Hemodynamic Resuscitation Research Articles

Increased atrial contraction contribution to left ventricular filling during early septic shock

PurposeTo assess the atrial systolic function and the contribution of atrial contraction to left ventricular (LV) filling in septic shock patients as compared with healthy volunteers. MethodsTwenty-seven septic patients evaluated during first 48 h of ICU admission and compared with 27 healthy volunteers. Left atrial (LA) contraction contribution to LV filling was calculated as the active emptying atrial volume/LV end-diastolic volume. Atrial systolic function was evaluated with the atrial kinetic force [LAKE = 0.5 × blood density × LVVactive × (peak A velocity)2] and atrial ejection force [LASF = 0.5 × blood density × mitral annulus area × (peak A velocity)2]. ResultsLV ejection fraction was lower in septic patients than in control group: 51 ± 14%vs 60 ± 6% (p < 0.01). Contribution of LA contraction to LV preload was greater in septic patients than in normal subjects (26.7 ± 11.3% vs 15.9 ± 5.9%, p < 0.001), even if adjusted for age (0.49 ± 0.19 vs 0.35 ± 0.13, p = 0.004). LAKE and LASF were also significantly larger in septic patients than in normal subjects (21.8 ± 9.1 vs 7.3 ± 3 kdynes·cm, p < 0.001; 16.1 ± 11.7 vs 9.8 ± 4.3 kdynes, p = 0.048, respectively), and remained unchanged during the next 48 h. ConclusionIn septic shock patients, LA systolic function increased and greatly contributed to support LV filling. These results highlight the role of preserving atrial contraction on the hemodynamic resuscitation in early septic shock.

Mikrosirkulasi Pada Resusitasi Cairan

The aim of fluid therapy during hemodynamic resuscitation is to increase global blood flow and increase flow to themicrocirculation and therby, and thus oxygen availability for cellular respiration. Effect of volume expansion onmicrovascular perfusion might not always be in coherence with its macrocirculatory. It should be stressed that the totalamount of volume administered during fluid resuscitation is believed to be a major determinant of outcome in criticallyill shock patients. The purpose of this review is to evaluate the boundaries of macrohemodynamic approach to fluidadministration and the integrated with microcirculatory.

Comparison of hemodynamic effects and resuscitation outcomes between automatic simultaneous sterno-thoracic cardiopulmonary resuscitation device and LUCAS in a swine model of cardiac arrest.

IntroductionMechanical cardiopulmonary resuscitation (CPR) devices are widely used to rescue patients from cardiac arrest. This study aimed to compare hemodynamic effects and resuscitation outcomes between a motor-driven, automatic simultaneous sterno-thoracic cardiopulmonary resuscitation device and the Lund University cardiac arrest system (LUCAS).Material and methodsAfter 2 minutes of electrically induced ventricular fibrillation (VF), Yorkshire pigs (weight 35–60 kg) received CPR with an automatic simultaneous sterno-thoracic CPR device (X-CPR group, n = 13) or the Lund University cardiac arrest system (LUCAS group, n = 12). Basic life support for 6 minutes and advanced cardiovascular life support for 12 minutes, including defibrillation and epinephrine administration, were provided. Hemodynamic parameters and resuscitation outcomes, including return of spontaneous circulation (ROSC), 24-hour survival, and cerebral performance category (CPC) at 24 hours, were evaluated.ResultsHemodynamic parameters, including aortic pressures, coronary perfusion pressure, carotid blood flow, and end-tidal carbon dioxide pressure were not significantly different between the two groups. Resuscitation outcomes were also not significantly different between the groups (X-CPR vs. LUCAS; rate of ROSC: 31% vs 25%, p = 1.000; 24-hour survival rate: 31% vs 17%, p = 0.645; neurological outcome with CPC ≤2: 31% vs 17%, p = 0.645). Also no significant difference in incidence complications associated with resuscitation was found between the groups.ConclusionsCPR with a motor-driven X-CPR and CPR with the LUCAS produced similar hemodynamic effects and resuscitation outcomes in a swine model of cardiac arrest.

Fournier Gangrene: A Review for Emergency Clinicians.

Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality, with many patients requiring emergency department (ED) management for complications and stabilization. This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of FG. Although originally thought to be an idiopathic process, FG has been shown to have a strong association for male patients with advanced age and comorbidities affecting microvascular circulation and immune system function, most commonly those with diabetes or alcohol use disorder. However, it can also affect patients without risk factors. The initial infectious nidus is usually located in the genitourinary tract, gastrointestinal tract, or perineum. FG is a mixed infection of aerobic and anaerobic bacterial flora. The development and progression of gangrene is often fulminant and can rapidly cause multiple organ failure and death, although patients may present subacutely with findings similar to cellulitis. Laboratory studies, as well as imaging including point-of-care ultrasound, conventional radiography, and computed tomography are important diagnostic adjuncts, though negative results cannot exclude diagnosis. Treatment includes emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and resuscitation with intravenous fluids and vasoactive medications. FG requires a high clinical level of suspicion, combined with knowledge of anatomy, risk factors, and etiology for an accurate diagnosis. Although FG remains a clinical diagnosis, relevant laboratory and radiography investigations can serve as useful adjuncts to expedite surgical management, hemodynamic resuscitation, and antibiotic administration.

Low-Dose Landiolol Reduces Heart Rate and Cardiac Oxygen Consumption Without Compromising Initial Hemodynamic Resuscitation in a Canine Model of Endotoxin Shock.

In septic shock, it is not known whether β-blocker can be used to reduce heart rate (HR) safely during the initial phase of hemodynamic resuscitation. The purpose of this study was to experimentally investigate the effects of low-dose landiolol, a β-blocker, on initial hemodynamic resuscitation in dogs with endotoxin shock. In 13 anesthetized dogs [n = 7 in control (CT) group, n = 6 in β-blockade (BB) group], after endotoxin shock was induced by intravenous infusion of lipopolysaccharide (4 mg kg), we started hemodynamic resuscitation to restore mean arterial pressure (AP) and cardiac output (CO) by infusing noradrenaline (NA) and Ringer acetate solution (RiA). During 4 h of hemodynamic resuscitation, dose of NA and RiA were automatically titrated with use of a computer-controlled drug infusion system that we developed previously. In BB group, landiolol was administered at a low-dose range (1-10 μg kg min) to lower HR to lower than 140 bpm. Hemodynamic resuscitation using the system restored AP to 70 mmHg and CO to greater than 90% of baseline level similarly in both groups. Throughout resuscitation, HR and indices of cardiac contractility were significantly lower in BB group than in CT group. However, there were no significant intergroup differences in the dose of NA and RiA. During First 2 h of resuscitation, cardiac oxygen consumption was significantly lower in BB group than in CT group. In conclusion, low-dose landiolol may reduce HR without compromising initial hemodynamic resuscitation in septic shock. To clearly establish this, large-size randomized study using animal models more relevant to septic shock is needed.

How can CO2-derived indices guide resuscitation in critically ill patients?

Assessing the adequacy of oxygen delivery with oxygen requirements is one of the key-goal of haemodynamic resuscitation. Clinical examination, lactate and central or mixed venous oxygen saturation (SvO2 and ScvO2, respectively) all have their limitations. Many of them may be overcome by the use of the carbon dioxide (CO2)-derived variables. The venoarterial difference in CO2 tension ("ΔPCO2" or "PCO2 gap") is not an indicator of anaerobic metabolism since it is influenced by the oxygen consumption. By contrast, it reliably indicates whether blood flow is sufficient to carry CO2 from the peripheral tissue to the lungs in view of its clearance: it, thus, reflects the adequacy of cardiac output with the metabolic condition. The ratio of the PCO2 gap with the arteriovenous difference of oxygen content (PCO2 gap/Ca-vO2) might be a marker of anaerobiosis. Conversely to SvO2 and ScvO2, it remains interpretable if the oxygen extraction is impaired as it is in case of sepsis. Compared to lactate, it has the main advantage to change without delay and to provide a real-time monitoring of tissue hypoxia.

Septic shock in the ER: diagnostic and management challenges.

Sepsis is a common presentation in the emergency department and a common cause of intensive care unit admissions and death. Accurate triage, rapid recognition, early resuscitation, early antibiotics, and eradication of the source of infection are the key components in delivering quality sepsis care. Evaluation of the patient’s volume status, optimal hemodynamic resuscitation, and evaluation of patient response is crucial for sepsis management in the emergency department.

The Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis, a multicentre observational study (ARISE FLUIDS observational study): Rationale, methods and analysis plan.

