Predicting intradialytic hypotension in critically ill patients undergoing intermittent hemodialysis: a prospective observational study.

BACKGROUND: Hypotension during dialysis arises from vasomotor tone alterations and hypovolemia, with disrupted counterregulatory mechanisms in acute kidney injury (AKI) patients. This study investigated the predictive value of preload dependency, assessed by the passive leg raising (PLR) test, and arterial tone, measured by dynamic elastance (Eadyn), for intradialytic hypotension (IDH). METHODS: In this prospective observational study conducted in a tertiary hospital ICU, hemodynamic parameters were collected from critically ill AKI patients undergoing intermittent hemodialysis using the FloTrac/Vigileo system. Baseline measurements were recorded before KRT initiation, including the PLR test and Eadyn calculation. IDH was defined as mean arterial pressure (MAP) < 65 mmHg during dialysis. Logistic regression was used to identify predictors of IDH, and Kaplan-Meier analysis assessed 90-day survival. RESULTS: Of 187 patients, 27.3% experienced IDH. Preload dependency, identified by positive PLR test, was significantly associated with IDH (OR 8.54, 95% CI 5.25-27.74), while baseline Eadyn was not predictive of IDH in this cohort. Other significant predictors of IDH included norepinephrine use (OR 16.35, 95% CI 3.87-68.98) and lower baseline MAP (OR 0.96, 95% CI 0.94-1.00). IDH and a positive PLR test were associated with lower 90-day survival (p < 0.001). CONCLUSIONS: The PLR test is a valuable tool for predicting IDH in critically ill AKI patients undergoing KRT, while baseline Eadyn did not demonstrate predictive value in this setting. Continuous hemodynamic monitoring, including assessment of preload dependency, may optimize patient management and potentially improve outcomes. Further research is warranted to validate these findings and develop targeted interventions to prevent IDH.

Critical Care Ultrasound in Shock: A Comprehensive Review of Ultrasound Protocol for Hemodynamic Assessment in the Intensive Care Unit.

Shock is a life-threatening condition that requires prompt recognition and treatment to prevent organ failure. In the intensive care unit, shock is a common presentation, and its management is challenging. Critical care ultrasound has emerged as a reliable and reproducible tool in diagnosing and classifying shock. This comprehensive review proposes an ultrasound-based protocol for the hemodynamic assessment of shock to guide its management in the ICU. The protocol classifies shock as either low or high cardiac index and differentiates obstructive, hypovolemic, cardiogenic, and distributive etiologies. In distributive shock, the protocol proposes a hemodynamic-based approach that considers the presence of dynamic obstruction, fluid responsiveness, fluid tolerance, and ventriculo-arterial coupling. The protocol gives value to quantitative measures based on critical care ultrasound to guide hemodynamic management. Using critical care ultrasound for a comprehensive hemodynamic assessment can help clinicians diagnose the etiology of shock and define the appropriate treatment while monitoring the response. The protocol's use in the ICU can facilitate prompt recognition, diagnosis, and management of shock, ultimately improving patient outcomes.

Effect of music on hemodynamic fluctuations in women during induction of general anesthesia: A prospective randomized controlled multicenter trial.

BACKGROUND: The authors aim to investigate the effect of music on hemodynamic fluctuations during induction of general anesthesia and reducing preoperative anxiety for women who underwent elective non-cardiac surgery. METHODS: It is a multicenter, double-blind, randomized, parallel-group clinical trial. Patients were randomized 1:1 to either a Music Intervention group (MI) or a Control group (Control). The MI participants listened to their preferred music for more than 30 minutes in the waiting area. The State-Trait Anxiety Inventory (STAI) was used to measure anxiety levels in the groups, and hemodynamic parameters (Heart Rate [HR], Mean Arterial Pressure [MAP]) were continuously recorded before induction (T0), at loss of consciousness (T1), immediately before intubation (T2), and after intubation (T3). Intubation-related adverse events were also recorded. The primary outcome was the incidence of MAP changes more than 20 % above baseline during T0-T2. RESULTS: A total of 164 patients were included in the final analyses. The incidence of MAP instability during T0-T2 was lower in the MI, and the 95 % Confidence Interval for the rate difference demonstrated the superiority of MI. HR instability was less frequent in MI participants both in T0-T2 and T2-T3. The overall incidence of preoperative anxiety was 53.7 % (88/164). After the music intervention, the mean score of STAI was significantly lower in the MI than in the Control, with a between-group difference of 8.01. CONCLUSIONS: Preoperative music intervention effectively prevented hemodynamic instability during anesthesia induction and significantly reduced preoperative anxiety in women undergoing elective non-cardiac surgery.

