Measurement of Clavicular Symmetry in Healthy Subjects Using Tomographic Database of Public Hospitals.

Objective This study aimed to perform an imaging evaluation to prove the existence or not of symmetry between the clavicles of healthy subjects from Curitiba, Paraná, Brazil, and identify potential factors influencing the clavicular length. Method The study analyzed chest computed tomography (CT) scans of 211 patients with no clavicular fracture or malformations (100 women and 111 men). We measured the greatest clavicular diagonal on both sides, and the software automatically generated the maximum distance in millimeters. Relative and absolute frequencies described qualitative variables and mean values; quantitative variables used a 95% confidence interval. Value comparisons employed the student's t-test, and correlations determinations used Pearson's correlation coefficient. The significance level adopted was 5%. Results There was a significant difference between the clavicular length (right clavicle, 143.58 mm; left clavicle, 145.72 mm; p = 0.037), indicating asymmetry. On average, the left clavicle was 3.71 mm larger. Asymmetry was significant for both men and women (p < 0.001). The average difference was 4.13 mm for men and 3.23 mm for women. Seventy-three percent of the sample had < 5 mm of asymmetry, 23.7% had 5 to 10 mm, and 3.3% had > 10 mm of asymmetry. Conclusion The studied population did not present clavicular symmetry. On average, the left clavicle was longer than the right clavicle, with differences of 3.71 mm in the general sample, 3.23 mm in women, and 4.13 mm in men. The only significant factor was gender since men presented longer clavicles and higher differences than women.

Measurement of Clavicular Symmetry in Healthy Subjects Using Tomographic Database of Public Hospitals / Mensuração de simetria clavicular em indivíduos saudáveis utilizando-se de banco de dados tomográficos de hospitais públicos

Abstract Objective This study aimed to perform an imaging evaluation to prove the existence or not of symmetry between the clavicles of healthy subjects from Curitiba, Paraná, Brazil, and identify potential factors influencing the clavicular length. Method The study analyzed chest computed tomography (CT) scans of 211 patients with no clavicular fracture or malformations (100 women and 111 men). We measured the greatest clavicular diagonal on both sides, and the software automatically generated the maximum distance in millimeters. Relative and absolute frequencies described qualitative variables and mean values; quantitative variables used a 95% confidence interval. Value comparisons employed the student's t-test, and correlations determinations used Pearson's correlation coefficient. The significance level adopted was 5%. Results There was a significant difference between the clavicular length (right clavicle, 143.58 mm; left clavicle, 145.72 mm; p = 0.037), indicating asymmetry. On average, the left clavicle was 3.71 mm larger. Asymmetry was significant for both men and women (p < 0.001). The average difference was 4.13 mm for men and 3.23 mm for women. Seventy-three percent of the sample had < 5 mm of asymmetry, 23.7% had 5 to 10 mm, and 3.3% had > 10 mm of asymmetry. Conclusion The studied population did not present clavicular symmetry. On average, the left clavicle was longer than the right clavicle, with differences of 3.71 mm in the general sample, 3.23 mm in women, and 4.13 mm in men. The only significant factor was gender since men presented longer clavicles and higher differences than women.

Resumo Objetivo Realizar avaliação imagiológica com intuito de comprovar a existência ou não de simetria entre as clavículas de indivíduos saudáveis da cidade de Curitiba/PR, aliada à identificação de possíveis fatores de influência no comprimento clavicular. Método Foram analisadas tomografias computadorizadas de tórax de 211 pacientes sem fratura ou malformações na clavícula (100 mulheres e 111 homens). A maior diagonal clavicular foi medida em ambos os lados e o software gerou automaticamente a máxima distância em milímetros. Foram utilizadas frequências relativas e absolutas para descrever variáveis qualitativas e a média e intervalo de 95% de confiança para as quantitativas. As comparações foram feitas com o teste t de Student e correlações calculadas pelo coeficiente de correlação de Pearson. O nível de significância adotado foi de 5%. Resultados Verificou-se diferença significativa entre o comprimento das clavículas (direita 143.58mm e esquerda 145.72mm, p = 0.037), indicando assimetria. Em média, o lado esquerdo é 3.71mm maior. A assimetria foi significativa tanto para homens quanto para mulheres (p < 0.001). A diferença média foi de 4.13mm para homens e 3.23mm para mulheres. 73% da amostra apresentou <5mm de diferença, enquanto 23.7% apresentou 5-10mm e 3.3% apresentou >10mm de assimetria. Conclusão Não foi possível encontrar simetria nas clavículas da população de Curitiba/PR. Em média, a clavícula esquerda é maior que a direita, com diferenças de 3.71mm na amostra geral, 3.23mm para mulheres e 4.13mm para homens. O único fator significativo foi o sexo, com homens tendo maiores comprimentos claviculares e maiores diferenças em comparação às mulheres.

