Comparison of intravenous dexmedetomidine versus ketamine-dexmedetomidine combination on spinal block characteristics in patients undergoing lower limb orthopaedic surgery - A randomised clinical trial.

Background and Aims: One major limitation of the spinal block remains the inability to extend the duration of the block intraoperatively unless planned before with spinal or epidural catheters and/or intrathecal additives. This study was designed to compare the effects of intravenous dexmedetomidine versus low-dose ketamine-dexmedetomidine combination infusion on spinal anaesthesia in lower limb orthopaedic surgeries. Methods: This randomised study was conducted in 60 patients scheduled for unilateral lower limb surgeries under spinal anaesthesia. Patients were randomised into Group D (n = 30) (0.5 µg/kg of intravenous (IV) dexmedetomidine bolus followed by maintenance infusion at 0.5 µg/kg/h) and Group LKD (n = 30) (IV bolus of 0.5 µg/kg of dexmedetomidine and 0.2 mg/kg of ketamine, followed by maintenance infusions of dexmedetomidine and ketamine at 0.5 µg/kg/h and 0.2 mg/kg/h, respectively). Ramsay Sedation Scale score of 3-4 was maintained. The t-test or the Wilcoxon-Mann-Whitney U test was used to compare the parameters between groups. Results: The mean sacral segment 1 (S1) regression time was 390.3 [standard deviation (SD):84.38] [95% confidence interval (CI): 360.13, 420.53] versus 393.23 (SD: 93.01) (95% CI: 363.04, 423.43) min in Group D versus Group LKD respectively ((P = 0.701). The number of episodes of hypotension was significantly higher in Group D (19 patients) compared to Group LKD (nine patients) (P = 0.001). Pre- and postoperative stress markers (24 h) and the incidence of postoperative nausea and shivering were comparable between the two groups (P > 0.05). Tramadol requirement in the postoperative period was significantly less in Group LKD compared to Group D (P = 0.003). Conclusion: The duration of S1 regression was similar between group dexmedetomidine (Group D) and group low-dose ketamine and dexmedetomidine (Group LKD).

In vivo hypotensive effect of a chemically characterised extract from the leaves of Lippia alba (Mill.) N.E.Br.

Lippia alba (erva-cidreira) is often mentioned in Brazilian ethnopharmacological studies. Although its leaves have been used to treat hypertension, few studies have evaluated its hypotensive effects. This work aimed to evaluate the haemodynamic effects of Lippia alba methanolic extract and to characterise its chemical composition. Normotensive rats received an intravenous injection of L. alba extract. Systolic, diastolic, mean arterial pressures, and electrocardiographic data were analysed.1H-qNMR and LC-MS were used to assess the chemical composition. L. alba extract had significant hypotensive effects on systolic, diastolic, and mean arterial pressure. Acteoside was identified as major compound (292.6 ± 2.7 mg/g). Sixty-one other compounds were tentatively identified, mainly phenylethanoids, flavonoids, and iridoids. L. alba extract reduces systolic, diastolic, mean arterial pressure, and appears to be associated with a reduction in heart rate. Acteoside, a known hypotensive compound, may be responsible for these effects, but other structurally similar minority compounds may also contribute.

A case report of an Adachi-Williams type CG plus H aortic arch anomaly and implications for the development of the cervicothoracic circulation.

BACKGROUND: It is unclear whether the development of the branches of the subclavian artery is dependent on the proximal part of this artery since great vessel formation is partially regulated by haemodynamic stress. For example, the vertebral artery that usually arises from the subclavian artery might be affected by anomalies in the aortic arch branches. This uncertainty is partly due to the limited reports of highly anomalous cases of proximal and distal branching morphologies. Here, we report an Adachi-Williams type CG plus H aortic arch case found during student dissection and discuss the development of the cervicothoracic circulation. CASE REPORT: Here, we report an aberrant right subclavian artery that arose from the aorta distal to the left subclavian artery, via a retroesophageal course, whereas the right and left common carotid arteries arose from a short common trunk from the aorta (the carotid trunk) (Adachi-Williams type H). In addition, the left vertebral artery arose directly from the aortic arch between the carotid trunk and the left subclavian artery (Adachi-Williams type CG). Anomalies in the branching arteries from this aberrant right subclavian artery (the right vertebral artery, internal thoracic artery, thyrocervical trunk, costocervical trunk and thoracoacromial artery) were unidentifiable. The right vagus nerve directly innervates the laryngeal muscles without forming the recurrent nerve. CONCLUSIONS: The development of an aberrant right subclavian artery might affect haemodynamic stress in both the proximal and distal regions of the anterior limb region. The distal branching morphology, however, was normal, suggesting an independence of proximal and distal vasculature development. Since the concomitance of Adachi-Williams-type CG and H is rare, rather than sequentially develop, the distal arteries develop in a fine-tuned manner to adapt to anomalies in the proximal arteries.

