Hemodynamic Derangements Research Articles

The Sedative and Propofol-Sparing Effect of Dexmedetomidine and Midazolam as Premedicants in Minor Gynecological Day Care Surgeries: A Randomized Placebo-Controlled Study.

Background and Aims:Ambulatory surgery is continually evolving specialty in the majority of surgical procedures. Dexmedetomidine and midazolam are newer adjuvants for sedation and reducing the dose of anesthetic agents. The aim of this study was to compare the sedative and propofol-sparing effect of dexmedetomidine and midazolam in minor gynecological day care surgeries. Observer's Assessment of Activity and Sedation, dose of additional propofol, Aldrete and street fitness score were studied as primary outcomes. Hemodynamic parameters and side effects were evaluated as secondary outcomes.Materials and Methods:A prospective randomized placebo-controlled study was conducted on 150 American Society of Anesthesiologists ASA physical status Classes I and II gynecological patients between 18 and 50 years and were allocated into three groups of fifty each. Group A received intravenous (i.v.) dexmedetomidine 0.1 μg/kg, Group B received i.v. midazolam 0.04 mg/kg, and Group C received normal saline 10 min before induction.Results:Sedation score was statistically highly significant between Group A and B (P < 0.001). Between Group A and C, it was statistically significant (P < 0.05); however, score was nonsignificant between Groups B and C (P > 0.05). During recovery at 120 min after surgery, score 5 was achieved equally by all three groups which was found to be statistically insignificant (P > 0.05). Mean dose of additional propofol used was less in Group A (14 ± 9.25) than B (25 ± 5.40) and C (53 ± 10.96). On intergroup comparison between all three groups, it was found to be statistically highly significant (P < 0.001). Comparison of bispectral index (BIS) values between Groups A and C and Groups B and C were highly significant (P < 0.001). However, it was statistically significant between Groups A and B (P < 0.05). Aldrete scoring and street fitness scores were highly significant between Groups A and B, B and C, and also between Groups A and C (P < 0.001). No significant hemodynamic derangements and side effects were noted in any of three groups.Conclusion:Dexmedetomidine had good sedation and better recovery characteristics than midazolam. BIS monitoring was helpful in maintaining the depth of anesthesia.

Recent advances in the pathogenetic mechanisms of sepsis-associated acute kidney injury.

Sepsis is a serious medical condition that can lead to multi-organ failure and shock, and it is associated with increased mortality. Acute kidney injury (AKI) is a frequent complication of sepsis in critically ill patients, and often requires renal replacement therapy. The pathophysiology of AKI in sepsis has not yet been fully defined. In the past, classic theories were mainly focused on systemic hemodynamic derangements, underscoring the key role of whole kidney hypoperfusion due to reduced renal blood flow. However, a growing body of experimental and clinical evidence now shows that, at least in the early phase of sepsis-associated AKI, renal blood flow is normal, or even increased. This could suggest a dissociation between renal blood flow and kidney function. In addition, the scant data available from kidney biopsies in human studies do not support diffuse acute tubular necrosis as the predominant lesion. Instead, increasing importance is now attributed to kidney damage resulting from a complex interaction between immunologic mechanisms, inflammatory cascade activation, and deranged coagulation pathways, leading to microvascular dysfunction, endothelial damage, leukocyte/platelet activation with the formation of micro-thrombi, epithelial tubular cell injury and dysfunction. Moreover, the same processes, through maladaptive responses leading to fibrosis acting from the very beginning, may set the stage for progression to chronic kidney disease in survivors from sepsis-associated AKI episodes. The aim of this narrative review is to summarize and discuss the latest evidence on the pathophysiological mechanisms involved in septic AKI, based on the most recent data from the literature.

The beneficial effects of curcumin in cirrhotic rats with portal hypertension.