Effect of anesthetic technique on the quality of anesthesia recovery for abdominal histerectomy: a cross-observational study.

INTRODUCTION: Spinal anesthesia combined with sedation and general anesthesia combined with epidural are two techniques often used for patients undergoing abdominal hysterectomy. There is no consensus that one of these techniques is superior regarding the perception of patients towards the quality of postoperative recovery. This observational cross-sectional study aimed to assess the quality of postoperative recovery in women undergoing open abdominal hysterectomy by comparing both anesthetic techniques. METHOD: We recruited 162 women aged between 30 and 74 years to be submitted to abdominal hysterectomy. The anesthetic technique used followed the preference of the attending anesthesiologist without interference of the investigators. After applying the exclusion criteria, 80 patients underwent spinal anesthesia combined with sedation (Group 1) and 62 women underwent epidural anesthesia combined with general anesthesia (Group 2). The quality of postoperative recovery was evaluated using the questionnaire Quality of Recovery-40 (QoR-40) completed 24 hours after the end of the surgery. RESULTS: Eighty patients in Group 1 answered the QoR-40 questionnaire with an average rating of 179.4 points, median of 186.5, standard deviation of 17.4 and a confidence interval of 3.8. The 60 patients in Group 2 answered the QoR-40 with an average of 174.9 points, median of 178 points, standard deviation of 16 points and a confidence interval of 4.0 (p = 0.024). CONCLUSION: Women who received spinal anesthesia combined with sedation considered quality of postoperative recovery better.

Sexual Dysfunction and Satisfaction in Kidney Transplant Patients.

INTRODUCTION: 10% of the world's population suffers from chronic kidney disease. Kidney transplants provide an improvement in the quality of life of those patients. Sexual dysfunction is common after kidney transplantation, and its etiology is presumed to be multifactorial. It has a negative impact on sexual satisfaction and health-related quality-of-life. The integration of a new organ into the body can imply an adjustment of body image, which may eventually have a negative influence on intimacy and sexual behaviors. AIM: To evaluate male sexual function, sexual satisfaction, and body image satisfaction among a convenience sample of patients who have had a kidney transplant. METHODS: This is a cross-sectional study that included 460 patients, from a single healthcare center, who had undergone a kidney transplant procedure >4 weeks ago. A total of 112 respondents (mean = 55.5 years, SD = 11.4) answered the questionnaires properly. MAIN OUTCOME MEASURES: All recruited patients answered a self-reported sociodemographic questionnaire, in addition to the International Index of Erectile function, the New Scale of Sexual Satisfaction, the Brief Symptom Inventory, and the Body Image Scale. RESULTS: A correlation was found between sexual function and sexual satisfaction (r = 0.598, P < .001, n = 112), as well as between body image satisfaction and sexual function (r = -0.193, P = .042, n = 112). The length of time after a kidney transplant (≤ or >36 months) was not associated with a difference in sexual functioning or sexual satisfaction. CLINICAL IMPLICATIONS: This study showed the obvious implications of sexual function on sexual satisfaction, which should alert healthcare professionals to the importance of identifying and managing sexual dysfunction in patients with chronic kidney disease, to optimize their global and sexual health satisfaction. STRENGTH & LIMITATIONS: This study identified a high prevalence of sexual dysfunction among kidney transplant recipients. This should reinforce the need for the medical community to evaluate the quality-of-life domains of patients with chronic disease. There is still a lack of information concerning any longitudinal evaluation of kidney transplant patients' sexual function and the effects that this surgery has on sexuality. CONCLUSIONS: This study corroborated the severe effects that kidney transplant patients often report regarding their sexuality. Among the patients who participated in the study, sexual function proved to be relevant in relation to sexual satisfaction. Mota RL, Fonseca R, Santos JC, et al. Sexual Dysfunction and Satisfaction in Kidney Transplant Patients. J Sex Med 2019;16:1018-1028.

