Emilio Sacristan

Gastric impedance spectroscopy in elective cardiovascular surgery patients

Impedance spectroscopy has been proposed as a method of monitoring mucosal injury due to hypoperfusion and ischemia in critically ill patients. The present study characterizes human gastric impedance spectral changes under gastric hypoperfusion in patients undergoing cardiovascular surgery, and evaluates spectral differences between patients with no evidence of gastric ischemia and complications, and patients who developed ischemia and complications. Cole and Kun parameters were calculated over time to characterize changes as tissue injury progresses. Gastric ischemia was determined by air tonometry. Impedance spectroscopy spectra were obtained from 63 cardiovascular surgery patients. The recorded spectra were classified into three groups: group 1 for patients without ischemia or complications, group 2 for patients with a short period of ischemia (less than 2 h) and group 3 for patients with more than 4 h of gastric ischemia and complications. Two distinct dispersion regions of the spectra centered at about 316 Hz and 215 kHz become clearer as tissue damage develops. The average spectrum in group 3 shows a significant difference in tissue impedance at all frequencies relative to group 1. The parameters obtained for human gastric tissue show significant changes that occur at different times and at different frequencies as ischemia progresses, and could be correlated with patient outcome. This confirms our hypothesis that hypoperfusion and ischemia cause evident changes in the impedance spectra of the gastric wall. Therefore, this technology may be a useful prognostic and diagnostic monitoring tool.

Effects of Noninvasive Facial Nerve Stimulation in the Dog Middle Cerebral Artery Occlusion Model of Ischemic Stroke

Background and Purpose— Facial nerve stimulation has been proposed as a new treatment of ischemic stroke because autonomic components of the nerve dilate cerebral arteries and increase cerebral blood flow when activated. A noninvasive facial nerve stimulator device based on pulsed magnetic stimulation was tested in a dog middle cerebral artery occlusion model. Methods— We used an ischemic stroke dog model involving injection of autologous blood clot into the internal carotid artery that reliably embolizes to the middle cerebral artery. Thirty minutes after middle cerebral artery occlusion, the geniculate ganglion region of the facial nerve was stimulated for 5 minutes. Brain perfusion was measured using gadolinium-enhanced contrast MRI, and ATP and total phosphate levels were measured using 31P spectroscopy. Separately, a dog model of brain hemorrhage involving puncture of the intracranial internal carotid artery served as an initial examination of facial nerve stimulation safety. Results— Facial nerve stimulation caused a significant improvement in perfusion in the hemisphere affected by ischemic stroke and a reduction in ischemic core volume in comparison to sham stimulation control. The ATP/total phosphate ratio showed a large decrease poststroke in the control group versus a normal level in the stimulation group. The same stimulation administered to dogs with brain hemorrhage did not cause hematoma enlargement. Conclusions— These results support the development and evaluation of a noninvasive facial nerve stimulator device as a treatment of ischemic stroke.

Development of a universal second generation pneumatic ventricular assist device and drive unit

This paper describes a pneumatic ventricular assist device designed to be used for any circulatory support application including RVAD, LVAD, or BIVAD, trans-operative, short-term or long-term, tethered implantable or extracorporeal. It consists of a contoured pumping shell and a supple and elastic silicon blood-sac/valve assembly specially designed to allow continuous and fluid movement of blood and to limit blood-contacting surfaces. The components can be inexpensively and reliably manufactured by injection molding. Its design facilitates priming, de-bubbling, and connection to the body. The driver, powered by pressurized air or oxygen, commonly available in hospital rooms, intensive care units and operating rooms, is also described. The driver can provide both blood-ejecting pressure (systole) and blood-filling vacuum (diastole) to the VAD. Pumping is controlled by a computer by means of pressure and volume sensors, and electromechanical valves. Ventricular pumping is performed by a single spring-loaded piston. The computer can actively regulate maximum systolic ventricular pressure, maximum diastolic vacuum, cycling rate and/or ejection volume (depending on the operating mode). The absence of a motor or electrical pump make the device small, easy to handle, and less expensive. A first prototype of the proposed system was tested in vitro and results are presented.

