Hemodynamic Changes Research Articles

Impact of positive end-expiratory pressure on renal resistive index in mechanical ventilated patients.

Growing evidence shows the complex interaction between lung and kidney in critically ill patients. The renal resistive index (RRI) is a bedside measurement of the resistance of the renal blood flow and it is correlated with kidney injury. The positive end-expiratory pressure (PEEP) level could affect the resistance of renal blood flow, so we assumed that RRI could help to monitoring the changes in renal hemodynamics at different PEEP levels. Our hypothesis was that the RRI at ICU admission could predict the risk of acute kidney injury in mechanical ventilated critically ill patients. We performed a prospective study including 92 patients requiring mechanical ventilation for ≥ 48h. A RRI ≥ 0.70, was deemed as pathological. RRI was measured within 24h from ICU admission while applying 5,10 and 15 cmH2O of PEEP in random order (PEEP trial). Overall, RRI increased from 0.62 ± 0.09 at PEEP 5 to 0.66 ± 0.09 at PEEP 15 (p < 0.001). The mean RRI value during the PEEP trial was able to predict the occurrence of AKI with AUROC = 0.834 [95%CI 0.742-0.927]. Patients exhibiting a RRI ≥ 0.70 were 17/92(18%) at PEEP 5, 28/92(30%) at PEEP 10, 38/92(41%) at PEEP 15, respectively. Thirty-eight patients (41%) exhibited RRI ≥ 0.70 at least once during the PEEP trial. In these patients, AKI occurred in 55% of the cases, versus 13% remaining patients, p < 0.001. RRI seems able to predict the risk of AKI in mechanical ventilated patients; further, RRI values are influenced by the PEEP level applied. Clinical gov NCT03969914 Registered 31 May 2019.

Biomarkers of in vivo platelet activation in thoroughbreds during their first long-term training

Physical exercise has an activating effect on platelet function that differs between trained and untrained subjects, depending on the type of exercise and training status. In humans, soluble P-selectin (sP-sel) and platelet-derived extracellular vesicles (PEVs) are considered reliable markers of in vivo platelet activation during exercise. In untrained humans, they increase after transient physical exercise, whereas long-term training induces a decrease in their resting levels due to an improved ability to adapt to hemodynamic changes. The aim of this study was to assess whether circulating levels of sP-sel and PEVs may be useful markers to explore in vivo platelet function in never-trained Thoroughbreds during their first 4 months of incremental training. A total of 29 clinically healthy, untrained Thoroughbreds (17 males and 12 females) were enrolled. All horses were trained with the same training schedule (90 days). Blood samples were collected on the day the training program began (T0), 30 days (T30), and 90 days (T90) after its incremental increase to quantify platelet count, sP-sel (horse enzyme-linked immunosorbent assay) and PEVs (flow cytometry). Statistical analysis was performed using RM one-way analysis of variance with the Geisser–Greenhouse correction. Soluble P-selectin tended to increase at T30 compared with T0, while T90 levels returned to baseline values. Significantly higher circulating levels of PEVs CD61+/AnnV+ were observed at T30 and T90 compared to baseline confirming platelet hyperactivity. The detection and quantification of sP-sel and PEVs in equine racehorses during the training period appears to be a promising tool to study exercise-induced primary hemostatic changes and may provide an important marker for exercise selection.

Cortical networks relating to arousal are differentially coupled to neural activity and hemodynamics.

Even in the absence of specific sensory input or a behavioral task, the brain produces structured patterns of activity. This organized activity is modulated by changes in arousal. Here, we use wide-field voltage imaging to establish how arousal relates to cortical network voltage and hemodynamic activity in spontaneously behaving head-fixed male and female mice expressing the voltage-sensitive fluorescent FRET sensor Butterfly 1.2. We find that global voltage and hemodynamic signals are both positively correlated with changes in arousal with a maximum correlation of 0.5 and 0.25 respectively at a time lag of 0 seconds. We next show that arousal influences distinct cortical regions for both voltage and hemodynamic signals. These include a broad positive correlation across most sensory-motor cortices extending posteriorly to the primary visual cortex observed in both signals. In contrast, activity in prefrontal cortex is positively correlated to changes in arousal for the voltage signal while it is a slight net negative correlation observed in the hemodynamic signal. Additionally, we show that coherence between voltage and hemodynamic signals relative to arousal is strongest for slow frequencies below 0.15 Hz and is near zero for frequencies greater than 1Hz. We finally show that coupling patterns are dependent on the behavioral state of the animal with correlations being driven by periods of increased orofacial movement. Our results indicate that while hemodynamic signals show strong relations to behavior and arousal, these relations are distinct from those observed by voltage activity.Significance Statement We leverage wide-field voltage imaging to examine the relation between cortical changes in membrane potential dynamics and hemodynamics. These two signals are then examined with respect to changes in arousal, as measured by pupil diameter, in awake head fixed mice. Our results show similarities as well as important differences in the correlation of arousal with neuronal population activity dynamics and the hemodynamic signal. Further, the spatial activity correlation maps with arousal depended differentially on the behavioral state of the animal in a frequency dependent manner. Our results indicate that the modulation of brain networks by arousal is dynamically regulated, and only partly overlap between functional networks determined from hemodynamic or voltage activity.

