Advancing shock prediction: leveraging prior knowledge and self-controlled data for enhanced model accuracy and generalizability.

Background :The aim of the study was to compare the effect of two different regimens of milrinone in pediatric patients with pulmonary artery hypertension (PAH) undergoing corrective procedure.Materials and Methods :This randomized prospective study included 100 pediatric patients undergoing corrective cardiac surgeries. Group E: Milrinone was started as infusion 0.5 μg/kg/min without a loading dose after induction of anesthesia and continued as infusion 0.5–0.75 μg/kg/min in the pediatric cardiac surgical intensive care unit (PSICU). Group L: Milrinone was started as a loading dose 50 μg/kg over 10 min before weaning from cardiopulmonary bypass (CPB) followed by infusion 0.5–0.75 μg/kg/min in the PSICU. We compared heart rate, mean arterial blood pressure, central venous pressure, cardiac index (CI), mean pulmonary arterial pressure (MPAP), serum lactate level, urine output, vasoactive inotropic score, mechanical ventilation duration, and intensive care unit (ICU)- and hospital length of stay between the groups.Results :There was an increase in mean arterial blood pressure, CI, and urine output in Group E compared to Group L (P < 0.05). MPAP, serum lactate level, and requirement of inotropes and vasopressors were lower in Group E compared to Group L (P < 0.05). Mechanical ventilation duration, ICU, and hospital length of stay were shorter in Group E than Group L (P < 0.05).Conclusions :Early use of milrinone in patients with PAH undergoing corrective cardiac surgeries improved CI and mean arterial pressure, decreased MPAP, improved urine output, decreased serum lactate level, and decreased requirement of inotropes and vasopressors after weaning from CPB compared to the milrinone bolus group.

### Case A 68-year-old right-hand-dominant man was brought to the hospital because of a speech disturbance and right arm and leg weakness. He awoke with these deficits and was last known to be symptom-free when retiring to bed the previous evening 8 hours earlier. His past medical history was notable for coronary heart disease, the patient having underwent coronary artery bypass surgery 7 years previously for unstable angina, but he had no known history of myocardial infarction. He also had hypertension and hyperlipidemia, and smoked 1 pack of cigarettes daily for more than 40 years. He had no history of calf claudication. His hypertension was being treated with a diuretic and β-adrenergic receptor blocker. He was also prescribed 325 mg of aspirin daily and an HMG CoA-reductase inhibitor (statin); however, his wife remarked that he often forgot to take his medications. His last total cholesterol was 240 mg/dL, with LDL cholesterol of 130 mg/dL. He had a strong family history of coronary heart disease after the age of 50. He had no known drug allergies. #### Physical Examination The patient’s blood pressure was 195/100 mm Hg in both arms, with a regular pulse of 90 bpm. His weight was 225 lb (body mass index: 31.4 kg/m2). His lungs were clear to auscultation. Cardiac examination showed a laterally displaced point of maximum impulse with an S4 gallop and a soft nonradiating systolic murmur at the base. His abdomen was obese without organomegaly and no abdominal bruits were detected. He had no rashes and no joint deformities. The left superficial temporal artery pulse was stronger than the right. There were soft bilateral anterior cervical bruits, left louder than right, but no supraclavicular bruits. There were bilateral femoral bruits. Radial pulses were 2+ and symmetric. Dorsalis pedis and posterior tibial pulses were 1+. …

This study aimed to compare non-invasive oscillometric blood pressure (NIBP) measurement with invasive arterial blood pressure (IBP) measurement in patients with sepsis. We conducted a retrospective study to evaluate the agreement between IBP and NIBP using the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Paired blood pressure measurements of mean arterial pressure (MAP), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were compared using Bland-Altman analysis and paired Student's t test. We also focus on the effect of norepinephrine (NE) on the agreement between the two methods and the association between blood pressure and mortality during intensive care unit (ICU) stay. A total of 96,673 paired blood pressure measurements from 6060 unique patients were analyzed in the study. In Bland-Altman analysis, the bias (± SD, 95% limits of agreement) was 6.21mmHg (± 12.05mmHg, -17.41 to 29.83mmHg) for MAP, 0.39mmHg (± 19.25mmHg, -37.34 to 38.12mmHg) for SBP, and 0.80mmHg (± 12.92mmHg, -24.52 to 26.12mmHg) for DBP between the two techniques. Similarly, large limits of agreement were shown in different groups of NE doses. NE doses significantly affected the agreement between IBP and NIBP. SBP between the two methods gave an inconsistent assessment of patients' risk of ICU mortality. IBP and NIBP were not interchangeable in septic patients. Clinicians should be aware that non-invasive MAP was clinically and significantly underestimated invasive MAP.