Diastolic Function and Peripheral Venous Pressure as Indices for Fluid Responsiveness in Cardiac Surgical Patients.

OBJECTIVE: Identifying fluid responsiveness is critical to optimizing perfusion while preventing fluid overload. An experimental study of hypovolemic shock resuscitation showed the importance of ventricular compliance and peripheral venous pressure (PVP) on fluid responsiveness. The authors tested the hypothesis that reduced ventricular compliance measured using transesophageal echocardiography results in decreased fluid responsiveness after a fluid bolus. DESIGN: Prospective observational study. SETTING: Two-center, university hospital study. PARTICIPANTS: The study comprised 29 patients undergoing elective coronary revascularization. INTERVENTION: Albumin 5%, 7 mL/kg, was infused over 10 minutes to characterize fluid responders (>15% increase in stroke volume) from nonresponders. MEASUREMENTS AND MAIN RESULTS: Invasive hemodynamics and the ratio of mitral inflow velocity (E-wave)/annular relaxation (e'), or E/e' ratio, were measured using transesophageal echocardiography to assess left ventricular (LV) compliance at baseline and after albumin infusion. Fifteen patients were classified as responders and 14 as nonresponders. The E/e' ratio in responders was 7.4 ± 1.9 at baseline and 7.1 ± 1.8 after bolus. In contrast, E/e' was significantly higher in nonresponders at baseline (10.7 ± 4.6; p = 0.04) and further increased after bolus (12.6 ± 5.5; p = 0.002). PVP was significantly greater in the nonresponders at baseline (14 ± 4 mmHg v 11 ± 3 mmHg; p = 0.02) and increased in both groups after albumin infusion. Fluid responsiveness was tested using the area under the receiver operating characteristic curve and was 0.74 for the E/e' ratio (95% confidence interval 0.55-0.93; p = 0.029) and 0.72 for the PVP (95% confidence interval 0.52-0.92; p = 0.058). CONCLUSION: Fluid responders had normal LV compliance and lower PVP at baseline. In contrast, nonresponders had reduced LV compliance, which worsened after fluid bolus. E/e,' more than PVP, may be a useful clinical index to predict fluid responsiveness.

A prospective case series evaluating use of an in-line air detection and purging system to reduce air burden during major surgery.

BACKGROUND: Intravascular air embolism (AE) is a preventable but potentially catastrophic complication caused by intravenous tubing, trauma, and diagnostic and surgical procedures. The potentially fatal risks of arterial AE are well-known, and emerging evidence demonstrates impact of venous AEs on inflammatory response and coagulation factors. A novel FDA-approved in-line air detection and purging system was used to detect and remove air caused by administering a rapid fluid bolus during surgery. METHODS: A prospective, randomized, case series was conducted. Subjects were observed using standard monitors, including transesophageal echocardiography (TEE) in the operating room. After general anesthesia was induced, an introducer and pulmonary artery catheter was inserted in the right internal jugular to administer fluids and monitor cardiac pressures. Six patients undergoing cardiac surgery were studied. Each patient received four randomized fluid boluses: two with the in-line air purging device, two without. For each bolus, a bulb infuser was squeezed three times (10-15 mL) over 5 s. The TEE was positioned in the mid-esophageal right atrium (RA) to quantify peak air clearance, and images were video recorded throughout each bolus. Air was quantified using optical densitometry (OD) from images demonstrating maximal air in the RA. RESULTS: All subjects demonstrated significantly lower air burden when the air reduction device was used (p = 0.004), and the average time to clear 90% of air was also lower, 3.7 ± 1.2 s vs. 5.3 ± 1.3 s (p < 0.001). CONCLUSION: An air purging system reduced air burden from bolus administration and could consequently reduce the risk of harmful or fatal AEs during surgery.

Multivariate physiological recordings in an experimental hemorrhage model.

