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      Dynamic Arterial Elastance Is Associated With the Vascular Waterfall in Patients Treated With Norepinephrine: An Observational Study

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          Abstract

          Introduction: It has been suggested that dynamic arterial elastance (Ea dyn) can predict decreases in arterial pressure in response to changing norepinephrine levels. The objective of this study was to determine whether Ea dyn is correlated with determinants of the vascular waterfall [critical closing pressure (CCP) and systemic arterial resistance (SARi)] in patients treated with norepinephrine.

          Materials and Methods: Patients treated with norepinephrine for vasoplegia following cardiac surgery were studied. Vascular and flow parameters were recorded immediately before the norepinephrine infusion and then again once hemodynamic parameters had been stable for 15 min. The primary outcomes were Ea dyn and its associations with CCP and SARi. The secondary outcomes were the associations between Ea dyn and vascular/flow parameters.

          Results: At baseline, all patients were hypotensive with Ea dyn of 0.93 [0.47;1.27]. Norepinephrine increased the arterial blood pressure, cardiac index, CCP, total peripheral resistance (TPRi), arterial elastance, and ventricular elastance and decreased Ea dyn [0.40 (0.30;0.60)] and SARi. Ea dyn was significantly associated with arterial compliance (C A), CCP, and TPRi ( p < 0.05).

          Conclusion: In patients with vasoplegic syndrome, Ea dyn was correlated with determinants of the vascular waterfall. Ea dyn is an easy-to-read functional index of arterial load that can be used to assess the patient’s macro/microcirculatory status.

          Clinical Trial Registration: ClinicalTrials.gov #NCT03478709.

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          Most cited references41

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          STARD 2015: an updated list of essential items for reporting diagnostic accuracy studies

          Incomplete reporting has been identified as a major source of avoidable waste in biomedical research. Essential information is often not provided in study reports, impeding the identification, critical appraisal, and replication of studies. To improve the quality of reporting of diagnostic accuracy studies, the Standards for Reporting Diagnostic Accuracy (STARD) statement was developed. Here we present STARD 2015, an updated list of 30 essential items that should be included in every report of a diagnostic accuracy study. This update incorporates recent evidence about sources of bias and variability in diagnostic accuracy and is intended to facilitate the use of STARD. As such, STARD 2015 may help to improve completeness and transparency in reporting of diagnostic accuracy studies.
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            The arterial Windkessel.

            Frank's Windkessel model described the hemodynamics of the arterial system in terms of resistance and compliance. It explained aortic pressure decay in diastole, but fell short in systole. Therefore characteristic impedance was introduced as a third element of the Windkessel model. Characteristic impedance links the lumped Windkessel to transmission phenomena (e.g., wave travel). Windkessels are used as hydraulic load for isolated hearts and in studies of the entire circulation. Furthermore, they are used to estimate total arterial compliance from pressure and flow; several of these methods are reviewed. Windkessels describe the general features of the input impedance, with physiologically interpretable parameters. Since it is a lumped model it is not suitable for the assessment of spatially distributed phenomena and aspects of wave travel, but it is a simple and fairly accurate approximation of ventricular afterload.
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              Hemodynamic coherence and the rationale for monitoring the microcirculation

              Can Ince (2015)
              This article presents a personal viewpoint of the shortcoming of conventional hemodynamic resuscitation procedures in achieving organ perfusion and tissue oxygenation following conditions of shock and cardiovascular compromise, and why it is important to monitor the microcirculation in such conditions. The article emphasizes that if resuscitation procedures are based on the correction of systemic variables, there must be coherence between the macrocirculation and microcirculation if systemic hemodynamic-driven resuscitation procedures are to be effective in correcting organ perfusion and oxygenation. However, in conditions of inflammation and infection, which often accompany states of shock, vascular regulation and compensatory mechanisms needed to sustain hemodynamic coherence are lost, and the regional circulation and microcirculation remain in shock. We identify four types of microcirculatory alterations underlying the loss of hemodynamic coherence: type 1, heterogeneous microcirculatory flow; type 2, reduced capillary density induced by hemodilution and anemia; type 3, microcirculatory flow reduction caused by vasoconstriction or tamponade; and type 4, tissue edema. These microcirculatory alterations can be observed at the bedside using direct visualization of the sublingual microcirculation with hand-held vital microscopes. Each of these alterations results in oxygen delivery limitation to the tissue cells despite the presence of normalized systemic hemodynamic variables. Based on these concepts, we propose how to optimize the volume of fluid to maximize the oxygen-carrying capacity of the microcirculation to transport oxygen to the tissues.
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                Author and article information

                Contributors
                Journal
                Front Physiol
                Front Physiol
                Front. Physiol.
                Frontiers in Physiology
                Frontiers Media S.A.
                1664-042X
                04 May 2021
                2021
                : 12
                : 583370
                Affiliations
                [1] 1Department of Anaesthesiology and Critical Care, Amiens University Hospital , Amiens, France
                [2] 2Department of Anaesthesiology and Critical Care, Centre Hospitalier Regional Universitaire De Dijon , Dijon, France
                [3] 3Université Boulogne Franche Comté, LNC UMR1231 , Dijon, France
                Author notes

                Edited by: Lacolley Patrick, Institut National de la Santé et de la Recherche Médicale (INSERM), France

                Reviewed by: Dimitrios Terentes-Printzios, University of Oxford, United Kingdom; Thomas Desaive, University of Liège, Belgium

                *Correspondence: Stéphane Bar, stephane.bar.sb@ 123456gmail.com

                This article was submitted to Vascular Physiology, a section of the journal Frontiers in Physiology

                Article
                10.3389/fphys.2021.583370
                8129527
                34017263
                6f743632-a925-4e90-8465-cc938edd98a2
                Copyright © 2021 Bar, Nguyen, Abou-Arab, Dupont, Bouhemad and Guinot.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 14 July 2020
                : 24 March 2021
                Page count
                Figures: 3, Tables: 4, Equations: 0, References: 41, Pages: 9, Words: 5751
                Categories
                Physiology
                Original Research

                Anatomy & Physiology
                dynamic arterial elastance,norepinephrine,waterfall phenomenon,vascular resistance,cardiac output

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