Hemodynamic and oxygenation profiles in the early period after hyperbaric oxygen therapy: an observational study of intensive‐care patients
Beatrice Ratzenhofer-KomendaA. OffnerFranz QuehenbergerH. KlemenJan BergerJ. H. FadaiP. SpernbauerGerhard PrauseF.-M. Smolle-Jüttner
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Background: We studied whether hemodynamic and oxygenation profiles are altered in critically ill patients after exposure to hyperbaric oxygen (HBO). Methods: Ten intensive‐care patients (two females, eight males) undergoing HBO treatment after major abdominal surgery, after burn injury and after CO poisoning were included. All subjects were put on mechanical ventilation and received continuous sedation, and had HBO treatment at 2.2 absolute atmospheres for 50 min. Design: Observational prospective study, and repeated measure design. Results: Hemodynamic and oxygen transport patterns were determined before (C0), 1 h (C1) and 2 h (C2) after HBO therapy with continuous cardiac output dual oximetry pulmonary arterial catheter, a central venous and radial arterial line. Data were analyzed with non‐parametric repeated measure analysis. Key results are expressed as a percentage of baseline (C0 values correspond to 100%) at C1 and C2 (median values, lower and upper limit of confidence interval): cardiac index [C1: 105% (98–135), C2: 99% (91–117), P = 0.19], systemic ( P = 0.62) and pulmonary vascular ( P = 0.76) resistance indices were unchanged, but pulmonary venous admixture (Qs/Qt) increased [C1: 173% (112–298), C2: 140% (92–241), P = 0.00002)] and arterial oxygen tension decreased [C1: 76% (67–94), C2: 82% (72–112), P = 0.010]. Conclusion: The hemodynamic profile remained unaffected. The increase in Qs/Qt and the decrease in PaO 2 may be attributed to the inhalation of HBO, and both are reversible.Keywords:
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Oxygen transport
Pulmonary artery catheter
Oxygen therapy
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The effects of ionophore X-537A in the doses of 0.5, 1, 2 and 3 mg/kg were studied on the blood pressure, heart rate, left ventricular contractility, cardiac output, cardiac index, left ventricular work index and systemic vascular resistance in open-chest anaesthetized cats. This compound increased the contractility significantly for 15, 60, 120 and 30 min in the doses of 0.5, 1, 2 and 3 mg/kg respectively. A dose of 0.5 mg/kg was ineffective in raising the blood pressure. Doses of 1, 2 and 3 mg/kg, however, raised the blood pressure significantly for 60, 60 and 15 min respectively. There was an increase in the heart rate, but significant only with doses of 1 and 2 mg/kg. Cardiac output, cardiac index, left ventricular work index and systemic vascular resistance did not change significantly with 0.5 mg/kg of X-537A. Doses of 1 and 2 mg/kg increased the cardiac output, cardiac index, left ventricular work index and total systemic vascular resistance for a variable period of time. A dose of 3 mg/kg of ionophore produced a decrease in the cardiac output, cardiac index, and left ventricular work index, and an increase in the total systemic vascular resistance and cardiac contractility for variable periods. Most of the cardiac effects did not last for more than 1 hr, and repeated administration had no effect on cardiovascular function.
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Twenty patients with congenital heart disease, ages 8 months to 6 years, received 1 to 5 micrograms/kg/min iv nitroglycerin after intracardiac repair to assess the hemodynamic effects of, and the pulmonary vascular response to, the drug in pediatric cardiac patients. Before surgery all patients had systemic-to-pulmonary blood flow ratios equal to or greater than 2.5:1. The pulmonary arterial pressure (PAP) was equal to aortic pressure in 14 patients and normal in six. The pulmonary vascular resistance (PVR) was elevated (more than 4 units) in five patients. After surgery, the right and left atrial pressures, PAP, and cardiac index were measured by thermodilution, and the systemic vascular resistance (SVR) and PVR were calculated. Intravenous nitroglycerin produced a significant drop in SVR at higher doses only (1602 +/- 359 to 1590 +/- 324 dynes X sec X cm-5, p = NS, at 2 micrograms/kg/min vs 1602 +/- 359 to 1247 +/- 417 dynes X sec X cm-5, p less than 0.01, at 5 micrograms/kg/min). Similarly, improvement in cardiac index was apparent only at higher doses (3.33 +/- 1.25 to 3.49 +/- 0.90 liters/min/m2, p = NS, at 2 micrograms/kg/min vs 3.33 +/- 1.25 to 3.82 +/- 0.98 liters/min/m2, p = NS, at 5 micrograms/kg/min). Also, the effect on the pulmonary vascular bed was most marked at higher doses and in patients with elevated PAP (175 +/- 27 to 148 +/- 28 dynes X sec X cm-5, p = NS, in patients with normal PAP vs 305 +/- 78 to 214 +/- 76 dynes X sec X cm-5, p less than .001, in patients with elevated PAP).(ABSTRACT TRUNCATED AT 250 WORDS)
