Correlation between four limbs perfusion index and lactic acid in patients with severe neurological diseases / 中华危重病急救医学

OBJECTIVE@#To observe the correlation between the four limbs perfusion index (PI) and blood lactic acid in patients with neurosis, and evaluate the predictive value of PI on microcirculation perfusion metabolic disorder in patients with neurosis.@*METHODS@#A prospective observational study was conducted. Adult patients admitted to the department of neurological intensive care unit (NICU) of the First Affiliated Hospital of Xinjiang Medical University from July 1 to August 20 in 2020 were enrolled. Under the condition of indoor temperature controlled at 25 centigrade, all patients were placed in the supine position, and the blood pressure, heart rate, PI of both fingers and thumb toes and arterial blood lactic acid were measured within 24 hours and 24-48 hours after NICU. The difference of four limbs PI at different time periods and its correlation with lactic acid were compared. Receiver operator characteristic curve (ROC curve) was used to evaluate the predictive value of four limbs PI on patients with microcirculatory perfusion metabolic disorder.@*RESULTS@#A total of 44 patients with neurosis were enrolled, including 28 males and 16 females; average age (61.2±16.5) years old. There were no significant differences in PI of the left index finger and the right index finger [2.57 (1.44, 4.79) vs. 2.70 (1.25, 5.33)], PI of the left toe and the right toe [2.09 (0.85, 4.76) vs. 1.88 (0.74, 4.32)] within 24 hours after entering the NICU, and the PI of the left index finger and the right index finger [3.17 (1.49, 5.07) vs. 3.14 (1.33, 5.36)], PI of the left toe and the right toe [2.07 (0.75, 5.20) vs. 2.07 (0.68, 4.67)] at 24-48 hours after NICU admission (all P > 0.05). However, compared to the PI of the upper and lower limbs on the same side, except for the 24-48 hours after ICU of the PI difference between the left index finger and the left toe (P > 0.05), the PI of the toe was lower than that of the index finger at the other time periods (all P < 0.05). The correlation analysis showed that the PI value of four limbs of patients in both time periods were significantly negatively correlated with arterial blood lactic acid (the r values of the left index finger, the right index finger, the left toe and the right toe were -0.549, -0.482, -0.392 and -0.343 respectively within 24 hours after entering the NICU; the r values of the left index finger, the right index finger, the left toe and the right toe were -0.331, -0.292, -0.402 and -0.442 respectively after entering the NICU 24-48 hours, all P < 0.05). Taking lactic acid ≥ 2 mmol/L as the diagnostic standard for metabolic disorder of microcirculation perfusion (total 27 times, accounting for 30.7%). The efficacy of four limbs PI in predicting microcirculation perfusion metabolic disorder were compared. ROC curve analysis showed that the area under the curve (AUC) and 95% confidence interval (95%CI) of left index finger, right index finger, left toe and right toe predicting microcirculation perfusion metabolic disorder were 0.729 (0.609-0.850), 0.767 (0.662-0.871), 0.722 (0.609-0.835), 0.718 (0.593-0.842), respectively. There was no significant difference in AUC compare with each other (all P > 0.05). The cut-off value of PI of right index finger for predicting microcirculation perfusion metabolic disorder was 2.46, the sensitivity was 70.4%, the specificity was 75.4%, the positive likelihood ratio was 2.86, and the negative likelihood ratio was 0.30.@*CONCLUSIONS@#There are no significant differences in PI of bilateral index fingers, bilateral toes in patients with neurosis. However, unilateral upper and lower limbs showed lower PI in the toe than in the index finger. There is a significantly negatively correlation between PI and arterial blood lactic acid in all four limbs. PI can predict the metabolic disorder of microcirculation perfusion, and its cut-off value is 2.46.

