Topic Speaker

Anaesthesia for remote location- CT/ MRI/ Chhavi Sawhney

Endoscopy/ MECT
Management of chronic Pain syndromes GP Dureja
(CRPS, LBA, Cancer Pain)
Basics of Invasive hemodynamic monitoring Aveek Jayant
Basics of TEE Vishwas Malik
Acromegaly/Cushing for Transnasal trans- Prasanna Bidkar
spheroidal Surgery
Craniotomy for aneurysm surgery and brain Keshav Goyal
tumor
Diagnosis of Brain Death and management Girija P Rath
of deceased organ donor
Ankylosing Spondylosis for total hip MK Arora
replacement – Case
Massive blood loss and massive transfusion Rajiv Chawla
Elderly man for TURP/ TURBT – Case Preethy Mathew

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THREE STEP APPROACH

ANAESTHESIA FOR REMOTE LOCATIONS
– CT/MRI/ENDOSCOPY/MECT PATIENT

DR CHHAVI SAWHNEY
PROFESSOR ANAESTHESIOLOGIST
DEPARTMENT OF ANAESTHESIOLOGY
JPNATC, AIIMS
NEW DELHI
PROCEDURE ENVIRONMENT

PATIENT FACTORS PROCEDURES

• Children ,especially less than 10 years • Radiologic imaging- CT/MRI/PET
• Claustrophobia, anxiety, panic disorders • Interventional Radiology- Vascular imaging,
• Seizures, movement disorders or muscular stenting, embolization, RFA, TIPS
contractures • Interventional Cardiology- cardiac
• Pain, related to procedure or other causes catheterisation, PCI, CAD plcement
• Acute trauma with unstable CVS, respiratory • Interventional Gastroenterology- Endoscopy,
or neurologic dysfunction ERCP, Colonoscopy
• Significant comorbidity and patient fraility • Psychiatry- ECT

SAFETY OF ANAESTHESIA AT REMOTE LOCATIONS: US CLOSED

PROCEDURES CLAIM ANALYSIS

Nature of Procedure

Patient Position Duration of Procedure

Pain during Procedure

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ASA STANDARDS FOR NORA ASA STANDARDS FOR NORA

• Oxygen- Reliable source with backup • Resuscitation equipment- defibrillator,
• Suction source- Adequate and reliable emergency drugs and equipment
• Adequate monitors • Adequate illumination- Patient, machine &
• Sufficient safe electrical outlets battery-powered backup
• Sufficient space and easy access to patient, • Trained staff for reliable communication
machine and monitoring equipment • Postanaesthesia care facilities- staff, safe
• Anaesthesia equipment- Anaesthesia machine transport to main PACU
Adequate drugs • Scavenging system

MONITORING FACILITIES AND EQUIPMENT

• Anaesthesia personnel • Gas pipeline, suction- gas cylinder supply for
• Continuous display of ECG anaesthesia machine
• NIBP-minimum 5 minutes interval • Anaesthesia machine- Essential safety features
• Pulse oximetry • Check- Maintained and serviced
• Continuous end-tidal carbon dioxide monitoring • Must be familiar with machine operation
• Mechanical ventilation- disconnection alarm • Must perform machine checks before starting
• Oxygen concentration of inspired gas with low
concentration alarm

MEDICATIONS LEVELS OF SEDATION/ANALGESIA

MINIMAL MODERATE DEEP GENERAL
Anaesthesia techniques used in NORA locations: SEDATION SEDATION/ANALGESIA( SEDATION/A ANAESTHESIA
(ANXIOLYSIS) CONSCIOUS SEDATION) NALGESIA
• No anaesthesia-minimal, moderate or deep
sedation/analgesia- General anaesthesia RESPOSIVENESS Normal Purposeful response to Purposeful Unarousable,
response to verbal or tactile response even with
Anaesthesia care depends upon: verbal stimulation after painful stimulus
stimulation repeated or
• Desired level of anaesthesia painful
stimulation
• Underlying medical condition AIRWAY Unaffected No intervention required Intervention Intervention
may be often required
• Procedure to be performed required
SPONTANEOUS Unaffected Adequate May be Frequently
VENTILATION inadequate inadequate
CV FUNCTION Unaffected Usually maintained Usually May be impaired
maintained

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MEDICATIONS ENVIRONMENT
• Combination of sedative (benzodiazepines) Occupational exposure- Ionising radiation and
and analgesic (opioids) medications – effective radiation safety issues-
moderate sedation - Limiting time of exposure
• Barbiturates/ - Increasing distance from source of radiation
propofol/Ketamine/Dexmedetomidine –
- Using protective shielding ( lead lined
Boluses & infusions
garments, fixed and movable shields)
• Carefully titrated
- Using dosimeters
• Oral premedication-
50mSv- maximum annual occupational dose
• Maintain intravenous access

ENVIRONMENT CONTRAST INDUCED NEPHROPATHY

Allergic Reactions-Radiologic and MRI contrast • Incidence 7-15%

agents • Increase in serum creatinine of 0.5mg/dl or 25%
increase from baseline within 24 hours
• Radiologic agents- Iodinated- osmolarity and
• Peak- 5 days
ionicity
• Risk factors- H/o renal disease, prior renal
• MRI agents-chelated metal complexes- surgery, proteinuria, DM, Hypertension, Gout,
Gadolinium,iron,manganese-ionic & nonionic Nephrotoxic drugs, metformin
• Adverse effects- Renal and Hypersensitivity • Prevention - adequate hydration and urine
output, NaHCO3

HYPERSENSITIVITY REACTIONS COMPUTED TOMOGRAPHY

• Anaphylactoid reactions-More common after • Painless, noninvasive, short duration procedure
iodinated contrast agents than gadolinium Indications
contrast agents Acute-
• Mild (0.5-3%)/ Moderate/ Severe(0.01-0.04%) • Trauma,
• Stroke
• Prophylaxis- Steroids, Antihistamines
Assessment of expanding intracranial masses
• Management- Discontinue agent and
Invasive procedures- Abscess localization &
supportive therapy- oxygen, securing airway, drainage, RFA, Ablation of bony metastasis
fluids, vasopressors, brochodilators

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COMPUTED TOMOGRAPHY COMPUTED TOMOGRAPHY

Issues • Premedication with oral chloral hydrate
• Airway management and adequate (50mg/kg) in children
oxygenation • Oral midazolam( 0.25-0.75mg/kg) at least 30
• Inaccessibility of patient minutes prior
• Monitor disconnection and kinking of tubes • Intravenous sedation- Ketamine,
• CECT-Oral contrast- Aspiration dexmedetomidine
• Resuscitation and stabilization before shifting • Another technique for healthy
neonates,”Wrap and scan”

MAGNETIC RESONANCE IMAGING MAGNETIC RESONANCE IMAGING

• Noninvasive, does not produce ionizing • Dislodgement and malfunction of implanted biologic
radiation devices
Limitations • Device safety to be confirmed before MRI
• Time consuming Projectile injuries
• Motion- Artifacts on image • Large,rapid movement of iron containing items in
• High level acoustic noise vicinity of magnetic field)
• Risk of thermal injury • Compatible monitoring equipment, infusion pumps
• Effect of magnet on ferrous objects Limited patient access and visibility

MAGNETIC RESONANCE IMAGING MAGNETIC RESONANCE IMAGING

Preoperative checklist – • Electrocardiography-
• Deep sedation/ Analgesia not advisable T- and ST- wave abnormalities, Thermal injury
ECG wires- straight and minimum contact
• No specific anaesthesia technique
• Pulse oximetry-
• General anaesthesia with airway control using
“Antenna effect” leading to thermal injury-
laryngeal mask airway/ Endotracheal fiberoptic signal linking
intubation • Capnography- Delay in signal transduction
• Paediatric patients- General anaesthesia • Noninvasive Blood Pressure- Connections of BP
cuff and hoses are plastic

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ELECTROCONVULSIVE THERAPY ELECTROCONVULSIVE THERAPY

Physiologic response to ECT : Preoperative evaluation
Generalised motor seizures ( >20 seconds) and acute
cardiovascular response ( short duration)
• Current medications- Antidepressant medications
Anaesthetic management Goals Anaesthesia Technique:
• Amnesia • Monitoring
• Airway management • Pre-oxygenation
• Prevention of seizure related injuries
• Induction- Propofol (1-1.5mg/kg) or Etomidate
• Control of haemodynamic responses
(0.15-0.30mg/kg)
• Smooth, rapid emergence
• Muscle relaxation- succinylcholine (0.5-1mg/kg)
• Supplemental oxygen and bite block

ELECTROCONVULSIVE THERAPY ENDOSCOPY

Post ECT Indications
• Diagnostic & Therapeutic
• Oxygenation
Issues
• Recovery position
• Comorbidities
• Monitored till discharge criteria are met • Risk of GER,hepatic
Recording- dysfunction, ascites,
coagulopathy
Patient’s condition, responses- extra precautions • Local anaesthetic spray-
can be taken during subsequent treatments Abolish gag reflex-
aspiration
A Panoramic face mask B Endoscopic mask C DSEAS mask

ENDOSCOPY ENDOSCOPY
• Position- Prone or semi prone Anaesthesia Technique
• Hypoxemia-Prevention and Management • Fentanyl (0.5-1mcg/kg)-Propofol (1-1.5mg/kg)
Increasing supplemental oxygen, Propofol infusion ( 120-150mcg/kg/min)-
nasopharyngeal airway, Airway manoeuvers Nasopharyngeal airway-Endoscope
(chin lift, jaw thrust), endoscope removal, • Dexmedetomidine infusion (0.5-1mcg/kg)
positive pressure ventilation, LMA or ETT over 10 min – 0.2-0.7 mcg/kg/h
insertion, if required
• Careful titration
• Bite blocks

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THANK YOU

6
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Concept of Pain & its Treatment

Management Of Chronic
The development of the
Pain concept of pain and its treatment
CRPS,Back Pain,Cancer Pain
constitutes one of the most interesting
Dr.(Prof).G.P Dureja and fascinating chapters in the
Director,
Delhi Pain Management Centre
history of medicine.

Pain is as old as
mankind…
PAIN
The word pain was attested
in English for the first time
in 1297. It is derived from
...yet it is the Greek word ποινή
still (poena) which means
mysterious "penalty" or "punishment"

Definition of Pain (IASP 1994) Chronic Pain Is a Disease

An unpleasant sensory and emotional experience associated

with actual or potential tissue damage, or described in ‘Persistent chronic pain should be considered as a disease
terms of such damage state of the nervous system, not merely a symptom of some
other disease conditions’
§ Pain is associated with injury and "threat" of injury WHO 2005
§ It is an "unpleasant" and "emotional" experience
§ It is "subjective“

International Association for the Study of Pain, 1994

www.painhospital.in

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Pain 2018: Towards a New Classification

Physiological Inflammatory Neuropathic Dysfunctional

Pain Pain Pain Pain

Nociceptive Inflammatory Nerve Fibromyalgia

stimulus lesion lesion
(OA, (diabetes, IBS
spondylitis, PHN, CRPS 1
infection) radiculopathy, Myofascial Pain
trauma)

Pain Management Today Evolution of Pain Medicine as a super speciality

Contemporary pain medicine is a multimodality

• Definite need for specialized Pain Clinics/Pain
and multidisciplinary field. Many of the current Management Centres providing a holistic approach
ideas and styles of practice that influence the to Pain Management
specialty today can be traced back to John
Bonica, M.D., and his model of pain management
• Tremendous scope for basic research, clinical
introduced more than 50 years ago research and trial of newer pharmacological agents

• Comprehensive diagnostic and therapeutic care

provided to patients with chronic Pain

Global Prevalence of Chronic Pain Prevalence of Chronic Pain in India

• 20-25% of 1.30 Billion population in India is

30%
26% suffering from Chronic pain ( back pain, arthritis,
25% musculoskeletal pain , neuropathic pain and
20%
cancer related pain )

15%

10% 7% 6%
5%
0.4%
0%
Pain Diabetes Coronary Heart Cancer
Disease & Stroke

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Multimodality Approach
as a basis of Pain Management

A multimodality approach to chronic pain includes a combination of

therapies selected from eight broad categories:

• Drug therapies
• Psychological therapies
• Rehabilitative therapies
• Neurolytic blocks and Spinal interventions
• Neurostimulatory therapies (Intrathecal pumps and Spinal
Cord stimulators)

Management of Chronic Pain • Surgical therapies

• Lifestyle changes
• Complementary and Alternative medicine therapies

Interventional Pain Management

Interventions under CT Guidance/Fluroscopy

Interventional Pain Management: It is the discipline of

medicine devoted to the diagnosis and treatment of pain-
related disorders principally with the application of
interventional techniques
Important Component of a Pain clinic and regular
upgradation of technology is mandatory

Ultrasound Guidance in Pain Interventions Radiofrequency Ablation of Neural Structures

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Trigeminal Ganglion RF Ablation Cooled RF for Genicular Nerves and Medial Branch Ablation

Advanced Interventions Challenge of Back Pain

Kyphoplasty in a patient with # Vertebra due to osteoporosis

• Back pain remains a challenging issue for

pain clinicians

• Peaks at 55 to 64 years of age; affects all

ages

• The most common cause of activity

limitations in persons <45 years of age
• More disability than cancer + heart disease + stroke +
AIDS

Challenge of Back Pain Back Pain

Major Concerns Important Issues :

• Increased utilization of imaging studies
• How to diagnose the cause of Back Pain
• Increased incidence of back surgery • Conservative approach in managing Back Pain:
• Increased use of spinal injections How long?
• Increased prescription of opioids • Type of Spinal Interventional techniques to be
used
• Increased costs for LBP • When to operate?
• No decrease in disability • How to rehabilitate the Back Pain Patient

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ACP and APS Guidelines on low Types of Back Pain

back pain
• Chronic axial LBP
– pain does not extend beyond mid-buttock
Categorises LBP into 3 categories:
– absence of radicular pain or sensory symptoms below
• Nonspecific low back pain- 85% of patients,where the knee
no cause can be found
• Chronic axial LBP with radiation
– pain with radiation beyond mid-buttock
• Specific Back Pain :Back pain associated with spinal – absence of radicular pain or sensory symptoms below
conditions e.g spinal stenosis, intervertebral disc the knee
prolapse, sciatica & vertebral compression • Chronic axial LBP with radicular component
fracture,cancer.(15%)
– radicular pain or sensory symptoms below the knee
October 2, 2007 Ann Intern Med. 2007;147:478-491.

Challenge of back Pain and

Challenge of Back Pain
Evidence based Medicine

Is Acute and Chronic Back Pain a

Simple Nociceptive/Inflammatory
Pain ?

27 28

Back Pain Sources of Back Pain

• Heterogeneous disorder • Damage to several structures

• “Mixed type of pain” in the low back can result in
• Nociceptive, neuropathic or central sensitization severe pain
– vertebrae
type of pain
– thoracolumbar fascia
• For efficient treatment of back pain in daily clinical – ligaments
practice it is very important for us to categorize – joints
this pain – specifically sacroiliac joint
– discs
– muscle

Ni js J, et al . P ai n P hysi ci an . 2 015 :18:E3 33 -E34 6. 29 Deyo RA, Weinstein JN. N Engl J Med. 2001;344:363-370.

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Management of Back Pain

Algorithmic Approach in Managing

Back Pain

• Appropriate History Taking

• Detailed Neurological Examination
• Appropriate Imaging
• Decision Making in the management of Back Pain
• Diagnostic and therapeutic approach to clinical
management
• Appropriate Rehabilitation

33

Neurologic Exam Determines

Presence/Absence and Level of Radiculopathy MRI of LS Spine

The exam should include

• Motor elements • Autonomic elements
– muscle bulk/tone – limb temperature
• atrophy/flaccidity
– sweating
– muscle strength
– hair/nail growth
– coordination
– skin color changes
– gait
• Sensory elements • Deep tendon reflexes
– sensory deficits, eg, touch,
position sense, temperature,
vibration
– allodynia: light touch
– hyperalgesia: single or multiple
pinpricks

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Therapeutic Recommendations for

Managing Back/Leg Pain Management of Back Pain

Non-specific Neck/Low Back Pain Radicular Pain

• Acetaminophen If radicular pain is prominent consider
• nsNSAIDs/coxibs addition of:
• Co-prescribe PPI for patients aged >45 • α 2 δ ligands like pregabalin

Acute
years • TCAs
• Weak opioids
• Muscle relaxants

• Cognitive behavioral therapy

Chronic
• Complex pharmacological management,
including opioids and neuropathic pain medications
• Consider interventional pain therapies
• Consider surgery

C o xi b , C OX-2 -speci fi c i nhi b ito r; n sNSAID , n on -sel ecti ve n on -stero id al an ti -in flammato ry d ru g; PP I, pro ton p ump in hi bi tor; TC A, tricycl i c an tid ep ressan t
Ad ap ted fro m: Lee J, et al . Br J An aesth . 2 01 3;11 1:11 2-20 . 38

Invasive Modalities for Back Pain Transforaminal Epidural Interventions

Management
• Facet block and denervation (Radiofrequency
lesioning)
• Interlaminar/Caudal Epidurals have no role
• Epidural steroids / Opioids / adjuvants • Transforaminal Epidurals are Preferred in
• Root Sleeve Injections Radicular Pain
• Vertebroplasty/Kyphoplasty • Instillation of Drug at the site of
• Ozone Discectomy inflammation (Targetted)
• RF Annuloplasty
• Can be used for adhesiolysis in canal/recess
• Nucleotome nucleoplasty
stenosis too.
• S I Joint injection/denervation (RF)
• Dorsal column stimulation(SCS) • Lesser dose of drugs required by this
approach

Epidural Steroids : Evidence Rating

42

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Complex Regional Pain Syndrome A tribute to Prof Sudeck !!

Paul Sudeck
• In early 19th Century
Suggested that the signs
and symptoms of RSD
may be caused by an
exaggerated
inflammatory response
to injury or operation of
an extremity.
• Sudeck’s Atrophy: Bone
loss associated with RSD

Complex Regional Pain Syndrome CRPS : Diagnosis

• CRPS is characterised by a typical clinical • The diagnosis of CRPS is made clinically using the
constellation of pain, sensory, autonomic, motor, diagnostic criteria of the “IASP”.
or trophic symptoms which can no longer be
explained by the initial trauma. • CRPS type I, without obvious nerve lesion
• CRPS type II, with verifiable nerve lesion.
• These symptoms spread distally and are not
• At first presentation, approximately 70% of patients
limited to innervation territories.
report about a “primarily warm” subtype with an
increased skin temperature at symptom onset, whereas
the remaining 30% report a “primarily cold” subtype.

Complex Regional Pain Syndrome Type I CRPS Type II Causalgia

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Severe Allodynia & Hyperalgesia Triphasic Bone scan and X Ray

50

Complex Regional Pain Syndrome :

Management of CRPS
Pathophysiology

• In the initial phase, the pathophysiology is Because of the various constellations in CRPS pathophysiology,
the following basic therapeutic principles have evolved:
dominated by a posttraumatic inflammatory
reaction by the activation of the innate and • Medical and nonmedical pain therapy (acute and chronic phases)
• Physiotherapy, occupational therapy and training therapy
adaptive immune system.
(acute and chronic phases)
• Anti-inflammatory therapy (acute phase)
• Psycho- and sociotherapy in a multimodal treatment setting
• In particular, without adequate treatment, central especially targeting pain-related fears; all phases if necessary)
nociceptive sensitization, reorganisation, and • A limited number of sympathetic nerve blocks (in selected cases
after successful test blocks)
implicit learning processes develop, whereas the • Therapy of dystonia (Botox)
inflammation moderates.

Sympathetically maintained Pain

Stellate Ganglion Block
Role of sympathetic blocks

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Other Medications

• Tricyclics-Effective for a variety of neuropathies

• Sodium channel blockers-IV lidocaine, Lidoderm,

mexilitene, lamotrigine.
Important Role of Pain Clinics
• Calcitonin (intranasal)-Effective in acute stage.
in Managing Cancer Pain
• Gabapentin and Pregabalin

• Nifedipine orally

Cancer Pain is a Major cause of intractable Chronic pain and Suffering Can we improve her Quality of Life ?
YES We Can

Management Of Cancer Pain Opioids in Cancer Pain

Comprehensive Pain and Palliative Care Use Narcotics as a part of Total Pain Treatment

Opioids play a very important Role

• They are the pillars around which other
modalities revolve

• Oral Morphine,Codeine,Tramadol,Ta pentadol,

Fentanyl Patches,Buprenorphine patches
Intrathecal Morphine through programmable
drug delivery systems/Epidural Morphine

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WHO Three Step ladder Regime(MODIFIED) for

Cancer Pain Management Interventions for Cancer Pain
Management

Most useful interventions are:

• Coeliac Plexus Block with alcohol
• Superior/inferior hypogastric plexus block
• Epidural infusions with morphine
• Intrathecal Morphine pumps
• Head and neck blocks with alcohol/RF Ablation
• Vertebroplasty

Fluoroscopic Vs CT Guided Celiac Plexus

Coeliac Plexus Block Block

• CT Guidance(Pilot Study done by us at AIIMS)

• Ultrasound Guidance (Anterior Approach)
• Fluoroscopic Guidance (posterior Approach)

Cervicothoracic sympathetic plexus(Stellate

Superior Hypogastric Plexus Block Ganglion Block)

• Posteromedian IntradiscalApproach is technically easy

and precise

•Ultrasound Guided Approach (Anterior) is also being

increasingly used to block the plexus

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Intrathecal Pump Implant for morphine delivery Cancer Breast Pain

Newer Paradigms in Pain Management

Cancer Breast :Pain Relief

Pain Management: An Ever-Evolving Field

Multimodal Management for Pain Relief: • A Holistic approach to Chronic Pain Management
• Specialty moving at a very fast pace
• Thoracic Paravertebral Block with neurolytics • New Techniques have been evolving
• Sympathetic Blocks ,if upper extremity pain • Patient (and even Doctors) Understanding of “Pain
Management” has been increasing
• Oral Opioids(Morphine) • New and more centres/Pain Clinics are coming up, both in
• Behavioural/Psychological Support metro cities as well as smaller cities
§ Training Opportunities in Pain Management have been
• Adjuvants (Amitryptiline) increasing
• Bisphosphonates (pamidronate)

Thank You

Special Registration Offer for Today

Only Rs. 2000/-

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What all we discuss:

Meaning / definition
Massive Blood Transfusion
•
• Effect Of Massive Blood Loss : Triad of Death
• Causes of Massive Blood Loss : Traumatic vs Non Traumatic
• Types of massive transfusion (MT) : Emperic vs Tailored
• Guidelines of Massive Transfusion
Dr Rajiv Chawla • Blood components
Director – Anaesthesiology
Rajiv Gandhi Cancer Institute & Research Centre • Selection of blood components : Fixed Ratio vs Individualize
Rohini, New Delhi 110085 • Hemostatic therapies
Email [email protected]
• Evaluation of coagulopathy
• Adverse complications of massive transfusion

Meaning
• MT refers to the transfusion of large volume of blood products
over a short period of time to a patient who has severe or un
Meaning / Definition of Massive Transfusion controlled haemorrhage.
• In adults, several definitions of MT exist based on the volumeof the
blood products transfused and also the time frames over which these
transfusions occurred

TBV estimation:
TBV for adults based on Gilcher’s rule of five for blood volume
Definition (in ml/kg body weight)

The three most common definitions of MT in adult patients are:

• Total blood volume is replaced within 24 hours
• 50% of total blood volume is replaced within 3 hours
• Rapid bleeding documented or observed
• More than 4 units of red blood cells (RBCs) transfused within 1 hours with
active major bleeding or
• More than 150 mL/minute of blood loss with hemodynamic instability

(The definition of MT in children is slightly different from the definition in adults)

Total blood Volume
If body weight : 50 kg
Blood volume range : 50x 55 =2750ml to 50x75=3750ml

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Massive Transfusion in Paediatric age group When is Massive Transfusion required ?

• Transfusion of > 100% TBV within 24 h (As in adults)
Trauma Non trauma
• Transfusion support to replace ongoing haemorrhage of >10% TBV / • About 40% of trauma-related • Obstetric emergencies
min, • Massive haemorrhage is the most
mortality is due to uncontrolled common cause of shock in obstetric
• Replacement of >50%TBV by blood products within3h.(As in adults) bleeding. patients and is the number one cause
of maternal mortality worldwide.
• Among the injured patients
admitted to trauma centres, up • Major Surgery
• Gastrointestinal haemorrhage
to 10% of military and up to 5% • Cardiac
of civilian patients require MT. • Spinal
(Diab ya, wong ec, lubannl. Massive transfusion in children and neonates. Br J haematol 2013; 161:
15–26) • Liver surgery,
• Multivisceral transplantation.

Massive Transfusion Experience is derived from Trauma

Injuries
• Trauma Setting
• Military
• Civilian
• Types of Trauma
Why need Massive Transfusion ? :
•
•
Blunt injury
Stabbing
Effects Of Massive Blood Loss
• Gun shot
• Military field trauma
• Massive Transfusion studies
• Military experience
• Level 1 trauma centers

Effects Of Massive Blood Loss

Effects Of Massive Blood Loss Pathogenesis of haemostasis
1. Reduced blood oxygen carrying capacity
• Loss of Hemoglobin
2. Coagulation disturbances
• Loss of platelets
• Loss of coagulation factors
• Initiation of intravascular coagulation secondary to injury & coagulation
cascade

Fro m: Up d a te o n ma s s i v e tra n s fu si o n
Br J An a e s h t . 20 13 ;111 (su pp l _1 ):i7 1-i 82 . do i: 1 0.1 09 3/b a
j /ae t37 6
Br J An a e s h t | © Th e Auth or [20 13 ]. Pu bl i sh ed b y Ox ford Uni ve rsi ty Pres s on be ha l f o f th e Brit i sh Jo urn al of Ana es the si a. All
ri g h ts re s erv ed . Fo rPe rmi ss io ns , p le a se e ma il : jo urn a ls .p ermi s si on s@o up .co m

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Trauma Induced Coagulopathy Triad of Death

The Role of Transfusion in Preventing

Treatment Options in Massive blood loss
Triad of Death
• Replace blood loss by IV Fluids : Crystalloids & Colloids
• Replace blood for blood : Whole Blood
• Replace blood lost by blood components after assessing what all is
lost / required to be replaced.

Treatment Options in Massive blood loss Massive Blood Loss & Massive Transfusion
• Replace blood loss by IV Fluids : Crystalloids & Colloids • Crisis situation
• Replace blood for blood : Whole Blood • Dynamic situation : fast changing hemodynamics, hemostasis &
metabolic changes
•Replace blood lost by various blood components
after assessing what all is lost / required to be
replaced : RATIONAL APPROACH Require for immediate intervention, repeated assessment &
modifications in a systematic manner
• Need for transfusion guidelines & massive transfusion protocol (MTP)
These are reasonable definitions and more likely to trigger awareness
to issue a Massive Transfusion Protocol (MTP)

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General Recommendations for Resuscitation in Patients Requiring

Massive Transfusion
Predicting those who need MT:
American Society of Anesthesiologists Committee on Blood Management 2011 {Trauma Associated Severe Hemorrhage (TASH)}
• Control hemorrhage (surgery, etc)
• Minimize consumptive coagulopathy
1. Haemoglobin
• Limit volume replacement by cystalloids 2. Base Excess
• Volume leads to dilution of the coag factors
• Limit use of 0.9% saline 3. Systolic Arterial Pressure
• Saline may exacerbate acidosis
• Early “point of care” assessment of coagulation 4. Heart Rate
• Thromboelastography (TEG, ROTEM)
• Transfuse FFP, Cyro and platelets based on coag results 5. Presence Of Free Intra-abdominal Fluid And /Or
• Restore oxygenation of muscles and organs 6. Complex Fractures
• But minimize RBC transfusions 7. Gender
(Massive Transfusion Protocol for Hemorrhagic Shock : American Society of Anesthesiologists, Committee
on Blood Management, 2011)

Guidelines for Massive Transfusion

• AAGB I b l o o d tran sfusi o n g u i d el i nes 2 0 16 : En d o rsed by th e R oyal
C o l l ege o f An aesth eti sts an d th e Netwo rk fo r Ad van cemen t o f
Tran sfu si o n Al tern ati ves (NATA). Th i s i s a co n sen su s d o cu men t p roduced
b y memb ers o f a W o rki n g P arty estab l i sh ed b y th e Asso ci ati o n o f
An aesth eti sts o f Grea t B ri ta i n an d Irel a nd (A AGB I) .
• Nati o n al In sti tu te fo r Heal th an d C are Excel l en ce (NIC E) 2 0 1 5
(h ttp ://www.n i ce.o rg .u k/gu i d an ce/i n d evel o p men t/gi d -C GW AV E0 6 63 ?)
• B ri ti sh C o mmi ttee fo r Stan d ard s i n Haemato l o gy, 2 0 1 2 -15
(h ttp ://www.b csh gu i d el i n es.co m/4 _h aemato l o gy_gu i d el i n es.h tml ?Dtyp
e=Tran sfu si o n &d p age=0 &ssp age=0 &i p age=0 #gl )
• P racti ce Gu i d el i n es fo r P eri -o p erati ve B l o o d M an agemen t– Ameri ca n
So ci ety o f An esth esi o l o g i sts
(h ttp ://an esth esi o l o gy.p u b s.asah q .o rg/arti cl e.asp x?Arti cl ei d =2 0 8 8 8 2 5 )
• M an agemen t o f severe p eri o p erati ve b l eed i n g –Gu i d el i n es fro m th e
Eu ro p ea n So ci ety o f An a esth esi o l o gy(2 0 13 ) ( h ttp ://an est-rean .l t/wp -
co n ten t/u p l o ad s/2 0 1 3 /0 5/
• M an agemen t_o f_severe_p eri o p erati v e_b l e ed i n g_.2 .p d f)Netwo rk fo r
th e Ad van cemen t o f P ati en t B l o o d Man agemen t, Haemo stasi s an d
Th ro mb o si s(NATA) (h ttp ://www.n atao n l i n e.co m)
• Na ti o n a l B l oo d Au tho rity Au stra il a P
B M Gu d
i el i n es
(h ttp ://www.b l o o d .go v.au /p b m-gu i d el i nes)

Massive Transfusion : Available options Component therapy

• Whole blood
Normal Components Special Blood Components
• Component therapy “The Red Stuff” to correct To correct coagulation : adjuncts
oxygenation
• Prothrombin Complex
Better understanding the pathophysiology of ETIC has led to early use • RBC transfusion : Concentrate (PCC)
of RBCs, plasma, and platelets and reduced crystalloid use in “The Yellow Stuff” to correct
resuscitation. coagulation • Fibrinogen concentrate
• Fresh Frozen Plasma • Recombinant factor VIIa
• Cryoprecipitate
• Platelets

4
 10/26/18

Coagulation Pathway Basic Blood Components

The s lower (2-6 mins ) More rapid (15-20 s ecs )

intrins ic s cheme extrins ic s cheme

Partial Thromboplas tin Time Prothrombin Time

Content of a Unit of Blood?

Blood Component Therapy

What all to give when ?

5
 10/26/18

Indications for FFP Indications for Cryoprecipitate

• Replacement of coagulation factors during major haemorrhage, • Hypofibrinogenaemia due to major haemorrhage and massive
particularly trauma and obstetrics transfusion. There is increased use of cryoprecipitate in major
trauma, obstetric haemorrhage and cardiac surgical bleeding. During
• Acute disseminated intravascular coagulation (DIC) with bleeding; major haemorrhage, fibrinogen should be maintained > 1.5 g/L
• In patients who are actively bleeding and whose INR is > 1.5 (or POC except in active obstetric haemorrhage where fibrinogen should be
equivalent) maintained > 2 g./L1
• Immediate reversal of warfarin-induced haemorrhage when PCC is • Combined liver and renal failure with bleeding
not available (PCC is the first choice) • Bleeding associated with thrombolytic therapy
• Thrombocytopenic purpura usually with plasmapheresis preferably • Disseminated intravascular coagulation with fibrinogen < 1.0 g/L
using pathogen-inactivated FFP • Advanced liver disease, to maintain fibrinogen level > 1.0 g/L

Special blood components:

Indications for Platelets
Prothrombin complex concentrate (PCC)
• Prevention and treatment of bleeding due to Thrombocytopenia or • PCC can be four factor or three factor
platelet function defects. • The four-factor concentrate contains factors II, VII, IX and X, with
• If patient is actively bleeding, transfuse to a platelet Count > 75000 protein S, C and heparin.
• The three factor : lacking factor VII
• It is indicated in
• acquired factor deficiency
• for urgent reversal of warfarin.
• There is limited evidence for use in any other setting.

Special blood components: Special blood components:

Fibrinogen concentrate Recombinant factor viia
• Has been used in management of bleeding after trauma in Europe • It is the most potent thrombin generator available at present
• Has been tried in patients after cardiac surgery, but role unclear. • Following cardiac surgery, it has been shown to reduce re-operation
• Its only licensed in UK for use in congenital hypofibrinogenemia rates and transfusion in the bleeding patient.
• However, its use may increase the risk of thrombotic complications
and its use except under haematological direction cannot be
recommended

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 10/26/18

Special blood components:

Antifibrinolytic agents
• Trenexamic acid (TXA) is een to reduce mortality in trauma patients
especially if given within 3 hours of injury
• It has been found to be cost effective Implementing Massive Transfusion In Hospital
• Seen to be effective in reducing blood loss in Caesarean section, PPH,
scoliosis surgery : Need For Protocol
So TXA recommended as part of resuscitation process

What’s a protocol ? How it helps? Communication is KEY

• Massive blood transfusions are unplanned, and require the processing and • FIRST communication piece is one of the MOST important parts of a
delivery of large amount of blood products rapidly for sustained period of successful protocol.
time
• The development and implementation of Massive Transfusion Protocols is • There must be specific “common language” that is used by both the
associated with reduced mortality. medical team and the blood bank. Every time.
Protocols Streamlines The Process of Managing Uncertainties • The “common language” needs to be determined and agreed upon by
Multidisciplin ary team : the parties designing the protocol. This should include blood bank
• Blood Bank staff, laboratory staff, surgeons, E.D. physicians and anesthesiologists.
• Emergency • The first 10 minutes of a patient needing blood is critical.
• Anaesthetist Mock Drills might be helpful
• Trauma Service

Sugges ted criteria for activation of MTP Mas s ive trans fus ion protocol (MTP) template
• Actu al o r anti cip ated 4
un ti s RB C n
i < 4 hrs, + h aemo dyn amical l y unstab l e, +/– an tici pated ongo i ng bl eed in g The inf or m at ion below, developed by cons ens us , br oadly cover s ar eas t hat s hould be included in a local M TP. This
• Severe th o raci c, ab d omi nal , p el vi c o r mul ti ple l on g b on e trau ma t em plat e can be us ed t o develop an M TP t o m eet t he needs of t he local ins t it ut ion's pat ient populat ion and r es our ces
• M ajo r o bstetri c, gastro in testi n al or surgi cal b leed i ng
Sen i o r cl i n i cian d etermi nes that pati en t meets cri teria for MTP acti vati on
In itial man age me n t o f b le e d in g R e su scitatio n OP TIM ISE:
• o xygen ati o n
• I dent if y c aus e
• Avoid hypot her m ia, ins t it ut e act iv e war m ing • card i ac o u tp u t
• Avoid exces s iv e cr ys t alloid
• I nit ial m eas ur es :
B ase lin e : • ti ssu e p erfu si o n
• Toler at e per m is s iv e hypot ens ion ( BP 80–100 m m Hg s ys t olic )
- com pr es s ion
Fu l l b l o od cou nt, co agul ati on screen (P T, I NR, A PTT, fib rino gen ), bi ochemi stry, • metab o l i c state
unt il act iv e bleeding cont r olled
- t our niquet
• Do not us e haem oglobin alone as a t r ans f us ion t r igger arteri al b l o o d gases
- packing
• Sur gic al as s es s m ent :
- ear ly s ur ger y or angiogr aphy t o s t op bleeding M ONITOR
Sp e cial clin ical situ atio n s ( ever y 30–60 m ins ) :
No tify tran sfu sio n labo rato ry (in sert con tact no .) to :
Sp e cific su rgical co n sid e ratio n s • W ar f ar in:
‘Activate M TP ’ • fu l l b l o od co un t
• add vit am in K, pr ot hr om binex/ FFP
• I f s ignif ic ant phys iologic al der angem ent , cons ider
• Obs t et r ic haem or r hage:
• co agu l ati o n screen
dam age cont r ol s ur ger y or angiogr aphy
• ear ly DI C of t en pr es ent ; c ons ider cr yopr ecipit at e
• i o n i sed cal ci u m
• Head injur y: 9
• arteri al b l o o d gases
• aim f or plat elet count > 100 ×10 / L
C e ll salvage • per m is s iv e hypot ens ion cont r aindic at ed
Se n io r clin ician
• Cons ider us e of cell s alv age wher e appr opr iat e
Lab o rato ry staff • R e q u e st: a
• Not if y haem at ologis t / t r ans f us ion s pecialis t o 4 unit s RBC AIM FOR :
• Pr epar e and is s ue blood com ponent s
C o n sid e ratio n s fo r u se o f rFVIIab o 2 unit s FFP
• temp eratu re > 3 5 0C
Do sage as r eques t ed • C o n sid er: a
The r out ine us e of r FVI I a in t r aum a pat ient s is not r ecom m ended due t o • Ant ic ipat e r epeat t es t ing and • p H > 7 .2
o 1 adult t her apeut ic dos e plat elet s
Plat elet count < 50 x 109/ L 1 adult t her apeut ic dose it s lack of ef f ect on m or t alit y ( Gr ade B) and var iable ef f ect on m or bidit y blood com ponent r equir em ent s
• b ase excess < –6
o t r anexam ic acid in t r aum a pat ient s
• M inim is e t es t t ur nar ound t im es
I NR > 1. 5 FFP 15 m L/ kg
a ( Gr ade C) . I ns t it ut ions m ay choos e t o develop a pr oces s f or t he us e of
• In clu d e :a • l actate < 4 mmo l /L
r FVI I a wher e t her e is : • Cons ider s t af f r es our ces
Fibr inogen < 1. 0 g/ L cr yopr ecipit at e 3–4 ga
o cr yopr ecipit at e if f ibr inogen < 1 g/ L • C a2+ > 1 .1 mmo l /L
• uncont r olled haem or r hage in s alv ageable pat ient , and a Or locally agr eed c onf igur ation
• f ailed s ur gic al or r adiologic al m eas ur es t o cont r ol bleeding, and Hae mato lo gist/tran sfu sio n • p l atel ets > 5 0 × 1 0 9/L
Tr anexam ic acid loading dose 1 g over 10 m in, t hen
• adequat e blood com ponent r eplacem ent , and sp e cialist • P T/AP TT < 1 .5 × n ormal
inf usion of 1 g over 8 hr s
• pH > 7. 2, t em per at ur e > 340C. • Liais e r egular ly wit h labor at or y • INR ≤ 1 .5
Dis cus s dos e wit h haem at ologis t / t r ans f us ion s pecialis t and clinic al t eam
B le e d in g co ntro l ed ? • fi b ri n o gen > 1 .0 g/L
a Local t r ansf usion labor at or y t o advise onnum ber of unit s b • As s is t in int er pr et at ion of r es ult s , and
needed t o pr ovide t his dose r FVI I a is not lic ens ed f or us e in t his s it uat ion; al us e m us t be par t of pr act ic e r eview.
advis e on blood com ponent s uppor t
YES NO
ABG ar te r ia l blo od gas FFP fr esh fr ozen pla sma APTT activ ate d par tia l th r ombopla stin time
I NR ni te r natio nal nor malis ed r atio BP blo od pr essur e M TP massiv e tr ansfu sio n pr oto col No tify tran sfu sio n labo rato ry to:
DI C dis semin ate d in tr avascula r coagula tio n PT pr oth r ombin time FBC fu l blo od count ‘C e ase M TP ’
RBC r ed blo od cell r FVlla activ ate d r ecombin ant fa cto r VII

7
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Massive Transfusion Protocols (MTP) Massive Transfusion Protocol

•Empiric MTP • It is recommended that institutions develop an MTP that includes the
dose, timing and ratio of blood component therapy for use in trauma
•“Tailored” MTP patients with, or at risk of, critical bleeding requiring massive
transfusion
• In patients with critical bleeding requiring massive transfusion, the
use of an MTP to facilitate timely and appropriate use of RBC and
other blood components may reduce the risk of mortality and ARDS.