In this paper we describe a data set of multivariate physiological measurements recorded from conscious sheep (N = 8; 37.4 ± 1.1 kg) during hemorrhage. Hemorrhage was experimentally induced in each animal by withdrawing blood from a femoral artery at two different rates (fast: 1.25 mL/kg/min; and slow: 0.25 mL/kg/min). Data, including physiological waveforms and continuous/intermittent measurements, were transformed to digital file formats (European Data Format [EDF] for waveforms and Comma-Separated Values [CSV] for continuous and intermittent measurements) as a comprehensive data set and stored and publicly shared here (Appendix A). The data set comprises experimental information (e.g., hemorrhage rate, animal weight, event times), physiological waveforms (arterial and central venous blood pressure, electrocardiogram), time-series records of non-invasive physiological measurements (SpO2, tissue oximetry), intermittent arterial and venous blood gas analyses (e.g., hemoglobin, lactate, SaO2, SvO2) and intermittent thermodilution cardiac output measurements. A detailed explanation of the hemodynamic and pulmonary changes during hemorrhage is available in a previous publication (Scully et al., 2016) [1].

Effectiveness of Colonic Fluid Resuscitation in a Burn-Injured Swine.

To determine the effectiveness of colonic fluid absorption as a route for fluid resuscitation of a major burn. In order to assess the feasibility and performance of colonic resuscitation, the authors compared plasma volume expansion and hemodynamic parameters of animals submitted to colonic or intravenous fluid resuscitation. Twelve anesthetized swine were submitted to a 40% full thickness flame burn. Thirty minutes later fluid resuscitation was initiated with either intravenous or colonic infusion of crystalloid based on the Parkland formula. This treatment lasted 4.5 hours. The volume of fluid infused was 86 ± 18 ml/kg for the intravenous treatment and 89 ± 14 ml/kg for the colonic treatment. The percentage of fluid absorbed by the colon at the end of the protocol was 30 ± 13% of the infused fluid. Enteral resuscitation was equally effective in expanding plasma volume at the end of the protocol. Laboratorial and hemodynamic parameters were similar between the two resuscitation strategies throughout the study. Urine output was significantly higher in the intravenous group (7.9 ± 4.2 ml/kg/hr vs 0.9 ± 0.3 ml/kg/hr, P = .03). This study demonstrates that colonic infusion of normal saline in a severe burn injury model can restore hemodynamic stability and expand plasma volume to a degree that rivals the effect of direct intravenous infusion for early burn resuscitation in a swine model.

Closed-Loop- and Decision-Assist-Guided Fluid Therapy of Human Hemorrhage.

OBJECTIVES: We sought to evaluate the efficacy, efficiency, and physiologic consequences of automated, endpoint-directed resuscitation systems and compare them to formula-based bolus resuscitation. DESIGN: Experimental human hemorrhage and resuscitation. SETTING: Clinical research laboratory. SUBJECTS: Healthy volunteers. INTERVENTIONS: Subjects (n = 7) were subjected to hemorrhage and underwent a randomized fluid resuscitation scheme on separate visits 1) formula-based bolus resuscitation; 2) semiautonomous (decision assist) fluid administration; and 3) fully autonomous (closed loop) resuscitation. Hemodynamic variables, volume shifts, fluid balance, and cardiac function were monitored during hemorrhage and resuscitation. Treatment modalities were compared based on resuscitation efficacy and efficiency. MEASUREMENTS AND MAIN RESULTS: All approaches achieved target blood pressure by 60 minutes. Following hemorrhage, the total amount of infused fluid (bolus resuscitation: 30 mL/kg, decision assist: 5.6 ± 3 mL/kg, closed loop: 4.2 ± 2 mL/kg; p < 0.001), plasma volume, extravascular volume (bolus resuscitation: 17 ± 4 mL/kg, decision assist: 3 ± 1 mL/kg, closed loop: -0.3 ± 0.3 mL/kg; p < 0.001), body weight, and urinary output remained stable under decision assist and closed loop and were significantly increased under bolus resuscitation. Mean arterial pressure initially decreased further under bolus resuscitation (-10 mm Hg; p < 0.001) and was lower under bolus resuscitation than closed loop at 20 minutes (bolus resuscitation: 57 ± 2 mm Hg, closed loop: 69 ± 4 mm Hg; p = 0.036). Colloid osmotic pressure (bolus resuscitation: 19.3 ± 2 mm Hg, decision assist, closed loop: 24 ± 0.4 mm Hg; p < 0.05) and hemoglobin concentration were significantly decreased after bolus fluid administration. CONCLUSIONS: We define efficacy of decision-assist and closed-loop resuscitation in human hemorrhage. In comparison with formula-based bolus resuscitation, both semiautonomous and autonomous approaches were more efficient in goal-directed resuscitation of hemorrhage. They provide favorable conditions for the avoidance of over-resuscitation and its adverse clinical sequelae. Decision-assist and closed-loop resuscitation algorithms are promising technological solutions for constrained environments and areas of limited resources.

