Background: Several dynamic parameters have been used clinically to predict volume responsiveness and to guide fluid administration of which passive leg raising (PLR) is one of the most reliable techniques. PLR induces rising in cardiac output attributes through an unstressed volume mobilization from legs to heart causing autologous preload increment. Appropriate fluid resuscitation is essential and can be optimized by hemodynamic-based approach to vasodilatory hypotension. Objective: This study aimed to evaluate the effectiveness and safety of PLR at early resuscitation among patients with vasoplegia. Methods: We conducted a comparison study concerning an experimental design using a single blinded assessment of the outcomes that assigned patients with shock to be treated with PLR or flat position at early resuscitation. Forty patients with shock were included in this study. Twenty patients performed PLR at early resuscitation compared with the others that performed in the flat position and were measured for cardiac output (CO), mean arterial pressure (MAP), diastolic blood pressure (DBP), heart rate (HR), central venous pressure (CVP) and systemic vascular resistance (SVR) immediately after the procedures. The primary outcome was to evaluate the effect of early PLR on hemodynamic variables among hypotensive patients by comparing the difference in CO while the secondary outcomes were differences in MAP, DBP, HR, CVP, SVR, survival at hospital admission and the pulmonary complications of chest x-rays between the two groups. Results: No difference was observed in baseline characteristics between the two groups of patients. Compared with the flat position, PLR at early resuscitation significantly increased CO (3.57 ± 0.27 vs. 2.2 ± 0.18 L/min, p = 0.037), MAP (22.48 ± 5.6 vs. 10.83 ± 4 mmHg, p<0.001), DBP (19 ± 0.20 vs. 1.23 ± 0.12 mmHg, p=0.001) and CVP (4.52 ± 0.19 vs. 2.18 ± 0.13 mmHg, p=0.002). However, no differences were observed in HR, SVR, pulmonary complications of chest X-rays [2 (10%) vs. 1 (5%), p = 0.23] as well as survival at hospital admission [16 (80%) vs. 13 (65%), p = 0.48] between the two groups. Conclusion: Among patients with shock, PLR at early resuscitation significantly increased CO, MAP, DBP and CVP than that of those performing the flat position. No differences were found in HR, SVR, pulmonary complications; PLR did not improve survival to hospital admission.
Background: Decompressive craniectomy (DC) significantly reduces mortality in large territory ischemic strokes that develop intractable cerebral edema. However, evidence for functional benefit remains sparse and contradictory. Objective: This study aimed to assess cut-off value for predictor outcomes of early DC. Methods: We conducted a prospective, observational cohort study from December 2016 to June 2021. Patients were screened for ischemic stroke involving the middle cerebral, internal carotid artery or both using the National Institutes of Health Stroke Scale score. All patients underwent DC. Multivariate analysis was performed for an array of clinical variables in relation to functional outcomes according to the modified Rankin Scale (mRS) and Pearson’s correlation coefficient analysis. Clinical outcome was assessed after 3- and 6-month follow-up. Results: In total, 243 patients were included in this study. Age ≤71 years (AUC=0.955, p <0.001 accuracy 89.7%), onset to DC ≤9 hours (AUC=0.824, p <0.001 accuracy 78.8%), volume of infarction ≤155 cm3 (AUC=0.939, p <0.001 accuracy 93.6%) and the Alberta Stroke Program Early CT Score or ASPECT score ≥6 (AUC = 1, p <0.001 accuracy 100%) were significantly associated with good clinical outcomes in early DC (mRS 0 to 3). Conclusion: Among patients with large territory ischemic strokes undergoing early DC, age ≤71 years, onset to DC ≤9 hours, volume of infarction ≤155 cm3 and ASPECT score ≥6 was significantly associated with good clinical outcomes. All prognostic factors in early DC correlated well with functional outcomes at 6 months which could be used to predict outcome, and consider clinical indications and informed postoperative complications among patients with large territory ischemic stroke.
Background: Cyclical change in central vein diameter during respiratory cycle can be used for fluid-responsiveness assessment. The purpose of this study is to assess variations in the diameter of central veins in upper body region, specifically internal jugular vein (IJV), subclavian vein (SCV), and brachiocephalic vein (BCV), in mechanically ventilated patients. We hypothesized that variations in the diameter of these veins caused by passive ventilation would be strongly concordant with pulse pressure variation (PPV). Methods: The study was conducted in mechanically ventilated, critically ill surgical and medical patients. The PPV values were automatically calculated and were recorded. The diameters of the study veins such as the IJV, SCV, and BCV were measured bedside using the ultrasound. Then respiratory variations of venous diameter were calculated into distensibility index, collapsibility index and variability index. The relationships between PPV and ultrasound-derived parameters were assessed. Patients were separated into two groups according to their PPV values (>13 and <10). The test performance and proper cut-off values of ultrasound-derived parameters to distinguish between these two groups were generated by receiver operating characteristic (ROC) curves. Results: A total of 44 patients were assessed. There were substantial correlations between PPV and ultrasound parameter namely IJV-DI (r=0.652, p<0.001), IJV-VI (r=0.655, p<0.001), SCV-CI (r=0.618, p<0.001), and SCV-VI (r=0.626, p<0.001). While PPV and BCV-CI show moderate correlation (r=0.531, p=0.008). The IJV-DI, IJV-VI, SCV-CI, SCV-VI and BCV-VI values were significantly greater in PPV>13 group than PPV<10 group. All these parameters were effective in distinguishing between PPV>13 from PPV<10 group with AUC 0.983, 0.983, 0.928, 0.928 and 0.826, respectively. The IJV-DI, IJV-VI, SCV-CI, SCV-VI and BCV-VI analysis demonstrated appropriate cut-off values for separating patients with PPV>13 from those with PPV<10 as 16.19% (sensitivity 92%, specificity 96%), 14.98 % (sensitivity 92%, specificity 96%), 9.74% (sensitivity of 93%, specificity of 91%), 12.33% (sensitivity of 87%, specificity of 100%) and 13.71% (sensitivity of 73%, specificity of 100%), respectively. Conclusions: In critically ill patients, all ultrasound-derived measures such as IJV-DI, IJV-VI, SCV-CI, SCV-VI, and BCV-VI revealed significant correlation with PPV value.
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