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Introduction: It is not known whether the optimal atrioventricular (AVopt) delay varies between left ventricular (LV) pacing site during endocardial biventricular pacing (BiVP) and may therefore needs consideration. Methods: We assessed the hemodynamic AVopt in patients with chronic heart failure undergoing endocardial LV lead implantation. AVopt was assessed during atrio‐BiVP with a "roving LV lead." Up to four locations were studied: mid‐lateral wall, mid‐septum (or a close alternative), site of greatest hemodynamic improvement, and LV lead implant site. The AVopt was compared to a fixed AV delay of 180 ms. Results: Seventeen patients were included (12 male, aged 66.5 ± 12.8 years, ejection fraction 26 ± 7%, 16 left bundle branch block or high percentage of right ventricular pacing [RVP], QRS duration 167 ± 27 ms). In most locations (62/63), AVopt increased systolic blood pressure during BiVP compared with RVP (relative improvement 6 mmHg, interquartile range [IQR] 4–9 mmHg). Compared to a fixed AV delay, the hemodynamic improvement at AVopt was higher (1 mmHg, IQR 0.2–2.6 mmHg, p <.001). Within most patients (16/17), we observed a difference in AVopt between pacing sites (median paced AVopt 209 ms, IQR 117–250). Within this range, the hemodynamic impact of these differences was small (median loss 0.6 mmHg, IQR 0.1–2.6 mmHg). Conclusion: Within a patient, different endocardial LV lead locations have slightly different hemodynamic AVopt which are superior to a fixed AV delay. The hemodynamic consequence of applying an optimum from a different lead location is small. [ABSTRACT FROM AUTHOR]

Objectives: This study aims to investigate the association between the 30-day mortality in patients with septic shock (SS) and a prehospital bundle of care completion, antibiotic therapy administration, and hemodynamic optimization defined as a fluid expansion of at least 10 mL.kg -1 .hr -1 .Design: To assess the association between prehospital BUndle of Care (BUC) completion and 30-day mortality, the inverse probability treatment weighting (IPTW) propensity method was performed.Setting: International guidelines recommend early treatment implementation in order to reduce SS mortality. More than one single treatment, a bundle of care, including antibiotic therapy and hemodynamic optimization, is more efficient.Patients: From May 2016 to March 2021, patients with SS requiring prehospital mobile ICU (mICU) intervention were retrospectively analyzed.Interventions: None.Measurements and Main Results: Among the 529 patients with SS requiring action by the mICU enrolled in this study, 354 (67%) were analyzed. Presumed pulmonary, digestive, and urinary infections were the cause of the SS in 49%, 25%, and 13% of the cases, respectively. The overall 30-day mortality was 32%. Seventy-one patients (20%) received prehospital antibiotic therapy and fluid expansion. Log binomial regression weighted with IPTW resulted in a significant association between 30-day mortality and prehospital BUC completion (respiratory rate [RR] of 0.56 [0.33-0.89]; p = 0.02 and adjusted RR 0.52 [0.27-0.93]; p = 0.03).Conclusions: A prehospital bundle of care, based on antibiotic therapy and hemodynamic optimization, is associated with a 30-day mortality decrease among patients suffering from SS cared for by an mICU. [ABSTRACT FROM AUTHOR]

Abstract Despite a large body of evidence, the implementation of guidelines on hemodynamic optimization and goal-directed therapy remains limited in daily routine practice. To facilitate/accelerate this implementation, a panel of experts in the field proposes an approach based on six relevant questions/answers that are frequently mentioned by clinicians, using a critical appraisal of the literature and a modified Delphi process. The mean arterial pressure is a major determinant of organ perfusion, so that the authors unanimously recommend not to tolerate absolute values below 65 mmHg during surgery to reduce the risk of postoperative organ dysfunction. Despite well-identified limitations, the authors unanimously propose the use of dynamic indices to rationalize fluid therapy in a large number of patients undergoing non-cardiac surgery, pending the implementation of a “validity criteria checklist” before applying volume expansion. The authors recommend with a good agreement mini- or non-invasive stroke volume/cardiac output monitoring in moderate to high-risk surgical patients to optimize fluid therapy on an individual basis and avoid volume overload. The authors propose to use fluids and vasoconstrictors in combination to achieve optimal blood flow and maintain perfusion pressure above the thresholds considered at risk. Although purchase of disposable sensors and stand-alone monitors will result in additional costs, the authors unanimously acknowledge that there are data strongly suggesting this may be counterbalanced by a sustained reduction in postoperative morbidity and hospital lengths of stay. Beside existing guidelines, knowledge and explicit clinical reasoning tools followed by decision algorithms are mandatory to implement individualized hemodynamic optimization strategies and reduce postoperative morbidity and duration of hospital stay in high-risk surgical patients.

