Fluid Responsiveness Is Associated with Successful Weaning after Liver Transplant Surgery

A positive fluid balance may evolve to fluid overload and associate with organ dysfunctions, weaning difficulties, and increased mortality in ICU patients. We explored whether individualized fluid management, assessing fluid responsiveness via a passive leg-raising maneuver (PLR) before a spontaneous breathing trial (SBT), is associated with less extubation failure in ventilated patients with a high fluid balance admitted to the ICU after liver transplantation (LT). We recruited 15 LT patients in 2023. Their postoperative fluid balance was +4476 {3697, 5722} mL. PLR maneuvers were conducted upon ICU admission (T1) and pre SBT (T2). Cardiac index (CI) changes were recorded before and after each SBT (T3). Seven patients were fluid-responsive at T1, and twelve were responsive at T2. No significant differences occurred in hemodynamic, respiratory, and perfusion parameters between the fluid-responsive and fluid-unresponsive patients at any time. Fluid-responsive patients at T1 and T2 increased their CI during SBT from 3.1 {2.8, 3.7} to 3.7 {3.4, 4.1} mL/min/m2 (p = 0.045). All fluid-responsive patients at T2 were extubated after the SBTs and consolidated extubation. Two out of three of the fluid-unresponsive patients experienced weaning difficulties. We concluded that fluid-responsive patients post LT may start weaning earlier and achieve successful extubation despite a high postoperative fluid balance. This highlights the profound impact of personalized assessments of cardiovascular state on critical surgical patients.</p

Persistent Sepsis-Induced Hypotension without Hyperlactatemia: A Distinct Clinical and Physiological Profile within the Spectrum of Septic Shock

Introduction. A subgroup of septic shock patients will never develop hyperlactatemia despite being subjected to a massive circulatory stress. Maintenance of normal lactate levels during septic shock is of great clinical and physiological interest. Our aim was to describe the clinical, hemodynamic, perfusion, and microcirculatory profiles associated to the absence of hyperlactatemia during septic shock resuscitation. Methods. We conducted an observational study in septic shock patients undergoing resuscitation. Serial clinical, hemodynamic, and perfusion parameters were registered. A single sublingual microcirculatory assessment was performed in a subgroup. Patients evolving with versus without hyperlactatemia were compared. Results. 124 septic shock patients were included. Patients without hyperlactatemia exhibited lower severity scores and mortality. They also presented higher platelet counts and required less intensive treatment. Microcirculation was assessed in 45 patients. Patients without hyperlactatemia presented higher PPV and MFI values. Lactate was correlated to several microcirculatory parameters. No difference in systemic flow parameters was observed. Conclusion. Persistent sepsis-induced hypotension without hyperlactatemia is associated with less organ dysfunctions and a very low mortality risk. Patients without hyperlactatemia exhibit less coagulation and microcirculatory derangements despite comparable macrohemodynamics. Our study supports the notion that persistent sepsis-induced hypotension without hyperlactatemia exhibits a distinctive clinical and physiological profile

Variación intraespecífica e individual de los pelos de mamíferos del Estado de México: implicaciones en la identificación interespecífica

Se determinó la variación del pelo de guardia dorsal entre individuos de la misma especie y se comparó la variación de un individuo en diferentes regiones. Se midió la longitud total y diámetro de la médula, además se determinó el patrón de tonalidad y tipo de médula. En la comparación intraespecífica se caracterizaron 530 pelos de guardia dorsales de 53 organismos. A pesar de las variaciones en la longitud y diámetro de la médula, puede realizarse una identificación exitosa de los organismos en un plano específico utilizando la guía de identificación de mamíferos terrestres a partir del pelo de guardia, excepto para Canis latrans y Liomys irroratus. En la comparación individual se describieron 560 pelos de guardia de 14 especies. Se encontraron diferencias en la longitud total del pelo, en el diámetro de la médula y en la coloración; el único carácter que permaneció constante fue la médula.Se determinó la variación del pelo de guardia dorsal entre individuos de la misma especie y se comparó la variación de un individuo en diferentes regiones. Se midió la longitud total y diámetro de la médula, además se determinó el patrón de tonalidad y tipo de médula. En la comparación intraespecífica se caracterizaron 530 pelos de guardia dorsales de 53 organismos. A pesar de las variaciones en la longitud y diámetro de la médula, puede realizarse una identificación exitosa de los organismos en un plano específico utilizando la guía de identificación de mamíferos terrestres a partir del pelo de guardia, excepto para Canis latrans y Liomys irroratus. En la comparación individual se describieron 560 pelos de guardia de 14 especies. Se encontraron diferencias en la longitud total del pelo, en el diámetro de la médula y en la coloración; el único carácter que permaneció constante fue la médula

Normalized medical information visualization

A new mark-up programming language is introduced in order to facilitate and improve the visualization of ISO/EN 13606 dual model-based normalized medical information. This is the first time that visualization of normalized medical information is addressed and the programming language is intended to be used by medical non-IT professionals.S

Systematic assessment of fluid responsiveness during early septic shock resuscitation: secondary analysis of the ANDROMEDA-SHOCK trial

BACKGROUND: Fluid boluses are administered to septic shock patients with the purpose of increasing cardiac output as a means to restore tissue perfusion. Unfortunately, fluid therapy has a narrow therapeutic index, and therefore, several approaches to increase safety have been proposed. Fluid responsiveness (FR) assessment might predict which patients will effectively increase cardiac output after a fluid bolus (FR+), thus preventing potentially harmful fluid administration in non-fluid responsive (FR-) patients. However, there are scarce data on the impact of assessing FR on major outcomes. The recent ANDROMEDA-SHOCK trial included systematic per-protocol assessment of FR. We performed a post hoc analysis of the study dataset with the aim of exploring the relationship between FR status at baseline, attainment of specific targets, and clinically relevant outcomes. METHODS: ANDROMEDA-SHOCK compared the effect of peripheral perfusion- vs. lactate-targeted resuscitation on 28-day mortality. FR was assessed before each fluid bolus and periodically thereafter. FR+ and FR- subgroups, independent of the original randomization, were compared for fluid administration, achievement of resuscitation targets, vasoactive agents use, and major outcomes such as organ dysfunction and support, length of stay, and 28-day mortality. RESULTS: FR could be determined in 348 patients at baseline. Two hundred and forty-two patients (70%) were categorized as fluid responders

