Hyperdynamic Patients Research Articles

Cardiodynamic state is associated with systemic inflammation and fatal acute-on-chronic liver failure.

Acute-on-chronic liver failure (ACLF) is characterized by high short-term mortality and systemic inflammation (SI). Recently, different cardiodynamic states were shown to independently predict outcomes in cirrhosis. The relationship between cardiodynamic states, SI, and portal hypertension and their impact on ACLF development remains unclear. The aim of this study was therefore to evaluate the interplay of cardiodynamic state and SI on fatal ACLF development in cirrhosis. At inclusion, hemodynamic measures including cardiac index (CI) and hepatic venous pressure gradient of 208 patients were measured. Patients were followed prospectively for fatal ACLF development (primary endpoint). SI was assessed by proinflammatory markers such as interleukins (ILs) 6 and 8 and soluble IL-33 receptor (sIL-33R). Patients were divided according to CI (<3.2; 3.2-4.2; >4.2L/min/m2 ) in hypo- (n=84), normo- (n=69) and hyperdynamic group (n=55). After a median follow-up of 3years, the highest risk of fatal ACLF was seen in hyperdynamic (35%) and hypodynamic patients (25%) compared with normodynamic (14%) (P=.011). Hyperdynamic patients showed the highest rate of SI. The detectable level of IL-6 was an independent predictor of fatal ACLF development. Cirrhotic patients with hyperdynamic and hypodynamic circulation have a higher risk of fatal ACLF. Therefore, the cardiodynamic state is strongly associated with SI, which is an independent predictor of development of fatal ACLF.

Surgical outcome in patients with biliary colic and atypical workup findings

BackgroundSurgical response of patients with symptomatic biliary colic but atypical findings of gallbladder polyps, hyper-dynamic gallbladder and otherwise negative biliary workup are underrepresented in the literature from community practice. MethodsA clinical outcome study with a retrospective design compared the short term and long term symptomatic improvement reported by patients with pre-operatively diagnosed biliary dyskinesia to all other biliary colic patients with atypical pre-operative diagnoses. All patients underwent surgery at Meridian Surgery Center from the years 2010–2017.600 patients were reviewed for biliary dyskinesia, gallbladder polyps, hyper-dynamic gallbladder and negative workup. ResultsShort term and long term results were compiled from a total 182 patients. Short term response rates were assessed from 74 biliary dyskinesia, 40 hyperdynamic, 23 gallbladder polyps, and 45 negative workup patients. Long term responses were received from 19 biliary dyskinesia patients, 11 hyperdynamic patients, 9 polyp patients, and 7 negative workup patients.Long term improvement among biliary dyskinesia patients was 84%, and 83% among patients with atypical findings, representing a long term drop in symptoms. There is no significant difference between symptom recovery of patients with biliary dyskinesia and those with another atypical diagnosis: hyper-dynamic (82%), polyps (89%), negative workup (57%). ConclusionThese results allow us to conclude that there is a comparable biliary colic improvement between biliary dyskinesia, gallbladder polyps, hyper-dynamic gallbladder and negative workup patients after cholecystectomy in both short term and long term follow up.

Antibiotic dose optimization in critically ill patients

The judicious use of existing antibiotics is essential for preserving their activity against infections. In the era of multi-drug resistance, this is of particular importance in clinical areas characterized by high antibiotic use, such as the ICU. Antibiotic dose optimization in critically ill patients requires sound knowledge not only of the altered physiology in serious infections – including severe sepsis, septic shock and ventilator-associated pneumonia – but also of the pathogen–drug exposure relationship (i.e. pharmacokinetic/pharmacodynamic index). An important consideration is the fact that extreme shifts in organ function, such as those seen in hyperdynamic patients or those with multiple organ dysfunction syndrome, can have an impact upon drug exposure, and constant vigilance is required when reviewing antibiotic dosing regimens in the critically ill. The use of continuous renal replacement therapy and extracorporeal membrane oxygenation remain important interventions in these patients; however, both of these treatments can have a profound effect on antibiotic exposure. We suggest placing emphasis on the use of therapeutic drug monitoring and dose individualization when optimizing therapy in these settings.

