Systolic blood pressure variability in patients with early severe sepsis or septic shock: a prospective cohort study.

BACKGROUND: Severe sepsis and septic shock are often lethal syndromes, in which the autonomic nervous system may fail to maintain adequate blood pressure. Heart rate variability has been associated with outcomes in sepsis. Whether systolic blood pressure (SBP) variability is associated with clinical outcomes in septic patients is unknown. The propose of this study is to determine whether variability in SBP correlates with vasopressor independence and mortality among septic patients. METHODS: We prospectively studied patients with severe sepsis or septic shock, admitted to an intensive care unit (ICU) with an arterial catheter. We analyzed SBP variability on the first 5-min window immediately following ICU admission. We performed principal component analysis of multidimensional complexity, and used the first principal component (PC1) as input for Firth logistic regression, controlling for mean systolic pressure (SBP) in the primary analyses, and Acute Physiology and Chronic Health Evaluation (APACHE) II score or NEE dose in the ancillary analyses. Prespecified outcomes were vasopressor independence at 24 h (primary), and 28-day mortality (secondary). RESULTS: We studied 51 patients, 51% of whom achieved vasopressor independence at 24 h. Ten percent died at 28 days. PC1 represented 26% of the variance in complexity measures. PC1 was not associated with vasopressor independence on Firth logistic regression (OR 1.04; 95% CI: 0.93-1.16; p = 0.54), but was associated with 28-day mortality (OR 1.16, 95% CI: 1.01-1.35, p = 0.040). CONCLUSIONS: Early SBP variability appears to be associated with 28-day mortality in patients with severe sepsis and septic shock.

Multi-complexity measures of heart rate variability and the effect of vasopressor titration: a prospective cohort study of patients with septic shock.

BACKGROUND: Septic shock is a common and often devastating syndrome marked by severe cardiovascular dysfunction commonly managed with vasopressors. Whether markers of heart rate complexity before vasopressor up-titration could be used to predict success of the up-titration is not known. METHODS: We studied patients with septic shock requiring vasopressor, newly admitted to the intensive care unit. We measured the complexity of heart rate variability (using the ratio of fractal exponents from detrended fluctuation analysis) in the 5 min before all vasopressor up-titrations in the first 24 h of an intensive care unit (ICU) admission. A successful up-titration was defined as one that did not require further up-titration (or decrease in mean arterial pressure) for 60 min. RESULTS: We studied 95 patients with septic shock, with a median APACHE II of 27 (IQR: 20-37). The median number of up-titrations, normalized to 24 h, was 12.2 (IQR: 8-17) with a maximum of 49. Of the up-titrations, the median proportion of successful interventions was 0.28 (IQR: 0.12-0.42). The median of mean arterial pressure (MAP) at the time of a vasopressor up-titration was 66 mmHg; the average infusion rate of norepinephrine at the time of an up-titration was 0.11 mcg/kg/min. The ratio of fractal exponents was not associated with successful up-titration on univariate or multivariate regression. On exploratory secondary analyses, however, the long-term fractal exponent was associated (p = 0.003) with success of up-titration. Independent of heart rate variability, MAP was associated (p < 0.001) with success of vasopressor up-titration, while neither Sequential Organ Failure Assessment (SOFA) nor Acute Physiology and Chronic Health Evaluation II (APACHE II) score was associated with vasopressor titration. CONCLUSIONS: Only a third of vasopressor up-titrations were successful among patients with septic shock. MAP and the long-term fractal exponent were associated with success of up-titration. These two, complementary variables may be important to the development of rational vasopressor titration protocols.

Coefficient of Variation of Coarsely Sampled Heart Rate is Associated With Early Vasopressor Independence in Severe Sepsis and Septic Shock.