Empiric MTP Approach : Fixed Ratio Approach “Tailored” (goal directed) MTP :
Individualized for each patient
• Empiric MTP: Tailored massive transfusion protocol bases transfusions on patient’s
• Concept comes from military based studies of transfusion ratios needs given each individual situation
• Blood products are issued in “packs” according to a set ratio of • Utilizes STAT laboratory testing and Point of Care
RBC: FFP: Platelets
• Thromboelastography (TEG/ROTEM)
• Released from the BB on a set time frame
• Transfusions are based on physiology and function rather than set
• Administered to the patient according to the set ratio
transfusion ratios
• Ratio and transfusion approach reflects the emphasis on preventing
coagulopathy • Randomized controlled trials of MTP to test the “empiric” vs “tailored”
protocol are needed
• Level I and Level II trauma centers are required to have an empiric
MTP

Surgeons MTP Requirements

• Transfuse RBC : Plasma in 1:1 or 2:1 ratio
• Transfuse one apheresis platelet per 6 units RBC
• Blood products should be sent to patient bedside in the established
ratios Plasma : Platelet :RBC ratios
• Subsequent coolers are issued every 15 minutes until MTP is Impact on Outcomes
terminated
• Goal is to keep one MTP cooler ahead for the duration of the protocol

Hemos tas is involves delicate interplay among hematocrit, platelets , and s oluble coagulation factors
• Adequate concentration
• G ood qualitative performance
• Correct ratios

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 10/26/18

JAMA Surg. 2013;148(2):127-136.

• RBC:Plasma Ratios and Mortality in TRAUMA Patients

• Civilian MTP guidelines 3 RBC:1 Plasma ratio
• Military MTP guidelines showed that 1:1:1 ratio improved outcomes in combat
Casualties
• Retrospective study of 466 trauma patients at Level I centers
• Patients transfused with a 1:1:1 ratio showed improved outcomes
• Increased survival at 6h, 24h and 30 days
•N o s ignificant difference in mortality between plas ma : platelet : RBCs of 1:1:1 or 1:1:2 at 24 hours
• Fewer intensive care unit, ventilator and hospital days or 30 days
• The transfusion ratio 1:1:1 is fairly consistent practice in trauma and massive •Higher plas ma and platelet ratios early in res us citation were as s ociated with decreas ed mortality in
hemorrhage patients patients who received trans fus ions of at leas t 3 units of blood products during the firs t 24 hours
(United States Army Institute of Surgical Research) after admis s ion.
•Among s urvivors at 24 hours , the s ubs equent ris k of death by day 30 was not as s ociated with
plas ma or platelet ratios .

• Ratios and Mortality in Trauma Vs Non-Trauma Patients Findings:

• Two different MTPs • Mortality:
• Trauma (T) 1 RBC:1 Plasma ratio • Mortality did not differ by type of hemorrhage (trauma vs non-trauma)
• Non-trauma (NT) ~2 RBC:1 Plasma ratio • Mortality did not vary by the ratio of RBC : Plasma transfused
• 167 patients with MTPs • Ratios and Transfusions
• Evaluated how the two MTPs impacted patient mortality at 24h • Total number of RBC, Plasma and Platelets transfused did not differ by type of
Hemorrhage
• Robert A. De Simone et al. Blood 2015;126:2348 • There was no difference in the RBC: Plasma ratios clinicians transfused for different
types of hemorrhage, despite the BB issuing different ratios for T-MTP and NT-MTP
• The ratio of products issued during a MTP was not what was actually transfused to
patients, indicating that clinicians were not transfusing according to protocol.
• Increased RBC transfusions were associated with increased mortality at 24 hours.

JAMA. 2015;313(5):471-482. doi:10.1001/ jama.2015.12 Trans fus ion Medicine Reviews 32 (2018) 6–15

•Among patients with s evere trauma and major bleeding, early

adminis tration of plas ma, platelets , and red blood cells in a 1:1:1 ratio compared with a 1:1:2
ratio did not res ult in s ignificant differences in mortality at 24 hours or at 30 days .
•More patients in the 1:1:1 group achieved hemos tas is and fewer experienced death due to Conclus ion
exs anguination by 24 hours •Higher trans fus ion ratios were as s ociated with trans fus ion of more FFP and platelets
without evidence of s ignificant difference with res pect to mortality or morbidity
•There is ins ufficient bas is to recommend a 1:1:1 over a 1:1:2 ratio or s tandard care for
adult patients with critical bleeding requiring mas s ive trans fus ion.

9
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Australian Guidelines
Journal of Surgical Res earch, January 2019 (233) : 213-220

• In trauma patients, a ratio of RBC:FFP:platelets of ≤ 2:1:1 was associated with improved survival
• In non-trauma patients, there were insufficient data to support or refute the use of a defined
ratio of blood component replacement.
• A survival advantage is associated with decreasing the ratio of RBCs to fresh frozen plasma (FFP),
platelets or cryoprecipitate/fibrinogen administered to patients undergoing massive transfusion
• Blood component replacement should be guided by clinical assessment and results of coagulation
tests.
• The decrease in mortality associated with administering low versus high ratios of RBCs to blood
components was associated with a significant decrease in deaths from exsanguination.
• More deaths were reported in patients receiving high ratios of RBCs to blood components
compared with low-ratio recipients. However, these results should be interpreted carefully,
because of the potential for survival bias (that is, patients who die early are more likely to have
received a higher RBC: component ratio)

How do we determine if we use an

Empiric vs Tailored MTP approach?
• IF the MTP is initiated for a TRAUMA, we use the EMPIRIC approach to issue
blood in a 2 RBC:1 Plasma ratio in a designated Trauma Cooler. We continue to
send 2:1 every 15-30 minutes. If/when the medical team switches to a “tailored”
approach, the BB stops sending the cooler at defined intervals and, switches to
issuing products as requested .
• For all other MTPs, the blood bank uses a “TAILORED approach” and issues
products as requested until they hear from the pathologist. At that point, the
No consensus on what is best Fixed Ratio pathologist conveys the transfusion plan to the BB.
• In cases of rapid bleeds/hemorrhage, products are released closer to a 2:1 ratio.
In cases of slower bleeds, a “tailored” approach is usually taken.
• In cases where there is concern for potential rapid blood loss/hemorrhage or if
the surgeon will need blood in a timely manner (ie: heart surgery coming off
pump, high risk C-section), the BB prepares the products and designates them to
that patient until he/she needs them or the protocol is ended

“Tailored” (goal directed)

Point of Care Tests
Massive Transfusion Protocol
Tailored massive transfusion protocol bases transfusions on patient’s Laboratory tests are used commonly to evaluate coagulation disorders:
• Prothrombin Time (PT) which measures the integrity of the extrinsic system as well as factors
needs given each individual situation common to both systems
• Utilizes STAT laboratory testing and Point of Care • Partial Thromboplastin Time (PTT), which measures the integrity of the intrinsic system and the
common components. ( Normal :60-70 seconds)
• Thromboelastography (TEG/ROTEM) • International Normalized Ratio Blood Test-INR (Normal : 1-1.5)
• Transfusions are based on physiology and function rather than set • APTT : an activator is added to APTT test to elevate the speed of the clotting time
and to get results in a narrower reference range while no activator is added to a normal PTT test
transfusion ratios and so PTT is less sensitive to heparin therapy as compared to APTT. (Normal : 30-40 seconds)
• Randomized controlled trials of MTP to test the “empiric” vs “tailored”
protocol are needed

• h ttp s://www.med i ci n e.mcg i l l .ca /p h ysi o /vl a b /b l o o d l a b /P T_P TT.h tm

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Practice Point : In patients with critical bleeding requiring massive

Point of Care Tests : Advanced Assessment transfusion, the following parameters should be measured early and
frequently
• Haemostasis assays: Graphic representation of coagulation process • Temperature
Provide quantitative measure of individual components • Acid–base status
• Thromboelastography (TEG) • Ionised calcium
• Rotational Thromboelastography (ROTEM)
• Haemoglobin
• Platelet count
• PT/INR
• APTT
• Fibrinogen level.
With successful treatment, values should trend towards normal.

Values indicative of critical physiologic

Point of Care Tests
derangement include:
• Temperature < 35 • Patients with active bleeding should be monitored by point of care for
• pH < 7.2, base excess > -6, lactate > 4mmol / L coagulation :
• FFP if INR > 1.5
• Ionised calcium < 1.1 mmol / L • Cryoprecipitate if fibrinogen < 1.5 g/l
• Platelets < 50,000/ml • Platelets if platelet count < 75000/ml
• PT > 1.5 times normal
• INR > 1.5
• APTT > 1.5 normal
• Fibrinogen < 1gm/ L

Brief summary of thromboelastography

Thromboelastography (TEG/ROTEM)
(not available at all hospitals)
• TEG or ROTEM TEG ROTEM
• Methodology provides a graph of the coagulation process based on the • Cup rotates • Cup is fixed
properties of the clot • Wire is fixed
• Time it takes to initiate a clot • Wire Rotates
• How quickly the clot forms • As the clot forms • As the clot forms
• Time to maximum clot formation
• Clot strength
the cup torque is the cup torque is
• Identifies when the clot starts to breakdown (fibrinolysis) measured
• Measures maximum fibrinolysis
measured
• Electromagnetically • Optically
• Results available in 15-30 minutes which allows closer “real time” assessment of
the patient’s coagulation status
• Usually only available in larger hospitals, CV surgery, Trauma Patient whole blood is put in the cup

11
 10/26/18

TEG graph Examples of TEG/ROTEM tracings

Blood Product Transfusion:

based on TEG/ROTEM tracing

Devising a Protocol : Institution Specific

In the Blood Bank, our MTP order set initiates

4 steps for the Medical Team the preparation of the following blood products:
• Call the Blood Bank to Initiate the MTP • Type and cross 4 units of RBCs - stay ahead 4 units
• Provide Patient information • Prepare 2 units FFP - stay ahead 2 units
• Place the MTP order set (when you can) • Prepare 1 apheresis platelet - stay ahead 1 unit
• Send a Blood Product Release slip every time you need products • Baseline Hgb, INR, platelet count, fibrinogen

Our RBC:FFP preparation can accommodate 1:1 or 2:1 ratios for rapid/massive
bleeds and Trauma cases . And also can be issued in a “tailored” approach. It’s
amendable to both

12
 10/26/18

Blood Bank PREPARES products for the patient. Those products

are set aside for that patient for the duration of the MTP “virtual basket”

• 1 PLATELET
• 2 units of FFP
• 4 units of RBC

Adverse effects of massive transfusion Adverse effects of massive transfusion : II

Transfusion reactions Immunological reactions Metabolic complications Other adverse events

• Allergic • Transfusion-related acute lung • Hypocalcaemia • Haemostatic defects
• Hemolytic transfusion (acute / injury (TRALI) • Hypomagnesaemia • Infection
delayed) • Transfusion-related • Hyperkalaemia • Transfusion-associated
• Febrile non hemolytic reaction immunomodulation (TRIM) circulatory overload (TACO)
• Hypokalaemia
• Transfusion-associated graft vs • Air embolism
host disease (Ta-GVHD) • Metabolic alkalosis
• Post-transfusion purpura (PTP) • Acidosis
• Hypothermia

The Best Patient Blood Management

Recommendation
Blood Transfusion is like marriage:
• It should not be entered upon lightly,
• Unadvisedly or wantonly, or
• More often than is absolutely necessary

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 10/26/18

References

• https://www.loyolamedicine.org/sites/default/files/gme/internal-
medicine/blood_components_and_indications_for_transfusion.pdf
• https://www.ascls.org/images/Meetings/Annual_Meeting/Handouts/SS08_Monday_500
Thank You
_handout.pdf
• http://www.lhsc.on.ca/Health_Professionals/CCTC/protocols/MassiveTransfusionProtoc
olKit.pdf
• http://ptsf.org/upload/PMG0019_02.08.2018.pdf
• https://academic.oup.com/bja/article/111/suppl_1/i71/228878

Mas s ive trans fus ion protocol (MTP) template Sugges ted criteria for activation of MTP
The inf or m at ion below, developed by cons ens us , br oadly cover s ar eas t hat s hould be included in a local M TP. This • Actu al o r anti cip ated 4
un ti s RB C n
i < 4 hrs, + h aemo dyn amical l y unstab l e, +/– an tici pated ongo i ng bl eed in g
t em plat e can be us ed t o develop an M TP t o m eet t he needs of t he local ins t it ut ion's pat ient populat ion and r es our ces • Severe th o raci c, ab d omi nal , p el vi c o r mul ti ple l on g b on e trau ma
• M ajo r o bstetri c, gastro in testi n al or surgi cal b leed i ng
Sen i o r cl i n i cian d etermi nes that pati en t meets cri teria for MTP acti vati on
OP TIM ISE: In itial man age me n t o f b le e d in g R e su scitatio n
• o xygen ati o n
• card i ac o u tp u t • I dent if y c aus e
• Avoid hypot her m ia, ins t it ut e act iv e war m ing
• Avoid exces s iv e cr ys t alloid
B ase lin e : • ti ssu e p erfu si o n • I nit ial m eas ur es :
• Toler at e per m is s iv e hypot ens ion ( BP 80–100 m m Hg s ys t olic )
Fu l l b l o od cou nt, co agul ati on screen (P T, I NR, A PTT, fib rino gen ), bi ochemi stry, • metab o l i c state - com pr es s ion
unt il act iv e bleeding cont r olled
- t our niquet
arteri al b l o o d gases • Do not us e haem oglobin alone as a t r ans f us ion t r igger
- packing
• Sur gic al as s es s m ent :
M ONITOR - ear ly s ur ger y or angiogr aphy t o s t op bleeding
( ever y 30–60 m ins ) :
Sp e cial clin ical situ atio n s
No tify tran sfu sio n labo rato ry (in sert con tact no .) to :
‘Activate M TP ’ • fu l l b l o od co un t Sp e cific su rgical co n sid e ratio n s • W ar f ar in:
• add vit am in K, pr ot hr om binex/ FFP
• co agu l ati o n screen • I f s ignif ic ant phys iologic al der angem ent , cons ider
• Obs t et r ic haem or r hage:
• i o n i sed cal ci u m dam age cont r ol s ur ger y or angiogr aphy
• ear ly DI C of t en pr es ent ; c ons ider cr yopr ecipit at e
• arteri al b l o o d gases • Head injur y: 9
• aim f or plat elet count > 100 ×10 / L
Se n io r clin ician C e ll salvage • per m is s iv e hypot ens ion cont r aindic at ed
Lab o rato ry staff • R e q u e st: a • Cons ider us e of cell s alv age wher e appr opr iat e
• Not if y haem at ologis t / t r ans f us ion
s pecialis t o 4 unit s RBC AIM FOR :
• Pr epar e and is s ue blood com ponent s o 2 unit s FFP
• temp eratu re > 3 5 0C C o n sid e ratio n s fo r u se o f rFVIIab
as r eques t ed • C o n sid er: a Do sage
• Ant ic ipat e r epeat t es t ing and • p H > 7 .2 The r out ine us e of r FVI I a in t r aum a pat ient s is not r ecom m ended due t o
o 1 adult t her apeut ic dos e plat elet s
blood com ponent r equir em ent s
• b ase excess < –6 Plat elet count < 50 x 109/ L 1 adult t her apeut ic dose it s lack of ef f ect on m or t alit y ( Gr ade B) and var iable ef f ect on m or bidit y
o t r anexam ic acid in t r aum a pat ient s
• M inim is e t es t t ur nar ound t im es
• In clu d e :a • l actate < 4 mmo l /L I NR > 1. 5 FFP 15 m L/ kg
a ( Gr ade C) . I ns t it ut ions m ay choos e t o develop a pr oces s f or t he us e of
• Cons ider s t af f r es our ces r FVI I a wher e t her e is :
o cr yopr ecipit at e if f ibr inogen < 1 g/ L • C a2+ > 1 .1 mmo l /L Fibr inogen < 1. 0 g/ L cr yopr ecipit at e 3–4 ga
a Or locally agr eed c onf igur ation • uncont r olled haem or r hage n i s alv ageable pat ient , and
Hae mato lo gist/tran sfu sio n • p l atel ets > 5 0 × 1 0 9/L • f ailed s ur gic al or r adiologic al m eas ur es t o cont r ol bleeding, and
sp e cialist • P T/AP TT < 1 .5 × n ormal Tr anexam ic acid loading dose 1 g over 10 m in, t hen
• adequat e blood com ponent r eplacem ent , and
inf usion of 1 g over 8 hr s
• Liais e r egular ly wit h labor at or y • INR ≤ 1 .5 • pH > 7. 2, t em per at ur e > 340C.
and clinic al t eam
B le e d in g co ntro l ed ? • fi b ri n o gen > 1 .0 g/L Dis cus s dos e wit h haem at ologis t / t r ans f us ion s pecialis t
• As s is t in int er pr et at ion of r es ult s , and a Local t r ansf usion labor at or y t o advise onnum ber of unit s b
needed t o pr ovide t his dose r FVI I a is not lic ens ed f or us e in t his s it uat ion; al us e m us t be par t of pr act ic e r eview.
advis e on blood com ponent s uppor t
YES NO
ABG ar te r ia l blo od gas FFP fr esh fr ozen pla sma APTT activ ate d par tia l th r ombopla stin time
No tify tran sfu sio n labo rato ry to: I NR ni te r natio nal nor malis ed r atio BP blo od pr essur e M TP massiv e tr ansfu sio n pr oto col
‘C e ase M TP ’ DI C dis semin ate d in tr avascula r coagula tio n PT pr oth r ombin time FBC fu l blo od count
RBC r ed blo od cell r FVlla activ ate d r ecombin ant fa cto r VII

https :/ / www.blood.gov.au/ s ys tem/ files / documents / pbm-

module-1-qrg.pdf
Component Therapy : What ratio ?

14
 10/26/18

Pathophysiology of Massive Transfusion Definition of a Massive Transfusion

• Improve Oxygen Carrying Capacity : Maintenance of tissue perfusion • Traditional definitions
• Arrest bleeding by treating the surgical cause • 20 units RBCs in 24 hours
• Commonly used in trauma literature: ≥ 10 units RBCs in 24 hours
• Prevent or Minimize Trauma Induced Coagulopathy
• Reasonable for publications but not practical in actual resuscitation
• Practical definitions
• > 4 units RBCs in 1 hour with need for ongoing transfusion
• Blood loss > 150 ml/min with hemodynamic instability and need for ongoing
transfusions
• These are reasonable definitions and more likely to trigger awareness to
issue a Massive Transfusion Protocol (MTP)

Coagulation pathway RGCI protocol

Massive Transfusion Protocols in India

15
 10/26/18

Basic Blood Components The reverse is NOT TRUE !

• If 1 unit each of erythrocytes,
Components R
e platelets and plasma are derived
Prepared d from 1 donated whole blood,
the recombination in 1:1:1 ratio
Sequentially, T is equivalent to whole blood
in a Hermetically O

Sealed Sterile System Y

e
ll
o
w

16
 10/26/18

Outline
Diagnosis of Brain Death
& To Discuss Not to Discuss
Management of Deceased Organ Donor • Rationale for diagnosis of BD
• Diagnostic criteria
• Screening
• Legal issues
• Pathophysiology of BD • Anesthetic management for
• Optimization of the donor procurement

Girija Prasad Rath

Department of Neuroanaesthesiology and Critical Care
AIIMS, New Delhi, India
Email: [email protected]
Disclosure: Nil

Rationale for Diagnosis of BD Brain Death Determination

• Transplant program requires donation of healthy peripheral organs Steps
§ Early d iag n o sis o f BD b efo re sy stemic circu latio n fails- allo ws salv ag e o f o rg an s 1. Clinical Evaluation
• Pre-req u isites o f b rain d eath d etermin atio n
• Ability of modern medicine to keep a body functioning for extended periods 2. Neurologic Assessments
§ Lead s to p ro lo n g ed , ex p en siv e, an d fu tile p ro ced u res acco mp an ied b y g reat emo tio n al • 2 Neu ro lo g ic Ex amin atio n s 6 h rs ap art
strain o n family 3. Ancillary Tests

• Critical care facilities are limited and expensive 4. Documentation

§ Drain o n o th er med ical reso u rces
§ ICUs sh o u ld n o t b e o v erlo ad ed with p ts wh o can n ev er reco v er cereb ral fu n ctio n

Clinical Evaluation Neurologic Examination

• Establish Irreversible And Proximate Cause Of Coma Cardinal Signs
§ Histo ry , Clin ical, Lab Test, Neu ro imagin g ev id ence o f an acu te CNS catastrop he th at is
co mp atib le with clin ical d iag n o sis o f brain d eath 1. Coma
2. Absence of Brainstem Reflexes
• Exclusion of Potentially Reversible Causes 3. Apnea [Complete Cessation Of Spontaneous Respiration]
§ Dru g in to x icatio n (CNS d epressants) or po ison ing (in jectio n s of sedativ es o r p aralytics)
§ Sev ere electro ly te, acid -b ase imb alan ces; en d ocrine, o r hemod yn amic d istu rbances Trans plant of Human Organs (THO) Act 1994 and 1995 THO rules
Determining brain death in adults . American Academy of Neurology 2010

• Achieve Normal Core Temperature >36oC

• Achieve Normal Systolic Blood Pressure (SBP)

§ Neu ro lo g ic ex aminatio n is u su ally reliab le with a SBP >10 0 mmHg

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Coma Absence of Brainstem Reflexes

• Unresponsiveness 1. Pupillary light reflex: CNs II, III
• Absence of response to noxious stimuli 2. Corneal reflex: CNs V, VII
§ Nail-bed or supra-orbital ridge pressure, 3. Pharyngeal (Gag) & Tracheal (Cough) reflex: CNs IX, X
Sternal Rub 4. Oculo-cephalic (Doll’s eyes) reflex: CNs III, VI, VIII
§ No eye opening
5. Oculo-vestibular (Cold Calorics) reflex: CNs III, VI, VIII
§ No motor response, including extensor/
flexor posturing N Engl J Med 2001; 345:616-8 6. Facial grimacing to noxious stimulus CNs V, VII
• Spinal reflexes may remain intact
§ Do not rule out the diagnosis of brain death
N Engl J Med 2001; 345:616-8

Pupillary Reflex Corneal Reflex

• Shining a bright light causes pupil to constrict • Touching cornea with a piece of tissue paper or a cotton
• Pupils: B/L fixed & dilated, mid-size (4-6 mm), may swab
be fully dilated • No eyelid movement Þ Absent corneal reflex
• Constricted pupils : possible drug intoxication • Fixed/ dilated: CN III compression (herniation, mid-
• Light reflex affected in case of brain stem dysfunction brain lesion)
§ IV atro p in e d oes n ot marked ly affect respo nse • Pinpoint Pupil: pontine lesion
§ Paraly tics d o n o t affect p up illary size
§ To p ical ad min istratio n o f drugs an d ey e trauma may
in flu en ce p u p illary size an d reactiv ity

Pharyngeal & Tracheal Reflexes Oculo-Cephalic Reflex

• Absence of the pharyngeal and tracheal reflexes • Integrity of the C-spine ensured Doll’s Eyes Maneuver
• Pharyngeal or Gag reflex • Head briskly rotated to 90º horizontally
§ Stimu latio n o f th e p o sterio r p h ary n x with a to n g u e b lad e o r su ctio n d ev ice • Normal Þ deviation of eyes to opposite side
• Brain death Þ No eye movement
• Tracheal reflex Cough reflex § Ocu lo cep h alic reflex es are ab sent (n o Doll’s
§ Co u g h resp o n se to trach eal su ctio n in g ey es)
§ Cath eter in serted in to trach ea; ad v an ced u p to th e lev el o f carin a fo llo wed b y 1 o r 2
su ctio n in g p asses

2
 10/26/18

Oculo-Vestibular Reflex Apnea Test

• Patency of external auditory canal (EAC) and Pre-requisites
tympanic membrane to be confirmed
§ Normothermia (>36°C)
• Elevate the HOB30° § Normotension: SBP≥100 mmHg (±Vasopressors)
• Each EAC irrigated (one ear at a time) with § Euvolemia (Option: positive fluid balance in the previous 6h )
60cc of ice-cold water § No electrolyte/Acid-Base imbalance
• Observe for 1min after each ear irrigation § Normoxia: Normal PaO 2 level
• 5min wait between tests § Eucapnia: Normal PaCO 2 level (35-45 mmHg)
Normal Abs ent § No prior evidence of CO 2 retention (COPD, Obesity, OSA)
• Normal: Nystagmus
§ Normal pH, not requiring high FiO 2 or mean airway pressure
§ Both eyes slow toward cold, fast to midline
• No eye movement: Brainstem death

Apnea Test Apnea Test

Methods Abort
§ Preoxygenation: 10-15 min ´100% O2; to PaO2 200 mmHg § SBP decreased to <90 mmHg
§ If SpO2 remains 95%, obtain a baseline ABG § SpO2 <85% for 30 seconds
§ Disconnect the patient from the ventilator § Occurrence of arrhythmias
§ Place an insufflation catheter through ETT, close to carina,
deliver 100% O2 at 6 L/min
§ Look closely for respiratory movements for 8-10 minutes
§ ABG 8-10 min later

Apnea Test Who Should Do It?

Interpretation • Two clinicians who are experts in the field are required for brain death
• Respiratory movements observed Þ -ve Apnea test certification
§ Do es n o t su p p o rt th e d iag n o sis o f b rain d eath Tran sp lan tatio n o f Human Organ (THO) Act 1 99 4
• No respiratory movement → Repeat ABG • A surgeon/ physician and an anesthetist/ intensivist, in the event of the non-
§ PaCO 2 ≥6 0 mmHg ; PaCO 2 ≥2 0 mmHg o v er BL v alu e Þ +v e Apnea test availability of neurosurgeon/ neurologist
§ Su p p o rts th e d iag n o sis o f b rain d eath Amen d men ts in THO Act (2 011 /14 )
• Inconclusive Apnea test; but patient is hemodynamically stable during • All tests to be repeated, after minimum interval of 6hr
procedure
§ “To en su re th at th ere h as b een n o o b serv er erro r”
§ Rep eat test fo r a lo n g er p erio d o f time (1 0 -1 5 min ) after th e p atien t is ag ain
ad eq u ately p reo x y g en ated § Persisten ce o f th e clin ical state can b e d o cu men ted

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Documentation of Brain Death Confirmatory (Ancillary) Tests

• Time of Death: It is the time the arterial PCO2 reached the target value (60) • Brain death is a clinical diagnosis
§ In adults, ancillary tests cannot replace neurologic examination

• In patients with an aborted apnea test, the time of death is when the
ancillary test has been officially interpreted • A confirmatory test is not mandatory
§ Desirable; when specific components of clinical testing cannot be reliably performed
or evaluated.
• The interpretation of each of these tests requires expertise

• DSA, EEG, Nuclear Scan, TCD, CTA, and MRI / MRA

EEG Cerebral Angiography

No electrical activity during at leas t 30 minutes

of recording
that adheres to the minimal technical criteria for
EEG recording in s us pected brain death as adopted
by the American electroencephalographic Society,
including 16-channel EEG ins truments .

Normal Electrocerebral Silence

Normal No I C Flow

No intracerebral filling at the level of the carotid bifurcation or circle of Willis

MR Angiography PET
Empty Skull Sign
• Cerebral metabolism after BD
• Measured by 15F-fluorodeoxyglucose-
PET
Saggital Trans verse Coronal

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 10/26/18

SPECT Tc-99m Isotope Brain Scan Somatosensory Evoked Potentials

• Cerebral Scintigraphy
• 99m Tc-hexamethylpropylene amine oxime
(HMPAO) single photon emission tomography

Hallow Skull Phenomenon

• Radioisotope is injected 30min after reconstitution
• No radionuclide localization in MCA, ACA, BA
• No tracer in the SSS
• No radioisotope in brain parenchyma

Transcranial Doppler Transcranial Doppler

a) No rmal sy sto lic u p stroke with step -d own of diasto lic flo w
b ) In creased p eak sy sto lic flo w with d ecreasin g d iasto lic flo w and
ev en tu al b lu n tin g of diasto lic flo w
c) Diasto lic flo w rev ersal
d ) Bip h asic o r o scillatin g flo w:- d iasto lic flo w reversal
ap p ro ach es eq ual size to sy sto lic flo w
e) Iso lated sh arp sy stolic p eak flows of <200 ms an d small
sy sto lic amp litu d e o f <5 0 cm/s
f) Zero flo w:- wh ere th ere wasp revio usly docu mented TCD flow

Increased Discard Rate

• Increased discard rate of organs procured from the cadaver donor
• Kidney: 15%
Management of Ro sendale et a l: AmJ Tra nspla nt 200 2
• Liver: 25%
• Heart & Lung: 60%

Deceased Organ Donor • Even higher for other organs

Za ro ff et al: Circula tio n 20 02

5
 10/26/18

Pathophysiology of Brain Death Cardiovascular Changes

↑I CP Coning
• Cardiovascular Changes
• Pulmonary Changes Cerebral I s chemia Vagal s timulation ¯HR, BP, CO

• Endocrine Changes Pro g ress ro stro cau da lly

• Metabolic & Stress Response Pons + Sympathetic s timulation ¯HR, ­BP, ¯CO
Cu sh in g ’s reflex

• Temperature Regulation
Medulla Sympathetic s timulation ­HR, BP, CO, S VR
• Coagulation Abnormalities Lo wer en d Un o p p o sed
Isch emic Va g a l Ca rd io-Motor
Au to n o mic sto rm
S ymp a th etic S to rm
Nu cleu s
• Inflammatory & Immunological Changes Ca tech o la min e S to rm

Spinal cord Sympathetic inhibition ¯HR, BP, CO, S VR

Cardi ovascular Collapse

Pulmonary Changes Pulmonary Changes

Brain Severe Brain I njury Sympathetic Storm
Unrelated to Brain death Brain Death-induced Injury death
• Aspiration • Inflammatory ALI ­SVR
• Pneumonia • NPE
• Contusion ­Ca rd ia c a fter lo a d
• Atelectasis ­LA/ LV Pressu re

• Fluid Overload
­Pu lm Blo o d Vo lu me
­PAP
­Pu lm Ca p illa ry Pressu re

­Hy d ro sta tic p ressu re

Da ma g ed ca p ill end oth elium

Pulmonary Edema

Endocrine and Metabolic Effects Endocrine and Metabolic Effects

• Progressive failure of hypothalamo-pituitary axis § ¯T3:
• Pro g ressiv e lo ss o f card iac co n tractility
• ¯ATP, ­An aero b ic Metab o lism, Lactic acid o sis
• Posterior pituitary: loss of function (MC) § ¯Plasma cortisol:
ØLo ss o f ADH secretio n ® DI (9 0 %)
• Hy p o ad ren alism
ØPo ly u ria ® Deh y d ratio n , metab o lic d eran g emen ts
Ø­Na+, ­S. Osmo lality , ¯K +, ¯Ca2+, ¯Mg 2+ • Imp air d o n o r stress resp o n se ® Card io v ascu lar co llap se
• ¯Insulin:
• Anterior pituitary: ØSeco n d ary to ¯stress resp o n se
دTh y ro id h o rmo n es: ¯TSH, T3 (MC), T4 ØIn su lin resistan ce
ØHy p erg ly cemia

6
 10/26/18

Temperature Regulation Coagulation Abnormalities

• Loss of hypothalamic function • 34% cases of isolated HI
ØLoss of control of body temperature • Thromboplastin release from necrotic brain tissue
• Hypothermia • Dilutional coagulopathy
ØAggravated by loss of vasomotor tone ØLarge volume resuscitation
ØPeripheral vasodilation ØMassive blood transfusion
ØFall in metabolic rate
• Disseminated Intravascular Coagulation (DIC)
• Core temperature <32oC
ØDysrrhythmias • Uncontrolled bleeding; aggravated by
ØBradycardia and myocardial depression ØHypothermia
ØCoagulopathy ØCatecholamine use
Hefty et al: Trans plantation 1993;55:442-3

Immunological Effects Management Goals

• Release of pro-inflammatory substances • Normalization of donor physiology
Ø­Plasma cy to k in es: TNF a, IL-6 , IL-8 , IL-1 b, IL-2 R • Ensure adequate oxygenation, circulating
Ø­TNF a, IL-6 Þ malfu n ctio n d o n o r h eart volume, cardiovascular stability
• Continued invasive monitoring
• Immunologically activated organs before engraftment • Maintain body temperature
• Adequate urine output
• Graft rejection after transplantation more alive donors • Adherence to infection control
Stangl M et al: Trans plant Proc 2001;33:1284-5
• Correction of electrolyte imbalances
• Aggressive management of arrhythmias

Management Goals General Care

Rule of 100s • Manage in ICU: nursing/ medical care
• Support for relatives
§ SBP >100 mmHg • Stop unnecessary drugs: sedatives, analgesics
§ Urine output >100 ml/hr • Actively identify and treat any current infections
§ PaO2 > 100 mmHg
• Broncho-alveolar lavage (lung recruitment)
§ Hemoglobin concentration > 100 gm/L
§ Blood sugar 100% normal
Can J Anas th1990;37:806-12

7
 10/26/18

Hemodynamic Management Hemodynamic Monitoring

• Goals: PARAMETER TARGET
ØAdequate perfusion pressure for optimal tissue Heart Rate 60-120 beats /min
oxygenation Arterial Pres s ure SBP ≥ 100 mmHg
M BP ≥70 mmHg
• Depends on the degree of hemodynamic instability
Central Venous Pres s ure 8-10 mmHg
ØFluid resuscitation
Urine Output 100 ml/hour
ØInotropic support
Blood Gas es Hb > 100gm/litre
ØVasopressors PH 7.35-7.45
ØHormonal substitution PaO2 100 mmHg
Blood glucos e 100 mg%
• Initial hypotension: 80% donors
PCWP 10-12 mmHg
ØSustained® graft dysfunction CI 2.4 L/min/m2
SVR 800-1200 dynes /cm5

Vasoactive Management Hormone Replacement Therapy

• SBP <100 mmHg, despite adequate fluid therapy (90%) • Polyuria despite vasopressin: DI®DDAVP
• Catecholamines • IV T 3 improves cardiovascular stability
ØImmu n o mo d u lato ry effect • Hyperglycemia treated with Insulin
ØHig h d o ses ® d amag e my o card iu m • MPS: Inflammatory modulator
• Dopamine: first line of choice (<10mg/kg/min)
Hormone Resuscitation (HR) Package
• Nor-Adrenaline: (if SBP still low with dopamine)
ØAd v : ­Ren al & Co ro n ary b lo o d flo w
• Vassopressin:
ØTreat DI, ¯Catech o lamin e req u iremen t fo r h emo d y n amics
ØFirst-ch o ice v aso p resso r fo r d o n o r resu scitatio n

Pulmonary Care Temperature Control

• Brain protective ®Lung protective ventilatory strategy • Goal: Normothermia
§ Reduce heat loss; active warming
§ Go a l: PaO 2>1 0 0 mmHg , lo w FiO 2, PEEP 5 -1 0 mmHg § Target core temperature > 36.5-37.5°
C

• Avoid ventilator associated lung injury TV 6-8 ml/kg • How to achieve?

