Quantification of Video Sequences of the Microcirculation: A Comparison Between Automated Analysis Using Analysis Manager and Manual Analysis Using Capillary Mapper.

OBJECTIVE: Microcirculatory disturbances can contribute to organ dysfunction in patients undergoing major surgeries and critical illness. Incident dark field imaging (CytoCam, Braedius Medical BV, Huizen, Netherlands) provides direct visualization of the microcirculation. To utilize this method in daily clinical practice, automated image analysis is essential. This study aims to compare the automated analysis of recorded microcirculation video sequences using CytoCamTools V2 Analysis Manager (Braedius Medical BV) with established manual analysis using Capillary Mapper (Version 1.4.5, University Hospital Münster, Germany) as reference method. METHODS: Sublingual microcirculation video sequences were recorded in patients undergoing laparotomy at four time points (before surgery, 2 and 6 h after surgery, and on the first postoperative day) using incident dark field imaging. Agreement between automated and manual analysis of total vessel density (TVD), perfused vessel density (PVD), and proportion of perfused vessels (PPV) was compared using intraclass correlation (ICC) and Bland-Altman method. RESULTS: A total of 336 videos from 30 patients were analyzed. The ICC between the two measurement methods was 0.13 for TVD, 0.14 for PVD, and 0.16 for PPV. Bland-Altman analysis showed mean differences (95% limits of agreement) of 10.46 mm/mm2 (-1.73-22.65 mm/mm2) for TVD, 8.25 mm/mm2 (-9.88-26.39 mm/mm2) for PVD, and - 3.96% (-59.58%-51.65%) for PPV. DISCUSSION: Automated microcirculatory analysis using the Analysis Manager did not show clinically acceptable agreement with manual analysis using Capillary Mapper. Consequently, automated video analysis using the Analysis Manager does not appear to be a suitable approach. TRIAL REGISTRATION: ClinicalTrials.gov identifier: DRKS00020264.

Cardiac index-guided therapy to maintain optimised postinduction cardiac index in high-risk patients having major open abdominal surgery: the multicentre randomised iPEGASUS trial.

BACKGROUND: It is unclear whether optimising intraoperative cardiac index can reduce postoperative complications. We tested the hypothesis that maintaining optimised postinduction cardiac index during and for the first 8 h after surgery reduces the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery. METHODS: In three German and two Spanish centres, high-risk patients having elective major open abdominal surgery were randomised to cardiac index-guided therapy to maintain optimised postinduction cardiac index (cardiac index at which pulse pressure variation was <12%) during and for the first 8 h after surgery using intravenous fluids and dobutamine or to routine care. The primary outcome was the incidence of a composite outcome of moderate or severe complications within 28 days after surgery. RESULTS: We analysed 318 of 380 enrolled subjects. The composite primary outcome occurred in 84 of 152 subjects (55%) assigned to cardiac index-guided therapy and in 77 of 166 subjects (46%) assigned to routine care (odds ratio: 1.87, 95% confidence interval: 1.03-3.39, P=0.038). Per-protocol analyses confirmed the results of the primary outcome analysis. CONCLUSIONS: Maintaining optimised postinduction cardiac index during and for the first 8 h after surgery did not reduce, and possibly increased, the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery. Clinicians should not strive to maintain optimised postinduction cardiac index during and after surgery in expectation of reducing complications. CLINICAL TRIAL REGISTRATION: NCT03021525.

Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies.

Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).

Regional ventilation in spontaneously breathing COVID-19 patients during postural maneuvers assessed by electrical impedance tomography.

BACKGROUND: Gravity-dependent positioning therapy is an established concept in the treatment of severe acute respiratory distress syndrome and improves oxygenation in spontaneously breathing patients with hypoxemic acute respiratory failure. In patients with coronavirus disease 2019, this therapy seems to be less effective. Electrical impedance tomography as a point-of-care functional imaging modality for visualizing regional ventilation can possibly help identify patients who might benefit from positioning therapy and guide those maneuvers in real-time. Therefore, in this prospective observational study, we aimed to discover typical patterns in response to positioning maneuvers. METHODS: Distribution of ventilation in 10 healthy volunteers and in 12 patients with hypoxemic respiratory failure due to coronavirus disease 2019 was measured in supine, left, and right lateral positions using electrical impedance tomography. RESULTS: In this study, patients with coronavirus disease 2019 showed a variety of ventilation patterns, which were not predictable, whereas all but one healthy volunteer showed a typical and expected gravity-dependent distribution of ventilation with the body positions. CONCLUSION: Distribution of ventilation and response to lateral positioning is variable and thus unpredictable in spontaneously breathing patients with coronavirus disease 2019. Electrical impedance tomography might add useful information on the immediate reaction to postural maneuvers and should be elucidated further in clinical studies. Therefore, we suggest a customized individualized positioning therapy guided by electrical impedance tomography.