Haemodynamic monitoring after paediatric cardiac surgery using echocardiography and PiCCO.

BACKGROUND: Haemodynamic instability is common after surgical repair of CHDs in infants and children. Monitoring cardiac output in addition to traditional circulation parameters could improve the postoperative care of these patients. Echocardiography and transpulmonary thermodilution are the two most common methods for measuring cardiac output in infants. OBJECTIVES: To compare the results of cardiac output measurements using echocardiography and a transpulmonary thermodilution setup after paediatric cardiac surgery. METHODS: Forty children, scheduled for elective repair of a ventricular septal defect or of an atrio-ventricular septal defect using cardiopulmonary bypass, were enrolled in this prospective, observational study. Cardiac output was simultaneously measured using echocardiography and a commercially available transpulmonary thermodilution method (PiCCO™) at 18 h after the end of surgery. RESULTS: At 18 h after surgery, PiCCO™ gave a mean of 3.0% higher cardiac output than echocardiography. This difference was not statistically significant. 95% of the observations fell within -50.0 to 82.6%. CONCLUSION: The methods were found to have a good agreement on average, with no statistically significant difference between them. However, the spread of the results was large. It is questionable whether the methods can be used interchangeably in clinical practice.

Evaluating Blood Pressure Variability in Type 2 Diabetic Patients: An Insight into Non-Dipping Patterns and Their Clinical Implications.

Background: Hypertension (HTN) is prevalent in individuals with type 2 Diabetes Mellitus (T2DM), doubling the risk of developing chronic complications. Despite normal routine checks, many patients with diabetes exhibit abnormal blood pressure (BP) profiles identified by 24-hour ambulatory Blood Pressure monitoring (ABPM). This study aimed to analyse blood pressure variability in patients with diabetes to enhance current knowledge and improve clinical practice. Methods: This cross-sectional study obtained ethical approval from Jazan University and involved 58 patients with type 2 Diabetes Mellitus (T2DM) who adhered to the strict inclusion and exclusion criteria. Comprehensive clinical and laboratory data, including demographic, clinical, and essential laboratory parameters, were collected using a standardized form. Blood Pressure (BP) was meticulously monitored using the Sun Tech Oscar 2 ABPMR device, with measurements commencing between 8 am and 10 am, extending over 24 hours. The study calculated averages and evaluated systolic and diastolic percentage dipping during 24-hour, daytime, and night-time intervals. Participants classified as "dippers" experienced a BP reductions of at least 10%. Results: Fifty-eight normotensive T2DM patients, with a mean age of 45.51 ± 6.7 years, were monitored over 24 months. Among the 58 individuals assessed using ABPM, a non-dipping pattern was observed in 45 participants (77.58%), whereas 13 (22.41%) exhibited a dipping pattern. Postprandial and fasting blood sugar levels were distinct; the dipper group demonstrated better post-meal glucose control (p=0.02), whereas the non-dipper group had superior fasting glucose control (p=0.04). The dipper group showed a higher 24-hour average systolic BP (p=0.00) and increased dipping percentages for systolic and diastolic BP during sleep. Conclusion: Over 77% of ABPM-evaluated individuals showed non-dipping patterns, with a higher BMI being strongly associated. Laboratory findings revealed distinct variations in the postprandial and fasting blood sugar levels, suggesting a potential genetic predisposition.

New diagnostic criteria and current issues for pulmonary hypertension.

In 2022, the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) proposed new diagnostic criteria for pulmonary hypertension (PH). These criteria include significant changes to the definitions of pulmonary hemodynamic indices. Specifically, the threshold for mean pulmonary artery pressure (mPAP) has been lowered from ≥25 mmHg to >20 mmHg, and the threshold for pulmonary vascular resistance (PVR) has been adjusted from ≥3 Wood units (WU) to >2 WU. Additionally, the diagnostic criterion for exercise-induced PH has been reintroduced. To differentiate between non-severe and severe PH associated with lung disease, a differential threshold of 5 WU for PVR has been proposed. However, the threshold for mean pulmonary artery wedge pressure (PAWP) remains unchanged. While these new criteria could provide a more refined approach to clinical practice, they may also raise clinical concerns and questions regarding the diagnosis and management of PH.

