Impaired Venous Return Research Articles

A kidney gone astray under pressure.

A 58-year-old man underwent elective repair of a type 2 thoracoabdominal aortic aneurysm. On post-operative day 10, he developed acute onset of dyspnoea and abdominal pain. He was hypotensive and oliguric, with a rigid and distended abdomen. Laboratories showed acute renal failure (ARF) with a rise in the serum creatinine to 2.7 mg/dL from a baseline of 1.4 mg/dL. Intra-abdominal pressure (IAP) measured via intravesical cannulation was 47 mmHg, consistent with grade 4 intra-abdominal hypertension [1]. A diagnosis of abdominal compartment syndrome (ACS) was made. Computed tomography (CT) of the abdomen and pelvis revealed a massive retroperitoneal fluid collection (asterisk) displacing the left kidney (solid arrow) from its normal position into the right upper quadrant (Figure ​(Figure1).1). The spleen (arrowhead) and bowel were also shifted, while the right kidney (hollow arrow) remained in the right retroperitoneum. Emergent decompressive laparotomy was performed with evacuation of 10 L of fluid and placement of a retroperitoneal drain. IAP decreased to 8 mmHg with resolution of the ARF. During his convalescence, the patient had persistently high drain outputs of 4–5 L a day suspicious for a chyle leak. After post-pyloric administration of heavy cream, the retroperitoneal fluid triglyceride level increased from 16 mg/dL to 477 mg/dL consistent with chylous fluid. The retroperitoneum was explored and multiple chyle leaks were seen along the aortic aortomy in the aneurysm sac and were ligated. The patient made a full recovery, and a subsequent CT angiogram to evaluate the aneurysm repair demonstrated return of the left kidney (solid arrow) to its normal position (Figure ​(Figure22). Fig. 1 Contrast-enhanced computed tomography of the abdomen and pelvis. The abdominal contents, including the left kidney (solid arrow) and spleen (arrowhead), are displaced into the right upper quadrant by a large retroperitoneal fluid collection (asterisk). ... Fig. 2 Contrast-enhanced computed tomography of the abdomen and pelvis performed 2 months after abdominal decompression. The retroperitoneal fluid collection is no longer present and the left (solid arrow) and right (hollow arrow) kidneys are back to their normal ... ACS is common in critically ill patients after abdominal trauma or surgery or aggressive volume resuscitation with the development of ascites. Renal injury is thought to be due to decreased renal perfusion from extrinsic compression of the kidneys and low cardiac output from impaired venous return [2]. Abdominal decompression is the hallmark of treatment in severe cases. Although ACS is an infrequent complication of aortic surgery, vigilance should be maintained as this case illustrates. Conflict of interest statement. None declared.

Physiological implications of high‐heeled shoes on the venous return for healthy women

Walking with high‐heeled shoes is a common cause of venous complains like pain, fatigue and heavy legs feeling. In this study, we tested the hypothesis that women using different high‐heeled shoes present an impaired venous return when compared with themselves barefooted. Women without venous disease were evaluated with Air Plethysmograpy, a test that measures changes in air volume on a cuff placed on the calf, while they perform orthostatic flexion and extension foot movements. The test was repeated 4 times: barefooted, with 3.5 cm heel, 7cm heel, and platform heel. The values for the parameters of Venous Filling Index (VFI), Ejection Fraction (EF), Residual Volume Fraction (RVF) were separated in 4 groups, one for each test situation in order to compare them applying Two Way Analysis of Variance. It was found that, on the 7cm high‐heel group, the EF reduces and the RVF increases in relation to barefooted group (p<0,05). The platform heel group presents an increase for RVF values compared with barefooted group (p<0,05). There is no statistical difference when comparing the 3.5 cm high‐heel with the other groups. VFI values did not show difference among the 4 groups. These results indicate that the 7cm and platform heels impair the muscle pump what changes the venous physiology. This is demonstrated by the increase on FVR values. The absence of variation for VFI indicates that the venous valves competence is preserved. FAEPA.

The Lazarus phenomenon

Even though Lazarus phenomenon is rare, it is probably under reported. There is no doubt that Lazarus phenomenon is a reality but so far the scientific explanations have been inadequate. So far the only plausible explanation at least in some cases is auto-PEEP and impaired venous return. In patients with PEA or asystole, dynamic hyperinflation should considered as a cause and a short period of apnoea (30–60 seconds) should be tried before stopping resuscitation. Since ROSC occurred within 10 minutes in most cases, patients should be passively monitored for at least 10 minutes after the cessation of CPR before confirming death.