Extracorporeal therapy of sepsis by purified granulocyte concentrates: ex vivo circulation model.

BACKGROUND: Immune cell dysfunction is a central part of immune paralysis in sepsis. Granulocyte concentrate (GC) transfusions can induce tissue damage via local effects of neutrophils. The hypothesis of an extracorporeal plasma treatment with granulocytes is to show beneficial effects with fewer side effects. Clinical trials with standard GC have supported this approach. This ex vivo study investigated the functional properties of purified granulocyte preparations during the extracorporeal plasma treatment. METHODS: Purified GC were stored for up to 3 days and compared with standard GC in an immune cell perfusion therapy model. The therapy consists of a plasma separation device and an extracorporeal circuit. Plasma is perfused through the tubing system with donor immune cells of the GC, and only the treated plasma is filtered for re-transfusion. The donor immune cells are retained in the extracorporeal system and discarded after treatment. Efficacy of granulocytes regarding phagocytosis, oxidative burst as well as cell viability and metabolic parameters were assessed. RESULTS: In pGC, the metabolic surrogate parameters of cell functionality showed comparable courses even after a storage period of 72 h. In particular, glucose and oxygen consumption were lower after extended storage. The course of lactate dehydrogenase concentration yields no indication of cell impairment in the extracorporeal circulation. The cells were viable throughout the entire study period and exhibited preserved phagocytosis and oxidative burst functionality. CONCLUSION: The granulocytes demonstrated full functionality in the 6 h extracorporeal circuits after 3 days storage and in septic shock plasma. This is demonstrating the functionality of the system and encourages further clinical studies.

Pressure- vs. volume-controlled ventilation and their respective impact on dynamic parameters of fluid responsiveness: a cross-over animal study.

BACKGROUND AND GOAL OF STUDY: Pulse pressure variation (PPV) and stroke volume variation (SVV), which are based on the forces caused by controlled mechanical ventilation, are commonly used to predict fluid responsiveness. When PPV and SVV were introduced into clinical practice, volume-controlled ventilation (VCV) with tidal volumes (VT) ≥ 10 ml kg- 1 was most commonly used. Nowadays, lower VT and the use of pressure-controlled ventilation (PCV) has widely become the preferred type of ventilation. Due to their specific flow characteristics, VCV and PCV result in different airway pressures at comparable tidal volumes. We hypothesised that higher inspiratory pressures would result in higher PPVs and aimed to determine the impact of VCV and PCV on PPV and SVV. METHODS: In this self-controlled animal study, sixteen anaesthetised, paralysed, and mechanically ventilated (goal: VT 8 ml kg- 1) pigs were instrumented with catheters for continuous arterial blood pressure measurement and transpulmonary thermodilution. At four different intravascular fluid states (IVFS; baseline, hypovolaemia, resuscitation I and II), ventilatory and hemodynamic data including PPV and SVV were assessed during VCV and PCV. Statistical analysis was performed using U-test and RM ANOVA on ranks as well as descriptive LDA and GEE analysis. RESULTS: Complete data sets were available of eight pigs. VT and respiratory rates were similar in both forms. Heart rate, central venous, systolic, diastolic, and mean arterial pressures were not different between VCV and PCV at any IVFS. Peak inspiratory pressure was significantly higher in VCV, while plateau, airway and transpulmonary driving pressures were significantly higher in PCV. However, these higher pressures did not result in different PPVs nor SVVs at any IVFS. CONCLUSION: VCV and PCV at similar tidal volumes and respiratory rates produced PPVs and SVVs without clinically meaningful differences in this experimental setting. Further research is needed to transfer these results to humans.