Early goal-directed therapy using a physiological holistic view: the ANDROMEDA-SHOCK—a randomized controlled trial

Septic shock is a highly lethal condition. Early recognition of tissue hypoperfusion and its reversion are key factors for limiting progression to multiple organ dysfunction and death. Lactate‐targeted resuscitation is the gold‐standard under current guidelines, although it has several pitfalls including that non‐hypoxic sources of lactate might predominate in an unknown proportion of patients. Peripheral perfusion‐targeted resuscitation might provide a real‐time response to increases in ow that could lead to a more timely decision to stop resuscitation, thus avoiding uid overload and the risks of over‐resuscitation. This article reports the rationale, study design and analysis plan of the ANDROMEDA‐SHOCK Study. Methods: ANDROMEDA‐SHOCK is a randomized controlled trial which aims to determine if a peripheral perfusion‐ targeted resuscitation is associated with lower 28‐day mortality compared to a lactate‐targeted resuscitation in patients with septic shock with less than 4 h of diagnosis. Both groups will be treated with the same sequential approach during the 8‐hour study period pursuing normalization of capillary re ll time versus normalization or a decrease of more than 20% of lactate every 2 h. The common protocol starts with uid responsiveness assessment and uid loading in responders, followed by a vasopressor and an inodilator test if necessary. The primary outcome is 28‐day mortality, and the secondary outcomes are: free days of mechanical ventilation, renal replacement therapy and vasopressor support during the rst 28 days after randomization; multiple organ dysfunction during the rst 72 h after randomization; intensive care unit and hospital lengths of stay; and all‐cause mortality at 90‐day. A sample size of 422 patients was calculated to detect a 15% absolute reduction in mortality in the peripheral perfusion group with 90% power and two‐tailed type I error of 5%. All analysis will follow the intention‐to‐treat principle. Conclusions: If peripheral perfusion‐targeted resuscitation improves 28‐day mortality, this could lead to simpli ed algorithms, assessing almost in real‐time the reperfusion process, and pursuing more physiologically sound objec‐ tives. At the end, it might prevent the risk of over‐resuscitation and lead to a better utilization of intensive care unit resources

Clinical Study Persistent Sepsis-Induced Hypotension without Hyperlactatemia: A Distinct Clinical and Physiological Profile within the Spectrum of Septic Shock

Introduction. A subgroup of septic shock patients will never develop hyperlactatemia despite being subjected to a massive circulatory stress. Maintenance of normal lactate levels during septic shock is of great clinical and physiological interest. Our aim was to describe the clinical, hemodynamic, perfusion, and microcirculatory profiles associated to the absence of hyperlactatemia during septic shock resuscitation. Methods. We conducted an observational study in septic shock patients undergoing resuscitation. Serial clinical, hemodynamic, and perfusion parameters were registered. A single sublingual microcirculatory assessment was performed in a subgroup. Patients evolving with versus without hyperlactatemia were compared. Results. 124 septic shock patients were included. Patients without hyperlactatemia exhibited lower severity scores and mortality. They also presented higher platelet counts and required less intensive treatment. Microcirculation was assessed in 45 patients. Patients without hyperlactatemia presented higher PPV and MFI values. Lactate was correlated to several microcirculatory parameters. No difference in systemic flow parameters was observed. Conclusion. Persistent sepsis-induced hypotension without hyperlactatemia is associated with less organ dysfunctions and a very low mortality risk. Patients without hyperlactatemia exhibit less coagulation and microcirculatory derangements despite comparable macrohemodynamics. Our study supports the notion that persistent sepsisinduced hypotension without hyperlactatemia exhibits a distinctive clinical and physiological profile

La agroecología lo hizo posible

Esta experiencia nace de un acuerdo rubricado entre la Municipalidad de Trelew y la Estación Experimental Chubut del Instituto Nacional de Tecnología Agropecuaria (EEA INTA Chubut) a finales del año 2019, en pos de garantizar la provisión de alimentos a los sectores más vulnerables de la comunidad, conformando los Bancos de Alimentos (BA) junto a diversas organizaciones sociales. Este relato pone de manifiesto la predisposición y el compromiso entre los actores involucrados en el ejido del Municipio de Trelew en la provincia del Chubut.EEA ChubutFil: Salgado, Edgardo. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Chubut. Agencia de Extensión Valle Inferior del Río Chubut; ArgentinaFil: Raguileo, Daniela. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Chubut. Agencia de Extensión Valle Inferior del Río Chubut; ArgentinaFil: Jones, María Itatí. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Chubut. Agencia de Extensión Valle Inferior del Río Chubut; ArgentinaFil: Hernández, Marcos. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Chubut. Agencia de Extensión Valle Inferior del Río Chubut; ArgentinaFil: Hurtado, Martín Ariel. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Chubut. Agencia de Extensión Valle Inferior del Río Chubut; ArgentinaFil: López, Juan Pablo. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Chubut. Agencia de Extensión Valle Inferior del Río Chubut; ArgentinaFil: Castro, Ramiro Hernán. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Chubut; ArgentinaFil: Zarias, Ricardo Oscar. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Chubut; Argentin