Search

Fenoldopam, a vasodilating agent, may represent a potential therapeutic opportunity to increase renal perfusion in those conditions where renal hemodynamics are severely impaired by vascular sub-occlusion, as, indeed, is the case in thrombotic microangiopathies. The renal resistance index (RRI) was measured, on and off fenoldopam, in 27 children with STEC-HUS. A 12% decrease in RRI was observed on fenoldopam compared to off treatment without changes in the systemic hemodynamics and with no side effects. If confirmed in larger series, fenoldopam may become an important addition to supportive care to reduce ischemic damage in STEC-HUS and improve long-term outcomes.

Background: Aging and frailty make the elderly patients susceptible to hypotension following spinal anesthesia. The systemic hemodynamic effects of spinal anesthesia are not well known. In this study, we examine the systemic hemodynamic effects of fractional spinal anesthesia following intermittent microdosing of a local anesthetic and an opioid.Methods: We included 15 patients aged over 65 with considerable comorbidities, planned for emergency hip fracture repair. Patients received a spinal catheter and cardiac output monitoring using the LiDCOplus system. Invasive mean arterial pressure (MAP), cardiac index, systemic vascular resistance index, heart rate and stroke volume index were registered. Two doses of bupivacaine 2.25 mg and fentanyl 15µg were administered with 25 minutes in between. Hypotension was defined as a fall in MAP by >30% or a MAP Results: The incidence of hypotension was 30%. Hypotensive patients (n=5) were treated with low doses of norepinephrine (0.003-0.12 µg/kg/min). MAP showed a maximum reduction of 17% at 10 minutes after the first dose. Cardiac index, systemic vascular resistance index and stroke volume index decreased by 10%, 6%, and 7%, respectively, while heart rate was unchanged over time. After the first dose, none of the systemic haemodynamic variables were affected.Conclusion: Fractional spinal anesthesia causes a low incidence of hypotension, induced mainly by a systemic venodilation, causing a decrease in venous return and fall in cardiac output. Our results show that fractional spinal anesthesia is a safe technique from a hemodynamic point of view and is probably underutilized in high-risk, elderly hip fracture patients

After a year of fellowship in liver disease with Dr. Zimmerman at the Boston VA Hospital (1968-1969) he returned to Washington as a Research Fellow and Instructor in Medicine, Georgetown University, to work with Dr. Cohn (1969-1971). Dr. Cohn was a cardiologist, who was interested in systemic hemodynamics. It is here that Dr. Groszmann recognized that hemodynamic alterations were fundmental to the pathogenesis of cirrhosis. These seminal observations that the splanchnic circulation was hyperdynamic, rather than congestive, gave rise to his paradigm changing publications and set the ground work for subsequenet use of beta-blockers and splanchnic vasoconstrictor therapy leading to his becoming the father of the syndrome of Portal Hypertension (PH).

This review is focused on the problem of the hemodynamics in patients with total anomalous pulmonary venous connection. The article describes a structural features of the pulmonary venous return depending on the anatomical type, pulmonary and systemic hemodynamics, origin and effect of the pulmonary venous return obstruction on the hemodynamics. We presented basic diagnostic problems and principles, including prenatal level, and discussed trends, results and unsolved questions of the surgical treatment of the patients with total anomalous pulmonary venous connection.

Balloon pulmonary angioplasty (BPA), for chronic thromboembolic pulmonary hypertension, improves pulmonary and systemic hemodynamics. The kidney might benefit from this effect. However, staged BPA therapy comes along with repetitive administration of contrast agent. This study examined the overall effect of BPA therapy on renal function. This study included consecutive patients who underwent BPA treatment and completed a 6-month follow-up between March 2014 and March 2017. Biomarker-based evaluation of renal function was performed at baseline, consecutively prior to and after each BPA and at 6-month follow-up. The 51 patients underwent an average of 5 (±2) BPA sessions. In this course, patients received 133 (±48; 21-300) mL of contrast agent per session and 691 (±24; 240-1410) mL during the whole sequence. Acute kidney injury occurred after 6 (2.3%) procedures. The creatinine [80.1 (IQR 67.8-96.8) µmol/L vs. 77.4 (IQR 66.9-91.5) µmol/L, p = .02] and urea level [13.7 (IQR10.7-16.6) mmol/L vs. 12.5 (IQR 10.0-15.5) mmol/L, p = .02] decreased from baseline to the 6-month follow-up. The estimated glomerular filtration rate (eGFR) [79 (IQR 59-94) mL/min/m

The purpose of the study: to study hemodynamic parameters and the degree of its orthostatic stability during verticalization in patients with long-term impairment of consciousness in post-comatose period of brain damage.Materials and methods. This study included 30 patients with long-term impairment of consciousness caused by severe brain damage (Group 1), 10 of whom were in a vegetative state (VS) and 20 patients had a minimally conscious state (MCS). A severe traumatic brain injury was the most frequent cause of long-term disorders of consciousness (53.3%), other causes were associated with severe disorders of cerebral circulation (13.4%) and following consequences: rupture of cerebral aneurysms (10%), or post-hypoxic brain damage (10%), or removal of brain tumors (13.3%). The second group was comprised of 24 patients with local neurological symptoms after cerebral circulation disorders. The third group included 40 healthy volunteers. Systemic hemodynamic parameters were monitored using a multifunctional monitor TFM 3040i (CNSystem Austria) . Blood pressure (BP), heart rate (HR), stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR) were measured in real time. The statistical analysis was carried out using the Statistica-10 software package.Results. 26 patients of the first group (86%) demonstrated satisfactory hemodynamic stability in the tilt test at 30° and 60°; 3 patients of this group presented signs of orthostatic hypotension and 1 patient developed postural orthostatic tachycardia syndrome (SPOT) when tilted by 30°. A comparative analysis of hemodynamic parameters in patients of the first and second groups did not demonstrate significant differences, except for significantly higher HR values and lower SV values in the first group. Parameters of systemic hemodynamics in the horizontal position were significantly different in healthy volunteers, and were characterized by higher SV and CO values and lower BP, HR and TPR values as compared to patients of groups 1 and 2.Conclusion. This study demonstrated a hypokinetic type of blood circulation in all patients with brain lesions; it was more severe in patients with long-term impaired consciousness after severe brain damage. The majority of patients in this group presented satisfactory orthostatic hemodynamic stability; different types of orthostatic disorders were found in 14% of cases. A passive orthostatic test (0—30—60°) applied in this study allowed to diagnose orthostatic disorders at a slight tilt up to the onset of clinical symptoms of brain hypoperfusion. This indicates the need for hemodynamic monitoring in the early stages of patients' verticalization.