Sulfato de magnesio como ahorrador de opioides en cirugía mayor abdominal / Magnesium sulfate as an opioid sparer in major abdominal surgery

Introducción: El efecto del sulfato de magnesio como adyuvante de la analgesia en la práctica de diferentes intervenciones quirúrgicas es un tema en debate y estudio constante con el fin de probar su eficacia y seguridad en la mejora de la evolución posoperatoria de los pacientes. Objetivo: Evaluar la efectividad y seguridad del sulfato de magnesio como ahorrador de opioides en la anestesia general de pacientes intervenidos por cirugía mayor abdominal. Métodos: Estudio cuasiexperimental, prospectivo, longitudinal realizado en 44 pacientes del Hospital Universitario "General Calixto García", desde diciembre de 2019 hasta diciembre de 2020. Se crearon dos grupos, un grupo estudio (sulfato de magnesio) y otro control. Se evaluó la analgesia intraoperatoria y posoperatoria, el consumo intraoperatorio de fentanil, la necesidad de analgesia de rescate y las complicaciones perioperatorias. Resultados: En los pacientes que se les administró el sulfato de magnesio la tensión arterial media, la frecuencia cardiaca y el índice de shock tuvieron una tendencia a mantenerse por debajo de la media global. El índice de perfusión aumentó y se mantuvo con esa tendencia y tuvieron un menor consumo de fentanil. Conclusiones: La administración de sulfato de magnesio como adyuvante de la anestesia general en pacientes intervenidos por cirugía abdominal mayor electiva, resultó efectiva y segura, pues brindó mayor analgesia perioperatoria, estabilidad hemodinámica, menor consumo de opioides intraoperatorio y menor rescate analgésico posoperatorio que cuando no se usó. La incidencia de complicaciones fue baja y sin repercusión clínica(AU)

Introduction: The effect of magnesium sulfate as an adjunct to analgesia during different surgical interventions is a subject under constant debate and study, with respect to showing its efficacy and safety in improving the postoperative evolution of patients. Objective: To assess the effectiveness and safety of magnesium sulfate as an opioid sparer in general anesthesia with patients undergoing major abdominal surgery. Methods: Quasiexperimental, prospective and longitudinal study carried out, from December 2019 to December 2020, with 44 patients from General Calixto García University Hospital. Two groups were created: a study group (magnesium sulfate) and a control group. Intraoperative and postoperative analgesia, intraoperative fentanyl consumption, requirement of salvage analgesia, as well as perioperative complications were evaluated. Results: In the patients who were administered magnesium sulfate, mean arterial pressure, heart rate and shock index tended to remain below the global mean. The perfusion index increased and maintained this trend, while they had a lower consumption of fentanyl. Conclusions: The administration of magnesium sulfate as an adjunct to general anesthesia in patients undergoing major elective abdominal surgery was effective and safe, as it provided greater perioperative analgesia, hemodynamic stability, less intraoperative opioid consumption and less postoperative analgesic rescue than in the control group. The incidence of complications was low and without clinical repercussions(AU)

Perfusion index: Could this be a new triage tool for upper gastrointestinal system bleeding in the emergency department? A prospective cohort study

ABSTRACT BACKGROUND: Many scoring systems for predicting mortality, rebleeding and transfusion needs among patients with upper gastrointestinal bleeding (UGIB) have been developed. However, no scoring system can predict all these outcomes. OBJECTIVE: To show whether the perfusion index (PI), compared with the Rockall score (RS), helps predict transfusion needs and prognoses among patients presenting with UGIB in emergency departments. In this way, critical patients with transfusion needs can be identified at an early stage. DESIGN AND SETTING: Prospective cohort study in an emergency department in Turkey, conducted between June 2018 and June 2019. METHODS: Patients' demographic parameters, PI, RS, transfusion needs and prognosis were recorded. RESULTS: A total of 219 patients were included. Blood transfusion was performed in 174 patients (79.4%). The PI cutoff value for prediction of the need for blood transfusion was 1.17, and the RS cutoff value was 5. The area under the curve (AUC) value for PI (AUC: 0.772; 95% confidence interval, CI: 0.705-0.838; P < 0.001) was higher than for RS (AUC: 0.648; 95% CI: 0.554-0.741; P = 0.002). 185 patients (84.5%) were discharged, and 34 patients (15.5%) died. The PI cutoff value for predicting mortality was 1.1, and the RS cutoff value was 7. The AUC value for PI (AUC: 0.743; 95% CI: 0.649-0.837; P < 0.001) was higher than for RS (AUC: 0.725; 95% CI: 0.639-0.811; P < 0.001). CONCLUSION: PI values for patients admitted to emergency departments with UGIB on admission can help predict their need for transfusion and mortality risk.

