerve fiber layer (RNFL) of macula. The fundus fluorescence angiography showed that most of the optic disc in RE had postponed or absent fluorescence filling. Visual evoked potential (VEP) confirmed that the amplitude of the P100 component was decreased in RE without significant prolongation of the latency. The patient was diagnosed with anterior ischemic optic neuropathy, but immediate pulse steroid therapy failed to rescue his vision.ConclusionPreoperative evaluation of the patient’s hemodynamic status and fundus examination are essential for assessing the risk of ischemic ocular complications, and the non-adhesive liquid embolic agent Onyx-18 should be used cautiously during endovascular embolization of intracranial artery.

The sevoflurane concentration for light sedation in critically ill patients: A protocol for experimental study

Background: Deep-inhaled sedation is increasingly used in Thai ICUs. However, there is a lack of information regarding the level of end-tidal sevoflurane concentration during light sedation. Objectives: The study aims to determine the effective dose (ED50 and ED95) of sevoflurane concentration for light sedation (RASS score -1 to 0) in mechanically ventilated critically ill patients. Methods: This is a prospective experimental single-center study. Mechanically ventilated patients with RASS ≥ 1 who required sedation in the medical and surgical intensive care unit were enrolled. Using an up-and-down sequential allocation technique, the inhaled sevoflurane level of each patient was allocated based on the previous patient’s response. RASS score and hemodynamic parameters were monitored. The primary outcome was the ED50 and ED 95 of end-tidal sevoflurane concentration. The secondary outcomes included the length of intensive care unit stay, duration of ventilator day, the incidence of delirium, hemodynamic status, and respiratory variables changed during the study period. Hypothesis: There exist specific end-tidal sevoflurane concentrations (ED50 and ED95) that will reliably induce a target RASS score of -1 to 0 in critically ill patients who are mechanically ventilated. Conclusion: This study will provide an effective dose of inhaled sevoflurane sedation for achieving targeted light sedation levels in critically ill patients, which may have minimal effects on hemodynamics. Ethics and dissemination: This study has been approved by the Office of Human Research Ethics Committee, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand, on 22nd May 2023 (COA.MURA2023/390). Trial registration: TCTR20230825001

The Role of International Normalized Ratio (INR) in Heart Failure Patient With Sepsis: Hidden in Plain Sight

Heart failure is a clinical syndrome characterized by symptoms and signs caused by a structural and/or functional impairment of the heart. Sepsis in heart failure may cause significant mortality and morbidity rates. Clinically, the presence of heart dysfunction in heart failure worsens outcomes in unstable hemodynamic conditions, for instance, in cases of sepsis, particularly in patients with HFrEF. This research aims to survey the blend of heart failure and sepsis and current updates regarding using the International Normalized Ratio (INR) to detect sepsis. Information was collected from various sources, and updated literature was compiled into a review article. The presence of heart failure with sepsis is associated with horrible clinical results. If fluid alone is insufficient to restore perfusion, the fundamental structure of sepsis includes strong fluid recovery followed by vasopressor association (and possibly inotropic support). In any case, in patients with heart failure, high-portion fluid boluses and vasoactive experts might deteriorate the condition. Heart failure and sepsis can overlap and lead to hemodynamic disturbances and challenging treatment. Meanwhile, aggressive fluid resuscitation is necessary for sepsis; conventional heart failure management requires reducing fluid intake. The International Normalized Ratio (INR) is one of the coagulation parameters that may help determine sepsis in patients with heart failure, thus improving appropriate diagnosis and treatment.

Target neonatal echocardiography as efficiency assessment method of shock therapy in newborns (a series of clinical observations)

The objective was to demonstrate clinical cases of shock therapy in newborns under the control of target neonatal echocardiography. This method of hemodynamic monitoring is performed at the bedside by intensive care physicians and is available around the clock.Materials and methods. The article describes three clinical cases of shock in newborns whose hemodynamic status was assessed by target neonatal echocardiography.Results. The use of target neonatal echocardiography made it possible to identify a disturbed component of hemodynamics (preload, contractility, postload). In some cases, the actual hemodynamic status differs from the hypothetical one. This made it possible to carry out targeted hemodynamic management and prevent pathogenetically unjustified therapy with potential iatrogenic complications.Conclusion. Target neonatal echocardiography has demonstrated its clinical effectiveness in bedside assessment of hemodynamics in critically ill newborns.