There is uncertainty about the optimal i.v. fluid volume and timing of vasopressor commencement in the resuscitation of patients with sepsis and hypotension. We aim to study current resuscitation practices in EDs in Australia and New Zealand (the Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis [ARISE FLUIDS] observational study). ARISE FLUIDS is a prospective, multicentre observational study in 71 hospitals in Australia and New Zealand. It will include adult patients presenting to the ED during a 30 day period with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation. We will obtain data on baseline demographics, clinical and laboratory variables, all i.v. fluid given in the first 24 h, vasopressor use, time to antimicrobial administration, admission to intensive care, organ failure and in-hospital mortality. We will specifically describe (i) the volume of fluid administered at the following time points: when meeting eligibility criteria, in the first 6 h, at 24 h and prior to vasopressor commencement and (ii) the frequency and timing of vasopressor use in the first 6 h and at 24 h. Screening logs will provide reliable estimates of the proportion of ED patients meeting eligibility criteria for a subsequent randomised controlled trial. This multicentre, observational study will provide insight into current haemodynamic resuscitation practices in patients with sepsis and hypotension as well as estimates of practice variation and patient outcomes. The results will inform the design and feasibility of a multicentre phase III trial of early haemodynamic resuscitation in patients presenting to ED with sepsis and hypotension.

A rare cause of postpartum hemorrhage: the genital thrombus

We report the case of a 30-year old primiparous patient, having given birth to a 3500g boy by cesarean section due to acute fetal distress. Two hours after childbirth, the patient had bilateral painful ecchymotic vulvar swelling suggesting post-partum thrombus of the vulva. Given the clinical stability of the size of this hematoma, the absence of unbearable pain and the stable hemodynamic status, conservative medical treatment (ice bag + NSAIDs). Output was favorable with progressive decrease in the size of the hematoma until disappearance 8 weeks after delivery. Thrombus or genital hematoma is a rare but potentially very serious post-partum haemorrhagic complication. There are four major types of genital hematomas: hematoma of the vulva, vulvo-vaginal hematoma, vaginal hematoma and pelvic-abdominal hematoma. The contributing factors are primiparity, instrumental extractions, toxaemia of pregnancy, twin pregnancies and vulvovaginal varicose veins. It is essential to suspect it in patients with pain and/or internal postpartum hemorrhage, and, if any doubt exists, to perform vulvovaginal inspection. Early treatment is necessary and should be associated with hemodynamic resuscitation, first-line surgery and percutaneous radiologic arterial embolization in case of failure of surgery.

Pre-clinical study protocol: Blood transfusion in endotoxaemic shock

The Surviving Sepsis Campaign (SCC) and the American College of Critical Care Medicine (ACCM) guidelines recommend blood transfusion in sepsis when the haemoglobin concentration drops below 7.0 g/dL and 10.0 g/dL respectively, while the World Health Organisation (WHO) guideline recommends transfusion in septic shock ‘if intravenous (IV) fluids do not maintain adequate circulation’, as a supportive measure of last resort. Volume expansion using crystalloid and colloid fluid boluses for haemodynamic resuscitation in severe illness/sepsis, has been associated with adverse outcomes in recent literature. However, the volume expansion effect(s) following blood transfusion for haemodynamic circulatory support, in severe illness remain unclear with most previous studies having focused on evaluating effects of either different RBC storage durations (short versus long duration) or haemoglobin thresholds (low versus high threshold) pre-transfusion.•We describe the protocol for a pre-clinical randomised controlled trial designed to examine haemodynamic effect(s) of early volume expansion using packed RBCs (PRBCs) transfusion (before any crystalloids or colloids) in a validated ovine-model of hyperdynamic endotoxaemic shock.•Additional exploration of mechanisms underlying any physiological, haemodynamic, haematological, immunologic and tissue specific-effects of blood transfusion will be undertaken including comparison of effects of short (≤5 days) versus long (≥30 days) storage duration of PRBCs prior to transfusion.

Abstract 236: Lactate Level at the Scene of Injury can Accurately Predict the Need for Massive Transfusion

Introduction: The lactate has been widely recognized as a marker of tissue hypoxia/hypoperfusion. Hyperlactatemia is common among patients requiring critical care, and lactate levels and their trend may be reliable markers of illness severity and mortality. Elevated plasma lactate levels have been recommended as a parameter for hemodynamic resuscitation. The aim of this study is to investigate the predictive value of the lactate levels at the scene of injury for the need for Massive Transfusion (MT). Patients and Methods: A single-center retrospective diagnostic study was conducted. The records of the emergency medical service (EMS) between Sep. 2012 and Apr. 2017 were reviewed and adult high-energy trauma patients transported by the EMS were included. The data about the lactate levels and the need for MT (10 units or more of packed red blood cells transfusion within 24 hours of injury) was collected, and the predictive value of the lactate levels at the scene of injury was analyzed by the area under the receiver operating characteristic curve (AUROC). Our EMS system is always with specialized emergency physician, and lactate level was measured by portable equipment. Results: 1039 patients were enrolled and 1025 patients were analyzed after exclusion of 14 patients with insufficient data. The mean age was 55.0 years, 77.6% male, 98.1% blunt trauma, and 6.6% underwent MT. The AUROC of the lactate levels at the scene of injury for MT was 0.91 [95% confidential interval; 0.90-0.93]. Conclusion: The lactate levels at the scene of injury can accurately predict the need for Massive Transfusion. The further investigation is warranted.