Antibiotic dose optimization in critically ill patients

The judicious use of existing antibiotics is essential for preserving their activity against infections. In the era of multi-drug resistance, this is of particular importance in clinical areas characterized by high antibiotic use, such as the ICU. Antibiotic dose optimization in critically ill patients requires sound knowledge not only of the altered physiology in serious infections – including severe sepsis, septic shock and ventilator-associated pneumonia – but also of the pathogen–drug exposure relationship (i.e. pharmacokinetic/pharmacodynamic index). An important consideration is the fact that extreme shifts in organ function, such as those seen in hyperdynamic patients or those with multiple organ dysfunction syndrome, can have an impact upon drug exposure, and constant vigilance is required when reviewing antibiotic dosing regimens in the critically ill. The use of continuous renal replacement therapy and extracorporeal membrane oxygenation remain important interventions in these patients; however, both of these treatments can have a profound effect on antibiotic exposure. We suggest placing emphasis on the use of therapeutic drug monitoring and dose individualization when optimizing therapy in these settings.

Outcomes of Pregnancies at Risk for Hypertensive Complications Managed Using Impedance Cardiography

We assessed the effect of antihypertensive therapy guided by impedance cardiography on maternal and fetal outcomes in pregnancies at risk for hypertensive complications. We performed a retrospective review of the outcomes of 318 singleton pregnancies with chronic hypertension or prior preterm delivery due to preeclampsia whose antihypertensive therapy was guided by impedance cardiography. Hemodynamic subsets were compared using analysis of variance. Impedance cardiography was used to evaluate cardiac output and total peripheral resistance starting at less than 24 weeks. All patients received atenolol; 24% required additional therapy with a vasodilator. The mean gestational age at delivery was 37 +/- 2 weeks. Preeclampsia developed in 14%. The incidence of birth weight less than the 10th percentile was 10%. There were no perinatal deaths, and 75% of the infants spent <3 days in the hospital. Hyperdynamic patients had less preeclampsia, less severe preeclampsia, fewer deliveries <34 weeks, and fewer neonatal intensive care unit days compared with those requiring a vasodilator. Antihypertensive therapy guided by hemodynamic information results in pregnancies delivering at or near term, little preeclampsia, and no increase in growth restriction. Hyperdynamic patients have better outcomes than patients with increased total peripheral resistance.

Pulmonary artery catheter: Rest in peace? Not just quite yet…

Patients with severe liver disease have a hyperdynamic circulation with an elevated cardiac output (CO), low systemic vascular resistance, and increased heart rate. During liver transplantation (LTx), most clinicians prefer to keep CO elevated in order to maintain tissue perfusion; this practice is based on common sense and supported indirectly by a clinical study by Parker et al. CO is one of the most important parameters that the anesthesiologist follows because it is a major factor in oxygen transport. Intraoperative hemodynamic management during LTx is based on the interpretation of the CO, heart rate, pulmonary artery (PA) pressures, filling pressures, and mixed-venous oxygen saturation (SvO2) and is influenced by the stage of the procedure and other factors (for example, the use of venovenous bypass). The pulmonary artery catheter (PAC) readily provides all this hemodynamic information, and every LTx anesthesiologist is very familiar with the PAC. Modified PACs give us continuous CO or additional information about the right ventricle (ejection fraction and end-diastolic and end-systolic volumes). The right ventricular ejection fraction catheter is used infrequently despite the better preload information it provides: filling pressures do not reflect preload very well because of compliance issues. Transesophageal echocardiography (TEE) gives other important hemodynamic information that is unavailable from the PAC: TEE allows the direct visualization of the volume status, overall contractility, regional wall motion, embolization, and large vessels. However, it does not provide the kind of hemodynamic information that is available from the PAC and is not as good at trending information (especially preload). Few LTx anesthesiologists are familiar with it, and the interpretation is highly user-dependent. Finally, TEE monitoring cannot be continued easily postoperatively. For these reasons, TEE is used fairly infrequently during LTx. The few anesthesiologists who do use TEE consider the information that it provides to be complementary to that provided by the PAC; in other words, TEE does not replace the PAC at this moment and is indicated only when there is a specific condition (for example, cardiac disease and pulmonary hypertension). In this issue of Liver Transplantation, 2 teams report that CO determined by ultrasound cardiac output monitoring (USCOM) correlates very well with thermodilution CO, the gold standard. These reports on USCOM are important because they are the first to document that in these hyperdynamic patients there is also a good correlation. USCOM is a noninvasive technique (the probe is placed at the suprasternal notch) and therefore is expected to have a very low complication rate. Whether USCOM-derived information such as the corrected flow time and stroke volume variation will provide clinically valuable information regarding preload, as promised by some, remains to be seen. Also, USCOM estimations of PA pressures based on Doppler interrogation of the PA remain unvalidated (especially in those with pulmonary hypertension), and the ability to estimate left ventricular contractility is currently just a promise. Particularly worrisome is that 3 of 13 patients in one of these studies were excluded: in 2 patients, diagnostic-quality images could not be obtained, and this occurred after the patients were screened preoperatively to see whether the suprasternal insonation window was appropriate.

