Tissue oxygen saturation and finger perfusion index in central hypovolemia: influence of pain.

OBJECTIVES: Tissue oxygen saturation and peripheral perfusion index are proposed as early indirect markers of hypovolemia in trauma patients. Hypovolemia is associated with increased sympathetic nervous activity. However, many other stimuli, such as pain, also increase sympathetic activity. Since pain is often present in trauma patients, its effect on the indirect measures of hypovolemia needs to be clarified. The aim of this study was, therefore, to explore the effects of hypovolemia and pain on tissue oxygen saturation (measurement sites: cerebral, deltoid, forearm, and thenar) and finger photoplethysmographic perfusion index. DESIGN: Experimental study. SETTING: University hospital clinical circulation and research laboratory. SUBJECTS: Twenty healthy volunteers. INTERVENTIONS: Central hypovolemia was induced with lower body negative pressure (-60 mm Hg) and pain by the cold pressor test (ice water exposure). Interventions were performed in a 2×2 fashion with the combination of lower body negative pressure or not (normovolemia), and ice water or not (sham). Each subject was thus exposed to four experimental sequences, each lasting for 8 minutes. MEASUREMENTS AND MAIN RESULTS: Measurements were averaged over 30 seconds. For each person and sequence, the minimal value was analyzed. Tissue oxygenation in all measurement sites and finger perfusion index were reduced during hypovolemia/sham compared with normovolemia/sham. Tissue oxygen saturation (except cerebral) and perfusion index were reduced by pain during normovolemia. There was a larger reduction in tissue oxygenation (all measurement sites) and perfusion index during hypovolemia and pain than during normovolemia and pain. CONCLUSIONS: Pain (cold pressor test) reduces tissue oxygen saturation in all measurement sites (except cerebral) and perfusion index. In the presence of pain, tissue oxygen saturation and perfusion index are further reduced by hypovolemia (lower body negative pressure, -60 mm Hg). Thus, pain must be considered when evaluating tissue oxygen saturation and perfusion index as markers of hypovolemia in trauma patients.

The anesthesia in abdominal aortic surgery (ABSENT) study: a prospective, randomized, controlled trial comparing troponin T release with fentanyl-sevoflurane and propofol-remifentanil anesthesia in major vascular surgery.

BACKGROUND: On the basis of data indicating that volatile anesthetics induce cardioprotection in cardiac surgery, current guidelines recommend volatile anesthetics for maintenance of general anesthesia during noncardiac surgery in hemodynamic stable patients at risk for perioperative myocardial ischemia. The aim of the current study was to compare increased troponin T (TnT) values in patients receiving sevoflurane-based anesthesia or total intravenous anesthesia in elective abdominal aortic surgery. METHODS: A prospective, randomized, open, parallel-group trial comparing sevoflurane-based anesthesia (group S) and total intravenous anesthesia (group T) with regard to cardioprotection in 193 patients scheduled for elective abdominal aortic surgery. Increased TnT level on the first postoperative day was the primary endpoint. Secondary endpoints were postoperative complications, nonfatal coronary events and mortality. RESULTS: On the first postoperative day increased TnT values (>13 ng/l) were found in 43 (44%) patients in group S versus 41 (43%) in group T (P = 0.999), with no significant differences in TnT levels between the groups at any time point. Although underpowered, the authors found no differences in postoperative complications, nonfatal coronary events or mortality between the groups. CONCLUSIONS: In elective abdominal aortic surgery sevoflurane-based anesthesia did not reduce myocardial injury, evaluated by TnT release, compared with total intravenous anesthesia. These data indicate that potential cardioprotective effects of volatile anesthetics found in cardiac surgery are less obvious in major vascular surgery.

Impaired cerebrovascular reactivity after acute traumatic brain injury can be detected by wavelet phase coherence analysis of the intracranial and arterial blood pressure signals.