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Follow-up of cardiac index and systemic vascular resistance index by bedside echocardiography until resuscitation.A set of hemodynamic parameters was obtained, including cardiac output, stroke volume, cardiac index, systemic vascular resistance index, velocity time integral, myocardial performance index, capillary refill time, and heart rate at 0 hours after fluid boluses before the start of inotropes, and followed up after 6 hours and 24 hours.Included were 45 patients with community-acquired septic shock. Septic foci were gastroenteritis (24%), intestinal perforation requiring emergency surgery (24%), pneumonia (20%), central nervous system infection (22%) and soft tissue infection (8%). Klebsiella and Enterobacter were the most frequent isolates. We estimated the factors affecting the cardiac index: high central venous pressure at zero time (r = 0.33, p = 0.024) and persistently high heart rate at hour 6 (r = 0.33, p = 0.03). The systemic vascular resistance index was high in most patients at 0 and 24 hours and at the time of resuscitation and inversely affected the cardiac index as well as affecting the velocity time integral (r = -0.416, -0.61, 0.55 and -0.295). Prolonged capillary refill time was a clinical predictor of the low velocity time integral at 24 hours (r = -0.4). The mortality was 27%. Lower systemic vascular resistance index and higher cardiac output were observed in nonsurviving patients.There was a persistently high systemic vascular resistance index in cold shock patients that influenced the stroke volume index, cardiac index, and velocity time integral. The use of echocardiograms for hemodynamic measurements is important in pediatric septic shock patients to adjust dilators, and vasopressor doses and achieve resuscitation targets in a timely manner.Acompanhar o índice cardíaco e o índice de resistência vascular sistêmica até a ressuscitação.Por meio de ecocardiografia junto ao leito, obteve-se um conjunto de parâmetros hemodinâmicos, inclusive débito cardíaco, volume sistólico, índice cardíaco, índice de resistência vascular sistêmica, integral velocidade-tempo, índice de desempenho miocárdico, tempo de reenchimento capilar e frequência cardíaca no momento zero após infusão de fluidos em bolo, e início e utilização de fármacos inotrópicos, com seguimento até 6 horas e 24 horas.Incluíram-se 45 pacientes com choque séptico adquirido na comunidade. Os focos de infecção foram gastrenterite (24%), perfuração intestinal com necessidade de cirurgia emergencial (24%), pneumonia (20%), infecção do sistema nervoso central (22%) e infecção de tecidos moles (8%). Os isolados mais frequentes foram de Klebsiella e Enterobacter. Estimamos os fatores que afetaram o índice cardíaco: pressão venosa central elevada no momento zero (r = 0,33; p = 0,024) e persistência de frequência cardíaca elevada após 6 horas (r = 0,33; p = 0,03). O índice de resistência vascular sistêmica foi alto na maioria dos pacientes no momento zero e após 24 horas, e por ocasião da ressuscitação, afetando inversamente o índice cardíaco, assim como a integral velocidade-tempo (r = -0,416; -0,61; 0,55 e -0,295). O tempo de reenchimento capilar aumentado foi preditor clínico de valores baixos de integral velocidade-tempo após 24 horas (r = -0,4). O índice de mortalidade foi de 27%. Nos pacientes que não sobreviveram, observaram-se índices de resistência vascular sistêmica mais baixos e débitos cardíacos mais altos.O índice de resistência vascular sistêmica esteve persistentemente elevado em pacientes com choque frio, o que influenciou no índice de volume sistólico, no índice cardíaco e na integral velocidade-tempo. O uso de ecocardiografia para obtenção de mensurações hemodinâmicas é importante em pacientes pediátricos com choque séptico, para que se possam ajustar as doses de vasodilatadores e vasopressores, e obter os objetivos da ressuscitação em tempo apropriado.
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For many years, the pulmonary artery catheter has been used to monitor cardiac filling pressures and to determine cardiac output in hemodynamically unstable patients. Recently, a new pulmonary artery catheter with fiberoptic capabilities, which provides continuous mixed venous O2 saturation (SvO2) measurements, has become available and has been found to be helpful in managing unstable patients. To determine the efficacy of this device in predicting early changes in cardiac output, we studied 46 patients catheterized with the opticath and 25 with the standard pulmonary artery catheter; we compared changes in the SvO2 with associated cardiac index changes. We found that small changes (5%) in SvO2 did not correlate well with changes in cardiac output, yet larger changes (10%) in SvO2 seemed to correlate better. More importantly, we found that only 50% of the SvO2 changes predicted anticipated changes in cardiac output. As can best be determined from the limitations of a nonrandomized study, the value of continuous SvO2 monitoring as an early predictor of cardiac output change remains questionable.