Role of aortic valve replacement in moderate aortic stenosis: a 10-year outcomes study

ObjectivePatients with moderate aortic stenosis (AS) exhibit high morbidity and mortality. Limited evidence exists on the role of aortic valve replacement (AVR) in this patient population. To investigate the benefit...

Isoflurane increases the activity of the vascular matrix metalloproteinase-2 in non-pregnant rats and increases the nitric oxide metabolites in pregnancy.

Surgeries that require general anesthesia occur in 1.5-2% of gestations. Isoflurane is frequently used because of its lower possibility of affecting fetal growth. Therefore, we examined the isoflurane anesthesia-induced effects on maternal hemodynamic and vascular changes. We hypothesized that isoflurane would enhance endothelium-dependent vasodilation as a consequence of increased nitric oxide and decreased metalloproteinases (MMPs). Female rats (n = 28) were randomized into 4 groups (7 rats/group): conscious (non-anesthetized) non-pregnant group, non-pregnant anesthetized group, conscious pregnant group, and pregnant anesthetized group. Anesthesia was performed on the 20th pregnancy day, and hemodynamic parameters were monitored. Nitric oxide metabolites, gelatinolytic activity of MMP-2 and MMP-9, and the vascular function were assessed. Isoflurane caused no significant hemodynamic changes in pregnant compared with non-pregnant anesthetized group. Impaired acetylcholine-induced relaxations were observed only in conscious non-pregnant group (by approximately 62%) vs 81% for other groups. Phenylephrine-induced contractions were greater in endothelium-removed aorta segments of both pregnant groups (with or without isoflurane) compared with non-pregnant groups. Higher nitric oxide metabolites were observed in anesthetized pregnant in comparison with the other groups. Reductions in the 75 kDa activity and concomitant increases in 64 kDa MMP-2 isoforms were observed in aortas of pregnant anesthetized (or not) groups compared with conscious non-pregnant group. Isoflurane anesthesia shows stable effects on hemodynamic parameters and normal MMP-2 activation in pregnancy. Furthermore, there were increases in nitric oxide bioavailability, suggesting that isoflurane provides protective actions to the endothelium in pregnancy.

Portopulmonary hypertension: peculiarities of diagnosis and treatment

Portopulmonary hypertension is defined as the development of pulmonary hypertension secondary to portal one. Its exact prevalence is difficult to determine due to the lack of routine screening in patients with portal hypertension. Hemodynamic changes associated with portal hypertension, including the hyperdynamic state, portosystemic shunts, and splanchnic vasodilation, cause significant disturbances in the pulmonary vasculature and play a key role in the pathogenesis of the disease. Without treatment, portopulmonary hypertension leads to progressive right ventricular failure with a poor prognosis. Although Doppler echocardiography is the best initial screening tool for symptomatic patients and candidates for liver transplant, right heart catheterization remains the gold standard for disease diagnosis. Treatment of patients with portopulmonary hypertension is aimed at improving cardiac function, reducing pulmonary vascular resistance, and optimizing functional capacity. Pulmonary hypertension-specific therapy, which includes prostacyclin and its receptor agonists, endothelin receptor antagonists, phosphodiesterase inhibitors, and guanylate cyclase stimulators, plays a key role in the treatment of patients with portopulmonary hypertension. Small uncontrolled and recent single randomized controlled trials have reported promising results of vasodilator therapy in terms of clinical and hemodynamic improvement in patients, allowing certain patients to undergo liver transplantation. This review discusses the epidemiology, approach to diagnosis and treatment of patients with portopulmonary hypertension. We used MEDLINE database on the PubMed platform and the Cochrane library to search for literature sources using the keywords: portopulmonary hypertension, portal hypertension, pulmonary hypertension, liver cirrhosis, pulmonary complications.