Abstract Background Several studies suggest that hemodynamic optimization therapies can reduce complications, the length of hospital stay and costs. However, Brazilian data are scarce. Therefore, the objective of this analysis was to evaluate whether the improvement demonstrated by hemodynamic optimization therapy in surgical patients could result in lower costs from the perspective of the Brazilian public unified health system. Methods A meta-analysis was performed comparing surgical patients who underwent hemodynamic optimization therapy (intervention) with patients who underwent standard therapy (control) in terms of complications and hospital costs. The cost-effectiveness analysis evaluated the clinical and financial benefits of hemodynamic optimization protocols for surgical patients. The analysis considered the clinical outcomes of randomized studies published in the last 20 years that involved surgeries and hemodynamic optimization therapy. Indirect costs (equipment depreciation, estate and management activities) were not included in the analysis. Results A total of 21 clinical trials with a total of 4872 surgical patients were selected. Comparison of the intervention and control groups showed lower rates of infectious (RR = 0.66; 95% CI = 0.58–0.74), renal (RR = 0.68; 95% CI = 0.54–0.87), and cardiovascular (RR = 0.87; 95% CI = 0.76–0.99) complications and a nonstatistically significant lower rate of respiratory complications (RR = 0.82; 95% CI = 0.67–1.02). There was no difference in mortality (RR = 1.02; 95% CI = 0.80–1.3) between groups. In the analysis of total costs, the intervention group showed a cost reduction of R$396,024.83-BRL ($90,161.38-USD) for every 1000 patients treated compared to the control group. The patients in the intervention group showed greater effectiveness, with 1.0 fewer days in the intensive care unit and hospital. In addition, there were 333 fewer patients with complications, with a consequent reduction of R$1,630,341.47-BRL ($371,173.27-USD) for every 1000 patients treated. Conclusions Hemodynamic optimization therapy is cost-effective and would increase the efficiency of and decrease the burden of the Brazilian public health system.

Background: The number of high-risk patients undergoing surgery is steadily increasing. In order to maintain and, if necessary, optimize perioperative hemodynamics as well as the oxygen supply to the organs (DO2) in this patient population, a timely assessment of cardiac function and the underlying pathophysiological causes of hemodynamic instability is essential for the anesthesiologist. A variety of hemodynamic monitoring procedures are available for this purpose; however, due to method-immanent limitations they are often not able to directly identify the underlying cause of cardiovascular impairment.Objective: To present a stepwise algorithm for a perioperative echocardiography-based hemodynamic optimization in noncardiac surgery high-risk patients. In this context, echocardiography on demand according to international guidelines can be performed under certain conditions (hemodynamic instability, nonresponse to hemodynamic treatment) as well as in the context of a planned intraoperative procedure, mostly as a transesophageal echocardiography.Methods and Results: Hemodynamically focused echocardiography as a rapidly available bedside method, enables the timely diagnosis and assessment of cardiac filling obstructions, volume status and volume response, right and left heart function, and the function of the heart valves.Conclusion: Integrating all echocardiographic findings in a differentiated assessment of the patient's cardiovascular function enables a (patho)physiologically oriented and individualized hemodynamic treatment. [ABSTRACT FROM AUTHOR]

Despite a large body of evidence, the implementation of guidelines on hemodynamic optimization and goal-directed therapy remains limited in daily routine practice. To facilitate/accelerate this implementation, a panel of experts in the field proposes an approach based on six relevant questions/answers that are frequently mentioned by clinicians, using a critical appraisal of the literature and a modified Delphi process. The mean arterial pressure is a major determinant of organ perfusion, so that the authors unanimously recommend not to tolerate absolute values below 65 mmHg during surgery to reduce the risk of postoperative organ dysfunction. Despite well-identified limitations, the authors unanimously propose the use of dynamic indices to rationalize fluid therapy in a large number of patients undergoing non-cardiac surgery, pending the implementation of a "validity criteria checklist" before applying volume expansion. The authors recommend with a good agreement mini- or non-invasive stroke volume/cardiac output monitoring in moderate to high-risk surgical patients to optimize fluid therapy on an individual basis and avoid volume overload. The authors propose to use fluids and vasoconstrictors in combination to achieve optimal blood flow and maintain perfusion pressure above the thresholds considered at risk. Although purchase of disposable sensors and stand-alone monitors will result in additional costs, the authors unanimously acknowledge that there are data strongly suggesting this may be counterbalanced by a sustained reduction in postoperative morbidity and hospital lengths of stay. Beside existing guidelines, knowledge and explicit clinical reasoning tools followed by decision algorithms are mandatory to implement individualized hemodynamic optimization strategies and reduce postoperative morbidity and duration of hospital stay in high-risk surgical patients. [ABSTRACT FROM AUTHOR]