In liver cirrhosis with portal hypertension, the uneven distribution of vasoactive substances leads to increased intrahepatic vascular resistance and splanchnic vasodilatation. Angiogenesis also induces increased portal inflow and portosystemic collaterals. The collaterals may induce lethal complications such as gastroesophageal variceal hemorrhage, but the therapeutic effect of vasoconstrictors is still suboptimal due to poor collateral vasoresponsivenss. Curcumin has aroused much attention for its antifibrosis, vasoactive, and anti-angiogenesis actions. However, whether it affects the aforementioned aspects is unknown. Liver cirrhosis was induced by common bile duct ligation (CBDL) in Sprague–Dawley rats. Sham-operated rats were controls. CBDL and sham rats were randomly allocated to receive curcumin (600 mg/kg per day) or vehicle since the 15th day after BDL. On the 29th day, portal hypertension related parameters were surveyed. Portosystemic collateral in situ perfusion was performed to evaluate vascular activity. Chronic curcumin treatment decreased portal pressure (PP), cardiac index (CI) and increased systemic vascular resistance (SVR) in cirrhotic rats. In splanchnic system, curcumin decreased superior mesenteric artery (SMA) flow and increased SMA resistance. Mesenteric angiogenesis was attenuated by curcumin. Acute administration of curcumin significantly induced splanchnic vasoconstriction. The mesenteric protein expressions of p-endothelial nitric oxide synthase (eNOS), cyclooxygenase (COX) 2 (COX2), vascular endothelial growth factor (VEGF), p-VEGF receptor 2 (VEGFR2), and p-Erk were down-regulated. In collateral system, curcumin decreased portosystemic shunting and induced vasoconstriction. In conclusion, chronic curcumin administration in cirrhotic rats ameliorated portal hypertension related hemodynamic derangements and portosystemic collaterals. Curcumin also attenuated splanchnic hyperdynamic circulation by inducing vasoconstriction through inhibition of eNOS activation and by decreasing mesenteric angiogenesis via VEGF pathway blockade.

Predictors of hemodynamic derangement during intubation in the critically ill: A nested case-control study of hemodynamic management – Part II

Predictors of hemodynamic derangement during intubation in the critically ill: A nested case-control study of hemodynamic management – Part II

Predictors of hemodynamic derangement during intubation in the critically ill: A nested case-control study of hemodynamic management—Part II

PurposeOur primary aim was to identify predictors of immediate hemodynamic decompensation during the peri-intubation period. MethodsWe conducted a nested case-control study of a previously identified cohort of adult patients needing intubation admitted to a medical-surgical ICU during 2013–2014. Hemodynamic derangement was defined as cardiac arrest and/or the development of systolic blood pressure <90mmHg and/or mean arterial pressure <65mmHg 30min following intubation. Data during the peri-intubation period was analyzed. ResultsThe final cohort included 420 patients. Immediate hemodynamic derangement occurred in 170 (40%) patients. On multivariate modeling, age/10year increase (OR 1.20, 95% CI 1.03–1.39, p=0.02), pre-intubation non-invasive ventilation (OR 1.71, 95% CI 1.04–2.80, p=0.03), pre-intubation shock index/1 unit (OR 5.37 95% CI 2.31–12.46, p≤0.01), and pre-intubation modified shock index/1 unit (OR 2.73 95% CI 1.48–5.06, p≤0.01) were significantly associated with hemodynamic derangement. Those experiencing hemodynamic derangement had higher ICU [47 (28%) vs. 33 (13%); p≤0.001] and hospital [69 (41%) vs. 51 (20%); p≤0.001] mortality. ConclusionsHemodynamic derangement occurred at a rate of 40% and was associated with increased mortality. Increasing age, use of non-invasive ventilation before intubation, and increased pre-intubation shock and modified shock index values were significantly associated with hemodynamic derangement post-intubation.

Review article: the role of the microcirculation in liver cirrhosis.

Intrahepatic microvascular derangements and microcirculatory dysfunction are key in the development of liver cirrhosis and its associated complications. While much has been documented relating to cirrhosis and the dysfunction of the microcirculation in the liver parenchyma, far less is known about the state of the extrahepatic microcirculation and the role this may have in the pathogenesis ofmultiple organ failure in end stage liver cirrhosis. To provide an update on the role of the microcirculation in the pathophysiology of cirrhosis and its associated complications and briefly discuss some of the imaging techniques which may be used to directly investigate the microcirculation. A Medline literature search was conducted using the following search terms: 'cirrhosis', 'microcirculation', 'circulation', 'systemic', 'inflammation', 'peripheral', 'hepatorenal' and 'hepatopulmonary'. Significant heterogeneous microvascular alterations exist in patients with cirrhosis. Data suggest that the systemic inflammation, associated with advanced cirrhosis, induces microcirculatory dysregulation and contributes to haemodynamic derangement. The resultant vasoconstriction and hypoperfusion in the systemic extrahepatic microvasculature, is likely to be instrumental in the pathophysiology of organ failure in decompensated cirrhosis, however the mechanistic action of vasoactive agents used to correct the circulatory disturbance of advanced cirrhosis is poorly understood. Further research into the role of the microcirculation in patients with liver cirrhosis, will improve physicians understanding of the pathophysiology of cirrhosis, and may provide a platform for real time evaluation of an individual's microcirculatory response to vasoactive mediators, thus guiding their therapy.

In vivo imaging of endothelial cell adhesion molecule expression after radiosurgery in an animal model of arteriovenous malformation.