Objective: Adverse factors of postoperative hemodynamic and myocardial performance remain largely unexplored in children with congenital heart disease following cardiopulmonary bypass due to technical limitations. Pressure recording analytical method (PRAM) is a continuous hemodynamic and myocardial performance monitoring technique based on beat-to-beat arterial pressure waveform. Using PRAM, we examined the temporal trends and adverse factors, in clinical management, of these performances.Methods: We monitored blood pressure, cardiac index, cardiac cycle efficiency (CCE), dP/dTmax, and systematic vascular resistance index in 91 children (aged 186 ± 256 days) during their first 48 h after cardiopulmonary bypass. Above parameters, inotropic and vasoactive drug dosages, and serum lactate were recorded 3-hourly. NT-proBNP was measured daily.Results: CCE and dP/dTmax gradually increased (Ps < 0.0001), while systematic vascular resistance index, diastolic blood pressure and inotrope dosages decreased (Ps < 0.0001) over time. Cardiac index, systolic blood pressure, and heart rate did not change significantly (Ps ≥ 0.231). Patients undergoing deep hypothermic circulatory arrest had significantly higher heart rate and lower CCE (Ps ≤ 0.006) over time. Multivariate analyses indicated that epinephrine dose significantly correlated with systolic blood pressure, cardiac index, CCE, and dP/dTmax after polynomial transformation, with the peak ranging from 0.075 to 0.097.Conclusions: Systemic hemodynamic and myocardial performance gradually improved in the first 48 h after cardiopulmonary bypass without the “classic” nadir at 9–12 h. Deep hypothermic circulatory arrest and higher epinephrine doses were adversely associated with these performances. CCE, rather than cardiac index or other common-used parameters, was the most sensitive and consistent indicator.

Introduction: Penetrating arteries supplying the basal ganglia and the brain stem are often affected by chronic hypertension whereas distal branching arteries supplying the brain convexity and corona radiata may be injured by hypoperfusion. We hypothesized that under equal systemic flow dynamics, distal branching brain arteries will have a lower pressure peak than penetrating arteries. Methods: We used an Anatomically Detailed Arterial Network (ADAN) model to predict pressure waveforms for brain and systemic arteries. The anatomical details were obtained from published literature and match for an average man, height of 170 cms and body surface area of 1.65 m2. Arterial length and radius were obtained from published literature for each organ. Standard governing equations for the flow of an incompressible fluid in compliant pipes are considered in each arterial segment. Proper coupling conditions at junctions are also postulated, as well as terminal Windkessel models. Results: Compared to systemic arteries, brain arteries have an early peak in flow and pressure, followed by a gradual decline in flow and pressure over time (figure 1). The posterior parietal artery has the lowest MAP and pulse pressure of the four brain arteries tested, even if the pulsatility and resistance indices remained relatively the same. Consequently, the pressure pulse peak for the posterior parietal artery hovers around 80 mmhg compared with approximately 110 mmHg for the lenticulostriate arteries and the middle cerebral and basilar arteries. Lenticulostriate arteries had similar hemodynamic profiles to the large artery branches of the circle of Willis. Conclusion: Penetrating brain arteries are susceptible to high pressure remodeling because of their immediate branching from a large artery, while distal cortical arteries are more susceptible to hypoperfusion. These regional susceptibilities to systemic hemodynamic may influence brain health and contribute to neurodegeneration.

Background Whether right and left heart hemodynamics are associated with myocardial injury in the acute respiratory distress syndrome (ARDS) is not known. Methods We performed a retrospective cohort study of subjects who had right heart catheterization within the ALVEOLI trial and Fluid and Catheter Treatment Trial. Myocardial injury was assessed using a highly sensitive troponin assay (hsTn; Abbot ARCHITECT). Hemodynamic variables included right atrial pressure, pulmonary artery wedge pressure, cardiac index and stroke volume, pulmonary vascular resistance, pulmonary arterial compliance, and pulmonary effective arterial elastance. We performed linear, logistic, and Cox regression to determine the association of hemodynamic variables with myocardial injury and to determine if hemodynamics mediated the association between myocardial injury and death. Results Among 252 ARDS patients, median day 0 troponin was 65.4 (13.8–397.8) ng/L. Lower cardiac index (β −0.23 SE 0.10; P

There are no studies in pediatrics evaluating the progression of acute kidney injury in septic shock. We investigated the evolution of sepsis-associated acute kidney injury and its association with systemic hemodynamics in children with fluid-refractory septic shock.Prospective cohort study.PICU of a tertiary care hospital.All patients with fluid-refractory septic shock (n = 61) between September 2010 and February 2014.Hemodynamic variables using noninvasive ultrasound cardiac output monitor were measured at admission and 6 hourly thereafter till 48 hours. We used the Kidney Disease: Improving Global Outcomes criteria to define and stage acute kidney injury. Associations between various hemodynamic variables and development of acute kidney injury were evaluated. Severe acute kidney injury was defined as stage 2 or 3 acute kidney injury and was compared with no acute kidney injury or stage 1 acute kidney injury.Severe acute kidney injury developed in 29.5% (n = 18) of the 61 children with fluid-refractory septic shock, whereas 43 patients (70.49%) had either no or stage 1 acute kidney injury. Most patients who developed acute kidney injury did so within the first 48 hours of PICU admission. Severe acute kidney injury conferred a three-fold increased risk of death by day 28 (hazard ratio, 3.23; 95% CI, 1.52-6.67; p = 0.002), longer ICU stay, and increased duration of mechanical ventilation. Central venous pressure at presentation was higher in severe acute kidney injury by 5 cm H2O. Highest lactate in the first 24 hours of PICU admission, low diastolic blood pressure, low systemic vascular resistance index at admission were associated with severe acute kidney injury. This model reliably predicted stage 2/3 acute kidney injury by day 3 with area under the curve equals to 94%; 95% CI, 88.3-99.99. None of the other hemodynamic variables showed any association with severe acute kidney injury.Manifestations of sepsis-associated acute kidney injury often occur early after PICU admission and is associated with increased morbidity and mortality. There is a need to develop a predictive model in septic shock which could facilitate early detection of acute kidney injury.