STATE OF HAEMODYNAMICS AND OXYGEN BUDGET IN THE PERIOPERATIVE PERIOD IN PATIENTS WITH OSTEOARTHRITIS AND CONCOMITANT CARDIAC PATHOLOGY DURING TOTAL HIP ARTHROPLASTY SURGERY DEPENDING ON THE TYPE OF SURGICAL ACCESS

Summary. Aim. To compare the hemodynamic status and oxygen budget in patients with osteoarthritis and comorbid cardiac pathology during total hip arthroplasty, based on the type of surgical approach used. Materials and Methods. The study analyzed the treatment outcomes of 90 patients with stage 3-4 osteoarthritis of the hip who underwent total cemented hip arthroplasty. All patients were divided into two groups according to the surgical approach (traditional posterior or modified posterior). The study was conducted at the following stages: before surgery, immediately after surgery, 24 hours post-surgery, and one week after surgery. The following parameters were recorded: hemodynamic parameters (heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and central venous pressure) and oxygen budget parameters (hemoglobin (Hb), lactate, hematocrit (Ht), oxygen saturation of hemoglobin in arterial and venous blood (SaO2 and SvO2), partial pressure of oxygen in arterial and venous blood (paO2 and pvO2)). Based on these data, the following indices were calculated: left ventricular ejection fraction (LVEF), cardiac index (CI); oxygen content in arterial and venous blood (CaO2 and CvO2), arteriovenous oxygen content difference (C(a-v)O2), oxygen transport (TO2), oxygen consumption (VO2); systemic perfusion pressure (SPP), blood flow power (BFP), oxygen reserve (OR), and circulatory reserve (CR). Results. The use of the modified posterior approach positively influenced hemodynamic parameters. After the surgery and on the 7th day post-surgery, SPP was significantly lower with the modified posterior approach. The CI was also significantly affected by the modified posterior approach. Throughout the study, except for the first stage, CI was significantly higher when using the modified posterior approach. LVEF increased significantly with both approaches, but on the 7th day post-surgery, it was significantly higher in the second group. BFP did not statistically differ between the two groups throughout the study, but its energy efficiency was lower, primarily due to the arteriovenous oxygen content difference (C(a-v)O2). C(a-v)O2 was the same before surgery for both approaches. At subsequent stages of the study, the differences between the groups increased, and on the 7th day, they were the most significant, with C(a-v)O2 being lower after using the modified posterior approach. The energy efficiency of blood flow was assessed by calculating OR and CR. Both indicators were significantly higher during the study, except at the preoperative stage, when using the modified posterior approach. Conclusions. Our study clearly demonstrates the benefits of implementing the modified posterior approach in total hip arthroplasty for patients with osteoarthritis and comorbid cardiac pathology. This approach improves hemodynamic and oxygen budget parameters compared to the traditional approach, which can significantly impact treatment outcomes for patients with cardiac comorbidity and reduce the number of postoperative complications.

Ultra-Low-Field Portable MRI and Extracorporeal Membrane Oxygenation: Preclinical Safety Testing.

Conventional MRI is incompatible with extracorporeal membrane oxygenation (ECMO) cannulas and pumps. Ultra-low-field portable MRI (ULF-pMRI) with 0.064 Tesla may provide a solution, but its safety and compatibility is unknown. ULF-pMRI does not cause significant displacement and heating of ECMO cannulas and does not affect ECMO pump function. ECMO cannulas in various sizes were tested ex vivo using phantom models to assess displacement force and heating according to the American Society for Testing and Materials criteria. ECMO pump function was assessed by pump flow and power consumption. In vivo studies involved five female domestic pigs (20-42 kg) undergoing different ECMO configurations (peripheral and central cannulation) and types of cannulas with an imaging protocol consisting of T2-weighted, T1-weighted, FLuid-Attenuated Inversion Recovery, and diffusion-weighted imaging sequences. Phantom models demonstrated that ECMO cannulas, both single lumen with various sizes (15-24-Fr) and double lumen cannula, had average displacement force less than gravitational force within 5 gauss safety line of ULF-pMRI and temperature changes less than 1°C over 15 minutes of scanning and ECMO pump maintained stable flow and power consumption immediately outside of the 5 gauss line. All pig models showed no visible motion due to displacement force or heating of the cannulas. ECMO flow and the animals' hemodynamic status maintained stability, with no changes greater than 10%, respectively. ULF-pMRI is safe and feasible for use with standard ECMO configurations, supporting its clinical application as a neuroimaging modality in ECMO patients.