Assessment of fluid responsiveness using pulse pressure variation, stroke volume variation, plethysmographic variability index, central venous pressure, and inferior vena cava variation in patients undergoing mechanical ventilation: a systematic review and meta-analysis.

IMPORTANCE: Maneuvers assessing fluid responsiveness before an intravascular volume expansion may limit useless fluid administration, which in turn may improve outcomes. OBJECTIVE: To describe maneuvers for assessing fluid responsiveness in mechanically ventilated patients. REGISTRATION: The protocol was registered at PROSPERO: CRD42019146781. INFORMATION SOURCES AND SEARCH: PubMed, EMBASE, CINAHL, SCOPUS, and Web of Science were search from inception to 08/08/2023. STUDY SELECTION AND DATA COLLECTION: Prospective and intervention studies were selected. STATISTICAL ANALYSIS: Data for each maneuver were reported individually and data from the five most employed maneuvers were aggregated. A traditional and a Bayesian meta-analysis approach were performed. RESULTS: A total of 69 studies, encompassing 3185 fluid challenges and 2711 patients were analyzed. The prevalence of fluid responsiveness was 49.9%. Pulse pressure variation (PPV) was studied in 40 studies, mean threshold with 95% confidence intervals (95% CI) = 11.5 (10.5-12.4)%, and area under the receiver operating characteristics curve (AUC) with 95% CI was 0.87 (0.84-0.90). Stroke volume variation (SVV) was studied in 24 studies, mean threshold with 95% CI = 12.1 (10.9-13.3)%, and AUC with 95% CI was 0.87 (0.84-0.91). The plethysmographic variability index (PVI) was studied in 17 studies, mean threshold = 13.8 (12.3-15.3)%, and AUC was 0.88 (0.82-0.94). Central venous pressure (CVP) was studied in 12 studies, mean threshold with 95% CI = 9.0 (7.7-10.1) mmHg, and AUC with 95% CI was 0.77 (0.69-0.87). Inferior vena cava variation (∆IVC) was studied in 8 studies, mean threshold = 15.4 (13.3-17.6)%, and AUC with 95% CI was 0.83 (0.78-0.89). CONCLUSIONS: Fluid responsiveness can be reliably assessed in adult patients under mechanical ventilation. Among the five maneuvers compared in predicting fluid responsiveness, PPV, SVV, and PVI were superior to CVP and ∆IVC. However, there is no data supporting any of the above mentioned as being the best maneuver. Additionally, other well-established tests, such as the passive leg raising test, end-expiratory occlusion test, and tidal volume challenge, are also reliable.

Correlation and concordance of carotid Doppler ultrasound and echocardiography with invasive cardiac output measurement in critically ill patients.