Effect of pulsed magnetic stimulation of the facial nerve on cerebral blood flow

In these experiments we define an effective means of pulsed magnetic stimulation of the facial nerve for the purpose of increasing cerebral blood flow (CBF). In normal anesthetized dog and sheep, a focal magnetic field was directed toward the facial nerve within the temporal bone by placing a 6.5 cm figure-8 stimulation coil over the ear. In an initial set of experiments, CBF was measured by laser Doppler flowmetry and the cerebral vasculature was visualized by angiography. The effect of facial nerve stimulation was found to be dependent on stimulation power, frequency, and the precise positioning of the stimulation coil. Furthermore, an increase in CBF was not observed after direct electrical stimulation in the middle ear space, indicating that non-specific stimulation of the tympanic plexus, an intervening neural structure with vasoactive effects, was not responsible for the increase in CBF after pulsed magnetic stimulation. Subsequent experiments using perfusion MRI demonstrated reproducible increases in CBF throughout the forebrain that manifested bilaterally, albeit with an ipsilateral predominance. These experiments support the development of a non-invasive pulsed magnetic facial nerve stimulator that will increase CBF as a treatment of ischemic stroke.

Gastrointestinal ischemia monitoring through impedance spectroscopy as a tool for the management of the critically ill.

Impedance spectroscopy (IS) has been proposed as a tool for monitoring mucosal tissue ischemia and damage in the gut of critically ill patients resulting from shock and hypoperfusion. A specific device and system have been developed and tested for this specific application over the past 12 years by our research group. This paper reviews previously published studies as well as unpublished experimental results, and puts the whole in context and perspective to help understand this technology. Results presented include summaries of gastric reactance measurement understanding, in vivo measurements in animal models, clinical significance of the measurement, and future perspectives of clinical use of this technology. All of the experimental work done to date has been designed to determine the evolving device prototypes’ performance and limitations from an instrumentation point of view. Although there are still questions to be answered with regard to the IS measurement, we conclude that we have reached enough confidence in the measurement and the device’s performance and safety to begin clinically oriented research to learn how this technology may be useful in the diagnosis and management of different populations of the critically ill.

Incidence of Gastric Mucosal Injury as Measured by Reactance in Critically Ill Patients

Gastric reactance has been proposed as a measure of mucosal ischemic injury in the critically ill. The purpose of this study was to evaluate the incidence of gastric mucosal injury as measured by gastric reactance in different subgroups of critical patients. We studied 100 adult patients admitted to 7 different hospital intensive care units, requiring a nasogastric tube. Gastric impedance measurements were continuously obtained from each patient for 24 hours. Patients were managed based on conventional protocols by hospital staff, blinded to the changes in gastric impedance parameters. The low-frequency central reactance (X L) reflects tissue edema caused by prolonged ischemia. The previously reported threshold of X L ≥ 13 − jΩ was used to classify injured mucosa; 80% of all patients had mean X L above this threshold. No significant differences were found in the incidence of mucosal ischemia between medical versus surgical, hemodynamic versus respiratory or neurological patients. Significant lower urine output was found in patients with X L above threshold (P < .01); also, there was a significant effect of fluid balance in those patients (P < .05). More complicated patients had higher average reactance. This study shows that gastric ischemia as estimated by gastric reactance has a very high incidence in the critically ill, independently of the reason for admission. High reactance is related with higher morbidity in agreement with other reports using different methods of assessing splanchnic hypoperfusion in this patient population.