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Objective To evaluate the hypothesis that heparin administration increases cardiac output and improves oxygenation in experimental hyperdynamic sepsis in sheep. Design Prospective trial. Setting Laboratory at a large university-affiliated medical center. Subjects A total of 14 sheep weighing 28 to 44 kg. Interventions All 14 chronically instrumented sheep received a continuous infusion of Escherichia coli endotoxin (10 ng/kg/min) over 24 hrs. Seven sheep received a fixed bolus of beef lung heparin (5000 units) every 4 hrs intravenously. The other seven sheep served as controls. Measurements and Main Results The heparinized animals showed a triphasic cardiovascular response. Cardiac index increased (p < .05), and systemic vascular resistance index decreased (p < .05) at 2 hrs after the start of the endotoxin infusion (early phase, 0 to 2 hrs). Both variables returned to approximately baseline levels at 4 hrs (second period, 2 to 4 hrs). A hyperdynamic state (in terms of an increased cardiac index), a decreased systemic vascular resistance index, and a decreased mean arterial pressure (MAP) (p <. 05 for all) was observed in the third phase (8 to 24 hrs). In the control group, cardiac index, systemic vascular resistance index, and MAP showed no changes in the first period, but a slight decrease in cardiac index and a slight increase in systemic vascular resistance index in the second period. The onset of the hyperdynamic state was less pronounced in the control group and cardiac index was lower (p < .05); likewise, systemic vascular resistance index was increased (p < .05) when compared with heparinized animals. Both groups developed pulmonary hypertension during the endotoxin infusion. The gas exchange in the heparia group was significantly impaired in the first and second periods, but returned to baseline levels in the hyperdynamic phase, whereas the oxygenation of the nonheparinized animals showed only minor changes in the first and second phases, but deteriorated significantly during the third phase of endotoxemia. Conclusions In this experimental model of hyperdynamic sepsis, heparin significantly in fluenced the cardiopulmonary performanec Heparin preserved gas exchange and increased cardiac output but lowered systemic vascular resistance and MAP in the hyperdynamic states (Crit Care Med 1993; 21:84–89)
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AIM:To investigate the systemic hemodynamic effects of two surgical procedures largely employed for treatment of schistosomal portal hypertension. METHODS:Thirty-six patients undergoing elective surgical treatment of portal hypertension due to h e p a t o s p l e n i c m a n s o n i c s c h i s t o s o m i a s i s w e r e prospectively evaluated.All patients were subjected to preoperative pulmonary artery catheterization; 17 were submitted to esophagogastric devascularization and splenectomy (EGDS) and 19 to distal splenorenal shunt (DSRS).The systemic hemodynamic assessment was repeated 4 d after the surgical procedure. RESULTS:Preoperative evaluation revealed (mean ± SD) an increased cardiac index (4.78± 1.13 L/min per m2 ), associated with a reduction in systemic vascular resistance index (1457 ± 380.7 dynes.s/cm 5 .m 2 ).The mean pulmonary artery pressure (18 ± 5.1 mmHg) as well as the right atrial pressure (7.9 ± 2.5 mmHg) were increased, while the pulmonary vascular resistance index (133 ± 62 dynes.s/cm 5 .m 2 ) was decreased.Four days after EGDS, a significant reduction in cardiac index (3.80 ± 0.4 L/min per m 2 , P < 0.001) and increase in systemic vascular resistance index (1901.4± 330.2 dynes.s/cm 5 .m 2 , P < 0.001) toward normal levels were observed.There was also a significant reduction in pulmonary artery pressure (12.65 ± 4.7 mmHg, P < 0.001) and no significant changes in the pulmonary vascular resistance index (141.6± 102.9 dynes.s/cm 5 .m 2 ).Four days after DSRS, a non-significant increase in cardiac index (5.2± 0.76 L/min per m 2 ) and systemic vascular resistance index (1389 ± 311 dynes.s/cm 5 .m 2 ) was observed.There was also a non-significant increase in pulmonary artery pressure (19.84 ± 5.2 mmHg), right cardiac work index (1.38 ± 0.4 kg.m/m 2 ) and right ventricular systolic work index (16.3± 6.3 g.m/m 2 ), without significant changes in the pulmonary vascular resistance index (139.7 ± 67.8 dynes.s/cm 5 .m 2 ). CONCLUSION:The hyperdynamic circulatory state observed in mansonic schistosomiasis was corrected by EGDS, but was maintained in patients who underwent DSRS.Similarly, the elevated mean pulmonary artery pressure was corrected after EGDS and maintained after DSRS.EGDS seems to be the most physiologic surgery for patients with schistosomal portal hypertension.
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