Development and external validation of temporal fusion transformer models for continuous intraoperative blood pressure forecasting.

Background: During surgery, intraoperative hypotension is associated with postoperative morbidity and should therefore be avoided. Predicting the occurrence of hypotension in advance may allow timely interventions to prevent hypotension. Previous prediction models mostly use high-resolution waveform data, which is often not available. Methods: We utilised a novel temporal fusion transformer (TFT) algorithm to predict intraoperative blood pressure trajectories 7 min in advance. We trained the model with low-resolution data (sampled every 15 s) from 73,009 patients who were undergoing general anaesthesia for non-cardiothoracic surgery between January 1, 2017, and December 30, 2020, at the General Hospital of Vienna, Austria. The data set contained information on patient demographics, vital signs, medication, and ventilation. The model was evaluated using an internal (n = 8113) and external test set (n = 5065) obtained from the openly accessible Vital Signs Database. Findings: In the internal test set, the mean absolute error for predicting mean arterial blood pressure was 0.376 standard deviations-or 4 mmHg-and 0.622 standard deviations-or 7 mmHg-in the external test set. We also adapted the TFT model to binarily predict the occurrence of hypotension as defined by mean arterial blood pressure < 65 mmHg in the next one, three, five, and 7 min. Here, model discrimination was excellent, with a mean area under the receiver operating characteristic curve (AUROC) of 0.933 in the internal test set and 0.919 in the external test set. Interpretation: Our TFT model is capable of accurately forecasting intraoperative arterial blood pressure using only low-resolution data showing a low prediction error. When used for binary prediction of hypotension, we obtained excellent performance. Funding: No external funding.

Remote haemodynamic-guided heart failure management in France: Results from the CardioMEMS HF System Post-Market Study (COAST) French cohort.

BACKGROUND: Previous studies have demonstrated the benefit of a haemodynamic-guided management strategy with the CardioMEMS™ HF System. No data from French patients have been published. AIMS: To analyse the feasibility, safety and clinical benefit of the CardioMEMS™ HF System in 103 French patients included in the CardioMEMS HF System Post-Market Study (COAST). METHODS: Prospective open-label cohort of New York Heart Association class III patients with at least one heart failure hospitalization in the 12 months before enrolment, regardless of left ventricular ejection fraction. The primary safety endpoints assessed the freedom from device/system-related complications and from pressure sensor failure at 2 years after implantation. The primary efficacy endpoint was evaluated comparing the rate of heart failure hospitalization during the year before and the year after implantation. RESULTS: At 2 years, there were no device/system-related complications or pressure sensor failures (P<0.0001). There were 179 heart failure hospitalizations in the year before implantation compared with 79 in the year after implantation (risk reduction 50.3%; rate ratio 0.50, 95% confidence interval 0.38-0.66; P<0.0001). During the 2 years of follow-up, pulmonary artery pressures were lowered significantly (mean pulmonary artery pressure -3.7±6.3mmHg; P<0.0001), with a significant improvement in functional class and quality of life. CONCLUSIONS: In the French cohort of the COAST study, we have demonstrated that the CardioMEMS™ HF System is a reliable device, with no device/system-related complications or pressure sensor failures. Patients in this open-label cohort had a significant reduction in pulmonary artery pressures, with an improvement in New York Heart Association classification and quality of life, and a 50% reduction in the heart failure hospitalization rate in the year following implantation compared with the previous year.

Haemodynamic Effects of Sodium-Glucose Cotransporter 2 Inhibitor Treatment in Chronic Heart Failure Patients.