Effectiveness of preoxygenation by conventional face mask versus non-invasive ventilation in morbidly obese patients: measurable by the oxygen-reserve index?

Preoxygenation is a crucial manoeuvre for patients' safety, particularly for morbidly obese patients due to their reduced pulmonary reserve and increased risk for difficult airway situations. The oxygen reserve index (ORI™) was recently introduced as a new parameter of multiple wavelength pulse oximetry and has been advocated to allow assessment of hyperoxia [quantified by the resulting arterial oxygen partial pressure (PaO2)]. This study investigates if ORI can be used to evaluate the impact of two different preoxygenation manoeuvres on the grade of hyperoxia. Two preoxygenation manoeuvres were sequentially evaluated in 41 morbidly obese patients: First, breathing 100% oxygen for 5 min via standard face mask. Second, after achieving a second baseline, 5 min of non-invasive ventilation (NIV) with 100% oxygen. The effect of preoxygenation on ORI compared to PaO2 was evaluated and whether differences in the two preoxygenation manoeuvres can be monitored by ORI. Overall correlation of PaO2 and ORI was significant (Spearman-Rho coefficient of correlation 0.818, p < 0.001). However, ORI could not differentiate between the two preoxygenation manoeuvres although the PaO2 values for NIV preoxygenation were significantly higher compared to standard preoxygenation (median 505 mmHg (M1) vs. 550 mmHg (M3); p < 0.0001). In contrast, ORI values did not differ significantly (median 0.39 (M1) vs. 0.38 (M3); p = 0.758). Absolute values of ORI cannot be used to assess effectiveness of a preoxygenation procedure in bariatric patients, mainly because its range of discrimination is considerably lower than the high ranges of PaO2 attained by adequate preoxygenation. Trial registration German Clinical Trials Register: DRKS00025023 (retrospectively registered on April 16th, 2021).

Dynamic relative regional strain visualized by electrical impedance tomography in patients suffering from COVID-19.

Respiratory failure due to SARS-CoV-2 may progress rapidly. During the course of COVID-19, patients develop an increased respiratory drive, which may induce high mechanical strain a known risk factor for Patient Self-Inflicted Lung Injury (P-SILI). We developed a novel Electrical Impedance Tomography-based approach to visualize the Dynamic Relative Regional Strain (DRRS) in SARS-CoV-2 positive patients and compared these findings with measurements in lung healthy volunteers. DRRS was defined as the ratio of tidal impedance changes and end-expiratory lung impedance within each pixel of the lung region. DRRS values of the ten patients were considerably higher than those of the ten healthy volunteers. On repeated examination, patterns, magnitude and frequency distribution of DRRS were reproducible and in line with the clinical course of the patients. Lung ultrasound scores correlated with the number of pixels showing DRRS values above the derived threshold. Using Electrical Impedance Tomography we were able to generate, for the first time, images of DRRS which might indicate P-SILI in patients suffering from COVID-19.Trial Registration This observational study was registered 06.04.2020 in German Clinical Trials Register (DRKS00021276).

Impact of Albumin Binding Function on Pharmacokinetics and Pharmacodynamics of Furosemide.

Background and Objectives: Albumin binding of the loop diuretic furosemide forms the basis for its transport to the kidney and subsequent tubular secretion, which is a prerequisite for its therapeutic effects. Accordingly, high albumin concentrations should result in higher efficacy of furosemide. However, study results on the combination of furosemide in conjunction with albumin, and on the efficacy of furosemide in hypoalbuminemia, did not confirm this hypothesis. The aim of this study was to determine the efficacy of furosemide not only in relation to albumin concentration, but also taking albumin function into account. Materials and Methods: In a prospective and non-interventional clinical observational trial, blood and urine samples from 50 intensive care patients receiving continuous intravenous furosemide therapy were evaluated. Albumin binding capacity (ABiC) determination allowed conclusions to be drawn about the binding site-specific loading state of albumin, by quantifying the unbound fraction of the fluorescent marker dansylsarcosine. In addition, assessment of the total concentration of furosemide in plasma and urine, as well as the concentration of free furosemide fraction in plasma, was performed by HPLC−MS. The efficacy of furosemide was evaluated by the ratio of urine excretion to fluid intake. Results: In patients with an ABiC ≥ 60% free furosemide fraction was significantly lower compared to patients with a lower ABiC (p < 0.001), urinary furosemide concentration was higher (p = 0.136), and a significantly higher proportion of infused furosemide was excreted renally (p = 0.010). ABiC was positively correlated (r = 0.908, p = 0.017) with increase in the urine excretion to fluid input ratio after initiation of furosemide therapy. Conclusions: ABiC could serve as a marker for individual response to furosemide and could be used to generate patient-specific therapeutic regimens. In view of the relatively low number of patients in this study, the relationship between furosemide efficacy and albumin function should be investigated in larger studies in the future.