Focussed radiosurgery may provide a means of inducing molecular changes on the luminal surface of diseased endothelium to allow targeted delivery of novel therapeutic compounds. We investigated the potential of ionizing radiation to induce surface expression of intercellular adhesion molecule 1 (ICAM-1) and vascular cell adhesion molecule 1 (VCAM-1) on endothelial cells (EC) in vitro and in vivo, to assess their suitability as vascular targets in irradiated arteriovenous malformations (AVMs). Cultured brain microvascular EC were irradiated by linear accelerator at single doses of 0, 5, 15 or 25 Gy and expression of ICAM-1 and VCAM-1 measured by qRT-PCR, Western, ELISA and immunocytochemistry. In vivo, near-infrared (NIR) fluorescence optical imaging using Xenolight 750-conjugated ICAM-1 or VCAM-1 antibodies examined luminal biodistribution over 84 days in a rat AVM model after Gamma Knife surgery at a single 15 Gy dose. ICAM-1 and VCAM-1 were minimally expressed on untreated EC in vitro. Doses of 15 and 25 Gy stimulated expression equally; 5 Gy was not different from the unirradiated. In vivo, normal vessels did not bind or retain the fluorescent probes, however binding was significant in AVM vessels. No additive increases in probe binding were found in response to radiosurgery at a dose of 15 Gy. In summary, radiation induces adhesion molecule expression in vitro but elevated baseline levels in AVM vessels precludes further induction in vivo. These molecules may be suitable targets in irradiated vessels without hemodynamic derangement, but not AVMs. These findings demonstrate the importance of using flow-modulated, pre-clinical animal models for validating candidate proteins for vascular targeting in irradiated AVMs.

Anesthetic management for intestinal transplantation: A decade of experience.

Intestinal transplantation (ITx) is the definitive therapy for patients suffering from intestinal failure. Previously published reports suggest that these cases should be managed perioperatively with the same intensive monitors and techniques as in liver transplantation. We retrospectively reviewed the anesthetic management of 67 isolated intestinal, intestinal-pancreas, and intestinal-kidney transplants over the previous decade (2005-2015) in our tertiary care institution. Patients were typically managed with a single arterial line, a single central venous catheter, and rarely intensive modalities such as a pulmonary artery catheter, a transesophageal echocardiography, a second arterial catheter or central venous catheter, a rapid infusion system, a cell salvage device, or viscoelastic testing. Significant hemodynamic derangements were rare, and the rate of postreperfusion syndrome was 8.96%. Our fluid administration type and volume and transfusion type and volume were similar to previous reports in which more intensive anesthetic management was employed. We demonstrate that ITx can safely occur without utilizing the intensive resources requisite for a liver transplant.

Contribution of Central Abnormalities to Exertional Dyspnea and Ventilatory Response in Heart Failure with Preserved Ejection Fraction

Introduction: Exercise intolerance is attributed to cardiac and peripheral abnormalities in heart failure with preserved ejection fraction (HFpEF). However, no study has evaluated the relationships between hemodynamics, dyspnea and ventilatory response in HFpEF. Methods and Results: Subjects with invasively-diagnosed HFpEF (n = 50) and participants with dyspnea but no identifiable cardiac pathology (controls, n = 24) underwent invasive catheterization at rest and during exercise with simultaneous expired gas analysis and spiroergometry. Compared to controls, subjects with HFpEF displayed higher exercise pulmonary capillary wedge pressures (PCWP) and pulmonary artery pressures, greater Borg perceived dyspnea and fatigue scores, and increased respiratory rate relative to exercise intensity (Figure). Exercise PCWP was directly correlated with Borg dyspnea and effort scores (r = 0.31 and r = 0.39, both P < .01). The ratio of dead space ventilation to tidal volume (VD/VT) was greater in HFpEF during exercise (0.25 ± 0.09 vs. 0.33 ± 0.11, P = .002), and this was correlated with exercise PA pressures (r = 0.42, P = .0003). Compared to controls, HFpEF subjects displayed lower increase in VT during peak exercise (ΔVT 831 ± 464 vs. 454 ± 233 ml, P = .001). Peak VT was inversely correlated with exercise PCWP (r = −0.38, P = .0007). Peak VO2 was markedly impaired in HFpEF subjects (8.1 ± 2.4 vs. 14.2 ± 4.0 ml/kg/min, P < .0001) and varied inversely with exercise PCWP (r = −0.65, P < .0001). Conclusions: Central hemodynamic derangements that develop during exercise in people with HFpEF are correlated with subjective symptoms of dyspnea, impaired tidal volume reserve, and increased dead space ventilation relative to tidal volume, supporting the relevance of central hemodynamics as a key mediator of disability in HFpEF and important therapeutic target.

