Optimizing Fluid Management Guided by Volumetric Parameters in Patients with Sepsis and ARDS.

We compared two de-escalation strategies guided by either extravascular lung water or global end-diastolic volume-oriented algorithms in patients with sepsis and ARDS. Sixty patients with sepsis and ARDS were randomized to receive de-escalation fluid therapy, guided either by the extravascular lung water index (EVLWI, n = 30) or the global end-diastolic volume index (GEDVI, n = 30). In cases of GEDVI > 650 mL/m2 or EVLWI > 10 mL/kg, diuretics and/or controlled ultrafiltration were administered to achieve the cumulative 48-h fluid balance in the range of 0 to -3000 mL. During 48 h of goal-directed de-escalation therapy, we observed a decrease in the SOFA score (p < 0.05). Extravascular lung water decreased only in the EVLWI-oriented group (p < 0.001). In parallel, PaO2/FiO2 increased by 30% in the EVLWI group and by 15% in the GEDVI group (p < 0.05). The patients with direct ARDS demonstrated better responses to dehydration therapy concerning arterial oxygenation and lung fluid balance. In sepsis-induced ARDS, both fluid management strategies, based either on GEDVI or EVLWI, improved arterial oxygenation and attenuated organ dysfunction. The de-escalation therapy was more efficient for direct ARDS.

The Validation of Cardiac Index and Stroke-Volume Variation Measured by the Pulse-Wave Transit Time-Analysis Versus Conventional Pulse-Contour Analysis After Off-Pump Coronary Artery Bypass Grafting: Observational Study.

OBJECTIVE: To compare the reliability of cardiac index (CI) and stroke-volume variation (SVV) measured by the pulse-wave transit-time (PWTT) method using estimated continuous cardiac output (esCCO) technique with conventional pulse-contour analysis after off-pump coronary artery bypass grafting (OPCAB). DESIGN: A single-center, prospective, observational study. SETTING: At a 1,000-bed university hospital. PARTICIPANTS: A total of 21 patients were enrolled after elective OPCAB. INTERVENTIONS: The study authors performed a method comparison study with simultaneous measurement of CI and SVV based on the esCCO technique (CIesCCO and esSVV, correspondingly) and pulse-contour analysis (CIPCA and SVVPCA, correspondingly). As a secondary analysis, they also assessed the trending ability of CIesCCO versus CIPCA. MEASUREMENTS AND MAIN RESULTS: The authors analyzed 178 measurement pairs for CI, and 174 pairs for SVV during the 10 study stages. The mean bias between CIesCCO and CIPCA was 0.06 L min/m2, with limits of agreement of ± 0.92 L min/m2 and a percentage error (PE) of 35.3%. The analysis of the trending ability of CI measured by PWTT revealed a concordance rate of 70%. The mean bias between esSVV and SVVPCA was -6.1%, with limits of agreement of ± 15.5% and a PE of 137%. CONCLUSIONS: The overall performance of CIesCCO and esSVV versus CIPCA and SVVPCA is not clinically acceptable. A further improvement of the PWTT algorithm may be required for an accurate and precise assessment of CI and SVV.

Extravascular lung water levels are associated with mortality: a systematic review and meta-analysis.