Sodium-glucose cotransporter 2 inhibitors (SGLT-2i) are now recommended in the current European Society of Cardiology/American College of Cardiology guidelines for the treatment of heart failure (HF) across the spectrum of left ventricular ejection fraction (LVEF) and several large trials have documented the beneficial effects of this drug class on cardiovascular outcomes. Although the clinical efficacy of SGLT-2 inhibition in HF is now well recognised, research is still ongoing to better understand the underlying mechanistic effects of this drug class. In this paper we assess the haemodynamic effects following SGLT-2i treatment in HF patients by reviewing the current literature. We focus our review on preload of the LV in terms of filling pressure and pulmonary artery pressure, cardiac output and afterload. We discuss these variables stratified according to HF with reduced LVEF (HFrEF) and HF with preserved LVEF (HFpEF). Finally, we examine the evidence of LV remodelling in the setting of SGLT-2i-related changes in haemodynamics.

Assessing cardiac mechanics through left ventricular haemodynamic forces.

Haemodynamic forces (HDFs), which represent the forces exchanged between blood and surrounding tissues, are critical in regulating the structure and function of the left ventricle (LV). These forces can be assessed on cardiac magnetic resonance or transthoracic echocardiography exams using specialized software, offering a non-invasive alternative for measuring intraventricular pressure gradients. The analysis of HDFs can be a valuable tool in improving our understanding of cardiovascular disease and providing insights beyond traditional diagnostic and therapeutic approaches. For instance, HDF analysis has the potential to identify early signs of adverse remodelling and cardiac dysfunction, which may not be detected by standard imaging methods such as bidimensional or speckle-tracking echocardiography. This review aims to summarize the principles of HDF analysis and to reappraise its possible applications to cardiac disorders.

Haemodynamic effect of dexmedetomidine during paediatric kidney transplantation.

BACKGROUND: Dexmedetomidine is increasingly used for its ability to stabilise haemodynamic status during general anaesthesia. However, there is currently no data on paediatric kidney transplant recipients (pKTR). This study investigates the haemodynamic impact of dexmedetomidine administered perioperatively in pKTR. METHODS: From 2019 to 2023, a retrospective study was conducted at Nantes University Hospital involving all pKTR under 18 years of age. The study compared intraoperative haemodynamic parameters between patients administered dexmedetomidine during kidney transplantation (DEX group) and those who did not receive it (no-DEX group). Mean arterial pressure (MAP) and heart rate (HR) were monitored throughout the duration of anaesthesia and compared. Graft function was assessed based on creatinine levels and glomerular filtration rate (GFR) at specific intervals. The perioperative use of fluids and vasoactive drugs, as well as their administration within 24 h post-surgery, were analysed. RESULTS: Thirty-eight patients were enrolled, 10 in the DEX group and 28 in the no-DEX group. Intraoperative HR was similar between the groups; however, MAP was higher in the DEX group (mean difference 9, standard deviation (SD, 1-11) mmHg, p = 0.039). No differences were found regarding the use of fluid and vasoactive drug therapy between groups. GFR at 1 month post-transplantation was significantly elevated in the DEX group (p = 0.009). CONCLUSIONS: pKTR receiving intraoperative dexmedetomidine exhibited higher perioperative MAP compared to those not administered dexmedetomidine. Additionally, the DEX group demonstrated superior graft function at 1 month. The direct impact of dexmedetomidine on immediate postoperative graft function in pTKR warrants further investigation in a prospective multicentre randomised study.

[The role of magnesium sulfate in providing hemodynamic stability in patients undergoing laparoscopic surgery: a prospective randomized controlled study]. / Intérêt du sulfate de magnésium pour la stabilitée hémodynamique en cœliochirurgie: étude prospective contrôlée randomisée.

Introduction: during laparoscopic surgery, carbon dioxide (CO2) insufflation to create pneumoperitoneum increases blood pressure, heart rate and systemic vascular resistance. The purpose of our study was to investigate the efficacy of magnesium sulfate in preventing adverse hemodynamic reactions associated with pneumoperitoneum in patients undergoing laparoscopic cholecystectomy. Methods: we conducted a prospective, randomized, double-blind, controlled clinical study of patients scheduled for laparoscopic cholecystectomy and divided into two equal groups: the Mg2+ group received slow intravenous magnesium sulfate 50 mg/kg injection prior to pneumoperitoneum insufflation while the S group received the same volume of 0.9 % saline. Our primary endpoint was intraoperative changes in systolic blood pressure (SBP) related to pneumoperitoneum, in particular at 1 minute after insufflation. The secondary endpoints were the haemodynamic effects of pneumoperitoneum in terms of systolic blood pressure (SP), diastolic blood pressure (DP), mean arterial pressure (MAP) and heart rate (HR) from 2 minutes after insufflation to extubation and postoperatively, and the presence of possible adverse reactions related to the administration of magnesium sulphate. Results: we included 70 patients divided into two groups of 35. SP was significantly higher in the S group at insufflation (T0), 3 min, 4 min and 5 min post-operative, and at 60 min after surgery. HR was significantly higher in patients in the S group compared to the Mg2+ group at 7 min and 8 min after insufflation. No significant differences in DP and MAP measurements were observed between the 2 groups. No adverse reactions related to magnesium administration were reported. Conclusion: magnesium sulfate administered prior to pneumoperitoneum insufflation provided improved intraoperative hemodynamic stability during laparoscopic surgery.