CHANGES IN LEFT ATRIAL VOLUME DURING ECHOSTRESS IN PATIENTS UNDERGOING MITRAL VALVE PLASTIC CARDIAC SURGERY

Abstract Mitral Regurgitation (MR) is characterized by a high morbidity and mortality that often finds a solution only in the reparative surgical treatment, in particular in presence of myxomatous degeneration that cause the prolapse of one or both leaflets. This results in an increase in diastolic pressure that leads to a progressive dilation of the left atrium. The increase in Left Atrium Volume Index (LAVI) during stress test represents a negative prognostic factor in the clinical evolution of many pathologies, such as ischemic heart disease, hypertrophic cardiomyopathy, heart failure. An increase in peak/rest LAVI &amp;gt;6.8 ml/m2 correlates with a higher incidence of heart failure decompensation, reduced left ventricular contractile reserve (LVCR), pulmonary congestion. We evaluate the effect of MR reparative surgery on the changes of LAVI during stress–echo. We enrolled 19 patients, 11 females and 8 males, affected by MR candidate to cardiac surgery. We performed a physical stress–echo test by using the ABCDE protocol suggested by the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI), before and after 12 weeks from surgery. During each test, the changes in LAVI (ΔLAVI) expressed as peak/rest difference in ml/m2 was measured. In addition, the prognostic score deriving from the sum of the ABCDE criteria was calculated, such as the LVCR (C parameter of the score) that represents a parameter of the force deriving from the hemodynamic changes during the test. In all patients we observed a significant reduction in ΔLAVI (8.4+0.5 mL/m2 vs 9.7+0.7 mL/m2; p&amp;lt;0.0001). In addition, there was a significant reduction in the ABCDE prognostic score (from 4.19+0.43 to 3.48+0.37; p=0.002), secondary to the increase in the LVCR observed approximately 3 months after surgery (from 1.77 mmHg/ml to 2.44 mmHg/ml, p&amp;lt;0.0001), as well as a significant reduction in pulmonary congestion during stress (B parameter). There were no significant changes in ejection fraction, wall motion score index–WMSI (A parameter), coronary reserve (D parameter) and heart rate reserve (E parameter). These data demonstrate for the first time that mitral valve plastic surgery is able to reduce the ΔLAVI during stress echocardiography in patients with severe MR. The surgical procedure also resulted in both an improvement in the LVCR and a reduction in the degree of pulmonary congestion, that ultimately led to an improvement in the ABCDE prognostic score.

Ketamine for mood disorders, anxiety, and suicidality in children and adolescents: a systematic review.

Mood disorders, anxiety, and suicidality in youth are increasing and rapid-acting treatments are urgently needed. One potential is ketamine or its enantiomer esketamine, which was FDA approved in 2019 to treat major depressive disorder with suicidality in adults. This systematic review evaluated the evidence for the clinical use of ketamine to treat mood disorders, anxiety, and suicidality in youth. The PRISMA guidelines were used, and a protocol registered prospectively ( https://osf.io/9ucsg/ ). The literature search included Pubmed/MEDLINE, Ovid/MEDLINE, Scopus, CINAHL, PsychInfo, and Google Scholar. Trial registries and preprint servers were searched, and authors contacted for clarification. Studies reported on the clinical use of ketamine to treat anxiety, depression, bipolar disorder, or suicidality in youth ≤19years old and assessed symptoms before and after ketamine use. Study screening and data extraction were conducted independently by 2-4 authors. Safety, tolerability, and efficacy data were collected. The Cochrane Risk of Bias guidelines assessed the quality of the evidence. Twenty-two published reports based on 16 studies were identified: 7 case studies, 6 observational studies, 3 randomized trials, and 6 secondary data analyses. Studies reported immediate improvements in depression, anxiety, and suicidality. Improvements were maintained for weeks-months following treatment. Ketamine was well-tolerated with the most common side effects being dizziness, nausea, and mild dissociation. Transient hemodynamic changes were reported, all of which resolved quickly and did not require medical intervention. Initial evidence suggests ketamine is safe and may be effective for mood disorders, anxiety, and suicidality in youth. Further randomized trials are warranted.

Evaluation of Visual Cortex Activity using Functional Near-Infrared Spectroscopy (fNIRS) in Primary Open Angle and Primary Angle Closure Glaucoma: A pilot study.