PaCO2 35-45 mmHg
pH 7.4 § Use of warm fluids
• Bronchoscopy:
Paw < 30 mmHg § Forced air warming blankets
ØAsp irate secretio n ; Detect activ e b ro n ch itis/ Aspiratio n , BAL § Active inspired gas humidification
ØFreq u en t ET su ctio nin g; p h ysio therapy ; lu ng recruitmen t
• Avoid hypervolemia and fluid overload

8
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Control of Bleeding Immunosuppressive Strategies

• Replacement of clotting factors • Catecholamine: anti-inflammatory effects
§ Transfusion of FFP & Platelets
§ Target INR <1.5; Platelet count
>50,000/mm 3 Methylprednisolone
§ ¯Immunological activation
• Blood transfusion: may be required § ¯Inflammatory responses in kidney, lung, heart, liver
§ Should be given as soon as possible
§ Target Hb 10 gm%; Ht 30%
§ Dose: Single bolus of 15 mg/kbw
§ Lower Hb: improved outcome Kots ch K et al: Ann Surg 2008;248:1042-50

Nutrition Take Home Message

• Insulin infusion: 1 U/h
• The diagnosis of brain death is primarily clinical
• The prerequisites should be fulfilled before the diagnosis
• Maintain feeding/ glucose source
• Ancillary tests are not mandatory
• Management: preferably in ICU
• Blood sugar: 80-160 mg/dl
• Reduce negative consequences of BD on organs suitable for transplantation
• Optimization: Optimum hemodynamic monitoring, Adequate fluid
resuscitation, Intense vasoactive medication, & Immunosuppressive therapy

Thank You

9
 10/26/18

The Statement

The prevention and management of secondary

brain injury by providing optimal brain conditions
is fundamental to the perioperative care of
CRANIOTOMY FOR BRAIN neurosurgical patients.
Basic Principles
TUMORS of
AND ANEURYSM
Neuroanaesthesia
SURGERY
Dr Keshav Goyal

Case Objectives
q 45 yrs M with Rt Frontotemporo parietal tumour
q Understand basic intracranial anatomy and physiology
q H/o Headache 1 yrs, progressively worsened over 1 mnth
q PMH hypertension -10 yrs; well controlled on amlodipine q Effects of anesthesia and surgery on ICP, cerebral perfusion
q MRI: Rt FTP 5.2cms tumour, peritumoural edema +, midline
q Therapeutic options for decreasing ICP, brain bulk
shift of 7 mm
q Past surgical / anaesthetic history UE perioperatively
q Physical examination: 65 kgs average built
q Implications of concurrent medications & surgical positioning
q Neurological exam: intact, No deficits
q Vitals: BP; 130/85mm Hg, HR:52/Min, RR 15/Min, afebrile
q Airway: MP 2, Normal
q Labs: Hb: 14 g/dl, Na 140meq/dl, K 3.8meq/dl, glucose –
130mg/dl, U/C 30/0.7mg/dl, ECG- WNL

1
 10/26/18

Anatomy and Physiology Monroe- Kellie Doctrine

q What is Unique?

q Rigid, nonexpansile skull filled with brain, CSF, and blood

q CBF autoregulated between MAP of 50-150mm of Hg

q Autoregulatory compensation disrupted by brain pathology

( tumour/ aneurysm)

Brain Compliance Herniation

1. Subfalcine

2. Transtentorial( Uncal)

3. Transtentorial( Central)

4. Transcalvarial

ICP Volume Pressure Curve Cerebral Autoregulation

Normal ICP=10-15 mm Hg.

Sustained ↑ ICP > 22 mmHg
Intracranial hypertension

2
 10/26/18

CO2 Reactivity
¨ Cerebral vasoconstriction à ↓CBF

¨ CBF – linear relationship if PaCO2 = 20-70 mmHg

¨ Δ1 mm Hg PaCO2 à 1-2 ml /100 gm/min ΔCBF

Hyperventilation CPP= MAP-ICP
¨ Target PaCO2 30 -35 mm Hg

¨ Duration of effectiveness à 4-6 hrs

¨ Impaired responsiveness àischemia, tumors, infection etc

¨ In patients with supratentorial brain tumors, intraoperative hyperventilation

improves surgeon-assessed brain bulk
(An esth An a lg 2 0 08 ;1 06 :5 8 5– 9 4)

ICP

¨ Intravenous anesthetics (except ketamine) are

cerebral vasoconstrictors

¨ Volatile anesthetics are cerebral vasodilators

¨ Nitrous oxide increases CMR and ICP

Prevention Prevention cont.

q No overhydration- Euvolemia q Beta-blockers or clonidine or lidocaine

q No noxious stimulus applied without sedation and Local q Steroids, if a tumor is present
Anesthesia q Adequate hemodynamics: Within 20% of baseline
q Head-up position, no compression of the jugular veins q Adequate ventilation: PaO2>100 mm Hg, Paco2 35 mm Hg

q Intrathoracic pressure as low as possible

q Use of intravenous anesthetic agents

3
 10/26/18

Treatment Of Brain Bulge Anaethesia considerations

q Venous drainage: head up, no PEEP, reduction of inspiratory time
q Premedication?
q CSF drainage if ventricular or lumbar catheter in situ
q Goals for induction and maintenance of anaesthesia?
q Avoid N2 O

q Osmotic agents q TIVA vs Inhalational?

q Hyperventilation q Muscle relaxants- Yes or No?
q Augmentation of anesthesia with intravenous anesthetic agents q Problems with patient positioning
q Muscle relaxant
q Postoperative recovery- Early vs Late?
q Mild controlled hypertension if autoregulation present
q Postop care

Presentation Concerns and Problems

q Increased ICP: Headache, nausea and vomiting, changes in

vision
q Main surgical concern: Brain exposure without retraction or
q Focal deficits: weakness, dysphasia (37-58%) mobilization damage.
q Headache:

§ ↑ICP q Main anesthetic concern: the avoidance of secondary brain

damage.
§ Invasion or compression of pain sensitive structures

q Seizures
q Mental status changes: D epression, lethargy, apathy,
confusion

Secondary Brain Damage Specific problems

q Brain Bulge/ Tight Brain

q Massive intraoperative hemorrhage
q Seizures

q Venous Air embolism (VAE)

q Monitoring brain function and environment

q Rapid versus prolonged anesthetic emergence

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 10/26/18

Eloquent Areas

Cushings Response: Hypertension+ Bradycardia+ Apnoae

¨ Advanced monitoring and technology

¤ Intraoperative neurophysiologic monitors
¤ Intraoperative MRI (iMRI),
¤ Neuro-navigation

help and work more efficiently in conjunction

with the patient in awake state

Awake patient is the best monitor

27 28

OR Environment Awake Craniotomy

29
¨ O2 by nasal cannula + EtCO2 monitoring
¨ Infusion of sedatives:
n Propofol/ Dexmedetomidine +
Opioid (Fentanyl)

5
 10/26/18

Determination of anaesthetic strategy Determination of anaesthetic strategy

q Vascular access: Risk of bleeding & VAE q Ventilatory regimen: Normoocapnia

Need for hemodynamic & metabolic monitoring Mild hyperoxia
Need for infusion of vasoactive drugs Low intrathoracic pressures

q Fluid therapy: Aim for normovolemia & normotension q Extracranial monitoring: Cardiopulmonary function
Avoid hypoosmolar fluids (ECG,ABP,CVP, SpO2 , EtCO2)
Avoid glucose-containing solutions
Renal function (urine output)
Specific (e.g. Precordial Doppler –VAE)
q Anaesthetic regimen:
q Intracranial monitoring:
Volatile-based Anaesthesia Total intravenous Anaesthesia
General intracranial environment- EEG
Simple procedures (i.e. procedures with low Complex procedures (anticipated
Specific functions & pathways- Evoked Potential
risk of ↑ed ICP risk or cerebral ischemia, & ↑ed ICP risk or cerebral ischemia, &
Metabolic- Jugular venous bulb monitoring
less need for brain relaxation need for excellent brain relaxation)
- Transcranial oximetry
Functional- Transcranial doppler

Induction Induction cont.

q Adequate anxiolysis in the anesthetic room q Preoxygenation and voluntary hyperventilation

q Adequate fluid loading (5 to 7 ml/kg of NaCl 0.9%) q Propofol or thiopentone for induction

Nondepolarizing muscle relaxant: Paco 2 of 35 mm Hg

q Routine monitors q

q Propofol 50 to 150 mg /kg/min or isoflurance 0.5% to 1.5% (or

q Insertion of intravenous and arterial lines under local
sevoflurane of desflurane) for maintenance and fentanyl 1 to 2
anesthesia mg/kg/hr
q Fentanyl 1 to 2 mg/kg

Induction cont. Positioning

q Lignocaine 1.5 mg/kg q Avoid extreme positioning
q Padding/ fixing of regions susceptible to injury by pressure/
q Intubation abrasion/ movement

q Pin holder application is a maximal nociceptive stimulus: Local ¨ Mild head-up position: - 15-30°, neutral rotation.
q Elevation of contralateral shoulder by wedge/ roll
anesthesia and intravenous fentanyl 2 mg/kg for skull-pin head-
q Care of ETT –easy intraoperative accessibility
holder placement and skin incision q Care of eyes
q Adequate head-up positioning; no compression of the jugular veins

q Mannitol 0.5 to 0.75 g/kg

q Insertion of a lumbar drain. If required

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Maintenance
q Control CMR, CBF
q Good depth of anesthesia

q Adequate CPP
q Maintenance of optimal intracranial environment
(neuroprotection)
q Volatile (<1 MAC)/intravenous anesthetics/N2O

q Mild hyperventilation
q Antiepileptic prophylaxis

q Aim for speedy emergence

TECHNIQUES
Oxygen / N2O / relaxant / inhalational agent
Oxygen / N2O / relaxant / propofol
Oxygen / Air / relaxant / Propofol
Oxygen / Air/N2O / Propofol / Narcotic
Mannitol + / -

ICP control: chemical brain retractor Anaesthetic Goal

§ To preserve brain from secondary
Anaesthetic Action
§ Conserve cerebral autoregulation and CO2
concept insult responsiveness
§ Maximize brain elastance to decrease
retractor pressure
q Mild hyperosmolality § Preserve intracranial pressure volume § Avoiding intracranial compartment volume
relationship increase , esp. for cerebral blood volume
q Iv anesthetic , adequate depth (anesthetics, MAP autoregulation, CO2 )
q Mild hyperventilation § Hemodynamic stability § Autoregulation (30-120sec to be
established); Sharp MAP fluctuations →
q Mild controlled hypertension ( MAP~ 100) undesirable CBF, CBV, ICP changes
q Normovolemia ; no vasodilators
§ To promote adequate oxygen and § Reducing ICP , Brain Bulk , and Tension
q Head up position, no venous compression nutrient supply by maintaining
adequate CPP ,oxygenation and
glucose supply
q No PEEP, no ventilator pt. asynchrony

q Lumbar drainage § Global maintenance of cerebral § Normovolemia, normotension,

homeostasis Normoglycemia
q Avoidance of brain retractors. § Mild hyperoxia and hypocapnia
§ Mild hyperosmolality

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 10/26/18

PEEP

¨ ↑ICP by ↑ mean intrathoracic pressure , impairing cerebral

venous outflow

¨ Used cautiously and with monitoring

¨ 10 cm H2 O or less have been used without significant rise in ICP

or ↓CPP

Early vs. delayed awakening: pros and cons Delayed Awakening : Causes
Early Awakening Delayed Awakening q Large tumor
Pros Pros q Preoperative low GCS
Earlier neurologic exam. & reintervention Less risk of hypoxemia and/or hypercarbia
q Anaesthetic Complication
Baseline neurology for subsequent exam. Better respiratory, hemodynamic control § Residual anesthetics
Less hypertension, catecholamine burst Easier to transfer to the ICU § Metabolic / electrolyte disturbances
Performed by anesthesiologist who Stabilization in same state as during § Hypothermia
knows patient surgery q Surgical complications
Surgery/recovery period separated, ↓costs ↑Better late hemostasis § Cerebral edema
Cons Cons § Hematoma
Increased risk of hypoxemia, hypercarbia Less neurologic monitoring § Pneumocephalus
§ Vessel occlusion/ischemia
Resp irato ry mo n ito rin g d uring tran sfer to ICU More hypertension, catecholamine release
→ ↑bleeding § Seizures

Postop Summary
¨ The 30-day mortality rate after surgery for intracranial tumor is around
2.2% .
q Basis of neuroanaesthesia for surgery of supratentorial
tumors is understanding of
¨ Pain and Postoperative Nausea and Vomiting; Optimal T/t
§ Pathophysiology of raised ICP
¨ Corticosteroids.
§ Regulation & maintenance of cerebral perfusion
¨ Prevention of Seizures.
§ Effects of anesthesia & surgery on ICP, CPP
¨ Thromboprophylaxis. § CPP= MAP-ICP

¨ Antibiotic prophylaxis.

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Summary
q Main objectives of anesthesia are
§ Preservation of cerebral homeostasis

§ Preservation of CBF autoregulation as well as

cerebral vasoreactivity to PaCO2

§ Minimizing need of surgical retraction ANAESTHESIA FOR

§ Early neurosurgical awakening INTRACRANIAL
ANEURYSM SURGERY
Keshav Goyal

Risk Factors Hunt and Hess Grade

¨ Age: Peak in 5th-6th decade Gra de Sy mpto ms Mo rtality

(%)
¨ Sex: F> M
Gra de I Minima l hea da che with no rma l neuro lo gic ex a mina tio n 2
¨ Family history
¨ Hypertension Gra de II Mo dera te to sev ere hea da che, nucha l rig idity , no 5
neuro lo g ic deficit o ther tha n cra nia l nerv e pa lsy
¨ Body mass index
¨ Smoking Gra de III Letha rg y , co nfusio n, or mild fo ca l deficit 15 — 20
¨ Cocaine Gra de IV Stupo r, mo dera te to severe hemipa resis, po ssible ea rly 30 — 40
¨ Size: Aneurysmal rupture increases linearly with the cross- decerebra te rig idity , v eg eta tiv e disturbances
sectional diameter of the aneurysm. Gra de V Deep co ma , decerebra te rig idity , mo ribund a ppea rance 50 — 80
n Small (<10 mm) 78%
n Large (10 - 24mm) 20% Modified classification-
n Giant (>24 mm) 2%
Grade 0 – Unruptured aneurysm
Grade 1a – no acute meningeal reaction but with fixed neurodeficit
Add one grade for HTN/DM/COPD/Severe Atherosclerosis/ angiographic
vasospasm

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Fischer scale (based on CT scan ) WFNS grading of SAH

Grade GCS Motor Deficit

I 15 Absent
II 13-14 Absent
III 13-14 Present
IV 7-12 +/-
V 3-6 +/-
¨ It is possibly the best predictor of cerebral vasospasm and
overall patient outcome

Diagnosis Complications
1. History “Sudden severe headache of my life” NEUROLOGICAL NON-NEUROLOGICAL

2. Physical examination 1. Cardiac

1. Due to rebleed
3. Lumbar puncture 2. Pulmonary
4. CT- Non-contrast, 1st Investigation 2. Vasospasm 3. Fluid and electrolyte
5. MRI
4. Fever
6. Cerebral angiography: Gold standard 3. Hydrocephalus
5.Hyper\hypotension
7. CT angiography ( CTA )
8. MR angiography (MRA ) 4. Seizures 6. Hyperglycaemia

9. TCD

Angiographic vasospasm TCD in vasospasm

Mean MCA MCA:ICA ( Lindegard ) Interpretation
velocity( cm/sec) ratio

<120 <3 normal

120 – 200 3–6 Mild vasospasm

>200 >6 Severe vasospasm

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CARDIAC COMPLICATIONS Timing of surgery

¨ Life-threatening arrhythmia (8%), myocardial ischemia Advantages of Early surgery
(6%) occur rarely q Eliminates risk of rebleeding
¨ Common Electrocardiographic abnormalities
q Allow aggressive treatment of vasospasm therapy
q T-wave changes (12–92%)
q ST segment alterations (15–51%) q Removal of clot
q Prominent U waves (4–47%) q Decreased duration of hospitalisation
q QT prolongation (11–66%)
q conduction abnormalities (7.5%)
Advantages of Late surgery
q sinus bradycardia (16%)
q Better operative conditions
q sinus tachycardia (8.5%)
Van den Berghe WM,Algr a A, Rinkel GJE.. Str oke 2004; 35:644–648.
“NEUROGENIC STUNNED MYOCARDIUM” q Lower operative morbidity / mortality

Coiling Vs Clipping Recommendations

q Surgical clipping or endovascular coiling of the ruptured
q For patients in good clinical condition with ruptured aneurysm should be performed as e arly as feasible in the majority
aneurysms of either the anterio r or posterior circulation, if of patients to reduce the rate of rebleeding after aSAH (Class I;
the aneurysm is considered suitable for both surgical Level of Evidence B).
clipping and endovascular treatment, coiling is associated
with a better outcome. q Should be a multidisciplinary decision based on characteristics of
Van der Schaaf I,Cochr ane Databas e Sys t Rev. 2005 Oct 19;(4)
the patient and the aneurysm (Class I; Level of Evidence C).

q For patients with ruptured aneurysms judged to be technically

amenable to both endovascular coiling and neurosurgical clipping,
endovascular coiling should be considered (Class I; Le vel of
Evidence B).

Primary goals Goals

q Control transmural pressure gradient (TMP G) – prevent q Optimise ventilation to achieve:
aneurysm rupture - Low mean airway pressure, to avoid increasing ICP;
- Normocapnia
q Optimise cerebral oxygenation and perfusion q Prevention or treatment of cerebral oedema

q Adequate preparation to manage potential intra-operative

q Optimise ICP
problems, such as aneurysm rupture.
q Cerebral protection during ischaemic periods q Optimal anaesthesia depth and analgesia

q Provision for rapid emergence

q Optimal operating conditions, and surgical exposure with the
least brain retraction.

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Anaesthesia Goals Temporary Clipping

q Smooth transition awake -anaesthetised state q Gained popularity in recent times
q Avoid significant haemodynamic changes q Effective reduction TMPG
q Maintenance GOALS q Reduced rupture
q “SLACK “brain -- reduces retraction pressure q Clipping easier
q Maintain CPP q Less requirement of controlled hypotension
q Reduce TMP q Critical threshold 15–20 min,
q Prompt awakening (good grade) q Safe limit < 10 min
Sams on D Neur os urgery 34:22–28, 1994 ; Ogilvy CS etal. J Neurosurg 1996; 84: 785–91

q Blood pressure should be maintained at or even slightly above

baseline values.

Extubation
q Decision to extubate made by anesthesia provider and
surgeon

q Higher grade bleeds may need to go to ICU intubated

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 10/26/18

Pituitary Gland

• Lies within pituitary fossa or sella

turcica
• Floor & anterior wall of sella –
Roof of sphenoid sinus
• Posterior wall – clivus

• Lateral wall –cavernous sinus

Dr.Prasanna Bidkar
• Roof – Diaphragmatic sella, optic
Additional Professor chiasma, hypothalamus
Department of Anaesthesiology and CC
JIPMER, Puducherry

2 histological entities-
• Adeno hypophysis Hormones
• Neuro hypophysis released by
Normal Size Pituitary
• 6 mm height,
• 13 mm width,
• 9 mm AP.

Anterior pituitary Hormones Hypothalamic control

Anterior Posterior
•Somatotrophs: GH; 50%
•Lactotrophs: Prolactin; 10–25%
•Corticotrophs: ACTH; 15%.
•Thyrotrophs: TSH; 5–10%
•Gonadotrophs: FSH &LH; 10%
•Null cells: non-functioning pituitary
adenomas
•Hypothalamic control
•Target organ feedback

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Epidemiology

• Difficult to determine epidemiology

-10% of brain neoplasms

-40% of pituitary adenomas prolactinomas

-35% non-functioning

-presentation 3 rd to 5th decade

Clinical presentation Classification

• Endocrine hypersecretion

• Mass effect Size

Endocrine
Function
• Nonspecific symptoms
• Incidentalomas Macroadenoma Microadenoma
Functional Non-functional
>10 mm <10 mm
• Pituitary apoplexy

Functioning Adenomas
Type of Adenoma Secretion Pathology
Corticotrophic ACTH Cushing’s Disease
Somatotrophic GH Acromegaly
Thyrotrophic ( Rare ) TSH Hyperthyroidism
(asymptomatic)
Gonadotrophic LH,FSH Asymptomatic
Lactotrophic or Prolactin Galactorrhoea,hypogonadism,
Prolactinomas amenorrhoea, impotence,
(most common) infertility
Null cell adenomas No secretion

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Growth Hormone (GH) Gigantism and Acromegaly

• Growth hormone acts on a wide variety of tissues : directly
• Excessive secretion of GH
and through release of Insulin-like growth factor I (IGF-I).
• Blood GH of >10 ng/mL(2 to 5 ng/mL normal)
• Stimulate bone and cartilage growth,
• Increase protein synthesis and lipolysis

• Decrease insulin sensitivity and

• Cause Na+ retention

Acromegaly- Features
• Bony and soft tissue enlargement (frontal bossing,
prognathism, enlarged hands, feet)

• Headache, Visual loss –large tumor

• Hoarseness (soft tissue stretching of cranial N X)

• Dyspnoea (narrow glottis -soft tissue overgrowth)

• Increased soft tissue growth Carpal tunnel syndrome

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Acromegaly and Airway Acromegaly- systemic effects

• Hypertension
• Hypertrophy of mandible, nasal • Occurs in 30%, usually responds to therapy
turbinates, soft palate, tonsils,
epiglottis, arytenoids, tongue, lips, and • Myocardial hypertrophy and interstitial fibrosis are common and
nose may be associated with reduced left ventricular function
• OSA
• Narrow glottis • Glucose intolerance
• Vocal cord paralysis § Diabetes Mellitus: 25%
• Cardiomyopathy from lymphocytic infiltration, a common cause of
death, if untreated

Treatment Preoperative Evaluation

§ Treatment
• A thorough history
•Surgery, with or without subsequentradiotherapy
• Evaluate pts for hypertension, hyperglycemia, peripheral nerve or artery
•Dopamine agonists entrapments, skeletal muscle weakness.
•Long-acting analogues of somatostatin(such as octreotide) • Check vision
•Somatuline inj. Every 1-2 weeks • Evidence of increased intracranial pressure
• Airway exam: Look for glottic or subglottic stenosis, nasal turbinate
enlargement, vocal cord thickening, or recurrent laryngeal nerve
involvement.
• C/O dyspnea, hoarseness or stridor or recently diagnosed w/ sleep
apnoea, consider an awake fiberoptic intubation.

Acromegaly – Anaesthesia implications

Face Large mandible Larger masks, Longer laryngoscope
ØAirway involvement in Acromegaly: blades
• Grade 1-- no significant involvement Mouth Macroglossia, OSA Difficult mask ventilation, Difficult
laryngoscopy
• Grade 2-- nasal and pharyngeal mucosa hypertrophy but normal cords
Hands & Feet Thickened soft tissue Venous access, SpO2 probe
and glottis
• Grade 3-- glottic involvement including glottic stenosis or vocal cord Skeleton Kyphosis, osteoporosis Positioning
paresis
Cardiovascular Hypertension, Monitoring, drug selection
• Grade 4-- combination of grades 2 and 3, i.e. pharyngeal mucosal
cardiomyopathy
hypertrophy, abnormalities of the glottis and soft tissue around it.
Metabolic Diabetes Blood glucose control
Endocrine Thyroid, ACTH Drug response, tracheal compr., steroid
therapy

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Cortisol Production
Acetylcholine Norepinephrine
Serotonin
-ve

Corticotropin
Releasing Factor

ACTH 9 - 52 pg/mL

4 am to 8 am: 25 mcg/dL;
Cortisol
4 pm to 8 pm: <10 mcg/dL.

Physiologic role of Cortisol Cortisol deficiency

• Stimulates gluconeogenesis and glycogen synthesis • As part of panhypopituirism- ¯ACTH
• Decreased sensitivity to insulin – hyperglycemia
• Acute cortisol insufficiency is life threatening and should be treated
• Stimulate protein degradation
promptly.
• Increase lipolysis
• Maintains sensitivity of vessels to vasoconstrictors helping maintain • When associated with hypothyroidism- glucocorticoid replacement should
blood pressure and cardiovascular function precede thyroid hormone replacement
• Anti-inflammatory and immunosuppressant action • Require increased doses of glucocorticoids following any form of stress,
• Facilitate free water excretion emotional or physical.
• Decompensation – nausea, vomiting, hypotension, ill look

Cortisol Overproduction Cortisol Overproduction - causes

Cushing’s Disease:
Relative Frequency
• ACTH secreting pituitary tumour
ACTH-producing pituitary adenoma (Cushing’s Disease) 68%
Cushing’s Syndrome:
• Excessive cortisol levels Ectopic ACTH syndrome (bronchial, thymic, pancreatic, 12%
• ACTH dependant- carcinoid tumours)
• ACTH administration, ectopic ACTH syndrome Ectopic CRH syndrome <1%
• ACTH independent- Adrenal adenoma 10%
• Adrenal tumour, cortisol administration, excessive cortisol secretion, Adrenal carcinoma 8%
Macronodular hyperplasia <1%
Micronodular hyperplasia 1%

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Cushing’s Syndrome-
Clinical features Cushing’s Disease- evaluate
• High blood pressure, IHD
• OSA, Obesity related problems
• Fractures due to osteoporosis
• Volume overload
• Gastrooesophageal reflux
• Hypokalemic metabolic alkalosis due to the
mineralocorticoid activity of ­glucocorticoids.

Perioperative Glucocorticoid Therapy

Diagnosis
Type of surgery Perioperative supplementation
• Elevated ACTH levels
Minor surgical stress colonoscopy 25 mg IV hydrocortisone or 5 mg
Hernia repair LA cases methylprednisolone on D-0 • Elevated cortisol levels

Moderate surgical stress open 50-75 mg IV hydrocortisone or 10-15 mg Ø High-dose dexamethasone-suppression test:
cholecystectomy, hemicolectomy methylprednisolone on D-0, taper over 1-2 days
• Eight doses of dexamethasone 2 mg are given orally over 48 h
Major surgical stress cardiac surgery, 100-150 mg IV hydrocortisone or 20-30 mg
• There is suppression of serum cortisol in pituitary dependent Cushing’s
liver resection methylprednisolone on D-0, taper over 1-2 days
disease but not in adrenal Cushing’s or ectopic ACTH secretion
Major critical illness septic shock 50-100 mg IV hydrocortisone every 6-8 h + 50
µg/d fludrocortisone until shock resolved, then
taper.

Anaesthesia concerns-
• Preoperatively optimize blood pressure, glucose control, electrolyte
balance and volume status
• Difficult Mask Holding & Intubation
• Careful positioning – prevent injuries
• Careful adhesive dressings –avoid skin damage
• Muscle weakness -­sensitivity to NMB
• Osteoporosis with possible vertebral body collapse is a consideration
for CNB techniques
• Postop steroid therapy –if pituitary surgery

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Prolactinoma-management Hyperprolactinemia
• No rmal P R L is 1 5 to 2 5 n
g/mL.
TRH
• Dopamine agonists – bromocryptine, pergolide, cabergoline Dopamine
• Surgical management Serotonin
• Often undetected till visual /pressure problems • S/S: ame n o rrh e a, galacto rrh e a, an o vu latio n , d e cre ase d libid o, gyn e co mastia, o ste o p oro sis.
• De te cte d e arlie r in w
o me n be cau se of in e
f rtility.
Stress
Anaesthesia concerns: Prolactin
• Increased ICP
• Related with chronic drug therapy –nausea, orthostatic hypotension,
cardiac valvulopathies

Hyperprolactinemia-causes
• Prolactinoma > 150 ng/ml
• Pregnancy and lactation
• Sleep / Exercise
• Compression of pituitary stalk
• Decreased clearance of prolactin (renal 25-50 ng/ml
failure, hypothyroidism)
• Decreased dopamine
production/antagonistic drugs

Surgical therapy Preoperative Work-up

ØTranssphenoidal :
• Through the nose® Sphenoid sinus® • Routine Laboratory test-
Sella complete blood count, electrolytes, coagulation tests, liver
• Sublabial Approach function tests, urinalysis
• Endoscopic or microscopic • Cardiac evaluation– optimisation
• Cranial MRI
ØTranscranial • Ophthalmic evaluation
• Evidence of raised ICP
• Correction of metabolic, fluid and electrolyte derangements

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Hormonal Profile

• T3, T4, TSH

• Serum levels of cortisol
• Adrenocorticotropic hormone
• Prolactin
• Insulin-like growth factor-1,
• Testosterone, luteinizing hormone, follicle-stimulating hormone,
• Women presenting with secondary amenorrhea should always have
a pregnancy test

Premedication Induction
• Glucocorticoid replacement if appropriate. • Routine IV induction
• Antibiotic prophylaxis. • SUXA / NDMR?
• Securing the airway
• Antisialogouge agent
• Reduce anxiety with oral benzodiazepine????
• Antiaspiration prophylaxis
üInstructions about mouth breathing in postoperative period

Airway Management
Positioning & Maintenance of Anesthesia
• Prepare for difficult airway
• Volatile / TIVA based technique
• Induction technique
• Control of hemodynamics –Adrenaline infiltration
• Videolaryngoscopes? • Dexmedetomidine infusion
• Tracheal Tube- PVC tube
• Positioned in left corner of mouth
• Pharyngeal packing: Prevents bleeding
into glottic region during surgery,
prevents entry of blood and secretions
into stomach which precipitate PONV

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Intraoperative Monitoring What about these?

• Routine monitors – ECG, NIBP, SPO2 • Mild to moderate hyperventilation
• Arterial line –Routinely placed
• Mannitol / Lasix / Hypertonic saline
• CVP monitoring- Not routinely placed for endoscopic Sx
• Urine output monitoring • CSF drainage
• Temperature/ NMJ monitoring
• VEP monitoring

Assisting in tumor removal Control of hemodynamics & blood loss

• Lumbar drain catheter • Variation in vital signs due to intense stimulation

• Good depth of Anesthesia
• Permissive hypercapnia
• Reduces the oozing
• Valsalva maneuver
• Topical applicants
• IV Labetalol / Esmolol

Lumbar intrathecal catheter Control of bleeding - Floseal

• To assist in visualization of the
tumor.
• To manipulate CSF pressure by the
injection of saline or removal of
CSF.
• Injection of intrathecal air. To
“push” the tumor down or outline
tumor on fluoroscopy.
Ø Discontinue N2O to avoid
expansion of the intracranial
airspace and increases in ICP.

Gelatin plus Thrombin complex

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Anaesthesia technique Blood pressure control

• Blood pressure to be maintained at preop. levels.
• Choice of drugs –Usually no constraints
• Bleeding more likely in Cushing's disease and
• Large tumour- Increased ICP acromegaly, with hypertension
• Induction: IV preferred-Thiopentone or Propofol • Severe cardiovasclar reactions have been reported:
Nondepolarising NMB agents • Deepening anesthesia or fentanyl/ remifentanil)
• Maintenance: Propofol/Inhalational agents • Labetolol,
• Inhaled agents increase CSF pressure • Vasodilators (NTG or sodium nitroprusside).
• Use shorter acting agents for early recovery • Alpha-antagonists (such as phentolamine),
• N 2 O: Avoid if pneumocephalus or VAE • Bilateral maxillary nerve blocks
• 1% lignocaine

Pituitary adenoma for surgery Facilitate excision of supracellar part

0800 hours cortisol and short ACTH 1–24 (synacthen)
• Controlled hypercapnia (< PaCO2 of 60 mmHg). Or high-
normocapnia (40–45 mmHg).
15-30 mg • Lumbar cerebrospinal fluid catheter.
Normal Abnormal Hydrocortisone
(cortisol >550 nmol/L) maintenance • A forced Valsalva maneuver.
Perioperative glucocorticoid cover
No Perioperative for 48 h
Glucocorticoid Cover •Hydrocortisone 50 mg i.v. 8-h on day 0 Typical neuroanesthetic maneuvers designed to
• 25 mg i.v. 8-h on day 1 reduce ICP are unsuitable as they make the
• 25 mg i.v. at 0800 AM day 2 pituitary retreat upward out of the sella
0800 hours cortisol for 1-3 d
Journal of Clinical Neuroscience 13 (2006) 413–418 0800 hours cortisol for 3-6 d

Steroid Regimen

§Basal S.cortisol level < §Basal cortisol level 5 -

5 μg/dl 10μg/dl ØHemorrhage from carotid artery damage
§Start steroid supplement §Basal cover in pre op • Fluid and BP management
• Surgical packing
§Prednisolone 2.5 to 7.5 §+ Stress cover • Blood loss replacement
mg/day intraoperatively
§Inj. Hydrocortisone 150- §Basal cortisol level ØPseudo-aneurysm and carotid-cavernous
300mg/24hrs. >10μg/dl fistula formation –
§Stress cover 100mg IV • Angiography
on table

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Diabetes Insipidus (DI) DI-Management

• Reduced ADH by neurohypophysis- central DI • Fluid management regimen:

• hourly maintenance fluids plus two thirds of the previous hour's urine output.
• Nephrogenic DI • An acceptable alternative is previous hour's urine output minus 50 mL plus
• Low U Specific gravity and U osmolarity (<1.005 and < 300 mOsm/L) maintenance.
with high S. osmolarity (>295 mOsm/L) • Choice of fluid as per patient's electrolyte status.
Causes: • 0.45 NaCl and 5% D or 0.9% NaCl
• Avoid Hyperglycemia.
• Postoperatively after Pituitary, craniopharyngiomaor supracellar
surgery • If the hourly requirement exceeds 350 to 400 mL, desmopressin
(DDAVP) IV 1–4 μg/day or Intranasally 10-40 μg/day
vasopressin 5U IV

Smooth and rapid emergence from anaesthesia is essential

ØVenous air embolism – not very common to allow early neurological assessment
• Reduced ETCO 2
• Aspiration of air
• At the completion of surgery, the oropharynx should also be
• Administration of 100% oxygen suctioned meticulously.
• Application of IJV pressure bilaterally
• Removal of pharyngeal pack, thorough suctioning
• Saline irrigation of the wound.
• Haemostasis of open vessels are crucial
• Awake patient
• Avoid coughing
• OSA - Oral airway

Postoperative management Postoperative Complications

ØFluid & electrolyte management.
• Postoperative Nausea & vomiting
ØSteroid Maintenance & Tapering
• CSF rhinorrhoea- lumbar drain
ØAcromegaly & Cushing’s
• Visual loss-III, IV or VI N palsy
§ Airway obstruction
§ Extra body water –Diuresis • Diabetes Incipidus
ØPatient with prior Adrenalectomies required
• Hemorrhage , meningitis
Fludrocortisone0.1to0.2mg/day/
ØDVT prophylaxis • Hydrocephalus

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To conclude-

ØPatients undergoing pituitary disorders can present different

anaesthetic challenges.
ØPreoperative optimisation with hormonal replacements is
essential.
ØSpecific issues in an individual patient should be anticipated
and managed.