Ascorbate lacks significant influence in rats with bile duct ligation-induced liver injury

BackgroundLiver inflammation may induce fibrogenesis, cirrhosis and portal hypertension. Liver cirrhosis is characterized by increased intrahepatic resistance and enhanced vasoconstrictive response. The splanchnic vasodilatation, angiogenesis and portosystemic collaterals formation further bring about lethal complications. Ascorbate is a potent antioxidant with anti-inflammation, anti-fibrosis, and anti-angiogenesis effects. However, the relevant influences in chronic liver injury have not been sufficiently explored. MethodsChronic liver injury was induced in Spraque-Dawley rats with common bile duct ligation (BDL). Ascorbate (250 mg/kg/day, oral gavage) or vehicle was administered starting on the 1st day after operation. On the 8th (hepatitis) and 29th (cirrhosis) day, serum biochemistry parameters, hepatic concentrations of lipid peroxidation-related substances, protein expressions of α-SMA, TGF-β, iNOS, eNOS, p-eNOS-Ser1177, p-eNOS-Thr496, VEGF, VEGFR2, p-VEGFR2, and liver histology were evaluated. In three series of paralleled groups, rats treated with 28-day ascorbate or vehicle received hemodynamic measurements, hepatic and collateral vasoresponsiveness perfusion experiments, mesenteric CD31 immunofluorescence staining, and Western blot analyses of mesenteric VEGF, VEGFR2, pVEGFR2, PDGF, PDGFβ, COX1, COX2, eNOS, p-eNOS-Thr495, p-eNOS-Ser1177 protein expressions. In another series, the severity of portosystemic shunting was evaluated. ResultsAscorbate did not influence hepatitis, oxidative stress, fibrosis, and hemodynamic parameters in BDL rats. The intrahepatic and collateral vasoresponsiveness were not affected, either from direct incubation or acute treatment with ascorbate. Furthermore, the mesenteric angiogenesis and severity of shunting were not influenced. ConclusionThe oxidative stress, fibrosis, hemodynamic derangements, angiogenesis and vascular functional changes in BDL-induced chronic liver injury may be too overwhelming to be modulated by ascorbate.

Arterial Stiffening With Exercise in Patients With Heart Failure and Preserved Ejection Fraction

BackgroundAortic stiffening and reduced nitric oxide (NO) availability may contribute to the pathophysiology of heart failure with preserved ejection fraction (HFpEF). ObjectivesThis study compared indices of arterial stiffness at rest and during exercise in subjects with HFpEF and hypertensive control subjects to examine their relationships to cardiac hemodynamics and determine whether exertional arterial stiffening can be mitigated by inorganic nitrite. MethodsA total of 22 hypertensive control subjects and 98 HFpEF subjects underwent hemodynamic exercise testing with simultaneous expired gas analysis to measure oxygen consumption. Invasively measured radial artery pressure waveforms were converted to central aortic waveforms by transfer function to assess integrated measures of pulsatile aortic load, including arterial compliance, resistance, elastance, and wave reflection. ResultsArterial load and wave reflections in HFpEF were similar to those in control subjects at rest. During submaximal exercise, HFpEF subjects displayed reduced total arterial compliance and higher effective arterial elastance despite similar mean arterial pressures in control subjects. This was directly correlated with higher ventricular filling pressures and depressed cardiac output reserve (both p < 0.0001). With peak exercise, increased wave reflections, impaired compliance, and increased resistance and elastance were observed in subjects with HFpEF. A subset of HFpEF subjects (n = 52) received sodium nitrite or placebo therapy in a 1:1 double-blind, randomized fashion. Compared to placebo, nitrite decreased aortic wave reflections at rest and improved arterial compliance and elastance and central hemodynamics during exercise. ConclusionsAbnormal pulsatile aortic loading during exercise occurs in HFpEF independent of hypertension and is correlated with classical hemodynamic derangements that develop with stress. Inorganic nitrite mitigates arterial stiffening with exercise and improves hemodynamics, indicating that arterial stiffening with exercise is at least partially reversible. Further study is required to test effects of agents that target the NO pathway in reducing arterial stiffness in HFpEF. (Study of Exercise and Heart Function in Patients With Heart Failure and Pulmonary Vascular Disease [EXEC]; NCT01418248. Acute Effects of Inorganic Nitrite on Cardiovascular Hemodynamics in Heart Failure With Preserved Ejection Fraction; NCT01932606. Inhaled Sodium Nitrite on Heart Failure With Preserved Ejection Fraction; NCT02262078)

Update on Finger-Application-Type Noninvasive Continuous Hemodynamic Monitors (CNAP and ccNexfin): Physical Principles, Validation, and Clinical Use.