Haemodynamic Forces: Emerging Markers of Ventricular Remodelling in Multiple Myeloma Cardiovascular Baseline Risk Assessment.

Multiple myeloma (MM) affects a population with a high prevalence of cardiovascular (CV) disease. These patients benefit from an accurate CV risk evaluation in order to choose the safest drug regimen. Haemodynamic forces (HDFs) analysis allows for the earlier detection of myocardial damage compared with standard markers; the role played by MM in HDFs alteration, with or without the influence of hypertension, is yet to be studied. Therefore, we aimed to identify differences in HDFs analysis in patients with MM, hypertension or both versus normotensive non-oncologic subjects. A total of 173 patients (MM hypertensive patients, MMHT; MM normotensive patients, MMNT; non-oncologic hypertensive patients, CoHT; and non-oncologic normotensive patients, CoNT) underwent transthoracic echocardiography for HDFs analysis and pulse wave velocity (PWV) assessment. Hypertensive patients (MMHT, CoHT) showed decreased ejection fraction (EF), global longitudinal strain (GLS) and HDFs values compared with CoNT, whereas ventricular mass (LVMi) and PWV increased. MMNT displayed a significant reduction in systolic HDFs (p < 0.006) and systolic ejection HDFs (p < 0.008) compared with CoNT, without significant change in EF, GLS, LVMi or PWV. In conclusion, MM leads to ventricular remodelling regardless of hypertension; HDFs application for MM patients could help detect early myocardial damage, especially in patients receiving cardiotoxic drugs.

Haemodynamics, side effects and safety of the combination of continuous femoral nerve block and intravenous parecoxib for pain management after Total Knee Arthroplasty: A pilot study.

Background: Total Knee Arthroplasty (TKA) is a well-established surgical procedure for the treatment of knee joint diseases. This operation leads to severe acute and chronic pain, and intravenous administration of parecoxib could provide significant pain relief. Objective: The aim of the study was to compare the hemodynamic data and safety profile of patients who received parecoxib compared to placebo following TKA. Methods: Ninety patients were followed during this study and were randomly assigned into two equal groups. Group P received parecoxib and Group C received the placebo. Exclusion criteria included age < 40 or > 80 years, ASA III or higher, obesity (>140 kg), allergy to local anaesthetics, opioid dependence, contraindications for subarachnoid anaesthesia, femoral block or the administration of parecoxib.The haemodynamic data collected were Systolic Arterial Pressure (SAP), Diastolic Arterial Pressure (DAP), Heart Rate (HR), Oxygen Saturation (Ox-Sat), blood transfusion requirements and side effects. Recordings were performed every hour for up to 10 hours and at 15min, 4, 8, 12, 24, 36 hours postoperatively. Results: The postoperative SAP and DAP data presented similar findings among groups (p>0.05) within the aforementioned time intervals. The postoperative HR data for both groups displayed no statistically significant difference between the two cohorts (p>0.05). Regarding the occurrence of transfusion, there is no statistically significant difference between the parecoxib and placebo cohorts. The frequency of side effects was negligible and could not be correlated with either group. Conclusion: Therefore, parecoxib did not render any noticeable impact on the hemodynamic profile of the patients.

Successful treatment of acute left main coronary artery disease with a drug-coated balloon under left ventricular unloading using Impella: a case report.