The Lazarus phenomenon.

Even though Lazarus phenomenon is rare, it is probably under reported. There is no doubt that Lazarus phenomenon is a reality but so far the scientific explanations have been inadequate. So far the only plausible explanation at least in some cases is auto-PEEP and impaired venous return. In patients with PEA or asystole, dynamic hyperinflation should considered as a cause and a short period of apnoea (30-60 seconds) should be tried before stopping resuscitation. Since ROSC occurred within 10 minutes in most cases, patients should be passively monitored for at least 10 minutes after the cessation of CPR before confirming death.

Anesthetic management of an extremely obese patient

We present the case of a morbidly obese woman, with a body mass index (BMI) of 73.7 kg.m(-2), who had a gynecological operation under combined general and epidural anesthesia. The patient's trachea was intubated, using a fiberscope, while she was breathing spontaneously after the intravenous injection of fentanyl and propofol as sedatives. Anesthesia was maintained with intravenous propofol and epidural mepivacaine. When the gynecologist placed a sponge in the abdominal cavity to retract the bowel, the patient experienced severe arterial deoxygenation and mild hypotension, due to massive atelectasis of the left lung. Both oxygenation and perfusion were corrected by the removal of the sponge and with the placement of a pillow under the patient's left shoulder. The atelectasis resulted from compression of the left lung by the fatty mediastinum and by the diaphragm being pushed up by the sponge. The hypotension resulted from impaired venous return and hypoxia. The patient suffered no perioperative complications other than atelectasis and a surgical-site infection. Key factors that contributed to the favorable outcome of this patient included a careful tracheal intubation technique, the choice and dose of anesthetic agents, immediate correction of the factors leading to atelectasis, early ambulation, and prophylaxis for deep vein thrombosis.

Acute Pericardial Effusion during Endovascular Intervention for Superior Vena Cava Syndrome: Case Series and Review

We describe three cases of acute pericardial effusion during endovascular treatment of superior vena cava (SVC) syndrome, one of which resulted in fatal pericardial tamponade. SVC syndrome results from impaired venous return from the head and upper extremities to the right atrium. Malignancy and catheter-induced SVC stenosis accounts for the majority of cases of SVC syndrome. Endovascular therapy is the treatment of choice for SVC syndrome due to its rapid relief of symptoms and low morbidity. Acute pericardial effusion and pericardial tamponade may result from inadvertent extraluminal traversal of the SVC in the so-called danger zone above the right atrium, as well as secondary to dissection of wires in a location where fascial planes have been altered by neoplasia or inflammation.

Prenatal Tracheal Obstruction Due to Double Aortic Arch: A Potential Mimic of Congenital High Airway Obstruction Syndrome

WEB This is a Web exclusive article. ouble aortic arch is a relatively common congenital anomaly of the aortic arch system resulting from failed regression of the fourth pharyngeal arch arteries. Symptoms develop postnatally due to compression of the trachea and esophagus, which are encircled by the left and right aortic arches. The classic history is noisy breathing during the first few weeks of life, and the diagnosis is usually confirmed by postnatal echocardiography or MRI. Prenatal diagnosis is rare [1, 2], and double aortic arch has not been previously described as a cause of prenatal tracheal obstruction, to our knowledge. Congenital high airway obstruction syndrome (CHAOS) is a recognized cause of prenatal central airway obstruction due to intrinsic atresia or stenosis of the larynx or upper trachea. CHAOS causes pulmonary overdistention due to retained bronchial secretions. Increased intrathoracic pressure with impaired venous return is believed to account for the associated development of fetal hydrops. The resulting constellation of large echogenic lungs with flattening or inversion of the diaphragm, dilated fluid-filled airways below the level of obstruction, and fetal hydrops or ascites is considered characteristic of CHAOS on prenatal sonography. Untreated CHAOS inevitably leads to fetal demise or stillbirth [3–5]. We present a case of double aortic arch that caused prenatal central airway obstruction and that mimicked CHAOS on fetal echocardiography and MRI.