BACKGROUND: The prognostic value of extravascular lung water (EVLW) measured by transpulmonary thermodilution (TPTD) in critically ill patients is debated. We performed a systematic review and meta-analysis of studies assessing the effects of TPTD-estimated EVLW on mortality in critically ill patients. METHODS: Cohort studies published in English from Embase, MEDLINE, and the Cochrane Database of Systematic Reviews from 1960 to 1 June 2021 were systematically searched. From eligible studies, the values of the odds ratio (OR) of EVLW as a risk factor for mortality, and the value of EVLW in survivors and non-survivors were extracted. Pooled OR were calculated from available studies. Mean differences and standard deviation of the EVLW between survivors and non-survivors were calculated. A random effects model was computed on the weighted mean differences across the two groups to estimate the pooled size effect. Subgroup analyses were performed to explore the possible sources of heterogeneity. RESULTS: Of the 18 studies included (1296 patients), OR could be extracted from 11 studies including 905 patients (464 survivors vs. 441 non-survivors), and 17 studies reported EVLW values of survivors and non-survivors, including 1246 patients (680 survivors vs. 566 non-survivors). The pooled OR of EVLW for mortality from eleven studies was 1.69 (95% confidence interval (CI) [1.22; 2.34], p < 0.0015). EVLW was significantly lower in survivors than non-survivors, with a mean difference of -4.97 mL/kg (95% CI [-6.54; -3.41], p < 0.001). The results regarding OR and mean differences were consistent in subgroup analyses. CONCLUSIONS: The value of EVLW measured by TPTD is associated with mortality in critically ill patients and is significantly higher in non-survivors than in survivors. This finding may also be interpreted as an indirect confirmation of the reliability of TPTD for estimating EVLW at the bedside. Nevertheless, our results should be considered cautiously due to the high risk of bias of many studies included in the meta-analysis and the low rating of certainty of evidence. Trial registration the study protocol was prospectively registered on PROSPERO: CRD42019126985.

Invasive and Non-invasive Dynamic Parameters to Predict Fluid Responsiveness After Off-pump Coronary Surgery.

OBJECTIVE: This study aimed to assess the predictive value of invasive and non-invasive dynamic parameters for evaluation of fluid responsiveness after off-pump coronary artery bypass grafting. METHODS: Thirty-two adult patients after off-pump coronary surgery were enrolled into a single-center pilot prospective observational study. After arrival to the intensive care unit, all patients received standard fluid challenge test to assess fluid responsiveness. The patients with an increase in cardiac index ≥ 15% after the test were defined as fluid responders. We measured pulse pressure variation using 2 monitoring systems (PPVPiCCO and PPVNK), stroke volume variation, heart-lung interaction index, and plethysmogram variability index before and after standard fluid challenge test. RESULTS: After intensive care unit admission, the absolute values of stroke volume variation, PPVPiCCO, PPVNK, and heart-lung interaction index were significantly higher among fluid responders (P < .05). Response to standard fluid challenge test was predicted by dynamic assessment of PPVPiCCO (area under the curve 0.84), PPVNK (area under the curve 0.71), stroke volume variation (area under the curve 0.77), and heart-lung interaction index (area under the curve 0.77) (P < .05). The plethysmogram variability index value did not demonstrate any predictive ability regarding fluid responsiveness (area under the curve 0.5, P =.1). CONCLUSIONS: In patients after off-pump coronary surgery, both invasive parameters such as pulse pressure and stroke volume variations and non-invasive parameter such as heart-lung interaction index are able to predict fluid responsiveness. Thus, these dynamic parameters can be used to guide fluid therapy during the early postoperative period after off-pump coronary surgery.

Volumetric Monitoring and Extravascular Lung Water in Perioperative Setting and Critically Ill.

In the new century, our diagnostic armamentarium has been significantly reinforced by the 'three-dimensional' volumetric haemodynamic monitoring currently available at the bedside in many perioperative and intensive care settings. The volumetric approach has improved our insight into the haemodynamic scenarios of many critical illnesses and surgical interventions, including sepsis, circulatory shock, acute respiratory distress syndrome as well as cardiothoracic and transplantation surgery. However, the influence of volumetric haemodynamic monitoring on clinical outcome is still a subject for debates. This review presents physiological background, technical details, aspects of bedside use, limitations and further perspectives of the volumetric approach to the cardiopulmonary monitoring.

Refractory gram-negative septic shock complicated by extended purpura fulminans and multiple organ failure in a 23-year-old puerpera -a case report.

