No description available.

The echocardiographic assessment of valvular heart diseases is the basic analysis of valvular defects next to clinical investigation and stethoscopy. Severity of mitral regurgitation (MR) is usually estimated by an integrated approach using semi quantitative parameters and is still one of the biggest challenges of echocardiography. Quantitative echocardiographic analysis of MR severity often fails to describe comprehensible hemodynamic conditions. However, comprehensive echocardiography based on standardized image acquisition and proper image quality is required to properly assess hemodynamic parameter comparable to cardiac magnetic resonance tomography. This review focuses on the uncertainty of MR severity assessed by echocardiography in recent trials of interventional MR treatment. In addition, the necessity to provide plausible echocardiographic data for individual decision making is highlighted. In conclusion, plausible functional diagnostics by rational echocardiography is a prerequisite in patients with valvular heart diseases.

Flow diversion (FD) is a novel endovascular technique based on the profound alteration of cerebrovascular hemodynamics, which emerged as a promising minimally invasive therapy for intracranial aneurysms. However, delayed post-procedural stroke remains an unexplained concern. A consistent follow-up-regimen has not yet been defined, but is required urgently to clarify the underlying cause of delayed ischemia. In the last two years, 223 patients were treated with six different FD devices in our center. We identified subacute, FD-induced segmental vasospasm (SV) in 36 patients as a yet unknown, delayed-type reaction potentially compromising brain perfusion to a critical level. Furthermore, 86% of all patients revealed significant SV approximately four weeks after treatment. In addition, 56% had SV with 25% stenosis, and 80% had additional neointimal hyperplasia. Only 13% exhibited SV-related high-grade stenosis. One of those suffered stroke due to prolonged SV, requiring neurocritical care and repeated intra-arterial (i.a.) biochemical angioplasty for seven days to prevent territorial infarction. Five patients suffered newly manifested, transient hemicrania accompanying a compensatorily increased ipsilateral leptomeningeal perfusion. One treated vessel obliterated permanently. Hence, FD-induced SV is a frequent vascular reaction after FD treatment, potentially causing symptomatic ischemia or even stroke, approximately one month post procedure. A specifically early follow-up-strategy must be applied to identify patients at risk for ischemia, requiring intensified monitoring and potentially anti-vasospastic treatment.

No description available.

Beneš J.: HEMODYNAMIKA V ČASNÉ FÁZI KRITICKÝCH STAVŮ A PERIOPERAČNÍ MEDICÍNĚ - Využití méně invazivních monitorovacích prostředků k cílené hemodynamické péči ABSTRACT Hemodynamic instability occurs very often in critically ill patients and during the perioperative period. Insufficiency in the preload, contractility and afterload contribute in major part to this phenomenon. Hemodynamic monitoring allows clinicians to recognize and to intervene early the underlying cause. Due to new technologies development in recent years it is possible to provide continuous monitoring of hemodynamic parameters with diminished invasivity. Hemodynamic optimization and goal directed therapy show treatment benefit in some groups of critically ill patients and mainly during the perioperative period. Aim of hemodynamic optimizations is to attain the best obtainable hemodynamic conditions with use of fluid loading and inotropic support. In many studies in recent years goal-directed therapy was associated with morbidity and mortality reduction. According to the results of our clinical research hemodynamic optimization using stroke volume variation and minimally invasive device based on the pressure wave analysis is feasible and show the same results as other works with more invasive devices. Key words Hemodynamic monitoring,...