Aim. Development of a novel method for non-invasive blood glucose measurement based on the hemodynamics parameters, and implementation of non-invasive glucometer. Material and methods. Totally, 170 persons studied, of the age 20-75 y.o.: with arterial hypertension (n=70), diabetes type 2 (n=70), healthy (n=30). Blood pressure (BP) was measured on both arms of patient, fasting and after a meal. The mean values of systolic BP, diastolic BP, pulse BP were calculated, and BP coefficient as their relation. At the same time chemistry was done for glucose levels. Results. The case was being resolved by the method of mathematical modelling using Statistica software. Correlational and functional multifactorial tests were done, in all groups. The highest correlational coefficients in all dimensions represent the relations of glucose level with BP response (0,75-0,85), which was selected for regression equations for BP and glucose relation. Optimal regression equations were used for the device measuring glycemia non-invasively. Conclusion. A novel method for non-invasive glycemia diagnostics is developed, based on the modelling of correlation of systemic hemodynamics and blood glucose concentration. The relations obtained, are used for invention of automatic non-invasive glucometer by the pulse wave parameters. Novelty has been proved by RF patents: “Method for non-invasive glucose concentration measurement in blood”; “Equipment for non-invasive assessment of blood glucose concentration”. Non-invasive glucometer can be used in healthcare institutions and for individual use.

Purpose During sepsis, improvement of hemodynamic may not be related to improvement of microcirculation. The aim of this study was to investigate influence of systemic circulation on microcirculation in septic ICU patients. Methods This is a prospective cohort study of septic ICU patients. Microcirculation was investigated with Near infrared spectrometry (NIRS) measuring tissue oxygen saturation (StO2). StO2 desaturation (desStO2) and resaturation (resStO2) slopes were determined. Analyses were made at baseline and after fluid challenges. Results Seventy-two patients were included. One hundred and sixty measures were performed at baseline. StO2 was 77.8% [72.4–85.0] and resStO2 was 87.3%/min [57.8–141.7]. Univariate analysis showed an association between resStO2 and diastolic arterial pressure (DAP) (p = .001), and norepinephrine dose (p = .033). In multivariate linear regression, there was an association between resStO2 and DAP (β = 1.85 (0.64 to 3.08), p = .004). Fluid challenges (n = 60) increased CO, and resStO2 (all p Conclusions DAP was the only independent determinant of resStO2 in septic patients. Fluid challenges may improve microcirculation. CVP did not influence resStO2.

Liver diseases have been known to induce changes in systemic hemodynamics and to modify the liver-heart-lung balance. Severe or chronic liver disease may result in several heart or pulmonary complications independently of any other existing cardiac or lung disease. The main liver diseases causing

Ascites is one of the complications in cirrhosis. Prognosis depends on systemic hemodynamics. This study was designed for determination of the liver and kidney hemodynamics in dogs with ascites via Doppler Ultrasonography (USG). 20 dogs with ascites and 10 healthy dogs were included. CBC, biochemical profile, USG and Doppler measurement were taken. Increased hepatic and renal RI and PI were statistically significant (p Less than 0,01-0,001). There were positive correlations between ALP and hepatic PI, between urea and renal RI, negative correlations between ALP and renal RI, between creatinine and hepatic and renal PI values (p less than 0,05-0,01). In conclusion, liver and kidney Doppler findings will help determination of the prognosis and implementation of effective treatment.

Background The beach chair position (BCP) is associated with hypotension that may lead to cerebral ischemia. Arginine vasopressin (AVP), a potent vasoconstrictor, has been shown to prevent hypotension in BCP. It also improves cerebral oxygenation in different animal models. The present study examined the effect of escalating doses of AVP on systemic hemodynamics and cerebral oxygenation during surgery in BCP under general anesthesia. Methods Sixty patients undergoing arthroscopic shoulder surgery in BCP under general anesthesia were randomly allocated to receive either saline (control, n = 15) or three different doses of AVP (0.025, 0.05, or 0.075 U/kg; n = 15 each) 2 minutes before BCP. Mean arterial pressure (MAP), heart rate (HR), regional cerebral oxygen saturation (SctO2), and jugular venous oxygen saturation (SjvO2) were measured after induction of anesthesia and before (presitting in supine position) and after BCP. Results AVP per se given before BCP increased MAP, and decreased SjvO2, SctO2, and HR in all patients (P < 0.05 for all). BCP decreased MAP, the magnitude of which and hence the incidence of hypotension was decreased by AVP in a dose-dependent manner. While in BCP, every dose of AVP reduced the HR and SctO2. Accordingly, it increased the incidence of cerebral desaturation (> 20% SctO2 decrease from the baseline value) with no differences in SjvO2 and the incidence of SjvO2 < 50% or SjvO2 < 40% among the groups. Conclusions AVP ameliorates hypotension associated with BCP in a dose-dependent manner in patients undergoing shoulder surgery under general anesthesia. However, AVP may have negative effects on SctO2 before and after BCP and on SjvO2 before BCP.