Prevention of preeclampsia: a randomized trial of atenolol in hyperdynamic patients before onset of hypertension

Objective: To determine if assessment of maternal hemodynamics could predict women at risk for the development of preeclampsia, if treatment directed at hemodynamic abnormalities before the onset of hypertension could prevent preeclampsia, and if mothers could be treated in a way that protects fetal growth. Methods: A double-blinded, randomized controlled trial was conducted. Subjects were considered to be at risk for preeclampsia if their cardiac output was greater than 7.4 L/min before 24 weeks’ gestation. Nulliparous and diabetic subjects at risk were treated with 100 mg of atenolol or placebo. Cardiac output was measured by Doppler technique. Inulin and para-aminohippurate clearances were performed. Results: Treatment with atenolol reduced the incidence of preeclampsia from 5 of 28 (18%) to 1 of 28 (3.8%), ( P = .04). Nulliparous women determined to be at risk for preeclampsia were similar to diabetic women at risk. Each was significantly heavier and had inulin and para-aminohippurate clearances greater than the control group. Treatment with atenolol was associated with infants weighing 440 g less than infants in the nulliparous placebo group, ( P = .02). No effect on birth weight was seen in the diabetic patients. Mothers of the smallest infants who were treated with atenolol could be identified by unexpectedly large reductions in cardiac output. Conclusion: Measurement of cardiac output in the second trimester identified women at risk for preeclampsia. Treatment with atenolol decreased the incidence of preeclampsia. Nulliparous and diabetic women at risk for preeclampsia were similar with regard to maternal hemodynamics, maternal weight, and renal function. Treatment with atenolol was associated with reduced infant birth weight.

Dopexamine Hydrochloride in Septic Shock

To test whether dopexamine hydrochloride, by its beta 2-adrenoreceptor and dopaminergic 1 (DA1) and dopaminergic 2 (DA2) agonistic properties, can improve oxygen consumption (VO2) in hyperdynamic patients with septic shock. Prospective, single-cohort study. ICU, university hospital. Twenty-nine postoperative, hemodynamically stabilized, hyperdynamic patients with septic shock. Short-term application (30 min) of dopexamine hydrochloride at a dose of 2 microgram/kg/min. Complete hemodynamic profile with O2 transport-related variables at baseline, 30 min after starting the dopexamine infusion, and 30 min after stopping the infusion. The dopexamine infusion resulted in significant increases in cardiac index (17%) (p<0.001) and O2 delivery (DO2) (16%) (p<0.001). VO2 increased slightly but significantly about 4% (p<0.001) by respiratory gas exchange measurements and 9% (p<0.001) by cardiovascular Fick calculations. The O2 extraction ratio decreased about 8% (0.001). The addition of dopexamine hydrochloride at a dose of 2 microgram/kg/min resulted in significant increases of DO2 and to a lesser extent VO2. Much of the global DO2 increase was not utilized, because O2 extraction ratio decreased. Direct calorigenic effects of dopexamine and an increase in myocardial VO2 likely account for a large portion of the increase in global VO2. Whether any of the VO2 increase reflects improvement in regions of jeopardized tissue oxygenation remains to be clarified before the definite value of this drug in septic shock can be established.