Physician-Directed Versus Computerized Closed-Loop Control of Blood Pressure Using Phenylephrine in a Swine Model.

BACKGROUND: Vasopressors provide a rapid and effective approach to correct hypotension in the perioperative setting. Our group developed a closed-loop control (CLC) system that titrates phenylephrine (PHP) based on the mean arterial pressure (MAP) during general anesthesia. As a means of evaluating system competence, we compared the performance of the automated CLC with physicians. We hypothesized that our CLC algorithm more effectively maintains blood pressure at a specified target with less blood pressure variability and reduces the dose of PHP required. METHODS: In a crossover study design, 6 swine under general anesthesia were subjected to a normovolemic hypotensive challenge induced by sodium nitroprusside. The physicians (MD) manually changed the PHP infusion rate, and the CLC system performed this task autonomously, adjusted every 3 seconds to achieve a predetermined MAP. RESULTS: The CLC maintained MAP within 5 mm Hg of the target for (mean ± standard deviation) 93.5% ± 3.9% of the time versus 72.4% ± 26.8% for the MD treatment (P = .054). The mean (standard deviation) percentage of time that the CLC and MD interventions were above target range was 2.1% ± 3.3% and 25.8% ± 27.4% (P = .06), respectively. Control statistics, performance error, median performance error, and median absolute performance error were not different between CLC and MD interventions. PHP infusion rate adjustments by the physician were performed 12 to 80 times in individual studies over a 60-minute period. The total dose of PHP used was not different between the 2 interventions. CONCLUSIONS: The CLC system performed as well as an anesthesiologist totally focused on MAP control by infusing PHP. Computerized CLC infusion of PHP provided tight blood pressure control under conditions of experimental vasodilation.

Automated closed-loop resuscitation of multiple hemorrhages: a comparison between fuzzy logic and decision table controllers in a sheep model.

BACKGROUND: Hemorrhagic shock is the leading cause of trauma-related death in the military setting. Definitive surgical treatment of a combat casualty can be delayed and life-saving fluid resuscitation might be necessary in the field. Therefore, improved resuscitation strategies are critically needed for prolonged field and en route care. We developed an automated closed-loop control system capable of titrating fluid infusion to a target endpoint. We used the system to compare the performance of a decision table algorithm (DT) and a fuzzy logic controller (FL) to rescue and maintain the mean arterial pressure (MAP) at a target level during hemorrhages. Fuzzy logic empowered the control algorithm to emulate human expertise. We hypothesized that the FL controller would be more effective and more efficient than the DT algorithm by responding in a more rigid, structured way. METHODS: Ten conscious sheep were submitted to a hemorrhagic protocol of 25 ml/kg over three separate bleeds. Automated resuscitation with lactated Ringer's was initiated 30 min after the first hemorrhage started. The endpoint target was MAP. Group differences were assessed by two-tailed t test and alpha of 0.05. RESULTS: Both groups maintained MAP at similar levels throughout the study. However, the DT group required significantly more fluid than the FL group, 1745 ± 552 ml (42 ± 11 ml/kg) versus 978 ± 397 ml (26 ± 11 ml/kg), respectively (p = 0.03). CONCLUSION: The FL controller was more efficient than the DT algorithm and may provide a means to reduce fluid loading. Effectiveness was not different between the two strategies. Automated closed-loop resuscitation can restore and maintain blood pressure in a multi-hemorrhage model of shock.

Long-term effect of critical illness after severe paediatric burn injury on cardiac function in adolescent survivors: an observational study.