The microcirculation is the place where oxygen exchanges take place at the organ level. The microcirculation has been neglected for a long time by clinicians due to technical difficulties to access it at bedside, but recent technological advances have allowed the identification of microcirculatory alterations in patients with sepsis. Microcirculatory alterations are frequently observed in sepsis even when systemic hemodynamics are within targets. These alterations are characterized by the heterogeneity of perfusion with nonperfused vessels in close vicinity of well perfused ones. These findings contribute to the alterations in oxygen extraction in sepsis and explain why signs of tissue hypoperfusion can be observed even in presence of normal or high venous oxygen saturation (ie, microcirculatory shunt). These alterations are associated with organ dysfunction and mortality. Different mechanisms can be involved in their development and this has major implications for the potential therapies that can be applied. This review focuses on the implications and mechanisms associated with these microcirculatory alterations and on potential therapeutic strategies.

In the article fi rst experience with the usage of coupled plasma fi ltration and adsorption in the treatment of sepsis in patients after kidney transplantation has been presented. Aim: to make a comparative assessment of the impact of hemo fi ltration and coupled plasma fi ltration and adsorption (CPFA) on systemic hemodynamics and alveolar-capillary diffusion, as well as the dynamics of the pro- and antiin fl ammatory cytokines in patients with sepsis after renal transplantation. Methods and results. The study included 24 recipients. In the main group (n = 14), we used a combination of CPFA and hemo fi ltration. The patients of the comparison group (n = 10) we used an isolated hemo fi ltration. In patients of both groups we observed improvement of hemodynamics and lung function. In doing so by the fi fth day after the second procedure in patients of the main group the results were signi fi cantly better. This effect we mainly associate with a reduction in the activity of the systemic in fl ammatory response and the rate of progression of sepsis. This is con fi rmed by the fact that circulating pro- and anti-in fl ammatory cytokines were expressly removed during the CPFA. Conclusion. As a result of the CPFA and the hemo fi ltration we observed an increase in mean arterial blood pres- sure, improving gas exchange in the lungs, as well as reducing the need for vasopressor support. In this case, the additional sorption removal of circulating in fl ammatory mediators reduces the activity of the systemic in fl am- matory response, which can signi fi cantly increase the effectiveness of the therapy.

Objectives: The purpose of this study was to investigate the relationships between the splenorenal shunt (SRS)/portal vein (PV) diameter ratio (SRS/PV ratio) and systemic hemodynamics in patients with liver cirrhosis. Patients and Methods: Thirty-seven patients with SRS due to liver cirrhosis were included in this study. SRS was evaluated in the retropancreatic space on contrast-enhanced CT and the diameter was measured at the maximum point. Systemic hemodynamics was studied using a thermodilution catheter. Results: The SRS/PV ratio showed a significant correlation with the cardiac index (p < 0.01), and showed an inverse correlation with the systemic vascular resistance index and the arteriovenous oxygen content difference [C(a-v)O2] (p < 0.01). The Child-Pugh score showed a correlation with the SRS/PV ratio (p < 0.01). The SRS/PV ratio was 0.89 ± 0.52, 1.02 ± 0.51, and 1.74 ± 0.50 in the Child-Pugh A, B, and C classes, respectively. The SRS/PV ratio in the Child-Pugh C class was significantly higher than those in classes A and B (p < 0.01). The plasma ammonia level was 75.3 ± 23.2 in the group with an SRS/PV ratio Conclusions: We conclude that the increase in the SRS/PV ratio is accompanied by deteriorated liver function, hyperdynamic status, and narrowed C(a-v)O2.

A comparative analysis of subjective and objective criterion was made in order to evaluate efficacy of preoperative preparation in 101 patients with pheochromocytoma of different clinical course. It was shown the reasonability of monitoring usage of noninvasive method of assessment of systemic hemodynamics (bio-impedance reo-vasography and daily monitoring of arterial pressure) for evaluation of preoperative preparation adequacy. The need of differentiated approach and strategy of preoperative preparation were based on clinical course of pheochromocytoma.

The purpose of this study was to investigate the effects of combined therapy using partial splenic embolization (PSE) and transjugular retrograde obliteration (TJO) on the systemic hemodynamics of gastric varices with a splenorenal shunt.Eleven patients having gastric varices with a splenorenal shunt were included in this study. PSE was applied 2 weeks before TJO. Systemic hemodynamic studies were performed before and 22 ± 12 months after the combined therapy.Complete obliteration of the splenorenal shunt and gastric varices was revealed by retrograde shuntography and computed tomography after TJO in all cases. The cardiac index (1/min/m2) before and after the combined therapy was 3.98 ± 0.85 and 4.05 ± 0.78, respectively. The systemic vascular resistance index (dynes s/cm5/m2) before and after the combined therapy was 1887 ± 450 and 1837 ± 4621, respectively. They showed no significant change. The arterio-venous oxygen content difference (vol%) before and after the combined therapy was 2.55 ± 0.55 and 3.21 ± 0.90, respectively, showing a significant change (P0.05). The splenic venous flow volume before and after the combined therapy was 307 ± 158 and 166 ± 78 mL/min, respectively, showing a significant change (P0.05).: We conclude that the combined therapy using PSE and TJO reduces the splenic venous flow and stops the splenorenal shunt flow, which improves the arterio-venous oxygen content difference.