Nonimmune Hydrops Fetalis in the Liveborn: Series of 32 Autopsies

Nonimmune hydrops fetalis (NIHF) or generalized soft tissue edema and cavity effusions may be due to cardiovascular diseases, congenital infections, genitourinary malformations, thoracic masses, placental conditions, chromosomal abnormalities, and idiopathic. We report 32 cases of NIHF from among 429 neonates who underwent autopsies (incidence 7.45%). Sixteen cases (50%) had cardiovascular disease; all were due to low output cardiac failure; 7 had structural congenital heart disease. Three of the children with congenital heart disease also had chromosomal abnormalities: 2 had trisomy 18 and 1 had Noonan syndrome. Among myocardial conditions were five subjects with cardiomyopathies (1 of each of the following types): oncocytic, dilated, endocardial fibroelastosis, cardiac glycogenosis, and carnitine deficiency; 3 had myocarditis, and 1 had cardiac rhabdomyomas. Congenital infections were due to cytomegalovirus in 3 cases, bacteria in 2, and parvovirus in 1. The mechanism of NIHF in these cases might be a combination of decreased myocardial contractility due to myocarditis and fetal anemia. Genitourinary diseases were present in 5 newborns: Two had congenital nephrotic syndrome, 1 had VACTER association, 1 had prune-belly syndrome, and 1 had urogenital sinus malformation. Intrathoracic lesions were found in 2 babies (pulmonary sequestration and diaphragmatic hernia). One twin died of volume overload due to twin transfusion syndrome. Only 2 newborns were classified as idiopathic. Our study shows that cardiovascular diseases that lead to heart failure or impaired venous return are more common in the liveborn (50%), whereas congenital infections are more common in the stillborn with NIHF.

Anaesthetic management of congenital lobar emphysema: A report of two cases

Congenital lobar emphysema (CLE) is a rare cause of sudden respiratory distress in the newborn and infants [1]. Hyperinflation and air trapping cause expansion of the affected lobe along with the compression of other lung tissue, mediastinal shifting and impaired venous return. Anaesthesia for CLE, is challenging, as often children are sick and the laid down principles of anaesthesia such as keeping the airway pressures low, cannot be adhered to. Attempts to maintain spontaneous respiration may not be successful and institution of positive pressure ventilation has the potential of worsening the condition. The aim of this paper is to present two case reports with unusual clinical features, each highlighting two different aspects of the disease. The first case had a short history, rapid downhill course with features of life threatening mediastinal shift whereas the second case had an eventful induction of anaesthesia. Anaesthetic management of cases with CLE is outlined and the relevant literature is discussed briefly.

Intensivmedizinische Therapie infektiöser Komplikationen in der pädiatrischen Hämatologie und Onkologie

Septic shock occurs in 6 % of paediatric cancer patients with neutropenia and fever. The mortality of the septic shock is 40 % in BMT patients and 5 % in others. One third of paediatric ARDS cases affect immunocompromised individuals with a total mortality of 45 % and 80 % after BMT. Septic shock is caused by gram-negative bacteria in more than 75 %. ARDS is due to pneumonia in more than 50 %, sepsis in about 25 %. This article provides the recommendations of the Infectious Diseases Working Party of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Hematology/Oncology (GPOH) for treatment of septic shock and ARDS. Therapy of septic shock includes early antibiotic therapy and volume expansion (> or = 40 ml/kg initially). Refractory shock requires vasopressors (noradrenaline), followed by a judicious circulatory management. Hydrocortisone is indicated in patients with high probability of adrenal insufficiency. Mainstay of ARDS therapy is ventilation with sufficient end-expiratory pressure (PEEP) to prevent loss of functional residual capacity and with limited tidal volumes (< or = 6 ml/kg) and limited inspiratory pressure (< 35 cm H(2)O) respectively, to minimize ventilator induced lung injury. Volume therapy consists of maintenance of sufficient preload to counteract the impaired venous return, induced by positive pressure ventilation. Diuretics and eventually veno-venous haemofiltration are used to reduce free lung water. Surfactant application may be considered in severe cases. Steroids are indicated in pneumocystis carinii pneumonia and in engraftment pneumonitis.