Traumatic Spinal Cord Injury

Traumatic spinal cord injury currently affects approximately 285,000 persons in the United States and carries with it significant morbidity and cost. Early management focuses on adequate ventilation and hemodynamic resuscitation of the patient and limiting motion of the spine to prevent a second injury. Medical management targets maintenance of adequate blood flow to the spinal cord, whereas surgical management focuses on decompression, realignment, and stabilization of the vertebral column. In this chapter, we discuss the approach to the patient with traumatic spinal cord injury, injury types, and medical and surgical management. This review contains 9 figures, 4 tables and 30 references Key Words: American Spinal Injury Association score, burst fracture, Chance fracture, compression fracture, hangman, mean arterial pressure therapy, odontoid fracture, spinal cord injury, traction

What Is the Best Endoscopic Strategy in Acute Non-variceal Gastrointestinal Bleeding?

PURPOSE OF REVIEW: Upper non-variceal gastrointestinal bleeding (UNVGIB) remains an important clinical challenge for endoscopists, requiring skill and expertise for correct management. In this paper, we suggest the best strategy for an effective treatment of this complex category of patients. Early endoscopic examination, the increasingly widespread use of endoscopic hemostasis methods, and the most powerful antisecretory agents that induce clot stabilization have radically modified the clinical scenario for treating this pathology. While hospitalization for digestive hemorrhage is decreasing, the incidence of bleeding seems to be increasing, especially in the elderly for whom a greater use of gastrolesive drugs and the presence of comorbidities are more common. A multidisciplinary approach for initial patient evaluation and hemodynamic resuscitation prior to endoscopic treatment is crucial for correct management, prevention of rebleeding, and reduction of morbidity and mortality rates and hospital stays. Appropriate operator technical expertise, together with the availability of a wide range of endoscopes and devices, is mandatory. Newer endoscopic techniques may improve patient outcomes for difficult-to-treat lesions. Today, endoscopic hemostasis can be achieved in over 95% of patients.

Diagnostic accuracy of a calibrated abdominal compression to predict fluid responsiveness in children

BackgroundFluid administration to increase stroke volume index (SVi) is a cornerstone of haemodynamic resuscitation. We assessed the accuracy of SVi variation during a calibrated abdominal compression manoeuvre (ΔSVi-CAC) to predict fluid responsiveness in children. MethodsPatients younger than 8 yr with acute circulatory failure, regardless of their ventilation status, were selected. SVi, calculated as the average of five velocity–time integrals multiplied by the left ventricular outflow tract surface area, was recorded at four different steps: baseline, after an abdominal compression with a calibrated pressure of 25 mm Hg, after return to baseline, and then after a volume expansion (VE) of 10 ml kg−1 lactated Ringer solution over 10 min. Patients were classified as responders if SVi variation after volume expansion (ΔSVi-VE) increased by at least 15%. ResultsThe 39 children included had a median [inter-quartile range (IQR)] age of 9 [5–31] months. Twenty patients were fluid responders and 19 were non-responders. ΔSVi-CAC correlated with ΔSVi-VE (r=0.829; P<0.001). The area under the receiver operating characteristic curve (ROCAUC) was 0.94 [95% confidence interval (CI), 0.85–0.99]. The best threshold for ΔSVi-CAC was 11% with a specificity of 95% [95% CI, 84–100] and a sensitivity of 75% [95% CI, 55–95]. ROCAUC of respiratory variation of IVC diameter (ΔIVC) was 0.53 [95% CI, 0.32–0.72]. ConclusionΔSVi-CAC during abdominal compression was a reliable method to predict fluid responsiveness in children with acute circulatory failure regardless of their ventilation status. Clinical trials registrationCPP Lyon sud est II: n° ANSM 2015-A00388-41 Clinicaltrial.gov: NCT02505646.

Early Hemodynamic Management of Critically Ill Burn Patients.

The challenge of initial hemodynamic resuscitation of severe burn patients is in avoiding under- and over-resuscitation associated with bad outcome. This review aims to propose strategies for the initial hemodynamic management of severe burns. Supplemental Digital Content is available in the text.