Background: Although the efficacy and safety of drug-coated balloons (DCBs) for acute left main coronary artery (LMCA) disease have not yet been proven, stentless percutaneous coronary intervention with a DCB is preferred for patients with high bleeding risk requiring a shorter duration of dual antiplatelet therapy. Mechanical circulatory support may improve haemodynamics in patients with cardiogenic shock caused by acute LMCA disease. Case summary: A 74-year-old man diagnosed with acute congestive heart failure underwent emergency coronary angiography (CAG) at our hospital owing to ischaemic changes on the electrocardiogram (ECG), indicating acute LMCA disease. Coronary angiography revealed severe LMCA ostial stenosis. Immediately after CAG, mechanical circulatory support was initiated using Impella CP® for haemodynamic collapse with abrupt ST-segment elevation in the precordial leads. The haemodynamics stabilized with a dramatic improvement in the ECG. We treated the culprit ostial lesion with inflation of a cutting balloon followed by DCB delivery because of an episode of haematochezia. Subsequently, his cardiac function recovered fully. Discussion: A case of acute LMCA disease was successfully treated with a DCB under haemodynamic support using Impella CP. The left ventricular (LV) unloading with Impella was indicated to contribute to stable haemodynamics, even during long inflation with the DCB, and the immediate recovery of LV function. Haemodynamic support using Impella may be effective, especially in cases requiring repeated and longer inflation of balloon catheters accompanied by extensive myocardial ischaemia.

Effects of different doses of alfentanil on cardiovascular response to rapid sequence intubation in elderly patients: a parallel-controlled randomized trial.

BACKGROUND: Rapid sequence intubation (RSI) have been shown to be effective in preventing reflux aspiration in patients with a full stomach during anaesthesia induction and endotracheal intubation. However, there is currently no standardized operation protocol or anaesthesia induction drug standard for RSI. Furthermore, there is a lack of evidence regarding the use of RSI in patients older than 65. In this study, we aimed to investigate the cardiovascular effects of different doses of alfentanil combined with propofol and etomidate during RSI in elderly patients aged 65-80 years. METHODS: A total of 96 patients aged 65-80 years who underwent general anaesthesia with tracheal intubation were selected for this study. The patients were randomly assigned to one of four groups using a random number table. Group A patients received an induction dose of 10 µg/kg alfentanil, group B patients received 15 µg/kg alfentanil, group C patients received 20 µg/kg alfentanil, and group D patients received 25 µg/kg alfentanil. Heart rate (HR), mean arterial pressure (MAP), cardiac index (CI), and ejection fraction (EF) were measured at three time points: 5 min before anaesthesia induction (T0), 1 min after endotracheal intubation (T1), and 5 min after endotracheal intubation (T2). Concurrently, 4 ml of arterial blood was collected from patients at three time points, and the concentrations of norepinephrine (NE) and cortisol (Cor) in plasma were detected. Occurrences of hypertension, hypotension, bradycardia and tachycardia during anesthesia induction to 5 min after tracheal intubation were noted. RESULTS: Compared with T0, the HR, MAP, NE and Cor concentrations in group A and group B were increased at the T1 and T2 time points, CI and EF values were decreased (P < 0.05). HR and MAP in groups C and D were increased at the T1 time point, while they were decreased at the T2 time point in group D (P < 0.05). The changes in CI and EF values, concentrations of NE and Cor, were not significant at T1 and T2 time points in group C (P > 0.05). Additionally, they were not significant in group D at the T1 time point (P > 0.05), but decreased at the T2 time point (P < 0.05). Compared with group A, the HR, MAP, NE and Cor concentrations in groups C and D were decreased at T1 and T2 time points (P < 0.05). The CI and EF values of groups C and D were increased at T1 time point but decreased at T2 time point in group D (P < 0.05). The incidence of hypertension and tachycardia in group A was significantly higher than that in group C and group D (P < 0.05), and the incidence of hypotension and bradycardia in group D was significantly higher than that in group A and group B (P < 0.05). CONCLUSION: Alfentanil 20 µg/kg for RSI in elderly patients, can effectively inhibit the violent cardiovascular reaction caused by intubation, and avoid the inhibition of cardiovascular system caused by large dose, hemodynamics more stable. TRIAL REGISTRATION: ChiCTR2200062034 ( www.chictr.org.cn ).

Venous return physiology applied to post-cardiac arrest haemodynamic management: a post hoc analysis of the NEUROPROTECT trial.