The objective of the study was to evaluate the wavelet spectral energy of oscillations in the intracranial pressure (ICP) signal in patients with acute traumatic brain injury (TBI). The wavelet phase coherence and phase shift in the 0.006-2 Hz interval between the ICP and the arterial blood pressure (ABP) signals were also investigated. Patients were separated into normal or impaired cerebrovascular reactivity, based on the pressure reactivity index (PRx). Spectral energy, phase coherence and phase shift in the low frequency and cardiorespiratory intervals were compared for the two groups. Data were prospectively collected and analyzed retrospectively in 22 patients, within the first week after acute TBI. The ICP and ABP signals were continuously recorded for [Formula: see text]40 min and the wavelet transform was used to calculate the spectral energy and phase of the signals. The average ICP wavelet energy spectrum showed distinct peaks around 1.0 (cardiac), 0.25 (respiratory) and 0.03 Hz. Patients with normal cerebrovascular reactivity (negative PRx) had 38.6 % (±SD 16.7 %) of the mean wavelet energy below the lower limit of the respiratory frequency band (0.14 Hz) compared to only 18.1 % (±SD 17.8 %) in patients with altered cerebrovascular reactivity (positive PRx) (difference: p = 0.0057). Wavelet phase coherence between the ABP and ICP signals was statistically significant (p < 0.05) in the 0.006-2 Hz interval. The phase shift between the ABP and ICP signals was around zero in the 0.14-1.0 Hz interval. Seven patients with PRx between -0.4943 and -0.1653 had a phase shift in the interval 0.07-0.14 Hz, whereas 15 patients with PRx between -0.1019 and 0.3881 had a phase shift in the interval 0.006-0.07 Hz. We conclude that the wavelet transform of the ICP signal shows spectral peaks at the cardiac, respiratory and 0.03 Hz frequencies. Normal cerebrovascular reactivity seems to be manifested as increased spectral energy in the frequency interval <0.14 Hz. A phase shift between the ICP and ABP signals in the interval 0.07-0.14 Hz indicates normal cerebrovascular reactivity, while a phase shift in the interval 0.006-0.07 Hz indicates altered cerebrovascular reactivity.

The importance of a skin bridge in peripheral tissue perfusion in perforator flaps.

BACKGROUND: Perforator flaps are increasingly used in reconstructive surgery. However, the microvascular perfusion pattern within these flaps remains essentially unknown. In perforator flaps, the importance of preserving the skin bridge at the base is still an object of debate. The authors hypothesized that dividing the skin bridge will increase peripheral tissue perfusion in islanded perforator flaps. METHODS: The abdominal panniculus in patients submitted to elective abdominoplasty was used (n = 24). Flap perfusion was measured by dynamic laser-induced fluorescence videoangiography. The fluorescent dye indocyanine green was injected intravenously before and after conversion of a perforator flap with an intact skin bridge into an islanded perforator flap. To evaluate perfusion, mean pixel intensity and mean perfusion index were calculated in a control zone and in two zones in the flap. RESULTS: In zone I (the most peripheral zone), surgical release of the skin bridge increased mean pixel intensity (19.1 ± 1.9 versus 24.1 ± 2.1; p < 0.001). The mean perfusion index was calculated as 7.5 ± 5.5 and 12.6 ± 6.3 before and after surgical conversion to islanded perforator flaps, respectively. In zone II (the more proximal zone), mean pixel intensity increased (from 30.8 ± 2.8 to 33.7 ± 2.3; p < 0.001) after surgical release of the skin bridge. The mean perfusion index was 18.5 ± 11.1 and 15.6 ± 6.2. CONCLUSIONS: In this human experimental study, conversion of a perforator flap with a skin bridge into an islanded perforator flap increases peripheral tissue perfusion. This finding provides a physiologic basis for using islanded perforator flaps, with enhanced flap mobility and length.

Poor agreement between respiratory variations in pulse oximetry photoplethysmographic waveform amplitude and pulse pressure in intensive care unit patients.

BACKGROUND: To identify fluid responsiveness, a correlation between respiratory variations in pulse pressure (DeltaPP) and respiratory variations in pulse oximetry photoplethysmographic waveform amplitude (DeltaPOP) in mechanically ventilated patients has been demonstrated. To evaluate the agreement between the two methods, knowledge about the repeatability of the methods is imperative. However, no such data exist. Based on knowledge of slow oscillation in skin blood flow, the authors hypothesized that the variability of DeltaPOP would be larger than that of DeltaPP when calculations were performed continuously over a long recording period. METHODS: Respiration, continuous invasive blood pressure, pulse oximetry, and skin microcirculation were recorded in 14 mechanically ventilated intensive care unit patients. No intravenous fluid challenges were given, and no other interventions were performed during the measurements. Seventy consecutive comparisons between DeltaPP and DeltaPOP were calculated for each of the 14 patients. RESULTS: For all patients, DeltaPOP was 13.7 +/- 5.8% and DeltaPP was 5.8 +/- 2.6% (P < 0.001). There was a larger intraindividual (8.94 vs. 1.29; P < 0.001) and interindividual (26.01 vs. 5.57; P < 0.001) variance of DeltaPOP than of DeltaPP. In six patients, there was no significant correlation between DeltaPP and DeltaPOP. A Bland-Altman plot showed poor agreement between the two methods. CONCLUSION: A large variability of DeltaPOP and a poor agreement between DeltaPP and DeltaPOP limits DeltaPOP as a tool for evaluation of fluid responsiveness in intensive care unit patients. This is in contrast to DeltaPP, which shows a small variability.