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We retrospectively analyzed the hemodynamic status and treatment results of aggressive intracranial dural arteriovenous fistulas (dAVFs) that presented with intracranial hemorrhage, cerebral infarction, status epilepticus, and symptoms of increased intracranial pressure (ICP). Out of 114 dAVFs we experienced since 1991, 31 were aggressive lesions. Eighteen cases presented with an intracranial hemorrhage, 4 with venous infarction, 3 with status epilepticus, and 6 with symptoms of increased ICP. We retrospectively analyzed the hemodynamic status (focusing on the retrograde leptomeningeal venous, and retrograde sinus drainage) and treatment results of these 31 cases. [cavernous sinus dAVF] Of 52 cases, retrograde leptomeningeal venous drainage (RLVD) was observed in 8, and 2 of these 8 cases presented with an intracerebral hematoma. One was successfully treated by surgical transvenous embolization, and the other by percutaneous transvenous embolization. [superior sagittal, transverse-sigmoid, and marginal sinus dAVF] Of 44 cases, RLVD was observed in 24 and retrograde sinus drainage in 3. Nineteen of these 27 cases presented with an aggressive pattern, including intracerebral hematoma in 8, venous infarction in 2, status epilepticus in 3, and increased ICP symptoms in 6. Eight of these 19 cases were treated only by endovascular procedures, 9 by surgical transvenous embolization, 2 by transarterial embolization combined with operation. [others] The location of dAVF in other cases was the cranial vault in 2 cases, anterior cranial base in 6, craniocervical junction in 7, and tentorium in 3. RLVD was seen in all of these 18 cases, and 10 presented with an aggressive course, including intracerebral hematoma in 8 and venous infarction in 2. Four cases were treated by transarterial embolization, and 6 by operation. Complete angiographic obliteration after treatment was obtained in 24 (77%) cases. The Glasgow Outcome Scale was GR in 18 cases, MD in 4, SD in 4, VS in 4, and D in 1. Procedure-related complications occurred in 2 cases. Aggressive lesions accounted for 2% of cavernous sinus, 43% of transverse-sigmoid & superior sagittal sinuses, and 55% of the other sinus or cortical dural AVFs. Impaired cerebral venous return due to RLVD was a main cause of the aggressive behaviors. Combined endovascular and surgical treatment was very effective for those lesions.

Nitric Oxide and Septic Vascular Dysfunction

Nitric Oxide and Septic Vascular Dysfunction

Prevention of the abdominal compartment syndrome

Although the abdominal compartment syndrome was not named as such until the past decade, it has been known for over 50 years. Ogilvie 1 Ogilvie WH The late complications of abdominal war-wounds. Lancet. 1940; ii: 253-256 Abstract Scopus (86) Google Scholar detailed the surgical management of the “burst abdomen”early in World War II. Gross, 2 Gross RE A new method for surgical treatment of large omphaloceles. Surgery. 1948; 24: 277-292 PubMed Google Scholar who in 1948 was the first to advocate the two-stage repair of omphalocele, described the “continual battle, often somewhat brutal, while trying to pack intestinal loops into a cavity which is too small to receive them”. He also identified the clinical triad expected when the abdominal cavity is overstuffed—respiratory failure (due to upward displacement of the diaphragm), impaired venous return (from pressure on the inferior vena cava), and intestinal obstruction (from compression of the viscera).

May-Thurner Syndrome: Management by Endovascular Surgical Techniques

May-Thurner syndrome is a condition in which there is impaired venous return due to compression of the left common iliac vein by the overlying right common iliac artery. The impedance of flow occurs both by the compressive force of the artery against the vein and by resultant intraluminal web formation inside the vein. Because of the mechanical nature of the obstruction, conservative management of these patients has resulted in poor outcomes. Typically, operative therapy is recommended and perused via various approaches. We have recently treated a 15-year-old patient with this disorder utilizing endovascular surgical techniques with an excellent outcome. A 1-year follow-up is presented.

Lingual ischemia following tongue entrapment in a glass bottle

A 10-year-old, previously healthy female presented to the emergency department via emergency medical service transport, with her tongue tightly entrapped inside a glass bottle (9 oz, Yoohoo brand of chocolate drink). The tongue was massively edematous and ecchymotic due to impaired venous return from constriction by the neck of the bottle. After repeated attempts at mechanically reducing the tongue out of the bottle, a professional glazier was contacted, who was able to remove the bottle in the operating room with a steel glass cutter. Needle evacuation of a small hematoma was then performed to decrease the pressure ischemia to the tongue, which began to improve quickly.

Thermal Balance and Dialysis Hypotension

Many studies have confirmed our original observation that dialysate T set at about 35 degrees C affords a better hemodynamic protection than the standard dialysate T of 37-38 degrees C. In this review we present some new data on the hemodynamic mechanism of the protective effect of cold dialysis on blood pressure. The study was based on serial assessment of the percent changes occurring during dialysis treatment in estimated stroke volume (aortic blood flow determined by Doppler echocardiography), blood volume (hemoglobinometry), arterial pressure (Dynamap), and heart rate (ECG), from which cardiac output (CO) indexes and total peripheral vascular resistances (TPVR) were derived. Of the 14 pts studied, 7 showed a drop in mean arterial pressure (MAP) of 25% or greater during standard dialysis (unstable patients). Compared with the 7 patients having more stable intradialysis MAP, unstable pts showed greater reduction in CO which was disproportionately greater than the reduction in blood volume, and a paradoxical decrease in TPVR, the difference being highly significant (p < 0.01 for both changes). When crossed-over to cold dialysis, along with a significantly lower reduction in MAP (p < 0.01) the unstable pts showed a lower decrease in CO which paralleled the reduction in blood volume, and an increase in TPVR. These changes were highly significant (p < 0.01). Data suggest that dialysis hypotension is characterized by an impaired venous return, probably due to the peripheral blood pooling (increased ratio between the 'unstressed' and 'stressed' blood volume) associated with the decrease in TPVR. Exposure of extracorporeal blood to cold dialysate favours the venous return to the heart by increasing TPVR and the 'stressed' blood volume.