Hypertension Optimal Treatment (HOT) trial

In two-thirds of intensive care unit (ICU) patients and 90% of surgical patients, arterial blood pressure (ABP) is monitored non-invasively but intermittently using a blood pressure cuff. Since even a few minutes of hypotension increases the risk of mortality and morbidity, for the remaining (high-risk) patients ABP is measured continuously using invasive devices, and derived values are extracted from the recorded waveforms. However, since invasive monitoring is associated with major complications (infection, bleeding, thrombosis), the ideal ABP monitor should be both non-invasive and continuous. With large volumes of high-fidelity physiological waveforms, it may be possible today to impute a physiological waveform from other available signals. Currently, the state-of-the-art approaches for ABP imputation only aim at intermittent systolic and diastolic blood pressure imputation, and there is no method that imputes the continuous ABP waveform. Here, we developed a novel approach to impute the continuous ABP waveform non-invasively using two continuously-monitored waveforms that are currently part of the standard-of-care, the electrocardiogram (ECG) and photo-plethysmogram (PPG), by adapting a deep learning architecture designed for image segmentation. Using over 150,000 min of data collected at two separate health systems from 463 patients, we demonstrate that our model provides a highly accurate prediction of the continuous ABP waveform (root mean square error 5.823 (95% CI 5.806–5.840) mmHg), as well as the derived systolic (mean difference 2.398 ± 5.623 mmHg) and diastolic blood pressure (mean difference − 2.497 ± 3.785 mmHg) compared to arterial line measurements. Our approach can potentially be used to measure blood pressure continuously and non-invasively for all patients in the acute care setting, without the need for any additional instrumentation beyond the current standard-of-care.

The depressant activity on sympathetic tone of subarachnoid anesthetic block is well known. The aim of this study was to compare cardiovascular response to an incremental dose of subarachnoid anesthesia administered through a small-bore microcatheter with the response to single-dose spinal anesthesia. The 26 ASA I or II patients, 45-65 years old, who were undergoing elective gynecologic, urologic, or orthopaedic surgery, were randomized into two groups of 13 each: the first group (SSA) underwent single-shot spinal anesthesia with 1% hyperbaric bupivacaine (0.27 mg/kg), while the second group (CSA) received an incremental 5-mg bolus of the same solution via a subarachnoid 32-gauge microcatheter every 10 minutes. All patients were premedicated and prehydrated with Ringer's acetate 8-10 mL/kg, infused over a 30-minute period. Heart rate, systolic, mean, and diastolic arterial blood pressure, arterial blood gas analysis, and cardiac index (measured by the noninvasive indirect Fick method) were recorded prior to preoperative subarachnoid anesthesia and then 15, 30, and 45 minutes after the first local anesthetic administration. The anthropometric parameters of the patients were homogeneous. No problems regarding anesthetic procedures occurred during the study, and none of the patients developed neurologic sequelae prior to discharge from the hospital. No relevant changes in blood gas parameters were found during the study in either the CSA or the SSA group. With regard to hemodynamic parameters, a significant reduction of systolic, diastolic, and mean arterial blood pressure was found in the SSA group following subarachnoid local anesthetic injection, while arterial pressures did not decrease in the CSA group. Cardiac index showed a nonsignificant increase with respect to baseline values in both groups, with no differences between groups during the study. In well-hydrated, healthy patients incremental local anesthetics offer adequate subarachnoid anesthesia with minimal hemodynamic effects.

Hypertension is highly prevalent in the United States and worldwide. In the United States, 1 in 3 adults (≈73 million people) have hypertension. The financial and human costs of hypertension are substantial. The estimated costs attributable to hypertension in the United States alone in 2010 were $70 billion direct costs for medical treatments and $24 billion indirect costs because of lost productivity.1 Awareness and treatment of hypertension have improved considerably during the past several decades: >80% of all people with hypertension are aware of the condition and 75% are using antihypertensive medications.2,3 However, despite enormous effort and treatment-related expenditures, only 53% of those with documented hypertension have their blood pressure controlled.3 Older age (Figure 1), left ventricular hypertrophy, and obesity are important risk factors for uncontrolled or drug-resistant hypertension.4 Importantly, the foregoing are also risk factors for increased aortic stiffness.5 Figure 1. Hypertension prevalence and control rates as a function of age in the National Health and Nutrition Examination Survey 2003 to 2004. Data derived from Wong et al.44 During the past 2 decades, measures of aortic stiffness have emerged as important risk factors for progression of blood pressure and incident cardiovascular disease. Carotid femoral pulse wave velocity (CFPWV), a measure of aortic wall stiffness, increases markedly with age, particularly after midlife. For example, Framingham Heart Study investigators have shown that the prevalence of CFPWV ≥12 m/s increases from a few percentage before 50 years of age to ≥60% after 70 years of age (Figure 2A). Importantly, elevated CFPWV is associated with high risk for incident hypertension (Figure 2B) and cardiovascular disease (Figure 2C). Figure 2C should be interpreted within the context that a normal value (<95th percentile) for CFPWV in a healthy Framingham Heart Study reference sample <50 years of age was 8.1 …

