Evaluation of monitoring readings, taking into account each patient’s pathology as well as the impact of every medical intervention can guide us to make optimal clinical decisions in the periopeative setting. We present three cases in which clinical decisions concerning the management of acute perioperative pulmonary hypertension were based both on haemodynamic monitoring readings and on each patient’s specific pathology. First case: After anesthesia induction in a patient with severe aortic valve insufficiency, an increase in pulmonary artery pressure was recorded. Infusion of isoprenaline, which has a positive chronotropic effect, decreased diastolic time, diastolic blood flow into the left ventricle and also pulmonary artery pressure. Second case: A patient with severe aortic valve stenosis was found with increased pulmonary artery pressure. Intravenous administration of atenolol (1+1mg) reduced the heart rate and the pulmonary artery pressure. Third case: A 15 year old patient with aortic isthmus rupture underwent open surgical repair with graft interposition. After establishment of one lung ventilation and left thoracotomy, pulmonary artery pressure increased. Pulmonary hypertension was managed successfully by oxygen insufflation to the non-ventilated left lung. In our first patient, heart rate increase reduced diastolic time, which decreased the amount of retrograde blood flow into the left ventricle through the regurgitant aortic valve. In the second patient, the heart rate reduction decreased blood flow velocity through the stenotic aortic valve as well as the pressure gradient between left ventricular chamber and aorta. In both patients, enhanced left ventricular function resulted in a reduction in pulmonary artery pressure. Decrease of the alveolar partial pressure of oxygen (PAO2) is the most important parameter that stimulates hypoxic pulmonary vasoconstriction. Oxygen insufflation increased PAO2, resulting in a decrease in pulmonary artery pressure .Clinical decisions based on haemodynamic monitoring readings resulted in effective management of pulmonary hypertension and in a good patient outcome. Continue reading
The interaction between increased Intra Abdominal Pressure (IAP) and Intrathoracic Pressure under different Positive End Expiratory Pressure (PEEP) levels is intriguing, since these two conditions coexist frequently in several clinical settings. The aim of our study was to investigate the interaction between different PEEP levels and increased IAP during laparoscopic cholecystectomy. In fifty two patients, who underwent scheduled laparoscopic cholecystectomy, cardiovascular parameters were determined by an Oesophageal Doppler Monitor device during two different time periods, before and after pneumoperitoneum, and under five conditions: (i) PEEP 0 cmH2O (ii) PEEP 5cm H2O (iii) PEEP 10cm H2O (iv) PEEP 15cm H2O and (v) in the absence of PEEP or ventilation. Cardiac output and stroke volume showed a statistically significant decrease compared to the baseline value after the application of different PEEP levels, when there was no pneumoperitoneum (p<0.05). However, both parameters increased, when PEEP and pneumoperitoneum were applied together (p<0.001). Corrected flow time, peak flow velocity in the descending thoracic aorta and mean acceleration showed similar alterations but not at all PEEP levels. Finally, αt the no PEEP or ventilation phase, the negative effects of increased IAP on the cardiocirculatory function were predominant. According to these results, application of PEEP seems to counterbalance the negative hemodynamic effects of increased IAP. Moreover, it could also be concluded that ‘ideal’ PEEP level might be the one that borders the IAP level, since the best cardiac output and stroke volume values were reported at that point. Continue reading
Factors affecting cardiac function in dialysis patients include arterial blood pressure, anemia, intra-vascular volume and the arteriovenous fistula (AVF). We investigated the acute and chronic effects of basilic vein transposition (mean upper arm brachial artery-basilic vein anastomosis) on both the cardiovascular system and the oxygen status.
Sixteen patients with end stage renal failure were enrolled in this study. Patients with heart failure, pericardial effusion or valvular heart disease were not included in the study. Echocardiography (preoperatively and six months after, stages 1 and 2 respectively) and a Swan-Ganz catheter (perioperatively) were used to assess the hemodynamic status during the phases of AVF construction. Flow measurements were made in the parts of the AVF system before, during and after the construction of the AVF.Moreover, at the same time phases blood sampling from the arterial line and the pulmonary artery catheter was performed, in order to assess oxygen and acidbase status. Continue reading