Functional Near Infrared Spectroscopy was used to assess visual cortical activity in patients with primary open angle and primary angle closure glaucoma. There was decreased activity in the visual cortex of glaucoma patients correlating with the severity of glaucoma. To evaluate visual cortex activity using fNIRS (Functional Near Infrared Spectroscopy) in primary open angle glaucoma (POAG) and primary angle closure glaucoma (PACG) compared to healthy controls. A total of 30 POAG, 31 PACG, and 30 healthy aged-matched controls from a single centre were recruited in this cross-sectional observational pilot study with purposive sampling. The POAG and PACG groups were age-matched but were not matched for disease severity at recruitment. All participants underwent fNIRS testing using a multi-channel continuous-wave near infra-red system NIRSport 8×7 device (NIRx Medizintechnik GmbH, Berlin, Germany). The visual cortex activity was evaluated in terms of maximum amplitude of change in oxyhemoglobin (OxyHb) concentration over 10 seconds and a comparison was done between three groups. Both POAG and PACG groups were combined (termed as glaucoma group) to assess relationship of visual cortical activity with disease severity {by visual field defect (mean deviation) and retinal nerve fiber layer (RNFL) thickness}. All participants showed the characteristic response of increased OxyHb and decreased DeoxyHb during stimulus presentation. The maximum amplitude of change in OxyHb concentration over 10 seconds was significantly lower in both POAG and PACG groups compared to control in the right and left middle occipital gyri (P<0.05). There was no significant difference between PACG and POAG. Importantly, there was a negative correlation of the visual cortex activity with the visual field defects (mean deviation) (P<0.05) and a positive correlation with RNFL thickness in the glaucoma group (P<0.05). In glaucoma patients, reduction in visual cortical activity was observed which may be indicative of neuronal degeneration occurring in the occipital cortex. Disease severity in glaucoma appears to be closely correlated with visual cortex activity. fNIRS can serve as a useful neuroimaging modality for assessing the hemodynamic and neurodegenerative changes in glaucoma.

Effectiveness of Segmental Thoracic Spinal Anaesthesia in Breast Surgery: An Observational Study

Background: General anaesthesia is usually performed for breast surgery but the risks and complications of general anaesthesia outweigh its benefits. For this, segmental thoracic spinal anesthesia might be an alternative to general anesthesia. Objectives: The objective of this study was to evaluate the effectiveness segmental thoracic spinal anaesthesia in breast surgery. Methods: This prospective observational study was conducted at surgery operation theatre in the Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh from January 2023 to December 2023. Patients of ASA (American Society of Anesthesiologist) class I and II, ageing above 18 years, and BMI &lt; 35 kg/m2 scheduled for breast surgery (modified radical mastectomy for carcinoma breast, lumpectomy for breast lump/gynaecomastia, and wide local excision for phylloids tumor) were included in this study. Segmental thoracic spinal anaesthesia was performed at T5-T6 space with injection 0.5% hyperbaric bupivacaine 1 ml (5mg) and fentanyl 0.5 ml (25 microgram). Perioperative hemodynamic changes, unwanted effects, time of first rescue analgesic, total opioid consumption in first 24 h, patient and surgeon satisfaction score were recorded in a data sheet. Results: Sixty patients were eligible for the study but 55 patients completed the study successfully. Modified radical mastectomy, Lumpectomy and Wide local excision were done in 42 (76%), 8 (15%) and 5 (9%) patients, respectively. The mean age of the patients was 50.78±8.98 years. There were no significant changes in haemodynamic parameters during the intraoperative period. The frequency of adverse effects were minimal. Mean time for 1st dose of analgesic was 5.8±1.8 hours and total opioid consumption was 76.77±15.7 mg in first 24 hours. Both patient (91%) and surgeon (95%) were highly satisfied with this technique. Conclusions: Segmental thoracic spinal anaesthesia provides better satisfaction and fewer complications in patients undergoing breast surgery. This regional anaesthesia technique can be used effectively for breast surgeries. J Shaheed Suhrawardy Med Coll 2022; 14(2): 47-52

Regulation of vascular remodeling by immune microenvironment after the establishment of autologous arteriovenous fistula in ESRD patients

Autogenous arteriovenous fistula (AVF) is the preferred dialysis access for receiving hemodialysis treatment in end-stage renal disease patients. After AVF is established, vascular remodeling occurs in order to adapt to hemodynamic changes. Uremia toxins, surgical injury, blood flow changes and other factors can induce inflammatory response, immune microenvironment changes, and play an important role in the maintenance of AVF vascular remodeling. This process involves the infiltration of pro-inflammatory and anti-inflammatory immune cells and the secretion of cytokines. Pro-inflammatory and anti-inflammatory immune cells include neutrophil (NEUT), dendritic cell (DC), T lymphocyte, macrophage (Mφ), etc. This article reviews the latest research progress and focuses on the role of immune microenvironment changes in vascular remodeling of AVF, in order to provide a new theoretical basis for the prevention and treatment of AVF failure.