BACKGROUND: Pregnancy-related infections are the third most common cause of maternal death worldwide. The aim of this report is to present a case of pregnancy-related infection, which progressed into refractory septic shock accompanied by purpura fulminans and multiple organ failure. CASE: A 23-year-old woman in the postpartum period developed fulminant, refractory septic shock complicated by purpura fulminans and multiple organ failure syndrome (acute respiratory distress syndrome, acute kidney injury, and encephalopathy). Management included antibacterial therapy, fluid and transfusion therapy, nutritional support, protective mechanical ventilation, hydrocortisone, a large dose of ascorbic acid, and thiamine. There were no neurological consequences and all organ functions returned to normal, although the predicted hospital mortality based on the Sequential Organ Failure Assessment (SOFA) score was more than 90%. CONCLUSIONS: Septic shock is a significant, yet not completely understood life-threatening condition, which can be associated with purpura fulminans, multiple organ dysfunction, disseminated intravascular coagulation, and massive tissue necrosis.

Lung Ultrasonography and Cardiac Surgery: A Narrative Review.

Pulmonary complications are common after cardiac surgery and are closely related to postoperative heart failure and adverse outcomes. Lung ultrasonography (LUS) is currently a widely accepted diagnostic approach with well-established methodology, nomenclature, accuracy, and prognostic value in numerous clinical conditions. The advantages of LUS are universally recognized and include bedside applicability, high diagnostic sensitivity and reproducibility, no radiation exposure, and low cost. However, routine perioperative ultrasonography during cardiac surgery generally is limited to echocardiography, diagnosis of pleural effusion, and as a diagnostic tool for postoperative complications in different organs, and few studies have explored the clinical outcomes in relation to LUS among cardiac patients. This narrative review presents the clinical evidence regarding LUS application in intensive care and during the perioperative period for cardiac surgery. Furthermore, this review describes the methodology and the diagnostic and prognostic accuracies of LUS. A summary of ongoing clinical trials evaluating the clinical outcomes related to LUS also is provided. Finally, this review discusses the rationale for upcoming clinical research regarding whether routine use of LUS can modify current intensive care practice and potentially affect the clinical outcomes after cardiac surgery.

Protective ventilation from ICU to operating room: state of art and new horizons.

The prevention of ventilator-associated lung injury (VALI) and postoperative pulmonary complications (PPC) is of paramount importance for improving outcomes both in the operating room and in the intensive care unit (ICU). Protective respiratory support includes a wide spectrum of interventions to decrease pulmonary stress-strain injuries. The motto 'low tidal volume for all' should become routine, both during major surgery and in the ICU, while application of a high positive end-expiratory pressure (PEEP) strategy and of alveolar recruitment maneuvers requires a personalized approach and requires further investigation. Patient self-inflicted lung injury is an important type of VALI, which should be diagnosed and mitigated at the early stage, during restoration of spontaneous breathing. This narrative review highlights the strategies used for protective positive pressure ventilation. The emerging concepts of damaging energy and power, as well as pathways to personalization of the respiratory settings, are discussed in detail. In the future, individualized approaches to protective ventilation may involve multiple respiratory settings extending beyond low tidal volume and PEEP, implemented in parallel with quantifying the risk of VALI and PPC.

Dynamic Tests to Predict Fluid Responsiveness After Off-Pump Coronary Artery Bypass Grafting.

OBJECTIVE: To test the hypothesis that a positive end-expiratory pressure test and the mini-fluid challenge predict fluid responsiveness in patients after off-pump coronary artery bypass grafting. DESIGN: Single-center pilot prospective observational study. SETTING: City Hospital #1 of Arkhangelsk, Russian Federation. PARTICIPANTS: Thirty-two adult patients after off-pump coronary artery surgery. INTERVENTIONS: To assess fluid responsiveness, after arrival to the intensive care unit, all patients received a test with increase in positive end-expiratory pressure from 5 to 20 cmH2O for 2 minutes, a mini-fluid challenge test with administration of crystalloids at 1.5 mL/kg during 2 minutes, and standard fluid challenge test using 7 mL/kg during 10 minutes. MEASUREMENTS AND MAIN RESULTS: The patients with an increase in cardiac index by ≥15% after a standard fluid challenge test were defined as fluid responders. According to receiver operating characteristic analysis, a decrease in mean arterial pressure exceeding 5 mmHg in 120 seconds of the positive end-expiratory pressure test identified fluid responsiveness with an area under the curve of 0.73 (p = 0.03). The reduction in pulse pressure and stroke volume variations by more than 2% during mini-fluid challenge test predicted positive response to fluid load with an area under the curve of 0.77 and 0.75, respectively (p < 0.05). CONCLUSION: Both the positive end-expiratory pressure test and the mini-fluid challenge test are feasible after off-pump coronary artery bypass grafting and can be used to predict fluid responsiveness in these patients.