Objective To explore the effective application of ventilation at prone position on patients with severe acute respiratory distress syndrome(ARDS) at high altitude. Methods A total of 19 severe ARDS patients in ICU of Qinghai Province People's Hospital were enrolled from February in 2016 to February. in 2018, all of them ventilated at the prone position, several indicators were assessed:heart rate (HR), respiratory (R), mean arterial pressure (MAP); blood gas indicators: arterial oxygen partial pressure (PaO2), inhaled oxygen concentration (FiO2), carbon dioxide partial pressure (PaCO2), blood oxygen saturation (SpO2), oxygenation index (PaO2/FiO2), PH, lung compliance, PEEP and so on, which assessed before and 12h, 24h, 48h, 72h after the ventilation. Results FiO2 and PEEP significantly declined at 12 h, 24 h, 48 h, 72 h after ventilation at the prone position. HR, MAP, R, PaO2, PaCO2, SPO2, PaO2/FiO2, pH and lung compliance significantly improved (F=32.30,24.73, P < 0.05). Conclusions It was an effective method for ARDS patients to improve the oxygenation status and vital signs at the plateau with ventilation used at the prone position and probably nursing intervention, which have clinical application value. Key words: Respiratory distress syndrome, adult; High attitude; Ventilation, prone position

Hypertension Editors' Picks: Preeclampsia, Pregnancy, and Hypertension.

The aim of this study was to clarify the mechanism of hemodynamic changes leading to intraoperative hypotension during evacuation of acute subdural hematoma. To our knowledge, little data is available about the mechanism of hemodynamic changes during surgical interventions to decrease intracranial pressure after severe head injury. The influence of preoperative hypotension on intraoperative hypotension was examined. Hemodynamic studies (pulmonary artery catheterization) were carried out in 15 patients before and after acute subdural hematoma evacuation. All patients were assessed for hemodynamic parameters, evacuated hematoma volume, and intracranial pressure measurements. Comparison between just before and after evacuation of the hematoma showed that the mean arterial pressure, pulmonary arterial pressure, systemic vascular resistance, pulmonary vascular resistance, central venous pressure, and pulmonary capillary wedge pressure all decreased after hematoma evacuation. However, the cardiac index was unchanged after hematoma evacuation. Mean arterial blood pressure is dependent on the cardiac index and vascular resistance, so the decrease in arterial blood pressure during hematoma evacuation was the result of a decline in vascular resistance. The influence of preoperative blood pressure on intraoperative hemodynamic changes was analyzed by dividing the patients into two groups, the preoperative hypotension group and preoperative nonhypotension group. The decrease in mean arterial blood pressure was more marked in the preoperative hypotension group than in the preoperative nonhypotension group. Intraoperative hypotension during evacuation of acute subdural hematoma is caused by a decrease in vascular resistance. Preoperative hypotension is a also risk factor for intraoperative hypotension.

Short-Term Angiotensin Subtype 1 Receptor Blockade Does Not Alter the Circulatory Responses to Sympathetic Nervous System Modulation in Healthy Volunteers Before and During Sevoflurane Anesthesia: Results of a Pilot Study