The CNAP HD Monitor (CNSystems, Graz, Austria) and the ccNexfin (The ClearSight System: Edwards Lifesciences Corporation, Irvine, CA) are continuous, noninvasive blood pressure monitors using a finger-application device. These devices show a promising ability to allow for rapid detection of hemodynamic derangement when compared with oscillometry. The accuracy and precision of these devices as blood pressure monitors has been evaluated when compared with intra-arterial catheters. Additionally, they can be used to measure beat-to-beat cardiac output (CO). As CO monitors, they are capable of trending changes in CO when compared with a transpulmonary thermodilution monitor. Difficulty with use in critically ill and awake patients has been encountered because of altered microvascular physiology and patient movement. The principles of operation and clinical validation of these devices are presented. The clinicians who are interested in using these devices in their clinical setting should be aware of the relatively large bias and CIs in the hemodynamic measurements.

P209 Effect of normobaric hypoxia on pulmonary hemodynamics in patients with precapillary pulmonary hypertension

Introduction: Patients with precapillary pulmonary hypertension (PH, pulmonary arterial or chronic thromboembolic pulmonary hypertension, PAH/CTEPH) may experience disease deterioration upon exposure to a hypoxic environment during air travel or altitude sojourns due to hypoxic pulmonary vasoconstriction. We investigated the effect of breathing a hypoxic air mixture on pulmonary hemodynamics and blood gases in PH in comparison with unaffected controls. Methods: Patients scheduled for diagnostic right heart catheterization had hemodynamic assessments under ambient air (FiO2 0.21) and after 10 min of breathing nitrogen-enriched air (hypoxia FiO2 0.16). Patients were stratified according to their mean pulmonary arterial pressure (mPAP): PH (mPAP ≥25mmHg, pulmonary artery wedge pressure (PAWP) ≤15mmHg), unaffected controls (patients undergoing RHC for evaluation of dyspnea with mPAP< 20mmHg) and intermediate (mPAP 20-24mmHg). Results: 20 patients with PH (12 females, 8 PAH, 12 CTEPH; mean±SD age 63±14y), 12 controls (12 females, age 63±7y) and 7 patients from the intermediate group (3 females, age 66±12y) were included. PaO2 significantly decreased in all groups upon exposure to hypoxia (see table). However, hypoxemia was not accompanied by significant changes in mPAP or cardiac index in any group. Unexpectedly, pulmonary vascular resistance significantly increased in the control group. The test was well tolerated by all participants.TablePAH/CTEPH (n=20)Intermediate (n=7)Controls (n=12)FiO2 0.21Mean Change 95%CI with FiO2 0.16FiO2 0.21Mean Change 95%CI with FiO2 0.16FiO2 0.21Mean Change 95%CI with FiO2 0.16Heart Rate, bpm70±94 (1 to 7)*78±123 (0 to 6)68±95 (2 to 9)*mPAP, mmHg40.5±12.22.6 (-0.1 to 5.2)23.9±4.20.7 (-3.5 to 4.9)16.7±1.71.7 (-0.2 to 3.6)Cardiac index, l/min/m22.6±0.7-0.04 (-0.3 to 0.2)5.2±1.90.04 (-0.5 to 0.6)3.2±0.9-0.1 (-0.4 to 0.1)PVR index, WU6.1±3.30.7 (-0.2 to 1.7)1.3±0.40.04 (-0.5 to 0.6)1.8±0.70.6 (0.1 to 1.0)*SaO2(%)93.9±3.5-7.4 (-12.2 to -2.6)**95.7±2.8-4.4 (-10.0 to 1.1)97.3±1.5-4.9 (-7.8 to -2.0)**PaO2 (kPA)9.3±1.6-2.5 (-3.4 to -1.6)***10.4±1.7-2.7 (-5.2 to -0.3)*10.7±1.4-3.3 (-4.5 to -2.1)***PaCO2 (kPA)4.6±0.5-0.3 (-0.5 to -0.1)*4.8±1.9-0.6 (-1.4 to 0.1)4.4±1.0-0.2 (-0.7 to 0.3)Abbreviations: mPAP: mean pulmonary artery pressure; PVR: pulmonary vascular resistance; SaO2: arterial oxygen saturation; PaO2: partial pressure of oxygen; PaCO2: partial pressure of carbon dioxide. Note: Data are given as mean±SD. Within group differences *: p<0.05; **: p<0.01; ***: p<0.001. Between group differences in the changes upon exposure to hypoxia were not statistically significant. Open table in a new tab Abbreviations: mPAP: mean pulmonary artery pressure; PVR: pulmonary vascular resistance; SaO2: arterial oxygen saturation; PaO2: partial pressure of oxygen; PaCO2: partial pressure of carbon dioxide. Note: Data are given as mean±SD. Within group differences *: p<0.05; **: p<0.01; ***: p<0.001. Between group differences in the changes upon exposure to hypoxia were not statistically significant. Conclusions: Our data suggest that a short-term exposure to a moderately reduced FiO2 in patients with PAH/CTEPH associated with chronic hypoxemia in sea level conditions seems not to further exacerbate derangements in pulmonary hemodynamics. Whether the hemodynamic effects of a short hypoxic challenge are in concordance with the response to prolonged hypoxia remains to be determined.