Quantitative computed tomography in comparison with transpulmonary thermodilution for the estimation of pulmonary fluid status: a clinical study in critically ill patients.

Extravascular lung water (index) (EVLW(I)) can be estimated using transpulmonary thermodilution (TPTD). Computed tomography (CT) with quantitative analysis of lung tissue density has been proposed to quantify pulmonary edema. We compared variables of pulmonary fluid status assessed using quantitative CT and TPTD in critically ill patients. In 21 intensive care unit patients, we performed TPTD measurements directly before and after chest CT. Based on the density data of segmented CT images we calculated the tissue volume (TV), tissue volume index (TVI), and the mean weighted index of voxel aqueous density (VMWaq). CT-derived TV, TVI, and VMWaq did not predict TPTD-derived EVLWI values ≥ 14 mL/kg. There was a significant moderate positive correlation between VMWaq and mean EVLWI (EVLWI before and after CT) (r = 0.45, p = 0.042) and EVLWI after CT (r = 0.49, p = 0.025) but not EVLWI before CT (r = 0.38, p = 0.086). There was no significant correlation between TV and EVLW before CT, EVLW after CT, or mean EVLW. There was no significant correlation between TVI and EVLWI before CT, EVLWI after CT, or mean EVLWI. CT-derived variables did not predict elevated TPTD-derived EVLWI values. In unselected critically ill patients, variables of pulmonary fluid status assessed using quantitative CT cannot be used to predict EVLWI.

Total Intravenous Versus Volatile Induction and Maintenance of Anesthesia in Elective Carotid Endarterectomy: Effects on Cerebral Oxygenation and Cognitive Functions.

OBJECTIVE: Carotid endarterectomy (CEA) is effective for the prevention of stroke, yet can be associated with a postoperative cognitive dysfunction (POCD) that may be affected by the type of anesthesia. The aim of the study was to compare the effects of total intravenous anesthesia (TIVA) with propofol to volatile induction and maintenance of anesthesia (VIMA) with sevoflurane on cerebral tissue oxygen saturation (SctO2) and POCD. DESIGN: Single-center, pilot randomized prospective study. SETTINGS: Single-center, 1,000-bed clinical hospital. PARTICIPANTS: The study included 40 adult male patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were randomized to the TIVA (n = 20) or the VIMA (n = 20) groups. Cardiorespiratory parameters and SctO2 were monitored during CEA and through 20 hours postoperatively. Cognitive functions were assessed preoperatively and on days 1 and 5 after CEA using the Montreal Cognitive Assessment Score (MoCA). In both groups, the ipsilateral SctO2 decreased after clamping, whereas the contralateral SctO2 asymmetrically decreased in the TIVA group only compared both with baseline and with the VIMA group. The changes in MoCA by day 1 correlated with the relative change in the ipsilateral SctO2 after the clamping in the TIVA group (ρ = 0.54, p = 0.015). The improvement of MoCA from days 1 to 5 was related to the relative decline in MAP after the clamping. Better cognitive function was observed by day 5 after sevoflurane VIMA compared with TIVA. CONCLUSION: In CEA, VIMA with sevoflurane might preserve oxygenation in the contralateral hemisphere, suppress an asymmetry of cerebral oxygenation, and improve the early postoperative cognition compared with propofol anesthesia.

The Predictive Value of Integrated Pulmonary Index after Off-Pump Coronary Artery Bypass Grafting: A Prospective Observational Study.