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy. [ABSTRACT FROM AUTHOR]

Abstract Background Postoperative morbidity and mortality in patients undergoing surgery is high, especially in patients who are at risk of complications and undergoing major surgery. We hypothesize that perioperative, algorithm-driven, hemodynamic therapy based on individualized fluid status and cardiac output optimization is able to reduce mortality and postoperative moderate and severe complications as a major determinant of the patients’ postoperative quality of life, as well as health care costs. Methods/design This is a multi-center, international, prospective, randomized trial in 380 patients undergoing major abdominal surgery including visceral, urological, and gynecological operations. Eligible patients will be randomly allocated to two treatment arms within the participating centers. Patients of the intervention group will be treated perioperatively following a specific hemodynamic therapy algorithm based on pulse-pressure variation (PPV) and individualized optimization of cardiac output assessed by pulse-contour analysis (ProAQT© device; Pulsion Medical Systems, Feldkirchen, Germany). Patients in the control group will be treated according to standard local care based on established basic hemodynamic treatment. The primary endpoint is a composite comprising the occurrence of moderate or severe postoperative complications or death within 28 days post surgery. Secondary endpoints are: (1) the number of moderate and severe postoperative complications in total, per patient and for each individual complication; (2) the occurrence of at least one of these complications on days 1, 3, 5, 7, and 28 in total and for every complication; (3) the days alive and free of mechanical ventilation, vasopressor therapy and renal replacement therapy, length of intensive care unit, and hospital stay at day 7 and day 28; and (4) mortality and quality of life, assessed by the EQ-5D-5L™ questionnaire, after 6 months. Discussion This is a large, international randomized controlled study evaluating the effect of perioperative, individualized, algorithm-driven ,hemodynamic optimization on postoperative morbidity and mortality. Trial registration Trial registration: NCT03021525. Registered on 12 January 2017.

Background: Several studies suggest that hemodynamic optimization therapies can reduce complications, the length of hospital stay and costs. However, Brazilian data are scarce. Therefore, the objective of this analysis was to evaluate whether the improvement demonstrated by hemodynamic optimization therapy in surgical patients could result in lower costs from the perspective of the Brazilian public unified health system. Methods: A meta-analysis was performed comparing surgical patients who underwent hemodynamic optimization therapy (intervention) with patients who underwent standard therapy (control) in terms of complications and hospital costs. The cost-effectiveness analysis evaluated the clinical and financial benefits of hemodynamic optimization protocols for surgical patients. The analysis considered the clinical outcomes of randomized studies published in the last 20 years that involved surgeries and hemodynamic optimization therapy. Indirect costs (equipment depreciation, estate and management activities) were not included in the analysis. Results: A total of 21 clinical trials with a total of 4872 surgical patients were selected. Comparison of the intervention and control groups showed lower rates of infectious (RR = 0.66; 95% CI = 0.58–0.74), renal (RR = 0.68; 95% CI = 0.54–0.87), and cardiovascular (RR = 0.87; 95% CI = 0.76–0.99) complications and a nonstatistically significant lower rate of respiratory complications (RR = 0.82; 95% CI = 0.67–1.02). There was no difference in mortality (RR = 1.02; 95% CI = 0.80–1.3) between groups. In the analysis of total costs, the intervention group showed a cost reduction of R$396,024.83-BRL ($90,161.38-USD) for every 1000 patients treated compared to the control group. The patients in the intervention group showed greater effectiveness, with 1.0 fewer days in the intensive care unit and hospital. In addition, there were 333 fewer patients with complications, with a consequent reduction of R$1,630,341.47-BRL ($371,173.27-USD) for every 1000 patients treated. Conclusions: Hemodynamic optimization therapy is cost-effective and would increase the efficiency of and decrease the burden of the Brazilian public health system. [ABSTRACT FROM AUTHOR]

