Glen Atlas

Development and Application of a Logistic-Based Systolic Model for Hemodynamic Measurements Using the Esophageal Doppler Monitor

The esophageal Doppler monitor (EDM) is a clinically useful device for minimally invasive assessment of cardiac output, preload, afterload, and contractility. An empirical model, based upon the logistic function, has been developed. Use of this model illustrates how the EDM could estimate the net effect of aortic and non-aortic contributions to inertia, resistance, and elastance within real time. This is based on an assumed mechanical impedance conceptually resembling that of a series arrangement of a spring, mass, and dashpot. In addition, when used with an invasive radial arterial catheter, the EDM may also estimate aortic pulse wave velocity, as well as aortic characteristic impedance, and characteristic volume. Approximations of left ventricular stroke work and stroke power can also be made. Furthermore, the effects of inertia, resistance, and elastance, on mean blood pressure during systole, can be quantified. These additional parameters could offer insight for clinicians, as well as researchers, and may be beneficial in further examining and utilizing clinical hemodynamics with the EDM. These additional measurements also underscore the need to integrate the EDM with existing and future monitoring equipment.

A Mathematical Model of Differential Tracheal Tube Cuff Pressure: Effects of Diffusion and Temperature

The tracheal tube cuff performs an important function during anesthesia and critical care situations by allowing positive pressure ventilation and isolating the lungs from aspiration. Other maneuvers, such as pressure support ventilation and positive end-expiratory pressure, are also cuff-dependent. However, excessive cuff pressure, as well as long-term intubation without excessive cuff pressure, have been associated with significant morbidity and mortality. A straightforward mathematical model of differential tracheal tube cuff pressure has been developed. This model incorporates compliance, temperature variation, and net molar diffusion in determining differential tracheal tube cuff pressure. In addition, temperature and diffusion are modeled as separate processes which effect differential cuff pressure independently. Support for the validity of this model is based upon an analysis of existing data from prior studies.

Brachial Artery Differential Characteristic Impedance: Contributions from Changes in Young’s Modulus and Diameter

This examination of brachial artery (BA) differential characteristic impedance, ΔZc, illustrates that changes in Zc can occur from changes in either BA wall stiffness (Young’s modulus, E) and/or its diameter, D. Furthermore, we assessed how changes in both E and D combine in either an isolated, synergistic, or antagonistic manner to yield the net change in BA Zc. The basis of this analysis is a partial differential equation which approximates ΔZc as a total differential. The effects on BA ΔZc of acetylcholine, atenolol, fenoldapine, nitroglycerin, hydrochlorothiazide and other medications are examined using data from previously published studies. Clinical situations which alter BA Zc, such as congestive heart failure, hypertension, and hyperemia, are also analyzed. Results illustrate the usefulness of the present approach in differentiating how medications, hyperemia, and pathological conditions affect BA ΔZc by causing independent changes to E and/or D.

Left Ventricle–Arterial System Interaction in Heart Failure

Ejection fraction (EF) has been viewed as an important index in assessing the contractile state of the left ventricle (LV). However, it is frequently inadequate for the diagnosis and management of heart failure (HF), as a significant subset of HF patients have been found to have reduced EF (HFrEF) whereas others have preserved EF (HFpEF). It should be noted that the function of the LV is dependent on both preload and afterload, as well as its intrinsic contractile state. Furthermore, stroke volume (SV) is dependent on the properties of the arterial system (AS). Thus, the LV-arterial system interaction plays an important role in those patients with HF. This aspect is investigated through the analysis of the specific parameters involved in the coupling of the LV and AS. This includes contractility and the systolic/diastolic indices of the LV. Furthermore, AS afterload parameters such as vascular stiffness and arterial compliance, and their derived coupling coefficient, are also investigated. We conclude that those parameters, which relate to LV structural changes, are most appropriate in quantifying the LV–AS interaction.

The use of the oesophageal Doppler in perioperative medicine: new opportunities in research and clinical practice

The oesophageal Doppler (OD) is a minimally invasive haemodynamic monitor used in the surgical theatre and the ICU. Using the OD, goal-directed therapy (GDT) has been shown to reduce perioperative complications in high-risk surgical patients. However, most GDT protocols currently in use are limited to stroke volume optimisation. In the present manuscript, we examine the conceptual models behind new OD-based measurements. These would provide the clinician with a comprehensive view of haemodynamic pathophysiology; including pre-load, contractility, and afterload. Specifically, volume status could be estimated using mean systemic filling pressure (MSFP), the pressure to which all intravascular pressures equilibrate during asystole. Using the OD, MSFP could be readily estimated by simultaneous measurements of aortic blood flow and arterial pressure with sequential manoeuvres of increasing airway pressure. This would result in subsequent reductions in cardiac output and arterial pressure and would allow for a linear extrapolation of a static MSFP value to a “zero flow” state. In addition, we also demonstrate that EF is proportional to mean blood flow velocity measured in the descending thoracic aorta with the OD. Furthermore, OD-derived indexes of blood flow velocity and acceleration, as well as force and kinetic energy, can be derived and used for continuous assessment of cardiac contractility at the bedside. Using OD-derived parameters, the different components of afterload: inertia, resistance and elastance, could also be individually determined. The integration of these additional haemodynamic parameters could assist the clinician in optimising and individualising haemodynamic performance in unstable patients.

The neural integrity monitor electromyogram tracheal tube: Anesthetic considerations

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Obtaining external jugular venous access in the prone-positioned patient

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Development and Retrospective Clinical Assessment of a Patient-Specific Closed-Form Integro-Differential Equation Model of Plasma Dilution

A closed-form integro-differential equation (IDE) model of plasma dilution (PD) has been derived which represents both the intravenous (IV) infusion of crystalloid and the postinfusion period. Specifically, PD is mathematically represented using a combination of constant ratio, differential, and integral components. Furthermore, this model has successfully been applied to preexisting data, from a prior human study, in which crystalloid was infused for a period of 30 minutes at the beginning of thyroid surgery. Using Euler’s formula and a Laplace transform solution to the IDE, patients could be divided into two distinct groups based on their response to PD during the infusion period. Explicitly, Group 1 patients had an infusion-based PD response which was modeled using an exponentially decaying hyperbolic sine function, whereas Group 2 patients had an infusion-based PD response which was modeled using an exponentially decaying trigonometric sine function. Both Group 1 and Group 2 patients had postinfusion PD responses which were modeled using the same combination of hyperbolic sine and hyperbolic cosine functions. Statistically significant differences, between Groups 1 and 2, were noted with respect to the area under their PD curves during both the infusion and postinfusion periods. Specifically, Group 2 patients exhibited a response to PD which was most likely consistent with a preoperative hypovolemia. Overall, this IDE model of PD appears to be highly “adaptable” and successfully fits clinically-obtained human data on a patient-specific basis, during both the infusion and postinfusion periods. In addition, patient-specific IDE modeling of PD may be a useful adjunct in perioperative fluid management and in assessing clinical volume kinetics, of crystalloid solutions, in real time.