BACKGROUND: Critical care management heavily relies on accurate cardiac output (CO) measurement. Echocardiography has been a mainstay in non-invasive cardiac monitoring; however, its comparability to invasive methods warrants further exploration. Recent studies have suggested the potential of carotid Doppler measurements as a promising approach to estimate CO. Despite this potential, the literature presents mixed outcomes regarding its reliability and accuracy. This study aims to evaluate the correlation and concordance between carotid Doppler ultrasonography and invasive hemodynamic monitoring in estimating CO in critically ill patients. Furthermore, it assesses the concordance and correlation between echocardiography CO and the standard invasive CO measurements. METHODS: This concordance study involved critically ill adults requiring invasive CO measurement. Patients with arrhythmias, severe valvulopathy, pregnancy, and poor acoustic window were excluded. Statistical analyses comprised univariate analysis, Wilcoxon signed-rank test, Spearman correlation, and intraclass correlation coefficient. Ethical approval was granted by the institution's ethics committee. RESULTS: A total of 49 critically ill patients were included, predominantly male (63.27%), with a median age of 57 years. Diagnoses included subarachnoid hemorrhage (53.06%) and heart failure (8.16%). Mean cardiac index was 3.36 ± 0.81 L/min/m2 and mean cardiac output was 5.98 ± 1.47 L/min. Spearman correlation coefficient between echocardiography and invasive CO measurements was 0.58 (p-value = p < 0.001), with an ICC of 0.59 for CO and 0.52 for cardiac index. Carotid measurements displayed no significant correlation with invasive CO. CONCLUSION: There is a moderate correlation and concordance between echocardiography and invasive CO measurements. There is no significant correlation between carotid variables and invasive CO, underscoring the necessity for cautious interpretation and application, particularly in patients with distinctive cerebral blood flow dynamics.

From bench to bedside: A review of the application and potential of microcirculatory assessment by hand-held videomicroscopy.

In clinical practice, there is vast knowledge regarding the evaluation of macrocirculatory parameters, such as systemic blood pressure and cardiac output, for the hemodynamic monitoring of patients. However, assessment of the microcirculation has not yet been incorporated into the bedside armamentarium. Hand-held intravital video microscopy enables the direct, noninvasive, evaluation of the sublingual microcirculation at the bedside, offering insights into the status of the systemic microcirculation. It is easily performed and may be employed in several clinical settings, providing immediate results that may help guide patient management. Therefore, the incorporation of hand-held intravital video microscopy into clinical practice may lead to tremendous improvements in the quality of care of critical, unstable patients or offer new data in the evaluation of patients with chronic diseases, especially those with microcirculatory involvement, such as occurs in diabetes.

Bright light increases blood pressure and rate-pressure product after a single session of aerobic exercise in men.

This study aimed to test whether bright light (BL) exposure attenuates the reduction in blood pressure (BP) postexercise compared to dim light (DL). Twenty healthy men (27 ± 5 years) randomly underwent two experimental sessions: one under BL (5000 lux) and another under dim light (DL <8lux). In each session, subjects executed a bout of aerobic exercise (cycle ergometer, 30 min, moderate intensity). BP (oscillometric) and heart rate (HR monitor) were measured, and rate-pressure-product (RPP) was calculated. Additionally, a 24-h ambulatory blood pressure monitoring (ABPM) was conducted after the sessions. Systolic BP decreased while HR increased significantly and similarly after the exercise in both sessions. Additionally, systolic BP levels were higher in BL than DL throughout the experimental session (Psession = 0.04). Diastolic (Pinteraction = 0.02) and mean (Pinteraction = 0.03) BPs decreased after exercise in DL (at 30 min), and increased in BL (at 60 and 90 min). RPP increased in both sessions postexercise, but with a main effect revealing higher levels throughout the experimental session in BL than DL (Psession = 0.04) and during the first 3 h of ABPM (p = 0.05). In healthy men, BL exposure increased systolic BP and cardiac work, and abolished the postexercise decreases of diastolic and mean BPs.

Respiratory, cardiovascular and musculoskeletal mechanisms involved in the pathophysiology of pulmonary hypertension: An updated systematic review of preclinical and clinical studies.