The accuracy of the Innovo Deluxe Fingertip Pulse Oximeter perfusion index in predicting hypotension during balanced general anesthesia induction – A prospective observational study / The Health Sciences Journal

INTRODUCTION@#Balanced general anesthesia technique is a popular choice for induction because it can minimize potential side effects from individual drugs when otherwise used alone. However, hypotension is still a common occurrence during induction. Perfusion Index (PI) has been used as a measure of systemic vascular resistance and has shown to predict hypotension after regional anesthesia and propofol induction. This study aimed to determine whether baseline PI can predict hypotension following balanced general anesthesia induction and determine a cut-off value where hypotension is expected to occur.@*METHODS@#Thirty-five ASA I/II adults for elective surgery under general anesthesia were enrolled. Heart rate, blood pressure and PI were measured every minute from baseline to 5 minutes following induction and 10 minutes after endotracheal intubation. Hypotension was defined as fall in systolic BP (SBP) by >30% of baseline and/or mean arterial pressure (MAP) to <60 mmHg. Severe hypotension (MAP of <55 mm Hg) was treated. @*RESULTS@#No hypotension was observed in the first 5 minutes. Within 10 minutes, hypotension occurred in 8.6% by SBP criterion and 2.6% by MAP criterion. Within 15 minutes, hypotension was seen in 5.7% by SBP and MAP criterion, respectively. PI showed very low (r < 0.2) to low (r = 0.2 to 0.39), negative to positive and insignificant correlation (p > 0.05) with hypotension whether using SBP or MAP criterion and whether observed at 10 or 15 minutes of anesthesia induction. The Area under the ROC curve is 0.397, 95% CI [0 .126, 0.667], p = 0.431.@*CONCLUSION@#This study lends inconclusive evidence on the usefulness of Innovo Deluxe Fingertip Pulse Oximeter with Plethysmograph and Perfusion Index to predict intraoperative hypotension following balanced general anesthesia induction for this sample of patients. However, there was a positive, moderate (r=0.538, 0.501 and 0.469) and significant (p<0.05) correlation between perfusion index and SBP, Diastolic BP and MAP, respectively.

Association between peripheral perfusion, microcirculation and mortality in sepsis: a systematic review / Associação entre perfusão periférica, microcirculação e mortalidade em sepse: uma revisão sistemática

Abstract Although increasing evidence supports the monitoring of peripheral perfusion in septic patients, no systematic review has been undertaken to explore the strength of association between poor perfusion assessed in microcirculation of peripheral tissues and mortality. A search of the most important databases was carried out to find articles published until February 2018 that met the criteria of this study using different keywords: sepsis, mortality, prognosis, microcirculation and peripheral perfusion. The inclusion criteria were studies that assessed association between peripheral perfusion/microcirculation and mortality in sepsis. The exclusion criteria adopted were: review articles, animal/pre-clinical studies, meta-analyzes, abstracts, annals of congress, editorials, letters, case-reports, duplicate and articles that did not present abstracts and/or had no text. In the 26 articles were chosen in which 2465 patients with sepsis were evaluated using at least one recognized method for monitoring peripheral perfusion. The review demonstrated a heterogeneous critically ill group with a mortality-rate between 3% and 71% (median = 37% [28%-43%]). The most commonly used methods for measurement were Near-Infrared Spectroscopy (NIRS) (7 articles) and Sidestream Dark-Field (SDF) imaging (5 articles). The vascular bed most studied was the sublingual/buccal microcirculation (8 articles), followed by fingertip (4 articles). The majority of the studies (23 articles) demonstrated a clear relationship between poor peripheral perfusion and mortality. In conclusion, the diagnosis of hypoperfusion/microcirculatory abnormalities in peripheral non-vital organs was associated with increased mortality. However, additional studies must be undertaken to verify if this association can be considered a marker of the gravity or a trigger factor for organ failure in sepsis.