BRAVO (British Randomized Controlled Trial of AV and VV Optimization) is a multicenter, randomized, crossover, noninferiority trial comparing echocardiographic optimization of atrioventricular (AV) and interventricular delay with a noninvasive blood pressure method. Cardiac resynchronization therapy including AV delay optimization confers clinical benefit, but the optimization requires time and expertise to perform. This study randomized patients to echocardiographic optimization or hemodynamic optimization using multiple-replicate beat-by-beat noninvasive blood pressure at baseline; after 6 months, participants were crossed over to the other optimization arm of the trial. The primary outcome was exercise capacity, quantified as peak exercise oxygen uptake. Secondary outcome measures were echocardiographic left ventricular (LV) remodeling, quality-of-life scores, and N-terminal pro–B-type natriuretic peptide. A total of 401 patients were enrolled, the median age was 69 years, 78% of patients were men, and the New York Heart Association functional class was II in 84% and III in 16%. The primary endpoint, peak oxygen uptake, met the criterion for noninferiority (p noninferiority = 0.0001), with no significant difference between the hemodynamically optimized arm and echocardiographically optimized arm of the trial (mean difference 0.1 ml/kg/min). Secondary endpoints for noninferiority were also met for symptoms (mean difference in Minnesota score 1; p noninferiority = 0.002) and hormonal changes (mean change in N-terminal pro–B-type natriuretic peptide -10 pg/ml; p noninferiority = 0.002). There was no significant difference in LV size (mean change in LV systolic dimension 1 mm; p noninferiority < 0.001; LV diastolic dimension 0 mm; p noninferiority <0.001). In 30% of patients the AV delay identified as optimal was more than 20 ms from the nominal setting of 120 ms. Optimization of cardiac resynchronization therapy devices by using noninvasive blood pressure is noninferior to echocardiographic optimization. Therefore, noninvasive hemodynamic optimization is an acceptable alternative that has the potential to be automated and thus more easily implemented. (British Randomized Controlled Trial of AV and VV Optimization [BRAVO]; NCT01258829) [ABSTRACT FROM AUTHOR]

Purpose: In order to increase the responder rate to CRT, stimulation of the left ventricular (LV) from multiple sites has been suggested as a promising alternative to standard biventricular pacing (BIV). The aim of the study was to compare, in a group of candidates for CRT, the effects of different pacing configurations-BIV, triple ventricular (TRIV) by means of two LV leads, multipoint (MPP), and multipoint plus a second LV lead (MPP + TRIV) pacing-on both hemodynamics and QRS duration.Methods: Fifteen patients (13 male) with permanent AF (mean age 76 ± 7 years; left ventricular ejection fraction 33 ± 7%; 7 with ischemic cardiomyopathy; mean QRS duration 178 ± 25 ms) were selected as candidates for CRT. Two LV leads were positioned in two different branches of the coronary sinus. Acute hemodynamic response was evaluated by means of a RADI pressure wire as the variation in LVdp/dtmax.Results: Per patient, 2.7 ± 0.7 veins and 5.2 ± 1.9 pacing sites were evaluated. From baseline values of 998 ± 186 mmHg/s, BIV, TRIV, MPP, and MPP-TRIV pacing increased LVdp/dtmax to 1200 ± 281 mmHg/s, 1226 ± 284 mmHg/s, 1274 ± 303 mmHg, and 1289 ± 298 mmHg, respectively (p < 0.001). Bonferroni post-hoc analysis showed significantly higher values during all pacing configurations in comparison with the baseline; moreover, higher values were recorded during MPP and MPP + TRIV than at the baseline or during BIV and also during MPP + TRIV than during TRIV. Mean QRS width decreased from 178 ± 25 ms at the baseline to 171 ± 21, 167 ± 20, 168 ± 20, and 164 ± 15 ms, during BIV, TRIV, MPP, and MPP-TRIV, respectively (p < 0.001).Conclusions: In patients with AF, the acute response to CRT improves as the size of the early activated LV region increases. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To report the hemodynamic and functional responses obtained with clinical optimization guided by hemodynamic parameters in patients with severe and refractory heart failure. METHODS: Invasive hemodynamic monitoring using right heart catheterization aimed to reach low filling pressures and peripheral resistance. Frequent adjustments of intravenous diuretics and vasodilators were performed according to the hemodynamic measurements. RESULTS: We assessed 19 patients (age = 48±12 years and ejection fraction = 21±5%) with severe heart failure. The intravenous use of diuretics and vasodilators reduced by 12 mm Hg (relative reduction of 43%) pulmonary artery occlusion pressure (P

Hemodynamic instability often leads to hypoperfusion, which has a significant impact on outcome in both medical and surgical patients. Measures to detect and treat tissue hypoperfusion early by correcting the imbalance between oxygen delivery and consumption is of particular importance. There are several studies targeting different hemodynamic end-points in order to investigate the effects of goal-directed therapy on outcome. A so called multimodal concept putting several variables in context follows simple logic and may provide a broader picture. Furthermore, rather than treating population based normal values of certain indices, this concept can be translated into the individualized patient care to reach adequate oxygen supply and tissue oxygenation in order to avoid under-, or over-resuscitation, which are equally harmful. The purpose of this review is to give an overview of current data providing the basis of this a multimodal, individualized approach of hemodynamic monitoring and treatment.

