The Rheology of the Carotid Sinus: A Path Toward Bioinspired Intervention.

The association between blood viscosity and pathological conditions involving a number of organ systems is well known. However, how the body measures and maintains appropriate blood viscosity is not well-described. The literature endorsing the function of the carotid sinus as a site of baroreception can be traced back to some of the earliest descriptions of digital pressure on the neck producing a drop in blood delivery to the brain. For the last 30 years, improved computational fluid dynamic (CFD) simulations of blood flow within the carotid sinus have demonstrated a more nuanced understanding of the changes in the region as it relates to changes in conventional metrics of cardiovascular function, including blood pressure. We suggest that the unique flow patterns within the carotid sinus may make it an ideal site to transduce flow data that can, in turn, enable real-time measurement of blood viscosity. The recent characterization of the PIEZO receptor family in the sinus vessel wall may provide a biological basis for this characterization. When coupled with other biomarkers of cardiovascular performance and descriptions of the blood rheology unique to the sinus region, this represents a novel venue for bioinspired design that may enable end-users to manipulate and optimize blood flow.

Human life cost in anaesthesiology cost-benefit decisions.

The United States (US) aviation industry provides a potentially useful mental model for dealing with certain cost-benefit decisions in aesthesiology. The Federal Aviation Administration (FAA), the national aviation authority of the United States, quantifies a price for the value of a human life based on the U.S. Department of Transportation's (DOT) value of a statistical life (VSL) unit. The current VSL is around $9.6 million, indexed to grow with consideration given to inflation and wage changes from the 2016 baseline of $9.4 million [1]. To illustrate the concept, if the FAA estimates that 100 people are likely to die in the future given the current practice standards then the monetary cost of this loss will be $940 million. The FAA uses this estimated monetary value as an official reference point in its regulatory decisions, and the agency publishes in detail how it derives the estimated value. When proposing new regulations, the FAA bases its decisions on comparisons of the human life cost associated with the existing regulation versus the alternative cost that the industry stakeholders will incur subsequent to the adoption of the regulation. In this example, if the cost incurred by the industry is more than the $940 million cost then the FAA will not adopt the proposed regulation and hence will not require the industry to undertake this cost.

Even the Simplest Devices May Malfunction: Split Septum Design Revisited.

Split septum medical devices are used in tubing for intravenous (IV) fluid administration-an extremely common clinical task. These tubing caps contain a needleless, valveless system that allows fluid to flow directly through the lumen of the catheter but prevents backflow of fluid or blood when the tubing extension is not connected. We experienced complete failure of a needle-free connector extension set with a Luer-access split septum device in multiple patients due to the split septum remaining fused and essentially unsplit despite being connected on both ends. This led to an adverse event in a patient due to repeated unnecessary IV insertion attempts. This case shows how even the simplest of devices can malfunction and highlights the need for vigilance in clinical practice.

A sudden presentation of abdominal compartment syndrome.

Abdominal compartment syndrome (ACS) is defined as sustained intra-abdominal pressure (IAP) exceeding 20 mm Hg, which causes end-organ damage due to impaired tissue perfusion, as with other compartment syndromes [1, 2]. This dysfunction can extend beyond the abdomen to other organs like the heart and lungs. ACS is most commonly caused by trauma or surgery to the abdomen. It is characterised by interstitial oedema, which can be exacerbated by large fluid shifts during massive transfusion of blood products and other fluid resuscitation [3]. Normally, IAP is nearly equal to or slightly above ambient pressure. Intra-abdominal hypertension is typically defined as abdominal pressure greater than or equal to 12 mm Hg [4]. Initially, the abdomen is able to distend to accommodate the increase in pressure caused by oedema; however, IAP becomes highly sensitive to any additional volume once maximum distension is reached. This is a function of abdominal compliance, which plays a key role in the development and progression of intra-abdominal hypertension [5]. Surgical decompression is required in severe cases of organ dysfunction - usually when IAPs are refractory to other treatment options [6]. Excessive abdominal pressure leads to systemic pathophysiological consequences that may warrant admission to a critical care unit. These include hypoventilation secondary to restriction of the deflection of the diaphragm, which results in reduced chest wall compliance. This is accompanied by hypoxaemia, which is exacerbated by a decrease in venous return. Combined, these consequences lead to decreased cardiac output, a V/Q mismatch, and compromised perfusion to intra-abdominal organs, most notably the kidneys [7]. Kidney damage can be prerenal due to renal vein or artery compression, or intrarenal due to glomerular compression [8] - both share decreased urine output as a manifestation. Elevated bladder pressure is also seen from compression due to increased abdominal pressure, and its measurement, via a Foley catheter, is a diagnostic hallmark. Sustained intra-bladder pressures beyond 20 mm Hg with organ dysfunction are indicative of ACS requiring inter-vention [2, 8]. ACS is an important aetiology to consider in the differential diagnosis for signs of organ dysfunction - especially in the perioperative setting - as highlighted in the case below.