Aim Chest compressions during cardiopulmonary resuscitation (CPR) increase arterial and venous pressures, delivering simultaneous bidirectional high-pressure compression waves to the brain. We hypothesized that this may be detrimental and could be partially overcome by elevation of the head during CPR. Measurements Female Yorkshire farm pigs (n = 30) were sedated, intubated, anesthetized, and placed on a table able to elevate the head 30° (15 cm) (HUP) and the heart 10° (4 cm) or remain in the supine (SUP) flat position during CPR. After 8 minutes of untreated ventricular fibrillation and 2 minutes of SUP CPR, pigs were randomized to HUP or SUP CPR for 20 more minutes. In Group A, pigs were randomized after 2 minutes of flat automated conventional (C) CPR to HUP (n = 7) or SUP (n = 7) C-CPR. In Group B, pigs were randomized after 2 minutes of automated active compression decompression (ACD) CPR plus an impedance threshold device (ITD) SUP CPR to either HUP (n = 8) or SUP (n = 8). Results The primary outcome of the study was difference in CerPP (mmHg) between the HUP and SUP positions within groups. After 22 minutes of CPR, CerPP was 6 ± 3 mmHg in the HUP versus -5 ± 3 in the SUP (p = 0.016) in Group A, and 51 ± 8 versus 20 ± 5 (p = 0.006) in Group B. Coronary perfusion pressures after 22 minutes were HUP 6 ± 2 vs SUP 3 ± 2 (p = 0.283) in Group A and HUP 32 ± 5 vs SUP 19 ± 5, (p = 0.074) in Group B. In Group B, 6/8 pigs were resuscitated in both positions. No pigs were resuscitated in Group A. Conclusions The HUP position in both C-CPR and ACD + ITD CPR significantly improved CerPP. This simple maneuver has the potential to improve neurological outcomes after cardiac arrest.

Terlipressin has been shown to improve both pulmonary and systemic hemodynamics in stable cirrhotic patients with pulmonary hypertension, whereas other vasoconstrictors may cause pulmonary pressures to deteriorate. We investigated the pulmonary and systemic hemodynamic effects of the first terlipressin dose (2 mg) in 7 cirrhotic patients with PH presenting with variceal bleeding (n=4) or hepatorenal syndrome (n=3). Terlipressin decreased pulmonary vascular resistance (158.8+/-8.9 vs 186.5+/-13.9 dynes · sec · cm-5; P=0.003) together with an increase in systemic vascular resistance (2143+/-126 vs 1643+/-126 dynes · sec · cm-5; P0.001). Terlipressin should be the vasoconstrictor treatment of choice when patients present with variceal bleeding or HRS.

PURPOSE OF REVIEW: To discuss the role of microcirculatory abnormalities in critically ill patients and the link between systemic hemodynamics and microvascular perfusion. RECENT FINDINGS: Microcirculatory alterations have been repeatedly observed in patients with severe sepsis, but recent findings show that these also occur in patients with severe heart failure and in those submitted to high-risk surgery. More severe and more persistent alterations are observed in patients with a poor outcome. Even though a minimal cardiac output and arterial pressure is mandatory to sustain the microcirculation, this level is not yet well defined and seems to be submitted to high individual variability. Above this level, microcirculation and systemic circulation are relatively dissociated, so that microcirculatory alterations can be observed even when systemic hemodynamics are within satisfactory goals. In addition, the response of the microcirculation to therapeutic inte ventions is often dissociated from systemic effects. However, microcirculatory perfusion can be affected by cardiac output and arterial pressure when these are critically altered. SUMMARY: Microvascular alterations frequently occur in critically ill patients and these may be implicated in the development of organ failure and are associated with outcome. The link between systemic hemodynamics and microcirculation is relatively loose. © 2010 Wolters Kluwer Health

Background/Aims Muscle wasting likely influences blood flow to muscle districts in advanced cirrhosis. Thus, we assessed systemic hemodynamics and femoral artery blood flow corrected by muscle mass of the lower limb in 13 patients (Child-Pugh classes B and C) and 11 healthy controls. Methods Systemic hemodynamics were assessed by transthoracic electrical bioimpedance, femoral artery blood flow by duplex-Doppler and muscle mass by magnetic resonance imaging. Results As expected, patients exhibited increased cardiac index and reduced peripheral vascular resistance. Femoral artery blood flow did not differ between patients and controls. However, when this parameter was indicized by the muscle mass of the lower limb, which was reduced in patients (median: 3391; range: [2546–4793] vs 5118 [3562–7077]cm 3 , p =0.0006), it proved almost doubled in patients (91.1 [59.9–119.4] vs 50.5 [38.6–69.8]μl/mincm 3 ; p =0.0001). Patient femoral blood flow indicized by muscle mass correlated inversely with peripheral vascular resistance ( r =−0.65; p =0.017) and directly with cardiac index ( r =0.57; p =0.042). Conclusions Vasodilation of muscle districts contributes to the reduced peripheral vascular resistance in advanced cirrhosis. Our findings provide a stronger rationale for the use of non-selective vasoconstrictors to treat hemodynamic-dependent complications of cirrhosis, such as hepatorenal syndrome.

Propranolol can prevent variceal bleeding by ameliorating portal hypertension. We conducted this study to determine the effect of propranolol on portal hypertension and the optimal required dose in Korean cirrhotic patients.This study prospectively evaluated 50 patients with cirrhosis who exhibited variceal bleeding. The hepatic venous pressure gradient (HVPG), portal venous flow, heart rate (HR), and blood pressure were assessed both at baseline and at 3 months after the treatment. The initial dose of propranolol (20 mg) was subsequently adjusted until the target HR was reached. Patients in whom HVPG reduced by20% or to less than 12 mmHg were defined as responders.Propranolol significantly (p0.01) reduced the HVPG (-21+/-26%, mean+/-standard deviation), portal venous flow (-25+/-21%), HR (-20+/-13%), and blood pressure (-3+/-13%). Twenty-nine patients were responders, and the optimal required dose was 154.4 mg. The main complication was dizziness (24%), but this was not serious enough to require medication withdrawal.Propranolol is safe and effective at reducing portal pressure in Korean cirrhotic patients. An effective improvement in portal hypertension requires the dose to be increased until the target HR is reached.