Metrology part 1: definition of quality criteria.

Any measurement is always afflicted with some degree of uncertainty. A correct understanding of the different types of uncertainty, their naming, and their definition is of crucial importance for an appropriate use of measuring instruments. However, in perioperative and intensive care medicine, the metrological requirements for measuring instruments are poorly defined and often used spuriously. The correct use of metrological terms is also of crucial importance in validation studies. The European Union published a new directive on medical devices, mentioning that in the case of devices with a measuring function, the notified body is involved in all aspects relating to the conformity of the device with the metrological requirements. It is therefore the task of the scientific societies to establish the standards in their area of expertise. Adopting the same understandings and definitions among clinicians and scientists is obviously the first step. In this metrologic review (part 1), we list and explain the most important terms defined by the International Bureau of Weights and Measures regarding quantities and units, properties of measurements, devices for measurement, properties of measuring devices, and measurement standards, with specific examples from perioperative and intensive care medicine.

Metrology part 2: Procedures for the validation of major measurement quality criteria and measuring instrument properties.

A measurement is always afflicted with some degree of uncertainty. A correct understanding of the different types of uncertainty, their naming, and their definition is of crucial importance for an appropriate use of the measuring instruments. However, in perioperative and intensive care medicine, the metrological requirements for measuring instruments are poorly defined and often used spuriously. The correct use of metrological terms is also of crucial importance in validation studies. The European Union published a new directive on medical devices, mentioning that in the case of devices with a measuring function, the notified body is involved in all aspects relating to the conformity of the device with the metrological requirements. It is therefore the task of scientific societies to establish the standards in their area of expertise. After adopting the same understandings and definitions (part 1), the different procedures for the validation of major quality criteria of measuring devices must be consensually established. In this metrologic review (part 2), we review the terms and definitions of validation, some basic processes leading to the display of an indication from a physiologic signal, and procedures for the validation of measuring instrument properties, with specific focus on perioperative and intensive care medicine including appropriate examples.

Assessing volume responsiveness using right ventricular dynamic indicators of preload.

PURPOSE: Dynamic indicators of preload currently only do reflect preload requirements of the left ventricle. To date, no dynamic indicators of right ventricular preload have been established. The aim of this study was to calculate dynamic indicators of right ventricular preload and assess their ability to predict ventricular volume responsiveness. MATERIALS AND METHODS: The study was designed as experimental trial in 20 anaesthetized pigs. Micro-tip catheters and ultrasonic flow probes were used as experimental reference to enable measurement of right ventricular stroke volume and pulse pressure. Hypovolemia was induced (withdrawal of blood 20 ml/kg) and thereafter three volume-loading steps were performed. ROC analysis was performed to assess the ability of dynamic right ventricular parameters to predict volume response. RESULTS: ROC analysis revealed an area under the curve (AUC) of 0.82 (CI 95% 0.73-0.89; p < 0.001) for right ventricular stroke volume variation (SVVRV), an AUC of 0.72 (CI 95% 0.53-0.85; p = 0.02) for pulmonary artery pulse pressure variation (PPVPA) and an AUC of 0.66 (CI 95% 0.51-0.79; p = 0.04) for pulmonary artery systolic pressure variation (SPVPA). CONCLUSIONS: In our experimental animal setting, calculating dynamic indicators of right ventricular preload is possible and appears promising in predicting volume responsiveness.

[Comments on the updated German S3 guidelines on intravascular volume therapy in adults]. / Kommentar zur aktualisierten S3-Leitlinie zur intravasalen Volumentherapie beim Erwachsenen.