BACKGROUND: The early warning scores may increase the safety of perioperative period. The objective of this study was to assess the diagnostic and predictive role of Integrated Pulmonary Index (IPI) after off-pump coronary artery bypass grafting (OPCAB). MATERIALS AND METHODS: Forty adult patients undergoing elective OPCAB were enrolled into a single-center prospective observational study. We assessed respiratory function using IPI that includes oxygen saturation, end-tidal CO2, respiratory rate, and pulse rate. In addition, we evaluated blood gas analyses and hemodynamics, including ECG, invasive arterial pressure, and cardiac index. The measurements were performed after transfer to the intensive care unit, after spontaneous breathing trial and at 2, 6, 12, and 18 h after extubation. RESULTS AND DISCUSSION: The value of IPI registered during respiratory support correlated weakly with cardiac index (rho = 0.4; p = 0.04) and ScvO2 (rho = 0.4, p = 0.02). After extubation, IPI values decreased significantly, achieving a minimum by 18 h. The IPI value ≤9 at 6 h after extubation was a predictor of complicated early postoperative period (AUC = 0.71; p = 0.04) observed in 13 patients. CONCLUSION: In off-pump coronary surgery, the IPI decreases significantly after tracheal extubation and may predict postoperative complications.

Automated Weaning from Mechanical Ventilation after Off-Pump Coronary Artery Bypass Grafting.

BACKGROUND: The discontinuation of mechanical ventilation after coronary surgery may prolong and significantly increase the load on intensive care unit personnel. We hypothesized that automated mode using INTELLiVENT-ASV can decrease duration of postoperative mechanical ventilation, reduce workload on medical staff, and provide safe ventilation after off-pump coronary artery bypass grafting (OPCAB). The primary endpoint of our study was to assess the duration of postoperative mechanical ventilation during different modes of weaning from respiratory support (RS) after OPCAB. The secondary endpoint was to assess safety of the automated weaning mode and the number of manual interventions to the ventilator settings during the weaning process in comparison with the protocolized weaning mode. MATERIALS AND METHODS: Forty adult patients undergoing elective OPCAB were enrolled into a prospective single-center study. Patients were randomized into two groups: automated weaning (n = 20) using INTELLiVENT-ASV mode with quick-wean option; and protocolized weaning (n = 20), using conventional synchronized intermittent mandatory ventilation (SIMV) + pressure support (PS) mode. We assessed the duration of postoperative ventilation, incidence and duration of unacceptable RS, and the load on medical staff. We also performed the retrospective analysis of 102 patients (standard weaning) who were weaned from ventilator with SIMV + PS mode based on physician's experience without prearranged algorithm. RESULTS AND DISCUSSION: Realization of the automated weaning protocol required change in respiratory settings in 2 patients vs. 7 (5-9) adjustments per patient in the protocolized weaning group. Both incidence and duration of unacceptable RS were reduced significantly by means of the automated weaning approach. The FiO2 during spontaneous breathing trials was significantly lower in the automated weaning group: 30 (30-35) vs. 40 (40-45) % in the protocolized weaning group (p < 0.01). The average time until tracheal extubation did not differ in the automated weaning and the protocolized weaning groups: 193 (115-309) and 197 (158-253) min, respectively, but increased to 290 (210-411) min in the standard weaning group. CONCLUSION: The automated weaning system after off-pump coronary surgery might provide postoperative ventilation in a more protective way, reduces the workload on medical staff, and does not prolong the duration of weaning from ventilator. The use of automated or protocolized weaning can reduce the duration of postoperative mechanical ventilation in comparison with non-protocolized weaning based on the physician's decision.

Estimated continuous cardiac output based on pulse wave transit time in off-pump coronary artery bypass grafting: a comparison with transpulmonary thermodilution.