Fine-tuning the needle: analysis of acupuncturist response to alarming events during gynecological oncology surgery.

Examining an intra-operative acupuncture/acupressure setting, with real-time "fine-tuning" in response to alarming events (AEvs) during gynecological oncology surgery. Narratives of acupuncturists providing intraoperative acupuncture during gynecological oncology surgery were qualitatively analyzed. These described real time "fine-tuning" in response to AEvs during surgery, identified through hemodynamic changes (e.g., systolic/diastolic arterial pressure); bispectral index (BIS) elevation; and feedback from surgeons and anesthesiologists. Documentation of acupuncturist responses to AEvs was addressed as well. Of the 48 patients in the cohort, 33 had at least one intraoperative AEv (69%), of which 30 were undergoing laparoscopic surgery and 18 laparotomies. A total of 77 AEvs were documented throughout surgery (range 1-7; mean: 2.3 events per patient), identified through increased (63 events) or decreased (8) mean arterial pressure (MAP); increased BIS levels (2), or other hemodynamic parameters (4). Integrative oncology interventions implemented in response to AEs included acupressure alone (59); combining acupressure with acupuncture (10); or acupuncture alone (4). In 54 (70%) events, documentation was provided from beginning to conclusion of the AEv, with a mean duration of 9.7 min, with 32 events including a documented anesthesiologist intervention. The present study demonstrated the feasibility of intraoperative acupuncture with acupressure, with ongoing "fine-tuning" to AEvs identified through objective pain-related parameters (MAP, heart rate and BIS) and real-time input from surgeons and anesthesiologists. Documentation of the intraoperative IO practitioner's response to these AEvs is important, and should be addressed in future research of the innovative integrative model of care. CMC-18-0037 (Carmel Medical Center, June 11, 2018).

Cerebral blood flow regulation and cognitive performance in hypertension.

We examined the relation between transcranial Doppler (TCD) markers of cerebral blood flow regulation and cognitive performance in hypertension (HT) patients to evaluate the predictive value of these markers for cognitive decline. We assessed dynamic cerebral autoregulation (dCA), vasoreactivity to carbon dioxide, and neurovascular coupling (NVC) in the middle (MCA) and posterior (PCA) cerebral arteries of 52 patients. Neuropsychological evaluation included the Montreal Cognitive Assessment and tests covering attention, executive function, processing speed, and memory. Notably, reduced rate time in the PCA significantly predicted better processing speed (p = 0.003). Furthermore, reduced overshoot systolic cerebral blood velocity in the PCA and reduced phase in the VLF range in the MCA (p = 0.021 and p = 0.017, respectively) significantly predicted better memory. Intriguingly, enhanced dCA in the MCA predicted poorer memory performance, while reduced NVC in the PCA predicted both superior processing speed and memory performance. These findings suggest that HT-induced changes in cerebral hemodynamics impact cognitive performance. Further research should verify these observations and elucidate whether these changes represent adaptive responses or neurovascular inefficiency. TCD markers might provide insights into HT-related cognitive decline.

Intraoperative pain prediction of percutaneous kyphoplasty under local anesthesia by preoperative experimental pain assessment.