Physiologic Cryoamputation in Managing Critically Ill Patients with Septic, Advanced Acute Limb Ischemia

Certain critically ill patients with advanced acute limb ischemia with a nonviable extremity may be unsuitable for transport to the operating room to undergo definitive amputation. In these unstable patients, rapid regional cryotherapy allows for prompt infectious source control and correction of hemodynamic and metabolic abnormalities, thereby lessening the risk associated with definitive surgical amputation. We describe our refined technique for lower extremity physiologic cryoamputation and review our institutional experience. After adequate analgesia is administered to the patient, a heating pad is secured circumferentially at the proximal amputation margin and the affected extremity is placed in a customized Styrofoam cooler. A circumferential seal is secured at the proximal chill zone without use of a tourniquet and dry ice is placed into the cooler to surround the entire affected leg. Delayed definitive lower extremity amputation is later performed when hemodynamic and metabolic derangements are corrected. We reviewed 5 patients who underwent lower extremity cryoamputation with this technique identified at our institution between 2005 and 2015. Age ranged from 31 to 79 years old. All presented with severe foot infection and septic shock requiring vasopressor support. All 5 patients stabilized hemodynamically following the initial cryoamputation and later underwent definitive lower extremity amputation, with a median time of 3 days following initial cryoamputation. Lower extremity physiologic cryoamputation is an effective, immediate bedside procedure that can provide local source control and the opportunity for correction of metabolic derangements in initially unstable patients to lessen the risk for definitive major lower extremity amputation. Refinement of the cryoamputation technique, as described in this report, allows for a predictable and reproducible physiologic amputation.

Insights into cardiorenal interactions in acute decompensated heart failure.

Acute decompensated heart failure (ADHF) is one of the biggest challenges in the management of chronic heart failure. Despite the advances in medical and device therapy, high readmission and mortality rates continue to be a burden on healthcare systems worldwide. One of the strongest predictors of adverse outcomes in ADHF is renal dysfunction, referred to as cardiorenal syndrome (CRS) type 1. This review discusses some of the recently introduced findings related to the pathophysiology, diagnosis, and management of this disorder. There is a better understanding of the pathophysiology of ADHF and CRS. Systemic and intrarenal hemodynamic data provided a much deeper insight into various mechanisms of interaction between the heart and the kidney. Novel biomarkers have been discovered and developed recently to help diagnose and predict prognosis of CRS. Although there was optimism toward using ultrafiltration in treating ADHF with CRS, recent data did not support that, and management remains primarily driven by reversing ADHF hemodynamic and neurohormonal derangements. ADHF with CRS carries poor prognosis and high mortality. There is a need for individual risk assessment and management. A dedicated experienced multidisciplinary team is needed to diagnose and manage patients with this problem. Different approaches are needed to address the complex elements of this disorder.

Predictors of survival in VA-ECMO: Whom should we cannulate?