PURPOSE: To determine whether variability of coarsely sampled heart rate and blood pressure early in the course of severe sepsis and septic shock predicts successful resuscitation, defined as vasopressor independence at 24 hours after admission. METHODS: In an observational study of patients admitted with severe sepsis or septic shock from 2009 to 2011 to either of 2 intensive care units (ICUs) at a tertiary-care hospital, in whom blood pressure was measured via an arterial catheter, we sampled heart rate and blood pressure every 30 seconds over the first 6 hours of ICU admission and calculated the coefficient of variability of those measurements. Primary outcome was vasopressor independence at 24 hours; and secondary outcome was 28-day mortality. RESULTS: We studied 165 patients, of which 97 (59%) achieved vasopressor independence at 24 hours. Overall, 28-day mortality was 15%. Significant predictors of vasopressor independence at 24 hours included the coefficient of variation of heart rate, age, Acute Physiology and Chronic Health Evaluation II, the number of increases in vasopressor dose, mean vasopressin dose, mean blood pressure, and time-pressure integral of mean blood pressure less than 60 mm Hg. Lower sampling frequencies (up to once every 5 minutes) did not affect the findings. CONCLUSIONS: Increased variability of coarsely sampled heart rate was associated with vasopressor independence at 24 hours after controlling for possible confounders. Sampling frequencies of once in 5 minutes may be similar to once in 30 seconds.

Initial fractal exponent of heart rate variability is associated with success of early resuscitation in patients with severe sepsis or septic shock: a prospective cohort study.

INTRODUCTION: Heart rate variability (HRV) reflects autonomic nervous system tone as well as the overall health of the baroreflex system. We hypothesized that loss of complexity in HRV upon intensive care unit (ICU) admission would be associated with unsuccessful early resuscitation of sepsis. METHODS: We prospectively enrolled patients admitted to ICUs with severe sepsis or septic shock from 2009 to 2011. We studied 30 minutes of electrocardiogram, sampled at 500 Hz, at ICU admission and calculated heart rate complexity via detrended fluctuation analysis. Primary outcome was vasopressor independence at 24 hours after ICU admission. Secondary outcome was 28-day mortality. RESULTS: We studied 48 patients, of whom 60% were vasopressor independent at 24 hours. Five (10%) died within 28 days. The ratio of fractal alpha parameters was associated with both vasopressor independence and 28-day mortality (P = .04) after controlling for mean heart rate. In the optimal model, Sequential Organ Failure Assessment score and the long-term fractal α parameter were associated with vasopressor independence. CONCLUSIONS: Loss of complexity in HRV is associated with worse outcome early in severe sepsis and septic shock. Further work should evaluate whether complexity of HRV could guide treatment in sepsis.

Blood pressure estimation in the human fetal descending aorta.

OBJECTIVES: The objectives of this study were to estimate fetal blood pressure non-invasively from two-dimensional color Doppler-derived aortic blood flow and diameter waveforms, and to compare the results with invasively derived human fetal blood pressures available from the literature. METHODS: Aortic pressures were calculated from digitally recorded color Doppler cineloops of the fetal descending aorta by applying the Womersley model in combination with the two-element Windkessel model, assuming constant pulse wave velocity during the second half of pregnancy. The results were compared with invasively derived human fetal blood pressures obtained from the literature. RESULTS: In 21 normal pregnancies the estimated mean aortic pressure regression line increased linearly from 28 mmHg at 20 weeks of gestation to 45 mmHg at 40 weeks of gestation. The pulse pressure based on the regression line increased linearly from 21 mmHg at 20 weeks of gestation to 29 mmHg at 40 weeks of gestation. The aortic compliance exhibited a log linear relationship with the gestational age and a statistically significant eightfold increase was observed between 20 and 40 weeks. The aortic downstream peripheral resistance exhibited an exponentially decaying relationship across the same gestational age range. Non-invasively derived aortic systolic and diastolic aortic pressures were comparable with previously reported invasively derived systolic and diastolic umbilical arterial pressures; however, the mean pressures differed significantly from those reported in the umbilical artery in a separate study. The aortic systolic pressures calculated in this study were significantly higher than invasively derived left ventricular systolic pressures that have been previously reported in the literature. CONCLUSIONS: This study demonstrates the feasibility of estimating arterial blood pressure in the human fetus. The method described is of potential use in assessing fetal blood pressure non-invasively, particularly for studying relative changes with time.