Thesis (MMed (Obstetrics and Gynaecology))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: OBJECTIVE: The aim of this study was to compare the accuracy of non-invasive blood pressure measurements, using automated and manual devices, against invasive intra-arterial blood pressure measurements in patients with pre-eclampsia, during a hypertensive blood pressure peak. STUDY DESIGN: In this prospective study, women admitted to the Obstetrics Critical Care Unit, with confirmed pre-eclampsia and acute severe hypertension, who had an intra-arterial line in situ, were asked to participate. During an intra-arterial blood pressure peak, both an automated oscillometric and a blinded manual aneroid sphygmomanometric blood pressure was recorded. These two methods of blood pressure measurements were compared to intra-arterial blood pressure measurements. The accuracy of a mean arterial pressure (MAP) ≥ 125mmHg in detecting a systolic blood pressure (SBP) ≥ 160mmHg, using all three methods, was also determined. RESULTS: There was poor correlation between intra-arterial SBP and automated and manual SBP (r = 0.34, p < 0.01; r = 0.41, p < 0.01 respectively). The mean differences between automated and manual SBP compared to the intra-arterial SBP was 24 ± 17mmHg (p < 0.01) and 20 ± 15 mmHg (p < 0.01) respectively. There was better correlation between intra-arterial diastolic blood pressure (DBP) and automated and manual DBP (r = 0.61, p < 0.01; r = 0.59, p < 0.01 respectively). The mean differences of the automated and manual DBP was not statistically significant when compared to the intra-arterial DBP. There was poor correlation between the intra-arterial MAP and the automated MAP (r = 0.44, p < 0.01) and good correlation with the manual MAP (r = 0.56, p < 0.01). The mean differences of the automated and manual MAP were statistically significant (5 ± 13mmHg, p < 0.01; 8 ± 11mmHg, p < 0.01 respectively). The sensitivity of automated and manual methods in detecting a SBP ≥ 160mmHg was 23.4% and 37.5% respectively. A MAP ≥ 125mmHg in detecting a SBP ≥ 160mmHg, when using intra-arterial, automated and manual methods of blood pressure measurements showed low sensitivity (35.9%, 21.9% and 17.2% respectively). CONCLUSION: This study demonstrated that both the automated and manual methods of blood pressure measurements were not an accurate measure of the true systolic intra-arterial blood pressure, when managing pre-eclamptic patients with acute severe hypertension. In such situations, intra-arterial blood pressure monitoring should be used when possible. When this is not possible, manual aneroid sphygmomanometry is recommended. Underestimating blood pressure, particularly SBP, may lead to severe maternal morbidity and mortality. / AFRIKAANSE OPSOMMING: DOELWIT: Die doel van hierdie studie is om die akuraatheid van nie invasiewe bloeddruk metings, wanneer geneem met outomatiese en manuele aparate, te vergelyk met intra-arteriele bloed druk metings in pasiente met pre-eklampsie, gedurende ‘n hipertensiewe bloeddruk piek. STUDIE ONTWERP: In hierdie prospektiewe beskrywende dwarssnit studie, was pasiente wat toegelaat was tot die Obstetriese Kritieke Sorg Eenheid met pre-eklampsie, akute erge hipertensie en ‘n intra-arteriele lyn in situ gevra om deel te neem. Gedurende ‘n intra-arteriele erge hipertensiewe piek is beide die outomatiese ossilometriese en die geblinde aneroide sfigmometer lesing neergeskryf. Hierdie twee metodes van non invasiewe bloed druk lesings is vergelyk met intra-arteriele bloed druk lesings. Die akuraatheid van ‘n gemiddelde arteriele bloeddruk ≥ 125mmHg om ‘n sistoliese bloeddruk ≥ 160mmHg op te tel met gebruik van al die drie metodes is ook uitgewerk. RESULTATE: Daar was swak korrelasie tussen intra-arteriele sistoliese bloed druk (SBD) metings en outomatiese en manuele SBD (r = 0.34, p < 0.01; r = 0.41, p < 0.01 onderskeidelik). Die gemiddelde verskille tussen outomatiese en manuele SBD wanneer vergelyk met intra-arteriele SBD was 24 ± 17mmHg (p < 0.01) en 20 ± 15 mmHg (p < 0.01) onderskeidelik. Beter korrelasie was gevind tussen intra-arteriele