Posterior pituitary hormones ADH secretion

• S. Osmolarity >285 mOsm/L
• Primary secretary units =
Distal axons of
hypothalamic neurons
• Octapeptide hormones
• Oxytocin
• Arginine Vasopressin
(AVP), also known as
Antidiuretic hormone
(ADH)

12
 10/26/18

SIADH
• Inappropriately elevated s. concentrations of ADH
leading to hypoosmolality
ØHyponatremia (S. Na <134 mEq/L)
ØS. Osmolarity < 275 mOsm/L
Causes: Head trauma, SAH, Infections, ­ICP, pituitary
stalk transaction, drugs, tuberculosis, stress
Treatment:
• Fluid restriction
• Loop diuretic
• 3% NaCl supplementation (0.5-1 mEq/h increase)

13
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Invasive hemodynamic
monitoring
A PRI ME R- AI I MS PO STG RADUATE ASSE MBLY

O CTO BE R 2 0 1 8 , DE LHI

AVE E K JAYANT DM AMRI TA I NSTI TUTE O F ME DI CAL SCI E NCE S AND RE SE ARCH CE NTRE , KO CHI

Disclosure slide

u No dis c los ure s or c onflic ts of inte re s t

u I am a s ubs pe c ialty ane s the s iologis t but… am an (inc re as ingly) old dog
hoping to le arn ne w tric ks

disclosures

Agenda

Se c tion I: will foc us on te c hnic alitie s (s low and painful but e s s e ntial)

Se c tion 2 Will be fas t and bus ine s s like with a c ookbook approac h (for thos e
who are e ithe r too brainy or too lazy to pay atte ntion
A little physics- and
hopefully non geek

1
 10/26/18

At the beginning A bit of arithmetic and de ja vu?

u 1mm Hg= 1.36 c m H 2 O

u 1 c m H 2 O= 0.74 mm Hg

u For Rev Hales who firs t meas ured blood pres s ure in a hors e (with water
manometry) the c olumn meas ured 8 feet! (180 mm Hg)

REGISTRAR PRIZE

Physics of Invasive Blood Pressure

Monitoring

IM Moxham
Medunsa

Study: Physics of Invasive Blood Pressure Monitoring Figure 2

Introduction
Intra-arterial cannulation allows for continuous, beat-to-beat blood
pressure measurement – it is considered the gold standard of
REGISTRAR blood
PRIZE
pressure monitoring techniques. The quality of the transduced arte-
rial pressure waveform depends on the dynamic characteristics of

Physics of Invasive Blood Pressure

the catheter-tubing-transducer system. As clinicians, we strive to
understand both the physiological and physical limitations of these
measurements, judge the potential for error, and intervene appropri-

Monitoring
ately in the face of these uncertainties.1

Discussion
Technical Aspects of Direct Blood Pressure

Transduce energy at the core

Measurement
Catheter-transducer systems as used in the operating theatre and in-
tensive care are characterized by an “underdamped, second-order
dynamic system”2 which is analogous to a bouncing tennis ball. Upon IM Moxham
dropping the ball, it bounces several times and comes to rest on the Medunsa

Birds of
floor. With each successive bounce, it does not rise as high as be-
fore. Each bounce has a characteristic frequency, and the time it
takes the ball to come to rest is related to the damping coefficient.3
Study: Physics of Invasive Blood Pressure Monitoring Figure 2
Figure 1: A common transducer in anesthesia changes mechanical energy
Introduction A Wheatstone bridge in a strain gauge pressure transducer is connected to a deform-

a
(arterial pulse) into electrical energy
Intra-arterial cannulation allows for continuous,
able diaphragm. Stretching ofbeat-to-beat
a wire changes bloodits electrical resistance. When pressure
pressure measurement – it isisapplied to the diaphragm,
considered the goldstrain standardon twoof of blood
the resistors (no 2 and no 3) increases,
whilst strain
pressure monitoring techniques. Theonquality
no 1 andof nothe4 willtransduced
decrease. Thearte- change in total resistance across the
bridge is proportional to the change in blood pressure.
rial pressure waveform depends on the dynamic characteristics of
the catheter-tubing-transducer system. As clinicians, we strive to nd
(From Morgan GE, Mikhail MS (ed): Clinical Anesthesiology, 2 ed. Appleton & Lange, 1996, fig 6-15)

feather
understand both the physiological and physical limitations of these
measurements, judge the potential for error, and intervene appropri-
ately in the face of these uncertainties.1
sine wave and is equal to the pulse rate, thus the first harmonic. The
th
(From Miller RD (ed): Anesthesia, 5 ed, Churchill Livingstone 2000, fig 28-3) second harmonic is a sinusoidal waveform with a frequency twice
Discussion
that of the fundamental harmonic. The waves are in phase, moving
Technical Aspects of Direct Blood Pressure
in the same direction and passing through zero amplitude together.5
Measurement
All pressure-monitoring systems attempt to accurately convert the The ideal measurement system should deal with all the harmon-
Catheter-transducer systems as used in the operating theatre and in-
physical energy of pressure-induced movements of a transducer dia- ics of the input waveform in the same way. The amplitudes of the
tensive care are characterized by an “underdamped, second-order
phragm to electrical energy. The fidelity with which the system output harmonics will bear a constant ratio to the corresponding
dynamic system”2 which is analogous to a bouncing tennis ball. Upon
performs is dependant on the transducer (being the weakest link), its amplitudes of the input harmonics and there will be no phase differ-
dropping the ball, it bounces several times and comes to rest on the
electrical components and the catheter-tubing system. ence between the output and input harmonics. It is rarely possible to
floor. With each successive bounce, it does not rise as high as be-
avoid phase shift, but a phase shift proportional to frequency is ac-
fore. Each bounce has a characteristic frequency, and the time it
Frequency Content of the Arterial Pressure ceptable.
Moxham S Afr J Ane s th Analg 2003
Waveform
takes the ball to come to rest is related to the damping coefficient.3
The natural frequency of the measuring system must exceed the
An arterial pulse wave contains a fundamental frequency and series natural frequency of the arterial pulse (approximately 16-24 Hz).6
of harmonics.4 The fundamental frequency is the Figure 1: A frequency
lowest common transducer
Theinlower
anesthesia changeshave
harmonics mechanical
the greatestenergyamplitude. By reproducing
(arterial pulse) into electrical energy A Wheatstone bridge in a strain gauge pressure transducer is connected to a deform-
able diaphragm. Stretching of a wire changes its electrical resistance. When pressure
Southern African Journal of Anaesthesia & Analgesia - February 2003 33 strain on two of the resistors (no 2 and no 3) increases,
is applied to the diaphragm,
whilst strain on no 1 and no 4 will decrease. The change in total resistance across the
bridge is proportional to the change in blood pressure.
nd
(From Morgan GE, Mikhail MS (ed): Clinical Anesthesiology, 2 ed. Appleton & Lange, 1996, fig 6-15)

sine wave and is equal to the pulse rate, thus the first harmonic. The
th
(From Miller RD (ed): Anesthesia, 5 ed, Churchill Livingstone 2000, fig 28-3) second harmonic is a sinusoidal waveform with a frequency twice
that of the fundamental harmonic. The waves are in phase, moving
in the same direction and passing through zero amplitude together.5
All pressure-monitoring systems attempt to accurately convert the The ideal measurement system should deal with all the harmon-
physical energy of pressure-induced movements of a transducer dia- ics of the input waveform in the same way. The amplitudes of the
phragm to electrical energy. The fidelity with which the system output harmonics will bear a constant ratio to the corresponding
performs is dependant on the transducer (being the weakest link), its amplitudes of the input harmonics and there will be no phase differ-
electrical components and the catheter-tubing system. ence between the output and input harmonics. It is rarely possible to
avoid phase shift, but a phase shift proportional to frequency is ac-
Frequency Content of the Arterial Pressure ceptable.
Waveform The natural frequency of the measuring system must exceed the
An arterial pulse wave contains a fundamental frequency and series natural frequency of the arterial pulse (approximately 16-24 Hz).6
of harmonics.4 The fundamental frequency is the lowest frequency The lower harmonics have the greatest amplitude. By reproducing

Southern African Journal of Anaesthesia & Analgesia - February 2003 33

Invasive Blood Pressure Monitoring The requisites of measurement

A dampener
26 CHAPTER 1. NATURAL RESPONSE
• COMPONENTS OF
AN IABP
MEASURING No o ffse t 0=0
SYSTEM : Amplitude line arity (
One vs 2 Point c alibration)
100=>100
1. Intra-arterial Cannula
Phase Line arity (phas e s
2. Fluid Filling tube
Figure 1.19: Second-order mechanical system.
of c ardiac c yc le )
3. Transducer
position is indicated in the figure by the vertical line connecting to the
arrow which indicates the direction of increasing x.
A free-body diagram for the system is shown in Figure 1.20. The forces Ade quate Bandwith Diffe re nt
A s e c ond orde r dampe d os
k b 4.c illatory
F and F are identical to those considered in Section Infusion/Flushing
1.1.1. That is, the
s ys te m?
spring is extended by a force proportional to motion in the x-direction,
he art rate s and inte rac tion
F = kx. The damper is translated by a force which is system
k proportional to ve- with native c irc ulation
locity in the x-direction, F = b dx/dt. As shown in the free-body diagram,
b
these forces have a reaction component acting in the opposite direction on
the mass m. The only di⇥erence here as compared 5. to Signal processor,
the first-order sys-
tem of Section 1.1.1 is that here the moving element has finite mass m.
In Section 1.1.1 the link was massless. amplifier and display
To write the system equation of motion, you sum the forces acting on
Philip JH, Brigham HMS
the mass, taking care to keep track of the reference direction associated with
these forces. Through Newton’s second law the sum of these forces is equal
to the mass times acceleration

dx d 2x
Fb Fk = b kx = m . (1.32)
dt dt2

Rearranging yields the system equation in standard form

d 2x dx
m +b + kx = 0. (1.33)
dt2 dt

(As a check on your understanding, convince yourself that the units of all
the terms in this equation are force [N].)

2
 10/26/18

Is the pressure correct? What can be

Zero?
wrong?

u Static errors u All hemodynamic values indexed to barometric pres s ure

u Dynamic errors
u Als o referenc ed to a s urfac e marking of the heart (the phlebos tatic axis )

u Static errors in ze ro
u Static errors in gain u Us ually referenc ed to the heart but s ometimes to a vas c ular bed (s itting
pos ition neuros urgery)

u Dynamic errors in me asure me nt syste m

u Dynamic errors in patie nt

Zeroing thus has two basic aims

The u Barome tric ambie nt pre s s ure (760 mm Hg or the re abouts ) is me as ure d as
ze ro

Phlebostatic
Re fe re nc e d to the he art
axis
u

u Als o onc e this ope ration has be e n pe rforme d to re as s e rt that whe n the
pre s s ure s hould re ad ze ro it ac tually doe s s o (s tatic drift)

Horizontal air bubble is OK

Also suppose a bubble was

Now to test you so
introduced by the devil?
Turn it one way + 3 mmHg

u Non le ve l bubble in tubing

Turn it one way + 3 mmHg

u Whic h re ading would be more inac c urate ?

The invas ive arte rial pre s s ure ?

The invas ive we dge pre s s ure ?

Whic h of the s e s ituations would introduc e

an e rror in the s tatic me as ure me nt?

3
 10/26/18

Invasive Blood Pressure Monitoring

• The normal
waveform for an
invasive ABP :
Non-Linearity 1. Initial sharp rise (left
ventricular systole)
2. Rounded slope

So far we have focused on the represents the peak

Static errors in gain

systolic pressure
3. Dicrotic notch:

number but not the shape represents the closure

of the aortic valve
4. Descending slope
signifies the beginning
Invasive Blood Pressure Monitoring of diastole.

u Es s entially means a bad trans duc er PHYSICAL PRINCIPLES

• Sine Waves :
Invasive Blood Pressure Monitoring
u When the MAP in the patient meas ures 86 mm Hg the trans duc er s hould 1. Amplitude
reas onably read this 2. Frequency • The arterial pressure
3. Wavelength wave consists of a
4. Phase fundamental wave (the
pulse rate) and a series
u However it may not – for both s tatic and dynamic reas ons . When s tatic of harmonic waves.
errors oc c ur not eas y to troubles hoot (reus e, non s tandard devic e) These are smaller waves
whose frequencies are
multiples of the
fundamental frequency
• The process of analyzing
a complex waveform in
terms of its constituent
sine waves
Adapted from Yus uf M
( Fourier Analysis )

Hemodynamic Monitoring: Principles to Practice – M. L. Cheatha

The inner outer conundrum Damping – over and under

PHYSICS OF PRESSURE MONITORING PHYSI

u The ac tual arte rial pre s s ure trac e is a s um total of the inte rac tion of two • For example, when dropped onto a hard floor, a ball • Howe
dis c re te os c illators (the patie nt and the me as ure me nt s ys te m) bounces several times before coming to rest the b
– With each successive bounce, it does not rise as decre
high as on the previous bounce reflec
u Sinc e the me as ure me nt s ys te m re c ons truc ts a phys iologic wave form us ing
harmonic s the s ys te m s hould be c apable of me as uring not only the – Each bounce has a characteristic frequency
q y (
(the – Th
original fre que nc y (e .g. 1Hz he art rate 60, 3 Hz HR 180) but als o its number of oscillations per unit time) and do
harmonic s damping coefficient (time that it takes the ball to
come to a rest)
u Typic al to s ugge s t that at le as t 6-10 harmonic s ne e d to be me as ure d (for
HR 180, 3X8= 24 Hz). Als o why trans duc e rs are c halle nge d by ne onate s
and atrial fibrillation alike Frequency
P1, P2 are
respectiv
Damping Coefficient ξ is the d
Che atham e t al

1352 PART IV: Anesthesia Management

ART 166/56 (82) NIBP 126/63 (84) 1 sec

1 sec
135
B
A
90
DETER
PHYSICS
45
OF PRESSURE MONITORING AND DA
160

• The accuracy
0 of a second
second- -order system is subject to
• This c
three mechanical factors
1 min you d
1. Compliance 200
80
• The stiffness of the fluid fluid- -filled system (tubing)
2. Fluid inertia B
Fn
A
100
• The pressure required to move fluid (blood)
0 through the system
Figure 45-3. Underdamped arterial pressure waveform. Systolic 3. Fluid resistance 0
pressure overshoot and additional small, nonphysiologic pressure
waves (arrows) distort the waveform and make it hard to discern the
•Figure
The viscosity of the
45-4. Overdamped fluid
arterial moving
pressure through
waveform. The over- the
damped pressure waveform (A) shows a diminished pulse pressure
system (resistance due to friction) Fn is th
Essentially the output is a constant
dicrotic notch (boxes). Digital values displayed for direct arterial blood
compared with the normal waveform (B). The slow-speed recording
pressure (ART 166/56, mean 82 mm Hg) and noninvasive blood pres- C
Translated to biologic systems
(bottom) demonstrates a 3-minute period of damped arterial pressure.
sure (NIBP 126/63, mean 84 mm Hg) show the characteristic relation-
Note that despite the damped system, mean arterial pressure remains

interaction
ship between the two measurement techniques in the presence of an
unchanged. (From Mark JB: Atlas of cardiovascular monitoring, New
underdamped system. (From Mark JB: Atlas of cardiovascular monitor-
York, 1998, Churchill Livingstone.)
ing, New York, 1998, Churchill Livingstone.)

of true intraarterial pressure. An underdamped pressure

Original waveform
waveform displays systolic pressure overshoot and may
contain elements produced by the measurement system
itself rather than the original propagated pressure wave
(Fig. 45-3 ). In contrast, an overdamped waveform is rec- 1.2 Overdamped
ognizable by its slurred upstroke, absent dicrotic notch,
and loss of fine detail. Damping
Such waves display a falsely nar- 1.0
PHYSICS OF PRESSURE MONITORING PHYSI
Damping coefficient

Coe ffic ie nt MAP may remain reason-

rowed pulse pressure, although 0.8
Unacceptable

ably accurate (Fig. 45-4).and ratio of

Catheter-tubing transducer systems in routine clini- Optimal dynamic
Natural/ input 0.6
cal use tend to be underdamped but have an acceptable • The complex pressure wave generated response with each • If the
natural frequency thatfreexceeds
que nc y 12 Hz68 (Fig. 45-5).beat
In of the0.4 heart is not unlike the bouncing ball obstr
general, the lower the natural frequency of the monitor- wave
– A pressure
0.2
waveform is propagated at a given
Adequate dynamic
ing system, the more narrow the range of damping coef- response
ficients necessary to ensure faithful reproduction of the frequency (beats per minute)
Underdamped – Th
0
pressure wave. For example, if the monitoring system’s – The vascular resistance acts as the damping p g in
natural frequency is 10 Hz, the damping coefficient must coefficient 0 5 10 15 20 25 30 35 40 45 50
and diminishes the
Natural frequency (Hz)
waveform’s
Wikipe dia be between 0.45 and 0.6 for accurate pressure waveform
monitoring. If the damping coefficient is too low, the
energy and magnitude over time
Figure 45-5. Interaction between damping coefficient and natural
monitoring system will be underdamped, resonate, • and frequency. Depending on these two parameters, catheter tubing-
The resulting arterial sine wave, occurring at the
display factitiously elevated systolic blood pressure; if the transducer systems may be classified by their dynamic response range.
damping coefficient is too high, the system will be over- rate of the
Systems withpatient’s pulse, dynamic
an optimal or adequate is called the
response will first
record
damped, systolic pressure will be falsely decreased, and harmonic or fundamental
and display all or most pressure waveforms encountered in clinical
fine detail in the pressure trace will be lost. practice. Overdamped and underdamped systems skew measure-
ments in predictable ways, with those having a natural frequency <7
For any specific system, the most rapid possible natural
Hz proving unacceptable. The rectangular crosshatched box indicates
frequency facilitates an optimal dynamic response.72 In the ranges of damping coefficients and natural frequencies commonly
theory, this is achieved best by using short lengths of stiff encountered in clinical pressure measurement systems. The red dot
pressure tubing and limiting the number of stopcocks within the box marks the mean values of 30 such systems.74 (From
and other monitoring system appliances. Blood clots and Mark JB: Atlas of cardiovascular monitoring, New York, 1998, Churchill
air bubbles concealed in stopcocks and other connections Livingstone.)
have a similar impact on system dynamic response. As
a general rule, adding air bubbles to a monitoring sys-
tem will not improve its dynamic response because any

Revised 01/13/2009
Downloaded for Aveek Jayant ([email protected]) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on October 19, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.

4
 Hemodynamic Monitoring: Principles to Practice – M. L. Cheatham, MD, FACS, FCCM

10/26/18
PHYSICS OF PRESSURE MONITORING UNDERDAMPED WAVEFORM

• Without some degree of damping within a system, • Note the characteristic

pressure waves reverberate within the catheter and narrow, peaked waveform
tubing leading to the formation of harmonics and – Overestimates systolic
overestimation of true blood pressure and underestimates
– An “underdamped
“underdamped”” system diastolic blood pressure
• With too much damping, the frictional forces impede – Mean arterial pressure
the arterial waveform such that it loses energy remains unchanged!
leading to underestimation of blood pressure • Causes
– An “overdamped
“overdamped”” system – Long stiff tubing,
increased vascular
resistance

Principles to Practice – M. L. Cheatham, MD, FACS, FCCM

SURE MONITORING UNDERDAMPED WAVEFORM OVERDAMPED WAVEFORM OPTIMAL DAMPING

damping within a system, • Note the characteristic • Note the characteristic widened
• Some damping is essential
rate within the catheter and narrow, peaked waveform and slurred waveform
to avoid harmonics
mation of harmonics and – Overestimates systolic – Underestimates systolic
lood pressure – The “optimal” amount of
and underestimates and overestimates diastolic
damping is crucial to
system diastolic blood pressure blood pressure
accurate measurement
– Mean arterial pressure – Mean
M arterial
i l pressure of physiologic pressures
, the frictional forces impede
uch that it loses energy remains unchanged! remains unchanged!

Overdamping
• A catheter-
catheter-transducer
ion of blood pressure
ystem
• Causes Underdamping • Causes system accurately measures
– Long stiff tubing, – Air bubbles, compliant pressure only if its natural
increased vascular tubing, catheter kinks, frequency and damping
resistance blood clots / fibrin, coefficient are appropriate
stopcocks, no fluid or low
flush bag pressure Cheatham et al
Cheatham et al

VEFORM OPTIMAL DAMPING FREQUENCY RESPONSE DYNAMIC RESPONSE ARTIFACTS

ened
• Some damping is essential • A pressure monitoring system should be able to • Underdamped and overdamped waveforms are
to avoid harmonics detect changes quickly (known as the “frequency encountered in the ICU on a daily basis
c response”)
– The “optimal” amount of – Look for them at the bedside!
tolic
damping is crucial to • Damping will tend to decrease frequency response • The ability to recognize when these potential
accurate measurement
– Important if changes are occurring rapidly such sources of error or “dynamic
dynamic response artifacts
artifacts” are
of physiologic pressures
as with tachycardia or a hyperdynamic heart present is essential to the…
• A catheter-
catheter-transducer – Appropriate use of hemodynamic measurements
• The ideal monitoring system has a high “natural” or
system accurately measures
“undamped”
undamped” frequency – Prevention of inappropriate therapy based upon
pressure only if its natural
– The frequency that would occur in the absence of erroneous data
frequency and damping
coefficient are appropriate any frictional forces or damping
ow – Allows accurate measurement of fast heart rates

ONSE DYNAMIC RESPONSE ARTIFACTS Revised 01/13/2009

What
system should be able to • Underdamped and overdamped waveforms are
determines
y (known as the “frequency encountered in the ICU on a daily basis
– Look for them at the bedside! dynamic
behavior?
crease frequency response • The ability to recognize when these potential
s are occurring rapidly such sources of error or “dynamic
dynamic response artifacts
artifacts” are
or a hyperdynamic heart present is essential to the…
stem has a high “natural” or – Appropriate use of hemodynamic measurements

A useful ‘to do’ list

– Prevention of inappropriate therapy based upon
would occur in the absence of erroneous data
or damping
asurement of fast heart rates

Che atham e t al
Mc Ghe e e t al AACN 2002
Hemodynamic Monitoring: Principles to Practice – M. L. Cheatham, MD, FACS, FCCM

5
DYNAMIC RESPONSE ARTIFACTS TROUBLESHOOTING

• Because dynamic response artifacts are commonly • OK, now let’s get practical…
encountered during patient monitoring, titration of
• The simpler the pressure monitoring system, the
medications should ALWAYS be based upon mean
higher its fidelity, the less it is subject to dynamic
arterial pressure (MAP)
response artifacts, and the less likely it will be to
– This variable is less subject to measurement produce erroneous data
p
error due to under
under-- or overdamping
• There are a number of steps that should be
• Systolic and diastolic blood pressure should NOT undertaken whenever setting up or troubleshooting
be used to titrate therapy! a catheter
catheter--transducer system

More rapid s ys tolic ups troke

Highe r he art rate

What is a simple troubleshooting list?

TROUBLESHOOTING TROUBLESHOOTING

• Remove multiple stopcocks, multiple injection ports, • Remove all air bubbles from the system
and long lengths of tubing whenever possible – Perhaps the single most important step in
– The optimal length of pressure tubing is 4 feet optimizing dynamic response Patie nt B
» Longer lengths of tubing promote harmonic Patie nt »A Air acts as a “shock absorber”
amplification
p and underdamping
p g – Bubbles as small as 1 mm in diameter can
– Ensure that arterial pressure tubing is being used
» Overly compliant tubing leads to overdamping
Why this is not gibberish? Need to individualise
cause substantial waveform distortion
» Leads to overdamping and flattened waveforms
– Avoid large diameter tubing – Ensure
Gardne r e t al Ane sthat
the s iolall connections are tight and
o gy 1981
» Prevents achievement of optimal damping periodically flush all tubing and stopcocks to
remove air bubbles

TROUBLESHOOTING TROUBLESHOOTING

• Whenever you are evaluating a patient’s changing • Zero the transducer

hemodynamics – The accuracy of invasive pressure measurements
– Check all transducers, stopcocks, tubing, and is dependent upon a proper reference point
injection ports for air » The “midaxillary line” or “phlebostatic axis” is
– Gentlyy tap
p the tubing
g and stopcocks
p as the commonlyy utilized
continuous flush valve is opened to dislodge any – Each transducer should be zeroed at least once
bubbles each day and whenever data is considered suspect
» This will usually clear the system and restore
measurement accuracy
» Flushing a few small bubbles through the
5
catheter is OK; if more air is present, aspirate it
from the tubing
 10/26/18

Physiology? Distal pulse amplification Why should this occur?

ment
1356 PART IV: Anesthesia Management

Aortic arch
Elas tic low res is tanc e c entral aorta
Aortic arch
2
1 sec 1 Res is tive elements in dis tal vas c ulature retard
R progres s ion of pres s ure wave
1 sec 1 3 3

120 Femoral artery

1 Out of phas e progres s ion between aorta and

3 80
4 5
2 periphery allows s ummation of forward
and reflec ted waves
6
Femoral artery Highe r SBP, late r pe ak 40
Figure 45-10. Distal pulse wave amplification of the arterial pres-
sure waveform. Compared with pressure in the aortic arch, the more
peripherally recorded femoral artery pressure waveform demonstrates

Wide pulse pre ssure a wider pulse pressure (compare 1 and 2), a delayed start to the sys-
tolic upstroke (3), a delayed, slurred dicrotic notch (compare arrows),
Ste e p upstro ke 0 and a more prominent diastolic wave. (From Mark JB: Atlas of cardio-
2 Figure 45-9. Normal arterial blood pressure waveform and its rela- vascular monitoring, New York, 1998, Churchill Livingstone.)
5 tion to the electrocardiographic R wave. (1) Systolic upstroke, (2) sys-
tolic peak pressure, (3) systolic decline, (4) dicrotic notch, (5) diastolic
runoff, and (6) end-diastolic pressure. (From Mark JB: Atlas of cardio- Mark JB Atl as of hemody nami c moni tori ng
vascular monitoring, New York, 1998, Churchill Livingstone.)

6 De laye d dic ro tic no tc h Mark JB

Figure 45-10. Distal pulse wave amplification of the arterial pres- curve divided by the beat period, averaged over multiple
sure waveform. Compared with pressure in the aortic arch, the more cardiac cycles. Although MAP is often estimated as dia-
stolic pressure plus one third times pulse pressure, this
peripherally recorded femoral artery pressure waveform demonstrates estimate is only valid at slower heart rates, because the
a wider pulse pressure (compare 1 and 2), a delayed start to the sys- proportion of the cardiac cycle spent in diastole decreases
as the heart rate increases.83
tolic upstroke (3), a delayed, slurred dicrotic notch (compare arrows), An important feature of the arterial pressure wave-
form is distal pulse amplification. Pressure waveforms
and a more prominent diastolic wave. (From Mark JB: Atlas of cardio- Systole Diastole Systole Diastole
hesia Management recorded simultaneously from different sites have dif-
re waveform and its rela- vascular monitoring, New York, 1998, Churchill Livingstone.) ferent morphologies due to the physical characteristics
of the vascular tree, namely, impedance and harmonic
Systolic upstroke, (2) sys- Aortic arch
resonance31,81 (Fig. 45-10). As the pressure wave trav- Young Elderly
els from the central aorta to the periphery, the arterial
icrotic notch, (5) diastolic upstroke becomes steeper, the systolic peak increases, the Figure 45-11. Impact of pressure wave reflection on arterial pres-
sure waveforms. In older individuals with reduced arterial compliance,
dicrotic notch appears later, the diastolic wave becomes
m Mark JB: Atlas of cardio- more prominent, and end-diastolic pressure decreases. As
early return of peripherally reflected waves increases pulse pressure,
produces a late systolic pressure peak (arrow), attenuates the diastolic
hill Livingstone.) 1 sec 1
a result, compared with central aortic pressure, peripheral pressure wave, and at times, distorts the smooth upstroke with an
2 arterial waveforms have higher systolic, lower diastolic, early systolic hump.
and wider pulse pressures. Furthermore, as the signal is
delayed in arriving at the peripheral site, the systolic pres-
R sure upstroke begins approximately 60 milliseconds later the shape of the arterial pulse wave recorded from dif-
in the radial artery than in the aorta. MAP in the aorta is ferent arterial sites. For example, reduced arterial compli-
veraged
3 over multiple 3 only slightly higher than that in the periphery. ance causes premature return of reflected pressure waves,
Reflection of pressure waves within the arterial tree has resulting in arterial pressure waveforms with increased
ten estimated as dia- Femoral artery a great impact on changes to the arterial pressure wave- pulse pressure, a late systolic pressure peak, attenuated
s pulse pressure, this form as it travels peripherally.81 As blood flows from the
aorta to the radial artery, mean pressure decreases only
diastolic pressure waves, and at times, an early systolic
hump distorting the smooth upstroke (Fig. 45-11).
art
1 rates, because the slightly because there is little resistance to flow in the
major conducting arteries. At the arteriolar level, though,
From these considerations, the morphology of the
arterial waveform and the precise values of systolic and
t in diastole
4 decreases 2 mean blood pressure decreases markedly as a result of a diastolic blood pressure vary throughout the arterial sys-
5 dramatic increase in vascular resistance. This resistance tem under normal conditions in otherwise healthy indi-
to flow diminishes pressure pulsations in smaller down- viduals. These variations are augmented and at times
terial pressure wave- stream vessels but augments upstream arterial pressure
pulses by way of pressure wave reflection.84 The summa-
greatly exaggerated by various factors, including but not
limited to age, pathologic processes, and pharmacologic
Pressure waveforms 6 V. Bouchard-Dechêne et al. / Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) 692–698
tion of these antegrade and reflected waves determine interventions. 695
Systole
Figure Diastole
45-10. Distal pulse wave amplification of Systole Diastole
the arterial pres-
erent sites have dif- sure waveform. Compared with pressure in the aortic arch, the more
hysical characteristics peripherally recorded femoral artery pressure waveform demonstratesTable 3 Downloaded for Aveek Jayant ([email protected]) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on October 19, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
dance and harmonic a wider pulse pressure (compare 1 and 2), a delayed start to the sys-
Intraoperative Data

Young vs old differences Pressure is not flow!

pressure wave trav- tolic upstroke (3), a delayed, slurred dicrotic notch (compare arrows),
and a moreYoung
prominent diastolic wave. (From Mark JB: Atlas Elderly
of cardio-
eriphery, the arterial Variables No gradient Presence of p Value
erial blood pressure waveform and its rela- vascular
Figure monitoring,
45-11. ImpactNew York, 1998, Churchill
of pressure waveLivingstone.)
reflection on arterial pres-
ic peak increases, the N ¼ 289 gradient N ¼ 146
aphic R wave. (1) Systolic upstroke, (2) sys- sure waveforms. In older individuals with reduced arterial compliance,
astolic wave becomes
tolic decline, (4) dicrotic notch, (5) diastolic
early return of peripherally reflected waves increases pulse pressure,
pressure decreases.
lic pressure. (From As
Mark JB: Atlas of cardio-
produces a late systolic pressure peak (arrow), attenuates CPB time (min)
the diastolic 84 (66; 113) 100 (76; 130) o 0.001
c pressure,
York, peripheral
1998, Churchill Livingstone.) pressure wave, and at times, distorts the smooth Aortic clamping time
upstroke with (min)an 61 (38; 84) Attenuation in IABP measurement systems 76 (57; 109) o 0.001
tolic, lower diastolic, early systolic hump. Complex procedures 102 (35.3%) 81 (55.5%) o 0.001
more, as the signal is Fluid balance (mL) 2,183.3 7 1,177.0 1,961.3 7 1,107.2 0.059
site,period,
beat the systolic
averaged overpres- multiple Norepinephrine (% Stiffofarte rie s
patients) 260 (95.9%) 140 (90.0%) 0.032
ugh
60 MAP is often estimated
milliseconds later as dia- the shape of the arterial pulse wave recorded from dif-
Norepinephrine (total μg) 880 (480; 1,440) 1,216 (784; 2,192) o 0.001
a.neMAPthird times
d periphery.
e
in the pulse pressure,
aorta
at slower heart rates, because the
is this
It is usual in the literature to describe the behaviour of
ferent arterial sites. For example, reducedVasopressin
ance causes premature return of reflected pressureHighe
arterial (% compli-
Highe
of
waves,
r re fle c tanc e
patients) A
135 (46.7%) V (t) 86 (58.9%)
o
0.016
diac cycle spent in diastole decreases Vasopressin (total UI) r afte rload due to 0.0 (0.0; 3.0) 1.0 (0.0; 5.0) Blo o d pre ssure 0.001
n the arterial tree has resulting in arterial pressure waveforms with increased
ases.83
rterial pressure wave-
IABP systems in isolation from the arterial tree to which it is
pulse pressure, a late systolic pressure peak, attenuated
Inhaled milrinoneRebefore
fle c teCPB
d wave s 33 (11.4%) 16 (11.0%) 0.89
ure of the arterial pressure wave- Inhaled milrinone after CPB 27 (9.3%) 20 (13.7%) 0.17
blood flows from the diastolic pressure waves, and at times, an early systolic
amplification. Pressure waveforms
essure decreases only Systole
hump distorting Diastolecoupled; this is a simplification. There is little bulk fluid flow
the smooth upstroke Systole DiastoleMinimal
(Fig. temperature
45-11). Als o de c re as e d e las tic ity o 0.001*
usly from
tance
different sites
to physical
flow in the
have dif-
From these considerations, the morphology o 301C Of
of c e ntral
thearte ry I (t) Z
15 (5.2%) = RSVR C LV 84 (57.5%)
3 (2.1%)
SVR
due to the
teriolar level,
characteristics
though,
namely, impedance and harmonic
within the IABP circuit and its behaviour is well described
arterial waveform and the precise values 30º-341C of systolic and 107 (37%)
kedly
5-10). As asthea result
pressureof wavea trav- diastolic blood pressure vary throughout 4 341C
the arterial sys- 167 (57.8%) 59 (40.4%)
ance.
aorta to This resistance
the periphery, the arterial
Young
as a classically resonant system. Damping is caused by
tem under normal conditions in otherwise
Elderly
Figure 45-11. Impact of pressure wave reflection on arterial
Type of CPB weaningindi-
healthy
pres-
0.49
eper, the
ons in systolic
smaller peak increases, the
down- viduals. These variations are augmentedEasy CPB weaning
and at times 205 (71.2%) 96 (65.8%)
s later,arterial
eam the diastolic
end-diastolic pressure
wave becomes
pressure
decreases. As
greatly
early exaggerated
return of peripherally
energy dissipation by imperfectly elastic elements of the
sure waveforms. In older individuals with reduced arterial compliance,
by various
reflected waves factors, Difficult CPB but
including
increases pulse pressure, weaning not 68 (23.6%) Cardiac Output Impe danc e 42 (28.8%)
ection. 84 The summa- Complex CPB weaning 15 (5.2%) 8 (5.5%)
h central aortic
ted waves determine pressure, peripheral
limited
producesto a age,
interventions.
pressure wave,
pathologic
late systolic
and at
pressure peak processes,
times, distorts
(arrow), attenuates
the smooth
and
upstroke
pharmacologic
the diastolic
system. The dynamics of the arterial tree are very different
Minimal hematocrit
with an B
0.26 7 0.046 Vo(t) o 0.001 0.24 7 0.045
ave higher systolic, lower diastolic, early systolic hump. V (t)
sures. Furthermore, as the signal is
the peripheral site, the systolic pres- as there is aAbbreviation:
(pulsatile) bulk flow of
CPB, cardiopulmonary blood past the arterial
bypass.
p Value for categorization 4 341C v r 341C. n
approximately 60 milliseconds later
an in the aorta. MAP in the aorta is
the shape of the arterial pulse wave recorded from dif-
cannula.
ferent arterial sites. For example, reduced In compli-
arterial this system energy can be dissipated as a result of
mrita.edu) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on October 19, 2018. Zart
e only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
han that in the periphery. ance causes premature return of reflected pressureunderwent
waves, procedures without CPB or with an intra-aortic (Tables 1 and 2). However, a higher EuroSCORE II did not
ure waves within the arterial tree has frictional
resulting in arterial pressure waveforms with forces
balloonarising
increased pump, and from 124 thisdidflow.
not haveThis is
both manifested
a femoral andas a correlate with I LV(t
the ) Z !SVRof a gradient (p ¼ 0.0630). ZPVR
presence
anges to the arterial pressure wave- pulse pressure, a late systolic pressure peak, attenuated
diastolic pressure waves, and at times, an early radial line inserted. Among the 502 patients that met the Among these patients, 146 had a significant radial-to-
pherally. 81
As blood flows from the
tery, mean pressure decreases only
pressure differences
hump distorting the smooth upstroke (Fig. 45-11).
systolic
between different parts of the vascular femoral
inclusion criteria, 56 were excluded because of missing data, artery pressure gradient (34%). Two hundred thirty-
e is little resistance to flow in the From these considerations, the morphology of the
eries. At the arteriolar level, though, system.
arterial waveform and the precise values The6 arterial
of systolic
because
and tree
of is not a resonant
atherosclerotic vascular system, at least
disease causing to a seven patients (56.3%) underwent single coronary artery
signifi-
decreases markedly as a result of a diastolic blood pressure vary throughout the arterial cant sys-
pressure difference at baseline, and 5 because of femoral bypass graft or single valve procedure and 183 patients
AttenuationThis
vascular resistance. in IABP measurement
resistance
essure pulsations in smaller down-
tem systems first approximation.
under normal conditions in otherwise healthylineindi-
dysfunction during the procedure. Four hundred and (42.1%) underwent complex procedures (coronary artery
viduals. These variations are augmented and at times
thirty-five
ugments upstream arterial pressure
sure wave reflection. The summa- 84
In particular,
greatly exaggerated by various factors, including
limited to age, pathologic processes, and pharmacologic
but not whatpatients
is notwere therefore included into the analysis
generally considered is the effect Figure
and were classified according to the presence or the absence
bypass graft1 (A)andElectrical
anomaly correction).
valve, more than of
analogy oneFrank’s
valve orWindkessel
congenital model. Left

ade and reflected waves determine interventions.

of any resistance or disturbance
of radial-to-femoral artery to pressure
laminar gradient.
flow proximal Older age to ventricular
Most of the contraction
preoperativecreates a current
comorbidities wereILV (t) not
found representing
to be pulsatile
(p ¼ 0.0470), female gender (p ¼ 0.0008), smaller weight associated
blood flowwith
as the appearance
a function ofoftime,
a radial-to-femoral
t. The SVR pressure and compliance are
escribe the behaviour of A Vo(t) the cannula.(pInothis0.0001), case alowerflow-dependent
height (p o pressure 0.0001), reduction
lower BMI gradient (Table 2). There was however a significant associa-
(p ¼ 0.0107), lower BSA (p o 0.0001), and a higher
yant ([email protected]) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on October 19, 2018. modelled as an impedance Z angina
tion with preoperative unstable SVR
, which combines parallel lumped
(p ¼ 0.0460). No
arterial tree to which it is can be expected, and thus the pressure recorded by the IABP parameters
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.

operative risk according to the Parsonnet score (p ¼ 0.0003) correlation was and regarding
RSVRfound C. The current
gradientthrough this and
appearance generates
the a voltage
re is little bulk fluid flow Remember your measurement system willwere beadds
reduced. aThe postulated
all associated with the presenceobstruction of amay take Vpreoperative
gradient
Just in case
use of angiotensin receptor antagonist or
o(t), which represents the true IABP, which is to be measured. (B) As
you think this is hot air
= RSVRthe form ofTable
aviour is well described quirk ILV(t) ZSVR
angiotensin converting enzymes inhibitors (p ¼ 0.2858),
C a 4physical narrowing through arterial spasm, the vascular beds
beta-blockers (p are¼ parallel,
0.2604), thecalcium
PVR ofchannel
the limbblockers
in which the arterial
thrombus Postoperative Data
secondary to endothelial trauma or any change in cannula is extracted from the lumped parameters (dotted box) is shown
Damping is caused by Variables No gradient Presence of p Value as an5impedance, ZPVR. For example, in the case of a radial arterial line,
Table
vessel geometry especially ifNit¼leads 289 to turbulent
gradient N ¼flow146 (even
elastic elements of the ZIndependent Variables for Gradient
PVR represents the lumped impedance of the vascular tree of the hand.
locally) as isICUpresumably
stay the case when the arterial lines0.17are This impedance may pbeValuepurely
al tree are very different B Vo(t) found to be o 3 days 187 (64.7%) 83 (56.8%)
OR resistive
95% CIor have reactive (including
Bootstrap

V (t‘positional’.
)3-5 days Indeed,
66 (22.8%)even without any physical capacitive) elements. Note the revised systemic vascular
36 (24.7%) 95% CI impedance and
f blood past the arterial abnormality,ICUthe
4 5 days
small lumen
stay (days) 1. Flow
36 (12.5%)
of 3.0)
into
2.0 (1.0; the
27 (18.5%)
artery2.0from
the radial which the compliance Z0 SVR. Additionally, an
(1.0; 4.0) Lowerarterial impedance
Upper Lower Upper Zart, which
Zart be d (vas oc ons tric tion o 0.001
Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) 692–698

Hospital stay
e dissipated as a result of pressure is being
1-5 daysmeasured Elasconstitutes
tic
103modulus
(35.6%) alte a reresistance
d) 34 (23.3%)in accord- represents
BSA
an obstruction to flow proximal to the arterial cannula is
o 0.0001 0.084 0.030 0.232 0.024 0.209 Contents lists available at ScienceDirect

included. (min) of Vo(t)

Some is 1.013
dropped 1.007across
1.018 Z1.008
art, and,Journaltherefore, theand Vascular Anesthesia
Clamping time 0.0001 1.018
ance withZthe
6-10 days 135 (46.7%) 64 (43.8%)
ow. This is manifested as ILV(t) Z !SVR PVR4 Hagen–Poiseuille
10 days 2. Flow51 as law.
s ample
(17.6%) Clearly
d these
48 (32.9%) considera- measured Fluid balance
o
0.0269 0.808 0.669 0.976 0.654 0.965
of Cardiothoracic
*

Hypertensionvoltage (measured
0.0132 IABP), which2.868
is represented
1.115 3.023by V(t), is less
journal homepage: www.jcvaonline.com
Hospital stay By c6.0
annula
(5.0; 9.0) 8.0 (6.0; 13.0) (Yes versus 1.801 1.131
ent parts of the vascular tions apply only
(days) to peripheral
Cannula arterial
and cannulae
native such as those No)
than the true IABP by a factor depending on Zart and ZPVR. Original Article
In-hospital Arte ry 5s ize )
(1.7%) 7 (4.8%) 0.065 Risk Factors for Radial-to-Femoral Artery Pressure
onant system, at least to a in the radial mortality
artery but these are the most commonly used. Abbreviations: interval.
BSA, body surface area; OR, odd ratios; CI, confidence
Gradient in Patients Undergoing Cardiac Surgery
With Cardiopulmonary Bypass
Abbreviation: ICU, intensive care unit.
n
For 1 liter.
Vincent Bouchard-Dechêne, MDn, Pierre Couture, MDn,
ance to flow (Zart) proximal to the measurement point is Antonio Su, MD†, Alain Deschamps, MD, PhDn,
Yoan Lamarche, MD‡,§, Georges Desjardins, MD, FRCPC, FASEn,
y considered is the effect Figure 1 (A) Electrical analogy of Frank’sModel Windkessel model.
description Left Sylvie Levesque, MSc‖, André Y. Denault, MD, PhDn,§,1
postulated
For personal use only. No other uses without permission. Copyright to represent
©2018. Elsevier the obstruction described above.
Downloaded for Aveek Jayant ([email protected]) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on October 19, 2018.
Inc. All rights reserved. n
Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, Montreal,

aminar flow proximal to ventricular contraction creates a current ILV(t) representing pulsatile †
Quebec, Canada
Department of Anesthesiology, Hôpital Cité de la Santé de Laval, Université de Montréal, Montreal,

blood flow as a function of time, t. The FigureSVR and1Acompliance

shows anareelectrical analogy of the two-element Examining the behaviour of the combination of Zart and ‡
§
Quebec, Canada
Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
Department of Surgery, Division of Cardiovascular Critical Care, Montreal Heart Institute, Montreal, Quebec,

ndent pressure reduction

Canada

of the vascular system originally ZPVR, these components behave as a potential divider. Such
‖
Montreal Health Innovations Coordinating Centre, Montreal Heart Institute, Montreal, Quebec, Canada

modelled as an impedance ZSVR, which Windkessel

combines parallel representation
lumped
4
re recorded by the IABP parameters RSVR and C. The current throughconceivedthis generates a voltageAlthough this model is clearly a sim- circuits are used in electronics to reduce voltages or attenu-
by Frank. Objective: To identify risk factors associated with radial-to-femoral pressure gradient during cardiac surgery with cardiopulmonary bypass
(CPB).
Design: This is a retrospective, observational study.

