Explore the vast range of titles available.

Objective The objective of this study was to investigate the efficacy and safety of tranexamic acid (TXA) in hepatectomy when administered as per the standardized protocol of controlled low central venous pressure (CLCVP). Methods This study was a randomized, double-blind, controlled study. Patients who fulfilled the inclusion criteria were randomly assigned to the TXA group (group T) or the placebo group (group N). The central venous pressure (CVP) was maintained at below 5 cmH2O before complete dissection of the liver parenchyma. Patients in group T received an intravenous infusion of 10 mg/kg of TXA 30 min before surgery, and it was continuously pumped intravenously at a rate of 1 mg/(kg.h) until the end of surgery. Patients in group N were infused with 1 mL/kg of normal saline 30 min before surgery, and it was continuously pumped intravenously at a rate of 0.1 mL/(kg.h) until the end of surgery. The primary outcome indicators were intraoperative blood loss, blood transfusion rate, intraperitoneal drainage at 24 h after surgery, and the occurrence of compound bleeding within 30 days. Results The baseline indicators were similar ( P  > 0.05), and there was no significant difference in intraoperative blood loss between the two groups, but the red blood cell transfusion rate was lower in the T group than in the N group ( P  < 0.05). The infusion volume, surgical field grade, and surgery duration were comparable between the two groups ( P  > 0.05). Patients in group T had a shorter hilar occlusion time, lower D-dimer and fibrinogen degradation products (FDPs) on the day of surgery, and significantly less intraperitoneal drainage at 24 h after surgery (all P  < 0.05). There were two cases of compound bleeding and three cases of thromboembolism among patients in group N, but there were no such complications in group T. Conclusion The use of TXA in hepatectomy under CLCVP reduced the intraoperative blood transfusion rate and improved the postoperative bleeding outcome without increasing the risk of adverse events such as hepatic and renal insufficiency and thrombosis.

Suboccipital craniotomy in the park bench position is linked to considerable physiological alterations. Effective fluid management in this context is a challenge to anesthesiologists. No published data exist on pulse pressure variation and central venous pressure guidance in patients undergoing tumor resection in the park bench posture. We undertake a study to evaluate the concept that two approaches of goal-directed fluid treatment enhance optimal fluid management and improve hemodynamic stability. We established the fluid management protocol for this process. This is a prospective randomized double-blinded study of adult patients undergoing suboccipital craniotomy to remove tumors in the park bench position. The comparison of pulse pressure variation and central venous pressure for fluid management regarding mean intraoperative fluid administration as the primary outcome. A sample size of 54 will yield over 80% power to identify a mean fluid difference of at least 500 ml between two specified methods. The secondary outcomes are data pertinent to fluid administered during and after surgery, including the lowest systolic blood pressure, serum lactate levels, vasopressor utilization, and duration of ICU stay. The statistical analysis will be validated based on the data distribution and types of data. This is the first study to examine two goal-directed fluid therapies, pulse pressure variation and central venous pressure, in patients with posterior fossa tumors and undergoing surgery in the park bench position. Researchers want to contribute novel information to the domain of fluid optimization in neurosurgery. ClinicalTrials.gov NCT06595667.