To evaluate the accuracy of estimated continuous cardiac output (esCCO) based on pulse wave transit time in comparison with cardiac output (CO) assessed by transpulmonary thermodilution (TPTD) in off-pump coronary artery bypass grafting (OPCAB). We calibrated the esCCO system with non-invasive (Part 1) and invasive (Part 2) blood pressure and compared with TPTD measurements. We performed parallel measurements of CO with both techniques and assessed the accuracy and precision of individual CO values and agreement of trends of changes perioperatively (Part 1) and postoperatively (Part 2). A Bland-Altman analysis revealed a bias between non-invasive esCCO and TPTD of 0.9 L/min and limits of agreement of ±2.8 L/min. Intraoperative bias was 1.2 L/min with limits of agreement of ±2.9 L/min and percentage error (PE) of 64 %. Postoperatively, bias was 0.4 L/min, limits of agreement of ±2.3 L/min and PE of 41 %. A Bland-Altman analysis of invasive esCCO and TPTD after OPCAB found bias of 0.3 L/min with limits of agreement of ±2.1 L/min and PE of 40 %. A 4-quadrant plot analysis of non-invasive esCCO versus TPTD revealed overall, intraoperative and postoperative concordance rate of 76, 65, and 89 %, respectively. The analysis of trending ability of invasive esCCO after OPCAB revealed concordance rate of 73 %. During OPCAB, esCCO demonstrated poor accuracy, precision and trending ability compared to TPTD. Postoperatively, non-invasive esCCO showed better agreement with TPTD. However, invasive calibration of esCCO did not improve the accuracy and precision and the trending ability of method.

Continuous Monitoring of Lactate Using Intravascular Microdialysis in High-Risk Cardiac Surgery: A Prospective Observational Study.

OBJECTIVE: To assess the accuracy and applicability of a novel system, not requiring calibration, for continuous lactate monitoring with intravascular microdialysis in high-risk cardiac surgery. DESIGN: Single-center prospective observational study. SETTING: City Hospital #1 of Arkhangelsk, Russian Federation. PARTICIPANTS: Twenty-one adult patients undergoing elective complex repair or replacement of two or more valves or combined valve and coronary artery cardiac surgery. INTERVENTIONS: After induction of anesthesia, in all patients a dedicated triple-lumen catheter functioning as a regular central venous catheter with integrated microdialysis function was inserted via the right jugular vein for continuous lactate monitoring using the intravascular microdialysis system. MEASUREMENTS AND MAIN RESULTS: Lactate values displayed by the microdialysis system were compared with the reference arterial blood gas (ABG) values. In total, 432 paired microdialysis-ABG lactate samples were obtained. After surgery, the concentration of lactate increased significantly, peaking at 8 hours (p<0.05). The lactate clearance within 8 hours after peak concentration was 50% (39%-63%). There was a significant correlation between Lactatecont and Lactatecont (rho = 0.92, p<0.0001). Bland-Altman analysis showed a bias (mean difference)±limits of agreement (±1.96 SD) of 0.09±1.1 mmol/L. In patients with postoperative complications, peak lactate concentration was significantly higher compared with those without complications: 6.75 (4.43-7.75) mmol/L, versus 4.20 (3.95-4.87) mmol/L (p = 0.002). CONCLUSIONS: Lactate concentration increased significantly after high-risk cardiac surgery. The intravascular microdialysis technique for lactate measurement provided acceptable accuracy and can be used for continuous blood lactate monitoring in cardiac surgery.

Protective Ventilation Improves Gas Exchange, Reduces Incidence of Atelectases, and Affects Metabolic Response in Major Pancreatoduodenal Surgery.

BACKGROUND: Protective perioperative ventilation has been shown to improve outcomes and reduce the incidence of postoperative pulmonary complications. The goal of this study was to assess the effects of ventilation with low tidal volume (VT) either alone or in a combination with moderate permissive hypercapnia in major pancreatoduodenal interventions. MATERIALS AND METHODS: Sixty adult patients scheduled for elective pancreatoduodenal surgery with duration >2 h were enrolled into a prospective single-center study. All patients were randomized to three groups receiving high VT [10 mL/kg of predicted body weight (PBW), the HVT group, n = 20], low VT (6 mL/kg PBW, the LVT group, n = 20), and low VT combined with a moderate hypercapnia and hypercapnic acidosis (6 mL/kg PBW, PaCO2 45-60 mm Hg, the LVT + HC group, n = 20). Cardiopulmonary parameters and the incidence of complications were registered during surgery and postoperatively. RESULTS AND DISCUSSION: The values of VT were 610 (563-712), 370 (321-400), and 340 (312-430) mL/kg for the HVT, the LVT, and the LVT + HC groups, respectively (p < 0.001). Compared to the HVT group, PaO2/FiO2 ratio was increased in the LVT group by 15%: 333 (301-381) vs. 382 (349-423) mm Hg at 24 h postoperatively (p < 0.05). The HVT group had significantly higher incidence of atelectases (n = 6), despite lower incidence of smoking compared with the LVT (n = 1) group (p = 0.017) and demonstrated longer length of hospital stay. The patients of the LVT + HC group had lower arterial lactate and bicarbonate excess values by the end of surgery. CONCLUSION: In major pancreatoduodenal interventions, preventively protective VT improves postoperative oxygenation, reduces the incidence of atelectases, and shortens length of hospital stay. The combination of low VT and permissive hypercapnia results in hypercapnic acidosis decreasing the lactate concentration but adding no additional benefits and warrants further investigations.