Objective We investigated whether hemodynamic optimization of systemic tissue perfusion based on PPV and CI improves microcirculatory perfusion when compared to a MAP-based strategy in patients undergoing elective abdominal surgery. Methods Patients were randomized into a PPV/ CI guided group ( n = 13, target PPV <12%, CI >2.5 L/min/m2, and MAP >70 mmHg) or MAP-guided group ( n = 18, target MAP >70 mmHg). PPV, CI, and MAP were measured using noninvasive arterial blood pressure measurements. Sublingual microcirculatory perfusion was measured at one, two, and three hours following anesthesia induction, and quantified as TVD, PVD or the proportion of perfused vessels. Data were analyzed using ANOVA RM. Results Patients in the PPV/ CI group required more fluid administration than control patients (1927 ± 747 mL versus 1283 ± 582 mL, respectively; p = 0.01). Despite this difference, we observed similar values for TVD ( RM; F(1.28) = 0.01; p = 0.92), PVD ( RM; F(1.28) = 0.09; p = 0.77) and the proportion of perfused vessels ( RM; F(1.28) = 0.01; p = 0.76) in both groups. Conclusion Hemodynamic optimization of systemic tissue perfusion is not associated with improvement of microcirculatory perfusion compared to a MAP-guided protocol in patients undergoing abdominal surgery. [ABSTRACT FROM AUTHOR]

Contemporary data suggest that approximately 18% of patients undergoing surgery will develop a major postoperative complication, and 3% to 5% will die prior to hospital discharge. Patients who develop a postoperative complication are at an increased risk of long-term mortality. Multiple studies have shown that perioperative hemodynamic optimization reduces the risk of postoperative complications and death in elective noncardiac surgical patients. [ABSTRACT FROM AUTHOR]

Background: Early goal-directed therapy refers to the use of predefined hemodynamic goals to optimize tissue oxygen delivery in critically ill patients. Its application in high-risk abdominal surgery is, however, hindered by safety concerns and practical limitations of perioperative hemodynamic monitoring. Arterial waveform analysis provides an easy, minimally invasive alternative to conventional monitoring techniques, and could be valuable in early goal-directed strategies. We therefore investigate the effects of early goal-directed therapy using arterial waveform analysis on complications, quality of life and healthcare costs after high-risk abdominal surgery. Methods/Design: In this multicenter, randomized, controlled superiority trial, 542 patients scheduled for elective, high-risk abdominal surgery will be included. Patients are allocated to standard care (control group) or early goal-directed therapy (intervention group) using a randomization procedure stratified by center and type of surgery. In the control group, standard perioperative hemodynamic monitoring is applied. In the intervention group, early goal-directed therapy is added to standard care, based on continuous monitoring of cardiac output with arterial waveform analysis. A treatment algorithm is used as guidance for fluid and inotropic therapy to maintain cardiac output above a preset, age-dependent target value. The primary outcome measure is a combined endpoint of major complications in the first 30 days after the operation, including mortality. Secondary endpoints are length of stay in the hospital, length of stay in the intensive care or post-anesthesia care unit, the number of minor complications, quality of life, cost-effectiveness and one-year mortality and morbidity. Discussion: Before the start of the study, hemodynamic optimization by early goal-directed therapy with arterial waveform analysis had only been investigated in small, single-center studies, including minor complications as primary endpoint. Moreover, these studies did not include quality of life, healthcare costs, and long-term outcome in their analysis. As a result, the definitive role of arterial waveform analysis in the perioperative hemodynamic assessment and care for high-risk surgical patients is unknown, which gave rise to the present trial. Patient inclusion started in May 2012 and is expected to end in 2016. [ABSTRACT FROM AUTHOR]

Background Perioperative goal directed therapy (GDT) can substantially improve the outcomes of high risk surgical patients as shown by many clinical studies. However, the approach needs initial investment and can increase the already very high staff workload. These economic imperatives may be at least partly responsible for weak adherence to the GDT concept. A few models are available for the evaluation of GDT cost-effectiveness, but studies of real economic data based on a recent clinical trial are lacking. In order to address this we have performed a retrospective analysis of the data from the "Intraoperative fluid optimization using stroke volume variation in high risk surgical patients" trial (ISRCTN95085011). Methods The health-care payers perspective was used in order to evaluate the perioperative hemodynamic optimization costs. Hospital invoices from all patients included in the trial were extracted. A direct comparison between the study (GDT, N = 60) and control (N = 60) groups was performed. A cost tree was constructed and major cost drivers evaluated. Results The trial showed a significant improvement in clinical outcomes for GDT treated patients. The mean cost per patient were lower in the GDT group 2877 ± 2336€ vs. 3371 ± 3238€ in controls, but without reaching a statistical significance (p = 0.596). The mean cost of all items except for intraoperative monitoring and infusions were lower for GDT than control but due to the high variability they all failed to reach statistical significance. Those costs associated with clinical care (68 ± 177€ vs. 212 ± 593€; p = 0.023) and ward stay costs (213 ± 108€ vs. 349 ± 467€ ; p = 0.082) were the most important differences in favour of the GDT group. Conclusions Intraoperative fluid optimization with the use of stroke volume variation and Vigileo/FloTrac system showed not only a substantial improvement of morbidity, but was associated with an economic benefit. The cost-savings observed in the overall costs of postoperative care trend to offset the investment needed to run the GDT strategy and intraoperative monitoring. [ABSTRACT FROM AUTHOR]