(B) As reproduces physiological behaviour ate signals. The total voltage applied Vo(t) (which represents
Setting: Single specialized cardiothoracic hospital in Montreal, Canada.

ted obstruction may take Vo(t), which represents the true IABP, whichplification, it grossly
is to be measured. Participants: Consecutive patients that underwent heart surgery with CPB between 2005 and 2015 (n ¼ 435).
Interventions: None.
Measurements and Main Results: A radial-to-femoral pressure gradient occurred in 146 patients of the 435 patients (34%). Based on the 10,000

a useful pedagogical paradigm. Pulsatile the true IABP) appears across both of these elements in
bootstrap samples, simple logistic regression models identified the 17 most commonly significant variables across the bootstrap runs. Using these

through arterial spasm, the vascular beds are parallel, the PVR of theandlimbthus remains
in which the arterial variables, a backward multiple logistic model was performed on the original sample and identified the following independent variables: body
surface area (m2) (odds ratio [OR] 0.08, 95% confidence interval [CI] 0.030-0.232), clamping time (minutes) (OR 1.01, 95% CI 1.007-1.018),
fluid balance (for 1 liter) (OR 0.81, 95% CI 0.669-0.976), and preoperative hypertension (OR 1.801, 95% CI 1.131-2.868).

is shown by the left ventricle develops a time- series. The fraction of this voltage which appears across
flow(dotted
cannula is extracted from the lumped parameters [ILV(t)]box)
generated
6
Conclusion: A radial-to-femoral pressure gradient occurs in 34% of patients during cardiac surgery. Patients at risk seem to be of smaller stature,

trauma or any change in hypertensive, and undergo longer and more complex surgeries.
& 2017 Elsevier Inc. All rights reserved.

as an impedance, ZPVR. For example, in the case of a radialvoltage

dependent o(t) across the systemic vascular imped- ZPVR is denoted by V(t) (which represents the measured
arterial Vline, Key Words: blood pressure; cardiopulmonary bypass; pressure gradient; radial artery; femoral artery

s to turbulent flow (even ZPVR represents the lumped impedance of theance vascularZSVRtreewhich has resistive (lumped systemic vascular IABP) and depends on the value of this impedance as a
of the hand. UNDER MOST CIRCUMSTANCES, radial blood pres-
sures accurately reflect the central pressures. However, during

hen the arterial lines are This impedance may be purely resistive orresistance,
have reactiveSVR) (including
and capacitive (from lumped vascular fraction of the total, namely:
Conflict of Interest: Dr. Denault is speaker for CAE Healthcare and
Covidien.
1
Address reprint requests to Dr. André Y. Denault, MD, PhD, Department
of Anesthesiology, Montreal Heart Institute, 5000 Belanger Street, Montreal,
cardiac surgery involving cardiopulmonary bypass (CPB), a
significant difference appears in some patients causing the
radial pressure to significantly underestimate the central
Quebec H1T 1C8, Canada. pressure.1–16 Since it was first described by Stern et al1 in

en without any physical capacitive) elements. Note the revised systemic vascular impedance
compliance) and
contributions as indicated. Vo(t) represents Z PVR
E-mail address: [email protected] (A.Y. Denault).

http://dx.doi.org/10.1053/j.jvca.2017.09.020
1053-0770/& 2017 Elsevier Inc. All rights reserved.
1985, the central-to-peripheral arterial pressure gradient has

e artery from which the compliance Z0 SVR. Additionally, an arterialtheimpedance

true arterial Zart, blood
which pressure to be faithfully measured. VðtÞ ¼ V o ðtÞ : ð1Þ
Z PVR þ Z art Downloaded for Aveek Jayant ([email protected]) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on October 19, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
 vasoconstriction could alter pulse wave transmission and were collected with regard to the presence or absence of a
therefore cause the pressure gradient.17,18,20 Other mechanisms radial-to-femoral pressure gradient. An electronic screenshot
have been proposed such as blood viscosity,21 hand vessels (Atomos, Global Pty LTD, Port Melbourne, Australia) of the
vasodilation,4,14 and blood vessel elasticity,15 all of which hemodynamic waveforms was obtained at the beginning and
could cause the phenomenon by influencing the blood flow whenever a radial-to-femoral arterial pressure gradient was
and the pulse wave transmission. Because there is still a lack present as shown in Figure 1.
of understanding regarding the mechanisms causing the The decision to insert a radial and/or a femoral artery
pressure gradient, studies identified risk factors that could catheter was left to the judgment of the attending anesthesiol-
help clarify the phenomenon. Risk factors that have been
reported are the hematocrit,21 minimal temperature,16 CPB and
ogist. All femoral artery catheters were inserted under ultra-
sound guidance. However, it is common practice for most of
10/26/18
SOURCE
clamping time,8,20 and factors associated with radial artery the anesthesiologists in the authors’ institution to insert both 120
Anacrotic limb Dicrotic limb
Systolic=115 mm Hg ARTIFAC
CHANGE
diameter such as demographic data,16,20,22 vasoactive medica-
Pulse pressure

catheters routinely in all patients.20,26,27 Exclusion criteria

97 =35 mm Hg
80
Diastolic=80 mm Hg WAVEFO
Dicrotic notch
MORPHO
tion,8,20 and plasma norepinephrine levels.8
MAP=Area + Base

were dysfunctional arterial line during the procedure and RECOMM

40 =97 mm Hg

0 FOR CLIN
These various hypotheses indicate that the pathophysiology missing data from the database with regard to the gradient. BASE
PRACTIC
Damping, O
Figure 2 The normal arterial pressure waveform.
of the gradient probably is multifactorial. It is therefore The patients were classified according to the presence or MAP indicates mean arterial pressure.
Reprinted from Darovic,10 with permission.
Underdamp
A comm

essential to identify risk factors that could guide future absence of radial-to-femoral pressure gradient. The authors
working with
comparing
recorded by
research and help clinicians identify patients who would most considered a significant radial-to-femoraltions,
pressure
80% of thegradient
pressure.
original waveto
Under normal condi- Pharmacological vasoconstriction
22,23

is can similarly increase wave reflec- with the bloo

manually or
benefit from femoral line insertion. However, although many
thought to be reflected. 22
tion and cardiac workload.23,39
be Z25 mmHg in systolic pressure and/or Z10
Clinically, wavemmHg in
reflection plays The contribution of reflected If a discrepan
catheter is of
an important role in left ventricu-
20 waves to the measured systolic
studies tried to recognize such risk factors, few were identified mean arterial blood pressure for a minimum of 5andminutes.
lar workload cardiac oxygen
consumption. In young adults
pressure is diminished during how “dampe
ing understa
hypovolemia, hypotension, the
and confirmation is still needed for most. Therefore, all these Data regarding the following preoperative variables was
with elastic arteries, the reflected
wave returns to the heart during
Valsalva maneuver, and vasodi-
latation. 23 In pharmacologically
readings obt
eter cannot

potential risk factors should be analyzed when studying collected: Parsonnet and the EuroSCORE II, demographics
the diastolic phase of the cardiac
cycle and thus augments coronary
induced vasodilation, such as
occurs with nitroglycerin for
interpretatio
and probabl
2 important fa
central-to-peripheral pressure gradient in cardiac surgery. (age, gender, height, weight, body mass artery
index
or patients[BMI,
with stiff, kg/m ],
perfusion. In elderly patients
atheroscle-
instance, peripherally measured
systolic pressure may not change
between (1) d

Pulse Pressure Amplification, Arterial Stiffness, and ing, and unde

So far, no study had enough patients to develop a predictive and body surface area [BSA, m2]), comorbidities (hyperten-
rotic vessels, the reflected wave in proportion to the actual degree
damped and
Peripheral Wave Reflection
Factors Determine
Involved inPulsatile Flow
When interpreting arterial pressures do
returns to the heart during systole
Risk Central-to-Radial Arterial and thus increases systolic pres-
of reduction in central aortic pres-
sure wavefor
Waveform of the Femoral Artery model. In addition, not all associated factors were reported in sion, diabetes, unstable angina, myocardial infarction, left sure.39,40 The effect of nitroglycerin
damped or u

True blood pressure? Pressure Gradient During Cardiac Surgery sure and left ventricular afterload. 39
may be visible in the appearance
toring system

all the studies. Finally, the impact of the radial-to-femoral

of reflected waves after the systolic
ventricular [LV] dilation, and LV hypertrophy), and preopera-
remember
Junichiro Hashimoto, Sadayoshi Ito or underd
Giuseppe Fuda, MD,* André Denault, MD, PhD,* Alain Deschamps, MD, PhD,* Denis Bouchard, MD,† peak (Figure 4), but reduced aortic
waveforms t
Annik Fortier, MSc,‡ andJean Lambert, PhD,§ andpressure
Pierre amplification
Couture, MD* Central pressure, afterload, and cardiac
Abstract—Aortic stiffness, peripheral wave reflection, aorta-to-peripheral pulse
cardiovascular risk. However, the pathophysiological mechanism behind it is unknown. Tonometric pressure waveforms
all predict
gradient in terms of postoperative hospitalization has not been tive medication. Fluid balance was defined as the total amount aorta
work load may be more evident
physiologica
and (3) blood
were recorded on the radial, carotid, and femoral arteries in 138 hypertensive patients
arterial (age: 56!13 years) to occur
estimate Brachial through clinical improvement of
reported. In this study, the authors investigate all these
BACKGROUND: A central-to-radial pressure gradient may after cardiopulmonary via direct ver
aorta-to-peripheral amplifications, aortic augmentation
femoral Doppler velocity waveform was recorded
bypass (CPB),index,
to calculate
is a pressure
andinaortic
which, some(carotid-femoral)
patients, may last for
the reverse/forward
gradient, flow index
the radial artery pressure
pulse wave velocity.
a prolonged time after
and diastolic/systolic
measure
TheCPB. Whenever there
may underestimate a more centrally
of fluid intake (crystalloids, medications, blood products, and the patient. During shock with
vasoconstriction, wave reflection
ing methods.
forward flow ratio. The aorta-to-femoral and measured systemicamplifications
aorta-to-radial pressure, whichcorrelated
may resultinversely
in a misguided
with therapeutic
the aortic strategy. It is clini- Radial All hemod
J Pediatr (Rio J). 2018;94(1):76- -
-81 can lead to the overestimation of
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cally important towaveform

identify thewas
risktriphasic,
factors that may predict the appearance
forward,of a central-to-radial systems are d
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augmentation index and pulse wave velocity. The femoral flow composed of systolic
subsequent reverse, and diastolic forward phases
Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) 692–698 pressure gradient,whereas
in 129 patients, becauseitmore central sites
was biphasic of measurements
and lacked might then be considered
a diastolic forward central aortic pressure, because desired, beca
Femoral
to monitor systemic arterial pressure in high-risk patients. The objective of this study was to peripheral SBP may be 20 mm Hg
flow in 9 patients. Both the femoral reverse index (30!10%) and diastolic forward ratio (12!4%) correlated positively ing the vibra

A B
assess preoperative and intraoperative risk factors for central-to-radial pressure gradient.
with the aorta-to-femoral amplification and inversely with the aortic augmentation index and pulse wave velocity;
usingthese
Before cardiopulmonary bypass After cardiopulmonary bypass
METHODS: Seventy-three patients undergoing cardiac surgery CPB were included in Dorsalis higher than aortic pressure. 36,39 fluid column
Contents lists available at ScienceDirect
correlations were independent of age, sex, diastolic
this pressure,
prospective andobservational
femoral artery diameter.
study. Patientscentral-to-radial
A significant with biphasic (versus
arterial pressure gradient pedis
triphasic) flow were older, shorter, included morewasdiabetics,
definedhadas smaller femoral
a difference of 25diameters,
mm Hg and showedpressure
in systolic greater aortic
or 10 pulse
mm Hg in mean arterial Pulse Pressure Amplification, Arterial Stiffness, and Peripherally measured SBP could
in this situation provide a false
al pressure
indefinitely
Journal of Cardiothoracic and Vascular wave Anesthesia pressure for a In
minimum of 5 minutes. Preoperative
the inversedata included demographics, presence of
velocity even when adjusted for all of these
pressure gradient, pulse pressure amplification normally
covariates.
comorbidities,
clamping
produces
time,
conclusion,
anda medications.
because of
Intraoperative
substantial reversal
usereflection.
of inotropic
of the femoral
drugs, and vasodilators
(peripheral-to-aortic)
data included type
flow, the of surgery,
degree of CPB and aortic Peripheral Wave Reflection Determine Pulsatile Flow Figure 3 Changes of the arterial
pressure waveform configuration
sense of security that the patient is waveform c
(increased or vasopressors agents. The diameter
journal homepage: www.jcvaonline.com
which is determined by the aortic distensibility and
augmentation, and reduced amplification) decreases
of
peripheral
the radial
wave
and femoral
Arteriosclerosis
artery was measured before the
stiffness,
induction
both the reverse and diastolic forward flows, potentially causing
ultrasonography.
increased
www.jped.com.br
of anesthesia using B-mode Waveform of the Femoral Artery throughout the arterial tree. Note
the increasing steepness and
maintaining adequate perfusion
pressures. A slower systolic up-
Conversely,
and underda
circulatory disturbance of truncal organs and lower extremities.
RESULTS: (Hypertension.
Thirty-three 2010;56:926-933.)
patients developed a central-to-radial arterial pressure gradient (45%). amplitude of the systolic upstroke stroke and a prominent diastolic and their rec
Junichiro Hashimoto, Sadayoshi Ito and the changing location of the
Key Words: blood pressure ! blood flow ! Patients
ORIGINAL
with a significant
arteriosclerosisARTICLE
! aorta
pressure gradient had a smaller weight (71.0 ± 16.9 vs 79.3 ±
! physiology ! femoral ! wave reflection dicrotic notch. waveform with reflected waves erroneous. W
Original Article 17.3 kg, P = 0.041), a smaller height (162.0 ± 9.6 vs 166.3 ± 8.6 cm, P = 0.047), a smaller
may be visual indicators of shock system, the
Abstract—Aortic stiffness, peripheral wave reflection, and radial artery diameterpulse
aorta-to-peripheral (0.24pressure
± 0.03 vs 0.29 ± 0.05 all
amplification cm,predict
P < 0.001), and were at a higher risk
Reprinted from Gorny,8 with permission.

a Differences in
timeperioperative femoral Pand radial arterial with vasoconstriction39 (Figure 5). characteris
Risk Factors for Radial-to-Femoral Artery Pressure as determined by the Parsonnet score (30.3 ± 24.9 vs 17.0 ± 10.9, P = 0.007). In addition,

T
cardiovascular
he risk. However,
arterial the pathophysiological
pulse provides mechanism
important information on thebehind
longer itclamping
is unknown.
aorticgential Tonometric
(frictional) shear
(85.8 pressure
stress
± 51.0 vson64.2waveforms
the ±arterial
29.3 endothelium,
minutes, = 0.036), mitral and
were recorded on the radial,
cardiovascular carotid, There
prognosis. and femoral arteriesevidence
is substantial in 138 hypertensive (P = patients (age:
P =56!13
0.017,years) to estimate
(Pblood pressure in neonates and Theinfants undergoing
complex whereas
surgery the mean
0.007 and flow contributes to tissue
respectively), perfusion. Pulsatile
and administration of vasopressin
Gradient in Patients Undergoing Cardiac
aorta-to-peripheral Surgery
that the aortic pulse wave velocity
amplifications, aortic (PWV) = 0.039)
and augmentation
augmentation index, were
and aorticflow identified
stress mayasexert
(carotid-femoral) potential
pulseindependent
wave
deleterious onpredictors
velocity.
effects of a central-to-radial
the microvasculature pressure
femoralindex (AIx)velocity
predict cardiovascular
waveform wasmorbidity
recordedand gradient.
to mortality intheByreverse/forward
using multivariateflowlogistic regression analysis,
stress. theThe
following independent risk factors !
With Cardiopulmonary Bypass
Doppler
cardiac
calculate
surgery
synergistically with
requiring
pulsatile
index pressure
and
cardiopulmonary
diastolic/systolic flow pulse
bypass CRITICAL CARE NURSE Vol 2
12
were identified:waveforms
Parsonnet score (odds and
ratioophthalmic
[OR], 1.076; 95% confidence interval [CI], 1.027–
forwarda variety of populations, as confirmed by recent meta-analysis
flow ratio. The aorta-to-femoral and aorta-to-radial amplifications of carotid
correlated inversely with the arteries
aortic have been 1.127,
15 16

studies.1,2 Similar prognostic significance has been alsoP = 0.002), aortic clamping time >90 minutes (OR, 8.521; 95% CI, 1.917–37.870,
shown Downloaded from http://ccn.aacnjournals.org/ by AACN on October 18, 2018
Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) 692–698 augmentation index and pulse wave velocity. The femoral Pflow waveform
= 0.005), and was to
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forward,
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J). 2018;94(1):76- risk
Vincent Bouchard-Dechêne, MDn, subsequent Pierredemonstrated
Couture,
tral reverse,
for pulse
MD
aorta to and
n
, pressure
diastolic
peripheral
amplification from the cen-
forward phases
medium-sized Hwa
(RR)
in 129 patients,
muscular arteries. Jin Cho
estimates
whereas
a
, Sang
arteriosclerosis.
remained
it was Hoon
statistically
biphasic Leeaa ,diastolic
significant
and lacked In
forSeok Jeongscore
theforward
Parsonnet b,∗ and the aortic clamp-
, Nam Sik Yoon c , Jae Sook Ma d , 3–5
The femoral arteries,
95%located between the Pbody trunkand
andRR, 2.253; 95% CI,
Risk Factors Involved P in
ing time ≥90 minutes
Central-to-Radial
(RR, 1.010; CI, 1.003–1.018,
Arterial
= 0.009
† bratio
Antonio
Contents Su, atMD
lists available , Alain Deschamps,
ScienceDirect 9MD,
flow in These PhD
patients.
pulse
n
Both , the
indices femoral
(PWV, reverse
AIx, andindex
pulse(30!10%) Byoung
amplification)
1.475–3.443, Hee
and diastolic Ahn
forward
< 0.001
lower
(12!4%)
respectively)
extremities, servewhile
correlated positively
to showing a trendflow
supply blood for patient height (RR, 0.974; 95%
inherently
Yoan Lamarche, MD‡,§, Georges Desjardins, with the
MD, aorta-to-femoral
depend amplification
on the structural
FRCPC, FASE and inversely
nand functional
,muscular with CI,
properties the aortic
the augmentation
of0.948–1.001, index
P = 0.058).
downstream. and pulse
However, quitewave velocity;
differently fromthese
the carotid and
Journal of Cardiothoracic
Sylvie Levesque, andMSc
Vascular
‖
, AndréAnesthesia
Y. Denault,
central
correlations
MD,
closely
elastic
were
PhD
through
Pressure
andn,§,1
peripheral
independent
pressure
of age,
wave
Gradient
arteries,pressure,
sex, diastolic
transmission and
whichCONCLUSIONS:
interact
reflection.
triphasic) flow were older, shorter, included more diabetics, hadChonnama
using a
During
and femoral
central
artery
site for
Cardiac
diameter.
Central-to-radial
ophthalmic
blood
Nationaldiameters,
smaller femoral
Patients
pressure
Universityand
Medical
thewith
gradients
waveforms,
showed
Surgery
arebiphasic
common
femoral
monitoring
School,
(versus
should
Chonnam
greater
in cardiacnormally
flow waveform surgery. The threshold for
pulse University high-risk
be
aortic Nationallow in small, Hospital,patients
Department of Pediatrics, Gwangju,
6 –9

Potential mechanisms mediating these pulse abnormalities exhibits a triphasic pattern, including reverse (upstream) flow
South Korea toward undergoing longer surgical interventions to avoid inappropriate administration of vasopressors
n
Department of Anesthesiology, wave
Montreal Heart Institute and velocity
Université
and de
even when
Montréal,
cardiovascular
adjusted
Giuseppe
Montreal, forFuda,
all of MD,*
disease progression
these
include
covariates.
André In conclusion,
Denault,
elevated MD, because
PhD,* of the
theAlain
central inverse
aorta.
Deschamps,17–19(peripheral-to-aortic)
Previous
MD, investigations
PhD,* studied
DenisUniversity
Bouchard, MD,†
journal homepage: www.jcvaonline.com b cen-inotropic
and/or agents. (Anesth Analg 2016;122:624–32)
Quebec, Canada pressuretral gradient, pulse pressure amplification Chonnam National University Medical School, Chonnam National
ofcardiovascu- Hospital, Department of Thoracic and www.jped.com.br
pressure Annik
leading to anFortier, in normally
MSc,‡
increase produces
Jeanafterload
cardiac Lambert, a substantial
10,11
PhD,§ theand reversal
reversal
Pierreofof the
femoral femoral
Couture, flow MD* flow,
in the degree
association with
†
Department of Anesthesiology, Hôpital Cité de la Santé de Laval,
whichUniversité
isand de Montréal,
determined by Montreal,
the aortic distensibility Cardiovascular larSurgery, Gwangju, South Korea
widened pulsatile pressure causingand peripheral wave ten-reflection. risk factors
Arteriosclerosis and(increased
pharmacological intervention20 –22 and
stiffness, increased

D
circumferential c

Original
Quebec, Canada augmentation, andthat
sile stress reduced
damagesamplification)
the vulnerabledecreases irect
both theChonnam
intraradial
microvasculature reverse National
in arterial
even
and University
pressure
postulated
diastolic forwardMedical
monitoring is School,
a potential
flows,rou- Chonnam
connection
potentially National
there causing
iswith
a pressure
renalUniversity
blood Hospital,
gradient, Department
the radial arteryofpressure
Internal Medicine,
‡
Department of Cardiac Surgery, Article
Montreal Heart Institute, Université de Montréal,
brain Montreal,
and kidney.Quebec,
12–14 Canada
BACKGROUND: tinely used in cardiac
Gwangju,
A central-to-radialSouth surgery;
Korea
flow. however,
23 Nevertheless,
arterial pressure alittle
central-
gradient attention
may occurmeasure
hasafter
so far ORIGINAL
may been paid toARTICLE
underestimate
cardiopulmonary a more centrally measured
§ circulatory
Department of Surgery, Division of Cardiovascular Critical Care, Montreal Heart
disturbance of truncal organs and lower extremities.
to-radial d (Hypertension.
arterial pressure
2010;56:926-933.)
gradient may occur after
It isInstitute,
not onlyMontreal,
bloodQuebec,
pressure bypass
but also(CPB),
blood which,
flow in KS
that Hospital,
some Department
is patients,
the may lastof
fundamental, for Pediatrics,
a prolonged
mechanical Gwangju, systemic
South
time after
etiology of CPB. pressure,
Wheneverwhich
the Korea
generation the may result in a misguided thera-
ofthere
Risk Factors for Radial-to-Femoral Artery Pressure
‖
Canada Key Words:
involved blood
in pressure
target organ ! blood
damage. flow
is a cardiopulmonary
arteriosclerosis
pressure
Pulsatile
! flow gradient,
produces bypass
the
tan-
! Differences in perioperative femoral and radial arterial
(CPB),
aorta
radial artery
flow
! which,
physiology
pressure
reversal.in !measure
some patients,
femoral may
! wave peutic
underestimate strategy.
reflection a more1
Fig 1. Screenshot of hemodynamic waveforms of a 58-year-old woman undergoing aortic surgery (A) before and (B) after CPB. A significant gradient between the
centrally
Montreal Health Innovations Coordinating Centre, Montreal Heart Institute, Montreal, Quebec, Canada may last
measured for a prolonged
systemic period,may
pressure, which varying
resultfrom
in a 10 minutestherapeutic
misguided Sincestrategy.
the first mention
It is clini-of this phenomenon by Stern et al.,1
Gradient in Patients Undergoing Cardiac Surgery cally after
Received 26 December 2016; accepted 20 February 2017
discontinuation of CPB to sternal
thatclosure. Whenever blood have pressure in neonates
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and infants undergoing 1 2

important to identify the risk factors may predict the appearance of a central-to-radial
numerous reports described a central-to-radial arterial
radial artery pressure (Pra) and the femoral artery pressure (Pfa) appeared after CPB. Note the change in right ventricular pressure waveform (Prv) and central
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Available online 30 August 2017

With Cardiopulmonary Bypass he arterialReceived pressure gradient, because more central sites of measurements might thengradient,
pressure be considered
thiscardiac
and the reported incidence varies from
surgery requiring cardiopulmonary bypass!
pulse July
provides

Objective: To identify risk factors associated with radial-to-femoral

important
14, 2010; information
first decision
From the Department of Blood Pressure
pressurethat
onsystemic
July 31, 2010;
to monitor
Research
the
cardiovascular
gradient
the
gential pressure
revision accepted
(J.H., S.I.)arterial
(frictional)
August shear stress
30, 2010.
in high-risk
and Division of Nephrology,
prognosis. There is substantial
University Graduate School of Medicine,
during
aortic cardiac
wavesurgery with
assess
on theThe
patients.
Endocrinology,
From
arterial endothelium,
and objective
evidence Vascular
trealpreoperative
Sendai,
cardiopulmonary
of72%,
10% to
Medicine
Japan.Institute,and
Heart
bypass
study
depending
whereas
Université
was to
the
intraoperative
on the definition used. Although
(S.I.), Tohoku
the Departments of *Anesthesiology and †Cardiac Surgery, Mon-
mean risk
de Montréal,
flow contributes
factors
Montreal, Quebec,
to Canada;
tissue perfusion.
for central-to-radial Pulsatile
thepressure
etiologygradient.
leading to central-to-radial artery pressure gra-
T 1–22

venous pressure (CVP) suggestive of right ventricular dysfunction associated with reduced regional oxygen saturation (rSO2). The patient was receiving inhaled
Vincent Bouchard-Dechêne, MDn, Pierre Couture, MD , pulse
n Correspondence velocity (PWV)
to Junichiro and
Hashimoto, augmentation
METHODS:
Department
‡Coordinating Blood flow
Seventy-three
of Center, stress
patients
Pressure
Montreal may
Research,
Heart exert
undergoing
Tohoku
Institute, deleterious
cardiac
University
Montreal, effects
Quebec,Graduateon the
surgery
Canada; microvasculature
using
School of CPB
dient haswere
Medicine, 1-1included
Hwa
been Jin Cho
Seiryo-cho,
studied in a
, Sang
extensively, Hoon
its exact Lee a , In
mechanism is Seok Jeong
b,∗
, Nam Sik Yoon c , Jae Sook Ma d ,
(CPB).
Design: This is Antonio MD†, Alain
Su, observational
a retrospective, study.Deschamps, MD, PhD
index n(AIx)Aoba-ku,
, predict
Sendai 980-8574, morbidity
cardiovascular Japan. [email protected]
this and §Department
mortality
prospective
© 2010 American Heart Association, Inc.Montreal, Quebec, Canada.
a variety of populations, as confirmed by recent wasmeta-analysis
defined as a difference
KEYWORDS
of Preventive
in observational andstudy.
synergistically
Infant;of 25ofmm
Social Medicine,
Hg in
Université
A significant
with pulsatile
15 systolic
deAbstract
Montréal, 12 arterial pressure gradient
central-to-radial
pressure stress. The
Objective:
pressure 16 or
stillflow
Several
10 mm
pulse
Byoung
controversial
reports
Hg in meanclaim and Hee
is
that
arterial blood Ahn
probably b
multifactorial.
pressure
1–3,6,8,17,20
(BP) in the radial artery may underesti- agents hence the end-tidal carbon dioxide (ETCO2) of 0. Ppa, pulmonary artery pressure; SpO2, arterial pulse oxygen saturation.
waveforms carotid and DOI:
ophthalmic arteries have
Despite beenthe manyillstudies published
Here, theon the subject, the differences in mean
‡,§
Yoan Single
Setting: Lamarche,
specializedMD , Georges
cardiothoracic hospital Desjardins, MD, FRCPC,
in Montreal, Canada. studies.1,2 FASESimilar ,prognostic significance pressure
n
Hypertension Accepted for publication
is available at http://hyper.ahajournals.org
hasFunding:
been for also September 20, 2015.
a minimumNeonate;
Montreal Heartshown
of 5 minutes. Preoperative
to Foundation.
Institute change with aging,
data10.1161/HYPERTENSIONAHA.110.159368
mate
indicating
the accurate
included
their
BP in critically
demographics,
association
data with
investigating
presencepatients.
of authors
the risk factors that may predict the
evaluated
Participants: Consecutive patients that underwent
‖ heart surgery with CPB between n,§,1
2005 and 2015 (n 435). comorbidities, and medications. Intraoperative data included
blood type
pressure of surgery,
(MBP) CPB
between and
theaortic
radial and femoral artery during pediatric cardiac surgeryUniversity
to
Sylvie Levesque, MSc , André Y. Denault, MD,demonstrated PhD ¼
for pulse pressure amplification from the cen-
The authors
clamping time,3–5declare
use of
Congenital
conflicts926
noarteriosclerosis.
inotropic
heart
of interest.
drugs, and vasodilators determine or vasopressors appearance
a
of
agents.South
Chonnam
The
National
a central-to-radial University
pressureMedical
gradientSchool,
are few. Chonnam National Hospital, Department of Pediatrics, Gwangju,
Interventions: None. tral aorta to peripheral medium-sized muscular arteries. disease; the effectiveness ofdiameter
femoral arterial BP monitoring.
Korea
of theReprints will not be available from the authors. In addition, the natural intraoperative evolution of the gra-
Measurements
n
and of
Department Main Results: A Montreal
Anesthesiology, radial-to-femoral pressure
Heart Institute gradient occurred
and Université in 146
de Montréal, patients
Montreal, of the(PWV,
435 patients
AIx, (34%). Based on radial and femoral The
the 10,000 artery was measured
femoral before the
arteries, located induction
between
Method: theTheof anesthesia
body
medical b using B-mode
trunkrecords
and of children
Chonnam under
National 1 year of age
University who underwent
Medical School, Chonnam open-heart surgery
National University Hospital, Department of Thoracic and
These pulse indices and pulse Address correspondenceInvasive
amplification)
ultrasonography. blood MD, Department of Anesthesiol-
to Pierre Couture, dient is unknown. This is Surgery,
clinicallyGwangju,
important because the
lower extremities, St.,serve to QC,supply blood flow inherently

