Ayyaz Hussain

The aim of the study. To compare the effectiveness of thrombolytic therapy in patients with ischemic stroke with forteplase and alteplase in clinical practice. Materials and methods. A single-center retrospective cohort study was conducted using data from the reperfusion interventions registry at the Arkhangelsk regional vascular center. The primary endpoint was patients’ functional recovery at discharge from the hospital. The incidence of type 2 intracranial hemorrhages according to the Heidelberg bleeding classification, mortality, and the duration of hospital stay were analyzed as the secondary endpoints. Descriptive statistics were used. Simple and multivariate multiple linear and logistic regression models were constructed to assess the relationship of forteplase use with functional recovery and length of hospital stay. Results. The study involved 213 patients with the mean age of 68 (60; 76) years, including 111 (52.1%) men. Forteplase was used in 91 (42.7%) patients. Modified Rankin scale scores of 0–2 were documented in 52 (57.14%) and 51 (41.8%) patients in the forteplase and alteplase groups, respectively, p = 0.019. After correction for potential confounders, no relationship was found between achieving good functional recovery and the use of forteplase: adjusted odds ratio was 1.04 [95% CI 0.54–2.01], p = 0.91. The incidence of type 2 parenchymal hemorrhages was 3.3% in the forteplase group vs 0.8% in the alteplase group, p = 0.315, and the mortality rates were 6.59% vs 11.48%, respectively, p = 0.247. The use of forteplase did not affect the length of hospital stay in a multivariate analysis: B = –0.54 [95% CI –3.74–2.66], p = 0.741. Conclusion. Thrombolysis with forteplase is an effective and safe method of treatment in the acute period of ischemic stroke. Rates of achieving good functional recovery, incidence of intracranial hemorrhage, and length of hospital stay were comparable in groups treated with forteplase and alteplase after correction for significant confounders.

Stroke is a leading cause of disability and mortality worldwide. The management of stroke involves several important stages, including prehospital, hospital, and outpatient care. The hospital phase of stroke management begins with critical care in many countries. Recent advances in clinical research and critical care have led to significant improvements in stroke management. In this chapter, we will discuss the current definition, classification, pathogenesis, and management of different types of stroke in the critical care setting. We will discuss the algorithm for the management of different types of stroke. The current practice of intravenous thrombolysis, mechanical thrombectomy in ischemic stroke and subarachnoid hemorrhage will be discussed.

Rationale: Ejection fraction (EF) has been recognized as a key echocardiographic parameter describing the systolic function of the heart. Nevertheless, its accuracy for the assessment of the hemodynamic status in the perioperative period of cardiac surgery remains a debate. Aim: To compare the EF values assessed by different techniques and to map those against the left ventricular systolic function parameters in the perioperative period of the off-pump coronary artery bypass grafting (OPCABG). Methods: We performed a post hoc analysis of two consequential randomized studies. EF was assessed with echocardiography in 115 patients in the perioperative period of OPCABG and its changes over time at the following timepoints: before admission to the hospital (EFscreening), on the day before surgery (EFsimpson) (transthoracic approach), before sternotomy, at the end of the surgery (transesophageal echocardiography, TEE), as well as at the end of the first postoperative day (POD1) and before discharge from the hospital (transthoracic approach). Preoperatively and at the end of POD1, the EF values were compared with those of the global longitudinal strain (GLS) and with the EF measured automatically (EFauto, QLAB 10.0), as well as with hemodynamic parameters measured by thermodilution (TD), such as cardiac index (CI) and stroke volume index (SVI). Results: There were no postoperative changes in the EFscreening and EFsimpson values. EFauto decreased from 48.4 ± 6.4 to 41.6 ± 7.3% (p 0.001), while EFtee increased from 49.7 [46.0; 57.0] to 53.0 [46.1; 58.1]% (p = 0.047) and was associated with a decrease in GLS from -14.6 ± 2.5 to -11.7 ± 2.6% (p 0.001). The bias in the measurement of EFsimpson and EFauto assessed a day before surgery and on POD1 according to the Bland-Altman test was 29.3% and 34.0%. There was a correlation between GLS and EFauto preoperatively (rho = -0.791, p 0.001) and on the POD1 (rho = -0.723, p 0.001), while EFscreening and EFsimpson did not show such a correlation. There was no correlation of EF or GLS with CI, as well. The bias in the measurement of the SVItd and SVIecho values was 11% (rho = 0.301, p = 0.001). Conclusion: The echocardiographic assessment of the EF in the perioperative period of OPCABG does not characterize the systolic function of the heart reliably and depends on the method of its measurement. These limitations of echocardiographic parameters require their critical evaluation, including a comparison with thermodilution variables.