BACKGROUND: Progressive exercise intolerance is a hallmark of pulmonary hypertension (pH), severely impacting patients' independence and quality of life (QoL). Accumulating evidence over the last decade shows that combined abnormalities in peripheral reflexes and target organs contribute to disease progression and exercise intolerance. OBJECTIVE: The aim of this study was to review the literature of the last decade on the contribution of the cardiovascular, respiratory, and musculoskeletal systems to pathophysiology and exercise intolerance in pH. METHODS: A systematic literature search was conducted using specific terms in PubMed, SciELO, and the Cochrane Library databases for original pre-clinical or clinical studies published between 2013 and 2023. Studies followed randomized controlled/non-randomized controlled and pre-post designs. RESULTS: The systematic review identified 25 articles reporting functional or structural changes in the respiratory, cardiovascular, and musculoskeletal systems in pH. Moreover, altered biomarkers in these systems, lower cardiac baroreflex, and heightened peripheral chemoreflex activity seemed to contribute to functional changes associated with poor prognosis and exercise intolerance in pH. Potential therapeutic strategies acutely explored involved manipulating the baroreflex and peripheral chemoreflex, improving cardiovascular autonomic control via cardiac vagal control, and targeting specific pathways such as GPER1, GDF-15, miR-126, and the JMJD1C gene. CONCLUSION: Information published in the last 10 years advances the notion that pH pathophysiology involves functional and structural changes in the respiratory, cardiovascular, and musculoskeletal systems and their integration with peripheral reflexes. These findings suggest potential therapeutic targets, yet unexplored in clinical trials, that could assist in improving exercise tolerance and QoL in patients with pH.

Hemodiafiltration: a synergy yet to be convincing / Hemodiafiltração: uma sinergia ainda não convincente

ABSTRACT The desperate attempt to improve mortality, morbidity, quality of life and patient-reported outcomes in patients on hemodialysis has led to multiple attempts to improve the different modes, frequencies, and durations of dialysis sessions in the last few decades. Nothing has been more appealing than the combination of diffusion and convection in the form of hemodiafiltration. Despite the concrete evidence of better clearance of middle weight molecules and better hemodynamic stability, tangible evidence to support the universal adoption is still at a distance. Survival benefits seen in selected groups who are likely to tolerate hemodiafiltration with better vascular access and with lower comorbid burden, need to be extended to real life dialysis patients who are older than the population studied and have significantly higher comorbid burden. Technical demands of initiation hemodiafiltration, the associated costs, and the incremental benefits targeted, along with patient-reported outcomes, need to be explored further before recommending hemodiafiltration as the mode of choice.

RESUMO A tentativa desesperada de melhorar a mortalidade, morbidade, qualidade de vida e desfechos relatados pelos pacientes em indivíduos em hemodiálise levou a diversas tentativas de aprimorar os diferentes modos, frequências e durações das sessões de diálise nas últimas décadas. Nada foi mais atrativo do que a combinação de difusão e convecção na forma de hemodiafiltração. Apesar das evidências concretas de melhor depuração de moléculas de peso médio e melhor estabilidade hemodinâmica, evidências tangíveis para apoiar a adoção universal ainda estão distantes. Os benefícios de sobrevida observados em grupos selecionados que provavelmente toleram a hemodiafiltração com melhor acesso vascular e com menor carga de comorbidades precisam ser estendidos aos pacientes reais em diálise, que são mais velhos do que a população estudada e apresentam uma carga de comorbidades significativamente maior. As exigências técnicas do início da hemodiafiltração, os custos associados e os benefícios incrementais almejados, juntamente com os desfechos relatados pelos pacientes, precisam ser melhor explorados antes de se recomendar a hemodiafiltração como o modo de escolha.

Maternal pregnancy hypertension impairs nitric oxide formation and results in increased arterial blood pressure in first-generation offspring female rats.