Traumatic Spinal Cord Injury

Traumatic spinal cord injury currently affects approximately 285,000 persons in the United States and carries with it significant morbidity and cost. Early management focuses on adequate ventilation and hemodynamic resuscitation of the patient and limiting motion of the spine to prevent a second injury. Medical management targets maintenance of adequate blood flow to the spinal cord, whereas surgical management focuses on decompression, realignment, and stabilization of the vertebral column. In this chapter, we discuss the approach to the patient with traumatic spinal cord injury, injury types, and medical and surgical management. This review contains 9 figures, 4 tables and 30 references Key Words: American Spinal Injury Association score, burst fracture, Chance fracture, compression fracture, hangman, mean arterial pressure therapy, odontoid fracture, spinal cord injury, traction

Traumatic Spinal Cord Injury

Traumatic spinal cord injury currently affects approximately 285,000 persons in the United States and carries with it significant morbidity and cost. Early management focuses on adequate ventilation and hemodynamic resuscitation of the patient and limiting motion of the spine to prevent a second injury. Medical management targets maintenance of adequate blood flow to the spinal cord, whereas surgical management focuses on decompression, realignment, and stabilization of the vertebral column. In this chapter, we discuss the approach to the patient with traumatic spinal cord injury, injury types, and medical and surgical management. This review contains 9 figures, 4 tables and 30 references Key Words: American Spinal Injury Association score, burst fracture, Chance fracture, compression fracture, hangman, mean arterial pressure therapy, odontoid fracture, spinal cord injury, traction

Traumatic Spinal Cord Injury

Traumatic spinal cord injury currently affects approximately 285,000 persons in the United States and carries with it significant morbidity and cost. Early management focuses on adequate ventilation and hemodynamic resuscitation of the patient and limiting motion of the spine to prevent a second injury. Medical management targets maintenance of adequate blood flow to the spinal cord, whereas surgical management focuses on decompression, realignment, and stabilization of the vertebral column. In this chapter, we discuss the approach to the patient with traumatic spinal cord injury, injury types, and medical and surgical management. This review contains 9 figures, 4 tables and 30 references Key Words: American Spinal Injury Association score, burst fracture, Chance fracture, compression fracture, hangman, mean arterial pressure therapy, odontoid fracture, spinal cord injury, traction

Traumatic Spinal Cord Injury

Traumatic spinal cord injury currently affects approximately 285,000 persons in the United States and carries with it significant morbidity and cost. Early management focuses on adequate ventilation and hemodynamic resuscitation of the patient and limiting motion of the spine to prevent a second injury. Medical management targets maintenance of adequate blood flow to the spinal cord, whereas surgical management focuses on decompression, realignment, and stabilization of the vertebral column. In this chapter, we discuss the approach to the patient with traumatic spinal cord injury, injury types, and medical and surgical management. This review contains 9 figures, 4 tables and 30 references Key Words: American Spinal Injury Association score, burst fracture, Chance fracture, compression fracture, hangman, mean arterial pressure therapy, odontoid fracture, spinal cord injury, traction

Pre-operative haemodynamic monitoring and resuscitation in hip fracture patients: Protocol for a prospective observational study.

In a frail patient group often suffering from dehydration, hip fracture is potentially fatal partly because of the blood loss and thus deteriorated circulation. An important goal for haemodynamic monitoring and resuscitation is early detection of insufficient tissue perfusion. "The peripheral perfusion index" reflects changes in peripheral perfusion and blood volume. We hypothesize that hip fracture patients are hypovolaemic with poor peripheral perfusion and accordingly respond to controlled fluid resuscitation. The peripheral perfusion index might reflect restricted tissue perfusion in spite of stable central haemodynamic variables. This prospective observational study assess to what extend hip fracture patients suffer from hypovolaemia and respond to a stroke volume-guided fluid challenge. The secondary objectives are to evaluate correlation between the non-invasive peripheral perfusion index and minimally invasive measures of stroke volume, changes in blood volume and near-infrared spectroscopy determined tissue- and cerebral oxygenation and to compare results to prevalence of post-operative complications including mortality. We will include 50 patients (>65years) presenting a hip fracture and treated in a multimodal fast-track regimen when written informed consent is available. This is likely the first study to address pre-operative haemodynamic monitoring and resuscitation in hip fracture patients where adequate resuscitation is easily missed. We aim to evaluate feasibility of pre-operative stroke volume-guided haemodynamic optimization in the context of minimally- and non-invasive monitoring of peripheral perfusion and measure of blood volume.