The German S3 guidelines on intravascular volume therapy in adults were updated in September 2020. Based on updated evidence recommendations for the diagnosis of isotonic dehydration and for fluid therapy with crystalloids and colloids in peri-interventional and intensive care medicine were proposed.

Large Duodenal Hematoma Causing an Ileus after an Endoscopic Duodenal Biopsy in a 6-Year-Old Child: A Case Report.

Intramural duodenal hematoma (IDH) in children is a rare complication after esophagogastroduodenoscopy. It is commonly described in patients with additional disorders or risk factors, such as coagulopathy. We present a case of a previously healthy 6-year-old boy with a large obstructing intramural duodenal hematoma and concomitant pancreatitis after an elective esophagogastroduodenoscopy. The patient presented with typical symptoms of an IDH, such as abdominal pain and distension, nausea and vomiting. IDH was diagnosed using ultrasound and magnetic resonance imaging examination. Conservative management with gastric decompression using a nasogastric feeding tube, bowel rest, total parenteral nutrition and analgesia was performed. After three weeks, the patient was discharged from the hospital without any complaints. Interventional management of IDH in pediatric patients with a lack of response to conservative therapy or complicating IDH should be discussed in an interdisciplinary team.

Personalised haemodynamic management targeting baseline cardiac index in high-risk patients undergoing major abdominal surgery: a randomised single-centre clinical trial.

BACKGROUND: Despite several clinical trials on haemodynamic therapy, the optimal intraoperative haemodynamic management for high-risk patients undergoing major abdominal surgery remains unclear. We tested the hypothesis that personalised haemodynamic management targeting each individual's baseline cardiac index at rest reduces postoperative morbidity. METHODS: In this single-centre trial, 188 high-risk patients undergoing major abdominal surgery were randomised to either routine management or personalised haemodynamic management requiring clinicians to maintain personal baseline cardiac index (determined at rest preoperatively) using an algorithm that guided intraoperative i.v. fluid and/or dobutamine administration. The primary outcome was a composite of major complications (European Perioperative Clinical Outcome definitions) or death within 30 days of surgery. Secondary outcomes included postoperative morbidity (assessed by a postoperative morbidity survey), hospital length of stay, mortality within 90 days of surgery, and neurocognitive function assessed after postoperative Day 3. RESULTS: The primary outcome occurred in 29.8% (28/94) of patients in the personalised management group, compared with 55.3% (52/94) of patients in the routine management group (relative risk: 0.54, 95% confidence interval [CI]: 0.38 to 0.77; absolute risk reduction: -25.5%, 95% CI: -39.2% to -11.9%; P<0.001). One patient assigned to the personalised management group, compared with five assigned to the routine management group, died within 30 days after surgery (P=0.097). There were no clinically relevant differences between the two groups for secondary outcomes. CONCLUSIONS: In high-risk patients undergoing major abdominal surgery, personalised haemodynamic management reduces a composite outcome of major postoperative complications or death within 30 days after surgery compared with routine care. CLINICAL TRIAL REGISTRATION: NCT02834377.

Anesthesia for Patients Undergoing Peroral Endoscopic Myotomy Procedures: A Review of the Literature.

Idiopathic achalasia is a motility disorder of the esophagus with important implications on anesthesia and periprocedural management. As new and more complex treatment options develop, anesthesiologists are increasingly involved with these patients. The cardinal symptoms of achalasia are as follows: dysphagia, regurgitation, chest pain, and weight loss. Achalasia is also associated with an increased risk of aspiration. Patients are frequently treated by endoscopic botulinum toxin injections, pneumatic dilation of the lower esophageal sphincter, laparoscopic Heller myotomy, or peroral endoscopic myotomy (POEM). The POEM procedure is based on the concept of "natural orifice transluminal endoscopic surgery." Because the integrity of the esophageal wall is deliberately interrupted during POEM, the mediastinum and the peritoneal cavity may be exposed. Thus, the insufflated carbon dioxide frequently causes hypercapnia, tension capnoperitoneum, capnomediastinum, or pneumothoraces. An interdisciplinary team, skilled in diagnostics and emergency measures such as therapeutic hyperventilation, percutaneous abdominal needle decompression, or pleural drainage, is essential for the successful periprocedural management of POEM. POEM is one endoscopic procedure that requires general anesthesia. But neither anesthesia-specific care algorithms nor evidence-based recommendations are currently available for these patients. Because institutional experience varies broadly across the globe, this review examines anesthesia recommendations and perioperative management of POEM procedures based on 7 retrospective case series, 1 prospective study, and our personal experience.