OBJECTIVES: Maternal endothelial dysfunction in pregnancy hypertension is related to impairment of nitric oxide (NO) formation. However, NO levels and hemodynamic repercussions on the female offspring remain unclear. Therefore, this study hypothesized that maternal pregnancy hypertension reduces circulating NO metabolites and increases arterial blood pressure in first-generation offspring female rats. STUDY DESIGN: Descendant female rats were distributed in four groups as follows: virgin offspring of normotensive (VN) and hypertensive (VH) mothers and pregnant offspring of normotensive (PN) and hypertensive (PH) mothers. Hemodynamic and biochemical analyses were performed. MAIN OUTCOME MEASURES: The systolic (SBP) and diastolic (DBP) blood pressure, heart rate (HR), and body weight were measured. NO metabolites in plasma, NO formation in human umbilical vein endothelial cells (HUVECs) incubated with plasma, and endothelial NO synthase (eNOS) expression in aortas were determined. RESULTS: Increased SBP, DBP, and reduced HR were found on the 60 days of life in the VH group, whereas the PH group showed increased SBP and HR on pregnancy day 7. All groups showed no differences in body weight gain and eNOS expression. Plasma levels of NO metabolites were increased in the PN compared to the other groups. Increases in the NO formation were greater in HUVECs incubated with plasma from VN and PN groups compared to the VH and PH groups. CONCLUSIONS: Female virgin and pregnant first-generation offspring rats from hypertensive pregnant mothers may have negative cardiovascular repercussions featured by increases in SBP, and possibly impaired NO formation is involved.

Correlation between the radial artery resistance index and the systemic vascular resistance index: a cross-sectional study.

INTRODUCTION: Ultrasound measurement of the radial resistance index (RRI) in the anatomical snuffbox has been proposed as a useful method for assessing the systemic vascular resistance index (SVRI). This study aims to establish the correlation between SVRI measured by pulmonary artery catheter (PAC) and RRI. METHODS: A cross-sectional study included all consecutive patients undergoing postoperative (POP) cardiac surgery with hemodynamic monitoring using PAC. Hemodynamic assessment was performed using PAC, and RRI was measured with ultrasound in the anatomical snuffbox. The Pearson correlation test was used to establish the correlation between RRI and SVRI measured using PAC. Hemodynamic behavior concerning RRI with a cutoff point of 1.1 (described to estimate under SVRI) was examined. Additionally, consistency between two evaluators was assessed for RRI using the intraclass correlation coefficient and Bland-Altman analysis. RESULTS: A total of 35 measurements were obtained. The average cardiac index (CI) was 2.73 ± 0.64 L/min/m², and the average SVRI was 1967.47 ± 478.33 dyn·s·m²/cm5. The correlation between RRI and SVRI measured using PAC was 0.37 [95% CI 0.045-0.62]. The average RRI was 0.94 ± 0.11. RRI measurements > 1.1 had a mean SVRI of 2120.79 ± 673.48 dyn·s·m²/cm5, while RRI measurements ≤ 1.1 had a mean SVRI of 1953.1 ± 468.17 dyn·s·m²/cm5 (p = 0.62). The consistency between evaluators showed an intraclass correlation coefficient of 0.88 [95% CI 0.78-0.93], and Bland-Altman analysis illustrated adequate agreement of RRI evaluators. CONCLUSIONS: For patients in cardiac surgery POP, the correlation between the SVRI measured using PAC and the RRI measured in the anatomical snuffbox is low. Using the RRI as a SVRI estimator for patients is not recommended in this clinical scenario.

Fluid therapy and pulmonary complications in abdominal surgeries: randomized controlled trial.

BACKGROUND: There is no consensus on the most effective strategy for Postoperative Pulmonary Complication (PPC) reduction. This study hypothesized that a Goal-Directed Fluid Therapy (GDFT) protocol of infusion of predetermined boluses reduces the occurrence of PPC in patients undergoing elective open abdominal surgeries when compared with Standard of Care (SOC) strategy. METHODS: Randomized, prospective, controlled study, conducted from May 2012 to December 2014, with ASA I, II or III patients undergoing open abdominal surgeries, lasting at least 120 min, under general anesthesia, randomized into the SOC and the GDFT group. In the SOC, fluid administration was according to the anesthesiologist's discretion. In the GDFT, the intervention protocol, based on bolus infusion according to blood pressure and delta pulse pressure, was applied. Patients were postoperatively evaluated by an anesthesiologist blinded to the group allocation regarding PPC incidence, mortality, and Length of Hospital Stay (LOHS). RESULTS: Forty-two patients in the SOC group and 43 in the GDFT group. Nineteen patients (45%) in the SOC and 6 in the GDFT (14%) had at least one PPC (p = 0.003). There was no difference in mortality or LOHS between the groups. Among the patients with PPC, four died (25%), compared to two deaths in patients without PPC (3%) (p = 0.001). The LOHS had a median of 14.5 days in the group with PPC and 9 days in the group without PPC (p = 0.001). CONCLUSION: The GDFT protocol resulted in a lower rate of PPC; however, the LOHS and mortality did not reduce.