Re ew A c es
bootstrap samples, simple logistic regressionQuebec,
modelsCanada
identified the 17 most commonly significant variables across the bootstrapproperties
runs.ogy,
Using these
Montreal pressure
Heart Institute, 5000 monitoring;
Bélanger Montreal, between
Canada H1T 2007 and 2013 wereCardiovascular
retrospectively reviewed. RadialSouthandKorea
femoral BP were measured
†
Department of Anesthesiology, Hôpital Cité de la Santé de Laval, Université de depend
Montréal, on the structural
Montreal, and functional RESULTS: ofThirty-three
thee-mail patients developed a central-to-radial arterial insertion
from thepressure
ofgradient
c a femoral
Chonnam (45%).
artery catheter
National Universityto monitor systemic
Medical School,
variables, a backward multiple logistic model was performed on the original central sample elastic
and identified the following
and peripheral independent
muscular
1C8. Address
variables:
Patients
arteries, which with body
interact
todownstream.
a significantFemoralpressure
However,
[email protected].
artery gradient
quite differently
had a smaller simultaneously,
weight arterial
carotid
and the
(71.0
and
differences
±pressure
16.9 vs may
79.3 between these
be± considered
values were analyzed Chonnam
in patients found to
at variousNational University Hospital, Department of Internal Medicine,
times: after
2 Quebec, Canada Copyright © 2015 International Anesthesia Research Society Gwangju, South Korea
surface
‡ area (m
Department ) (oddsSurgery,
of Cardiac ratio [OR] 0.08,Heart
Montreal 95% Institute,
confidence interval
Université de [CI] 0.030-0.232),
Montréal, clamping
closelyQuebec,
Montreal, through time (minutes) (OR 1.01, 95%17.3
pressure wave transmission and
Canada CI 1.007-1.018), aophthalmic
kg,10.1213/ANE.0000000000001096
P = 0.041),
reflection. smaller height waveforms,
(162.0 the ± 9.6femoral
vs 166.3flow±waveform
catheter insertion,
8.6 cm,
be at Pnormally
=after dthe initiation
0.047),
high risk aofsmaller of cardiopulmonary
developing bypassGwangju,
a central-to-radial (CPB-on),South
arterial after Korea
aortic cross
fluid
§ balanceof(for
Department 1 liter)
Surgery, (OR 0.81,
Division 95% CI 0.669-0.976),
of Cardiovascular Critical Care,and preoperative
Montreal hypertension
Heart Institute, Montreal,
Potential
(OR
Quebec,
mechanisms
DOI:

mediating these pulse abnormalities

6 –9
1.801, 95% CI 1.131-2.868). radial artery diameter exhibits (0.24 ± a0.03 triphasic
vs 0.29pattern,
± 0.05including P reverse
cm,clamping
< 0.001), (upstream)
(ACC),andafterwereflow
the
KS Hospital,
at release
a higherofrisk
Department of Pediatrics,
ACC, after weaning from CPB, at arrival in the intensive Downloaded for Aveek Jayant ([email protected]) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on October 19, 2018.
Conclusion: A radial-to-femoral pressure gradient occurs in 34% of patients during cardiac surgery. Patients at risk seem to be as
Canada
and cardiovascular disease progression include determined
of smaller stature,by the Parsonnet
elevated
624 aortic
a longer
cen- toward the score
www.anesthesia-analgesia.org
clamping
central(30.3
aorta.±17–19
24.9 vs care
Previous17.0investigations
± 10.9,
unit (ICU),Pand = 0.007).
studied 6 In
everyReceived addition,
h during26 the first day2016;
December in the ICU.
accepted
March 2016 Volume 122 Number 3
20 February 2017 For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
the time (85.8 ± 51.0 vs 64.2 ± Results:
29.3 minutes, Pof=1210.036), mitral and
‖
hypertensive, and undergo
Montreal Health longer
Innovations and moreCentre,
Coordinating complex surgeries.
Montreal Heart Institute, Montreal, Quebec, Canada reversal of femoral flow in association A total
with cardiovascu- patients
Available who underwent
online 30 Augustopen-heart
2017 surgery met the inclusion criteria.
tral pressure leading to an increase in Copyright cardiac afterload 10,11
©surgery
2015(PInternational
= 0.007 and Anesthesia Research Society. Unauthorized reproduction oftothis
& 2017 Elsevier Inc. All rights reserved. complex P = 0.017, respectively),
lar risk factors and pharmacological During and theadministration
intraoperative
intervention 20 –22 and ofperiod,
vasopressin
from the beginning the article
end of CPB,is prohibited.
radial MBPs were signif-
and widened pulsatile pressure causing circumferential (P = 0.039) ten- were identified as potential independent predictors of a central-to-radial pressure
even postulated a potential icantly lower
connection with thanrenal femoral
blood MBPs at each time-point measured (p < 0.05). Multivariate analysis
sile stress that damages the vulnerable microvasculature gradient. By using in multivariate logistic regression analysis, the following independent risk factors
Key Words: blood pressure; cardiopulmonary bypass; pressure gradient; radial artery; femoral artery
brain and kidney. 12–14 were identified: Parsonnet flow.score
23 Nevertheless, little attention has so far been paid to
(odds ratio [OR], 1.076; 95% confidence interval [CI], KEYWORDS
1.027– Abstract
Objective: To identify risk factors associated with radial-to-femoral pressure gradient during cardiac surgery with cardiopulmonary bypass Objective: Several reports claim that blood pressure (BP) in the radial artery may underesti-
It is not only blood pressure but also blood 1.127,flowP = that0.002),
is aortic clamping time
the fundamental, >90 minutes
mechanical etiology (OR, 8.521;
of the 95% CI,
generation 1.917–37.870,
of the Infant;
(CPB). P = 0.005), and patient height (OR, 0.933, 95% CI, 0.876–0.993, P = 0.029). The relative
Neonate; risk mate the accurate BP in critically ill patients. Here, the authors evaluated differences in mean
Design: This is a retrospective, observational study. involved in target organ damage. Pulsatile flow produces tan- flow reversal. blood pressure (MBP) between the radial and femoral artery during pediatric cardiac surgery to
UNDER MOST CIRCUMSTANCES, radial (RR)blood
estimates
pres-remained statistically significant for the Parsonnet score and the aortic clamp-heart
Congenital
Setting: Single specialized cardiothoracic hospital in Montreal, Canada. ing time ≥90 minutes (RR, 1.010; 95% CI, 1.003–1.018, P = 0.009 and RR, 2.253; disease;
95% CI, determine the effectiveness of femoral arterial BP monitoring.
Participants: Consecutive patients that underwent heart surgery with CPB between 2005 and sures 2015 (n accurately
¼ 435). reflect the central pressures. However, during
1.475–3.443, P < 0.001 respectively) Invasive blood Method: The medical records of children under 1 year of age who underwent open-heart surgery
! Please cite this while
articleshowing a trend
as: Cho HJ, Lee for
SH, patient height
Jeong IS, Yoon (RR, 0.974;
NS, Ma 95%
JS, Ahn BH. Differences in perioperative femoral and radial arterial
Interventions: None. Conflict of Interest: Dr. Denault is speaker for CAE Healthcare and cardiac surgery
Received Julyinvolving cardiopulmonary
14, 2010; first bypass
decision July 31, 2010; (CPB),
CI, 0.948–1.001,
revision a PAugust
accepted =blood
0.058).
30, 2010. in neonates and infants undergoing cardiac surgery requiringpressure monitoring; between 2007 and 2013 were retrospectively reviewed. Radial and femoral BP were measured
Covidien. pressure cardiopulmonary bypass. Jsimultaneously,
Pediatr (Rio J). 2018;94:76---81.
and the differences between these values were analyzed at various times: after
Measurements and Main Results: A radial-to-femoral pressure gradient occurred in 146 patientssignificant of theFrom difference
435 patients (34%).appears
Based
Bloodon inPressure
some
the 10,000 patients causing
CONCLUSIONS: theDivision
Central-to-radial gradients Femoral artery
1
Address reprint requests to Dr. identified
André Y. Denault, MD, commonly
PhD, Department
the Department of Research (J.H., S.I.) and ∗of Nephrology,
Corresponding author.are common
Endocrinology, in cardiac
and Vascular Medicinesurgery. The threshold
(S.I.), Tohoku for
catheter insertion, after the initiation of cardiopulmonary bypass (CPB-on), after aortic cross
bootstrap samples, simple logistic regression models the 17 most significantradial
variables across
University
pressure thetobootstrap
Graduate School ofruns.
significantly Using
Medicine, these Japan.
Sendai,
underestimate usingthea central
central site for E-mail:
blood pressure monitoring should
[email protected] be low in small, high-risk patients
(I.S. Jeong).
of Anesthesiology, Montreal Heart Institute, 5000 Belanger Street, Montreal, Correspondence to Junichiro variables:
Hashimoto,bodyDepartment of Blood Pressure Research, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, clamping (ACC), after the release of ACC, after weaning from CPB, at arrival in the intensive
variables, a backward multiple logistic model was performed on the original sample and identified the
Quebec pressure.following
1–16
Since independent
it was first E-mail described by undergoing
Stern et allonger
1
in surgical interventions to avoid inappropriate administration of vasopressors care unit (ICU), and every 6 h during the first day in the ICU.
surface area (m2) (odds ratioH1T
[OR] 1C8, Canada.
0.08, 95% confidence interval [CI] 0.030-0.232), clamping timeAoba-ku, (minutes)Sendai
(OR 980-8574,
1.01, 95%Japan. [email protected]
CI 1.007-1.018), and/or inotropic agents. (Anesth Analg 2016;122:624–32)
https://doi.org/10.1016/j.jped.2017.03.011
fluid balance (for 1 liter)E-mail address: [email protected]
CI 0.669-0.976), and(A.Y. Denault). hypertension (OR 1985, 1.801, the
© 2010central-to-peripheral
American Heart Association, arterial
Inc. pressure gradient has Results: A total of 121 patients who underwent open-heart surgery met the inclusion criteria.

Does he Cen a Venous P essu e P ed c F u d

(OR 0.81, 95% preoperative 95% CI 1.131-2.868). 0021-7557/© 2017 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. This is an open access Duringarticle under the CC BY-NC-ND
the intraoperative period, from the beginning to the end of CPB, radial MBPs were signif-
Hypertension is available at http://hyper.ahajournals.org DOI: 10.1161/HYPERTENSIONAHA.110.159368

D
Conclusion: A radial-to-femoral pressure gradient occurs in 34% of patients during cardiac surgery. Patients at risk seem to be of smaller stature, license (http://creativecommons.org/licenses/by-nc-nd/4.0/). icantly lower than femoral MBPs at each time-point measured (p < 0.05). Multivariate analysis
http://dx.doi.org/10.1053/j.jvca.2017.09.020
hypertensive, and undergo longer and more complex surgeries. irect intraradial arterial pressure monitoring is rou- there is a pressure gradient, the radial artery pressure
tinely used in cardiac surgery; 926 however, a central- measure may underestimate a more centrally measured
& 2017 Elsevier Inc.1053-0770/& 2017 Elsevier Inc. All rights reserved.
All rights reserved.
to-radial arterial pressure gradient may occur after systemic pressure, which may result in a misguided thera-
Key Words: blood pressure; cardiopulmonary bypass; pressure gradient; radial artery; femoral artery cardiopulmonary bypass (CPB), which, in some patients, peutic strategy.1
may last for a prolonged period, varying from 10 minutes Since the first mention of this phenomenon by Stern et al.,1

Respons veness? An Upda ed Me a Ana ys s

after by
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Elsevier on October 19, CPB1 to sternal closure.2 Whenever numerous reports have describedPlease
! cite this article
a central-to-radial as: Cho HJ, Lee SH, Jeong IS, Yoon NS, Ma JS, Ahn BH. Differences in perioperative femoral and radial arterial
arterial
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. blood pressure in neonates and infants undergoing cardiac surgery requiring cardiopulmonary bypass. J Pediatr (Rio J). 2018;94:76---81.
UNDER MOST CIRCUMSTANCES, radial blood pres- pressure gradient, and the reported incidenceauthor.
∗ Corresponding varies from

Cook book page 1

sures accurately reflect the central pressures. However, From during
the Departments of *Anesthesiology and †Cardiac Surgery, Mon- 10% to 72%, depending on the definition used.1–22 Although (I.S. Jeong).
E-mail: [email protected]
Conflict of Interest: Dr. Denault is speaker for CAE Healthcare and cardiac surgery involving cardiopulmonary bypasstreal Heart Institute,
(CPB), a Université de Montréal, Montreal, Quebec, Canada; the etiology leading to central-to-radial artery pressure gra-
‡Coordinating Center, Montreal Heart Institute, Montreal, Quebec, Canada; https://doi.org/10.1016/j.jped.2017.03.011
Covidien. significant difference appears in some patients causing the of Preventive and Social Medicine, Université de Montréal,
and §Department
dient has been studied extensively, its exact mechanism is
0021-7557/© 2017 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND
1
Address reprint requests to Dr. André Y. Denault, MD, PhD, Department Montreal, Quebec, Canada. still controversial and is probably multifactorial. 1–3,6,8,17,20
of Anesthesiology, Montreal Heart Institute, 5000 Belanger Street, Montreal,
radial pressure to significantly underestimate the central license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

and a P ea o Some Common Sense

pressure. 1–16
Since it was first described by Stern Accepted 1
et al forinpublication September 20, 2015. Despite the many studies published on the subject, the
Quebec H1T 1C8, Canada.
E-mail address: [email protected] (A.Y. Denault). 1985, the central-to-peripheral arterial pressure gradient Funding: Montreal
has Heart Institute Foundation. data investigating the risk factors that may predict the
The authors declare no conflicts of interest. appearance of a central-to-radial pressure gradient are few.
http://dx.doi.org/10.1053/j.jvca.2017.09.020 Reprints will not be available from the authors. In addition, the natural intraoperative evolution of the gra-
1053-0770/& 2017 Elsevier Inc. All rights reserved. Address correspondence to Pierre Couture, MD, Department of Anesthesiol- dient is unknown. This is clinically important because the
ogy, Montreal Heart Institute, 5000 Bélanger St., Montreal, QC, Canada H1T
1C8. Address e-mail to [email protected].
insertion of a femoral artery catheter to monitor systemic
Copyright © 2015 International Anesthesia Research Society arterial pressure may be considered in patients found to
be at high risk of developing a central-to-radial arterial
Te c hnic al c ons ide rations are important in as s e s s ing ac c urac y of invas ive
DOI: 10.1213/ANE.0000000000001096
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CHEST
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
624 www.anesthesia-analgesia.org March 2016 Volume 122 Number 3
blood pre s s ure
Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
FOR THOSE WHO ARE NOT M MD M MD
Section 2 SpecialFeature INTERESTED BEYOND AN
IMMEDIATE EXAM: BUT
u Trans duc e r offs e t and dynamic re s pons e of s ys te ms mus t be c he c ke d on a
pe riodic bas is
u Inte rpre tation of arte rial blood pre s s ure value s s hould be bas e d on the
HOPING YOU CHANGE TOO me an (le as t affe c te d by dynamic re s pons e )
u Choic e of anatomic s ite and c linic al c onte xt are important in

Does Central Venous Pressure Predict inte rpre tation of a value

Fluid Responsiveness?*
A Systematic Review of the Literature and the Tale w
of Seven Mares
Paul E. Marik, MD, FCCP; Michael Baram, MD, FCCP; and Bobbak Vahid, MD Doe he Cen Venou P e u e P ed Fud
Re pon ene ? An Upd ed Me An
nd P e o Some Common Sen e

Background: Central venous pressure (CVP) is used almost universally to guide fluid therapy in
hospitalized patients. Both historical and recent data suggest that this approach may be flawed.
Objective: A systematic review of the literature to determine the following: (1) the relationship
between CVP and blood volume, (2) the ability of CVP to predict fluid responsiveness, and (3) the
ability of the change in CVP (!CVP) to predict fluid responsiveness.
Datasources:MEDLINE,Embase,CochraneRegisterofControlledTrials,andcitationreviewof
relevant primary and review articles.
Study selection: Reported clinical trials that evaluated either the relationship between CVP and
blood volume or reported the associated between CVP/!CVP and the change in stroke
T
T
volume/cardiac index following a fluid challenge. From 213 articles screened, 24 studies met our
inclusion criteria and were included for data extraction. The studies included human adult
subjects, healthy control subjects, and ICU and operating room patients.
Data extraction:What Data were abstracted onis studyit design,about the
study size, study setting, patient CVP?
population, As if this was not enough
CHEST
correlation coefficient between CVP and blood volume, correlation coefficient Special (or receive operator
Feature
Review Articles
characteristic [ROC]) between CVP/!CVP and change in stroke index/cardiac index, percentage of
patients
Does who responded
Central to a Venous
fluid challenge,Pressure
and baseline CVPPredictof the fluid responders and
Fluid Responsiveness?*
nonresponders. Metaanalytic techniques were used to pool data. Do h C V ou P u P d ud
DataAof synthesis:
Systematic Review of the Literature and the Tale
SevenThe 24 studies included 803 patients; 5 studies compared CVP with measured
Mares R po A Upd d M A
circulating blood volume,
Paul E. Marik, MD, FCCP; whileMichael
19 studies determined
Baram, MD, FCCP; the relationship
and Bobbakbetween CVP/!CVP and
Vahid, MD d P o Som Commo S
change in cardiac performance following a fluid challenge. The pooled correlation coefficient
Background: Central venous pressure (CVP) is used almost universally to guide fluid therapy in
betweenpatients.
hospitalized CVP and Bothmeasured
historicalblood volumedata
and recent wassuggest
0.16 (95%thatconfidence
this approach
Objective: A systematic review of the literature to determine the following: (1) the relationship
interval
may [CI], 0.03 to 0.28).
be flawed.

Overall, 56"16% of the(!CVP)

patientsto included in thisresponsiveness.
review responded to a fluid challenge. The pooled
between CVP and blood volume, (2) the ability of CVP to predict fluid responsiveness, and (3) the
ability of the change in CVP predict fluid
Background:

correlationcoefficientbetweenbaselineCVPandchangeinstrokeindex/cardiacindexwas0.18(95%
Data sources: MEDLINE, Embase, Cochrane Register of Controlled Trials, and citation review of
relevant primary and review articles.
Study selection: Reported clinical trials that evaluated either the relationship between CVP and Aim:

CI, 0.08 to 0.28). The pooled area under the ROC curve was 0.56 (95% CI, 0.51 to 0.61). The pooled
blood volume or reported the associated between CVP/!CVP and the change in stroke
volume/cardiac index following a fluid challenge. From 213 articles screened, 24 studies met our

correlationbetween!CVPandchangeinstrokeindex/cardiacindexwas0.11(95%CI,0.015to0.21).
inclusion criteria and were included for data extraction. The studies included human adult
subjects, healthy control subjects, and ICU and operating room patients. Data Sources:
Data extraction: Data were abstracted on study design, study size, study setting, patient population,
Baseline
correlation CVP wasbetween
coefficient 8.7"2.32CVP mmand Hg blood[mean"SD] in the responders
volume, correlation coefficient
characteristic [ROC]) between CVP/!CVP and change in stroke index/cardiac index, percentage of
as(orcompared to 9.7"2.2 mm
receive operator
Study Selection:

Hg in nonresponders
nonresponders. Metaanalytic (not significant).
patients who responded to a fluid challenge, and baseline CVP of the fluid responders and
techniques were used to pool data. Figure 1. Fifteen hundred simultaneous measurements of blood volume and CVP in a heterogenous
Data synthesis: The 24 studies included 803 patients; 5 studies compared CVP with measured cohort of 188 ICU patients demonstrating no association between these two variables (r ! 0.27). The
Conclusions:
circulating This
blood volume, systematic
while 19 review
studiesdemonstrated
determined the a very poor relationship
relationship between between
CVP/!CVPCVPandand blood correlation between "CVP and change in blood volume was 0.1 (r2 ! 0.01). This study demonstrates
that patients with a low CVP may have volume overload and likewise patients with a high CVP may be

T
change in cardiac performance following a fluid challenge. The pooled correlation coefficient

Overall,volume as ofwelltheaspatients
the inability ofinCVP/!CVP
this reviewto predict the
to a hemodynamic
fluid challenge.response to a fluid
volume depleted. Reproduced with permission from Shippy et al.11
between CVP and measured blood volume was 0.16 (95% confidence interval [CI], 0.03 to 0.28).
56 " 16% included responded The pooled
n n n
CI, 0.08challenge. CVP should not be used thetoROC
make clinical
wasdecisions
0.56 (95%regarding fluid management.
correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 (95%
to 0.28). The pooled area under curve CI, 0.51 to 0.61). The pooled
conditions. In none of the studies included in this 1 (0.8 to 0.9 indicates adequate accuracy with 0.7 to
Data Extraction:
correlation between !CVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.015 to 0.21). analysis was CVP able to predict either of these 0.8 being fair, 0.6 to 0.7 being poor, and 0.5 to 0.6
Baseline CVP was 8.7 " 2.32 mm Hg [mean " SD] in the responders as compared to 9.7 " 2.2variables.
Hg in nonresponders (not significant).
(CHEST 2008; 134:172–178)
mm Indeed, the pooled area under the ROC
curve was 0.56. The ROC curve is a statistical tool
indicating failure). In other words, our results sug-
gest that at any CVP the likelihood that CVP can
Conclusions: This systematic review demonstrated a very poor relationship between CVP and blood
that helps assess the likelihood of a result being a accurately predict fluid responsiveness is only 56%
volume as well as the inability of CVP/!CVP to predict the hemodynamic response to a fluid
true positive vs a false positive. As can be seen from (no better than flipping a coin). Furthermore, an
challenge. CVP should not be used to make clinical decisions regarding fluid management.
Figure 2, an ROC of 0.5 depicts the true-positive AUC of 0.56 suggests that there is no clear cutoff
Keywords:anesthesia;bloodvolume;centralvenouspressure;fluid responsiveness;fluid therapy;hemodynami
(CHEST 2008; 134:172–178)
c moni
rate torintog; the false-positive rate; graphically, this
equal
is represented by the straight line in Figure 1. The
point that helps the physician to determine if the
patient is “wet” or “dry.” It is important to emphasize
ICU; preload; stroke volume
Key words: anesthesia; blood volume; central venous pressure; fluid responsiveness; fluid therapy; hemodynamic monitoring;
ICU; preload; stroke volume higher
the AUC, the greater the diagnostic accuracy that a patient is equally likely to be fluid responsive
Abbreviations: AUC ! area under the curve; CI ! confidence interval; CVP ! central venous pressure; "CVP ! change in
central venous pressure; ROC ! receiver operator characteristic
of a test. Ideally, the AUC should be between 0.9 to with a low or a high CVP (Fig 1). The results from
this study therefore confirm that neither a high CVP, W
Abbreviations:AUC!areaunderthecurve;CI!confidenceinterval; CVP!centralvenouspressure;"CVP!changein a normal CVP, a low CVP, nor the response of the
CVP to fluid loading should be used in the fluid
central venous pressure; ROC!receiver operator characteristic management strategy of any patient.
The strength of our review includes the rigorous
C recorded
entral venous pressure (CVP) is the pressure
from the right atrium or superior vena
department patients, well as in patients undergoing
major surgery. CVP is frequently used to make
selection criteria used to identify relevant studies as
well as the use of quantitative end points.8,9,34 Fur-
cava. CVP is measured (usually hourly) in almost all decisions regarding the administration of fluids or thermore, the studies are notable for the consistency
patients in ICUs throughout the world, in emergency diuretics. Indeed, internationally endorsed clinical (both in magnitude and direction) of their findings.
This suggests that the findings are likely to be
172 Special Feature
true.8,9,34 The results of our study are most disturb- 1774 www.ccmjournal.org
ing considering that 93% of intensivists report using

C 7
CVP to guide fluid management.35 It is likely that a
entral venous pressure (CVP) is the pressure department patients, well as in patients undergoing similar percentage (or more) of anesthesiologists,
nephrologists, cardiologists, and surgeons likewise

recorded from the right atrium or superior vena major surgery. CVP is frequently used to make use CVP to guide fluid therapy. It is important to
note that none of the studies included in our analysis
took the positive end-expiatory pressure levels or
cava. CVP is measured (usually hourly) in almost all decisions regarding the administration of fluids or
Figure 2. Comparison of ROC curves showing tests with
different diagnostic accuracies. changes in intrathoracic pressure into account when

patientsinICUsthroughouttheworld,inemergency diuretics. Indeed, internationally endorsed clinical www.chestjournal.org CHEST / 134 / 1 / JULY, 2008 175

172 Special Feature

 406 MAGDER

measurements with the two methods can be compared, we found that, on

average, the sternal angle–based measurement gives a value that is 3 mm Hg
less than the midthoracic measurement [3]. Consider the consequences of
changes in the level of the transducer relative to the midpoint of the
right atrium. Most often, the transducer is not attached to the bed, such
that changes in the bed relative to the mounting for the transducer change
10/26/18
the value. For example, lowering the bed by 10 cm changes the recorded
pressure by almost 8 mm Hg (see Fig. 2). This difference in the CVP mea-
surement could mean the difference between a fluid challenge and an
order for furosemide.
As discussed previously, the measured value is not the same as the actual
pressure throughout the system. Thus, when the measured pressure for CVP
is 10 mm Hg based on the sternal angle reference, it is actually around
17 mm Hg in veins along the patient’s back because of the vertical distance
between the level and the bottom of the patient [3]. This is the pressure in the
capillaries that regulate filtration in this region. Of importance, leveling is 405 INVASIVE INTRAVASCULAR HEMODYNAMIC MONITORING

not an issue when measuring gas pressures. Thisat is because

an angle thethe mass
of 60 . This is because right atrium isofa relatively round !

structure and is located just under the sternum. The radius of the atrium
the gas is small, such that the weight of the gas isalsotrivial
does not vary byover the
large amounts amongheights
individuals. This means that
the transducer can be leveled to this position even when the patient is not
we have to consider for the measurements. Thus, itsupine,is asnot is oftennecessary
the case when patientsto level
are being fed, when they have
transducers for air-based measurements, such pulmonaryisas
achieved
edema, or when they are bleeding after cardiac surgery. Leveling
airway pressure
by placing a carpenter’s level on the sternalon
angle and setting the
a ventilator. transducer 5 cm under this level (Fig. 2). As already noted, it does not
matter whether the patient is supine or sitting at 60 as long as the trans- !

ducer is 5 cm under this level. It is also important to consider the appropri-

ate position on the transducer for leveling. The level representing the
midpoint of the right atrium should be leveled to the top of the fluid column
Transmural pressure that is necessary to zero the transducer. This is situated at the level of the

Static pressures are NOT useful Is it the real pressure

stopcock that is opened for zeroing the transducer. The difference between
this value and the bottom of the transducer can be as much as 3 to 4 mm Hg,
Another important concept is that of transmural pressure. The walls of such that incorrect placement can have a considerable effect on the mea-
sured pressure.
elastic structures are stretched by the difference in pressure between the pres- A much more common leveling position in the intensive care unit (ICU)
sure inside the structure versus the pressure outside the structure, and the is the midthoracic position at the level of the fourth rib. It is argued that the
advantage of this position is that it is easier to teach and does not require
difference in these two pressures is called the transmural pressure (Fig. 3). a leveling device. Measurements should only be made with this level in
the supine position, however, because the middle right atrium does not
maintain a constant relation to this position when the upper body is
elevated. In the author’s experience, the greater amount of teaching and
u Is it the real pres s ure care required for the sternal angle–based measurement is actually an advan-
tage because it sensitizes the team to the importance of the level and means
that the level is checked more often. As a useful conversion so that

u Pres s ure volume s urrogac y

Fig. 2. Illustration of what happens when the bed is lowered but the transducer is not. The left
side shows the change in pressures (top, arterial [Part]; middle, Ppao; lower, CVP), and on the
right side, water monometers demonstrate how lowering the bed relative to the transducer
lowers the measured pressure. In this case, the bed was lowered by 10 cm, which means that
u What is the pos ition of the heart on the Starling c urve? the proper level (A) is 10 cm lower than the current level (B), and this translates to a decrease
in pressure of approximately 8 mm Hg.

Downloaded for Aveek Jayant ([email protected]) at Amrita Institute of Medical Science and Research Centre from
Fig. 3. Illustration of the concept of transmural pressure. (A) System
ClinicalKey.com by Elsevier onis surrounded
October 18, 2018. For personal use only. Noby atmo-
other uses without permission. Copyright ©2018. Elsevier
Inc. All rights reserved.
spheric pressure, and the transmural pressure (TM) is 100 ! 0 ¼ 100 mm Hg. (B) Pressure sur-
Is it the the
rounding realelastic
meas chamber
ured value? Remember
is !40 mm Hg,the c hes
such t cthe
that an be
TM a is pres 100 s ure ! (!40)c ooker ¼ 140 mm Hg.
(C) Surrounding pressure is þ40, such that the TM is 100 ! 40 ¼ 60 mm Hg.

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ClinicalKey.com by Elsevier on October 18, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier
Inc. All rights reserved.

An old wise man?

What is the
exact
translational
constant
(pressure to
volume)?

736 SIMON GELMAN

Definitions and Basic Concepts It is important to distinguish intraluminal (intramu-

ral) venous pressure, which is the pressure within a
Venous Capacity and Compliance
vessel (which can be measured directly via an inserted
There is some confusion in the literature regarding the
736 catheter), regardless of the pressure surrounding the SIMON GELMAN
relevant terminology. The definitions described in this
vessel. Transmural pressure or distending pressure re-
article are used by the majority of authors and clearly
summarized by the authority in the field.1,9 Definitions and fers to a difference between the pressure within the
Basic
vessel Concepts
and outside the vessel. It is important to distinguish intraluminal (intramu-
Venous capacity is a blood volume contained in a vein ral) venous pressure, which is the pressure within a

Venous system is not inert What about the more exalted PAC?
at a specific distending pressure.6,9 –11 Venous Capacity and Compliance
vessel (which can be measured directly via an inserted
There
Venous compliance is a change in volume (!V) of is some confusion in the literature regarding the
Stressed and Unstressed Volume catheter), regardless of the pressure surrounding the
relevant terminology. The definitions described in this
blood within a vein (or venous system) associated with a The intersection of the line of compliance withTransmural
vessel. the pressure or distending pressure re-
article are used by the majority of authors and clearly
change in intravenous distending pressure (!P).
summarized by y-axis reflects an
the authority the field.1,9volume (Vu; fig. 1),
in unstressed ferswhich
to a is difference between the pressure within the
Venous(1) a volume
capacity of blood
is a blood volume in acontained
vein at transmural ! vessel
in a vein pressure
REVIEW and outside
equal ARTICLE
the vessel.
Venous Compliance ! "V/"P.
to zero. Stressed
at a specific distending pressure.volume
6,9 –11 is a volume of blood within a
Therefore, capacity is a point of volume at Venous
a certaincompliance
vein underis atransmural
change in pressure
volume (!V)aboveofzero
David (Vs; fig. 1).and
S. Warner,
Stressed M.D., and MarkVolume
Unstressed A. Warner, M.D., Editors
pressure while compliance is a slope of blood change in The sum of stressed (approximately
within a vein (or venous system) associated with a 30% of total vol-
The intersection of the line of compliance with the
volume associated with a change in pressure. change A in
de-intravenous
ume) and unstressed
distending (approximately
pressure (!P). 70% of totalreflects
y-axis vol- an unstressed volume (Vu; fig. 1), which is
crease in volume within a vein (or venous system) can ume) volumes is the total blood volume awithin
Anesthesiology
volume the
2008;
of108:735–
blood48in a vein at transmural pressureCopyright © 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
equal
be achieved by a decrease in capacity (position of the Venous Compliance ! "V/"P.
venous system.
(1)
to zero. Stressed volume is a volume of blood within a
curve) or by a change in compliance (slope of the capacity
Therefore, is a point
An analog withofa volume
tub is at a certain
helpful to understand Venous Function and Central Venous Pressure
the
vein under transmural pressure above zero (Vs; fig. 1).
curve) or both (fig. 1). Venoconstrictors, #-adrenergic
pressure whilerelation
compliance
between is aVuslope
and Vsof13–15
change
(fig. in
2). Both Thevolumes
sum of stressed (approximately 30% of total vol-
agonists, decrease venous capacity withoutvolumechanging associated with a change
are important: in pressure.
Vs determines meanA de- A Physiologic
ume) filling
circulatory and unstressed Story(approximately 70% of total vol-
12
compliance. crease in volume within (MCFP;
pressure a vein (or seevenous
Mean system) can Simon
Circulatory ume)
Filling volumes
Pressure
Gelman, M.D.,isPh.D.*
the total blood volume within the
be achieved bysection)
a decreaseand in capacity
directly (position
affects venousofreturn
the (VR) venous
and CO, system.
curve) or by awhereas
change Vu in iscompliance
a reserve of(slope
blood ofthatthe An analog with a tub is helpful to understand the
can be mobilized
curve) or both (fig. 1). Venoconstrictors, #-adrenergic The veins contain
relation between Vu and Vs13–15
approximately 70% of(fig.
total2).
blood
Both volumes iologic relation within the venous system rather than on
volume
into circulation when needed.
agonists, decrease venous capacity without changing and are are 30 times more compliant than arteries; therefore,
important: Vs determines mean circulatory filling molecular and biochemical mechanisms of smooth mus-
compliance.12 changes in blood volume within the veins are associated with
pressure (MCFP; see
relatively small changes in venous Meanpressure.
Circulatory Pressure cle contraction and relaxation of the venous walls. Fi-
Fillingvenous
The terms
section)
capacity, and directly
compliance, affectsand
and stressed venous returnvolumes
unstressed (VR) and areCO, nally, the article will address the question of usefulness
whereas
defined. Vu isina flow
Decreases reserve
into of blood
a vein arethat can bewith
associated mobilized
de- (or lack of it) of the CVP as a clinical guide for physio-
creases in intravenous pressure
into circulation when needed. and volume, and vice versa. logic diagnoses and therapeutic interventions.
Changes in resistance in the small arteries and arterioles may

Sitting in this
affect venous return in opposite directions; this is explained by
a two-compartment model: compliant (mainly splanchnic
veins) and noncompliant (nonsplanchnic veins). Effects of in- Function of the Venous System
trathoracic and intraabdominal pressures on venous return and
The main functions of the venous system are to return
Auto in this gre at c ity
central venous pressure as well as the value of central venous
pressure as a diagnostic variable are discussed. blood to the heart from the periphery and to serve as a Can you pre dic t the front
capacitance to maintain filling of the heart. Veins contain
Fig. 2. Stressed and unstressed volumes—tub analogy. IN the era Waterof genetic
in revolution and exciting discoveries approximately 70% of total blood volume compared
Fig. 1. Venous capacity and compliance, stressed and unstressed a tub represents total blood volume. A hole in the wall of the tub with 18% in arteries and only 3% in terminal arteries and
in molecular mechanisms of diseases, the systems’ phys-
volumes. Point A1 represents total volume of blood in veins at between the surface of the water and the bottom of the tub arterioles; veins are 30 times more compliant than the
transmural pressure p1. Points A2 and A3 represent change in divides total volume into stressed (Vs) andiology is often
unstressed (Vu) forgotten and poorly understood by many,
arteries.1,2 The compliance of the arteries, being much
volume induced by change in pressure within the veins. Thick volumes, above and below the hole, respectively. including The anesthesiologists.
water This review intends to cover
black line represents baseline compliance. Point A0 is obtained leaves the tub through the hole at a certain rateone thatof depends gaps on in the understanding of cardiovascular lower than compliance of the veins, may increase under
Fig.many
2. Stressed and unstressed volumes—tub analogy. Water in
by extrapolation of the thick black line until itFig. crosses the the diameter of the hole (which would reflect venous
1. Venous capacity and compliance, stressed and unstressed physiology.
resistance certain conditions, e.g., arterial compliance significantly
y-axis; this point (A0) represents volume of blood atvolumes.
transmural
The main
a tub represents total goal
bloodof this article
volume. is the
A hole in to wall
describe
of the tub 3
Point A1[VenR]),
represents and total
on the heightofofblood
volume the water
in veinsabove
at thebetween
hole, repre-the surface of the water and the bottom of the tub increases during pregnancy and during certain pharma-
pressure zero, which is unstressed volume (Vu1). Differencepressure
transmural senting Vs; theA2larger
p1. Points and A3 therepresent
Vs, the higherchangethe
the functions
in flowdivides
throughtotal of volume
the the venous system as an important part
into stressed (Vs) and unstressed (Vu) cologic interventions such as nitroglycerin administra-
between total volume (Vt) and Vu1 is stressed volume (Vs).
volume induced hole.
by The water
change between
in pressure the hole
within the andveins.theThick
bottomof of
the theoverall
tub does
volumes, cardiovascular
above and below physiology. Understanding
the hole, respectively. The water 4,5
When a certain amount of blood is mobilized from theline
black veins, not baseline
represents affect thecompliance.
flow of water through
Point the hole;ofthis
A0 is obtained theseis the
leaves Vu,tub
functions
the a through
wouldthe help
holetoatprevent
a certain many
rate that depends on tion.
mistakes
The splanchnic system receives approximately
point A1 moves to point B; the veins contain now by lessextrapolation
blood at sequestered
of the thickvolume black that
linedoes
untilnotit directly
crosses participate
the thein the rate of the hole (which would reflect venous resistance 25% of cardiac output (CO) and contains approximately
diameter
the same intramural pressure p1. Removal of the volume
y-axis; thisof of0water
point (A flow (venous
) represents volumereturn).
of bloodWith the samein
at transmural
the
amount interpretation
of water
[VenR]),
of one or another variable, particu-
and on the height of the water above the hole, repre- 20% of total blood volume. Because of high compliance
blood between points A1 and B may be associated with zero,
pressure no whichin theistub (total blood
unstressed volume
volume (Vuin ). the venous
Difference larly
system),values
the
senting of
rela-
Vs; central
the larger venous
the Vs, pressure
the higher (CVP),
the in
flow clinical
through the
up between the hole and the bottom of the tub does of the veins, changes in blood volume are associated
1
change in the slope of the pressure–volume relation (thin black
between tion between
total volume (Vt) and VsVuand1 isVustressed
can be changed
volume by moving
(Vs). the hole
hole.
settings. The water
line parallel to the thick black line); this means When that venous or down.
a certain amount Movingis the
of blood hole down
mobilized fromrepresents not affect the flow of water through the hole; this is the Vu, a with relatively small changes in venous transmural pres-
the veins, venoconstriction
compliance did not change, but capacity did. Point pointB0A1(thin
moves toand point B; the veins
increases Vs (and contain
venousnow less blood
return). at Schematically
The distal end sequestered we can look at the cardiovascular system
of the tube,volume that does not directly participate in the rate sure.2 Veins are the most compliant vasculature in the
black line extrapolated to the y-axis) represents thedecreased
same intramural pressure
attached to thephole
1. Removal
in the tubof the
wall, volume of as central
represents a heart
of water and flow
venous a circuit.
(venousThis article
return). Withis focused
the same on one part
amount of water
blood between points A1 (CVP):
and B the mayhigher
be associated
the distalwith end, no in circuit,
the tubCVP(total blood human body and are easily able to accommodate changes
unstressed volume (from Vu1 to Vu2). However, the pressure– pressure theofhigher
the the namely thevolume
venousinsystem.
the venousThesystem),
functiontheofrela-
volume relation within the veins might look like the change
grayin the slope
line. andofthe
thelower
pressure–volume
the pressurerelation
gradient(thin black return,
for venous tion between
and vice Vs and Vu can be changed by moving the hole up in the blood volume. Therefore, they are called capaci-
line A1
parallel the heart and the arterial system will be mentioned only
The same amount of blood is mobilized (from point to B), to the thick
versa. Theblack line);
inflow tapthis means the
represents thatarterial
venousflow. or
The down.
hydrau- Moving the hole down represents venoconstriction tance vessels and serve as a reservoir of blood that easily
but Vu did not change: The gray line crossed the compliance
y-axis at thedid not change, butbetween
lic disconnect capacitythe did.
tapPoint
and Bthe tub in
0 (thin light of func-
their Vs
and increases
represents effects on the
(and venous venous
return). Thesystem
distal end and thetube,
of the
same point A0; the mobilized blood was recruited by black line extrapolated
a decrease to the y-axis)between
tional disconnection representsthe decreased
two (arterial effectsattached
flow theto
ofand the hole
venous
the in the on
system tubthe
wall, represents
function central
of the venous and immediately changes volume in it to maintain filling
heart.
in compliance rather than from a decrease in Vu. unstressed volume (fromsystem)
venous Vu1 to Vu due2).to
However,
high arterial resistance. pressurethe
the pressure– (CVP): the higher the distal end, the higher the CVP pressure in the right heart. Splanchnic and cutaneous
volume relation within the veins might look like the gray line. Moreover, and the lower focus of this gradient
the pressure article isfor onvenous
the gross phys-
return, and vice veins are the most compliant and represent the largest
The same amount of blood is mobilized (from point A1 to B), versa. The inflow tap represents the arterial flow. The hydrau-
Anesthesiology, V 108, No 4, Apr 2008 but Vu did not change: The gray line crossed the y-axis at the lic disconnect between the tap and the tub represents func- blood volume reservoirs in the human body. Veins of the
same point A0; the mobilized blood was recruited by a decrease * Chairman Emeritus, Department
tional disconnection of Anesthesiology,
between Perioperative
the two (arterial and and
flow Pain the
extremities are less compliant than splanchnic veins, and
Medicine, Brigham and Women’s Hospital, and Leroy D. Vandam and Benjamin
in compliance rather than from a decrease in Vu. venous system) due to high arterial resistance.
G. Covino Distinguished Professor of Anaesthesia, Harvard Medical School, Bos- therefore, their role as blood volume reservoir is rela-
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ton, Massachusetts.
tively minimal. Splanchnic and cutaneous veins have a
Anesthesiology, V 108, No 4, Apr 2008 Received from the Department of Anesthesiology, Perioperative and Pain
Medicine, Brigham and Women’s Hospital, Boston, Massachusetts. Submitted for
high population of !1- and !2-adrenergic receptors and
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publication August 15, 2007. Accepted for publication November 21, 2007.
on 10/19/2018
therefore are highly sensitive to adrenergic stimulation,
Support was provided solely from institutional and/or departmental sources.
contrary to skeletal muscle veins, which have relatively
Mark A. Warner, M.D., served as Handling Editor for this article. insignificant sympathetic innervation.6 This pattern of
Address correspondence to Dr. Gelman: Brigham and Women’s Hospital, 75
Francis Street, Boston, Massachusetts 02115. [email protected]. Information
innervation of the veins and the fact that cutaneous
on purchasing reprints may be found at www.anesthesiology.org or on the circulation is controlled mainly by the temperature sug-
masthead page at the beginning of this issue. ANESTHESIOLOGY’s articles are made
freely accessible to all readers, for personal use only, 6 months from the cover
gest that venoconstriction and mobilization of blood
date of the issue. volume is mainly limited to the splanchnic veins.7,8