The application of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is becoming an increasingly frequent procedure in emergency medicine.1 Correct appraisal of clinical conditions and patient selection are critical not only in terms of expected outcome, but also in terms of adequate temporary support configuration, optimization of resources, and organization of daily hospital activities, since inappropriate implant may remarkably impact all these aspects. According to recent analysis of ECMO use in the USA,1 VA-ECMO was most commonly applied in post-cardiac surgery candidates, however with a constant decline for the period from 2007 to 2011. Indeed, from 57% of the total ECMO cases, post-cardiotomy VA-ECMO went to 38%, but with a significant rise in cases of cardio-pulmonary failure (from 3.9 to 11.1%).1 This situation is certainly further changing during the last 5 years as VA-ECMO in cardiogenic shock and cardiac arrest is becoming more popular. Cardiac arrest: Patient selection in this setting is rather variable. However, potential cardiac etiology (acute myocardial infarction – AMI) represents almost 50% of the causes, and witnessed cardiac arrest, immediate cardio-pulmonary resuscitation (CPR) by bystanders, adequate CPR (possibly with mechanical cardiac massage devices), and not prolonged time from cardiac arrest to ECMO application ( &lt; 60 min) represent positive predictors in the setting of extracorporeal cardio-pulmonary resuscitation (ECPR).2 Recent publications have shown that ECPR might achieve respectful outcome also in elderly patients.3,4,5 Therefore, age should not disqualify potential candidates. Absence of severe acidosis and still acceptable end-tidal CO2 may represent additional elements for patient selection in this setting. Post-cardiotomy: ECMO results in this setting appear rather unsatisfactory with in-hospital survival below 30%.5 Prompt initiation of ECMO and avoiding unnecessary prolonged cardio-pulmonary bypass and metabolic as well as coagulation derangement are among the most relevant key factors. The absence of severe cardiac or co-morbidities prior to surgery and the expected temporary impairment of the cardio-respiratory systems represent additional indications for post-cardiotomy ECMO. Cardiogenic shock: This setting represents the most expanding field of ECMO application. Indications may derive from refractoriness of cardio-circulatory impairment to conventional therapies (drug and IABP). Moreover, in this setting, advanced age and severe co-morbidities may represent relative contraindications. Furthermore, in this field, the potential for cardiac recovery or the possibility to bridge the patient to other treatments, if recovery is considered unlikely, represents indication for ECMO use. Respiratory distress: VA-ECMO is generally indicated if right ventricular dysfunction is present or develops, and if VV-ECMO does not provide sufficient peripheral oxygenation. In the last case, hybrid configuration (VVA or VAV) might be more suitable and advisable. Uncommon indications: Sepsis, trauma (most often treated with VV-ECMO), fulminant myocarditis, Tako-Tsubo, or complicated interventional procedures (TAVI, PCI, balloon valvuloplasty) represent areas in which ECMO is increasingly applied.6,7 Despite wider use in these settings, more clinical evidences are still needed to conclusively define patient selection criteria and ultimate benefits. Finally, a developing indication might be prophylactic VA-ECMO in critically ill patients undergoing either cardiac surgery or interventional cardiological procedures. In these patients, in whom post-procedural severely complicated course is expected, timely and pre-crash support may help to provide a smooth peri-procedural period. Short-time controlled support of cardio-circulatory system and peripheral organ perfusion, with avoidance of metabolic and hemodynamic derangement, may also affect emergency VA-ECMO implant should patient deterioration occur, and allow a better complicated patient management with better final outcome.

Bougie assisted endotracheal intubation using the Air-Q™ Intubating Laryngeal Airway: A prospective randomized clinical study

BackgroundAir-Q™ Intubating Laryngeal Airway is an extraglottic airway device used as a primary airway tool or as an adjunct to tracheal intubation. The bougie is a simple flexible device that might increase the success rate of endotracheal intubation either blindly or through a supraglottic device. We hypothesized that using bougie guided intubation through air-Q™ can improve the success rate with minimal complications.MethodsOne hundred and forty patients of either sex, >18 years old, ASA I-II scheduled for elective surgical procedures under general anesthesia with intubation were randomly allocated to one of two groups of 70 patients each. Blind tracheal intubation was performed through air-Q™ with bougie assistance (Group B) or without (Group Q). In both groups, 3 attempts were allowed for successful device insertion. After obtaining normal capnographic wave, 3 more attempts were tried for intubation with or without bougie guidance. Lung ventilation through air-Q™ was permitted between intubation attempts. If tracheal intubation through air-Q™ was unsuccessful, it was performed by direct laryngoscopy.ResultsAir-Q™ time, ease, attempts number of insertion and ventilation grade were comparable between both groups. Total intubation time was significantly longer in group-B (P = 0.001) while overall success rate for intubation was comparable (64.3%). Group-B showed significant (P = 0.001) higher incidence of complications (trauma (P = 0.023), sore throat (P = 0.001), dysphonia (P = 0.023) and dysphagia (P = 0.001)) as compared with group-Q. In spite of significant decrease in both heart rate and mean arterial pressure in both groups after air-Q™ insertion, yet there was significant increase in both parameters after intubation compared to baseline values (P < 0.05) which was more prominent in group-B than in group-Q. Significant increase in HR and MAP was elicited after bougie placement in group-B (P < 0.01).ConclusionBougie guided tracheal intubation through air-Q™ didn’t improve overall success rate with significant longer time, hemodynamic derangement and traumatic sequelae.

Study to Compare the Effect of Oral, Rectal, and Intravenous Infusion of Paracetamol for Postoperative Analgesia in Women Undergoing Cesarean Section Under Spinal Anesthesia.