Résumé: La période périopératoire est particulièrement à risque d’insuffisance rénale aiguë car l’anesthésie (générale ou périmédullaire) et la chirurgie sont elles-mêmes sources d’agression rénale. La définition de l’insuffisance rénale aiguë repose le plus souvent sur la créatininémie que l’on sait imparfaite en période per- et postopératoire. De plus, cette définition est très variable d’une étude à l’autre, de sorte que leurs résultats ne sont que difficilement comparables. La classification risk, injury, failure, loss, end stage kidney disease (RIFLE) permet d’homogénéiser les définitions de l’insuffisance rénale aiguë et de détecter les patients à une phase précoce de défaillance rénale en substituant à l’insuffisance rénale la notion d’agression rénale aiguë. Par ailleurs, l’insuffisance rénale aiguë périopératoire est souvent d’origine multifactorielle associant des facteurs iatrogènes, hémodynamiques et chirurgicaux. Elle est probablement responsable d’une morbi-mortalité qui lui est directement imputable. La prévention de celle-ci repose sur l’optimisation hémodynamique (retour veineux, débit cardiaque, résistances vasculaires), l’éviction de médicaments néphrotoxiques mais également sur une connaissance des temps chirurgicaux pour anticiper une éventuelle dégradation de l’hémodynamique rénale. Les diurétiques ne préviennent pas la survenue d’une insuffisance rénale aiguë mais peuvent, au contraire, la favoriser surtout dans la période périopératoire, particulièrement sujette à la réduction du retour veineux. En période postopératoire, il faut garder à l’esprit qu’une éventuelle prise de poids ou la présence d’œdèmes périphériques même importants ne reflètent pas l’état de réplétion du compartiment vasculaire et encore moins l’hémodynamique rénale. Les principes du traitement de l’insuffisance rénale aiguë périopératoire ne diffèrent pas des autres types d’insuffisance rénale aiguë. Le recours aux techniques d’épuration extrarénale doit être parfaitement maîtrisé pour ne pas faire courir de risques surajoutés au patient, notamment en termes de stabilité hémodynamique ou d’équilibre hydroélectrolytique. [Copyright &y& Elsevier]

Objectives: Levosimendan is a calcium sensitizer drug which has been used in cardiac surgery for the prevention of postoperative low cardiac output syndrome (LCOS) and in difficult weaning from cardiopulmonary bypass (CPB). This study aims to evaluate perioperative hemodynamic effects of levosimendan pretreatment in patients for offpump coronary artery bypass graft (OPCABG) surgery with low left ventricular ejection fractions (LVEF < 30%). Materials and Methods: Fifty patients undergoing OPCABG surgery with low LVEF (<30%) were enrolled in the study. Patients were randomly divided in two groups: Levosimendan pretreatment (Group L) and placebo pretreatment (Group C) of 25 each. Group L, patients received levosimendan infusion 200 mg/kg over 24 h and in Group C Patients received placebo. The clinical parameters measured before and after the drug administration up to 48 h were heart rate (HR; for the hour after drug infusion), cardiac index (CI), and pulmonary capillary wedge pressure (PCWP). The requirement of inotropes, intraaortic balloon pump (IABP), CPB, intensive care unit (ICU) stay, and hospital stay were also measured. Results: The patients in group L exhibited higher CI and PCWP during operative in early postoperative period as compared to control group C. Group L also had a less requirement for inotropes, CPB support and IABP with shorter ICU stay as well as hospital stay. Conclusion: Levosimendan pretreatment (24 h infusion) in patient for OPCABG with poor LVEF shows better outcomes and hemodynamics in terms of inotropes, CPB and IABP requirements. It also reduces ICU stay. [ABSTRACT FROM AUTHOR]