Tissue oxygenation during liver transplantation.

a) To assess perioperative changes in tissue oxygenation parameters during liver transplantation; b) to evaluate the need for venovenous bypass as hemodynamic support; and c) to assess the efficacy of mixed venous oxygen saturation monitoring and the importance of lactate determinations in the management of patients following liver transplantation. Prospective case series. Liver transplant unit in a university hospital. A total of 68 consecutive patients undergoing liver transplantation. The entire population was analyzed before and after transplantation, dividing the patients into two groups, based on whether their initial cardiac index was higher (n = 37) or lower (n = 31) than 4.5 L/min/m2. Hemodynamic measurements and blood gas analyses were made before incision, before vascular clamping (including hepatic artery, portal vein and inferior vena cava), during the anhepatic phase, and at 5, 30, 60, and 120 mins following unclamping. Oxygen transport and oxygen consumption values were calculated. Serum lactate concentrations were measured by enzymatic technique. Mixed venous oxygen saturation was correlated with oxygen transport (Do2) in the whole population in which an abnormal oxygen consumption (Vo2)-Do2-dependent relationship occurred from the beginning of operation until 30 mins following unclamping. The comparison between hyperdynamic patients (initial cardiac index greater than 4.5 L/min/m2) with impaired tissue oxygenation and normodynamic patients showed that mixed venous oxygen saturation failed to correlate with Do2 when the cardiac index was greater than 4.5 L/min/m2 and that the Vo2-Do2 dependency was only noted in these patients. The serum lactate concentrations were similar in both groups. The Vo2-Do2-dependent relationship and mixed venous oxygen saturation-Do2 correlation noted in the 68 studied patients suggest the need for venovenous bypass and the reliability of mixed venous oxygen saturation monitoring in all patients scheduled for liver transplantation. However, a sharper comparison between hyperdynamic and normodynamic patients demonstrated the lack of efficacy of mixed venous oxygen saturation monitoring in predicting adequate tissue oxygenation in the first group and the mandatory need for venous shunting to limit tissue hypoxia which occurred despite its use only in these patients. Lactic acidosis appeared similarly in both groups and could not be linked to tissue hypoxia.

Relative myocardial depression in normotensive sepsis

To assess biventricular performance in normotensive sepsis, the measurements of cardiovascular function in 69 septic patients were compared with those in 18 similarly hyperdynamic patients who had sustained multisystem trauma. All studies were performed following initial resuscitation, during a period in which the blood pressure was stable and no sympathomimetics were required. Although the two study groups demonstrated a similar increase in the mean cardiac index (CI), and similar levels of systemic oxygen transport and consumption, the machanisms by which these groups maintained the high Cl were dissimilar. Mean ejection fractions were significantly lower in the septic group than in the trauma group for both the left ventricles (0.49 ± 0.13 v 0.62 ± 0.10; P < .001) and right ventricles (0.41 ± 0.10 v 0.50 ± 0.10; P < .005). Concurrently, mean end-diastolic volume indexes were significantly greater in the septic group for both the left ventricles (97 ± 31 v 74 ± 18 mL/m 2; P < .005) and right ventricles(117 ± 45 v 91 ± 25 mL/m 2; P < .05). Thus, indexes of myocardial performance influenced by ventricular contractility were not augmented in septic patients to the same degree as was found in a similarly hyperdynamic reference group. This study suggests that normotensive, hyperdynamic sepsis is associated with a “relative” depression in biventricular contractile performance when compared with a reference group of similarly hypermetabolic, but nonseptic, patients.