Effect of intra-abdominal pressure on respiratory function in patients undergoing ventral hernia repair.

AIM: To determine the influence of intra-abdominal pressure (IAP) on respiratory function after surgical repair of ventral hernia and to compare two different methods of IAP measurement during the perioperative period. METHODS: Thirty adult patients after elective repair of ventral hernia were enrolled into this prospective study. IAP monitoring was performed via both a balloon-tipped nasogastric probe [intragastric pressure (IGP), CiMON, Pulsion Medical Systems, Munich, Germany] and a urinary catheter [intrabladder pressure (IBP), UnoMeterAbdo-Pressure Kit, UnoMedical, Denmark] on five consecutive stages: (1) after tracheal intubation (AI); (2) after ventral hernia repair; (3) at the end of surgery; (4) during spontaneous breathing trial through the endotracheal tube; and (5) at 1 h after tracheal extubation. The patients were in the complete supine position during all study stages. RESULTS: The IAP (measured via both techniques) increased on average by 12% during surgery compared to AI (P < 0.02) and by 43% during spontaneous breathing through the endotracheal tube (P < 0.01). In parallel, the gradient between РаСО2 and EtCO2 [Р(а-et)CO2] rose significantly, reaching a maximum during the spontaneous breathing trial. The PаO2/FiO2 decreased by 30% one hour after tracheal extubation (P = 0.02). The dynamic compliance of respiratory system reduced intraoperatively by 15%-20% (P < 0.025). At all stages, we observed a significant correlation between IGP and IBP (r = 0.65-0.81, P < 0.01) with a mean bias varying from -0.19 mmHg (2SD 7.25 mmHg) to -1.06 mm Hg (2SD 8.04 mmHg) depending on the study stage. Taking all paired measurements together (n = 133), the median IGP was 8.0 (5.5-11.0) mmHg and the median IBP was 8.8 (5.8-13.1) mmHg. The overall r (2) value (n = 30) was 0.76 (P < 0.0001). Bland and Altman analysis showed an overall bias for the mean values per patient of 0.6 mmHg (2SD 4.2 mmHg) with percentage error of 45.6%. Looking at changes in IAP between the different study stages, we found an excellent concordance coefficient of 94.9% comparing ΔIBP and ΔIGP (n = 117). CONCLUSION: During ventral hernia repair, the IAP rise is accompanied by changes in Р(а-et)CO2 and PаO2/FiO2-ratio. Estimation of IAP via IGP or IBP demonstrated excellent concordance.

Derecruitment test and surfactant therapy in patients with acute lung injury.

Introduction. A recruitment maneuver (RM) may improve gas exchange in acute lung injury (ALI). The aim of our study was to assess the predictive value of a derecruitment test in relation to RM and to evaluate the efficacy of RM combined with surfactant instillation in patients with ALI. Materials and Methods. Thirteen adult mechanically ventilated patients with ALI were enrolled into a prospective pilot study. The patients received protective ventilation and underwent RM followed by a derecruitment test. After a repeat RM, bovine surfactant (surfactant group, n = 6) or vehicle only (conventional therapy group, n = 7) was instilled endobronchially. We registered respiratory and hemodynamic parameters, including extravascular lung water index (EVLWI). Results. The derecruitment test decreased the oxygenation in 62% of the patients. We found no significant correlation between the responses to the RM and to the derecruitment tests. The baseline EVLWI correlated with changes in SpO(2) following the derecruitment test. The surfactant did not affect gas exchange and lung mechanics but increased EVLWI at 24 and 32 hrs. Conclusions. Our study demonstrated no predictive value of the derecruitment test regarding the effects of RM. Surfactant instillation was not superior to conventional therapy and might even promote pulmonary edema in ALI.

