scholarly journals Early Effects of Passive Leg-Raising Test, Fluid Challenge, and Norepinephrine on Cerebral Autoregulation and Oxygenation in COVID-19 Critically Ill Patients

2021 ◽  
Vol 12 ◽  
Author(s):  
Chiara Robba ◽  
Antonio Messina ◽  
Denise Battaglini ◽  
Lorenzo Ball ◽  
Iole Brunetti ◽  
...  
Keyword(s):  
High Risk ◽  
Cerebral Autoregulation ◽  
Cerebral Oxygenation ◽  
Fluid Challenge ◽  
Neurological Complications ◽  
Passive Leg Raising ◽  
Therapeutic Interventions ◽  
Test Fluid ◽  
Mechanically Ventilated ◽  
Early Effects

Background: Coronavirus disease 2019 (COVID-19) patients are at high risk of neurological complications consequent to several factors including persistent hypotension. There is a paucity of data on the effects of therapeutic interventions designed to optimize systemic hemodynamics on cerebral autoregulation (CA) in this group of patients.Methods: Single-center, observational prospective study conducted at San Martino Policlinico Hospital, Genoa, Italy, from October 1 to December 15, 2020. Mechanically ventilated COVID-19 patients, who had at least one episode of hypotension and received a passive leg raising (PLR) test, were included. They were then treated with fluid challenge (FC) and/or norepinephrine (NE), according to patients' clinical conditions, at different moments. The primary outcome was to assess the early effects of PLR test and of FC and NE [when clinically indicated to maintain adequate mean arterial pressure (MAP)] on CA (CA index) measured by transcranial Doppler (TCD). Secondary outcomes were to evaluate the effects of PLR test, FC, and NE on systemic hemodynamic variables, cerebral oxygenation (rSo2), and non-invasive intracranial pressure (nICP).Results: Twenty-three patients were included and underwent PLR test. Of these, 22 patients received FC and 14 were treated with NE. The median age was 62 years (interquartile range = 57–68.5 years), and 78% were male. PLR test led to a low CA index [58% (44–76.3%)]. FC and NE administration resulted in a CA index of 90.8% (74.2–100%) and 100% (100–100%), respectively. After PLR test, nICP based on pulsatility index and nICP based on flow velocity diastolic formula was increased [18.6 (17.7–19.6) vs. 19.3 (18.2–19.8) mm Hg, p = 0.009, and 12.9 (8.5–18) vs. 15 (10.5–19.7) mm Hg, p = 0.001, respectively]. PLR test, FC, and NE resulted in a significant increase in MAP and rSo2.Conclusions: In mechanically ventilated severe COVID-19 patients, PLR test adversely affects CA. An individualized strategy aimed at assessing both the hemodynamic and cerebral needs is warranted in patients at high risk of neurological complications.

scholarly journals Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Chiara Robba ◽  
◽  
Lorenzo Ball ◽  
Denise Battaglini ◽  
Danilo Cardim ◽  
...  
Keyword(s):  
Carbon Dioxide ◽  
Acute Respiratory Distress Syndrome ◽  
Observational Study ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Prospective Observational Study ◽  
Distress Syndrome ◽  
Cerebral Oxygenation ◽  
Arterial Blood ◽  
Early Effects