Background:Effective pain relief therapy after caesarean section is essential for the parturient's comfort and early ambulation. Paracetamol has an excellent safety profile when compared to opioids.Aim:To assess and evaluate the effect of oral, rectal, and intravenous infusion of paracetamol for post-operative analgesia in women undergoing caesarean section under spinal anaesthesia.Settings and Design:We conducted a prospective, randomized controlled study (18-35 years of age) of the ASA- I and II parturient scheduled for lower segment caesarean section were included.Methods and Materials:They were randomly allocated to 3 groups of 50 each. Group A received oral paracetamol tablet 650mg (1 tablet) 20min before shifting to operation room, group B received rectal paracetamol suppository 35-45 mg/kg immediately after spinal anaesthesia and group C received i.v. paracetamol infusion of 10-15mg/kg over 15min duration 20min before finishing the operation. Duration of analgesia was evaluated as primary outcome and other parameters as secondary outcome.Statistical Tests:All statistical analyses were performed using the SPSS statistical package 17.0 version. Results were analyzed using Chi Square test for non-parametric data and ANOVA for parametric data. P value of less than 0.05 was considered significant and less than 0.001 as highly significant.Results:Duration of analgesia was significantly longer in group B as compared to group A and C. The requirement of supplemental rescue analgesia was also lower in group B compared to group A and C. No significant haemodynamic derangements and adverse effects were noted among all the three groups.Conclusion:Paracetamol when given rectally improves the quality and duration of postoperative analgesia to a greater extent as compared to oral and intravenous route of paracetamol without any side effects.

SOFA score and left ventricular systolic function as predictors of short-term outcome in patients with sepsis.

In a group of septic patients, we assess the short-term prognostic value of LV systolic performance, evaluated through conventional left ventricular ejection fraction (LVEF) and left ventricular global longitudinal strain (LV GLS). One hundred forty-seven patients with sepsis were recruited; LVEF by planimetry and peak GLS by 2D speckle tracking could be assessed within 24h. The study population was stratified according to SOFA tertiles assessed at the time of the echocardiogram (G1: SOFA score <5; G2: SOFA score 5-7; G3: SOFA score >7). Day-7 follow-up data were used as reference. Patients in G2 and G3 show a significant hemodynamic derangement, paralleling the more pronounced organ damage by definition; nevertheless, LVEF and GLS are comparable among the three groups (both p>0.1). All-cause mortality at day-7 follow-up is slightly lower in G1 (9%) versus G2 and G3 (14 and 26%, respectively, p=NS). Analyses through ROC curves focusing on day-7 mortality show that the SOFA score fairly correlates with events (AUC 0.635, p=0.037), while low LVEF (AUC 0.35, p=0.022) and less negative GLS (AUC 0.73, p=0.001) do so. In multivariate analyses, mortality by day-7 follow-up is more likely per higher GLS (i.e., indicative of worst systolic dysfunction, HR 1.22/%, p=0.005) and per increasing SOFA score (HR 1.22/unit, p=0.010), whereas LVEF, adjusted for age and SOFA score, does not enter the prognostic model. In the very short term in patients with severe sepsis, LV systolic function assessment by means of GLS predicts the short-term prognosis, independent of SOFA.

Myocardial injury in patients with hemodynamic derangements during and/or after liver transplantation.

Myocardial injury, defined as an elevation of cardiac troponin (cTn) resulting from ischemia, is associated with substantial mortality in surgical patients, and its incidence, risk factors, and impact on patients undergoing liver transplantation (LT) are poorly understood. In this study, adult patients who experienced perioperative hemodynamic derangements and had cTn measurements within 30days after LT between 2006 and 2013 were studied. Of 502 patients, 203 (40.4%) met the diagnostic criteria (cTn I ≥0.1ng/mL) of myocardial injury. The majority of myocardial injury occurred within the first three postoperative days and presented without clinical signs or symptoms of myocardial infarction. Thirty-day mortality in patients with myocardial injury was 11.4%, significantly higher compared with that in patients without myocardial injury (3.4%, P<.01). Cox analysis indicated the peak cTn was significantly associated with 30-day mortality. Multivariable logistic analysis identified three independent risk factors: requirement of ventilation before transplant (odds ratios (OR) 1.6, P=.006), RBC≥15 units (OR 1.7, P=.006), and the presence of PRS (OR 2.0, P=.028). We concluded that post-LT myocardial injury in this high-risk population was common and associated with mortality. Our findings may be used in pretransplant stratification. Further studies to investigate this postoperative cardiac complication in all LT patients are warranted.