Background Conventional anesthesia used to reduce central venous pressure (CVP) during hepatectomy includes fluid restriction and vasodilator drugs, which can lead to a reduction in blood perfusion in vital organs and may counteract the benefits of low blood loss. In this study, we hypothesized that milrinone is feasible and effective in controlling low CVP (LCVP) during laparoscopic hepatectomy (LH). Compared with conventional anesthesia such as nitroglycerin, milrinone is beneficial in terms of intraoperative blood loss, surgical environment, hemodynamic stability, and patients’ recovery. Methods In total, 68 patients undergoing LH under LCVP were randomly divided into the milrinone group ( n  = 34) and the nitroglycerin group ( n  = 34). Milrinone was infused with a loading dose of 10 µg/kg followed by a maintenance dose of 0.2–0.5 µg/kg/min and nitroglycerin was administered at a rate of 0.2–0.5 µg/kg/min until the liver lesions were removed. The characteristics of patients, surgery, intraoperative vital signs, blood loss, the condition of the surgical field, the dosage of norepinephrine, perioperative laboratory data, and postoperative complications were compared between groups. Blood loss during LH was considered the primary outcome. Results Blood loss during hepatectomy and total blood loss were significantly lower in the milrinone group compared with those in the nitroglycerin group ( P  < 0.05). Both the nitroglycerin group and milrinone group exerted similar CVP ( P  > 0.05). Nevertheless, the milrinone group had better surgical field grading during liver resection ( P  < 0.05) and also exhibited higher cardiac index and cardiac output during the surgery ( P  < 0.05). Significant differences were also found in terms of fluids administered during hepatectomy, urine volume during hepatectomy, total urine volume, and norepinephrine dosage used in the surgery between the two groups. The two groups showed a similar incidence of postoperative complications ( P  > 0.05). Conclusion Our findings indicate that the intraoperative infusion of milrinone can help in maintaining an LCVP and hemodynamic stability during LH while reducing intraoperative blood loss and providing a better surgical field compared with nitroglycerin. Trial registration ChiCTR2200056891,first registered on 22/02/2022.

BackgroundDiuretic resistance is a common issue in patients with acute decompensation of advanced chronic heart failure (ACHF). The aim of this trial was to compare boluses and continuous infusion of furosemide in a selected population of patients with ACHF and high risk for diuretic resistance.MethodsIn this single-centre, double-blind, double-dummy, randomized trial, we enrolled 80 patients admitted for acute decompensation of ACHF (NYHA IV, EF ≤ 30%) with criteria of high risk for diuretic resistance (SBP ≤ 110 mmHg, wet score ≥ 12/18, and sodium ≤ 135 mMol/L). Patients were assigned in a 1:1 ratio to receive furosemide by bolus every 12 h or by continuous infusion. Diuretic treatment and dummy treatment were prepared by a nurse unassigned to patients’ care. The study treatment was continued for up to 72 h. Coprimary endpoints were total urinary output and freedom from congestion at 72 h.Results80 patients were enrolled with 40 patients in each treatment arm. Mean daily furosemide was 216 mg in continuous-infusion arm and 195 mg in the bolus intermittent arm. Freedom from congestion (defined as jugular venous pressure of < 8 cm, with no orthopnea and with trace peripheral edema or no edema) occurred more in the continuous infusion than in the bolus arm (48% vs. 25%, p = 0.04), while total urinary output after 72 h was 8612 ± 2984 ml in the bolus arm and 10,020 ± 3032 ml in the continuous arm (p = 0.04). Treatment failure occurred less in the continuous-infusion group (15% vs. 38%, p = 0.02), while there was no significant difference between groups in the incidence of worsening of renal function.ConclusionAmong patients with acute decompensation of ACHF and high risk of diuretic resistance, continuous infusion of intravenous furosemide was associated with better decongestion.DRAIN trialClinicalTrials.gov number NCT03592836.Graphic abstract

Background Central venous pressure (CVP) and right atrial pressure (RAP) are important parameters in the complete hemodynamic assessment of a patient. Sonographic measurement of the inferior vena cava (IVC) diameter is a non-invasive method of estimating these parameters, but there are limited data summarizing its diagnostic accuracy across multiple studies. We performed a comprehensive review of the existing literature to examine the diagnostic accuracy and clinical utility of sonographic measurement of IVC diameter as a method for assessing CVP and RAP. Methods We performed a systematic search using PubMed of clinical studies comparing sonographic evaluation of IVC diameter and collapsibility against gold standard measurements of CVP and RAP. We included clinical studies that were performed in adults, used current imaging techniques, and were published in English. Results Twenty one clinical studies were identified that compared sonographic assessment of IVC diameter with CVP and RAP and met all inclusion criteria. Despite substantial heterogeneity in measurement techniques and patient populations, most studies demonstrated moderate strength correlations between measurements of IVC diameter and collapsibility and CVP or RAP, but more favorable diagnostic accuracy using pre-specified cut points. Findings were inconsistent among mechanically ventilated patients, except in the absence of positive end-expiratory pressure. Conclusion Sonographic measurement of IVC diameter and collapsibility is a valid method of estimating CVP and RAP. Given the ease, safety, and availability of this non-invasive technique, broader adoption and application of this method in clinical settings is warranted.

