Relationship Between Baroreflex and Cerebral Autoregulation in Patients With Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage

Introduction: Common consequences following aneurysmal subarachnoid hemorrhage (aSAH) are cerebral vasospasm (CV), impaired cerebral autoregulation (CA), and disturbance in the autonomic nervous system, as indicated by lower baroreflex sensitivity (BRS). The compensatory interaction between BRS and CA has been shown in healthy volunteers and stable pathological conditions such as carotid atherosclerosis. The aim of this study was to investigate whether the inverse correlation between BRS and CA would be lost in patients after aSAH during vasospasm. A secondary objective was to analyze the time-trend of BRS after aSAH.Materials and Methods: Retrospective analysis of prospectively collected data was performed at the Neuro-Critical Care Unit of Addenbrooke's Hospital (Cambridge, UK) between June 2010 and January 2012. The cerebral blood flow velocity (CBFV) was measured in the middle cerebral artery using transcranial Doppler ultrasonography (TCD). The arterial blood pressure (ABP) was monitored invasively through an arterial line. CA was quantified by the correlation coefficient (Mxa) between slow oscillations in ABP and CBFV. BRS was calculated using the sequential cross-correlation method using the ABP signal.Results: A total of 73 patients with aSAH were included. The age [median (lower-upper quartile)] was 58 (50–67). WFNS scale was 2 (1–4) and the modified Fisher scale was 3 (1–3). In the total group, 31 patients (42%) had a CV and 42 (58%) had no CV. ABP and CBFV were higher in patients with CV during vasospasm compared to patients without CV (p = 0.001 and p < 0.001). There was no significant correlation between Mxa and BRS in patients with CV, neither during nor before vasospasm. In patients without CV, a significant, although moderate correlation was found between BRS and Mxa (rS = 0.31; p = 0.040), with higher BRS being associated with worse CA. Multiple linear regression analysis showed a significant worsening of BRS after aSAH in patients with CV (Rp = −0.42; p < 0.001).Conclusions: Inverse compensatory correlation between BRS and CA was lost in patients who developed CV after aSAH, both before and during vasospasm. The impact of these findings on the prognosis of aSAH should be investigated in larger studies.

An innovative mobile application to improve the efficiency of common procedures in the paediatric intensive care unit: a pilot study

Background/Aims Procedures performed in the paediatric intensive care unit require optimal efficiency. This study evaluated the feasibility of a mobile app for paediatric critical care trainees to help improve the efficiency of three common procedures: central line placement, arterial line insertion and chest tube insertion. Methods Data regarding frequency of forgotten items were collected during the pre-intervention stage. A mobile app was developed with a checklist to help users to gather all the correct equipment. Data regarding the number of forgotten items were collected from the app in the period following initial implementation (March–August 2019) and after a software update (August–October 2019). Results Once the mobile application was introduced, all 13 (100%) fellows and 2 (20%) of the 10 advanced practice registered nurses accessed the application's checklist to record their procedures. From March–August 2019, 19 users submitted post-completion assessments, of which four included records of forgotten items (21%). After a software update, from August–October 2019, there were eight post-procedure assessments submitted with zero forgotten items. After using the mobile application, over half (13/24) of users surveyed agreed that the mobile application was useful for helping select items. Conclusions A considerable decrease in the proportion of procedures with forgotten items was recorded after the implementation of the app and after the software update. However, there was also a decrease in use of the app during the study period, so more research is required into the use of mobile apps for this purpose.

Platypnea–orthodeoxia syndrome in a postoperative patient: a case report

Background We report a case of platypnea–orthodeoxia syndrome observed in a complex clinical situation associating a bilateral pleural effusion, lobar pulmonary embolism, and a partial anomalous pulmonary venous return. Case presentation A 57-year-old Caucasian woman developed acute dyspnea in the postoperative course of an elective gynecological surgery for advanced stage ovarian cancer. Preoperative evaluation had failed to reveal any respiratory or cardiac problem. After evidence of a low arterial oxygen saturation, blood gas analysis from the central venous line correctly inserted in the right internal jugular vein revealed a higher oxygen saturation than in the arterial compartment. A thoracic computed tomography showed bilateral pleural effusion, lobar pulmonary embolism, and a drainage of a left pulmonary vein into the left innominate vein. This unique combination resulted in an uncommon cause of platypnea–orthodeoxia syndrome. Conclusion Often associated with right-to-left shunting, platypnea–orthodeoxia syndrome may be observed in complex clinical conditions with several factors influencing the ventilation/perfusion ratio. The paradoxical finding of a higher oxygen saturation in a central venous line than in an arterial line should prompt the clinician to look at the possibility of partial anomalous pulmonary venous return. No specific treatment is required in asymptomatic adults, except for an echocardiographic follow-up to detect the onset of pulmonary hypertension.

Outcomes and Risk Factors of Critically Ill Patients with Hematological Malignancy. Prospective Single-Centre Observational Study

Background and Objectives: Oncohematological patients have a high risk of mortality when they need treatment in an intensive care unit (ICU). The aim of our study is to analyze the outcomes of oncohemathological patients admitted to the ICU and their risk factors. Materials and Methods: A prospective single-center observational study was performed with 114 patients from July 2017 to December 2019. Inclusion criteria were transfer to an ICU, hematological malignancy, age >18 years, a central line or arterial line inserted or planned to be inserted, and a signed informed consent form. Univariate and multivariable logistic regression models were used to evaluate the potential risk factors for ICU mortality. Results: ICU mortality was 44.74%. Invasive mechanical ventilation in ICU was used for 55.26% of the patients, and vasoactive drugs were used for 77.19% of patients. Factors independently associated with it were qSOFA score ≥2, increase of SOFA score over the first 48 h, mechanical ventilation on the first day in ICU, need for colistin therapy, lower arterial pH on arrival to ICU. Cut-off value of the noradrenaline dose associated with ICU mortality was 0.21 μg/kg/min with a ROC of 0.9686 (95%CI 0.93–1.00, p < 0.0001). Conclusions: Mortality of oncohematological patients in the ICU is high and it is associated with progression of organ dysfunction over the first 48 h in ICU, invasive mechanical ventilation and need for relatively low dose of noradrenaline. Despite our findings, we do not recommend making decisions regarding treatment limitations for patients who have reached cut-off dose of noradrenaline.

Dynamic changes in arterial blood gas during cardiopulmonary resuscitation in out-of-hospital cardiac arrest

We aimed to investigate the prognostic value of dynamic changes in arterial blood gas analysis (ABGA) measured after the start of cardiopulmonary resuscitation (CPR) for return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA). This prospective observational study was conducted at the emergency department of a university hospital from February 2018 to February 2020. All blood samples for gas analysis were collected from a radial or femoral arterial line, which was inserted during CPR. Changes in ABGA parameters were expressed as delta (Δ), defined as the values of the second ABGA minus the values of the initial ABGA. The primary outcome was sustained ROSC. Out of the 80 patients included in the analysis, 13 achieved sustained ROSC after in-hospital resuscitation. Multivariable logistic analysis revealed that ΔpaO2 (odds ratio [OR] = 1.023; 95% confidence interval [CI] = 1.004–1.043, p = 0.020) along with prehospital shockable rhythm (OR = 84.680; 95% CI = 2.561–2799.939, p = 0.013) and total resuscitation duration (OR = 0.881; 95% CI = 0.805–0.964, p = 0.006) were significant predictors for sustained ROSC. Our study suggests a possible association between ΔpaO2 in ABGA during CPR and an increased rate of sustained ROSC in the late phase of OHCA.

The association between end-tidal carbon dioxide and arterial partial pressure of carbon dioxide after cardiopulmonary bypass pumping in cyanotic children

Introduction: Evidence suggests the high capability of non-invasive assessment of the End-tidal carbondioxide (ETCO2) in predicting changes in arterial carbon dioxide pressure (PCO2) following major surgeries in children. We aimed to compare EtCO2 values measured by capnography with mainstream device and EtCO2 values assessed by arterial blood gas analysis before and after cardiopulmonary bypass pumping in cyanotic children. Methods: This cross-sectional study was performed on 32 children aged less than 12 years with ASA II suffering cyanotic heart diseases and undergoing elective cardiopulmonary bypass pumping. Arterial blood sample was prepared through arterial line before and after pumping and arterial blood gas (ABG)was analyzed. Simultaneously, the value of EtCO2 was measured by capnography with mainstream device. Results: A significant direct relationship was found between the changes in ETCO2 and arterialPCO2 (r = 0.529, P = 0.029) postoperatively. According to significant linear association between postoperative change in ETCO2 and arterial PCO2, we revealed a new linear formula between the two indices: ΔPCO2 = 0.89× ETCO2-0.54. The association between arterial PCO2 and ETCO2 remained significant adjusted for gender, age, and body weight. Conclusion: the value of ETCO2 can reliability estimate postoperative changes in arterial PCO2 in cyanotic children undergoing cardiopulmonary bypass pumping.

Abstract 14095: Use of Femoral Arterial Doppler Velocity to Detect Perfusing Pulses During Cardiac Arrest

Introduction: Manual pulse detection is inaccurate in cardiac arrest(CA) and Doppler ultrasound may detect blood flow without an adequate perfusion blood pressure (pseudo-pulseless electrical activity). The purpose of this study is to assess whether maximum femoral arterial velocity during a pulse check is correlated with arterial line systolic blood pressure (SBP) and whether it can be used to accurately identify a SBP of ≥60mmHG. Methods: This is a prospective study of CA patients at a quaternary care Emergency Department. During a pulse check, a linear ultrasound was placed at the common femoral artery and the presence or absence of an arterial Doppler waveform, the associated maximum velocity value, and arterial line SBP were recorded simultaneously. The correlation between SBP and maximum waveform velocity was assessed. Arterial SBPs were dichotomized as <60mmHG or ≥60mmHg, as this was deemed as an adequate perfusion pressure, and a receiver operator characteristic curve analysis was performed to determine optimal cutoff value of maximum velocity associated with SBP ≥60mmHG. Sensitivity (Sn), specificity (Sp), and accuracy (Acc) of manual palpation and femoral artery pulse wave doppler for detection of SBP ≥60mmHg were calculated. Results: A total of 51 patients and 183 pulse checks were analyzed. There was a strong correlation between arterial line SBP and maximum waveform velocity (Spearman correlation coefficient: 0.92; p<0.001). The optimal cutoff value of waveform velocity associated with a SBP ≥60mmHG was 20 cm/second (Sn: 0.89; specificity: 0.94; area under the curve: 0.98) with an Acc of 0.92. To detect SBP ≥60mmHg, manual palpation had a Sn of 0.45, Sp of 0.82, and Acc of 0.67 McNemar's test showed that Sn (p<0.001), Sp (p=0.009), and Acc (p<0.001) was significantly higher for doppler ultrasound >=20cm/sec compared with manual palpation. Conclusion: In this study, during a pulse check, patients with a femoral arterial doppler waveform with a maximum velocity greater than 20cm/sec had a high probability of having a SBP ≥60mmHg, and improved Sn, Sp and Acc over manual palpation. The results demonstrate femoral arterial doppler maximum velocity is an accurate and objective tool to determine the presence of a pulse with adequate perfusion pressures.

Abstract 17034: Acute Ventricular Septal Rupture Management By The Cardiac Intensivist

Case Presentation: A 59-year-old male presented with chest pain and electrocardiogram showed convex ST elevations in the inferior leads. He underwent emergent coronary angiography revealing a 99% mid-distal right coronary artery thrombotic occlusion followed by placement of a drug-eluting stent. Transthoracic echocardiogram (TTE) revealed a 2.5 cm muscular ventricular septal rupture (VSR) with a calculated pulmonary-systemic flow ratio (Qp/Qs) of 2.4 in the setting of normal right and left ventricular systolic function. In the intensive care unit, he still had nausea and chest discomfort, along with acute kidney injury and elevated lactate levels. A trial of aggressive medical management was pursued to avoid emergent cardiac surgery. We placed an arterial line and initiated afterload reduction with sodium nitroprusside, utilizing serial bedside TTEs to monitor his Qp/Qs, which trended down to 1.8 over the subsequent 12 hours followed by normalization of lactate and kidney function. His symptoms resolved and he remained stable while transitioning to oral vasodilators. After four weeks of medical therapy, he underwent timely surgical repair of his VSR and discharged home. Discussion: Ventricular septal rupture is a serious complication of inferior myocardial infarctions (MI). From a cardiac intensivist perspective, we maintained the patient at a euvolemic state while using systemic vasodilators to divert the left-to-right shunt flow and augment his systemic flow. We want to highlight the utility of serial bedside TTEs to guide therapy for VSR (Figure 1). Fortunately, our patient did not require mechanical circulatory support to maintain his hemodynamics. We also discussed with our cardiothoracic surgeons about the optimal timing for surgical repair. The guidelines suggest urgent VSR repair following an MI; however, the exact timing is debatable given the fragility of the inflamed post-MI myocardium and better surgical outcomes with maturation of the VSR.

Subxiphoid Video-Assisted Thoracoscopic Surgery for Lung Resection Under Spontaneous Ventilation: Case Report

This case report describes two patients that underwent successful video-assisted thoracoscopic surgery (VATS) lung resections under spontaneous ventilation using the uniportal subxiphoid approach. The authors performed lung wedge resection in both patients under local anesthesia without using of a Foley catheter, arterial line, or intercostal chest drain. Only intravenous drugs and an oxygen mask with reservoir bag were used. The postsurgical course for both patients was uneventful. Both were discharged on postoperative day 2 and were doing well at 1- and 3-month follow-ups. Keywords: Subxiphoid approach; Pulmonary resection; Lung cancer