Quantitative Comparison of Color-Coded Parametric Imaging Technologies Based on Digital Subtraction and Digital Variance Angiography: A Retrospective Observational Study.

The evaluation of hemodynamic conditions in critical limb-threatening ischemia (CLTI) patients is inevitable in endovascular interventions. In this study, the performance of color-coded digital subtraction angiography (ccDSA) and the recently developed color-coded digital variance angiography (ccDVA) was compared in the assessment of key time parameters in lower extremity interventions. The observational study included 19 CLTI patients who underwent peripheral vascular intervention at our institution in 2020. Pre- and post-dilatational images were retrospectively processed and analyzed by a commercially available ccDSA software (Kinepict Medical Imaging Tool 6.0.3; Kinepict Health Ltd., Budapest, Hungary) and by the recently developed ccDVA technology. Two protocols were applied using both a 4 and 7.5 frames per second acquisition rate. Time-to-peak (TTP) parameters were determined in four pre- and poststenotic regions of interest (ROI), and ccDVA values were compared to ccDSA read-outs. The ccDVA technology provided practically the same TTP values as ccDSA (r = 0.99, R2 = 0.98, p < 0.0001). The correlation was extremely high independently of the applied protocol or the position of ROI; the r value was 0.99 (R2 = 0.98, p < 0.0001) in all groups. A similar correlation was observed in the change in passage time (r = 0.98, R2 = 0.96, p < 0.0001). The color-coded DVA technology can reproduce the same hemodynamic data as a commercially available DSA-based software; therefore, it has the potential to be an alternative decision-supporting tool in catheter labs.

Transcranial doppler (TCD) in predicting outcomes following successful mechanical thrombectomy of large vessel occlusions in anterior circulation: a systematic review and meta-analysis

BackgroundTranscranial Doppler (TCD) is a non-invasive, bedside tool that allows for real-time monitoring of the patient’s hemodynamic status following mechanical thrombectomy (MT). This systematic review and meta-analysis aims to evaluate...

Endovascular treatment of aortic coarctation using covered balloon-expandable stents—a systematic review and meta-analysis

ObjectivesBalloon dilation followed by balloon-expandable stent implantation is an effective treatment for improving hemodynamic status in patients with coarctation of the aorta (CoA). However, limited evidence exists regarding the safety and efficacy of covered balloon-expandable stents (CBSs) in a large cohort. In this meta-analysis, we aimed to evaluate the overall success rates, hemodynamic and anatomical benefits, complications, and mid-term results of CBSs in treating CoA.MethodsThe PubMed, Embase, and Cochrane Library databases were systemically searched for studies reporting outcomes of CBSs in treating CoA. Single-group rate meta-analyses were performed to calculate estimated pooled procedural success rates, the incidence of complications, and re-coarctation rates. A meta-analysis using standardized mean differences was conducted to compare pre- and postoperative trans-coarctation pressure gradients (PGs), coarctation diameter, and overall changes in systolic blood pressure (SBP). Subgroup analyses were performed to identify potential sources of heterogeneity.ResultsThe final analysis included 12 studies with a total of 411 patients. The estimated pooled procedural success rate was 100% [95% confidence interval (CI): 98%–100%, I2 = 0, P = 0.78]. Significant decreases in trans-coarctation PGs and SBP were observed. The pooled incidences of stent-related, aortic, and access site complications were 2% (95% CI: 0%–5%, I2 = 30.4%, P = 0.15), 2% (95% CI: 0%–4%, I2 = 0%, P = 0.76), and 3% (95% CI: 1%–7%, I2 = 52.9%, P = 0.02), respectively. Subgroup analyses showed that implantation of BeGraft stents was related to a significantly higher incidence of access site complications.ConclusionCovered balloon-expandable stent implantation in treating CoA is safe and effective with high procedural success rates, an acceptable incidence of complications, and a low incidence of re-coarctation.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/, PROSPERO (CRD42023430356).