diastoliese bloed druk (DBD) en outomatiese en manuele DBD (r = 0.61, p < 0.01; r = 0.59, p < 0.01 onderskeidelik). Die gemiddelde verskille tussen outomatiese en manuele DBD wanneer dit vergelyk was met intra-arteriele DBD was nie statisties betekenisvol nie. Daar was swak korrelasie tussen intra arteriele gemiddelde arteriele bloeddruk en outomatiese gemiddelde arteriele bloeddruk (r = 0.44, p < 0.01) en beter korrelasie met manuele gemiddelde arteriele bloeddruk (r = 0.56, p < 0.01). Die gemiddelde verskille van outomatiese en manuele gemiddelde arteriele bloeddruk was betekenisvol (5 ± 13mmHg, p < 0.01; 8 ± 11mmHg, p < 0.01 onderskeidelik). Die sensitiwiteit van outomatiese en manuele metodes om ‘n intra-arteriele SBD ≥ 160mmHg op te tel was 23.4% en 37.5% onderskeidelik. Die vermoë van ‘n gemiddelde arteriele bloeddruk ≥ 125mmHg om ‘n SBD ≥ 160mmHg op te tel, gemeet deur intra-arterieel, outomatiese en manuele metodes het lae sensitiwiteit getoon (35.9%, 21.9% en 17.2% onderskeidelik). GEVOLGTREKKING: Hierdie studie het gedemonstreer dat outomatiese en manuele metodes van bloeddruk meting nie akurate metodes is om ware intra-arteriele sistoliese bloeddruk te meet in pasiente met erge pre-eklampsie tydens ‘n erge hipertensiewe episode nie. In hierdie omstandighede moet intra-arteriele bloeddruk gemeet word indien beskikbaar. Indien dit nie beskikbaar is nie moet die manuele aneroiede sfigmomanometer gebruik word. Onderskatting van bloeddruk, veral sistoliese bloeddruk, kan lei tot erge moederlike morbiditeit en mortaliteit.

Résumé : Les réanimateurs ont recours à des interventions à la fois médicales et chirurgicales en contexte de choc traumatique. Le rôle des vasopresseurs dans cette prise en charge est controversé. Alors que les lignes directrices américaines considèrent que les vasopresseurs sont contre-indiqués, certains experts européens en encouragent l’utilisation pour diminuer le recours aux liquides intraveineux. Avant d’élaborer un essai clinique, il importe de comprendre la pratique actuelle à laquelle se comparera une intervention expérimentale, ainsi que de connaître le niveau d’incertitude dans la littérature entourant la question de recherche. Le Chapitre 2 de ce travail présente une étude observationnelle effectuée dans un centre régional de traumatologie québécois. Cette étude documente les pratiques de réanimation adoptées par les équipes de traumatologie en 2013, particulièrement le recours aux liquides intraveineux et aux vasopresseurs. Les résultats démontrent que les vasopresseurs ont été utilisés chez plus de 40% des patients, particulièrement les victimes de traumatismes crâniens (RC 10.2, IC 95% 2.7-38.5). De plus, les vasopresseurs ont été administrés dans les phases précoces de la réanimation, soit avant l’administration d’un volume important de liquides. Le Chapitre 3 présente une revue systématique portant sur l’utilisation précoce de vasopresseurs en traumatologie. Les bases de données MEDLINE, EMBASE, CENTRAL et ClinicalTrials.gov ont été interrogées, ainsi que les abrégés présentés dans les conférences majeures en traumatologie depuis 2005. La sélection des études et l’extraction des données ont été effectuées en duplicata. Aucune donnée interprétable n’a pu être extraite des études observationnelles et le seul essai clinique identifié n’avait pas une puissance suffisante (RR de mortalité avec vasopresseurs 1.24, IC 95 % 0.64-2.43). Cette synthèse met en lumière l’incertitude scientifique sur le rôle des vasopresseurs en traumatologie. Les vasopresseurs ont des bénéfices potentiels importants, puisqu’ils permettent entre autres de supporter étroitement l’hémodynamie des patients. En revanche, ils présentent aussi un fort potentiel de dangerosité. Ils sont utilisés fréquemment, malgré l’absence de données sur leurs risques et bénéfices. Ces trouvailles établissent clairement la pertinence clinique et le bien-fondé éthique d’un essai clinique sur le rôle des vasopresseurs dans la prise en charge précoce des victimes de traumatismes. / Abstract : Trauma teams often make use of both medical and surgical interventions