Abstract Background In COVID-19 patients with acute respiratory distress syndrome (ARDS), the effectiveness of ventilatory rescue strategies remains uncertain, with controversial efficacy on systemic oxygenation and no data available regarding cerebral oxygenation and hemodynamics. Methods This is a prospective observational study conducted at San Martino Policlinico Hospital, Genoa, Italy. We included adult COVID-19 patients who underwent at least one of the following rescue therapies: recruitment maneuvers (RMs), prone positioning (PP), inhaled nitric oxide (iNO), and extracorporeal carbon dioxide (CO2) removal (ECCO2R). Arterial blood gas values (oxygen saturation [SpO2], partial pressure of oxygen [PaO2] and of carbon dioxide [PaCO2]) and cerebral oxygenation (rSO2) were analyzed before (T0) and after (T1) the use of any of the aforementioned rescue therapies. The primary aim was to assess the early effects of different ventilatory rescue therapies on systemic and cerebral oxygenation. The secondary aim was to evaluate the correlation between systemic and cerebral oxygenation in COVID-19 patients. Results Forty-five rescue therapies were performed in 22 patients. The median [interquartile range] age of the population was 62 [57–69] years, and 18/22 [82%] were male. After RMs, no significant changes were observed in systemic PaO2 and PaCO2 values, but cerebral oxygenation decreased significantly (52 [51–54]% vs. 49 [47–50]%, p < 0.001). After PP, a significant increase was observed in PaO2 (from 62 [56–71] to 82 [76–87] mmHg, p = 0.005) and rSO2 (from 53 [52–54]% to 60 [59–64]%, p = 0.005). The use of iNO increased PaO2 (from 65 [67–73] to 72 [67–73] mmHg, p = 0.015) and rSO2 (from 53 [51–56]% to 57 [55–59]%, p = 0.007). The use of ECCO2R decreased PaO2 (from 75 [75–79] to 64 [60–70] mmHg, p = 0.009), with reduction of rSO2 values (59 [56–65]% vs. 56 [53–62]%, p = 0.002). In the whole population, a significant relationship was found between SpO2 and rSO2 (R = 0.62, p < 0.001) and between PaO2 and rSO2 (R0 0.54, p < 0.001). Conclusions Rescue therapies exert specific pathophysiological mechanisms, resulting in different effects on systemic and cerebral oxygenation in critically ill COVID-19 patients with ARDS. Cerebral and systemic oxygenation are correlated. The choice of rescue strategy to be adopted should take into account both lung and brain needs. Registration The study protocol was approved by the ethics review board (Comitato Etico Regione Liguria, protocol n. CER Liguria: 23/2020).

PREDICTORS OF NEUROLOGICAL COMPLICATIONS AFTER CARDIAC SURGICAL INTERVENTIONS IN OLDERY PATIENTS

2020 ◽  
pp. 319-324
Author(s):  
О. В. Каменская ◽  
А. С. Клинкова ◽  
В. В. Ломиворотов ◽  
В. А. Шмырев ◽  
А. М. Чернявский
Keyword(s):  
Intraoperative Monitoring ◽  
Cerebral Oxygenation ◽  
Artery Bypass ◽  
Neurological Complications ◽  
Myocardial Infarctions ◽  
Bypass Grafting ◽  
Surgical Interventions ◽  
Increased Risk ◽  
History Of ◽  
Left And Right

Для выявления предикторов неврологических осложнений в госпитальный период после коронарного шунтирования (КШ) проанализированы данные 92 больных 70 лет и старше с ИБС. Интраоперационно проведен мониторинг церебральной оксигенации ( rSO , %). На этапе вводной анестезии средний уровень rSO по правому и левому полушариям составлял 64-65% без значительных изменений во время операции. Снижение rSO во время искусственного кровообращения (ИК) связано с увеличением риска развития неврологических осложнений в раннем послеоперационном периоде. При снижении rSO во время ИК на 20% и более относительно исходных значений по левому и правому полушариям риск неблагоприятных неврологических событий возрастает в 7 и 9 раз соответственно. Два и более инфаркта миокарда в анамнезе в 3 раза увеличивают риск неврологических осложнений после КШ. To identify predictors of neurological complications in the hospital period after coronary artery bypass grafting (CABG), 92 patients with coronary heart disease aged 70 years and over were analyzed. Intraoperative monitoring of cerebral oxygenation ( rSO , %) was carried out. At the stage of induction anesthesia, the average level of rSO for left and right hemispheres was 64-65 % without significant changes during the operation. A decrease in rSO during cardiopulmonary bypass (CPB) was associated with increased risk of neurological complications. The risk of neurological complications increase 7-fold and 9-fold with a decrease in rSO by 20 % or more during CPB relative to baseline for left and right hemispheres, respectively. A history of two or more myocardial infarctions increases 3-fold the risk of neurological complications after CABG.

scholarly journals Risk stratification for intestinal dysbiosis in hospitalized adult patients according to the National Dysbiosis Survey (INDIS)