Wall shear stress and related hemodynamic parameters in the fetal descending aorta derived from color Doppler velocity profiles.

This paper presents a methodology for estimating the wall shear stress in the fetal descending aorta from color Doppler velocity profiles obtained during the second half of pregnancy. The Womersley model was applied to determine the wall shear stress and related hemodynamic parameters. Our analysis indicates that the aortic diameter can be modeled as a function of the gestational age in weeks as: Diameter (mm) = 0.17.ga + 0.15 (R2 = 0.64, p < 0.001). The aortic volume flow showed a log linear gestational age-related increase that fit the model: F (mL/min) = e(0.08.ga + 3.49) (R2 = 0.61, p < 0.001). The Womersley number increased linearly with gestational age from 3.3 to 6.2 (p < 0.001) and the pressure gradient decreased linearly from 2.68 to 1.16 mPa/mm (p = 0.003) during the second half of pregnancy; the mean wall shear stress for the study group was 2.2 Pa (SD = 0.59) and was independent of gestational age. This study suggests that the size of the fetal aorta adapts to flow demands and maintains constant mean wall shear stress.

Image enhancement via adaptive unsharp masking.

This paper presents a new method for unsharp masking for contrast enhancement of images. The approach employs an adaptive filter that controls the contribution of the sharpening path in such a way that contrast enhancement occurs in high detail areas and little or no image sharpening occurs in smooth areas.

Multiplication free vector quantization using L(1) distortion measure and its variants.

The author considers vector quantization that uses the L (1) distortion measure for its implementation. A gradient-based approach for codebook design that does not require any multiplications or median computation is proposed. Convergence of this method is proved rigorously under very mild conditions. Simulation examples comparing the performance of this technique with the LBG algorithm show that the gradient-based method, in spite of its simplicity, produces codebooks with average distortions that are comparable to the LBG algorithm. The codebook design algorithm is then extended to a distortion measure that has piecewise-linear characteristics. Once again, by appropriate selection of the parameters of the distortion measure, the encoding as well as the codebook design can be implemented with zero multiplications. The author applies the techniques in predictive vector quantization of images and demonstrates the viability of multiplication-free predictive vector quantization of image data.

Computerized artifact detection for ventilatory inductance plethysmographic apnea monitors.

Ventilatory inductive plethysmography allows noninvasive monitoring of patient ventilation. Patient movements unrelated to breathing introduce severe errors in ventilator inductive plethysmographic measurements and restrict its usefulness. The purpose of this research was to develop and test a microprocessor-based real-time digital signal processor that uses an adaptive filter to detect patient movements unrelated to breathing. The adaptive filter processor was tested for retrospective identification of artifacts in 20 male volunteers who performed the following specific movements between epochs of quiet, supine breathing: raising arms and legs (slowly, quickly, once, and several times), sitting up, breathing deeply and rapidly, and rolling from a supine to a lateral decubitus position. Flow was simultaneously measured directly with a pneumotachography attached to a mouthpiece. A multilinear regression was used to continuously calculate the calibration constants that relate the pneumotachographic and ventilatory inductive plethysmographic signals. Ventilatory inductive plethysmographic data were then processed, and results scored. There were a total of 166 movements. The calibration coefficients changed dramatically in 146 (88%) of the 166 movements. These movements would have significant errors on ventilatory inductive plethysmographic flow calculation. The changes lasted for the duration of the movements and returned to baseline within two to three breaths. The changes in the coefficients were five or more times larger than the variability around baseline during quiet, supine breathing. All of the total body movements and changes in breathing patterns were detected accurately. The filter detected 46 of 53 upper body movements, 34 of 36 lower body movements, 38 of 38 total body movements, and 19 of 19 breathing pattern changes where the calibration changed.(ABSTRACT TRUNCATED AT 250 WORDS)