Purpose: The 2010 AHA Guidelines for Post-Cardiac Arrest Care recommend immediate treatment of hypotension to maintain adequate tissue perfusion with a goal of mean arterial pressure (MAP) of ≥65 mmHg. However, no studies exist examining the relationship between early hemodynamic goals and outcomes in post-cardiac arrest syndrome (PCAS) patients undergoing therapeutic hypothermia (TH). In this investigation, we examined the relationship between MAP, vasoactive agents, and survival or neurologic outcomes. Methods: Consecutive PCAS patients treated with algorithmic post-arrest care between 2005 and 2011 were included in this retrospective study. MAP and number of vasoactive agents were analyzed at 1, 6, 12, and 24 h after arrest. Primary outcome was survival at discharge. Data were analyzed using logistic regression analysis and ANOVA. Results: Of 168 patients, 45 % (75/168) survived, and 35 % (58/168) had cerebral performance category (CPC) scores 1-2. Survivors had higher MAPs at 1 h (96 vs. 84 mmHg, p < 0.0001), 6 h (96 vs. 90 mmHg, p = 0.014), and 24 h (86 vs. 78 mmHg, p = 0.15) than non-survivors. Increased requirement for vasoactive agents was associated with mortality at all time points. Among those requiring vasoactive agents, survivors had higher MAPs than non-survivors at 1 h (97 vs. 82 mmHg, p = <0.0001) and 6 h (94 vs 87 mmHg, p = 0.05). Conclusions: Higher MAPs are associated with better outcomes in PCAS patients undergoing TH. Vasoactive agent requirement is associated with poor outcomes. Further prospective studies with specific MAP goals and hemodynamic optimization algorithms need to be performed. [ABSTRACT FROM AUTHOR]

Abstract: Background: Reproducibility and hemodynamic efficacy of optimization of AV delay (AVD) of cardiac resynchronization therapy (CRT) using invasive LV dp/dtmax are unknown. Method and results: 25 patients underwent AV delay (AVD) optimisation twice, using continuous left ventricular (LV) dp/dtmax, systolic blood pressure (SBP) and pulse pressure (PP). We compared 4 protocols for comparing dp/dtmax between AV delays: Immediate absolute: mean of 10s recording of dp/dtmax acquired immediately after programming the tested AVD, Delayed absolute: mean of 10s recording acquired 30s after programming AVD, Single relative: relative difference between reference AVD and the tested AVD, Multiple relative: averaged difference, from multiple alternations between reference and tested AVD. We assessed for dp/dtmax, LVSBP and LVPP, test–retest reproducibility of the optimum. Optimization using immediate absolute dp/dtmax had poor reproducibility (SDD of replicate optima=41ms; R2 =0.45) as did delayed absolute (SDD 39ms; R2 =0.50). Multiple relative had better reproducibility: SDD 23ms, R2 =0.76, and (p<0.01 by F test). Compared with AAI pacing, the hemodynamic increment from CRT, with the nominal AV delay was LVSBP 2% and LVdp/dtmax 5%, while CRT with pre-determined optimal AVD gave 6% and 9% respectively. Conclusions: Because of inevitable background fluctuations, optimization by absolute dp/dtmax has poor same-day reproducibility, unsuitable for clinical or research purposes. Reproducibility is improved by comparing to a reference AVD and making multiple consecutive measurements. More than 6 measurements would be required for even more precise optimization — and might be advisable for future study designs. With optimal AVD, instead of nominal, the hemodynamic increment of CRT is approximately doubled. [Copyright &y& Elsevier]

Introduction: Pulse pressure variation predicts fluid responsiveness in mechanically ventilated patients passively adapted to the ventilator. Its usefulness in actively breathing ventilated patients was examined only by few studies with potential methodological shortcomings. This study sought to describe the performance of pulse pressure variation as a predictor of fluid responsiveness in hypotensive critically ill patients who trigger the ventilator. Methods: We studied forty two hypotensive, mechanically ventilated patients with documented spontaneous breathing activity in whom a fluid challenge was deemed necessary by the attending physician. All patients were ventilated with a Maquet Servo-i Ventilator in different ventilatory modes with a flow-regulated inspiratory trigger set on position 4. Pulse pressure variation, mean and systolic arterial pressure were observed before and after the fluid challenge, which consisted in the intravenous administration of a 250 ml bolus of 6% hetastarch. Fluid responsiveness was defined as a more than 15 % increase in arterial pressure after volume expansion. Results: The area under the receiver operator characteristic curve for pulse pressure variation was 0.87 (95 % CI 0.74-0.99; p < 0.0001) and the grey zone limits were 10 % and 15 %. Pulse pressure variation was correlated with increase in systolic arterial pressure (r2 = 0.32;p< 0.001) and mean arterial pressure (r2 = 0.10; p = 0.037). Conclusions: Pulse pressure variation predicts fluid responsiveness in patients who actively interact with a Servo-i ventilator with a flow-regulated inspiratory trigger set on position 4. [ABSTRACT FROM AUTHOR]