The objective is to explore the value of end-tidal carbon dioxide (ETCO2) in replacing cardiac index for evaluating fluid responsiveness during the passive leg raising (PLR) test and mini-fluid challenge (mini-FC). Patients experiencing septic shock and who were on mechanical ventilation in an intensive care unit were divided into responder and nonresponder groups according to whether their cardiac index increased by more than 10% after the FC. Before and after those tests, the changes in ETCO2, central venous pressure, heart rate, mean arterial pressure, pulse pressure, and cardiac output were recorded. Of the 48 patients in the study, 34 had fluid responsiveness according to the changes in cardiac output or stroke volume. The ΔCI and ΔETCO2 in the responder group were larger than the changes in the nonresponder group during the PLR test (1.1 ± 0.7 vs 0.2 ± 0.4 L/min per square meter, 3.0 ± 3.0 vs 0.5 ± 2.5 mm Hg; P < .05) but not during mini-FC. ΔETCO2 greater than or equal to 5% during the PLR test predicted fluid responsiveness with 93.4% specificity and 75.8% sensitivity in a receiver operating characteristic curve. The area under the curve was 0.849 (95% confidence interval, 0.739-0.930). ΔETCO2 greater than or equal to 3% during the mini-FC predicted fluid responsiveness with 93.4% specificity and 33.3% sensitivity in a receiver operating characteristic curve, and the area under the curve was 0.781 (95% confidence interval, 0.646-0.915). The changes in ETCO2 may predict fluid responsiveness during the PLR test in patients with septic shock, but similar results were not found with the mini-FC.

Previous studies reported that controlled low central venous pressure (CVP) can reduce blood loss during liver resection. This systematic review and meta-analysis sought to explore the efficacy and safety of low CVP in patients undergoing hepatectomy. A systematic review and meta-analysis of randomized controlled trials (RCTs). RCTs were searched in PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese BioMedical database, Chinese Scientific Journals Database, and Wanfang database from inception to April 30, 2021. Subgroup analyses were performed based on different surgical methods (open hepatectomy vs laparoscopic hepatectomy) and published countries (China vs other countries). The quality of evidence was assessed by Grading of Recommendations, Assessment, Development, and Evaluation. Eighteen RCTs containing 1285 participants (626 patients in the low CVP group and 659 patients in the control group) were included in this study. The forest plot showed that low CVP effectively reduced blood loss during liver resection compared with the control group (MD = −311.92 mL, 95% CI [−429.03, −194.81]; P < 0.001, I2 = 96%). Furthermore, blood transfusion volume (MD = −158.85 mL, 95% CI [−218.30, −99.40]; P < 0.001, I2 = 55%) and the number of patients requiring transfusion (RR 0.41, 95% CI 0.27–0.65, P < 0.001, I2 = 0%) were decreased in the low CVP group. Subgroup analyses showed similar results. Notably, the alanine transaminase level was significantly lower in the low CVP group during the first five postoperative days. However, no significant differences were observed for other postoperative liver function indicators (aspartate aminotransferase, total bilirubin, serum albumin, and prothrombin time), renal function indicators (blood urea nitrogen and serum creatinine) and perfusion parameters (heart rate, mean arterial pressure, and urine volume). The incidence of complications was similar between the two groups. The findings of this study showed that low CVP is effective and safe during hepatectomy. Therefore, this technique is recommended to reduce blood loss during hepatectomy. PROSPERO registration number: CRD42021232829. •Controlled low central venous pressure significantly reduce intraoperative blood loss during liver resection.•Controlled low central venous pressure had no negative impact on liver and renal function.•Controlled low central venous pressure did not increase postoperative complications.