BACKGROUND: Sepsis, trauma, and burn injury acutely depress systolic and diastolic cardiac function; data on long-term cardiac sequelae of pediatric critical illness are sparse. This study evaluated long-term systolic and diastolic function, myocardial fibrosis, and exercise tolerance in survivors of severe pediatric burn injury. METHODS: Subjects at least 5 years after severe burn (post-burn:PB) and age-matched healthy controls (HC) underwent echocardiography to quantify systolic function (ejection fraction[EF%]), diastolic function (E/e'), and myocardial fibrosis (calibrated integrated backscatter) of the left ventricle. Exercise tolerance was quantified by oxygen consumption (VO2) and heart rate at rest and peak exercise. Demographic information, clinical data, and biomarker expression were used to predict long-term cardiac dysfunction and fibrosis. FINDINGS: Sixty-five subjects (PB:40;HC:25) were evaluated. At study date, PB subjects were 19±5 years, were at 12±4 years postburn, and had burns over 59±19% of total body surface area, sustained at 8±5 years of age. The PB group had lower EF% (PB:52±9%;HC:61±6%; p=0.004), E/e' (PB:9.8±2.9;HC: 5.4±0.9;p<0.0001), VO2peak (PB:37.9±12;HC: 46±8.32 ml/min/kg; p=0.029), and peak heart rate (PB:161±26;HC:182±13bpm;p=0.007). The PB group had moderate (28%) or severe (15%) systolic dysfunction, moderate (50%) or severe diastolic dysfunction (21%), and myocardial fibrosis (18%). Biomarkers and clinical parameters predicted myocardial fibrosis, systolic dysfunction, and diastolic dysfunction. INTERPRETATION: Severe pediatric burn injury may have lasting impact on cardiac function into young adulthood and is associated with myocardial fibrosis and reduced exercise tolerance. Given the strong predictive value of systolic and diastolic dysfunction, these patients might be at increased risk for early heart failure, associated morbidity, and mortality. FUNDING: Conflicts of Interest and Sources of Funding: The authors do not have any conflicts of interest to declare. This work was supported by NIH (P50 GM060338, R01 GM056687, R01 HD049471, R01 GM112936, R01-GM56687 and T32 GM008256), NIDILRR (H133A120091, 90DP00430100), Shriners Hospitals for Children (84080, 79141, 79135, 71009, 80100, 71008, 87300 and 71000), FAER (MRTG CON14876), and the Department of Defense (W81XWH-14-2-0162 and W81XWH1420162). It was also made possible with the support of UTMB's Institute for Translational Sciences, supported in part by a Clinical and Translational Science Award (UL1TR000071) from the National Center for Advancing Translational Sciences (NIH).

Closed-Loop Control of FiO2 Rapidly Identifies Need For Rescue Ventilation and Reduces ARDS Severity in a Conscious Sheep Model of Burn and Smoke Inhalation Injury.

Pulmonary injury can be characterized by an increased need for fraction of inspired oxygen or inspired oxygen percentage (FiO2) to maintain arterial blood saturation of oxygenation (SaO2). We tested a smart oxygenation system (SOS) that uses the activity of a closed-loop control FiO2 algorithm (CLC-FiO2) to rapidly assess acute respiratory distress syndrome (ARDS) severity so that rescue ventilation (RscVent) can be initiated earlier. After baseline data, a pulse-oximeter (noninvasive saturation of peripheral oxygenation [SpO2]) was placed. Sheep were then subjected to burn and smoke inhalation injury and followed for 48 h. Initially, sheep were spontaneously ventilating and then randomized to standard of care (SOC) (n = 6), in which RscVent began when partial pressure of oxygen (PaO2) < 90 mmHg or FiO2 < 0.6, versus SOS (n = 7), software that incorporates and displays SpO2, CLC-FiO2, and SpO2/CLC-FiO2 ratio, at which RscVent was initiated when ratio threshold < 250. RscVent was achieved using a G5 Hamilton ventilator (Bonaduz, Switzerland) with adaptive pressure ventilation and adaptive support ventilation modes for SOC and SOS, respectively. OUTCOMES: the time difference from when SpO2/FiO2 < 250 to RscVent initiation was 4.7 ±â€Š0.6 h and 0.2 ±â€Š0.1 h, SOC and SOS, respectively (P < 0.001). Oxygen responsiveness after RscVent, defined as SpO2/FiO2 > 250 occurred in 4/7, SOS and 0/7, SOC. At 48 h the SpO2/FiO2 ratio was 104 ±â€Š5 in SOC versus 228 ±â€Š59 in SOS (P = 0.036). Ventilatory compliance and peak airway pressures were significantly improved with SOS versus SOC (P < 0.001). Data suggest that SOS software, e.g. SpO2/CLC-FiO2 ratio, after experimental ARDS can provide a novel continuous index of pulmonary function that is apparent before other clinical symptoms. Earlier initiation of RscVent translates into improved oxygenation (reduces ARDS severity) and ventilation.

Effect of hemorrhage rate on early hemodynamic responses in conscious sheep.