in the early management of traumatic shock. Vasopressors have an important clinical potential, namely because they allow fluid restriction and narrow hemodynamic support. However, they also have the potential for significant harm. The role of vasopressors in this early phase of care is controversial. Although North American guidelines consider that vasopressors are contraindicated in this clinical setting, some European experts encourage their use in the hopes of reducing intravenous fluid administration and its inherent risks. Before designing an adequate clinical trial on vasopressor use, a number of vital questions must be answered. First, current accepted practice must be described in order to determine how it will compare with an eventual experimental intervention. Second, relevant knowledge gaps in the scientific literature must be identified in order to establish equipoise and refine the research question. Chapter 2 of this document presents an observational study conducted in a regional trauma centre in the province of Québec. This retrospective study documents current practice patterns adopted by trauma teams over the course of 2013, with particular emphasis on vasopressor and intravenous fluid use. Over this timeframe, more than 40 % of patients received vasopressors, most often in the presence of traumatic brain injury (OR 10.2, 95% CI 2.7-38.5). Moreover, these vasopressors were often administered in the very early phases of trauma care, before any significant intravenous fluid loading. Chapter 3 consists of a systematic review on the early use of vasopressors in the management of traumatic shock. MEDLINE, EMBASE, CENTRAL and ClinicalTrials.gov were searched, as well as conference proceedings from major trauma meetings since 2005. Independent reviewers completed study selection and data extraction in duplicate. Observational studies yielded no interpretable data, and the only clinical trial addressing the research question had insufficient power to inform clinical practice (RR of death with vasopressor use 1.24, 95% CI 0.64-2.43). This knowledge synthesis highlights the uncertainty surrounding the role of vasopressors in trauma. Trauma teams routinely make use of vasopressors despite the absence of data on their risks and benefits. These findings clearly establish both the clinical impetus and ethical justification for a clinical trial focusing on the early use of vasopressors in the management of traumatic shock.

Dans le but de mieux comprendre le rôle et le fonctionnement des régions cérébrales impliquées dans le traitement et la modulation de la perception douloureuse, la première partie de cette thèse s’intéresse à l’évaluation en IRMf des modifications de la réponse cérébrale à la douleur grâce à deux modulations de la perception douloureuse. La première s’intéresse à l’effet d’un contexte émotionnel négatif sur la perception douloureuse afin de dissocier des aires cérébrales répondant à la douleur, les réponses liées à la composante émotionnelle. La deuxième s’intéresse à l’effet d’une manipulation de l’appréciation de la durée d’une stimulation douloureuse sur la perception de la douleur. L’utilisation d’une illusion permet, pour une intensité de stimulation thermique donnée, de modifier la perception douloureuse et d’évaluer les zones cérébrales impliquées dans ce type de modulation. Nous avons modulé la douleur perçue et pu observer que l’émotion met en jeu la partie prégénuale du cortex cingulaire antérieur, tandis que l’illusion d’une durée raccourcie met en jeu un réseau occipito-pariétal attentionnel. La seconde partie de cette thèse s’intéresse à la caractérisation du décours temporel de la réponse hémodynamique dans deux régions importantes pour le traitement de l’information douloureuse qui sont l’insula et le cortex cingulaire. La douleur est caractérisée par une latence de la réponse plus courte, par rapport à une stimulation non-douloureuse, dans l’insula antérieure et le cortex cingulaire moyen, tandis qu’il est possible de différencier une stimulation douloureuse d’une stimulation non-douloureuse grâce à l’amplitude