Pausas inspiratórias de 0.5 e 2.0 segundos durante avaliação de mecânica respiratória não produzem alterações hemodinâmicas em pacientes sob ventilação mecânica: estudo transversal / Inspiratory pauses of 0.5 and 2.0 seconds during respiratory mechanics assessment do not produce hemodynamic changes in mechanically ventilated patients: cross-sectional study

INTRODUÇÃO: A interação coração-pulmão influenciada pela Ventilação Mecânica (VM), que impacta diretamente no retorno venoso e débito cardíaco através, e não somente, de ajustes da Pressão Positiva Expiratória Final (PEEP) e Pressão média nas vias aéreas (Pmed). Além disso, as pausas inspiratórias para avaliação da mecânica pulmonar interrompem o movimento torácico, pode impactar mais nesta interação. OBJETIVO: Comparar as alterações hemodinâmicas durante os tempos de 0,5 e 2,0 segundos de pausa inspiratória durante as mensurações de mecânica respiratória. MÉTODOS: Trata-se de um estudo transversal, realizado nas unidades de terapia intensivas de um hospital público de Salvador/BA. Foram incluídos pacientes em uso de VM e acima de 18 anos. Os excluídos foram aqueles que apresentassem instabilidade hemodinâmica e hipoxemia sustentada durante a avaliação. Para caracterização amostral, os pacientes foram divididos em grupos daqueles com e sem afecções pulmonares. Os principais dados coletados e analisados foram PEEP, Pmed, Pressão Arterial Sistólica (PAS), Pressão Arterial Diastólica (PAD), Pressão Arterial Média (PAM), Frequência Cardíaca (FC). Para comparação de dados foram utilizados os testes Wilcoxon-Rank e Mann-Whitney para dados pareados e não pareados, respectivamente. RESULTADOS: Foram incluídos 37 pacientes, mediana de idade 63 anos, 19 (51,4%) do sexo masculino, 30 (81,1%) com diagnóstico admissional de natureza clínica. Não foram identificadas alterações hemodinâmicas estatisticamente significantes entre os tempos de pausa inspiratória de 0,5 e 2,0 segundos nas variáveis PAS (p=0,99), PAD (p=0,11), PAM (p=0,29) e FC (p=0,25). CONCLUSÃO: Não foram identificadas variações hemodinâmicas durante as mensurações da mecânica respiratória nas pausas de 0,5 e 2,0 segundos.

INTRODUCTION: The heart-lung interaction is influenced by Mechanical Ventilation (MV), which directly impacts venous return and cardiac output through, but not limited to, adjustments in Positive End-Expiratory Pressure (PEEP) and mean airway pressure (Pmean). Additionally, inspiratory pauses for the assessment of pulmonary mechanics interrupt thoracic movement, potentially further impacting this interaction. OBJECTIVE: To compare hemodynamic changes during 0.5 and 2.0-second inspiratory pauses during respiratory mechanics measurements. METHODS: This is a cross-sectional study conducted in the intensive care units of a hospital in Salvador/BA. Patients on MV and over 18 years old were included. Exclusions were made for those with hemodynamic instability and sustained hypoxemia during the evaluation. For sample characterization, patients were divided into groups with and without pulmonary conditions. The main data collected and analyzed were PEEP, Pmean, Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), and Heart Rate (HR). For data comparison, Wilcoxon-Rank and Mann-Whitney tests were used for paired and unpaired data, respectively. RESULTS: Thirty-seven patients were included, with a median age of 63 years, 19 (51.4%) males, and 30 (81.1%) with an admission diagnosis of a clinical nature. No statistically significant hemodynamic changes were identified between the 0.5 and 2.0-second inspiratory pause times in the variables SBP (p=0.99), DBP (p=0.11), MAP (p=0.29), and HR (p=0.25). CONCLUSION: No hemodynamic variations were identified during respiratory mechanics measurements at 0.5 and 2.0-second inspiratory pauses.