Percutaneous kyphoplasty (PKP) is the preferred treatment for osteoporotic vertebral compression fractures (OVCF) Currently, the preoperative anesthesia methods for PKP are mainly local anesthesia and tracheal intubation general anesthesia. To assess whether patient sensitivity to pain measured preoperatively could predict the patients' pain response during PKP treatment under local anesthesia, to facilitate the development of an optimal preoperative anesthesia plan for patients. Fifty-five female patients diagnosed with osteoporotic single vertebral fracture who were treated with PKP under local anesthesia were selected. The patients' pain sensitivities, including pain threshold and pain tolerance threshold, were evaluated with a pain test device on the day before the operation in the ward. Heart rate (HR), mean arterial pressure (MAP), and blood oxygen saturation (SpO2) were recorded before anesthesia, post-anesthesia, after needle puncture, and after balloon dilatation. At the same time, blood was drawn at the above time points to determine the level of norepinephrine (NA) as an indicator of intraoperative pain stress response. The numerical rating scale (NRS) during surgery was recorded at the end of the surgery. The preoperative pain tolerance threshold of 55surgical patients was correlated with the intraoperative NRS score (r=-0.768, P< 0.001), as well as with the preoperative and intraoperative changes in HR (r=-0.791, P< 0.001), MAP (r=-0.819, P< 0.001), and NA (r=-0.553, P< 0.001). Thus, the lower the preoperative pain tolerance threshold, the more severe the patient's response to pain during PKP treatment under local anesthesia, and the greater the hemodynamic changes. Consequently, the intraoperative experience becomes worse. However, there was no correlation between preoperative pain threshold and NRS scores (r=-0.069, P= 0.616) nor between the preoperative and intraoperative changes in HR (r= 0.103, P= 0.453), MAP (r= 0.086, P= 0.535), and NA (r=-0.058, P= 0.674). The results indicated that preoperative pain assessment could predict the level of pain response in OVCF patients during PKP surgery under local anesthesia.

Comparison between the Hemodynamic Profile with Esmolol versus Morphine as an Adjuvant Agent during Induction of Anesthesia

Background: The induction of general anesthesia is a critical phase in anesthetic practice, often associated with significant hemodynamic changes. These changes can lead to complications due to autonomic adrenergic responses. Esmolol, a beta-1 antagonist, is commonly used to blunt these responses, but its availability is limited in some settings. Morphine, a pure mu receptor antagonist, presents a potential alternative. Objective: This study aimed to compare the efficacy of intravenous esmolol versus intravenous morphine in stabilizing the hemodynamic profile during the induction of general anesthesia. Methods: This randomized controlled trial was conducted at the Department of Anesthesiology, Combined Military Hospital, from January to June 2023. After obtaining ethical approval and trial registration, 220 ASA-II patients aged 25-55 years scheduled for elective surgeries under general anesthesia were enrolled. Patients were randomized into two groups: Group E (n=110) received 1.5 mg/kg intravenous esmolol three minutes before laryngoscopy and intubation, and Group M (n=110) received 0.1 mg/kg intravenous morphine five minutes before laryngoscopy and intubation. Baseline heart rate, systolic and diastolic blood pressure, and oxygen saturation were recorded after pre-oxygenation with 100% oxygen for three minutes. Post-intubation, the same parameters were measured five minutes after intubation. Statistical analysis was performed using SPSS version 25.0, with independent samples T-tests used to compare means. A p-value of ≤0.05 was considered statistically significant. Results: The mean age was 39.41 ± 5.13 years in Group E and 39.97 ± 5.08 years in Group M (p=0.414). Mean weight was 68.14 ± 3.88 kg in Group E and 68.08 ± 3.80 kg in Group M (p=0.916). Pre-induction mean heart rate was 71.75 ± 2.33 bpm in Group E and 71.58 ± 2.35 bpm in Group M (p=0.585). Five minutes post-intubation, mean heart rate was significantly lower in Group E (80.73 ± 2.54 bpm) compared to Group M (87.62 ± 2.83 bpm) (p&lt;0.001). Mean systolic blood pressure post-intubation was 132.88 ± 4.65 mm Hg in Group E and 140.25 ± 2.39 mm Hg in Group M (p&lt;0.001). Mean diastolic blood pressure post-intubation was 77.58 ± 2.35 mm Hg in Group E and 85.33 ± 3.71 mm Hg in Group M (p&lt;0.001). Oxygen saturation remained stable in both groups. Conclusion: Intravenous esmolol is superior to intravenous morphine in blunting the hemodynamic responses to laryngoscopy and intubation, providing a more stable hemodynamic profile during the induction of general anesthesia.

Quantitative analysis of hemodynamic changes induced by the discrepancy between the sizes of the flow diverter and parent artery

The efficacy of flow diverters is influenced by the strut configuration changes resulting from size discrepancies between the stent and the parent artery. This study aimed to quantitatively analyze the impact of size discrepancies between flow diverters and parent arteries on the flow diversion effects, using computational fluid dynamics. Four silicone models with varying parent artery sizes were developed. Real flow diverters were deployed in these models to assess stent configurations at the aneurysm neck. Virtual stents were generated based on these configurations for computational fluid dynamics analysis. The changes in the reduction rate of the hemodynamic parameters were quantified to evaluate the flow diversion effect. Implanting 4.0 mm flow diverters in aneurysm models with parent artery diameters of 3.0–4.5 mm, in 0.5 mm increments, revealed that a shift from oversized to undersized flow diverters led to an increase in the reduction rates of hemodynamic parameter, accompanied by enhanced metal coverage rate and pore density. However, the flow diversion effect observed transitioning from oversizing to matching was less pronounced when moving from matching to undersizing. This emphasizes the importance of proper sizing of flow diverters, considering the benefits of undersizing and not to exceed the threshold of advantages.