Background In congestive heart failure, enalapril (E), metoprolol (M), and spironolactone (S) improve survival. Their direct effects on cardiac remodeling, when administered in combination, remain to be assessed. Methods and Results One hundred and five cardiomyopathic hamsters were divided into 5 groups (control, E, E-M, E-S, E-M-S) and treated from 150 to 240 days of age (E: 3 mg/kg, M: 1 mg/kg, S: 20 mg/kg). Cardiac and systemic hemodynamics, and cardiac remodeling were investigated. There was no difference between groups on blood pressure. Compared with C, both S-treated groups significantly increased cardiac index (E-S: +49%; E-M-S: +46%). Compared with C, E significantly decreased left ventricular (LV) cavity area (−10%). Compared with E, all combinations significantly decreased LV cavity area (E-M: −13%, E-S: −22%, E-M-S: −19%) and right ventricular (RV) collagen density (E-M: −18%, E-S: −30%, E-M-S: −34%), and the tri-therapy significantly decreased LV collagen density (−18%). Compared with bi-therapies, the tri-therapy significantly decreased LV (−19% vs. E-M, −16% vs. E-S) and RV (−20% vs. E-M) collagen densities. Conclusion At subdepressor doses, both bi-therapies induced similar effects on myocardial remodeling, enhancing the effects of E on LV cavity area and reducing RV collagen density. Compared with bi-therapies, the tri-therapy induced additional effects on LV and RV collagen densities.

Objectives Maintenance of residual renal function (RRF) is an important determinant of outcome in peritoneal dialysis patients. It remains contentious as to whether automated peritoneal dialysis (APD) leads to an increased rate of decline of RRF compared with continuous ambulatory peritoneal dialysis (CAPD). We studied whether APD was associated with significant systemic hemodynamic changes that may play a role in the accelerated loss of RRF. Methods As a follow-on from a previous study, 8 well-established CAPD patients underwent a 4-hour APD treatment consisting of 3 drain/fill cycles using 2 x 2.5 L 1.36% glucose and 1 x 3.86% glucose dialysate. Each dwell phase lasted 76 minutes. Blood pressure (BP) and a full range of hemodynamic variables, including pulse (HR), stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR), were measured noninvasively using continuous arterial pulse wave analysis. Results BP fell during 2 of the 3 drain/fill periods when dialysate was drained from the peritoneal cavity, but then rose upon instillation of dialysate fluid. The fall in BP was associated with a fall in TPR, matched by an inadequate rise in SV and CO. Over the entire study period, TPR progressively rose to +53.4% above baseline ( p = 0.032). Both SV and CO fell over the same period, to -21.1% ( p = 0.060) and -22.4% from baseline ( p = 0.037) respectively. This did not result in any significant difference between start and end BP. Conclusions This study demonstrates that APD is associated with significant systemic hemodynamic effects. The increased number of drain/fill cycles compared to CAPD, or the progressive rise in TPR and reduction in CO (possibly due to a cooling effect), may potentially be factors that adversely affect RRF in APD patients.

Tetrahydrobiopterin (BH4), a cofactor of nitric oxide synthase, might have a role in the treatment of portal hypertension (PHT) as its administration improves endothelial nitric oxide generation and hepatic endothelial dysfunction, and reduces portal pressure in experimental models of cirrhosis. Sapropterin is an oral synthetic analogue of BH4 recently approved for the treatment of phenylketonuria. This study evaluated the safety and effects of sapropterin on hepatic and systemic hemodynamics in patients with cirrhosis and PHT.Forty patients with cirrhosis and PHT (hepatic venous pressure gradient (HVPG) ≥10 mm Hg) were randomly allocated to receive sapropterin (n=19) for 2 weeks (5 mg/kg/day increased to 10 at day 8) or placebo (n=21) in a double-blind multicenter clinical trial. Randomization was stratified according to concomitant treatment with β-adrenergic blockers. We studied at baseline and post-treatment splanchnic (HVPG and hepatic blood flow (HBF)) and systemic hemodynamics, endothelial dysfunction and oxidative stress markers (von Willebrand factor and malondialdehyde), liver function tests, and safety variables.HVPG was not modified by either sapropterin (16.0±4.4 vs. 15.8±4.7 mm Hg) or placebo (16.0±4.6 vs. 15.5±4.9 mm Hg). HBF, systemic hemodynamics, endothelial dysfunction markers, and liver function tests remained unchanged. Sapropterin was well tolerated (no patient required dose adjustment or withdrawal), and adverse events were mild and similar between groups.Sapropterin, an oral synthetic analogue of BH4, at the used dose did not reduce portal pressure in patients with cirrhosis. Sapropterin was safe and no serious adverse effects or deleterious systemic hemodynamic effects were observed.

Hypertension represents the most common associated cause of heart failure, and it is frequently involved in the pathogenesis of left ventricular dysfunction and its progression towards congestive heart failure. A common pathophysiological link of hypertension to heart failure is represented by the abnormalities of the neurohormonal profile and its impact on cardiac function, systemic hemodynamics and salt/water balance. This article synthetically reviews this aspect together with a specific analysis of the significance of measurements of neurohormones for diagnosis and prognostic stratification in heart failure.

Detailed analysis of the subjective sensations of 135 healthy subjects during 20- to -30 min voluntary hyperventilation was performed. The hyperventilation levels (V EI = 20 l/min, V EII = 30 l/min, V EIII = 40 l/min) were chosen so that manifestations of paroxysms of hyperventilation syndrome (HVS) of different severity were simulated. Regular features in the time course of development of HVS symptoms were revealed: (1) specific peripheral subjective sensations and symptoms changed consistently, being peculiar sensory equivalents (correlates) of hyperventilation-related changes in gaseous metabolism and acid-base balance; (2) sensations and symptoms of central origin developed in waves, with considerable individual variations in manifestation and emotional hue and were closely correlated with changes in systemic hemodynamics and brain circulation disorders.

Common faint and the so-called situational syncope are usually listed together in the category of “neurally mediated syncope”. Although vasovagal syncope has been subject of extensive research in the past years, its mechanism is not fully understood. Much less information is available about situational syncope. Numerous entities in this heterogeneous group are related to excessive straining (e.g. weight lifter's or trumpet player's syncope). Cough syncope is also associated with tremendous intrathoracic, intravascular, and even intracranial pressure fluctuations. Although reflex responses are certainly triggered during cough, their relative role, and their analogy with the classical vasovagal reaction are not clear. We report a case of vasovagal syncope and cough reaction occurring in the same subject during laboratory testing.