There was major progress through 2012 in cardiovascular anesthesia and intensive care. Although recent meta- analysis has supported prophylactic steroid therapy in adult cardiac surgery, a large Dutch multicenter trial found no outcome advantage with dexamethasone. A second large randomized trial is currently testing the outcome effects of methyprednisolone in this setting. Due to calibration drift, the logistic EuroSCORE has recently been recalibrated. Despite this model revision, EuroSCORE II still overestimates mortality after trans- catheter aortic valve implantation. It is likely that a specific perioperative risk model will be developed for this unique patient population. Recent global consensus has prioritized 12 non-surgical interventions that merit further study for reducing mortality after surgery. There is currently a paradigm shift in the conduct of adult aortic arch repair. Recent advances have facilitated aortic arch reconstruction with routine antegrade cerebral perfusion at mild-to-moderate hypothermia. Further integration of hybrid endovascular techniques may allow future aortic arch repair without hypothermia or circulatory arrest. These advances will likely further improve patient outcomes. [ABSTRACT FROM AUTHOR]

Hemodynamic optimization of high-risk surgical patients has been increasingly used in the peri-operative setting. The benefit of this approach for the morbidity and mortality reduction in the postoperative period has been proved by many studies. In this article we summarize and comment on the articles published on perioperative goal-directed therapy. [ABSTRACT FROM AUTHOR]

Abstract: Background: Comatose survivors of out-of-hospital cardiac arrest (OHCA) have high in-hospital mortality due to a complex pathophysiology that includes cardiovascular dysfunction, inflammation, coagulopathy, brain injury and persistence of the precipitating pathology. Therapeutic hypothermia (TH) is the only intervention that has been shown to improve outcomes in this patient population. Due to the similarities between the post-cardiac arrest state and severe sepsis, it has been postulated that early goal-directed hemodyamic optimization (EGDHO) combined with TH would improve outcome of comatose cardiac arrest survivors. Objective: We examined the feasibility of establishing an integrated post-cardiac arrest resuscitation (PCAR) algorithm combining TH and EGDHO within 6h of emergency department (ED) presentation. Methods: In May, 2005 we began prospectively identifying comatose (Glasgow Motor Score<6) survivors of OHCA treated with our PCAR protocol. The PCAR patients were compared to matched historic controls from a cardiac arrest database maintained at our institution. Results: Between May, 2005 and January, 2008, 18/20 (90%) eligible patients were enrolled in the PCAR protocol. They were compared to historic controls from 2001 to 2005, during which time 18 patients met inclusion criteria for the PCAR protocol. Mean time from initiation of TH to target temperature (33°C) was 2.8h (range 0.8–23.2; SD=h); 78% (14/18) had interventions based upon EGDHO parameters; 72% (13/18) of patients achieved their EGDHO goals within 6h of return of spontaneous circulation (ROSC). Mortality for historic controls who qualified for the PCAR protocol was 78% (14/18); mortality for those treated with the PCAR protocol was 50% (9/18) (p =0.15). Conclusions: In patients with ROSC after OHCA, EGDHO and TH can be implemented simultaneously. [Copyright &y& Elsevier]

Abstract: Background: Several hemodynamic measures have been used for optimization of the AV delay of cardiac resynchronization therapy (CRT), including pulse pressure (PP), systolic blood pressure (SBP) and cardiac output (CO). We aimed to determine whether these measures identify the same optimum and whether they have the same efficiency and reproducibility at identifying this optimum. Methods and results: In 22 patients with cardiac resynchronization therapy, we adjusted the AV delay while atrially pacing at 110 bpm and simultaneously recording SBP, diastolic blood pressure (DBP), PP, mean arterial pressure (MAP) and CO. SBP, PP and CO all had essentially the same signal-to-noise ratios (15.4±5.4, 15.5±6.4, 15.3±7.4 respectively p =NS). In contrast, MAP and DBP had significantly worse signal-to-noise ratios than SBP (14.2±5.6, p =0.003 and 12.1±4.4, p <0.0001 respectively). The optimal AV delay was very similar between SBP, PP, MAP and DBP. For example, the optima identified by SBP correlated strongly with those identified by PP (r =0.94), MAP (r =0.96) and DBP (r =0.90). In contrast, the optima detected by CO was poorly related to these (e.g. r =0.36 with SBP optima). Reproducibility was best for optima detected by SBP followed by MAP and PP. Conclusions: Essentially the same AV optimum is identified, regardless of whether the parameter chosen for maximization is SBP, PP, MAP or DBP. We conclude that optimizing the CRT AV delay using SBP gives the best combination of efficiency and reproducibility, with PP and MAP being reasonable alternatives. [Copyright &y& Elsevier]