To compare the influence on caesarean section morbidity of uterine exteriorisation or in situ repair. Randomised controlled trial. Princess Anne Maternity Unit of the Royal Bolton Hospital, UK. One hundred and ninety-four women undergoing delivery by caesarean section. Two intra-operative readings of arterial pulse rate, mean arterial blood pressure, and arterial haemoglobin oxygen saturation were obtained. Pre-operative and day-3 haemoglobin concentrations were determined. Intra- and post-operative complications, puerperal pain scores, and febrile and infectious morbidity were assessed. A postal questionnaire was used to assess morbidity six weeks after delivery. Intra-operative changes in pulse rate, mean arterial blood pressure and oxygen saturation; peri-operative changes in haemoglobin concentration; incidence of intraoperative vomiting, pain, intra- and post-operative complications, and febrile and infectious morbidity; immediate and late puerperal pain scores; satisfaction with the operation. No clinically significant differences between uterine exteriorisation and in situ repair were found in pulse rate, mean arterial pressure, oxygen saturation and haemoglobin changes. Likewise, the incidence of vomiting and pain was similar. Vomiting occurred in 10% of all the women, and 57% of all pain complaints occurred at the initial skin incision. There was a trend towards higher immediate and late pain scores in the exteriorisation group, reaching statistical significance on day 3. Overall, pain scores averaged 6/10 on day 1 despite patient-controlled analgesia, and three-quarters of all women reported persisting pain on day 42. Intra- and post-operative complications, febrile and infectious morbidity, and duration of hospital stay were similar in both groups. We have demonstrated that uterine exteriorisation and in situ repair have similar effects on peri-operative caesarean section morbidity. Intra-operative pain reflected adequacy of anaesthesia, while vomiting reflected adequacy of pre-operative preparation of patients. Exteriorising the uterus at caesarean section is a valid option.

Parkinson's disease (PD) is a common chronic degenerative disease, and its exact pathological mechanism remains unclear. In this study, we identified covariates associated with the clinical outcomes of PD using patient data from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database, providing new references for the treatment of patients. The data of patients with PD and relevant covariates were obtained from the MIMIC-IV database. The patients were categorized into the in-hospital death and in-hospital survival groups based on their survival status, and the relationship between their outcomes and covariates was investigated. Key covariates markedly associated with the clinical outcomes of PD were further screened using regression analysis. Finally, a nomogram for predicting the risk of in-hospital mortality in patients with PD was constructed and validated. A total of 143 patients with PD and 37 covariates were included in this study. Of the included patients, 25 were assigned to the in-hospital death group and 118 were assigned to the in-hospital survival group. Covariates such as the respiratory rate, mean arterial pressure (MAP), respiratory failure, anion gap, bicarbonate levels, blood urea nitrogen levels, and sequential organ failure assessment (SOFA) scores were markedly associated with in-hospital mortality in patients with PD. Subsequently, age [hazard ratio (HR) = 1.0565, 95% confidence interval (CI) = 1.0065-1.1090, p < 0.05], bicarbonate levels (HR = 0.8988, 95% CI = 0.8310-0.9722, p < 0.05), BUN levels (HR = 1.0292, 95% CI = 1.0084-1.0503, p < 0.05), and SOFA scores (HR = 1.1510, 95% CI = 1.0324-1.2831, p < 0.05) were identified as key covariates associated with in-hospital mortality. The nomogram incorporating these covariates exhibited favorable performance in predicting the risk of in-hospital mortality in patients with PD. This study revealed four key covariates associated with the clinical outcomes of PD, providing new references for the treatment of patients.

The present experiments were carried out to investigate the usefulness of measuring peripheral tissue metabolism for the clinical assessment of shock. Male Wistar/ST rats (8 weeks-old) were used. All rats were placed in a supine position while anesthetized. A tube for measuring arterial pressure and collecting blood samples was cannulated into the femoral artery. For microdialysis, the introducer was inserted into the subcutaneous tissue in the abdominal wall. Blood was exsanguinated to maintain the mean arterial pressure at 40 +/- 5 mmHg. Mean arterial pressure, arterial blood gas and serum lactate levels were measured. Microdialysis was performed to quantify the levels of lactate and pyruvate in the subcutaneous tissue. Six rats died due to hemorrhagic shock by 350 min (Group D) while six rats had survived for the 350 min period after exsanguination (Group A). These data was obtained at intervals of 50 min after exsanguination up to a period of 250 min and compared between Groups A and D. In Group A, serum lactate levels did not increase throughout the entire period of observation. Serum lactate levels in Group D transiently increased, but did not show a dramatic increase during the blood pressure maintenance period. In particular, serum lactate levels increased again after a period of more than 150 min following exsanguination. Lactate levels in the subcutaneous tissue gradually increased and were significantly higher in Group D than that in Group A after 150 min. The L/P ratio in Group A remained fairly constant during the period of observation. In contrast, the L/P ratio in Group D increased gradually, and was significantly higher than that in Group A after 100 min. It was concluded that the continuous increase in the L/P ratio in the subcutaneous tissue in Group D was indicative of tissue circulatory failure and of an abnormality in tissue oxygen metabolism prior to the detection of the collapse of compensatory mechanisms appearing in the vital signs. These findings suggest that measuring the L/P ratio is useful for the clinical assessment and monitoring of shock.

Effects of labetalol on uterine blood flow and cardiovascular hemodynamics in the hypertensive gravid baboon