Passive leg raising test using the carotid flow velocity-time integral to predict fluid responsiveness.

PURPOSE: The passive leg raising test (PLR) is a noninvasive method widely adopted to assess fluid responsiveness. We propose to explore if changes in the carotid flow assessed by echo-Doppler can predict fluid responsiveness after a PLR. METHODS: We conducted a performance diagnostic study in two intensive care units from Argentina between February and April 2022. We included patients with signs of tissular hypoperfusion that required fluid resuscitation. We labeled the patients as fluid responders when we measured, after a fluid bolus, an increase greater than 15% in the left ventricle outflow tract (LVOT) VTI in an apical 5-chamber view and we compared those results with the carotid flow (CF) velocity-time integral (VTI) from the left supraclavicular region in a semi-recumbent position and during the PLR. RESULTS: Of the 62 eligible patients, 50 patients (80.6%) were included. The area under the ROC curve for a change in CF VTI during the PLR test was 0.869 (95% CI 0.743-0.947). An increase of at least of 11% in the CF VTI with the PLR predicted fluid-responsiveness with a sensitivity of 77.3% (95% CI 54.6-92.2%) and specificity of 78.6% (95% CI 59-91.7%). The positive predictive value was 73.9% (95% CI 57.4-85.6%) and the negative predictive value was 81.5% (95% CI 66.5-90.7%). The positive likelihood ratio was 3.61 and the negative likelihood ratio was 0.29. CONCLUSION: An increase greater than 11% in CF VTI after a PLR may be useful to predict fluid responsiveness among critically ill patients.

Improving perioperative care in low-resource settings with goal-directed therapy: a narrative review.

Perioperative Goal-Directed Therapy (PGDT) has significantly showed to decrease complications and risk of death in high-risk patients according to numerous meta-analyses. The main goal of PGDT is to individualize the therapy with fluids, inotropes, and vasopressors, during and after surgery, according to patients' needs in order to prevent organic dysfunction development. In this opinion paper we aimed to focus a discussion on possible alternatives to invasive hemodynamic monitoring in low resource settings.

Hemoglobin Threshold for Blood Transfusion in Young Children Hospitalized with Iron Deficiency Anemia.

Current recommendations advise against blood transfusion in hemodynamically stable children with iron deficiency anemia. In an observational study of 125 children aged 6 through 36 months, hospitalized with iron deficiency anemia, we found that hemoglobin level predicted red blood cell transfusion (area under the curve 0.8862). A hemoglobin of 39 g/L had sensitivity 92% and specificity 72% for transfusion.

Pressão arterial invasiva: o YouTube é uma plataforma que compartilha informações confiáveis para enfermeiros? / Invasive blood pressure: is Youtube a platform for sharing controlled information for nurses? / Presión arterial invasiva: ¿es Youtube una plataforma para compartir información controlada para enfermeras?

Objetivo: identificar a qualidade e confiabilidade das informações sobre a pressão arterial invasiva abordadas em vídeos do YouTube. Método: pesquisa descritiva e exploratória com vídeos do YouTube sobre pressão arterial invasiva, identificados em busca única no dia 23 de fevereiro de 2023. Os vídeos foram organizados em uma lista de reprodução e submetidos à análise utilizando a ferramenta Discern Questionnaire para a qualidade educacional do vídeo e a Journal of American Medical Association Benchmarks para a confiabilidade e qualidade da informação e realizada análise estatística descritiva simples. Resultados: elencou-se 62 vídeos publicados há dois anos, dos quais 93,55% apresentaram qualidade educacional dos vídeos ruim, 6,45% moderada, demonstrando 70,97% baixa confiabilidade das informações e 32,25% citaram informações incompatíveis com a ciência. Conclusão: os vídeos encontrados na plataforma do YouTube apresentaram lacunas relacionados ao conteúdo de pressão arterial invasiva demonstrando não ser uma fonte confiável de respaldo para aprendizado do enfermeiro.