The predictive value of gastric reactance for postoperative morbidity and mortality in cardiac surgery patients

No useful method to directly monitor the level of end organ tissue injury is currently available clinically. Gastric reactance has been proposed to measure changes in a tissue structure caused by ischemia. The purpose of this study was to assess whether gastric reactance is a reliable, clinically relevant predictor of complications and a potentially useful tool to assess hypoperfusion in cardiovascular surgery patients. The value of gastric reactance measurements, standard hemodynamic and regional perfusion variables, and scores to predict postoperative complications were compared in 55 higher risk cardiovascular surgery patients with cardiopulmonary bypass. Low frequency gastric reactance, X(L), had a significant predictive value of postoperative persistent shock requiring more than 48 h of vasopressors and associated complications, before, during and after surgery (p < 0.05). Results suggest that reactance is an earlier predictor of patients at risk than all other variables tested. Patients with a high reactance (X(L) > 26) before surgery had a significantly higher incidence of complications, higher mortality and more days in the ICU than patients with a low reactance (X(L) < 13). X(L) was found to be a reliable and clinically relevant measurement. These results justify further clinical research to explore how this information may be used to improve patient management.

Steady State Condition in the Measurement of VO 2 and VCO 2 by Indirect Calorimetry

Resting metabolic rate (RMR) is computed using VO2 and VCO2 short time 15-minute window measurement with indirect calorimetry (IC) instruments designed with mixing chamber. Steady state condition using a 10% variation coefficient criteria is the main objective to achieve metabolic long time prediction reliability. This study address how susceptible is the steady state VO2, VCO 2 measurement condition to the clino-orthostatic physiological maneuver. 30 young healthy subjects were analyzed. Only 18 passed the 10% variation coefficient inclusive criteria. They were exposed to 10 minutes clino-stage and 10 minutes orthostage. The hypothesis tests show not statistical significance (ples0.1) in the average and variance analysis. It is concluded that the steady state is not influenced by the patient position IC test, probably because IC mixing chamber instruments are insensitive to detect a mayor physiological dynamics changes that can modify the steady state definition

Algorithm for Characteristic Parameter Estimation of Gastric Impedance Spectra in Humans

Impedance spectroscopy has been proposed as a method of monitoring mucosal injury due to hypoperfusion and ischemia in the critically ill. The present paper presents an algorithm developed to calculate the characteristic electrical values that best describe human gastric impedance measurements and simplify the information obtained with this method. An impedance spectroscopy probe and nasogastric tube (ISP/NGT) was placed into the stomach of healthy volunteers, cardiovascular surgery and critically ill patients, and a database with 16199 spectra was obtained. The gastric spectrum forms two semi circles in the complex domain, divided into low frequency (F < 10 kHz) and high frequency (F > 10 kHz). A fitting algorithm was developed based on the Cole model, and central characteristic parameters were calculated. The parameters were validated using the normalized mean squared error and 0.66% of the spectra were discarded. From the experimental data obtained in humans, the greatest changes observed as the gastric mucosa becomes ischemic occur at low frequencies, which are specific and sensitive to tissue damage, and vary with the degree of hypoperfusion.

Hydrodynamic Effects of the Partial Opening of a Trileaflet Valve

Manufacturing process of medical grade silicon rubber trileaflet valves for VADs could propitiate important leaflet thickness variations which could result in partial opening of the valve and affect its hydrodynamic performance. The leaflets of a total of 10 valves were measured to assess its thickness variability. Two experiments were performed to asses the impact of the leaflets thickness variation under hypothetical situations. The first experiment was divided into three hypothetical cases. In each case either none, one or two leaflets of different valves were mechanically blocked, resembling possible critical working circumstances. The second experiment was intended to know how the variation on the leaflets thickness affects the hydrodynamic performance of the valves. The results demonstrated a significant variation on the leaflets thickness was found. As for the first experiment, a small variation on the hydrodynamic performance was found above 4 L/min flow rates and a slightly higher energy loss was found in one of the cases. As for the second experiment, the results showed that the variation of the leaflet thickness does not affect the general hydrodynamic performance of the valves. No relationship between the thickness variability and the hydrostatic performance of the valves was found