BACKGROUND: The European Resuscitation Council 2021 guidelines for haemodynamic monitoring and management during post-resuscitation care from cardiac arrest call for an individualised approach to therapeutic interventions. Combining the cardiac function and venous return curves with the inclusion of the mean systemic filling pressure enables a physiological illustration of intravascular volume, vasoconstriction and inotropy. An analogue mean systemic filling pressure (Pmsa) may be calculated once cardiac output, mean arterial and central venous pressure are known. The NEUROPROTECT trial compared targeting a mean arterial pressure of 65 mmHg (standard) versus an early goal directed haemodynamic optimisation targeting 85 mmHg (high) in ICU for 36 h after cardiac arrest. The trial data were used in this study to calculate post hoc Pmsa and its expanded variables to comprehensively describe venous return physiology during post-cardiac arrest management. A general estimating equation model was used to analyse continuous variables split by standard and high mean arterial pressure groups. RESULTS: Data from 52 patients in each group were analysed. The driving pressure for venous return, and thus cardiac output, was higher in the high MAP group (p < 0.001) along with a numerically increased estimated stressed intravascular volume (mean difference 0.27 [- 0.014-0.55] L, p = 0.06). The heart efficiency was comparable (p = 0.43) in both the standard and high MAP target groups, suggesting that inotropy was similar despite increased arterial load in the high MAP group (p = 0.01). The efficiency of fluid boluses to increase cardiac output was increased in the higher MAP compared to standard MAP group (mean difference 0.26 [0.08-0.43] fraction units, p = 0.01). CONCLUSIONS: Calculation of the analogue mean systemic filling pressure and expanded variables using haemodynamic data from the NEUROPROTECT trial demonstrated an increased venous return, and thus cardiac output, as well as increased volume responsiveness associated with targeting a higher MAP. Further studies of the analogue mean systemic filling pressure and its derived variables are warranted to individualise post-resuscitation care and evaluate any clinical benefit associated with this monitoring approach.

Effectiveness of different doses of dexmedetomidine on intraoperative haemodynamic profiles and postoperative pain in patients undergoing abdominal surgery at Dilla University Referral Hospital, Ethiopia, 2024: a double-blind randomized controlled trial.

Background and objective: Abdominal surgery stands as one of the most frequently conducted procedures across surgical specialties, accounting for up to half of surgery-related expenses. Hemodynamic instability emerges as a significant concern during anaesthesia and surgery, provoked by the stress of intubation, surgical incision, and anaesthetic agents. Following abdominal surgery, pain is an inevitable consequence, typically managed with opioid-based analgesia. However, the adverse effects associated with opioids often overshadow their analgesic benefits, particularly in the context of abdominal surgery. Consequently, there exists a necessity to explore and assess alternative non-opioid pain management options post-abdominal surgery as part of a broader strategy to reduce opioid usage. The primary aim of this investigation is to assess the effectiveness of varying doses of dexmedetomidine in regulating intraoperative hemodynamics and alleviating postoperative pain in patients undergoing abdominal surgery. Methods: Ethical clearance and institutional review board were obtained from the ethical clearance committee of Dilla University College of Medicine and Health Sciences with protocol unique number of duirb/008/22-01. Our trial has been prospectively registered on the Pan African Clinical Trial Registry with a unique identification number for the registry PACTR202208813896934. Statistical package and analysis were performed by using SPSS version 25. The distribution of data was checked by using Shapiro-Wilk test and the homogeneity of variance was checked by Levene's test. Analysis of variance (ANOVA) and Kruskal-Wallis H test were used for normally distributed continuous data and non-normally distributed or non-parametric data, respectively. P value less than 0.05 with a power of 90% was considered statistically significant. Result: There was a statistically significant increase in mean SBP in the control group at the different critical time points (P<0.05), as compared to the baseline value, while there was no significant difference in mean systolic blood pressure (SBP) between the baseline and all other levels for group 2 and group 3. A statistically significant increase in mean arterial pressure (MAP) was detected in the control group at immediately after intubation (P=0.009) as compared to the baseline value, while a statistically significant reduction in mean heart rate (HR) was observed in group 3 at 15th min after infusion and at 30th 30 min after induction compared to baseline with a P value of 0.002 and 0.008, respectively.Conclusion:Perioperative low-dose infusion of dexmedetomidine at the rate of 0.4 mcg/kg/h is a useful anaesthesia adjuvant to control hemodynamic stress response to critical periods. It is wise to use this infusion dose as part of general anaesthesia to achieve better hemodynamic stability.

Comparison of the Magnesium Sulphate With Paracetamol Combination vs the Fentanyl With Lignocaine Combination in Attenuating the Hemodynamic Response During Laryngoscopy and Intubation: A Prospective, Double-Blinded Randomized Controlled Study.