Anesthesiology, V 108, No 4, Apr 2008 735

8
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 10/26/18

THE PA is closer to the left heart than

But our friend is at it again!
the CVP
Marik Annals of Intensive Care 2013, 3:38
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REVIEW Open Access

u Cannot us e the CVP in any manner to predic t left s ided filling pres s ures
Obituary: pulmonary artery catheter 1970 to 2013
Paul E Marik

Abstract
u Intervening lung? The birth of the intermittent injectate-based conventional pulmonary artery catheter (fondly nicknamed PAC) was
proudly announced in the New England Journal of Medicine in 1970 by his parents HJ Swan and William Ganz. PAC
CO meas
grewurements are not
rapidly, reaching manhood in 1986 quite
where, in thethe
US, he gold
was shownsto
tandard (inac cofurac
influence the management over ies inherent in method, trac king c hange)
40% of all ICU patients. His reputation, however, was tarnished in 1996 when Connors and colleagues suggested
that he harmed patients. This was followed by randomized controlled trials demonstrating he was of little use.
u Can however us e in right heart failure/ peric arditis Furthermore, reports surfaced suggesting that he was unreliable and inaccurate. It also became clear that he was
poorly understood and misinterpreted. Pretty soon after that, a posse of rivals (bedside echocardiography, pulse
Static meas
invasively ure
contour technology) moved into the neighborhood and claimed they could assess cardiac output more easily, less
and no less reliably. To make matter worse, dynamic assessment of fluid responsiveness (pulse pressure
variation, stroke volume variation and leg raising) made a mockery of his ‘wedge’ pressure. While a handful of
u A high CVP is not innoc uous ! die-hard followers continued to promote his mission, the last few years of his existence were spent as a castaway
What tountil
do with an as trologer who predic ts doom?
his death in 2013. His cousin (the continuous cardiac output PAC) continues to eke a living mostly in cardiac
surgery patients who need central access anyway. This paper reviews the rise and fall of the conventional PAC.
Keywords: Pulmonary artery catheter; Right heart catheterization; ICU; Hemodynamic monitoring; Operating room

Review patients who were hospitalized were reported to undergo

Pulmonary artery (PA) catheterization was first per- pulmonary artery catheterization [4]. This phenomenon
formed by Lewis Dexter in 1945 [1]. After observing a occurred despite that fact that the safety, accuracy, and
spinnaker on a sailboat off Santa Monica beach, the idea benefit of the device had never been established.
of a flow-directed PA catheter (PAC) was developed by Eugene Robin was the first clinician to challenge the
Swan and Ganz in 1970, allowing bedside placement [2]. widespread adoption of the PAC. He wrote two edito-
The PAC was subsequently modified with a thermistor rials in the mid 1980s in which he called for a morator-
to allow measurement of cardiac output (CO) [3]. ium on the use of the PAC until randomized controlled
Shortly after the publication by Swan et al. in 1970, the trials (RCTs) were performed which demonstrated the
balloon tipped PA catheter became commercially avail- safety and improved outcomes associated with the use of
able and it began to be used in a variety of clinical the PAC [5,6]. A decade later the landmark study
settings. The use of the PAC moved from the cardiac by Connors and coworkers was published [7]. Using
catheterization laboratory to the ICU and operating propensity matching, this study demonstrated a 24%
room and its use changed from being used as a diagnos- increased risk of death in ICU patients who received a
tic to a therapeutic tool. Clinicians began to use the PAC within 24 hours of admission to an ICU. The first
hemodynamic data derived from the PAC to select, large randomized, controlled, prospective, evaluation of
modify and monitor medical treatments. After the intro- the PAC was published by Sandham and colleagues in
duction of the PAC, enthusiasm for the device increased 2003 [8]. These authors randomized 1,994 high risk
and its use increased exponentially. Indeed, the PAC patients aged 60 years or older who were scheduled for
became the cornerstone of critical care and a hallmark major surgery to goal directed therapy guided by a PAC
of the ICU. In the 1980s 20% to 40% of seriously ill compared to standard care without a PAC. Hospital and
six month mortality and length of stay were similar
Correspondence: [email protected]
between the two groups. Except for pulmonary embol-
Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical ism, which was higher in the PAC group, morbidity was
School, 825 Fairfax Avenue, Suite 410, Norfolk, VA, USA

© 2013 Marik; licensee Springer. This is an open access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.

But beware of wise men- preacher vs

IS this the new hip hop?
practitioner
Society of Cardiovascular Anesthesiologists
Cardiovascular Anesthesiology Section Editor: Charles W. Hogue, Jr.
Perioperative Echocardiography and Cardiovascular Education Section Editor: Martin J. London
AJRCCM Articles in Press. Published on 23-August-2018 as 10.1164/rccm.201801-0088CI
Hemostasis and Transfusion Medicine Section Editor: Jerrold H. Levy Page 26 of 30

Lack of Effectiveness of the Pulmonary Artery High PPV

Catheter in Cardiac Surgery

Stroke
Nanette M. Schwann, MD,*† Zak Hillel, PhD, MD,‡ Andreas Hoeft, MD,§ Paul Barash, MD,! volume
Patrick Möhnle, MD,¶ Yinghui Miao, MD, MPH,** and Dennis T. Mangano, PhD, MD††
Intensive Care Med (2018) 44:730–741 Current Use of the Pulmonary Artery Catheter in Cardiac Surgery:
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https://doi.org/10.1007/s00134-018-5187-8
BACKGROUND: The pulmonary artery catheter (PAC) continues to be used for monitoring of A Survey
Current UseStudy of the Pulmonary Artery Catheter in Cardiac Surgery:
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hemodynamics in patients undergoing coronary artery bypass graft (CABG) surgery despite concerns
raised in other settings regarding both effectiveness and safety. Given the relative A Survey Study
OnkarpaucityJudge, of MD,*
data Fuhai Ji, MD,*† Neal Fleming, MD, PhD,* and Hong Liu, MD* Preload responsiveness
regarding its use in CABG patients, and given entrenched practice patterns, we assessed the impact
of PAC use on fatal and nonfatal CABG outcomes as practiced at a diverse set Current of medical centers. Use of the Pulmonary Onkar Judge, ArteryMD,* FuhaiCatheter Ji, MD,*† in Neal
Cardiac Fleming, Surgery:
MD, PhD,* and Hong Liu, MD*
REVIEW Objective: Because of its invasive nature, debated effect
METHODS: Using a formal prospective observational study design, 5065 CABG patients from 70 A Survey
(29.6%) did more than 800 cases annually. For cases using
Study bypass, 583 (68.2%) of the respondents
on patient outcome, and the development of alternative cardiopulmonary
centers were enrolled between November 1996 and June 2000 using a systemic sampling protocol. Objective: Because of its invasive nature, debated effect (29.6%) did more than 800 cases annually. For cases using
hemodynamic monitoring technologies, the intraoperative used a PAC more than 75% of the time, while 30 (3.5%) did

Alternatives to the Swan–Ganz catheter

Propensity score matched-pair analysis was used to adjust for differences in likelihood of PAC on patient outcome, and the development of alternative cardiopulmonary bypass, 583 (68.2%) of the respondents
use of the pulmonary artery Onkar catheter
Judge, (PAC)
MD,*has significantly
Fuhai Ji, MD,*† Neal not use the PAC
Fleming, atintraoperative
MD, all.
PhD,* and Hong Liu, MD*more than 75% of the time, while 30 (3.5%) did
insertion. The predefined composite endpoint was the occurrence of any of the following: death (any hemodynamic monitoring technologies, the used a PAC
decreased. The authors conducted a survey use of the
of the members
pulmonary ofartery catheter
Ninety-four(PAC) percent
has of respondentsnot
significantly used
use transesophageal
the PAC at all.
cause), cardiac dysfunction (myocardial infarction or congestive heart failure), cerebral dysfunction Preload unresponsiveness
the Society of Cardiovascular
Objective: BecauseAnesthesiologists
of(acute
its invasive
decreased. (SCA)
Theto
nature, assessconducted
debated
authors echocardiography
effect a(29.6%)
survey of didthe(TEE)
more as
than
members part800ofcases
of theNinety-four
intraoperative
annually. For mon-ofusing
cases
percent respondents used transesophageal
(stroke or encephalopathy), renal dysfunction (dysfunction or failure), or pulmonary dysfunction
included current use of the PAC 7and alternative hemodynamic monitor- itoring. When not using a PAC,583 FloTrac/Vigileo was the as part of the intraoperative mon-
Backer1* distress
Daniel Derespiratory , Jan Bakker 2,3,4
syndrome). , Maurizio
Secondary Cecconi 5
variables, Ludhmila Hajjaron
treatment
6 patient
, Da Wei(inotrope
indices Liu , Suzanna
outcome, use,andfluidLobo
thethe 8Society of Cardiovascular
,
development of alternative cardiopulmonary
Anesthesiologists (SCA) tobypass,
assess (68.2%) of the
echocardiography respondents
(TEE)
ing technologies
unit in patients undergoing cardiacuse surgery. alternative cardiac monitoring modality in When
15.2% of (3.5%)
the adidPAC, FloTrac/Vigileo was the
hemodynamic monitoring current
technologies, of the PAC and alternative hemodynamic monitor- ofitoring. whilenot using Low PPV
administration), duration 10of postoperative intubation, 14 the intraoperative used a PAC more than 75% the time, 30
Xavier Monnet 9
, Andreabased
categorization
Morelli , Sheila Neinan Myatra11
on PAC and transesophageal
, and intensive
Azriel Perel
echocardiography
12care
Design: , use
Michael
use
length
the R.
Aof(both,
survey
of stay.
Pinsky
study.
pulmonary
neither,
13 After
PAC
, Bernd
artery Saugel
ing
only,cathetertechnologies, hasinsignificantly
(PAC) responses.
patients undergoing not useSimilar
cardiac trends
the surgery.
PAC at in
all.monitoralternative
preferencescardiac
were seen monitoring modality in 15.2% of the
9 15,16 17
Setting: Hospitals in North America, Europe, Asia, Aus- in off-pump coronary artery bypass grafting and minimally
Teboul , Antoine
Jean-Louistransesophageal Vieillard-Baron
echocardiography only), weandperformed
Jean-Louis theVincent decreased. The authors
primary analysis contrasting PAC only conducted Design:
a survey A survey
of the study.
members of Ninety-four percent of responses.
respondents used Similar trends in monitor preferences were seen
transesophageal
and neither (total, 3321 patients), from which propensity paring tralia, New
yieldedthe 1273Zealand,
Society and South
pairs. America.
of Cardiovascular
matched Setting: Hospitals
Anesthesiologists (SCA) to invasive/robotic
in assess
North America, heartAsia,
Europe,
echocardiography surgery.Aus-as part
(TEE) in off-pump coronary artery
of the intraoperative mon-bypass grafting and minimally
RESULTS: The primary endpoint occurred in 271 PAC patientsParticipants: versuscurrent196use SCA of members
withoutthe PAC
PAC (21.3%
andin alternative
North
tralia,America,
New
hemodynamicEurope,
Zealand, and South
monitor- Conclusions:
America.
itoring. WhenThe resultsnot usingof this study suggested heart
invasive/robotic
a PAC, FloTrac/Vigileo thatwas asurgery.
the
© 2018 Springer-Verlag GmbH Germany, part of Springer Nature and ESICM
vs.15.4%; adjusted odds ratio [AOR], 1.68; 95% confidence Asia, Australia, [CI],New
ing technologies
interval 1.24Zealand,
toin 2.26; and
patients ! Participants:
South
P undergoing America. cardiac SCA members
surgery. in alternative
majority North
of theAmerica,
respondents
cardiac Europe, still preferConclusions:
monitoring to use the
modality The
in PAC
15.2% results
forof the of this study suggested that a
Interventions: Asia, Australia, New to Zealand, and cardiac
South America. majority ofofthe respondents
were seenstill prefer to use the PAC for
0.001). The PAC group had an increased risk of all-cause mortality, 3.5% vsThe
Design: A1.7% survey
survey was
study.
(AOR, 2.08; e-mailed by the SCA most responses. surgeries.
Similar trendsSubgroup analysis
in monitor the
preferences data
roughly(AOR, 6,000
Setting:of its members.
Hospitals Interventions: The surveyrevealed was in e-mailed by coronary
that geographicalthe SCAlocation,to most
type cardiac surgeries.
of practice,and and Subgroup analysis of the data
95% CI, 1.11 to 3.88; P " 0.02) and an increased risk of cardiac 1.58; 95% CI,in1.14 North to America, Europe, Asia, Aus- off-pump artery bypass grafting minimally
A B
roughly 6,000 was
of its left
members. surgery.revealed that geographical location, type of practice, and
Te boul AJRCCM 2018
2.20; P " 0.007), cerebral (AOR, 2.02; 95% CI, 1.08 to 3.77;Measurements P "tralia,
0.03)New andand Main
Zealand,
renal (AOR, Results:
and South
2.47; The survey
America. surgeon support playedheart
invasive/robotic a significant role in the decision to Cardiac
open for 30 days.
Participants: Respondents
SCA members accessed Measurements
in the survey
North America, andaEurope,
via Mainuse Results:
a PAC. The survey
Although
Conclusions: mostwasrespondents
The left ofsurgeon
results prefer
this studysupport played
to suggested
use TEE a significant
as that a role in the decision to
Abstract95% CI, 1.68 to 3.62; P ! 0.001) morbid outcomes. PAC patients received inotropic drugs more preload
frequently (57.8% vs 50.0%; P ! 0.001), had a larger positive secured web-based
IVAsia,
fluidAustralia,
balance database.
New A totalopen
afterZealand,
surgery of 854
and forquestionnaires
South 30America.
days. Respondents accessed
majority the
a complimentary survey
of tool,
the TEEvia also
respondents a remains
use prefer
still a the
PAC.most
Although
to use themost
popular PAC respondents
for prefer to use TEE as
While the(3220pulmonarymL vsartery
3022catheter
mL; P "(PAC) 0.003),is still
andinteresting
experienced in specific situations,
longerwere
time completed. thereA
Interventions:
to tracheal are many
total The
extubation alternatives.
of survey
705
(15.40
secured
(82.6%)
was Awere
e-mailedweb-based
group from thedatabase.
by North to A total of 854 questionnaires
SCA supplemental/alternative
most cardiac surgeries. hemodynamic a complimentary
Subgroup monitoring tool, TEE also remains the most popular
analysistechnol-
of the data Figure 1
were completed. A total of 705 (82.6%) were from North supplemental/alternative hemodynamic monitoring technol-
of expertshours
from[11.28/20.80]
different backgrounds discusses
versus 13.18 hours their
[9.58/19.33], American
respective interests
median and
plus members.
limitations
roughly
Q1/Q3 6,000 Four
of
of its hundred
the
interquartile various
members.
range; twelve of the respond-
techniques ogy. revealed that geographical location, type of practice, and Copyright © 2018 by the American Thoracic Society
American members. Four hundred twelve of the respond- ogy.
and related P !measured
0.0001).variables.
Use of PAC Thewas also
goal associated
of this review iswith prolonged
to highlight ents (48.1%)
intensive
the conditions worked
Measurements
care inunit in
stay
which a and
private
(14.5%
the Main practice
vsResults:
alternative setting,
The while
survey350 was left& 2014surgeon
Elsevier support
Inc. All rights
playedreserved.
a significant role in the decision to
entsdevices
(48.1%) worked in a private practice setting, while 350 & 2014 Elsevier Inc. All rights reserved.
(40.9%)open were for from 30 an
days. Respondents
academic practice. accessed
A majority the ofsurvey
the via a use a PAC. Although most respondents prefer to use TEE as
will suffice10.1%;
and when AOR,they1.55;
will95%
notCI, 1.06 to
or when 2.27;
these P " 0.02).
alternative techniques cansecured
respondents provide information
web-based
(57.9%) were not available
database.
from
(40.9%)
A total
hospitals withwere from an academic practice. A majority of the
of 854
that questionnaires
performed KEY a complimentary
WORDS: pulmonary tool,
arteryTEEcatheter,
also remains cardiacthe surgery,
most popular
CONCLUSIONS: Use of a PAC during CABG surgery was associated with increased mortality and respondents (57.9%) were from hospitals that performed KEY WORDS: pulmonary artery catheter, cardiac surgery,
PAC. The panel
a higher concluded that itend-organ
risk of severe is useful tocomplications
combine different in thistechniques
more thaninstead
were400
propensity-matched ofcardiac
relyingsurgeries
completed.
observational on
A a single
total of one
705 and
a year,
study. (82.6%)
morea than subset were
400
from North
ofcardiac
which surgeries
supplemental/alternative hemodynamic monitoring technol-
hemodynamic
a year, amonitoring
subset of which hemodynamic monitoring
to adapt the “package” of
A randomized interventions
controlled to the
trial with condition
defined of the patient.
hemodynamic goals As a first
would bestep,
Americanidealthe to clinicalconfirm
members.
either and
Fourbiologic
hundred
or signs
twelve of the respond- ogy.
ents (48.1%) worked in a private practice setting, while 350 & 2014 Elsevier Inc. All rights reserved.
should berefute
used our findings.
to identify (Anesth
patients Analg
with 2011;113:994
impaired –1002)Whenever
tissue perfusion. available, echocardiography should
(40.9%) were from an academic practice. A majority of the
be performed as it provides a rapid and comprehensive hemodynamic evaluation. If the patient
respondents (57.9%) responds rapidly
were from to
hospitals that performed KEY WORDS: pulmonary artery catheter, cardiac surgery,

S C C
therapy, either no additional monitoring or pulse 1wave analysis (allowing continuous more thanmonitoring
OMPREHENSIVE insurgeries
HEMODYNAMIC
400 cardiac case potential MONITORING
a OMPREHENSIVE
year, a subset of which HEMODYNAMIC hemodynamic monitoring
MONITORING METHODS METHODS
ince its introduction more than 40 years ago, the bypass graft (CABG) surgery or cardiac valvular surgery,
degradation
flow-directedis balloon-tipped
anticipated) canpulmonary
be applied.artery
If the patient
cath- does not rapidly
however, PACandrespond
use to therapy
optimization
is still a standard or complex
of cardiac function
procedure hemody-
provide
and the founda-of cardiacA function
optimization
in many 17-question provide
surveythe wasfounda-
developed by the A authors
17-question and approved
survey was developed by the authors and approved
namic alterations are observed, pulse wave analysis tion
4,5 is for critical care and perioperative tion patient management.
for critical care and perioperative patient
assessmanagement.
eter (PAC) has become a monitoring standard andcoupled
a with TPTD
practices. Insuggested.
2000 it was estimated that 500,000 cardiac by the SCA to the current use ofbyhemodynamicthe SCA to monitoring
assess the current use of hemodynamic monitoring
Numerous strides have been made to Numerous strides have beentechnologies
improve hemodynamic made to improve hemodynamic
during cardiac surgery (Tabletechnologies during cardiac
1). Three questions were surgery (Table 1). Three questions were
guideKeywords:
to therapy Hemodynamic
for patients suffering critical
monitoring, illnesses
Cardiac output, surgery
or Tissue patients
perfusion, werefailure
Cardiac monitored annually with a PAC in
monitoring
surgery. of patientstheundergoing relatedcardiac surgery. Perhapsdata andthe
C
monitoring ofOMPREHENSIVE
patients undergoing cardiac Perhaps to demographic practice related
type. to Onedemographic
question was data and practice type. One question was
for those undergoing complex surgical procedures.2 Over the United States alone, 6
and that HEMODYNAMICinsertion largest rates
came inMONITORING
in 1970 when Swan et alto 1
usedthe theopinion
pulmonary
METHODS
included to evaluate the opinion of the cardiac surgeon with respect to
largest came and in 1970 when Swan
optimization of et al1 first
cardiac used
function the pulmonary
provide the founda-
included evaluate
first of the cardiac surgeon with respect to
the past decade PAC monitoring has become less common, cardiac surgery have not paralleled the downward artery cardiac trend (PAC) at beside
catheter Ahemodynamic
to assess
alternative 17-question
cardiac survey was developed
function.
monitoring by thehemodynamic
alternative
technologies. authors
The and approved
remaining monitoring technologies. The remaining
artery catheter (PAC)
critical atcare
tion for populations. beside
and to assess
perioperative patient function.
although its use varies markedly between institutions and
Introduction seen
Still,innoother patient
monitoring device advanceswill improve
3
Arguably,
patient
Through there
outcomes
subsequentis management.
advances by were
in technology
questions the SCA andtosome
related assess
to the
thesimple current
types use of hemodynamic
questions
of procedures were related monitoring
and monitoring to the types of procedures and monitoring
Through subsequent
Numerous inbeentechnology and some hemodynamic
simple
clinical settings.3 For patients undergoing coronary artery in strides
these have made togrowing improve
allows technologies during cardiacofsurgery technologies
(Table 1). used.
ThreeBefore dissemination,
questions were a pilot questionnaire was sent
Human right heart catheterization was first performed rationale for such
unless coupled
calculations, touse
monitoringathetreatment
PAC
patients,
nowthat
of patients allows
given
calculations,
itselfroutine
undergoing improves
cardiac out-
measurements the PACofnow technologies
surgery. Perhaps the
used. measurements
routine Before dissemination, a pilot
and to
questionnaire
cardiactype.
anesthesia
was sent
faculty
central venous pressure, to cardiac
pulmonary related
artery to demographic
anesthesia
pressure, faculty data
at the
continuous authors’ practice
institution to evaluate the at was
One question the authors’ institution to evaluate the
in 1929 by Werner Forssmann and then developed by comes [10, 11].venous
central largest came pressure, pulmonary
in 1970 when Swan artery et pressure,
al1 first continuous
used the pulmonary survey’s included to evaluate
claritycatheters),
and reliability.the The
opinion of survey’s
survey the
then cardiacclarity and with
surgeon
was e-mailed
reliability.
respectThe
by the to survey then was e-mailed by the
From *Allentown Anesthesia Associates and the Department of Anesthesiol- cardiac output (in specially designed systemic
AndréValley
ogy, Lehigh Cournand and Dickinson
Health Network, Allentown, PA;W.†Department
Richards,of Anesthe-
the three ported As the
Funding: cardiac
The PAC
Ischemia output
isartery
a Research (in and
multifaceted
catheter specially
hemodynamic
Education
(PAC) designed
at Foundation
beside catheters),
monitor,
to (IREF)
assess sup-its systemic
cardiac function. alternative hemodynamic monitoring technologies. The remaining
data collection, including site grants, central analysis vascular and resistance,
data and mixed venous oxygen (SvO2 with
sia, Thomas
authorsJefferson
receivingUniversity Hospital,
the Nobel PrizePhiladelphia,
for it in 1956 PA; [1].
‡Depart-
It was disposition, vascular
use is complex.
manuscript
resistance,
When
Through using
grants, subsequent
and
andall mixed
publicationits
advances venous
ofcapabilities,
in
the findings.
oxygen it offers
technology (SvO and22somewith simple questions were related to the types of procedures and monitoring
ment of Anesthesiology, St. Luke’s—Roosevelt Hospital Center, NY, NY; 2 oximetric PAC). These measurements technologiesallowed used. forBeforebetter
dissemination, a pilot questionnaire was sent
oximetric PAC).
manuscript wascalculations,
These
the artery
PAC measurements
now allows allowed
routine for better
measurements of
in the of1970s,
§Department when and
Anesthesiology Drs. SwanCare
Intensive and Ganz Bonn
Medicine, added balloon This
University, measurement of pulmonary
handled by Charles W. Hogue, pressure,
Jr., MD. pulmonary
characterization of preload, afterload,
From tothe contractility,
cardiac anesthesia
*Department and
of faculty
Anesthesiology
From the *Department of Anesthesiology and Pain Medicine, Uni-
tissueat the authors’
and Paininstitution
Medicine,to evaluate
Uni- the
Bonn, Germany; !Department of Anesthesiology, Yale University School of characterization
central of
venous preload,
pressure,afterload,
pulmonary contractility,
artery and
pressure, tissue
continuous versity of California, Davis, California; and †Department of Anesthe-
flotation [2] and thermodilution [3] to the catheteriza- Theartery authorsocclusion
declare no
oxygenation.
pressure
conflict (PAOP),
of interest. right atrial oxygenation.pressure Although it was
versityfirst introduced
survey’s
of California,clarity for reliability.
and
Davis, use in The
California; and survey
†
then
First was
Department e-mailed
of Anesthe- by the of Soochow University, Suzhou,
Medicine, New Haven, CT;, ¶Department of Anesthesiology, Ludwig- cardiacAlthough output it was
(in specially introducedill
designed
first critically for
catheters), use in
patients, systemic
use of siology,
the PAC quickly expanded into siology, Affiliated Hospital
tion technique,Munich,
MaximiliansUniversität, that the pulmonary
Germany; artery
**Ischemia Researchcatheter (PAC) Reprints
and Education (RAP), will not be available
cardiac output
critically
from
illtopatients, (CO),the authors.
and mixed-venous oxygen First Affiliated Hospital of Soochow
Jiangsu,University,
China. Suzhou,
Foundation, San Bruno, CA; ††for the Investigators of the Multicenter Study of Address correspondence vascular Nanette M.use
resistance, ofand
Schwann, the MD,PAC
mixedLeigh quickly
the venous
operating
Valley expanded
oxygen
Health- room(SvO into 2that
such with hemodynamic
Jiangsu, China. monitoring with a
became popular.
(McSPI)The PACGroup
hasand been consideredResearchuseful, saturation (SvO
theDepartment 2). of
operating
oximetric Pulmonary
room such 2that
PAC). artery capillary
hemodynamic
These measurements pressure
monitoring allowed with a better This work was supported by the Department of Anesthesiology and
Perioperative Ischemia Research the Ischemia and care Network, Anesthesiology, 1245 Cedar Crest has
PAC Blvd., Suite
become an for
integral aspect
This workof thewasanesthetic
supported manage-
by the Department Pain of Anesthesiology
Medicine, Universityandof California Davis Health System (H.L.).
useless,
Education and (IREF),
Foundation even San
harmful [4–6].
Bruno, CA. A meta-analysis
See Appendix 2 for a completeof
listPAC
of can
300, be PAC
estimated
Allentown, PA 18103.
has and
become Address
characterization upan to ten
e-mail
integral
of toadditional
[email protected].
aspectafterload,
preload, of ment variables
the anesthetic canmanage-
contractility,
of cardiac and
surgery tissue
patients. From
It the *Department
provides invaluable
Pain Medicine, University of California Davis
of Anesthesiology
Health
and Pain
System
Medicine, Uni-
(H.L.). by grant from Jiangsu Province’s by Key
the investigators and centers. This study was also supported
efficacy and safety in 5051 patients (13 RCTs) showed DOI: be calculated
Copyright ©ment [12].
2011 International Using
ofoxygenation.
cardiac all
Anesthesia
surgery ofResearch
Although this
patients.itatSociety
the
was bedside
Itinformation
provides isboth
introduced a intra-
invaluable for use in versity of California, Davis, California; and †Department of Anesthe-
Accepted for publication June 29, 2011. 10.1213/ANE.0b013e31822c94a8
first and This
postoperatively
study was also in the intensive
supported by grant fromProvincial
Jiangsu Province’s by Key China (F.J.), by Jiangsu Province’s six
Talents Program,
siology, First Affiliated Hospital of Soochow University, Suzhou,
no evidence of harm or of a conferred overall benefit [7]. challenge to even
information the
criticallybothmostillintra- experienced
and postoperatively
patients, use of the clinician.
carePAC unitin How-
the
quickly
(ICU). intensive
expanded
However,into because of
Provincial its invasive
Talents
Jiangsu, China.
Program, nature-China (F.J.),major
by Jiangsu Province’s
peak talents six China (F.J.), and by Suzhou Science and
program,
These studies mostly demonstrated that PAC is safe when ever, thecare unit
unique the(ICU).
operating
data However,
availableroom suchfrombecause
thata PAC of its
hemodynamic
associated
make invasive an nature- with
monitoring
itcomplications, a
debated
major effect
peak on patient
talents program,outcomeChina (F.J.), andTechnology
by Suzhou
This work was supported by the Department of Anesthesiology and
Bureau’s
Scienceprogram
and No.SYS201111 (F.J). from China. The
994 www.anesthesia-analgesia.org associated November
complications, 2011an Volume
•debated
in theeffect
113 and•on Number
of patient 5outcome authors(F.J).thank
from Ms. JoyceTheSchamburg for her technical support and AJRCCM Articles in Press. Published on 23-August-2018 as 10.1164/rccm.201801-0088CI
Page 25 of 30
PAC has become integral aspect the development
the anesthetic and clinical
manage- introduction
Technology Bureau’s of alternative,
program No.SYS201111 China.
properly used. Recent studies have suggested better out- attractive hemodynamic monitor care of patients
authors
Pain Medicine, University
thank Ms. Joyce Schamburg
of California Davis Health System (H.L.).
artwork.
and thement development
of cardiac and surgery
clinical introduction less invasive
patients. It of hemodynamic
alternative,
provides invaluable monitoring
This studytechnologies, the byfor her technical support and
comes in selected patients with heart failure and trauma with severe circulatory shock, particularly those withuse of the PAC
intraoperative artwork.
has decreased
was also supported
significantly
grantAddress
from Jiangsu Province’s by Key
reprint requests to Hong Liu, MD, Department of Anes-
less invasive
information hemodynamic
both intra- monitoring
and postoperatively technologies, in thethe intensive Provincial Talents Program, Chinathesiology
(F.J.), byand Jiangsu Province’s University
six
when a PAC was part of a given strategy of care [8, 9]. right ventricular care(RV)
intraoperative unitusedysfunction
of theHowever,
(ICU). PAC and/orhasbecauseacutetheof
over
decreased respira-
years. 3–5
significantly
its invasive authorsAddress
The nature- conducted
major reprint
peakthisrequests
survey
talents toofHong
program, Liu, MD,
theChina (F.J.),Department
and
Painof Medicine,
by VSuzhou Anes-
Science
of California Davis Health
and Sacramento, CA 95817. E-mail:
System, 4150 Street Suite 1200,
tory failure,
over the asassociated
recommended3–5
years. complications,
The authorsby theconductedESICM
debated Society task force
thisofsurvey
effect Cardiovascular
on patient
of the outcome thesiology
Anesthesiologistsand Pain
Technology(SCA) Medicine,
Bureau’s University
members of
program No.SYS201111 California Davis Health
(F.J). from China. The
[email protected]
[13]. Societyand the development
of Cardiovascular and clinical
Anesthesiologists to assess
introduction
(SCA)the current usage System,
of alternative,
members
4150
PAC Vand
of the authors Street
thank otherSuite
Ms. 1200,
hemody-
Joyce Sacramento,
Schamburg ©for
CA
2014
95817.
herElsevier
technicalE-mail:
Inc.support andreserved.
All rights
namic monitoring technologies [email protected]
*Correspondence: [email protected] Due to concerns
to assess about
current the
lesstheinvasive invasiveness
hemodynamic
usage of the PAC ofand
monitoringthe PAC,
other technologies,
hemody- the©in2014patients
artwork.undergoing cardiac
Elsevier reprint
Inc. All requests
rights reserved.
1053-0770/2601-0001$36.00/0
1
Department of Intensive Care, CHIREC Hospitals, Université Libre de intraoperative use of the PAC hassurgery. decreasedcardiac significantly Address to Hong Liu, MD, Department of Anes-
http://dx.doi.org/10.1053/j.jvca.2014.07.016
Bruxelles, Brussels, Belgium
less or even non-invasive techniques have become avail-
namic monitoring technologies in patients undergoing
1053-0770/2601-0001$36.00/0
thesiology and Pain Medicine, University of California Davis Health
3–5
Full author information is available at the end of the article able [14]. over the years.
surgery.
Alternative The authors
techniques, conducted
including this survey of thehttp://dx.doi.org/10.1053/j.jvca.2014.07.016
minimally System, 4150 V Street Suite 1200, Sacramento, CA 95817. E-mail:
Society of Cardiovascular Anesthesiologists (SCA) members
Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 1 (February), 2015: pp 69–75 69
[email protected]
to assess the current usage of the PAC and other hemody- ©69–75
2014 Elsevier Inc. All rights reserved.
Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 1 (February), 2015: pp 69
namic monitoring technologies in patients undergoing cardiac

New hip hop? Some limits?

1053-0770/2601-0001$36.00/0
surgery. http://dx.doi.org/10.1053/j.jvca.2014.07.016

Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 1 (February), 2015: pp 69–75 69

AJRCCM Articles in Press. Published on 23-August-2018 as 10.1164/rccm.201801-0088CI

Page 27 of 30
Figure 2

↘ RV preload
↘ RV stroke Blood pulmonary ↘ LV stroke
transit time ↘ LV preload
volume volume
Michard et al. Critical Care (2015) 19:144 Page 2 of 3
↗ intrathoracic
↗ RV afterload
pressure

↗ transpulmonary
↘ LV afterload
pressure
↗ LV stroke
volume
↗ LV preload

PPmax PPmin
at inspiration at expiration

Mic hard 2015

Te boul 2018
Copyright © 2018 by the American Thoracic Society
Figure 1 Most common physiological limitations to the use of pulse pressure variation can be summarized as ‘LIMITS’. HR/RR, heart
rate/respiratory rate.

fluid loading as knowing if CO will increase by more or Conclusion

less than 15%. What is the clinically relevant difference Recent studies about the applicability of PPV [5-7], or
between two patients increasing their CO by 14 and the study from Biais and colleagues [13] reporting a
16%, respectively? Studies have repeatedly documented a large grey zone, may lead to the wrong conclusion that
linear and positive relationship between PPV before fluid PPV has limited clinical value. Several randomized con-
administration and the percentage increase in CO in trolled trials have investigated whether fluid manage-
response to fluid loading [1-3,15]. This means that, in ment based on PPV (or on surrogate parameters) may
the presence of an intermediate PPV value - that is, improve patients’ outcomes. A recent meta-analysis [16]
within the grey zone - one may expect a mild increase in of these trials showed that PPV-based fluid management
CO. This is not minor information when assessing the is associated with a significant decrease in post-surgical
benefit/risk ratio of fluid therapy. morbidity and length of stay. In other words, PPV-based

Figure 2 Not respecting pulse pressure variation limitations and methodological noise artificially increase the zone of uncertainty, also
called the grey zone.
9
Michard et al. Critical Care (2015) 19:144 Page 2 of 3

10/26/18

Figure 1 Most common physiological limitations to the use of pulse pressure variation can be summarized as ‘LIMITS’. HR/RR, heart
rate/respiratory rate.

fluid loading as knowing if CO will increase by more or Conclusion

less than 15%. What is the clinically relevant difference Recent studies about the applicability of PPV [5-7], or
between two patients increasing their CO by 14 and the study from Biais and colleagues [13] reporting a

Grey and not white or black?