Resumo Embora evidências crescentes apoiem a monitoração da perfusão periférica em pacientes sépticos, nenhuma revisão sistemática foi feita para explorar a força da associação entre a má perfusão avaliada na microcirculação dos tecidos periféricos e a mortalidade. Uma busca nas bases de dados mais importantes foi feita para encontrar artigos publicados até fevereiro de 2018 que correspondessem aos critérios deste estudo, com diferentes palavras-chave: sepse, mortalidade, prognóstico, microcirculação e perfusão periférica. Os critérios de inclusão foram estudos que avaliaram a associação entre perfusão/microcirculação periférica e mortalidade em sepse. Os critérios de exclusão adotados foram os seguintes: artigos de revisão, estudos com animais/pré-clínicos, metanálises, resumos, anais de congressos, editoriais, cartas, relatos de casos, artigos duplicados e artigos que não continham resumos e/ou texto. Foram selecionados 26 artigos nos quais 2465 pacientes com sepse foram avaliados com pelo menos um método reconhecido para monitorar a perfusão periférica. A revisão demonstrou um grupo heterogêneo de pacientes gravemente enfermos com uma taxa de mortalidade entre 3% e 71% (mediana = 37% [28%-43%]). Os métodos de avaliação mais comumente usados foram a espectroscopia na região do infravermelho próximo (Near-Infrared Spectroscopy - NIRS) (7 artigos) e a análise de imagens em campo escuro (Sidestream Dark-Field - SDF) (5 artigos). O leito vascular mais avaliado foi a microcirculação sublingual/bucal (8 artigos), seguida pela ponta do dedo (4 artigos). A maioria dos estudos (23 artigos) demonstrou uma clara relação entre má perfusão periférica e mortalidade. Em conclusão, o diagnóstico de hipoperfusão/anormalidades microcirculatórias em órgãos não vitais periféricos foi associado ao aumento da mortalidade. No entanto, estudos adicionais devem ser feitos para verificar se essa associação pode ser considerada um marcador da gravidade ou um fator desencadeante da falência de órgãos na sepse.

Trombo serpiginoso em átrio direito: apresentação atípica de tromboembolismo pulmonar. Relato de caso / Serpiginous thrombus in right atrium: atypical presentation of pulmonary thromboembolism. Case report

O tromboembolismo pulmonar é um grave problema de saúde pública devido ao subdiagnóstico e às elevadas morbidade e mortalidade. Quando a embolia pulmonar é maciça com repercussão hemodinâmica importante e a terapia adequada não ocorre nas primeiras horas, a mortalidade é superior a 85%. Na suspeita clínica de tromboembolismo pulmonar, a avaliação ecocardiográfica pode ter papel fundamental na avaliação da mobilidade e da estrutura do ventrículo direito, presença de hipertensão pulmonar e documentação da presença de trombo. A detecção ecocardiográfica de trombo móvel nas câmaras cardíacas direitas permite identificar um grupo de pacientes de alto risco, com mortalidade muito elevada, quando comparada ao tromboembolismo pulmonar em geral. Além da terapia clínica clássica, com heparinas e trombolíticos, as terapêuticas endovascular e cirúrgica devem ser consideradas e podem contribuir para o prognóstico desses pacientes. Relata-se um caso de uma paciente de 33 anos de idade admitida em uma unidade de emergência da no 8o dia de pós-operatório de apendicectomia, com queixas de dor torácica e dispneia de início súbito. Ecocardiograma transtorácico evidenciou presença de trombo serpiginoso solto em átrio direito, que ocluía intermitentemente a valva tricúspide durante o ciclo cardíaco. Diante das características ecocardiográficas atípicas do trombo e da significativa chance de embolização maciça, optou-se por intervenção cirúrgica de emergência.

Pulmonary thromboembolism is a serious public health problem due to misdiagnosis and high morbidity and mortality. When pulmonary embolism is massive with important hemodynamic repercussion, and the appropriate therapy does not take place in the early hours, mortality is higher than 85%. If there is clinical suspicion of pulmonary thromboembolism, an echocardiographic evaluation may have a key role in the evaluation of mobility and structure of the right ventricle, presence of pulmonary hypertension, and documentation of the presence of thrombus. Echocardiographic detection of mobile thrombus in right cardiac chambers allows the identification of a group of high-risk patients with very high mortality when compared to pulmonary thromboembolism in general . In addition to the classical clinical therapy with heparins and thrombolytics, endovascular and surgical therapy should be considered and may contribute to these patients' prognosis. A case is reported of a 33-year-old female patient admitted to an Emergency Unit at 8th postoperative day (POD) of appendectomy, with complaints of chest pain and dyspnea of sudden onset. Transthoracic echocardiography showed the presence of a floating serpiginous thrombus in the right atrium, which intermittently occluded the tricuspid valve during the cardiac cycle. Due to the atypical echocardiographic features of the thrombus, and significant chance of massive embolization, an emergency surgery was chosen.