Automated Ambulatory Blood Pressure Measurements and Intraoperative Hypotension in Patients Having Noncardiac Surgery with General Anesthesia: A Prospective Observational Study.

BACKGROUND: Normal blood pressure varies among individuals and over the circadian cycle. Preinduction blood pressure may not be representative of a patient's normal blood pressure profile and cannot give an indication of a patient's usual range of blood pressures. This study therefore aimed to determine the relationship between ambulatory mean arterial pressure and preinduction, postinduction, and intraoperative mean arterial pressures. METHODS: Ambulatory (automated oscillometric measurements at 30-min intervals) and preinduction, postinduction, and intraoperative mean arterial pressures (1-min intervals) were prospectively measured and compared in 370 American Society of Anesthesiology physical status classification I or II patients aged 40 to 65 yr having elective noncardiac surgery with general anesthesia. RESULTS: There was only a weak correlation between the first preinduction and mean daytime mean arterial pressure (r = 0.429, P < 0.001). The difference between the first preinduction and mean daytime mean arterial pressure varied considerably among individuals. In about two thirds of the patients, the lowest postinduction and intraoperative mean arterial pressures were lower than the lowest nighttime mean arterial pressure. The difference between the lowest nighttime mean arterial pressure and a mean arterial pressure of 65 mmHg varied considerably among individuals. The lowest nighttime mean arterial pressure was higher than 65 mmHg in 263 patients (71%). CONCLUSIONS: Preinduction mean arterial pressure cannot be used as a surrogate for the normal daytime mean arterial pressure. The lowest postinduction and intraoperative mean arterial pressures are lower than the lowest nighttime mean arterial pressure in most patients.

Muscular Ultrasound, Syndecan-1 and Procalcitonin Serum Levels to Assess Intensive Care Unit-Acquired Weakness.

BACKGROUND: Intensive care unit-acquired weakness (ICU-AW) is associated with poorer outcome of critically ill patients. Microcirculatory changes and altered vascular permeability of skeletal muscles might contribute to the pathogenesis of ICU-AW. Muscular ultrasound (MUS) displays increased muscle echogenicity, although its pathogenesis is uncertain. OBJECTIVE: We investigated the combined measurement of serum and ultrasound markers to assess ICU-AW and clinical patient outcome. METHODS: Fifteen patients and five healthy controls were longitudinally assessed for signs of ICU-AW at study days 3 and 10 using a muscle strength sum score. The definition of ICU-AW was based on decreased muscle strength assessed by the muscular research council-sum score. Ultrasound echogenicity of extremity muscles was assessed using a standardized protocol. Serum markers of inflammation and endothelial damage were measured. The 3-month outcome was assessed on the modified Rankin scale. RESULTS: ICU-AW was present in eight patients, and seven patients and the control subjects did not develop ICU-AW. The global muscle echogenicity score (GME) differed significantly between controls and patients (mean GME, 1.1 ± 0.06 vs. 2.3 ± 0.41; p = 0.001). Mean GME values significantly decreased in patients without ICU-AW from assessment 1 (2.30 ± 0.48) to assessment 2 (2.06 ± 0.45; p = 0.027), which was not observed in patients with ICU-AW. Serum levels of syndecan-1 at day 3 significantly correlated with higher GME values at day 10 (r = 0.63, p = 0.012). Furthermore, the patients' GME significantly correlated with mRS at day 100 (r = 0.67, p = 0.013). CONCLUSION: The combined use of muscular ultrasound and inflammatory biomarkers might be helpful to diagnose ICU-AW and to predict long-term outcome in critical illness.

Continuous Noninvasive Arterial Pressure Monitoring in Obese Patients During Bariatric Surgery: An Evaluation of the Vascular Unloading Technique (Clearsight system).

