Introduction: Blood pressure (BP) monitoring is an essential component of sepsis management. The Surviving Sepsis Guidelines recommend invasive arterial BP (IABP) monitoring, although the benefits over non-invasive BP (NIBP) monitoring are unclear. This study investigated discrepancies between IABP and NIBP measurement and their clinical significance. We hypothesized that IABP monitoring would be associated with changes in management among patients with sepsis requiring vasopressors. Methods: We performed a retrospective study of adult patients admitted to the critical care resuscitation unit at a quaternary medical center between January 1–December 31, 2017. We included patients with sepsis conditions AND IABP monitoring. We defined a clinically significant BP discrepancy (BPD) between NIBP and IABP measurement as a difference of > 10 millimeters of mercury (mm Hg) AND change of BP management to maintain mean arterial pressure ≥ 65 mm Hg. Results: We analyzed 127 patients. Among 57 (45%) requiring vasopressors, 9 (16%) patients had a clinically significant BPD vs 2 patients (3% odds ratio [OR] 6.4; 95% CI: 1.2-30; P = 0.01) without vasopressors. In multivariable logistic regression, higher Sequential Organ Failure Assessment (SOFA) score (OR 1.33; 95% CI: 1.02-1.73; P = 0.03) and serum lactate (OR 1.27; 95% CI: 1.003-1.60, P = 0.04) were associated with increased likelihood of clinically significant BPD. There were no complications (95% CI: 0-0.02) from arterial catheter insertions. Conclusion: Among our population of septic patients, the use of vasopressors was associated with increased odds of a clinically significant blood pressure discrepancy between IABP and NIBP measurement. Additionally, higher SOFA score and serum lactate were associated with higher likelihood of clinically significant blood pressure discrepancy. Further studies are needed to confirm our observations and investigate the benefits vs the risk of harm of IABP monitoring in patients with sepsis.
Sexual dichromatism is widespread among animals, but examples of “reverse” sexual dichromatism, in which females are more brightly colored than males, are extremely rare. We discovered a unique case of reverse sexual dichromatism in the golden rocket frog (Anomaloglossus beebei), a diurnal Neotropical frog. Females are bright “golden” in color, and males are drab tan with brown pigmentation that darkens when they are calling. Here, we document this color variation with calibrated digital photography and further show that there is no evidence for sex‐specific habitat matching; both sexes live in the same well‐lit habitat on green bromeliad leaves. Our results suggest that color variation in this species is an intraspecific signal and provide an important exception to the general expectation that males are more visually conspicuous in species with conventional sex roles.
We aim to determine the overall diagnostic yield of HM in pediatric patients presenting to the ED with symptomology suggestive of possible cardiac arrythmia after a benign screening electrocardiogram (ECG).Methods: We performed a retrospective cohort study of patients 18 years of age presenting to an academic tertiary care center between January 2015-January 2019 with symptoms suggestive of cardiac arrythmia who were discharged with a HM after ED evaluation. Patients with a known cardiac history or an abnormal ECG at presentation were excluded. Positive diagnostic yield for the HM was defined as either capture of patient's reported symptoms while wearing the HM or detection of a silent arrythmia. All patients were followed for 6 months post discharge for safety monitoring of the practice.Results: There were 107 patients enrolled in the study. Twenty three patients with a known cardiac history and one patient with an abnormal ECG were excluded. The most common presenting symptoms were palpitations (n¼27, 32.5%), followed by syncope (n¼23, 27.7%), and chest pain (n¼ 17, 20.4%). HM were worn for a median duration of 24 hours. Thirty eight (45.8%) patients reported symptoms while wearing the monitor. The rhythm was sinus or sinus tachycardia in all cases. HM recorded significant "silent" arrythmias in 5 (6%) patients.Those arrythmias were supraventricular tachycardia (n¼3) and ectopic atrial tachycardia (n¼2). None of these patients reported symptoms during the episodes of arrythmia. The overall diagnostic yield for HM in our study cohort was 51.8%. There were no deaths or other serious adverse events reported in the study cohort.Conclusion: Ambulatory cardiac monitoring through the utilization of a Holter monitor in low risk pediatric patients presenting to the ED with symptoms suggestive of cardiac arrythmia provides useful diagnostic information in at least half of patients studied. This information can be incredibly reassuring for patients and care providers when symptoms are demonstrated to be inconsistent with an arrythmia. In addition, a not insignificant subset of patients will have potentially relevant silent arrythmia's detected. The practice of ambulatory cardiac monitoring in a selected pediatric patient population appears to be safe.
BACKGROUND: Blood pressure (BP) monitoring is essential for patient care. Invasive arterial BP (IABP) is more accurate than non-invasive BP (NIBP), although the clinical signifi cance of this diff erence is unknown. We hypothesized that IABP would result in a change of management (COM) among patients with non-hypertensive diseases in the acute phase of resuscitation.METHODS: This prospective study included adults admitted to the Critical Care Resuscitation Unit (CCRU) with non-hypertensive disease from February 1, 2019, to May 31, 2021. Management plans to maintain a mean arterial pressure >65 mmHg (1 mmHg=0.133 kPa) were recorded in real time for both NIBP and IABP measurements. A COM was defined as a discrepancy between IABP and NIBP that resulted in an increase/decrease or addition/discontinuation of a medication/infusion. Classification and regression tree analysis identified significant variables associated with a COM and assigned relative variable importance (RVI) values.RESULTS: Among the 206 patients analyzed, a COM occurred in 94 (45.6% [94/206]) patients. The most common COM was an increase in current infusion dosages (40 patients, 19.4%). Patients receiving norepinephrine at arterial cannulation were more likely to have a COM compared with those without (45 [47.9%] vs. 32 [28.6%], P=0.004). Receiving norepinephrine (relative variable importance [RVI] 100%) was the most signifi cant factor associated with a COM. No complications were identifi ed with IABP use. CONCLUSION:A COM occurred in 94 (45.6%) non-hypertensive patients in the CCRU. Receiving vasopressors was the greatest factor associated with COM. Clinicians should consider IABP monitoring more often in non-hypertensive patients requiring norepinephrine in the acute resuscitation phase. Further studies are necessary to confi rm the risk-to-benefi t ratios of IABP among these high-risk patients.
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