16%, respectively? Studies have repeatedly documented a
linear and positive relationship between PPV before fluid
administration and the percentage increase in CO in
large grey zone, may lead to the wrong conclusion that
PPV has limited clinical value. Several randomized con-
trolled trials have investigated whether fluid manage-
Can J Anesth/J Can Anesth (2015) 62:1139–1142
response to fluid loading [1-3,15]. This means that, in ment based on PPV (or on surrogate parameters) may
DOI 10.1007/s12630-015-0465-1
the presence of an intermediate PPV value - that is, improve patients’ outcomes. A recent meta-analysis [16]
EDITORIALS
within the grey zone - one may expect a mild increase in of these trials showed that PPV-based fluid management
CO. This is not minor information when assessing the is associated with a significant decrease in post-surgical
benefit/risk ratio of fluid therapy. morbidity and length of stay. In other words, PPV-based
The ‘‘grey zone’’ or how to avoid the binary constraint
of decision-making

summary
Maxime Cannesson, MD, PhD
Michard et al. Critical Care (2015) 19:144
DOI 10.1186/s13054-015-0869-x

Received: 5 August 2015 / Accepted: 16 August 2015 / Published online: 22 August 2015
! Canadian Anesthesiologists’ Society 2015
EDITORIAL Open Access
In this issue of the Journal, Vos et al. report on the ranges from 0 to 1. An area of 1 represents an ideal test,
Applicability of pulse pressure
accuracy of pulse pressure variation (PPV), stroke volume
variation (SVV), and stroke volume index (SVI) to predict
variation:
while an area of 0.5 represents a worthless test (i.e., same
predictive value as flipping a coin). While this approach

how
they show many shades used to of grey?
1
fluid responsiveness at multiple thresholds. In their study, has been used for years to assess the accuracy of diagnostic
3
that the threshold define fluid tools (such as the ability of PPV to separate responders
responsiveness impacts the predictive value of these
1* 2 from non-responders to fluid administration), its main
Frederic Michard
indices and , Denis
the range Chemla
of their and
zones forJean-Louis Teboul3 limitation is that it transforms the biological nature of a
decision-making
(i.e., the ‘‘grey zone’’)—the lower the threshold for the continuous variable into an artificially dichotomous (i.e.,
definition
Since of fluid
its first responsiveness,
description in 1999 [1],the lower
many the predictive
studies have ‘‘black value
practical or white’’)
becausestatistical
it allows the index that does not
determination always
of three
value and the the
demonstrated wider the of
value grey zone.
pulse Although
pressure these (PPV)
variation results accurately
zones: a zonereflect
wherethe PPV decision-making
predicts a positive process applied
response to to
4
are a not
as
Figure 2 Not respecting pulse pressure variation limitations and methodological noise artificially increase the zone of uncertainty, completely
predictor
also surprising
of fluid (i.e., how These
responsiveness. one defines
studiesan clinical
fluid loading,management.
a zone whereIndeed, PPV predictsthe very reasonre-we
a negative
outcome
were generally
pooled impacts
together in the
a accuracy of the tools used
recent meta-analysis [2]to originally
sponse, and aproposed
third zoneusing the greyor zone
of uncertainty approach
‘grey zone’. This to
called the grey zone.
predict that that
concluding outcome) or entirely
PPV predicts fluidnew (i.e., the concept
responsiveness accur-of evaluateshould
approach PPV was to avoid
be used this type
exclusively of binary
to assess the constraint.
intrinsic
using(sensitivity
ately a PPV grey 88%,zone - though89%),
specificity perhaps not as
so long these authors’
limitations The grey
predictive valuezoneof technique
PPV, onceproposes limitations twoto numerical
its use havecutoffs
precise
to its usedefinition - for understanding
[3,4] are understood and respectedfluid (Figure
responsiveness
1). that discarded.
been constituteUnfortunately,
its borders. The whenfirst cutofftheir
assessing is used
grey to
had already been reported),2 they nevertheless remind us of exclude
zone, both the diagnosis
Cannesson and (e.g., a 9%
colleagues [12]PPVand where
Biais and fluid
the importance
The applicability of using the grey
of pulse zone methodology
pressure variation when responsiveness
colleagues [13] have is analyzed
not present) manywith near certainty
measurements coming (i.e.,
approaching
Several studiesanyhavediagnostic tool (such
quantified as PPV andofSVV).
the proportion pa- privilege
from patientssensitivity
ventilated with and a negative
small tidal predictive
volume, or with value),
Accordingly,
tients in whomthis PPV editorial
can be serves
used asasa apredictor
reminderof of the
fluid a whereas
low heart the second cutoff
rate/respiratory rate is chosen
ratio. Because to PPV
includedoesthe
relevance, impact,
responsiveness andLogically,
[5-7]. global meaning of the greyis zone
the applicability higher for notdiagnosis
work well (e.g., a 13%
in this PPV their
context, where greyfluid responsiveness
zones were artifi- is
diagnostic
in tools. theatre than in the ICU, because limita-
the operating present)
cially withIn similar
extended. this respect,near Biaiscertainty (i.e., privilege
and colleagues [13]
4
The predictive value of continuous
tions are less often encountered [8,9]. There diagnostic indices
is currently specificity and positive predictive
showed in a subgroup analysis that the grey zone was lar- value). Intermediate
asuch
trendas PPV
towardsare best evaluated
a reduction inusing
tidal the receiver
volume, notoperating
only in gervalues representing
in patients with a low the tidal
greyvolumezone than correspond
in patients to a
characteristic
ICU patients with(ROC) acutecurve
lungapproach.
injury, butVery also inbriefly,
patientsthis prediction
with a tidal that
volume is tooof imprecise
at least 8 for ml/kg,a diagnostic
and clearly decision,
ac-
approach
with healthydetermines an optimal threshold
lungs undergoing that provides
surgery. Futier and col- the knowledged
referring to thatwhat wide rangecalled
‘the Feinstein of tidal volume
‘‘the can ex- of
inadequacy
highest [10]
leagues combination
showed that of sensitivity
a tidal volume and of specificity
6 ml/kg dur- for a plain
binarythe importance
models forof the the grey zone reality
clinical and the of variation of
three-zone
5
givensurgery
ing diagnostic tool. In addition,
is associated with a the accuracy
better of a test
post-surgical grey zone values
diagnostic among centers’.
decisions’’. Indeed,Both forCannesson
PPV, the and firstcol-
study
outcome
depends on thantheaability
tidal volume
of the testof 11 ml/kg. However,
to separate the group leagues
published[12] on
andthe Biais andfound
topic colleagues [13] also
a threshold pooled
of 13% to data
predict
nothing
being testedindicates that with
into those 6 ml/kg is better
and those withoutthanthe 8 disease,
ml/kg. from
fluidstudies where different
responsiveness, techniques
an associated were used
sensitivity of 94%,to a
Actually, a recent comparison
and it is quantified between
by the area under the tidal
ROCvolume and
curve which measure
specificitycardiac
of 96%,output and(CO).an area Cannesson
(standardand colleagues
deviation) under
6
outcome done on 29,343 patients who underwent gen- [12]
the mentioned
ROC curve that of they0.98 (0.03).responder
‘classified and non-
Most subsequently
eral anesthesia with mechanical ventilation suggests that responder
publishedpatients
studiesusingfound various
similar results.of7 CO
methods measure- a
Nevertheless,
M. Cannesson, MD, PhD (&)
the ideal of
Department tidal volume is& somewhere
Anesthesiology Perioperative Care,between 8 and
University
ments, all of later
few years whichwhen havewe unique
studiederrorsthe of measurements
predictive value of
10 ml/kg [11].
of California, Ultimately,
Irvine, CA, USA the applicability of PPV de- andPPV limited
usingclinical
a grey agreement
zone approach, between them’, asuggesting
we found similar area
pends on case mix (whether patients are mechanically
e-mail: [email protected] that a responder
under the curve,with but one method
the grey zone could
ranged have been9-13%
from classi-and
ventilated, and whether they have arrhythmia), and on fied as a non-responder by another method [14]. Biais and
clinicians beliefs and practice (do they prefer ventilating colleagues [13] acknowledged that ‘the methods of CO
their patients with 6 or 8 ml/kg?). It may easily vary from measurements were not uniform and this may have ex-
123
0% (extubated patients) to 99% (typical open colorectal or tended the grey zone’. Therefore, from a methodological
hip fracture patient ventilated with 8 ml/kg) [8]. standpoint, the grey zones in both studies [12,13] were un-
doubtedly enlarged by these confounding factors, or
The zone of uncertainty, also called the grey zone shades of grey… and readers were left in the dark with re-
Cannesson and colleagues [12], and more recently Biais gard to the real zone of uncertainty for PPV (Figure 2).
and colleagues [13], have used the ‘grey zone’ approach
to investigate the clinical value of PPV. The concept has
The limits of the ‘responders versus
non-responders’ binary approach
* Correspondence: [email protected]
1
Edwards Lifesciences, 1 Edwards Way, Irvine, CA, USA In daily practice, it is at least as important to have a pre-
Full list of author information is available at the end of the article dictor of the amount of the increase in CO induced by
© 2015 Michard et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and

Sound wise and ‘senior’

reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.

Do not
u CVP s hould not be us e d ot titrate fluid the rapy
forget
u The PA offe rs c ontinuous data in patie nts with le ft he art failure ; it is not the
the true
gold s tandard!
wise men
u Dynamic indic e s are good but not always e quivoc al

10
 10/26/18

Case history

Ankylosing spondylitis for Total Hip • 42 years old male

• Pain & Difficulty in walking – 20 yrs
replacement – case
• Deformity of b/l hip -18 yrs
Dr. M. K. Arora • Morning stiffness
Sr. Prof. And HOD Anaesthesiology – Duration – 30 min
ILBS , Vasant Kunj , New Delhi – Improved with activity

Physical examination
• Neck pain since 10 years • General examination
• stiffness /decreased range of motion progressed to – Conscious, oriented, comfortable at rest
absent neck movements .
– Wt – 55 kg; Ht – 146 cm
• History of snoring – No pallor, icterus, cyanosis, clubbing,
• Difficulty in chewing lymphadenopathy, pedal edema
• Effort tolerance limited due to pain and – Gait – bipedal /patient bending forward 60 deg
from vertical with b/l hip in adduction
stiffness
• Family H/o stiffness of joint
– Vitals -unremarkable

Systemic Examination Airway Examination

• Mouth opening – about 2 fingers breath
• Respiratory- • MMP class - IV
• decreased Chest movement • Teeth – intact, no loose tooth/dentures
• Spine • Neck movements – severely restricted
– Severely restricted movements • Neck circumference – 47 cm
– No tenderness/ swelling • TMD- < 6 cm
– Intervertebral Spaces poorly felt • Mandibular compliance – poor

– CNS & Abdomen : Unremarkable

1
 10/26/18

Summary
• 42 yr old male with ankylosing spondylitis
– Restricted neck movements and restrictive
lung disease.
– Examination reveals
• reduced chest expansion,
• difficult airway,
• poorly felt interspinal spaces
• fixed flexion deformity of b/l hip.

Investigations
• Hemogram, LFT, KFT: WNL
• CXR : cardiomegaly
• ECG : NSR
• ECHO :
• Normal LV function : EF-60%
• Mild MR

•PFT
• FVC - 2.02 L (57%)
• FEV1 - 1.71 L (49%)
• FEV1/FVC- 107 %
• FEF25-75 – 2.18 L/sec (74%) X ray Spine- Bamboo appearence

Preop Management Intraoperative management

• High risk consent • CSE –attempted –failed
• Difficult airway, difficult regional, intraop blood • Awake FOB with b/l SLN block & transtrcheal
loss, hypothermia, restrictive lung disease and injection of lignocaine
postoperative ventilatory care with intensive care • Postinduction – caudal epidural catheter placed
monitoring.
• Duration of surgery – 3hrs
• NPO > 12 mn • Input – 3 ltr crystalloids, 500 ml colloids, two
• Adequate blood & blood products to be arranged units PRBC, two units FFP through hotline tubing.
• Premedication • Total blood loss – 1.5 ltr [MABL 1300 ml(target 8)]
– T. pantoprazole 40 mg 10 pm & 6 am • Extubated on table & shifted to AB8 ICU
– Inj.glycopyrrolate 0.2mg i.m. 30 min before shifting to
O.T.

2
 10/26/18

Site of injection

Caudal catheter- dye injection Postoperative course

• Monitored in ICU 48 hrs
• Investigations
– Hb – 8.7 gms 1 unit PRBC given
– Plt, TLC : WNL
• Epidural catheter removed on -3rd POD
• Discharged on – 10th POD

Ankylosing spondylitis Clinical features

• An autoimmune seronegative spondyloarthropathy, • Sacroilitis, peripheral arthropathy,
• A painful chronic inflammatory arthritis punctuated enthesopathy
by exacerbations (‘flares’) and quiescent periods. • Pain & morning stiffness worse at rest and
• Primarily affects the spine and sacroiliac joints and improves with exercise
eventually causes fusion and rigidity of the spine
(‘bamboo spine’)
• Most common – hip and shoulder joints
• Incidence – males 1%, females 0.5% • TM joint involvement – 10% pts
• Peak age of onset – 20-30yrs • Cricoarytenoid joint – rare, leads to dyspnoea,
hoarseness and vocal cord fixation

3
 10/26/18

Extra-articular manifestations
• Osteoporosis • Cardiovascular system
– Compression fractures – Aortic regurgitation
– Iatrogenic spinal injury while shifting – Conduction defects
• Unsteady gait – Increased risk of MI
– Increased incidence of falls
• Respiratory complications
• Cervical fractures – Upper lobe fibrosis
– Most common. in C5-6
– Restrictive lung disease
– Occur with minimal trauma or hyperextension
– Atlanto-axial subluxation in 21% pts

Extra-articular manifestations Management

• Anterior uveitis 20-40% • NSAIDs
• Psoariasis 9% • DMARDs
• Inflammatory bowel disease 6%
• Anti-TNF alpha drugs
• Neurological complications
– Spinal cord compression • Intra-articular corticosteroid injection
– Cauda equina syndrome • Exercise
– Cervical spine fracture
• Physiotherapy
– Peripheral nerve lesion
– Acute epidural hematoma

Airway management The intubating laryngeal mask airway in severe ankylosing

spondylitis.
• Preoperative assessment Lu PP, Brimacombe J, Ho AC, Shyr MH , Liu HP.
– Cervical spine & TM joint involvement
Can J Anaesth. 2001 Nov;48(10):1015-9.
– Neck movements •RESULTS: The ILM provided an effective airway on 11/11
– Radiological screening occasions at the first attempt. Intubation was successful at the
first attempt on 7/11 occasions, at the second attempt on 2/11
– Indirect laryngoscopy and at the third attempt in 1/11. Intubation failed in one
patient. The mean (range) minimal oxygen saturationwas 99.4%
– Fixed flexion deformity – difficult tracheostomy (97-100%). There were noproblems with ILM removal.
• Awake fibreoptic intubation – safest
•CONCLUSION: Inhalational induction followed by ILM insertion
• ILMA/ Classic LMA – alternatives / aid in and blind intubation is a reasonable option in patients with
severe ankylosing spondylitis undergoing elective surgery who
failed intubation prefer airway management under anesthesia.
• Glidescope

4
 10/26/18

The use of the GlideScope for tracheal intubation in patients with

ankylosing spondylitis.
Lai HY , Chen IH , Chen A, Hwang FY, Lee Y.

Br J Anaesth .2006 Sep;97(3):419-22.

Methods: One hundred patients, with at least one difficult intubation criteria METHODS: 2 0 AS pati ent s wer e cho sen t o un dergo t racheal int ubat ion by the
(Mallampati class III or IV,thyromental distance < 65 mm,interincisor d istance < GlideScope.
35 mm) were enrolled (FIB group,n = 49; ILMAgroup,n = 51) RESULTS: Tw elve of the AS pa tie nts w ere ju dged to have had d ifficu lt int ubat ion
Results: The rate of successful tracheal intubation with ILMA was 94% and by pr eop erative a irway as se ssme nt. E leven of t he twe lve pat ient s had M CLS
grades III or IV by d irect laryngo scopy a nd were con si dere d to have had a
comparable with FIB (92%). The number of attempts and the time to succeed difficu lt laryng osco py. Naso-tr acheal i ntuba tio ns by the Gl ideSco pe were
were not significantly different between groups. In case of failure of the first successf ul on 17/2 0 occasi on s, incl udi ng 8 of the 1 1 diff icult laryng osco py. The
technique, the alternative technique always succeeded. Failures in FIB group Glid eScope im proved th e MCLS gra de and P OGO score i n t he majority of AS
were related to oxygen desaturation (oxygen saturation < 90%) and bleeding, patients compared with direct laryngoscopy (P<0.01).
and to previous cervical radiotherapy in the ILMA group. Adverse events
occurred significantly more frequently in FIB group than in ILMA group (18 vs. CONCLUSIONS: The G li deScope prov ide s a bette r lary ngosco pic vie w tha n that
0%, P < 0.05). of d irect laryng osco py. Mos t of th e AS pati ents pr ese nti ng wit h MCLS gra de III or
Conclusion: The author s obta ined a high successrate and comparable duration IV by direct la ryngo scopy can be i ntuba ted succe ssfu lly by t he G li deScope. In
of trachealintubation with ILMA and FIB techniques. The use of the ILMA was elective pat ient s wi th AS , a wake f ibre opt ic i ntub ati on offers a hig her leve l of
associated with fewer adverse events. securi ty becaus e it can be app lie d wh ile ma inta in ing sp onta neo us brea thi ng.
The u se of G lideSco pe for t rachea l intu bation may be an a lte rnat ive o pt io n in
these patients who prefer their airway management under anaesthesia.

Emergency tracheal intubation in an ankylosing spondylitis patient in the lateral

position using the GlideScope.
Wang PK, Luo PH , Chen A , Chen A , Chen TY , Lai HY . Regional anaesthesia
Acta Anaesthesiol Taiwan. 2008 Jun;46(2):80-1. • Technical difficulty
•Abstract: Anesthesia for ankylosing spondylitis (AS) patients
with difficult airway is of great stress to anesthesiologists. If • Increased risk of complications
tracheal intubation is not mandatory for general anesthesia,
laryngeal mask airway (LMA) may suffice for adequate • SAB- lateral approach
ventilation. Yet, in certain circumstances, no one can guarantee
that LMA will reliably serve the purpose in surgical AS patients, • Epidural hematoma
especially in operations performed in the lateral decubitus
position. We present here an AS patient with difficult airway • Urtrasound guided blocks –epidural
scheduled for hip surgery. General anesthesia with sevoflurane
conveyed by an LMA through spontaneous ventilation in the
lateral decubitus position was planned, and the induction was
smoothly done. Unfortunately, laryngospasm and oxygen
desaturation occurred during the operation; the patient was
successfully rescued by nasal intubation with a GlideScope in
the lateral decubitus position without interrupting the
operation.

Epidural anaesthesia and spinal haematoma.Wulf H.Can

Anaesth. 1996 Dec;43(12):1260-71
.
•FINDINGS: Fifty-one confirmed spinal haematomas associated
with epidural anaesthesia were found. Most were related to the
insertion of a catheter, a procedure that was graded as difficult or
traumatic in 21 patients. Other risk factors were: fibrinolytic
therapy (n = 2), previously unknown spinal pathology (n = 2), low
• Canadian Journal of Anaesthesia 1995; 42: 73–6. molecular weight heparin (n = 2), aspirin or other NSAID (n = 3),
epidural catheter inserted during general anaesthesia (n = 3),
thrombocytopenia (n = 5), ankylosing spondylitis (n = 5),
preexisting coagulopathy (n = 14), and intravenous heparin
therapy (n = 18).
•CONCLUSION: Coagulopathies or anticoagulant therapy (e.g., full
heparinization) were the predominant risk factors, where-as low-
dose heparin thromboprophylaxis or NSAID treatment was rarely
associated with spinal bleeding complications. Ankylosing
spondylitis was identified as a new, previously unreported risk
factor. Analysis of reported clinical practice suggests an incidence
of haematoma of 1:190,000 epidurals.

5
 10/26/18

Ankylosing spondylitis and neuraxial

anaesthesia:a a 10 year review

In conclusion we have retrospectiv ely reviewed 82 surgical procedures on AS

patients over a 10 year period and found that neuraxial anaesthesia can be u sed in
AS patients for perineal and lower limb surgery safely.

Spinalanaesthes ia was successful in 76.2% of cases for wh ich it was p lanned. Both
the midline and paramedian approaches to spinal anaesthesia may be successful in
these patients.

Epidural anaesthesia may also be successful but was not found to be so in this
review.

Difficult airway algorithm Awake fibreoptic intubation

• Preoperative assessment & preparation
• Operating room set-up
• Equipment preparation
• Suction
• Oxygenation
• Pharmacological aids
• Local anaesthesia

Local anaesthesia
• Nasal cavity & • Oral cavity
nasopharynx – Lidocaine 10% spray
– 10% lidocaine spray – Gargling viscous
– 4% lidocaine + adr lidocaine 2%
– 2% lidocaine gel in NPA – Lingual nerve block
– Nebulization

6
 10/26/18

• Larynx and trachea

– Superior laryngeal nerve
block
– Transcricoid instillation
– Spray as you go

7
 The patient: How do you approach the case?

Geriatric
Elderly man for TURP/TURBT:
 • 74 year old male
concerns
• 74 year old male
Case Discussion
• Known history of hypertension
Co-morbid
• Scheduled for TURP • Known history of hypertension conditions
Dr.Preethy J Mathew

Related to
Professor
• Scheduled for TURP TURP
PGIMER, Chandigarh.

Pre-op assessment Issues related to age…

• ↑risk of postop complicationsà poor outcome

• Progressive loss of functional reserve in body systems

– Arterial ageingà secondary changes in heart, brain & kidney. • Functional Reserve assessment using ‘Frailty Criteria’

GOALà Decision making – Cognitive decline

• Weight loss- Exhaustion-Physical activity- Walk time- Grip
strength
– Autonomic nervous system changesà ↓ ß receptor sensitivity

– Respiratory changesà VC ↓, CC ↑, paO2 ↓

Normal mean PaO2 • Co-morbidities
20-29 y 94 – Incidence of systemic disease in TURP patients
I. Fitness for procedure/
II. Anaesthesia plan • Sensitive to anaesthetic drugs 30-39y 91 • Cardiac :67%
Acceptance for anaesthesia
40-49 y 88 • Cardiovascular :50%
– Less drug for same clinical effect
50-59 y 84 • COPD :29%
– Prolonged drug effects
60-69 y 81 • DM :8%
– Exaggerated hemodynamic responses
 • Drug history
History and examination • Beta blockersà suppress compensatory tachycardic
responseà to be continued peri-op
On PAC:
• Cardiovascular
• ACE inhibitorsà limits renin-angiotensin mediated response
• HTN, IHD, arrhythmias to hypovolemia- also impaired by SAB • 74 year old male, scheduled for TURP
• Respiratory – To omit 24 hours pre-op
• Known history of hypertension for 15 yrs and
• ? ↓ in functional ability • Alpha blockersà first line medical treatment for BPHà
may precipitate severe hypotension after SAB. hypercholesterolemia
• ? Ability to lie flat
• Investigations
• Neurological • H/o smoking 20 cigarettes/ day for 30 yrs
– Complete Blood count/ Hb
• Able to lie still
– Blood sugar, creatinine and electrolytes • Good effort tolerance, no symptoms of cardiac failure, BP-
• Musculo-skeletal
– ECG for symptomatic patients or > 45 yrs
146/80 mm Hg.
• Degenerative changes in vertebral columnà difficult – Chest X-ray
positioning and SAB • Blood results, EKG and CXR- unremarkable
– Blood- group and save
• Joint replacements or arthritisà damage or dislocation • Other tests
• Renal- ? Obstructive uropathy – Clotting studies- Prothrombin time
• Airway- assessment even if SAB is planned. – Blood gas and pulmonary function tests Risk stratification ??

Anatomy Nerve supply

Choice of anaesthesia
Bladder Prostate &
Urethra
• Deciding factors: Sympath
T11-L2
– Noxious stimulià depends on anatomy
Afferents:
•Stretchà PS
– Intra-op and post-op procedure related concerns
Zones in prostate •Pain, touch, tempà
Normal structure
Symp
– Patient’s medical status
Parasympath
– Informed consent S2-4 Sympath &
Parasympath

Prostatic hyperplasia

Normal Weightà upto 20-30 g Sensory

 The procedure Irrigation for visualisation Crystalloid irrigation solutions
Solution Osmolality Disadvantages
(mOsm/kg) ?
• Ideal solution ion
• Distilled water Glycine, 1.2% 175 lut
Retinal toxicity, Hyperammonemia
o
• Isotonic × Isotonic ’ ss
Glycine, 1.5% 220 ‘’
er
ng
• Electrically inert ✓Electrically inert Sorbitol,3.5% 165 Ri
Hyperglycemia, lactic acidosis,
ed
• Nontoxic ✓Nontoxic at diuresis
osmotic
t
lac
• Transparent ✓Transparent
Mannitol, 5% 275 (iso)
e orAcute intravascular expansion,
lin Osmotic diuresis
• Easy to sterilise ✓Easy to sterilise sa
Cytal (Sorbitol 178 al Expensive, not easily available
• Inexpensive ✓Inexpensive 2.7%+ Mannitol no
rm
se
0.54%) u
ou
Physiologic implicationà Systemic absorption ny
Glucose,2.5% 139 Hyperglycemia
Ca
Conventional TURP Urea, 1% 167 ↑ blood urea

What absorption entails to physiology? TUR syndrome

• Upto 8% of cases in mild form
• Absorbed crystalloidà 20-30% remains in intravascular,
remaining enters interstitial space. • Severe in 2%
• Average fall in serum Na+à 3.65-10 mEq/L
• What determines the volume of fluid absorbed?
Duration of procedure-larger gland
10-30 ml absorbed /minute of resection time (1800 ml/
• Excessive absorption
hr)
Hydrostatic pressureà Height of the irrigation fluid bag • Hypervolemia
above pt. • TUR syndrome.
Vascularity of diseased prostate
 Features Advantages
Recent advances in TURP….
• Dilutional hyponatremia- CNSà CVS effects
• Bipolar TURP • Laser-TURP
– < 120 mEq/L- irritability, apprehension, confusion, headache Laser TURP – Less fluid absorption à ↓ – Minimal irrigating fluid
Bipolar TURP
– <115 mEq/Là Early
QRS widening warning
and signs elevation.
ST-segment TURP syndrome absorption- ↓ risk of TURP
• Negative inotropy, hypotension and dysrrhythmias. – ↓ in transfusion rate
syndrome
e
lut
– <102 mEg/L à Encephalopathy,soCerebral edema – Fewer postop readmissions
– Minimal blood loss-50-70 mlà
and
e
m coma
• Generalized seizure land – Faster postop recovery
Fewer transfusions
ou
fv
mo
– Comparable urologic efficacy
• Fluid overload le – In anticoagulated patients
b
Pro and equivalent long-lasting
• Pulmonary edema results as conventionalTURP.
– Outpatient procedure

• Cardiac failure – Fewer strictures

Irrigating solution is Normal saline à minimises TURP syndrome
– Shorter hospitalizations

Options of anaesthetic technique Advantages of subarachnoid block – Sympathetic block ↑ venous capacitanceà mitigates intra-
operative fluid overload.
– Early detection of complications
• Regional-Subarachnoid block – Avoid effects of GA on pulmonary pathology
• TUR syndromeà Monitoring for change in mentation
– Sensory level of T10 required – Good early postop analgesia
• Bladder perforationà Conscious pts experience symptoms
• Eliminates discomfort caused by bladder distension. – Reduced incidence of postop DVT/PE
of bladder perforation before it becomes manifest to
surgeon • RA ↓ hypercoagulable tendency- maintains normal
• Obliterates visceral pain sensation from prostate and
– Bradycardia, hypotension, restlessness, diaphoresis, coagulation and platelet function.
bladder neck.
nausea, abdominal pain, dyspnea, shoulder pain, hiccups. – Lower cost
– Sensory level above T9 to be avoided
– Operative blood loss is reduced - ↓ transfusions
• For manifestation of capsular sign- should perforation
• ↓ in systemic BP due to sympathetic block
occur.
• ↓ in peripheral venous pressure
 Contraindications Can continuous epidural be given? General anaesthesia

– Patient refusal • Advantages

– Incomplete block of sacral roots
– Infection- either localised or generalised – Patients with chest disease may not tolerate lying flat or
be able to suppress their cough
– Raised intracranial pressure
Can caudal block be considered? – Maybe less hemodynamically challenging than SAB in pts
– Hypovolemia or shock of any cause
with AS or IHD
– Coagulopathy-platelet count<80-100, 000 or INR<1.5 • When and what precautions?
– Allows better control of CO2-may reduce bleeding from
– Pre-operative neurological disease-postoperative – For laser prostatecomy in high risk patients.
prostatic bed.
exacerbation of disease. – Avoid bladder distensionà continuous irrigation
– Patient preference.

Anaesthesia plan? Anaesthetic technique Conduct of SAB

• Fluid pre-load-500-1000 ml of warmed 0.9% NaCl
• 74 year old male, scheduled for TURP
• Pre-medication
– Dehydration due to fasting, use of diuretics
• Known history of hypertension for 15 yrs and – Anxiolytics
• Block to at least T10
hypercholesterolemia • Short acting BZDs- in elderly, can lead to postop
confusion – 2-2.5 ml of heavy bupivacaineà 3 hrs of dense motor and
• H/o smoking 20 cigarettes/ day for 30 yrs
– Medications for HTN. In case of GA: sensory block.
• Good effort tolerance, no symptoms of cardiac failure, BP-
• Monitoring Capnography • If hypotensionà use vasopressors
146/80 mm Hg. • NIBP Volatile agent levels
– Ephedrine-3-6 mg/ Mephentermine-3-6 mg
• Blood results, EKG and CXR- unremarkable • Pulse oximetry Airway pressure
• Intra-op sedation- sparingly
• ECG
• Prevent hypothermiaà Warming blanket/ Fluid warmer
• Temperature
ASA II • Supplementary oxygen.
• IV cannula- large bore
 Either RA or GA Index patient, in OT:
Conduct of GA
• On routine monitoring, Preloaded with 500 ml of NS
• Under spinal anaesthesiaà Level T8
• Either spontaneously breathing- supraglottic airway or • IV Fluids to replace blood loss. • Oxygen via Face mask
• 60 minutes into procedureà c/o nausea/ retching. IV ondansetron 4 mg given
relaxant technique. • Maintenance fluids- not required as irrigation fluid is • HR ↑ to 106/min, BP- 106/66 mmHg
• Another 15 minà pt anxious, pulled the mask off, SpO2 dropped quickly.
• Elderly susceptible to hypotensive effects of absorbed.
• Urgent blood gasà pH-7.33, pCO2- 42, pO2- 66, Na- 109 mmol/L, Hb-9.2 g/
dL.
induction and maintenance drugs • Antimicrobial prophylaxisà gram negative bacteremia- • Severe resp distress, unable to maintain on high flow oxygen.
Gentamicin 3-4 mg/kg. • Pulmonary edema suspectedà Intubated, ventilated.
• Analgesic requirementsà Paracetamol/ NSAIDs/
• Surgery terminated
Increments of opioid- fentanyl or morphine. • Frusemide 40 mg IV stat
• Shifted to ICU
• Consider renal function when choosing IV drugs.
Diagnosis??

Red flags
TUR syndrome-Signs and symptoms Challenge…
• Assessment of absorbed volume of the irrigation fluid is • Prostate size > 60-100 g
Na+ • Tachycardia

• Nausea & vomiting difficult. • Procedure duration> 1 hour

120à
• Confusion/ disorientation • Early detectionà depends on
• Hydrostatic pressure > 60 cm H2O
• Hypertension, then hypotension – Awareness of high risk situation
• Transient blindness • Inexperienced or slow surgeon
– Continuous observation for s/s
• Angina
• Reduced venous pressure (dehydration)
• Dyspnoea and hypoxiaà pulmon edema
• Preventive steps
115à
• Cardiovascular collapse and arrhthmias-VF/VT – Keep surgical time < 1 hour • Large volumes of hypotonic IV fluids-eg 5%D
100à
• Convulsions – Limit the volume of irrigation fluid • Pre-existing hyponatremia/ pulmon edema
• Coma
– Limit the height of irrigation fluid.
 Management • Hyponatremia causing encephalopathy
Investigations – Target rapid correction and close monitoring
• ABC
• ↑ Na by 1 mmol/L/hr (Not > 20 mmol/L in 48 hrs)
– Serum Na – Intubate and ventilate. • Hypertonic saline -1.8%, 3%, 5%.
– Arterial blood gas analysis
• Inform surgeon, terminate surgery. • Check Na every few hrs
– Anion gap = [Na+] – [Cl-] – [HCO3-] – Stop hypertonic saline when Na reaches 124-132 mol/L.
• Fluid overload and hyponatremia
• Normal-4-12 mmol/L – Rapid correction can cause central pontine myelinolysis and
– Stop IV fluids irreversible brain damage.
• ↑in lactic acidosis, ketoacidosis, ↑ glycine
– Promote diuresis • Convulsions
• ↔ acidosis due to loss of HCO3 or ↑ in Cl- – Benzodiazepine- Diazepam 1-5 mg
• IV frusemide
– CXR – Thiopentone- 25-100 mg
– Fluid restriction – Intractable seizuresà Correct Na @ 8-10 mmol/L/hr for first 4
– ECG
• 800 ml/24 hrsà hrs.
achieve Na+ rise of 1.5 mmol/L/24 hrs

Bladder perforation
Index patient, in ICU:
– 1% of TURP

• Results from:
• Tempà 33.8 C • CXRà Enlarged heart,
– Cutting loop or knife electrode during difficult resection
pulmon edema
• Art and central line
• Pulm edema resolved with
Name a life-threatening complication other – Overdistension of bladder with irrigation fluid.
• Hot air blower warming
frusomide boluses than TURP syndrome? • When to suspect?
• Hypertonic saline 3% infusion – Irregular return of irrigating fluid- noticed by surgeon
• ABG after 36 hrs:pO2- 94.5
@100 ml/hr – Signs/ symptoms in awake patient
mmHg on 30% O2
• Rpt Na+ after 1 hrà 116 • Extraperitonealà Suprapubic/ inguinal/ periumbilical pain
• Na+ at 48 hrsà 132 mmol/
• Intraperitonealà far less, but more serious
mmol/L
L
– Generalised abdominal pain, shoulder tip pain
• Hypertonic saline 1.8% @50
• Extubated and discharged
– Pallor sweating, peritonism, nausea, vomiting, hypotension
ml/hr
to ward
– ↓GAà unexpected hypotension
• Na+ at 24 hrsà 127 mmol/L
• Managementà Immediate laparotomy & correction of defect.
 1. Hypotension 2. Haemorrhage
– Quantification of blood loss- difficult
• Most common complication
• Clinical judgement
– Vital signs
• Usually follows sympathetic block of SAB
Complications to prevent/ watch for during – Observation of surgical field/ drain bucket
– Resection time- 2-5 mL/ min
TURP?? • Esp. if cardioaccelerator fibres-T1-4 are blocked.
– Size of mass excised- 20-50 mL/g
• Treatment – Communication with surgeon
• Serial hematocrit levels
• Fluid – Factors that influence blood loss
• Gland size and vascularity
• Vasopressor • Presence of prostate infection/ inflammation
• Duration of surgery
• Inotropes if required • Number of sinuses opened during resection
• Prostate tissue release urokinase/ tissue plasminogen activator/
thromboplastin à ↑ fibrinolysis

3. Hypothermia
– Measures to minimise blood loss 4. Bacteremia and sepsis
– Predisposing factors
• Antifibrinolytics
• GA
– IV tranexamic acid
• Use of room temperature IV fluids – Prostate harbours bacteriaà source of intraop and
• Foley catheter à balloon inflated and traction applied. • Large volume of irrigation fluids postop bacteremia through prostatic venous sinuses.
– Lateral pressure on the prostatic bed to reduce • Elderly vulnerable – Indwelling urinary catheter ↑ the risk
bleeding. – Prevention
– 6-7% may develop septicemia
– Blood transfusion required ~ 2.5% of TURP. • Warm IV fluids and irrigation fluids
• Forced air active warming
– Septic shock is rare but with 75% mortality
– Measure Hb and electrolytes on POD1.
– Shivering – Prevention
• To detect sub-clinical anemia and hyponatremia • Can increase myocardial oxygen requirement • Antibiotic prophylaxis- Gentamicin 3-4 mg/kg single
• Reduction in CO dose/ Cephalosporins.
– Treatment
• Systemic/ Intrathecal opioids
 Unlikely, yet known complications Few points about toxicity…. To watch out after procedure
• Glycine toxicity • Lowering of legs from lithotomy
• Positioning – Nonessential amino acid – Check BPà Hypovolemia manifests as hypotension.
– Lithotomy + Trendelenburg tilt – Major inhibitory neurotransmitter in spinal cord and brainstem. • Hypothermia/ Hypotension/ Hemorrhage

• Nerve compression-common peroneal nerve – Normal plasma glycine levels- 13-17 mg/L • S/S of TUR syndrome/ Septicemia
– Glycine toxicity implicated in transient blindness- levels as high as 1029 • Clot retentionà Clot blocking urinary catheter
• Dislocation of hip prosthesis
mg/L measured. – Bladder distension
• Respiratory compromise in those with pre-existing lung – Prevented by continuous bladder washouts.
– No overall correlation between plasma glycine levels and CNS toxicity
disease-due to ↓ in FRC. • Bladder spasm
• Ammonia toxicity
– Indwelling catheter stimulates bladder neck to cause painful
• Erection – Formed by oxidative biotransformation of glycine.
involuntary contraction of bladder
– Usually due to surgical stimulation during inadequate plane – Delayed awakeningà elevated blood ammonia concn. – Irrigation fluid prevents bladder from draining completely and
of anaesthesia. – Deterioration of CNS function when ammonia levels> 150 M. aggravates pain
– Glycine and ammonia levels did not correlate with each other – Treatment:
– Subsides with deepening of anaesthesia
• Low dose diazepam- 2.5-5 mg iv
– Low-dose ketamine helps if it persists. Case reports only…… • Hyoscine (Buscopan)- 20 mg iv slow

Morbidity & Mortality Summarise…

• 30-day mortality of Conventional TURPà 0.2-0.8% • Regional anaesthesia offers several advantages over GA for
• Morbidity-18% conventional TURP.
• Risk factors:
– Resections >90 min • Vigilant monitoring is the key for early detection of TUR Thank you!!
– Gland size >45 g syndrome.
– Acute urinary retention
• ABC followed by controlled correction of hyponatremia to
– Patient age > 80 yr
• Similar incidence with either RA or GA manage TUR syndrome

– Mortality • TUR syndrome is rare with newer techniques of prostate

– Complicns- MI, pulm embolism, CVA, TIA, Renal failure
removal-bipolar/ laser TURP
– Postop cognitive function