BACKGROUND: Continuous monitoring of arterial pressure is important in severely obese patients who are at particular risk for cardiovascular complications. Innovative technologies for continuous noninvasive arterial pressure monitoring are now available. In this study, we compared noninvasive arterial pressure measurements using the vascular unloading technique (Clearsight system; Edwards Lifesciences Corp, Irvine, CA) with invasive arterial pressure measurements (radial arterial catheter) in severely obese patients during laparoscopic bariatric surgery. METHODS: In 35 severely obese patients (median body mass index, 47 kg/m2), we simultaneously recorded noninvasive and invasive arterial pressure measurements over a period of 45 minutes. We compared noninvasive (test method) and invasive (reference method) arterial pressure measurements (sampling rate 1 Hz = 1/s) using Bland-Altman analysis (accounting for multiple measurements per subject), 4-quadrant plot/concordance analysis (2-minute interval, 5 mm Hg exclusion zone), and error grid analysis (calculating the proportions of measurements in risk zones A-E with A indicating no risk, B low risk, C moderate risk, D significant risk, and E dangerous risk for the patient due to the risk of wrong clinical interventions because of measurement errors). RESULTS: We observed a mean of the differences (±SD, 95% limits of agreement) between the noninvasively and invasively assessed arterial pressure values of 1.1 mm Hg (±7.4 mm Hg, -13.5 to 15.6 mm Hg) for mean arterial pressure (MAP), 6.8 mm Hg (±10.3 mm Hg, -14.4 to 27.9 mm Hg) for systolic arterial pressure, and 0.8 mm Hg (±6.9 mm Hg, -12.9 to 14.4 mm Hg) for diastolic arterial pressure. The 4-quadrant plot concordance rate (ie, the proportion of arterial pressure measurement pairs showing concordant changes to all changes) was 93% (CI, 89%-96%) for MAP, 93% (CI, 89%-97%) for systolic arterial pressure, and 88% (CI, 84%-92%) for diastolic arterial pressure. Error grid analysis showed that the proportions of measurements in risk zones A-E were 89.5%, 10.0%, 0.5%, 0%, and 0% for MAP and 93.7%, 6.0%, 0.3%, 0%, and 0% for systolic arterial pressure, respectively. CONCLUSIONS: During laparoscopic bariatric surgery, the accuracy and precision of the vascular unloading technique (Clearsight system) was good for MAP and diastolic arterial pressure, but only moderate for systolic arterial pressure according to Bland-Altman analysis. The system showed good trending capabilities. In the error grid analysis, >99% of vascular unloading technique-derived arterial pressure measurements were categorized in no- or low-risk zones.

Continuous noninvasive arterial blood pressure monitoring using the vascular unloading technology during complex gastrointestinal endoscopy: a prospective observational study.

The innovative vascular unloading technology (VUT) allows continuous noninvasive arterial blood pressure (AP) monitoring. We aimed to investigate whether the VUT enables AP changes to be detected earlier compared with intermittent AP monitoring in patients undergoing gastrointestinal endoscopy. In this prospective observational study, we recorded continuous AP measurements with the VUT (CNAP system; CNSystems Medizintechnik AG, Graz, Austria) and intermittent AP measurements with upper arm cuff oscillometry in 90 patients undergoing complex gastrointestinal endoscopy (Department of Interventional Endoscopy at the University Medical Center Hamburg-Eppendorf, Hamburg, Germany). A "hypotensive phase" was defined as a time period of at least 30 s during which ≥ 50% of the VUT-AP values were in a predefined range of hypotension, i.e., AP value a) ≥ 10% below the last oscillometric value and b) ≤ 65 mmHg for mean AP or ≤ 90 mmHg for systolic AP. In the 5-min-interval between two oscillometric measurements, one or more hypotensive phases were detected in 26 patients (29%) for mean AP and in 27 patients (30%) for systolic AP. Hypotensive phases had a mean duration of 195 ± 99 s for mean AP and 197 ± 97 s for systolic AP with a mean procedure duration of 36 (± 21) min. Continuous noninvasive AP monitoring using the VUT enables hypotensive phases to be detected earlier compared with intermittent AP monitoring during complex gastrointestinal endoscopy. These hypotensive phases may be missed or only belatedly recognized with intermittent AP monitoring. Continuous noninvasive AP measurement facilitates detecting hemodynamic instability more rapidly and therefore may improve patient safety.