Arterial stiffness in hypertension is markedly influenced by age, mean arterial pressure (MAP) and heart rate, whereas factors influencing this parameter in diabetes mellitus are not yet fully understood. The aim of our study was to compare central hemodynamics in diabetics (n = 126) versus non-diabetic controls (n = 203), most of whom were hypertensive, and with similar MAP. Anthropometric, laboratory and clinical measurements were collected. Hemodynamic parameters (central blood pressure, aortic pulse wave velocity [PWV], augmentation index [AIx] and pulse pressure amplification [PPA]) were measured using applanation tonometry. PWV and AIx were significantly higher in diabetics, after adjustment for age, gender, MAP, and heart rate. After further adjustment for metabolic syndrome, only the difference in PWV persisted (P

Background: Recently, the beneficial effects of ursodeoxycholic acid (UDCA) on the portal hypertensive state have been demonstrated in patients with primary biliary cirrhosis. However, it is not known whether UDCA has direct or indirect effects on the vascular smooth muscles in humans, thereby leading to a change in splanchnic or systemic hemodynamics. Aims: We therefore evaluated the hemodynamic effects of UDCA as to its established effect on gallbladder motility under fasting and postprandial conditions in healthy volunteers. Methods: In a double-blind, cross-over study of 20 healthy volunteers, placebo or UDCA (750 mg/d) were randomly administered over 4 weeks with an interim 4-week washout period. Portal blood flow, cardiac output and gallbladder motility were measured using echo-Doppler and b-mode sonography before and after placebo and verum, respectively. ECG, blood pressure, heart rate and blood chemistry were also measured. Results: UDCA did not significantly change fasting portal flow or meal-induced portal hyperemia. Both fasting and postprandial gallbladder volumes increased (26.5 ± 6.0 vs. 40.7 ± 13.8 ml, p < 0.05, and 11.2 ± 6.2 vs. 14.8 ± 6.7 ml, p < 0.05). Diastolic blood pressure decreased under UDCA (71.2 ± 8.7 vs. 66.5 ± 6.5 mm Hg, p < 0.05). Serum levels of chloride and γ-glutamyltransferase decreased slightly, while alkaline phosphatase increased. Conclusions: UDCA affected systemic but not portal hemodynamics. The increase in gallbladder volume is obviously mediated by factors that do not influence the splanchnic vascular bed.

A case is presented in which a large embolus was detected passing through the right side of the heart during total hip arthroplasty. Although tricuspid regurgitation and an elevated right ventricular pressure resulted, there was no perturbation in systemic hemodynamics or gas exchange. The emboli detected during total hip arthroplasty are most likely composed of fat. No specific treatment is required, although heightened vigilance for disturbances in systemic hemodynamics is important.

Objective At present, non-invasive continuous monitoring of finger arterial blood pressure by the volume-clamp technique is considered the best approach to obtain reliable assessments of beat-to-beat blood pressure. However, data on the reproducibility (accuracy and precision) of prolonged recordings and of the hemodynamics derived from wave-form analysis are not available. Design Ten patients with untreated essential hypertension and eight normotensive subjects were monitored by Portapres over 24 h in the hospital on two occasions with 1-4 weeks in-between. Physical and mental activities were standardized as far as possible to minimize intra- and intersubject biological variability. Stroke volume was obtained by the Modelflow method. Differences between the two recordings were computed separately for the day (0700 to 2300 h) and the night (2300 to 0700 h) and for all hours. Differences in stroke volume were calculated as percentage change from the first recording. Results Accuracy was good in both groups and bias was close to zero. Precision was also remarkable in the daytime, and at least as good as values reported in studies that used the standard intra-arterial recording. The SD of the differences in systolic and diastolic pressure in the hypertensives in the daytime were 6.6 and 4.7 mmHg, respectively. At night, precision was less good, possibly because of the 30 min finger-cuff switching: 12.5 and 6.5 mmHg for systolic and diastolic pressure, respectively. The average stroke volume did not change more than 8% at most between the first and the second recordings. Conclusion These results indicate that the Finapres and Portapres devices are a reliable substitute for intra-arterial recording, and are most useful instruments for the study of blood pressure regulation.

One of the hallmarks of cardiac failure is that despite persistent and often elevated sympathetic stimulation reflecting the body's effort to compensate for depressed systemic hemodynamics, the response by the heart is muted. This can be viewed as a protective mechanism, because unbridled

Summary We report a case of cerebral infarction following traumatic brain injury associated with low cerebral blood flow, but not detected by measurements of jugular venous oxygen saturation, cerebral lactate production, cerebral perfusion pressure, transcranial Doppler ultrasound, or measures of systemic hemodynamics.

Purpose: The lazaroids are a new class of potent free-radical scavengers. We tested whether U-74389G, a lazaroid, could attenuate some of the adverse cardiopulmonary effects of sepsis. Methods: Dogs were randomized to receive either 10 mg/kg U-74389G (n = 10), or a saline control (n = 11). After baseline measurements of hemodynamics and gas exchange, they were then randomized to receive either 0.2 mg/kg endotoxin or a saline infusion. Measurements of hemodynamics and gas exchange were repeated. The study was concluded 70 minutes after endotoxin infusion and the lungs were then removed for histologic evaluation. Results: In endotoxin-treated control animals, P02 decreased (278 ± 123 mm Hg to 67 ± 13 mm Hg, P < .05) and intrapulmonary shunt increased (12.9% ± 1.1% to 28.2% ± 11.4%, P < .05) after endotoxin. Pretreatment with U-74389G attenuated the decrease in PO2 (476 ± 61 mm Hg to 226 ± 143) and the increase in intrapulmonary shunt (12.6% ± 6.1% to 14.3% ± 6.8%) observed after endotoxin. The extent of lung injury and systemic hemodynamics were similar between control or U-74389G-treated dogs. Conclusions: A free-radical-scavenger can attenuate the gas exchange defect commonly associated with endotoxin but it does not improve the derangement of systemic hemodynamics.

