Comparison of esophageal Doppler and plethysmographic variability index to guide intraoperative fluid therapy for low-risk patients undergoing colorectal surgery.

STUDY OBJECTIVE: This study aims to investigate if there is equivalence in volumes of fluid administered when intravenous fluid therapy is guided by Pleth Variability Index (PVI) compared to the established technology of esophageal Doppler in low-risk patients undergoing major colorectal surgery. DESIGN: Randomized controlled trial. SETTING: Operating room. PATIENTS: Forty low-risk patients undergoing elective colorectal surgery. INTERVENTION: Patients were monitored by esophageal Doppler and PVI probes and were randomized to have fluid therapy directed by using one of these technologies, with 250 mL boluses of colloid to maintain a maximal stroke volume, or a PVI of less than 14%. MEASUREMENTS: Absolute volumes of fluid volumes given intraoperatively were measured as were 24 hours fluid volumes. Perioperative measurements of lactate and base excess were recorded as were postoperative complications. MAIN RESULT: There was no significant difference between PVI and esophageal Doppler groups in mean total fluid administered (1286 vs 1520 mL, P=.300) or mean intraoperative fluid balance (+839 v+1145 mL, P=.150). CONCLUSIONS: PVI offers an entirely non-invasive alternative for goal-directed fluid therapy in this group of patients.

Dynamic hyperinflation is associated with a poor cardiovascular response to exercise in COPD patients.

BACKGROUND: Pulmonary hyperinflation has the potential for significant adverse effects on cardiovascular function in COPD. The aim of this study was to investigate the relationship between dynamic hyperinflation and cardiovascular response to maximal exercise in COPD patients. METHODS: We studied 48 patients (16F; age 68 yrs ± 8; BMI 26 ± 4) with COPD. All patients performed spirometry, plethysmography, lung diffusion capacity for carbon monoxide (TLco) measurement, and symptom-limited cardiopulmonary exercise test (CPET). The end-expiratory lung volume (EELV) was evaluated during the CPET. Cardiovascular response was assessed by change during exercise in oxygen pulse (ΔO2Pulse) and double product, i.e. the product of systolic blood pressure and heart rate (DP reserve), and by the oxygen uptake efficiency slope (OUES), i.e. the relation between oxygen uptake and ventilation. RESULTS: Patients with a peak exercise EELV (%TLC) ≥ 75% had a significantly lower resting FEV1/VC, FEF50/FIF50 ratio and IC/TLC ratio, when compared to patients with a peak exercise EELV (%TLC) < 75%. Dynamic hyperinflation was strictly associated to a poor cardiovascular response to exercise: EELV (%TLC) showed a negative correlation with ΔO2Pulse (r = - 0.476, p = 0.001), OUES (r = - 0.452, p = 0.001) and DP reserve (r = - 0.425, p = 0.004). Furthermore, according to the ROC curve method, ΔO2Pulse and DP reserve cut-off points which maximized sensitivity and specificity, with respect to a EELV (% TLC) value ≥ 75% as a threshold value, were ≤ 5.5 mL/bpm (0.640 sensitivity and 0.696 specificity) and ≤ 10,000 Hg · bpm (0.720 sensitivity and 0.783 specificity), respectively. CONCLUSION: The present study shows that COPD patients with dynamic hyperinflation have a poor cardiovascular response to exercise. This finding supports the view that in COPD patients, dynamic hyperinflation may affect exercise performance not only by affecting ventilation, but also cardiac function.

Early results of rheolytic thrombectomy in patients with proximal deep vein thrombosis.

BACKGROUND: The utility of rheolytic thrombectomy as a treatment for proximal deep vein thrombosis (DVT) is not well understood. METHODS AND RESULTS: Patients with proximal DVT were treated with rheolytic thrombectomy, and the safety and efficacy of the procedure were evaluated. The improvement of venous thrombi was assessed using the venographic segment (VS) score. The rheolytic rate was defined as the percentage thrombus aspiration achieved. We also evaluated whether there were differences in age, aspiration time, D-dimer concentration, or the duration from onset to therapy between the high and low rheolytic rate groups. The mean VS score before thrombectomy was 28.8 ± 7.9 points, and the mean VS score after thrombectomy was 10.4 ± 7.1 points (ie, the VS score was significantly decreased after thrombectomy). There were no major treatment-related adverse complications. The mean duration from onset to rheolytic therapy in the 4 patients with a low rheolytic rate was 13.5 ± 13.2 days, which was much longer than for the 9 patients with a high rheolytic rate (mean duration: 4.0 ± 2.2 days: P = 0.045). CONCLUSIONS: Rheolytic thrombectomy is safe and effective for treating proximal DVT. The duration from onset to therapy was the only factor that was significantly predictive of the outcome of rheolytic thrombectomy. Rheolytic thrombectomy was especially effective when performed within 1 week of onset.

Influência da atividade diária na volumetria dos membros inferiores medida por perimetria e pela pletismografia de água / Assessing the influence of daily activities in the volumetry of inferior limbs via circunference measurement and water displacement volumetry

Objetivo: Demonstrar a influência da atividade diária laboral na alteração da volumettia dos membros inferiores medida pela perimetria e pela pletismografia de água.Método: Foram recrutados 28 indivíduos (56 membros), sendo22 do sexo feminino e seis do sexo masculino, com idades entre 16 e 64 anos, sem história prévia de doença venosa, pertencentes às classes CO e Cl da classificação CEAP. Todos foram avaliados em dois horários distintos: às 8h, antes do início das atividades laborais cotidianas,e às 18h, após O término das mesmas; os meios de avaliação foram: volumetria por deslocamento de água e por perimetria das regiões maleolares e das panturrilhas.Resultados: A volumetria em ambos os membros inferiores e a perimetria da panturrilha do membro inferior direito sofreram um aumento médio estatisticamente significativo. Para o membro inferior esquerdo, a diferença média da perimetria de panturrilha assim como das regiões maleolares de ambos os membros não foram estatisricamente significantes. Conclusão: Conclui-se que a atividade diária laboral pode interferir no volume dos membros inferiores.

Plethysmography: safety, effectiveness, and clinical utility in diagnosing vascular disease.

Plethysmography, a semiquantitative method of measuring segmental blood flow and velocity in the carotid and peripheral vascular systems, is safe, easy to perform, and inexpensive. Impedance, strain guage, air, and photoelectric plethysmographic methods are assessed in this publication for their relative safety, efficacy, and clinical utility in diagnosing vascular disease. Clinical evidence has demonstrated, for example, that oculoplethysmography is not a reliable screening test for carotid artery disease, particularly in bilateral disease and nonocclusive unilateral disease. Oculoplethysmography is thus no longer recommended for the diagnosis of carotid artery disease. Impedance, strain guage, and photoplethysmography methods can be used for the initial evaluation of acute and chronic venous insufficiency, although there is great variability in the reliability of these tests to predict venous disease in the presence of nonobstructive thrombi and comorbid conditions. Strain guage and photoelectric plethysmography can be safely used for the evaluation of peripheral arterial disease. But surgical candidates for arterial reconstruction and some venous disorders may require additional imaging such as duplex ultrasound, venography, or arteriography for anatomic information that is not elucidated by plethysmography. The plethysmographic techniques reviewed in this assessment, evaluating the ability to predict the presence of flow reduction in the carotid and peripheral circulations, are based on the technical performance of the tests as compared with a reference method. Establishing evidence-based conclusions proved difficult in light of biases such as nonrandomization, unstated patient selection criteria, poor followup of patients, and lack of blindness in some studies.