2020 ◽  
Vol 2 (35) ◽  
pp. 149-159
Author(s):  
Aline Okipney ◽  
Jéssica Romanelli Amorim de Souza ◽  
Antonio Carlos Ligocki Campos ◽  
Leticia Fuganti Campos ◽  
Paula Rodrigues Anjo ◽  
...  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Risk Stratification ◽  
Elderly Patients ◽  
Univariate Analysis ◽  
Intestinal Flora ◽  
Adult Patients ◽  
Therapeutic Interventions ◽  
Intestinal Dysbiosis ◽  
Very High

Introduction: The intestinal microbiota has a symbiotic relationship with the human being. Its alteration, known as dysbiosis, can result in several diseases. Some risk factors may predict the occurrence of this condition. The purpose of this study was to evaluate the effectiveness of the National Dysbiosis Survey (INDIS) in the risk stratification of hospitalized adult patients that presented with intestinal dysbiosis. Methods: 100 patients hospitalized at the Hospital das Clínicas da UFPR were interviewed through INDIS. In this questionnaire, risk factors for dysbiosis of each patient were established and the dysbiosis degree was stratified in low, medium, high, and very high risk. Results: Most patients were classified as medium (43%) and high risk (39%) of dysbiosis. The univariate analysis revealed an association between the degree of dysbiosis and elderly patients (p=0.034), number of comorbidities (p<0.001), presence of diarrhea or constipation (p<0.001) and medication in use [antibiotic and/or proton pump inhibitor (PII); p<0.001]. In the multivariate analysis, the most important influence in classification was the presence of diarrhea or constipation (OR=3.00, 95% CI [1.73, 5.21] p<0.001) and medication in use (Score 3: OR = 53.4, 95% CI [2.73, 1045.5], p=0.009 and Score 4-8: OR = 1709.1, 95% CI [50.27, 58103.5] p<0.001), both independent predictors of high and very high risk of dysbiosis. Conclusion: The risk degree of intestinal dysbiosis is greater in the presence of diarrhea or constipation, the use of antibiotics and/or PII, and in elderly patients. Once the risks of dysbiosis have been defined, INDIS proved to be an effective and rapid tool for risk stratification of dysbiosis in the study population, future studies should determine the relevance of therapeutic interventions with the purpose of normalizing the intestinal flora.

Development of a method to measure regional perfusion of the lung in anesthetized ponies using computed tomography angiography and the maximum slope model

2022 ◽  
pp. 1-9
Author(s):  
Adam Auckburally ◽  
Görel Nyman ◽  
Maja K. Wiklund ◽  
Anna K. Straube ◽  
Gaetano Perchiazzi ◽  
...  
Keyword(s):  
Ct Angiography ◽  
Lung Tissue ◽  
Lung Perfusion ◽  
Therapeutic Interventions ◽  
Maximum Slope ◽  
Mechanically Ventilated ◽  
Regional Lung ◽  
Microsphere Method ◽  
Perfusion Measurements ◽  
Spontaneously Breathing

Abstract OBJECTIVE To develop a method based on CT angiography and the maximum slope model (MSM) to measure regional lung perfusion in anesthetized ponies. ANIMALS 6 ponies. PROCEDURES Anesthetized ponies were positioned in dorsal recumbency in the CT gantry. Contrast was injected, and the lungs were imaged while ponies were breathing spontaneously and while they were mechanically ventilated. Two observers delineated regions of interest in aerated and atelectatic lung, and perfusion in those regions was calculated with the MSM. Measurements obtained with a computerized method were compared with manual measurements, and computerized measurements were compared with previously reported measurements obtained with microspheres. RESULTS Perfusion measurements obtained with the MSM were similar to previously reported values obtained with the microsphere method. While ponies were spontaneously breathing, mean ± SD perfusion for aerated and atelectatic lung regions were 4.0 ± 1.9 and 5.0 ± 1.2 mL/min/g of lung tissue, respectively. During mechanical ventilation, values were 4.6 ± 1.2 and 2.7 ± 0.7 mL/min/g of lung tissue at end expiration and 4.1 ± 0.5 and 2.7 ± 0.6 mL/min/g of lung tissue at peak inspiration. Intraobserver agreement was acceptable, but interobserver agreement was lower. Computerized measurements compared well with manual measurements. CLINICAL RELEVANCE Findings showed that CT angiography and the MSM could be used to measure regional lung perfusion in dorsally recumbent anesthetized ponies. Measurements are repeatable, suggesting that the method could be used to determine efficacy of therapeutic interventions to improve ventilation-perfusion matching and for other studies for which measurement of regional lung perfusion is necessary.

Impact of the superior cavopulmonary anastomosis on cerebral oxygenation

2020 ◽  
Vol 30 (4) ◽  
pp. 585-587
Author(s):  
Nikhil Thatte ◽  
Lingyu Zhou ◽  
John N. Kheir
Keyword(s):  
Cerebral Autoregulation ◽  
Cerebral Oxygenation ◽  
Arterial Switch Operation ◽  
Venous Pressure ◽  
Case Control ◽  
Univentricular Heart ◽  
Arterial Blood ◽  
Point Increase ◽  
Cavopulmonary Anastomosis ◽  
Oxyhaemoglobin Saturation

AbstractBackground:Patients with univentricular heart disease may undergo a superior cavopulmonary anastomosis, an operative intervention that raises cerebral venous pressure and impedance to cerebral venous return. The ability of infantile cerebral autoregulation to compensate for this is not well understood.Materials and methods:We identified all patients undergoing a superior cavopulmonary anastomosis (cases) and compared metrics of cerebral oxygenation upon admission to the ICU with patients following repair of tetralogy of Fallot or arterial switch operation (controls). The primary endpoint was cerebral venous oxyhaemoglobin saturation measured from an internal jugular venous catheter. Other predictor variables included case–control assignment, age, weight, sex, ischemic times, arterial oxyhaemoglobin saturation, mean arterial blood pressure, and superior caval pressure.Results:A total of 151 cases and 350 controls were identified. The first post-operative cerebral venous oxyhaemoglobin saturation was significantly lower following superior cavopulmonary anastomosis than in controls (44 ± 12 versus 59 ± 15%, p < 0.001), as was arterial oxyhaemoglobin saturation (81 ± 9 versus 98 ± 5%, p < 0.001). Cerebral venous oxyhaemoglobin saturation correlated poorly with superior caval pressure in both groups. When estimated by linear mixed effects model, arterial oxyhaemoglobin saturation was the primary determinant of central venous oxyhaemoglobin saturation in both groups (β = 0.79, p = 3 × 10−14); for every 1% point increase in arterial oxyhaemoglobin saturation, there was a 0.79% point increase in venous oxyhaemoglobin saturation. In this model, no other predictors were significant, including superior caval pressure and case–control assignment.Conclusion:Cerebral autoregulation appears to remain intact despite acute imposition of cerebral venous hypertension following superior cavopulmonary anastomosis. Following superior cavopulmonary anastomosis, cerebral venous oxyhaemoglobin saturation is primarily determined by arterial oxyhaemoglobin saturation.

Mini-fluid Challenge of 100 ml of Crystalloid Predicts Fluid Responsiveness in the Operating Room

2017 ◽  
Vol 127 (3) ◽  
pp. 450-456 ◽  
Author(s):  
Matthieu Biais ◽  
Hugues de Courson ◽  
Romain Lanchon ◽  
Bruno Pereira ◽  
Guillaume Bardonneau ◽  
...  
Keyword(s):  
Stroke Volume ◽  
Operating Room ◽  
Fluid Responsiveness ◽  
Pulse Pressure ◽  
Fluid Challenge ◽  
Stroke Volume Index ◽  
Volume Index ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Ventilated Patients