Background and aims Laryngoscopy and intubation cause an increased sympatho-adrenergic pressor response, which can be detrimental to patients with coronary artery disease, hypertension, etc. Various drugs and manoeuvres have been tried to reduce the pressor response with acceptable results but the quest for the ideal drug still continues. Hence, we planned to compare the effects of magnesium sulfate with paracetamol and fentanyl with lignocaine on attenuating the hemodynamic responses due to direct laryngoscopy and intubation and to note the complications of these drugs. Methods We studied 60 adult patients of the American Society of Anaesthesiologists (ASA) physical status I and II of either sex, scheduled for elective surgery under general anaesthesia. The patients were randomly divided into two groups. Group A received 25 mg/kg magnesium sulphate mixed with paracetamol 1 gram IV (100 ml) given over 10 minutes before induction and Group B received 2 mcg/kg fentanyl and 1.5 mg/kg lignocaine, 3 minutes before intubation. All patients were uniformly pre-medicated, induced, and intubated as per standard protocol. Heart rate (HR) and systemic arterial pressures were recorded at baseline, after study drug infusion, after induction, and 1, 3, 5, 10, and 15 mins after intubation. Hemodynamic parameters were compared using repeated measures analysis of variance (ANOVA). In the post-hoc tests, p value < 0.05 was considered statistically significant. Results We observed the mean pre-op HR (p = 0.161) and mean HR one-minute post-induction (p = 0.144). The percentage change from baseline at one-minute post-induction was 9.7 in Group A and 15.2 in Group B. We observed the mean pre-op mean arterial pressure (MAP) (p = 0.119) and mean MAP one minute post-induction (p = 0.585). The percentage change from baseline at one-minute post-induction was 3.3 in Group A and 2.8 in Group B. The percentage change from baseline was found to be within 15%, for HR in Group A and for systolic blood pressure (SBP), diastolic blood pressure (DBP), and MAP in Group B. However, there was no statistically significant difference (p > 0.05) between the mean HR, SBP, DBP, and MAP between the time points. Conclusion In our study, both the combinations of drugs, magnesium sulphate with paracetamol (Group A drugs) and fentanyl with lignocaine (Group B drugs) were found to be equally effective (i.e. neither group was superior to the other) in attenuating the hemodynamic response to laryngoscopy and intubation.

Comprehensive non-invasive haemodynamic assessment in acute decompensated heart failure-related cardiogenic shock: a step towards echodynamics.

AIMS: Haemodynamic assessment can be determinant in phenotyping cardiogenic shock (CS) and guiding patient management. Aim of this study was to evaluate the correlation between echocardiographic and invasive assessment of haemodynamics in acute decompensated heart failure-related CS (ADHF-CS). METHODS AND RESULTS: All consecutive ADHF-CS patients (SCAI shock stage ≥B) undergoing right heart catheterization (RHC) between 2020 and 2022 were prospectively enrolled. Patients underwent echocardiography 30 min before RHC. The evaluated haemodynamic parameters and their echocardiographic estimates ('e') comprised cardiac index (CI), wedge pressure (WP), pulmonary artery pressures (PAP), cardiac power output (CPO) and pulmonary artery pulsatility index (PAPi). Hundred and one ADHF-CS patients (56 ± 11 years, 64% SCAI shock stage C, left ventricular ejection fraction 29 ± 5%) were included. Good correlation was found for CI, systolic PAP, RAP, and CPO (Pearson r > 0.8 for all), moderate correlation for ePAPi (r = 0.67) and PVR (r = 0.51), while estimation of WP was weak. The sensitivity and specificity of eCI to identify low output state (CI ≤2.2 L/min/m2) were 0.97 and 0.73, respectively, those of eWP for elevated filling pressures (WP >15 mmHg) were 0.84 and 0.55, those of ePAPs for PAPs ≥35 mmHg were 0.87 and 0.63, those of eCPO for CPO <0.6 W were 0.76 and 0.85, those of ePAPi for PAPi <1.85 were 0.89 and 0.92. Echocardiographic phenotyping of CS showed a good agreement with invasive classification (K value 0.457, P < 0.001). CONCLUSION: Echocardiographic estimation of haemodynamics and subsequent phenotypization of CS is feasible with good agreement with invasive evaluation.