Background Thoracic epidural anesthesia (TEA) exacerbates hypotension due to peripheral vasodilator effects following the use of general anesthetics. This study aimed to compare the hemodynamic changes caused by three different concentrations of epidural ropivacaine and to evaluate the performance of the stroke-volume variation (SVV) and central venous pressure (CVP) during TEA with general anesthesia. Methods A total of 120 patients were administered 8 mL of ropivacaine solution via epidural injection, following randomization into one of three groups based on the concentration of ropivacaine in the study solution: 0.75%, 0.375%, or 0.2%. Hemodynamics were monitored for 30 min after loading. We analyzed the hemodynamic changes in the subgroups according to an age cutoff of 60 years. Receiver operating characteristic (ROC) analysis was performed to characterize the relationship of the SVV, CVP, and a 20% decrease in the mean arterial pressure (MAP) following TEA. Results Data from 109 patients were analyzed. MAP and systemic vascular resistance index were significantly decreased, and SVV was significantly increased after epidural loading only in the 0.75% ropivacaine group. There was a significant difference in hemodynamics between young and elderly subgroups in the 0.75% ropivacaine group. SVV showed a negative correlation with MAP, whereas CVP showed no correlation. The ROC analysis of SVV demonstrated a weak predictive ability of a 20% decrease in MAP at 10 min after the loading dose, with an area-under-the-curve of 0.687 and a 9.5% optimal cutoff value (sensitivity, 60.6%; specificity, 68.9%). Conclusions A high concentration of ropivacaine through TEA caused a significant decrease in the systemic vascular resistance and blood pressure. More significant decreases were shown in the elderly patients. Though the change of SVV showed a negative correlation with hypotension and indicated functional hypovolemia after TEA, the predictability was limited. Clinical trials registration Number: NCT01559285 , date: January 24, 2013.

Purpose Measurement of central venous pressure (CVP) can be a useful clinical tool. However, the formal utility of CVP measurement in preventing mortality in septic patients has never been proven. Methods The Medical Information Mart for Intensive Care III (MIMIC-III) database was searched to identify septic patients with and without CVP measurements. The primary outcome was 28-day mortality. Multivariate regression was used to elucidate the relationship between CVP measurement and 28-day mortality, and propensity score matching (PSM) and an inverse probability of treatment weighing (IPTW) were employed to validate our findings. Results A total of 10,275 patients were included in our study, of which 4516 patients (44%) underwent CVP measurement within 24 h of intensive care unit (ICU) admission. The risk of 28-day mortality was reduced in the CVP group (OR 0.60 (95% CI 0.51–0.70; p  < 0.001)). Patients in the CVP group received more fluid on day 1 and had a shorter duration of mechanical ventilation and vasopressor use, and the reduction in serum lactate was greater than that in the no CVP group. The mediating effect of serum lactate reduction was significant for the whole cohort ( p  = 0.04 for the average causal mediation effect (ACME)) and patients in the CVP group with an initial CVP level below 8 mmHg ( p  = 0.04 for the ACME). Conclusion CVP measurement was associated with decreased risk-adjusted 28-day mortality among patients with sepsis and was proportionally mediated through serum lactate reduction.

Introduction: Central venous pressure (CVP) measurement is essential in the management of certain clinical situations, including cardiac failure, volume overload and sepsis. CVP measurement requires catheterization of the central vein which is invasive and may lead to complications. The aim of this study was to evaluate the accuracy of measurement of CVP using a new noninvasive method based on near infrared spectroscopy (NIRS) in a group of cardiac surgical Intensive Care Unit (ICU) patients. Methodology: Thirty patients in cardiac surgical ICU were enrolled in the study who had an in situ central venous catheter (CVC). Sixty measurements were recorded in 1 h for each patient. A total of 1800 values were compared between noninvasive CVP (CVPn) obtained from Mespere VENUS 2000 CVP system and invasive CVP (CVPi) obtained from CVC. Results: Strong positive correlation was found between CVPi and CVPn (R = 0.9272, P < 0.0001). Linear regression equation - CVPi = 0.5404 + 0.8875 × CVPn (r2 = 0.86, P < 0.001), Bland-Altman bias plots showed mean difference ± standard deviation and limits of agreement: −0.31 ± 1.36 and − 2.99 to + 2.37 (CVPi-CVPn). Conclusion: Noninvasive assessment of the CVP based on NIRS yields readings consistently close to those measured invasively. CVPn may be a clinically useful substitute for CVPi measurements with an advantage of being simple and continuous. It is a promising tool for early management of acute state wherein knowledge of CVP is helpful.