Pregnancy is a unique physiological condition of profound maternal renal and systemic vasodilation. Our goal has been to unveil the reproductive hormones mediating this remarkable vasodilatory state and the underlying molecular mechanisms. In addition to advancing our knowledge of pregnancy physiology, reaching this goal may translate into therapeutics for pregnancy pathologies such as preeclampsia and for diseases associated with vasoconstriction and arterial stiffness in nonpregnant women and men. An emerging player is the 6 kDa corpus luteal hormone relaxin, which circulates during pregnancy. Relaxin administration to rats and humans induces systemic and renal vasodilation regardless of sex, thus mimicking the pregnant condition. Immunoneutralization or elimination of the source of circulating relaxin prevents renal and systemic vasodilation in midterm pregnant rats. Infertile women who become pregnant by donor eggs (IVF with embryo transfer) lack a corpus luteum and circulating relaxin, and they show a markedly subdued gestational increase in glomerular filtration rate. These data implicate relaxin as one of the vasodilatory reproductive hormones of pregnancy. There are different molecular mechanisms underlying the so-called rapid and sustained vasodilatory actions of relaxin. The former is mediated by Gαi/oprotein coupling to phosphatidylinositol-3 kinase/Akt (protein kinase B)-dependent phosphorylation and activation of endothelial nitric oxide synthase, the latter by vascular endothelial and placental growth factors, and increases in arterial gelatinase(s) activity. The gelatinases, in turn, hydrolyze big endothelin (ET) at a gly-leu bond to form ET1–32, which activates the endothelial ETBreceptor/nitric oxide vasodilatory pathway.

Conclusions In Vivo Studies • Nineteen dogs were divided into three groups: Control (CON; n =7); LVH (n=7), and LVH/HF (n= 5). • LVH was induced by placing a 1-cm wide Teflon cuff around the ascending aorta. • Approximately 30-35 months following aortic banding, animals were chronically instrumented to measure systemic hemodynamics and LV function (Figure 1). • In LVH/HF group, HF was induced by right ventricular pacing at 210-240 beats/min for 3 to 4 weeks in LVH dogs, using a programmable pacemaker (Pace Medical, Waltham, MA).

The effect of acute streptozotocin-induced diabetes mellitus on the systemic hemodynamic parameters was studied in conscious rats by thermodilution technique. Male Wistar rats were made diabetic with a single intravenous injection of streptozotocin (STZ, 50 mg/kg). The most important finding of this work was the elucidation of the systemic vasodilation and increased cardiac index one day after STZ injection. Such alteration in hemodynamic parameters could result in the increased blood flow and capillary hypertension in some vascular beds and, therefore, be considered as a pathogenic factor in the development of diabetic microangiopathy.

Hemodynamic monitoring is an essential tool for evaluation and management of patients with acute kidney injury (AKI). Hemodynamic support includes identification of preload-response, volume resuscitation, vasopressor, and inotropic management. An evidence-based management strategy with the goal of increasing tissue oxygen delivery can improve outcome in AKI.

The effects of Polyosm (polyethylene oxide 400 solution) on viscoelastic properties of the craniospinal system in cats and parameters of systemic hemodynamics were studied on the model of acute hypertensive encephalopathy, induced by intravenous injection of norepinephrine hydrotartrate and intracarotid infusion of papaverine hydrochloride. In control series, a sustained increase in the central venous and intracranial pressure, enhancement of resistance to liquor drainage, and pronounced increase in rigidity of the craniospinal system were observed. Intravenous infusion of Polyosm moderated these disturbances of the blood and liquor dynamics and restored viscoelastic properties of the craniospinal system to an almost initial level.

Bei 28 Patienten mit Leberzirrhose wurde die Wirkung von Pituitrin und Phentolamin allein und von der Kombination von beiden auf WHVP (wedged hepatic venous pressure) und auf die systemische Hamodynamik beobachtet. Die Ergebnisse haben gezeigt, das jede der beiden Substanzen bei separater Anwendung zur signifikanten Abnahme von WHVP, aber gleichzeitig auch zu Nebenwirkungen auf die systemische Hamodynamik fuhren konnte. Wenn Pituitrin plus Phentolamin angewandt wurde, konnten wir eine signifikante Senkung von WHVP, jedoch keine signifikante Veranderung von IVCP (inferior vena cava pressure), MAP (mean arterial pressure), P (pulse rate) und CI (cardiac index) beobachten. Auserdem zeigte sich bei der Kombinationstherapie auch eine Verbesserung der Lebermikrozirkulation. Diese Befunde stutzen die Empfehlung zur gleichzeitigen klinischen Anwendung von vasodilatatorischen und vasokonstriktorischen Medikamenten bei der Behandlung der Blutung aus Osophagusvarizen.

Effects of acute portal hypertension on systemic hemodynamics after hepatectomy were evaluated by portal venous stenosis (PVS) model in dogs. In protocol 1, portal hypertension of about twice portal venous pressure (PVP) decreased cardiac output (CO) and left atrial pressure (LAP) by 24.5% (p less than 0.01) and 1.0 mm Hg (p less than 0.01), respectively. In protocol 2, stepwise PVS demonstrated that CO change (%) and LAP change (mm Hg) were inversely proportional to PVP change (r = -0.937 and -0.883, respectively). The ratio of CO change to LAP change with stepwise PVS was comparable to that obtained by repeated hemorrhage in protocol 3. The present study shows that low CO with portal hypertension is caused by a reduction of venous return to the heart.

Two types of hemodynamic rearrangements, due to a decrease in the stroke index and a decrease in the total peripheral vascular resistance, are revealed. As a result of treatment these rearrangements allow the systolic and diastolic arterial pressure to be corrected and enable the severity of clinical symptoms to be reduced along with the doses of administered drugs.