Introduction. New anesthesia techniques require evidence of the safety of their implementation, however there is still the opinion about negative impact of regional anesthesia on heart performance and central hemodynamics. The objective of our study was to evaluate effect of regional anesthesia on systolic and diastolic myocardial function in off-pump coronary artery bypass grafting (OPCAB).Materials and methods. A prospective randomized controlled trial included 45 patients who underwent elective OPCAB, equally divided into 3 groups – general anesthesia in combination with epidural anesthesia (GA+EA), general anesthesia with erector spinae plane block (GA+ESPB) and general anesthesia without regional anesthesia (GA). The systolic function of the left (LV) and right ventricle (RV), as well as the diastolic function of the LV were evaluated during five stages perioperatively, using echocardiography and thermodilution via Swan-Ganz catheter.Results. There were no intergroup differences in parameters of LV or RV systolic function and LV diastolic function during study stages. Perioperatively, there was a decrease in LV end-diastolic volume in the groups of OA+ESPB (p = 0.001) and OA (p = 0.003).At the end of the first postoperative day (POD), pulmonary artery wedge pressure decreased in the groups of OA+EA (p = 0.003) and OA+ESPB (p = 0.008); meanwhile, ejection time (p = 0.003) and velocity-time integral (p = 0.005) from RV reduced only in the OA+ESPB group. In the OA+EA group at the end of POD1, the reservoir strain of left atrium (p = 0.022) and isovolumic relaxation time (p = 0.006) decreased.Conclusion. In OPCAB, epidural anesthesia and ESPB do not result in deterioration of LV systolic and diastolic function and do not have a negative impact on the RV.

ВВЕДЕНИЕ Отклонения температуры тела от нормального значения, включая гипотермию, часто встречаются у больных с сепсисом. Наличие гипотермии на фоне сепсиса может ассоциироваться с иммуносупрессией, гиподинамическим шоком и рядом осложнений. ЦЕЛЬ ИССЛЕДОВАНИЯ Оценить связь нарушений температуры тела с динамикой органной дисфунции и исходом сепсиса. МАТЕРИАЛ И МЕТОДЫ Проведен ретроспективный анализ реанимационных карт 353 пациентов с сепсисом при поступлении в отделение реанимации и интенсивной терапии (ОРИТ). Учитывали биометрические показатели, сопутствующие заболевания, показатели гемодинамики и лабораторные данные, а также продолжительность пребывания в ОРИТ и летальность. У 21 пациента выполнены забор образцов крови и оценка компонентов эндотелиального гликокаликса (ЭГ), включая синдекан-1 (S1). РЕЗУЛЬТАТЫ По сравнению с больными с нормальной или повышенной температурой тела у пациентов с гипотермией при поступлении в ОРИТ отмечали более низкий уровень среднего артериального давления на момент поступления и через 24 ч, что сопровождалось повышением потребности в вазопрессорной поддержке, а также более выраженным ацидозом. Дополнительно к этим изменениям у пациентов с гипотермией терапевтического профиля регистрировали повышение показателей лактата и МНО. При гипотермии на фоне сепсиса у пациентов терапевтического профиля выявлена более высокая летальность по сравнению с пациентами других групп: 53,3% при гипотермии по сравнению с 31,5% при нормальной/фебрильной температуре тела (p=0,023). Сравнительный анализ значений показателей компонентов ЭГ выявил более высокие концентрации S1 в течение первых суток пребывания в ОРИТ при гипотермии. ЗАКЛЮЧЕНИЕ Гипотермия на фоне сепсиса при поступлении в отделение реанимации и интенсивной терапии сопровождается более выраженными проявлениями шока и ацидоза. Более того, у больных терапевтического профиля с гипотермией по сравнению с пациентами с нормальной или фебрильной температурой тела отмечается развитие гипоперфузии и коагулопатии, а также повышение летальности. Эти нарушения могут быть обусловлены развитием сепсис-индуцированной эндотелиопатии.

To evaluate the accuracy of estimated continuous cardiac output (esCCO) based on pulse wave transit time in comparison with cardiac output (CO) assessed by transpulmonary thermodilution (TPTD) in off-pump coronary artery bypass grafting (OPCAB). We calibrated the esCCO system with non-invasive (Part 1) and invasive (Part 2) blood pressure and compared with TPTD measurements. We performed parallel measurements of CO with both techniques and assessed the accuracy and precision of individual CO values and agreement of trends of changes perioperatively (Part 1) and postoperatively (Part 2). A Bland–Altman analysis revealed a bias between non-invasive esCCO and TPTD of 0.9 L/min and limits of agreement of ±2.8 L/min. Intraoperative bias was 1.2 L/min with limits of agreement of ±2.9 L/min and percentage error (PE) of 64 %. Postoperatively, bias was 0.4 L/min, limits of agreement of ±2.3 L/min and PE of 41 %. A Bland–Altman analysis of invasive esCCO and TPTD after OPCAB found bias of 0.3 L/min with limits of agreement of ±2.1 L/min and PE of 40 %. A 4-quadrant plot analysis of non-invasive esCCO versus TPTD revealed overall, intraoperative and postoperative concordance rate of 76, 65, and 89 %, respectively. The analysis of trending ability of invasive esCCO after OPCAB revealed concordance rate of 73 %. During OPCAB, esCCO demonstrated poor accuracy, precision and trending ability compared to TPTD. Postoperatively, non-invasive esCCO showed better agreement with TPTD. However, invasive calibration of esCCO did not improve the accuracy and precision and the trending ability of method.