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Adequate function of the heart and circulatory system is necessary for oxygen supply and tissue perfusion. In patients undergoing cardiac surgery, these may be compromised even prior to the surgical procedure. Surgery, anesthesia, and the use of cardiopulmonary bypass (CPB) may further worsen cardiovascular performance and compromise oxygen supply in the end-organs such as the brain and kidneys. This can lead to end-organ dysfunction and death. Healthcare costs increase due to the prolonged intensive care and hospital stays. In cardiac surgical patients, accurate hemodynamic monitoring and treatment is crucial, as these have been demonstrated to improve patient outcome. A pulmonary artery catheter (PAC) is utilized to monitor several hemodynamic variables valuable in evaluating cardiovascular function. Inserting a PAC is an invasive procedure and is associated with some potential risks. Therefore, less invasive devices and methods have been developed to replace the PAC. In study I, we compared the noninvasive Starling SV and mini-invasive LiDCOrapid, which are continuous cardiac output monitors, to PAC in cardiac surgical patients with CPB. The trending ability of both devices was poor. LiDCOrapid showed sufficient accuracy, while the accuracy of the Starling SV was poor. Neither of the devices demonstrated sufficient measurement precision. In study II, we compared central venous oxygen saturation (ScvO2) values to mixed venous oxygen saturation (SvO2) values drawn from a PAC. ScvO2 values showed acceptable accuracy. The precision of ScvO2 was inadequate, as was its trending ability. Study III was performed to evaluate the association between transcranial near-infrared spectroscopy (NIRS) and cardiac index (CI) measured with PAC during cardiac surgery. The analysis of separate NIRS and CI pairs revealed a poor association. When the changes in NIRS from baseline or from the previous measurement were compared to those of CI, a significant association was disc, Tiivistelmä Sydänleikkauspotilaiden sydän- ja verenkiertoelimistön toimintakyky voi olla heikentynyt jo ennen leikkausta. Leikkaus, anestesia ja sydänkeuhkokoneen käyttö huonontavat tilannetta entisestään niin, että kudosten riittävä hapensaanti saattaa vaarantua. Tämä voi johtaa elinvaurioiden syntymiseen, kuolleisuuden nousuun, hoitoaikojen pitenemiseen ja terveydenhuollon kustannusten kasvuun. Tarkka verenkierron riittävyyden arviointi on ensiarvoisen tärkeää sydänleikkauspotilaiden hoidossa ja sillä voidaan vaikuttaa potilaan ennusteeseen. Verenkierron riittävyyttä voidaan arvioida keuhkovaltimokatetrin avulla, mutta sen käyttöön liittyy mahdollisia haittoja. Tämän vuoksi on kehitetty vähemmän kajoavia laitteita ja menetelmiä korvaamaan keuhkovaltimokatetrista saatavaa tietoa. Ensiksi vertasimme vähemmän kajoavan LiDCOrapid- ja täysin kajoamattoman Starling SV-monitorin antamia sydämen minuuttitilavuusarvoja (CI) keuhkovaltimokatetrista saataviin arvoihin sydänleikkauksissa, joissa käytettiin sydänkeuhkokonetta. Molempien vertailulaitteiden kyky seurata arvojen muutoksia oli huono. Yksittäisissä arvoissa LiDCOrapid-laitteen tarkkuus oli riittävä, kun taas Starling SV-monitorin tarkkuus oli huono. Kummankaan laitteen täsmällisyys ei ollut riittävä. Toiseksi tutkimme keskuslaskimoveren happisaturaation (ScvO2) luotettavuutta verrattuna keuhkovaltimokatetrista otettuun sekoittuneen laskimoveren happisaturaatioon (SvO2). ScvO2-arvot olivat riittävän tarkkoja, mutta niiden täsmällisyys ja kyky seurata SvO2-arvojen muutoksia olivat riittämättömät. Kolmanneksi vertasimme aivojen lähi-infrapunaspektroskopia-arvoja (NIRS) keuhkovaltimokatetrin avulla mitattuihin CI-arvoihin. Yksittäisten NIRS- ja CI-arvojen välinen yhteys oli heikko. Kun tarkasteltiin NIRS-ja CI-arvojen muutoksia joko lähtötilanteeseen tai edelliseen lukemaan verrattuna, muutosten välillä todettiin tilastollisesti merkitsevä yhteys etenkin ohitusleikkauksissa, jotka toteutettiin ilman sydänkeuhkokonetta.

Monitoring cardiac output is essential for critically ill patients and patients undergoing high-risk surgeries. Although bolus thermodilution technique with pulmonary artery catheter is considered the gold standard for measuring cardiac output, it is invasive and can cause harm to patients. New, less invasive monitors have therefore been developed. However, results regarding their reliability are conflicting. The aim of this prospective method comparison study was to evaluate the accuracy, precision and trending ability of less invasive cardiac output monitors compared with bolus thermodilution cardiac output with pulmonary artery catheter in patients undergoing high-risk surgery. The study monitors were a non-invasive bioreactance-based device (Starling SV) and two mini-invasive monitors utilizing either pulse pressure analysis (FloTrac/EV1000) or pulse power analysis (LiDCOrapid). Bioreactance analyses cardiac output through four non-invasive electrode stickers placed on the skin of the thoracic cavity, whereas pulse pressure and pulse power analyses require an arterial line. In Study I, cardiac output was measured in patients undergoing off-pump coronary artery bypass surgery. The study monitors bioreactance and pulse pressure analysis were accurate, but they were imprecise in measuring cardiac output, and their ability to track changes in cardiac output was insufficient. The patients in Study II underwent cardiac surgery with cardiopulmonary bypass. Bioreactance showed inaccuracy, whereas pulse power analysis calibrated with pulmonary artery catheter was accurate. Both devices were imprecise, with poor trending ability. Study III consisted of patients undergoing cytoreductive abdominal surgery with hyperthermic intraperitoneal chemotherapy. Bioreactance and non-calibrated pulse power analysis were accurate, but they were imprecise with insufficient trending ability. In conclusion, bioreactance, pulse pressure analysis and pulse power analysis were not i, Tiivistelmä Sydämen minuuttitilavuuden monitorointi on tärkeää hoidettaessa suuren riskin leikkaukseen joutuvia ja kriittisesti sairaita potilaita. Keuhkovaltimokatetrin lämpölaimennusmenetelmää pidetään kultaisena standardina sydämen minuuttitilavuuden mittaamisessa, mutta se on kajoava menetelmä, johon voi liittyä haittavaikutuksia. Sen vuoksi on kehitetty uusia, vähemmän kajoavia seurantamenetelmiä. