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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

How I use skeletal muscle Near Infrared Spectroscopy to non-invasively assess hemodynamic status of the critically ill


The major goal of hemodynamic treatment is to reach adequate flow. Near infrared spectroscopy (NIRS) allows non-invasive assessment of skeletal muscle tissue oxygenation during rest and also during vascular occlusion test (VOT). VOT allows estimation of tissue oxygen extraction capability, which could be preserved (i.e. hypovolemic, obstructive and cardiogenic shock) or inappropriate (i.e. sepsis/septic shock). By using ultrasound to estimate cardiac output, arterial hemoglobin oxygen saturation, skeletal muscle NIRS, arterial lactate and hemoglobin, therapeutic goals in critically ill patients with preserved oxygen extraction capability can easily be targeted. Current controversies of NIRS technology and approach to patients with impaired oxygen extraction are discussed as well.

Key words: shock, skeletal muscle, near-infrared spectroscopy, critically ill

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Real-time 3-dimensional transesophageal echocardiography assessment of left ventricular shape and function after surgical remodelling


Background Real-time three dimensional transoesophageal echocardiography (RT 3D-TEE) may better reflect left ventricle (LV) shape and function than cconventional 2D-TEE. The goal of this study was to evaluate the advantages of 3D analysis in shape assessment and to quantify the LV volume by ejection fraction (EF) measurement, after LV surgical remodelling.

Methods In a prospective manner, twenty consecutive coronary surgery patients with LV anteroapical aneurysm and functional mitral regurgitation were analyzed by 2D- and thereafter by 3D- TEE before and after surgery. The key intraoperative inclusion criteria was a LVEF < 30% confirmed by intraoperative 3D-TEE immediately before surgical remodeling.

Results Before surgery, the geometry of post infarction aneurysm shows negative curvatures of the antero-basal and infero-apical segment and the apex of LV is shifted clockwise, towards the mitral valve. Surgery had significantly reduced the LV volumes and the LVEF had increased by 13.3% as recorded by 2D-TEE and by 18.3% as assessed by 3D-TEE quantification (p < 0.001 for both). Accordingly, the longitudinal plane had been shortened, the apex was now shifted anti-clockwise towards the aorta and the inferior region had taken a more important function of the LV. Significantly lower values were observed in the EF measurement with 3D- vs 2D-TEE before remodelling (22.3 vs. 29.7%, p = 0.048).

Conclusion Improvement of LV function occurred due to the increased systolic contraction of the inferior region after remodelling in patients with postinfarction aneurysm.

Key words: intraoperative transesophageal echocardiography (TEE), real-time three dimensional TEE (RT-3D TEE), left ventricle, cardiac surgery

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Right ventricular function in critically ill patients


The right ventricular function is crucial for maintaining hemodynamic stability in critically ill patients who suffer from sudden increases of right ventricular pressure overload and/or severely decreased right ventricular contractility. The morphological and functional assessment of the right ventricle is usually performed by bedside echocardiography and hemodynamic measurements with a pulmonary artery catheter. The therapeutic approach to patients with right ventricular failure includes measures to decrease right ventricular afterload and to improve its coronary perfusion and contractility.

Key words: right ventricle, failure, systolic function

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Assesment of hemodynamics by basic ultrasound


Basic ultrasound can provide important information about the main parts of the circulatory system, the heart, and the main vessels. At the bedside, only by brief visual impression of the heart function and inferior vena cava diameter, and without any measurements, the attending physician can get important information which can influence the clinical opinion-making process and the management of the hemodynamically unstable patient. No less important is to obtain information about the lungs, particularly to estimate if extravascular lung water is present in excess or not. Ultrasound can help in the detection of the potentially reversible causes of hemodynamic instability or arrest and can guide the treatment. Examples are pneumothorax, cardiac tamponade, thromboembolism, the detection of blood in the pleural, pericardial or abdominal space after trauma and the detection and treatment of the source of the infection.

Key words: ultrasound, hemodynamic monitoring, shock

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Comparison of haemodynamic parameters between the high and low spinal block in young healthy patients


Background: For some surgical procedures a higher sensory block is needed. However, it is complicated by a higher incidence of hypotension, more bradycardia and nausea and a higher use of vasoactive drugs. In elderly and obstetric population complications have been attributed to the decrease in cardiac output and systemic vascular resistance, especially in a high block (above Th6). The aim of our study was to find the incidence of hypotension and bradycardia after a spinal anaesthesia in young, healthy patients. As young patients compensate more, we aimed to find the difference in haemodynamic variables between the group with a high and the group with a low spinal block and the underlying mechanisms of hypotension.

Methods: in a prospective, randomized study 44 ASA 1 patients scheduled for knee arthroscopy under spinal anaesthesia were randomly distributed to a high (group H) and a low (group L) spinal block group. In a group H patients were placed into horizontal, whereas in a group L in 15-degree anti-Trendelenburg position immediately after the spinal block. Haemodynamic parameters were measured continuously noninvasively from 10 min before to 25 min after the spinal block using the CNAPTM device with the LiDCORapid monitor.

Results: The differences in haemodynamic parameters between the groups were not statistically significant at all measured times despite a significant difference in the spinal block level (18.5 vs 13.3 dermatomes above S5, p<0.001) and a significant difference in haemodynamic variables inside each group compared to the baseline value. With cardiac index (CI) as a dependent variable, a significant correlation between CI and stroke volume index (SVI) was found (β=0.849, p<0.001) and also between CI and heart rate (HR) (β=0.573, p<0.001). In group H the incidence of hypotension was 35%, whereas in group L it was 10%. The same difference was seen in the use of phenylephrine between the groups, however the difference was not significant.

Conclusion: In our study it was found that in young, healthy patients there are no significant differences in haemodynamic parameters and in incidence of hypotension between a high and low spinal block. Young, healthy patients compensate a decrease in systemic vascular resistance caused by the spinal anaesthesia with a compensatory increase in CI resulting from an increase in SVI and HR. However, a trend towards less hypotension, less bradycardia and less frequent phenylephrine use in a low spinal block was noted.

Keywords: spinal anaesthesia, hyperbaric bupivacaine, haemodynamic parameters, cardiac output, hypotension

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