de la réponse dans l’insula postérieure. / Pain is a complex and multidimensional experience that can be modulated by many factors. In order to better understand the respective role and function of the brain regions involved in the processing and the modulation of pain perception, the first part of this thesis focuses on the evaluation with functional magnetic resonance imaging (fMRI) of changes in the brain response to pain through two modulations of pain perception. The first study examines the effect of a negative emotional context on pain perception in order to dissociate the brain areas responding to pain from that related to the emotional context. The second study focuses on the effect of the manipulation of perceived duration of a painful stimulation on the perception of pain. The use of this illusion allows us to change the perceived intensity of pain and to assess the brain areas involved in this type of modulation at given intensity of thermal stimulation. We succeeded to increase or decrease perceived pain intensity and we observed that emotion involves pregenual part of the anterior cingulate cortex, while the illusion of a shortened duration involves an occipito-parietal attentional network. The second part of this thesis focuses on characterizing the time course of the hemodynamic response recorded with fMRI in two important areas processing pain that are the insula and the cingulate cortex. Painful sensation is characterized by a shortened latency of hemodynamic response compared to a non-painful sensation in the anterior insula and the midcingulate cortex, while it is possible to differentiate painful and non-painful sensation by the amplitude of the hemodynamic response in the posterior insula.

Introdução: Os anestésicos inalatórios empregados atualmente na prática clinica (isoflurano, sevoflurano e desflurano) possuem propriedades farmacocinéticas que favorecem rápida recuperação da anestesia, porém seu uso pode causar instabilidade hemodinâmica dose-dependente, relacionado à depressão direta da contratilidade miocárdica ou à hipovolemia relativa, derivado de um sequestro de sangue devido à vasodilatação do leito vascular periférico. Este estudo visa avaliar o comportamento da VPP durante a anestesia inalatória. Para tanto se utilizou três diferentes agentes inalatórios (isoflurano, sevoflurano e desflurano) em diferentes concentrações inaladas. Métodos: Foram utilizados 25 suínos divididos aleatoriamente em três grupos. Os animais foram submetidos à anestesia com o anestésico do respectivo grupo. Imediatamente após a determinação da CAM individual do agente inalatório em cada animal, ocorreu a primeira coleta de dados. O animal foi, então, exposto a diferentes níveis de CAM (1,0 CAM; 1,25 CAM) seguido por uma exposição decrescente de CAM (1,0 CAM); provocou-se então uma hemorragia correspondente a 30% da volemia e exposição a dois níveis de CAM (1,0 e 1,25), com 20 minutos em cada exposição. Ao final de cada período os valores ecocardiográficos e do VPP foram mensurados. A análise estatística foi realizada através de provas paramétricas empregando-se o método de comparações múltiplas para análise de variância com medidas repetidas (ANOVA). O grau de significância foi de 5% (p < 0,05). Resultados: Há aumento na variação de pressão de pulso com incremento de 25% na CAM dos anestésicos inalatórios (de 8±1 para 11±3% no grupo DESF, de 7±2 para 9±2 no grupo SEVO e de 9±4 para 10±3% no grupo ISO) sem diferença estatística entre os anestésicos. Apesar deste aumento na CAM e significativa hipotensão e queda no débito cardíaco, o aumento na VPP não torna o paciente responsivo a infusão de fluidos (o VPP permaneceu abaixo de 13%). Há pequena queda na PAM quando se eleva a CAM dos anestésicos em 25%, porém só há queda estatisticamente significativa no grupo DESF (de 84±7 para 68±12 mmHg). Não foram observadas alterações importantes em relação à contratilidade miocárdica. Conclusão: Observou-se que a VPP não é influenciada como o uso dos diferentes anestésicos inalatórios e apesar dos efeitos cardiovasculares esperados destes agentes, mantem-se