Increased extravascular lung water reduces the efficacy of alveolar recruitment maneuver in acute respiratory distress syndrome.

Introduction. In acute respiratory distress syndrome (ARDS) the recruitment maneuver (RM) is used to reexpand atelectatic areas of the lungs aiming to improve arterial oxygenation. The goal of our paper was to evaluate the response to RM, as assessed by measurements of extravascular lung water index (EVLWI) in ARDS patients. Materials and Methods. Seventeen adult ARDS patients were enrolled into a prospective study. Patients received protective ventilation. The RM was performed by applying a continuous positive airway pressure of 40 cm H(2)O for 40 sec. The efficacy of the RM was assessed 5 min later. Patients were identified as responders if PaO(2)/FiO(2) increased by >20% above the baseline. EVLWI was assessed by transpulmonary thermodilution before the RM, and patients were divided into groups of low EVLWI (<10 mL/kg) and high EVLWI (≥10 mL/kg). Results. EVLWI was increased in 12 patients. Following RM, PaO(2)/FiO(2) increased by 33 (4-65) % in the patients with low EVLWI, whereas those in the high EVLWI group experienced a change by only -1((-13)-(+5)) % (P = 0.035). Conclusion. In ARDS, the response to a recruitment maneuver might be related to the severity of pulmonary edema. In patients with incresed EVLWI, the recruitment maneuver is less effective.

Inhibitor of neuronal nitric oxide synthase improves gas exchange in ventilator-induced lung injury after pneumonectomy.

BACKGROUND: Mechanical ventilation with high tidal volumes may cause ventilator-induced lung injury (VILI) and enhanced generation of nitric oxide (NO). We demonstrated in sheep that pneumonectomy followed by injurious ventilation promotes pulmonary edema. We wished both to test the hypothesis that neuronal NOS (nNOS), which is distributed in airway epithelial and neuronal tissues, could be involved in the pathogenesis of VILI and we also aimed at investigating the influence of an inhibitor of nNOS on the course of VILI after pneumonectomy. METHODS: Anesthetized sheep underwent right pneumonectomy, mechanical ventilation with tidal volumes (VT) of 6 mL/kg and FiO2 0.5, and were subsequently randomized to a protectively ventilated group (PROTV; n = 8) keeping VT and FiO2 unchanged, respiratory rate (RR) 25 inflations/min and PEEP 4 cm H2O for the following 8 hrs; an injuriously ventilated group with VT of 12 mL/kg, zero end-expiratory pressure, and FiO2 and RR unchanged (INJV; n = 8) and a group, which additionally received the inhibitor of nNOS, 7-nitroindazole (NI) 1.0 mg/kg/h intravenously from 2 hours after the commencement of injurious ventilation (INJV + NI; n = 8). We assessed respiratory, hemodynamic and volumetric variables, including both the extravascular lung water index (EVLWI) and the pulmonary vascular permeability index (PVPI). We measured plasma nitrite/nitrate (NOx) levels and examined lung biopsies for lung injury score (LIS). RESULTS: Both the injuriously ventilated groups demonstrated a 2-3-fold rise in EVLWI and PVPI, with no significant effects of NI. In the INJV group, gas exchange deteriorated in parallel with emerging respiratory acidosis, but administration of NI antagonized the derangement of oxygenation and the respiratory acidosis significantly. NOx displayed no significant changes and NI exerted no significant effect on LIS in the INJV group. CONCLUSION: Inhibition of nNOS improved gas exchange, but did not reduce lung water extravasation following injurious ventilation after pneumonectomy in sheep.