Serial invasive hemodynamics and clinical characteristics of patients with shock with and without invasive mechanical ventilation

Abstract Funding Acknowledgements None. Background Invasive mechanical ventilation (IMV) is commonly used in the Cardiac Intensive Care Unit (CICU) in patients with cardiogenic shock (CS). IMV causes hemodynamic changes that may impact outcomes based upon a patient’s profile. Our aim is to characterize the clinical profile and detailed serial hemodynamic parameters in the first 24-hours according to the use of IMV in patients with shock admitted to the CICU. Methods Retrospective analysis of consecutive patients with shock admitted to the CICU at Bellevue Hospital, undergoing pulmonary artery catheter (PAC) placement within the first 24 hours of admission, from February 2022 to June 2023. Clinical characteristics, as well as specific hemodynamic parameters collected and curated at times 0, 6, 12, 18 and 24 hours were from PAC placement compared between patients with and without IMV. Results A total of 101 patients were included (95% with cardiogenic shock), 59 receiving IMV (age 64 ± 15, 24% women) and 42 non-intubated (61 ± 13, 33% women). Non-intubated patients had higher prevalence of hypertension, prior coronary artery disease and heart failure with reduced ejection fraction (HFrEF), while acute coronary syndromes (44%) and cardiac arrest (12%) were more common causes of admission in patients undergoing IMV. Mixed shock predominated in IMV patients (51 vs 17%, p &amp;lt;0.001), whereas cardiogenic shock (CS) was more common in non-intubated patients (83 vs 41%, p &amp;lt;0.01). Patients with acute myocardial infarction CS (AMI-CS) were more likely to undergo IMV, while patients with heart failure CS (HF-CS) were more likely to be non-intubated. Patients undergoing IMV were more likely to have mechanical circulatory support (MCS) and ventricular dilatation compared to non-intubated patients (LVEDD 5.7 cm vs 4.9 cm, p 0.002). Patients undergoing IMV had a higher incidence of severe shock compared to the non-intubated group (31% vs 19% SCAI Shock D), higher lactate levels and greater use of vasoactive drugs (figure 1A). Patients undergoing IMV had significant improvements in cardiac power output (CPO), diastolic blood pressure and systemic vascular resistance (SVR) (figure 1B). Shock severity by SCAI SHOCK classification had a more notable improvement at 24 hours in patients with IMV compared to non-intubated patients (figure 1C), with a non-statistically significant improvement in lactate clearance in the first 24 hours (Figure 1D). Conclusions IMV in patients with CS is more commonly seen in patients with AMI-CS and among those with higher baseline shock severity and greater use of vasoactive medications. IMV is associated with significant improvements in shock severity, CPO and SVR at 24 hours when compared to patients with shock who are not intubated, which could be related to higher use of vasopressors. Further investigations are warranted to understand the impact of IMV on outcomes of patients with CS and how they might vary according to hemodynamic profile.

Renal Calcium and Magnesium Handling During Pregnancy: Modeling and Analysis.

Pregnancy is associated with elevated demand of most nutrients, with many trace elements and minerals critical for the development of fetus. In particular, calcium (Ca2+) and magnesium (Mg2+) are essential for cellular function, and their deficiency can lead to impaired fetal growth. A key contributor to the homeostasis of these ions is the kidney, which in a pregnant rat undergoes major changes in morphology, hemodynamics, and molecular structure. The goal of this study is to unravel the functional implications of these pregnancy-induced changes in renal handling of Ca2+ and Mg2+, two cations that are essential in a healthy pregnancy. We developed computational models of electrolyte and water transport along the nephrons of a rat in mid and late pregnancy. Model simulations reveal a substantial increase in the reabsorption of Mg2+ along the proximal tubules and thick ascending limbs. In contrast, the reabsorption of Ca2+ is increased in the proximal tubules but decreased in the thick ascending limbs, due to the lower transepithelial concentration gradient of Ca2+ along the latter. Despite the enhanced transport capacity, the marked increase in glomerular filtration rate results in elevated urinary excretions of Ca2+ and Mg2+ in pregnancy. Furthermore, we conducted simulations of hypocalcemia and hypomagnesemia. We found that hypocalcemia lowers Ca2+ excretion substantially more than Mg2+ excretion, especially in virgin rats. Conversely, hypomagnesemia reduces the excretion of Mg2+ and Ca2+ to more similar degrees. These differences can be explained by the greater sensitivity of the calcium-sensing receptor (CaSR) to Ca2+ compared to Mg2+.