a capacidade de demonstrar alterações de pré-carga mesmo em concentrações correspondentes a 1,25 CAM / Background: Inhalant anesthetics, such as isoflurane, sevoflurane and desflurane are widely used in daily clinical practice due to its pharmacological properties allowing a rapid recovery from anesthesia. Nevertheless, its use can lead to dose-dependent hemodynamic instability related to direct depression in myocardial contractility or to a relative hypovolemia caused by vasodilation of peripheral capillary bed. This study aims to evaluate the behavior of PPV during inhalant anesthesia. For this, three different anesthetics were used (isoflurane, sevoflurane and desflurane) with different inhaled concentrations. Methods: 25 young pigs were randomly assigned into three groups. Animals were anesthetized with its correspondent agent according to its group. After individual determination of minimal alveolar concentration (MAC), first data collection occurred. Pigs were then exposed to different MAC (1MAC and 1,25 MAC) followed by a decrease in MAC (1 MAC). At this point a 30% of estimated volemia hemorrhage was caused and pigs were exposed to a period of 1 MAC and after that 1,25 MAC. Each period lasted 20 minutes. At the end of each period, hemodynamic parameters and echocardiography were collected. Data were submitted to analysis of variance for repeated measures (ANOVA). P<0,05 was considered statistically significant. Results: There was an increase in PPV when with 1,25 MAC of all anesthetics. (from 8±1 to 11±3% in group DESF, from 7±2 to 9±2 in group SEVO and from 9±4 to 10±3% in group ISO), but without statistical difference among groups. Although there was an increase in PPV, followed by hypotension and drop in cardiac index, patients werent fluid responsive with a 25% increase in MAC, since PPV was lower than 13%. The decrease in blood pressure followed by 1,25MAC was only significant in DESF group (from 84±7 to 68±12 mmHg). No important alterations related to myocardial contractility were observed. Conclusion: PPV is not influenced by the use of different inhalant anesthetics and although there are cardiovascular effects of these agents which are expected, and were able to demonstrate alterations in preload even in concentration of 1,25 MAC

Ziel der vorliegenden Arbeit war es, die Blutdruckregulation und die hormonelle Stressantwort unter Kombinationsanästhesie mit der unter Allgemeinanästhesie zu vergleichen. Methoden: 49 Patienten ohne kardiovaskuläre Vorerkrankungen wurden zufällig 2 Gruppen zugeordnet: 25 Patienten erhielten eine Kombination aus volatiler (Isofluran in Luft/Sauerstoff) und thorakaler epiduraler Anästhesie (CA-Gruppe). 24 Patienten erhielten eine balancierte Anästhesie (Isofluran in Luft/Sauerstoff und Fentanyl i.v. nach Bedarf) (BA-Gruppe). In beiden Gruppe wurde die Anästhesietiefe mittels Bispectral Index überwacht (Zielwert: 40-50). Die Blutentnahmen für die Bestimmung der Hormon-Plasmaspiegel erfolgten jeweils vor Narkoseeinleitung, 30 min vor Hautschnitt und 40 min nach Hautschnitt. Zeitverläufe wurden mit Hilfe der GLM-ANOVA Varianzanalyse, Einzelwerte mit einem t-Test für unabhängige Stichproben verglichen (p / Objective: To study whether there are differences regarding blood pressure regulation and hormonal response in patients receiving combined anesthesia (thoracic epidural and general anesthesia) or general anesthesia alone. Methods: 49 patients without cardiovascular diseases, scheduled for abdominal surgery, were randomly assigned to 2 groups: 25 patients received a combination of volatile anesthesia (isoflurane in oxygen/air) and thoracic epidural anesthesia (CA group); 24 patients had a balanced anesthesia (isoflurane in oxygen/air plus fentanyl i.v. as required) (BA group). In both groups, depth of anesthesia was controlled by Bispectral Index (target 40-50). Blood samples for plasma hormonal measurements were drawn before induction of anesthesia, 30 min before incision and 40 min after incision. Longitudinal data were analysed using GLM-ANOVA, and single parameters by independent samples t-test (p