Pulmonary Artery Catheter Migration Causing Venous Cannula Obstruction during Cardiopulmonary Bypass

Pulmonary Artery Catheter Migration Causing Venous Cannula Obstruction during Cardiopulmonary Bypass

Trapezius Osteomyocutaneous Flap in Reconstructive Surgery for Mandibular and Oral Defects

A scapular-trapezius osteomyocutaneous flap was used for mandibular reconstruction in 4 cases of oral cavity carcinoma after segmental resection of the mandible. In 3 cases, both the flap and bone took well, and the functional and morphological results were satisfactory. In one case, impaired venous return resulted in flap necrosis; a second reconstruction was performed using a rib-latissimus dorsi osteomyocutaneous flap. Functional disturbances of the donor site were minimal and, because the donor site was on the back, the cosmetic result was excellent. This flap is a bone-attached compound flap using the transverse cervical artery and veins as the vascular bundle, and is thought to be useful in the reconstruction of mandibular defects associated with extensive tissue defects of the oral cavity.

Abnormal Hemodynamic Response to Valsalva Maneuver in Patients with Atrial Septal Defect Evaluated by Doppler Echocardiography

Hemodynamic responses to the Valsalva maneuver were studied in eight healthy subjects (group 1) and eight patients with ASD (group 2) using Doppler echocardiography. The acute changes of aortic blood flow profiles during the Valsalva maneuver were investigated on a basis of beat-to-beat estimation. During the active strain phase (phase 2), group 1 showed a significant decrease in systolic blood pressure, SV and CO with reflex tachycardia; in group 2, there was a significant decrease in SV and CO with reflex tachycardia, but not systolic blood pressure. The percentage decreases in SV and CO in group 2 were significantly less than those in group 1 (23 +/- 16 percent vs 48 +/- 10 percent for SV, p less than 0.01; 17 +/- 12 percent vs 40 +/- 13 percent for CO, p less than 0.05). After release of strain phase (phase 4), group 1 showed significant reversed changes in systolic blood pressure, SV and heart rate, indicating an overshoot effect which was, however, not observed in group 2. Thus, patients with ASD presented abnormal Valsalva response which was characterized by the absence of phase 4 overshoot and a less marked phase 2 change. The findings suggest that the decremental effect of impaired venous return on stroke output during active strain may be attenuated by the increased pulmonary blood volume due to left-to-right shunt. In patients with ASD, the lesser decrement of CO during phase 2 may not provoke sufficient sympathetic activity to induce overshoot response in phase 4.

Cardiovascular responses to manual dissection associated with transhiatal esophageal resection

Marked cardiovascular responses to esophageal manipulation are commonly observed during transhiatal esophagectomy without thoracotomy. To delineate the mechanism and the time course of these hemodynamic changes, 10 patients undergoing this surgical procedure were studied. Heart rate (HR), mean arterial blood pressure (MAP), pulmonary capillary wedge pressure IPCWP), cardiac output (CO), cardiac index (CI), systemic vascular resistance (SVR), and arteriovenous oxygen content difference (C[av]O 2) were measured or calculated each time the surgeon's hand entered the thorax to dissect the esophagus. Significant and simultaneous decreases in both MAP and CI were observed in all cases during manipulations (−46% from the baseline value). A significant increase in PCWP also occurred, whereas HR and SVR were unchanged. All parameters returned to control values once manipulation was stopped. The simultaneous decreases in MAP and CI were clearly related to impaired venous return and/ or ventricular ejection from manual compression. From these findings, it can be assumed that long-lasting alterations in hemodynamic status could be detrimental to patients with cardiac disease; therefore, careful intraoperative hemodynamic monitoring is advisable. In addition, some patients with advanced cardiac dysfunction may not tolerate these manipulations and may require an open thoracic surgical procedure.