Impact of anesthetic induction with etomidate, thiopentone, and propofol on regional cerebral oxygenation: An observational study in patients with traumatic brain injury

Abstract Background and Aims: Anesthetic induction plays a pivotal role in determining the operative course and the outcome in patients with acute traumatic brain injury (TBI). The present study compared the effect of anesthetic induction with etomidate, thiopentone, and propofol primarily on systemic hemodynamics and regional cerebral oxygenation (rScO2) and secondarily on the serum cortisol levels in TBI patients. Material and Methods: In this prospective observational study, eligible patients were recruited and divided into three groups as per the induction agent received. Data collected were hemodynamic parameters and rScO2 levels at baseline, following 3 min of preoxygenation, and over 10 min of induction. Serum cortisol levels were measured before and after 24 h of induction. The statistical analysis was done using R software. Results: A total of 115 patients were included: 32, 33, and 50 in thiopentone, propofol, and etomidate groups, respectively. A significant increase (P &lt; 0.001) in bilateral rScO2 was noted in all three groups following anesthetic induction. Intergroup comparison of the propofol and the etomidate groups revealed significantly lesser increase in contralateral rScO2 (P = 0.019) and a greater fall in mean arterial pressure (P = 0.003) on using propofol as an induction agent. Trend changes in bilateral rScO2 and hemodynamic parameters were comparable between thiopentone and etomidate groups. An insignificant fall in serum cortisol was observed in etomidate (P = 0.332) and thiopentone (P = 0.364) groups, but a significant increase was observed in the propofol group (P = 0.004). The Glasgow coma scale (GCS) score at discharge improved significantly in all the groups (P &lt; 0.001). Conclusions: In TBI patients, anesthetic induction with etomidate resulted in least hemodynamic changes compared to induction with thiopentone and propofol. The rScO2 increased in all three groups after induction, with the maximal increase observed with etomidate compared to propofol and thiopentone. Insignificant fall in serum cortisol was observed with etomidate and thiopentone, but not with propofol. Outcome at discharge, assessed with GCS, was comparable in all the groups. Key Messages: Anesthetic induction with etomidate produced least hemodynamic changes compared to induction with thiopentone and propofol in patients with traumatic brain injury. Consequently, maximal increase in cerebral oxygen saturation occurred with etomidate among the three induction agents. An insignificant decrease in serum cortisol was observed with etomidate and thiopentone, but not with propofol. Neurological outcome at discharge was similar with all drugs.

Successful treatment for pseudoaneurysm following distal pancreatectomy with celiac axis resection without postoperative pancreatic fistula: a case report

BackgroundDistal pancreatectomy with celiac axis resection (DP–CAR) represents an innovative surgical approach for locally advanced pancreatic body cancer in cases involving celiac axis invasion. However, this procedure carries significant perioperative risks, including arterial aneurysms and organ ischemia. Understanding these risks is crucial for optimizing patient outcomes and guiding treatment decisions.Case presentationThis case report describes a unique case of a 74-year-old male patient who was diagnosed with locally advanced pancreatic body cancer with invasion of the celiac and splenic arteries. He underwent DP–CAR after six cycles of chemotherapy. His postoperative course was uneventful without any evidence of postoperative pancreatic fistula. However, at the 10-month postoperative follow-up, pseudoaneurysm was incidentally detected in the anterior superior pancreaticoduodenal artery by follow-up computed tomography. It was successfully treated with coil embolization. He had no signs of tumor recurrence or relapse of pseudoaneurysm formation 2 years postoperatively. This case report discusses the potential risks of pseudoaneurysm formation in patients undergoing DP–CAR due to hemodynamic changes. We emphasize the significance of close monitoring in such cases.ConclusionsThe case highlights the importance of recognizing and managing potential complications associated with DP–CAR in patients with pancreatic cancer. Despite its effectiveness in achieving complete resection, DP–CAR carries inherent risks, including the development of pseudoaneurysms. Vigilant surveillance and prompt intervention are crucial for optimizing patient outcomes and minimizing postoperative complications.