Physiological compensatory mechanisms can mask the extent of hemorrhage in conscious mammals, which can be further complicated by individual tolerance and variations in hemorrhage onset and duration. We assessed the effect of hemorrhage rate on tolerance and early physiologic responses to hemorrhage in conscious sheep. Eight Merino ewes (37.4 ± 1.1 kg) were subjected to fast (1.25 mL/kg/min) and slow (0.25 mL/kg/min) hemorrhages separated by at least 3 days. Blood was withdrawn until a drop in mean arterial pressure (MAP) of >30 mmHg and returned at the end of the experiment. Continuous monitoring includedMAP, central venous pressure, pulmonary artery pressure, pulse oximetry, and tissue oximetry. Cardiac output by thermodilution and arterial blood samples were also measured. The effects of fast versus slow hemorrhage rates were compared for total volume of blood removed and stoppage time (whenMAP < 30 mmHg of baseline) and physiological responses during and after the hemorrhage. Estimated blood volume removed whenMAPdropped 30 mmHg was 27.0 ± 4.2% (mean ± standard error) in the slow and 27.3 ± 3.2% in the fast hemorrhage (P = 0.47, pairedttest between rates). Pressure and tissue oximetry responses were similar between hemorrhage rates. Heart rate increased at earlier levels of blood loss during the fast hemorrhage, but hemorrhage rate was not a significant factor for individual hemorrhage tolerance or hemodynamic responses. In 5/16 hemorrhages MAP stopping criteria was reached with <25% of blood volume removed. This study presents the physiological responses leading up to a significant drop in blood pressure in a large conscious animal model and how they are altered by the rate of hemorrhage.

Passive leg raising during pregnancy.

OBJECTIVE: To determine if passive leg raising (PLR) significantly increases cardiac output in a cohort of healthy pregnant women during the third trimester. STUDY DESIGN: Using a noninvasive monitor, baseline hemodynamic measurements for arterial blood pressure, systolic and diastolic blood pressure, heart rate, cardiac output, cardiac index, stroke volume, and systemic vascular resistances were obtained with patients in the semirecumbent position. Measurements were repeated after a 3-minute PLR maneuver in supine, right lateral decubitus, and left lateral decubitus positions. RESULTS: After 10 minutes of bed rest, the cohort's mean baseline heart rate was 80 ± 12 beats/minute. Baseline stroke volume was 98 ± 14 mL, mean cardiac output was 7.8 ± 1.2 L/min, and mean cardiac index was 4.32 ± 0.63 L/min. The baseline systemic vascular resistance value was 893 ± 160 dynes/sec/cm(5). Baseline mean arterial blood pressure was 84 ± 11 mm Hg. Following a PLR maneuver in the supine position, heart rate decreased significantly. No difference was noted in other measurements. Findings were similar with PLR in the left lateral decubitus. PLR in the right lateral decubitus resulted in significantly decreased heart rate, cardiac output, and cardiac index. CONCLUSIONS: PLR did not result in cardiac output recruitment in a cohort of healthy pregnant women during the third trimester.

Trending, Accuracy, and Precision of Noninvasive Hemoglobin Monitoring During Human Hemorrhage and Fixed Crystalloid Bolus.

Automated critical care systems for en route care will rely heavily on noninvasive continuous monitoring. It has been reported that noninvasive assessment of blood hemoglobin via CO-oximetry (SpHb) assessed by spot measurements lacks sufficient accuracy for clinical decision making in trauma patients. However, the precision and utility of trending of continuous hemoglobin have not been evaluated in hemorrhaging humans. This study measured the trending and concordance of SpHb changes during dynamic variations resulting from controlled hemorrhage with concomitant fluid infusion. With institutional review board approval and informed consent, 12 healthy volunteers under general anesthesia were subjected to hemorrhage (10 mL/kg for 15 min) accompanied by Ringer's lactate solution infusion (30 mL/kg for 20 min). The SpHb was measured continuously by the Masimo Radical-7, whereas total blood hemoglobin was measured by arterial blood sampling. Trend analysis, assessed by plots of SpHb against time of 12 subjects, shows consistent falls in SpHb during hemodilution without exception. Four-quadrant concordance analysis was 95.4% with an exclusion zone of 1 g/dL. Spot comparisons of 106 data pairs (SpHb and total blood hemoglobin) showed that 50% exhibited an error of more than 1 g/dL with bias of 1.08 ± 0.82 g/dL and 95% limits of agreement of -0.5 to 2.6. Both trend analysis and concordance analysis suggest high precision of pulse CO-oximetry during hemodilution by hemorrhage and fluid bolus in human volunteers. However, accuracy was similar to other studies and therefore the use of pulse CO-oximetry alone is likely insufficient to make transfusion decisions.