Polytetrafluoroethylene Ingestion as a Way to Increase Food Volume and Hence Satiety Without Increasing Calorie Content.

Since satiety is largely due to stretch of the stomach and people tend to eat a consistent weight of food, increasing food volume and mass increases satiety. This can be achieved without increasing the calories of food by mixing food with a material that cannot be metabolized. Such a material should be inert, safe, resistant to stomach acid, lack taste, available in powder form, smooth, resistant to heat, and cost effective. Polytetrafluoroethylene (PTFE) is an ideal substance for this purpose. It is a soft plastic that is widely considered to be the most inert material known and is extremely stable. Animal feeding trials showed that rats fed a diet of 25% PTFE for 90 days had no signs of toxicity and that the rats lost weight. This article publishes the data from these subchronic animal feeding trials, reviews the relevant available literature, and hypothesizes that increasing the volume of food by mixing the food with PTFE powder at a ratio of 3 parts food to 1 part PTFE by volume will substantially improve satiety and reduce caloric consumption in people.

Error in noninvasive spectrophotometric measurement of blood hemoglobin concentration under conditions of blood loss.

This paper discusses a current misinterpretation between different parameters of hemoglobin concentration measurement and its amplification under conditions of blood loss. The paper details the distinction between microcirculatory hematocrit and the hematocrit of the macrocirculation to analyze clinical use of real-time patient hemoglobin concentration measurement by noninvasive point-of-care devices such as the Rainbow Pulse CO-Oximetry™ (Masimo Corp., Irvine, CA). The hemoglobin concentration or hematocrit values have clinical significance such as for diagnosing anemia or as indicators to when a blood transfusion is needed. The device infers hemoglobin concentration from spectrophotometry of the fingertip and therefore the measured absorption is due to hemoglobin present in capillaries as well as in larger vessels, and the device accordingly reports the hemoglobin concentration as 'total hemoglobin' in a proprietary SpHb parameter. SpHb and macro hemoglobin concentration are different parameters. However, the numerical resemblance of SpHb values to values of macro hemoglobin concentrations, combined with the widely used unspecified term "Hb" in the medical setting, suggests that SpHb values are often interpreted by the clinician as macro hematocrit values. The claim of this paper is that under conditions of blood loss the portion of the SpHb total hemoglobin measure that is contributed from microcirculation increases, due to the decrease of macro hematocrit while microcirculatory hematocrit remains constant when above a critical value. The device is calibrated from phlembotomy drawn blood (from a vein in the arm), which is the gold standard in blood collection, and hence this changing contribution of microcirculatory hemoglobin to the SpHb value would distort the gap between macro hemoglobin and total hemoglobin, SpHb. The hypothesis is that if clinicians indeed interpret the SpHb values as macro hemoglobin values then there is an unreported discrepancy between SpHb to macro hemoglobin concentrations during blood loss due to the increasing effect of microcirculatory hemoglobin measurement on the mixed parameter, SpHb.