Objective: to identify the quality and reliability of information on invasive blood pressure covered in YouTube videos. Method: descriptive and exploratory research with YouTube videos on invasive blood pressure, identified in a single search on February 23, 2023. The videos were organized into a playlist and subjected to analysis using the Discern Questionnaire tool for the educational quality of the video and the Journal of American Medical Association Benchmarks for reliability and quality of information and performed simple descriptive statistical analysis. Results: 62 videos published two years ago were listed, of which 93.55% presented poor educational quality, 6.45% moderate, 70.97% demonstrated low reliability of information and 32.25% cited information incompatible with science. Conclusion: The videos found on the You Tube platform presented gaps related to the content of invasive blood pressure, demonstrating that it is not a reliable source of support for nurses' learning.

Objetivos:identificar la calidad y confiabilidad de la información sobre presión arterial invasiva cubierta en videos de YouTube. Método: investigación descriptiva y exploratoria con videos de YouTube sobre presión arterial invasiva, identificados en una única búsqueda el 23 de febrero de 2023. Los videos fueron organizados en una lista de reproducción y sometidos a análisis mediante la herramienta Discernir Cuestionario para la calidad educativa del video y la Journal of American Medical Association Se tomaron puntos de referencia para la confiabilidad y calidad de la información y se realizó un análisis estadístico descriptivo simple. Resultados: Se enumeraron 62 videos publicados hace dos años, de los cuales el 93,55% presentó mala calidad educativa, el 6,45% moderada, el 70,97% demostró baja confiabilidad de la información y el 32,25% citó información incompatible con la ciencia. Conclusión: Los videos encontrados en la plataforma You Tube presentaron lagunas relacionadas al contenido de presión arterial invasiva, demostrando que no es una fuente confiable de apoyo para el aprendizaje de los enfermeros.

Effect of music on hemodynamic fluctuations in women during induction of general anesthesia: A prospective randomized controlled multicenter trial

Abstract Background: The authors aim to investigate the effect of music on hemodynamic fluctuations during induction of general anesthesia and reducing preoperative anxiety for women who underwent elective non-cardiac surgery. Methods: It is a multicenter, double-blind, randomized, parallel-group clinical trial. Patients were randomized 1:1 to either a Music Intervention group (MI) or a Control group (Control). The MI participants listened to their preferred music for more than 30 minutes in the waiting area. The State-Trait Anxiety Inventory (STAI) was used to measure anxiety levels in the groups, and hemodynamic parameters (Heart Rate [HR], Mean Arterial Pressure [MAP]) were continuously recorded before induction (T0), at loss of consciousness (T1), immediately before intubation (T2), and after intubation (T3). Intubation-related adverse events were also recorded. The primary outcome was the incidence of MAP changes more than 20 % above baseline during T0-T2. Results: A total of 164 patients were included in the final analyses. The incidence of MAP instability during T0-T2 was lower in the MI, and the 95 % Confidence Interval for the rate difference demonstrated the superiority of MI. HR instability was less frequent in MI participants both in T0-T2 and T2-T3. The overall incidence of preopera-tive anxiety was 53.7 % (88/164). After the music intervention, the mean score of STAI was significantly lower in the MI than in the Control, with a between-group difference of 8.01. Conclusions: Preoperative music intervention effectively prevented hemodynamic instability during anesthesia induction and significantly reduced preoperative anxiety in women undergoing elective non-cardiac surgery.

Improving perioperative care in low-resource settings with goal-directed therapy: a narrative review

Abstract Perioperative Goal-Directed Therapy (PGDT) has significantly showed to decrease complications and risk of death in high-risk patients according to numerous meta-analyses. The main goal of PGDT is to individualize the therapy with fluids, inotropes, and vasopressors, during and after surgery, according to patients' needs in order to prevent organic dysfunction development. In this opinion paper we aimed to focus a discussion on possible alternatives to invasive hemodynamic monitoring in low resource settings.