Correlación del índice de perfusión con la repercusión del conducto arterioso en prematuros / Correlation of perfusion index with patent ductus arteriosus repercussion in premature newborns

Resumen Antecedentes: El conducto arterioso es una estructura necesaria en la circulación fetal, su persistencia puede provocar alteraciones hemodinámicas. El estándar de oro diagnóstico es la ecocardiografía, no siempre disponible. Las unidades de cuidados intensivos neonatales (UCIN) cuentan con oximetría de pulso, que mide el índice de perfusión (IP), el cual podría funcionar como auxiliar en el diagnóstico de persistencia del conducto arterioso hemodinámicamente significativo (PCAHs). Objetivo: Correlacionar el incremento del índice de perfusión (ΔIP) a las 24 y 72 h de vida extrauterina con PCAHs en recién nacidos prematuros de la UCIN de un hospital de segundo nivel. Material y métodos: Estudio de cohorte analítico prospectivo donde se incluyeron neonatos de 26 a 34 semanas de gestación, sin comorbilidades, a quienes se les realizó ecocardiograma y medición de IP en brazo y pierna a las 24 y 72 h. Se efectuó análisis bivariante con Y2/prueba exacta de Fisher y t de Student/U de Mann-Whitney, además correlación de Spearman y regresión lineal para predicción de valores. Resultados: Se incluyeron 39 prematuros. No se encontró diferencia significativa entre los pacientes sin y con PCAHs (mediana: 0.22 [0.06, 0.58] vs. 0.03 [–0.27, 0.2]; p = 0.09) a las 24 h de vida y tampoco a las 72 h de vida (mediana: 0.2 [0, 0.47] vs. 0.45 [–0.37, 0.76], p = 0.47). Se encontró una correlación positiva entre el diámetro del conducto arterioso (DCA) y el ΔIP (r: 0.78; IC 95%: 0.60-0.88; p = 0.01). La fórmula de predicción por regresión lineal se expresa así: DCA = 1.31 + (2.05 x ΔIP). Conclusiones: El IP no permite discriminar entre pacientes sin y con PCAHs. El ΔIP podría ser una herramienta para la monitorización del diámetro del conducto en neonatos después de las 72 h de vida.

Abstract Background: The ductus arteriosus is a necessary structure in fetal circulation, and its patency can produce hemodynamic alterations. The diagnostic gold standard is echocardiography, not always available. In the neonatal intensive care unit (NICU) they have pulse oximetry that measures perfusion index (PI), which could be used as a diagnostic tool in hemodynamic significant patent ductus arteriosus (HSPDA). Objective: To correlate the perfusion index increment (ΔPI) in 24 and 72 h after birth with HSPDA in premature newborns of NICU in a second level hospital. Materials and methods: This is an analytic prospective study which included neonates of 26-34 weeks of gestational age, without comorbidities, who underwent echocardiography and measurement of PI in arm and leg, 24 and 72 h after birth. We did bivariate analysis with Y2/exact Fisher test and Student t-test/Mann-Whitney U test, besides Spearman correlation and linear regression for value prediction. Results: We included 39 premature newborns. We did not find significant differences between patients without and with HSPDA (Median: 0.22 [0.06-0.58] vs. 0.03 [–0.27-0.2]; p = 0.09) at 24 h neither 72 h after birth (Median: 0.2 [0-0.47] vs. 0.45 [–0.37-0.76]; p = 0.47). We found a positive correlation between ductus arteriosus diameter (DAD) and ΔPI (r: 0.78; CI 95%: 0.6-0.88; p = 0.01). The prediction formula with linear regression is expressed this way: DAD = 1.31 + (2.05 x ΔIP). Conclusions: The PI doesn´t allow us to discriminate between patient without and with HSPDA. The ΔPI could be a tool for the monitorization of DAD in neonates 72 h after birth.