The effects of general anesthesia on human skin microcirculation evaluated by wavelet transform.

BACKGROUND: Time-frequency analysis of the laser Doppler flowmetry signal, using wavelet transform, shows periodic oscillations at five characteristic frequencies related to the heart (0.6-2 Hz), respiration (0.15-0.6 Hz), myogenic activity in the vessel wall (0.052-0.15 Hz), sympathetic activity (0.021-0.052 Hz), and very slow oscillations (0.0095-0.021), which can be modulated by the endothelium-dependent vasodilator acetylcholine. We hypothesized that wavelet transform of laser Doppler flowmetry signals could detect changes in the microcirculation induced by general anesthesia, such as alterations in vasomotion and sympathetic activity. METHODS: Eleven patients undergoing faciomaxillary surgery were included. Skin microcirculation was measured on the lower forearm with laser Doppler flowmetry and iontophoresis with acetylcholine and sodium nitroprusside before and during general anesthesia with propofol, fentanyl, and midazolam. The laser Doppler flowmetry signals were analyzed using wavelet transform. RESULTS: There were significant reductions in spectral amplitudes in the 0.0095-0.021 (P < 0.01), the 0.021-0.052 (P < 0.001), and the 0.052-0.15 Hz frequency interval (P < 0.01) and a significant increase in the 0.15-0.6 Hz frequency interval. General anesthesia had no effect on the difference between acetylcholine and sodium nitroprusside on relative amplitudes in the 0.0095-0.021 Hz frequency interval (P < 0.001). CONCLUSION: General anesthesia reduces the oscillatory components of the perfusion signal related to sympathetic, myogenic activity and the component modulated by the endothelium. However, the iontophoretic data did not reveal a specific effect on the endothelium. The increase in the 0.15-0.6 Hz interval is related to the effect of mechanical ventilation.

Human skin microcirculation after brachial plexus block evaluated by wavelet transform of the laser Doppler flowmetry signal.

BACKGROUND: The skin microcirculation may be evaluated noninvasively by laser Doppler flowmetry and iontophoresis with acetylcholine and sodium nitroprusside. Wavelet transform of the perfusion signal shows periodic oscillations of five characteristic frequencies in the interval 0.0095-1.6 Hz. The aim of the current study was to investigate alterations in skin microcirculation induced by brachial plexus block, with emphasis on the periodic oscillations. METHODS: Healthy nonsmokers undergoing hand surgery (n = 13) were anesthetized with brachial plexus block, using bupivacaine, lidocaine, and epinephrine. Skin microcirculation was evaluated by laser Doppler flowmetry and iontophoresis with acetylcholine and sodium nitroprusside before and after brachial plexus block. Wavelet transform of the perfusion signal was performed. As a control group, 10 healthy nonsmokers were included. RESULTS: In the anesthetized arm, skin perfusion after brachial plexus block increased from 19 (12-30) to 24 (14-39) arbitrary units (P < 0.01). A significant increase was also seen in the contralateral arm from 17 (14-32) to 20 (14-42) arbitrary units (P < 0.01). After brachial plexus block, spectral analysis revealed a significant reduction in relative amplitude of the oscillatory components within the 0.0095- to 0.021- (P < 0.001) and 0.021- to 0.052-Hz (P < 0.001) intervals in the anesthetized arm. CONCLUSION: Alterations in skin microcirculation induced by brachial plexus block can be evaluated by wavelet transform of the laser Doppler flowmetry signal. Brachial plexus block reduces the oscillatory components within the 0.0095- to 0.021- and 0.021- to 0.052-Hz intervals of the perfusion signal. These alterations are related to inhibition of sympathetic activity and a possible impairment of endothelial function.