Abstract Background Mini-fluid challenge of 100 ml colloids is thought to predict the effects of larger amounts of fluid (500 ml) in intensive care units. This study sought to determine whether a low quantity of crystalloid (50 and 100 ml) could predict the effects of 250 ml crystalloid in mechanically ventilated patients in the operating room. Methods A total of 44 mechanically ventilated patients undergoing neurosurgery were included. Volume expansion (250 ml saline 0.9%) was given to maximize cardiac output during surgery. Stroke volume index (monitored using pulse contour analysis) and pulse pressure variations were recorded before and after 50 ml infusion (given for 1 min), after another 50 ml infusion (given for 1 min), and finally after 150 ml infusion (total = 250 ml). Changes in stroke volume index induced by 50, 100, and 250 ml were recorded. Positive fluid challenges were defined as an increase in stroke volume index of 10% or more from baseline after 250 ml. Results A total of 88 fluid challenges were performed (32% of positive fluid challenges). Changes in stroke volume index induced by 100 ml greater than 6% (gray zone between 4 and 7%, including 19% of patients) predicted fluid responsiveness with a sensitivity of 93% (95% CI, 77 to 99%) and a specificity of 85% (95% CI, 73 to 93%). The area under the receiver operating curve of changes in stroke volume index induced by 100 ml was 0.95 (95% CI, 0.90 to 0.99) and was higher than those of changes in stroke volume index induced by 50 ml (0.83 [95% CI, 0.75 to 0.92]; P = 0.01) and pulse pressure variations (0.65 [95% CI, 0.53 to 0.78]; P &lt; 0.005). Conclusions Changes in stroke volume index induced by rapid infusion of 100 ml crystalloid predicted the effects of 250 ml crystalloid in patients ventilated mechanically in the operating room.

Prevention in High Risk Children of Depressed Parents

1986 ◽  
Vol 31 (2) ◽  
pp. 161-165 ◽  
Author(s):  
Catherine Laroche
Keyword(s):  
High Risk ◽  
Adult Patient ◽  
Family Members ◽  
Clinical Findings ◽  
Therapeutic Interventions ◽  
Children And Families ◽  
The Family ◽  
The Impact ◽  
Depressed Parents ◽  
High Risk Children

Opportunities for prevention of psychopathology in children and families are often overlooked in the treatment of the depressed adult patient. Research and clinical findings are reviewed which highlight the impact on children and the family of depressed parents. They range from illness serious enough to require hospitalization to cases in which depression has not yet been diagnosed. These findings are used as guidelines for the development of preventive and therapeutic interventions for all family members.

Need for evidence-based early intervention programmes: a public health perspective

2018 ◽  
Vol 21 (4) ◽  
pp. 128-130 ◽  
Author(s):  
Sinan Guloksuz ◽  
Jim van Os
Keyword(s):  
Public Health ◽  
Early Intervention ◽  
High Risk ◽  
Help Seeking ◽  
Health Impact ◽  
Assessment Tools ◽  
Therapeutic Interventions ◽  
Psychotic Symptoms ◽  
Public Health Perspective ◽  
Prognostic Accuracy

This paper attempts to discuss why the early intervention agenda based on the current convention of ‘ultra-high risk’ (UHR) or ‘clinical high risk’ (CHR) for ‘transition’ to psychosis framework has been destined to fall short of generating a measurable and economically feasible public health impact. To summarise: (1) the primary determinant of the ‘transition’ rate is not the predictive value of the UHR/CHR but the degree of the risk-enrichment; (2) even with a significant pre-test risk enrichment, the prognostic accuracy of the assessment tools in help-seeking population is mediocre, failing to meet the bare minimum thresholds; (3) therapeutic interventions arguably prolong the time-to-onset of psychotic symptoms instead of preventing ‘transition’, given that the UHR/CHR and ‘transition’ lie on the same unidimensional scale of positive psychotic symptoms; (4) meta-analytical evidence confirms that specific effective treatment for preventing ‘transition’ (the goal—primary outcome—of the UHR/CHR framework) is not available; (5) the UHR/CHR-‘transition’ is a precarious target for research given the unpredictability driven by the sampling strategies and the natural ebb and flow of psychotic symptoms within and between individuals, leading to false positives; (6) only a negligible portion of those who develop psychosis benefits from UHR/CHR services (see prevention paradox); (7) limited data on the cost-effectiveness of these services exist. Given the pitfalls of the narrow focus of the UHR/CHR framework, a broader prevention strategy embracing pluripotency of early psychopathology seems to serve as a better alternative. Nevertheless, there is a need for economic evaluation of these extended transdiagnostic early intervention programmes.

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