Intestinal intraluminal injection of glutamine increases trolox total equivalent antioxidant capacity (TEAC) in hepatic ischemia-reperfusion.

PURPOSE: To evaluate the effects of intraluminal injection of glutamine on the serum trolox equivalent antioxidant capacity in an experimental model of ischemia-reperfusion of the liver observing the applicability of modifications on the original assay method. METHODS: Thirty Wistar rats underwent laparotomy to perform a 20 cm blind sac of small bowel and occlusion of the hepatic hilo for 30 minutes and reperfusion for 5 minutes. Into the gut sac it was injected glutamine (glutamine group, n=10) or distilled water (control group, n=10). Ten other animals (sham group) underwent laparotomy without artery occlusion. Blood samples were collected for trolox equivalent antioxidant capacity assays in different temperature conditions, reagent quantities and time for spectrophotometer readings. RESULTS: Total antioxidant capacity was significantly greater in glutamine group than in both control group (1.60[1.55-1.77] vs 1.44[1.27-1.53]) and sham group (1.60[1.55-1.77] vs 1.48[1.45-1.59]). CONCLUSION: Glutamine enhanced serum antioxidant capacity. The assay technique consistently reflected the changes in the antioxidant defenses in this experimental model.

Intestinal intraluminal injection of glutamine increases trolox total equivalent antioxidant capacity (TEAC) in hepatic ischemia-reperfusion

PURPOSE: To evaluate the effects of intraluminal injection of glutamine on the serum trolox equivalent antioxidant capacity in an experimental model of ischemia-reperfusion of the liver observing the applicability of modifications on the original assay method. METHODS: Thirty Wistar rats underwent laparotomy to perform a 20 cm blind sac of small bowel and occlusion of the hepatic hilo for 30 minutes and reperfusion for 5 minutes. Into the gut sac it was injected glutamine (glutamine group, n=10) or distilled water (control group, n=10). Ten other animals (sham group) underwent laparotomy without artery occlusion. Blood samples were collected for trolox equivalent antioxidant capacity assays in different temperature conditions, reagent quantities and time for spectrophotometer readings. RESULTS: Total antioxidant capacity was significantly greater in glutamine group than in both control group (1,60[1,55-1,77] vs 1,44[1,27-1,53]) and sham group (1,60[1,55-1,77] vs 1,48[1,45-1,59]). CONCLUSION: Glutamine enhanced serum antioxidant capacity. The assay technique consistently reflected the changes in the antioxidant defenses in this experimental model.

OBJETIVO: Avaliar em um modelo experimental de isquemia-reperfusão hepática os efeitos da injeção intraluminal de glutamina na capacidade anti-oxidante total em equivalência ao trolox (TEAC) do plasma, verificando a aplicabilidade de modificações ao método original de dosagem. MÉTODOS: Trinta ratos Wistar foram submetidos a laparotomia e confecção de uma alça fechada de 20 cm de comprimento envolvendo o intestinal delgado distal seguido do clampeamento do hilo hepático por 30 minutos e reperfusão por 5 minutos. Na alça fechada foi injetada glutamina (grupo glutamina; n=10) ou água destilada (grupo controle; n=10). Em dez animais (grupo sham) não foi realizado clampeamento hilar. Coletou-se sangue para dosagem da capacidade antioxidante total em equivalência ao trolox em condições modificadas de temperatura, proporções relativas dos reagentes e tempo de leitura sob espectrofotometria. RESULTADOS: A capacidade antioxidante total foi significantemente maior (p<0.05) no grupo glutamina que no grupo controle (1,60[1,55-1,77] vs 1,44[1,27-1,53]) e grupo sham (1,60[1,55-1,77] vs 1,48[1,45-1,59]). Não houve diferenças estatísticas entre o grupo controle e o grupo sham. CONCLUSÃO: A glutamina melhorou a capacidade anti-oxidante total plasmática. O método de dosagem refletiu consistentemente alterações na defesa anti-oxidante nesse modelo experimental.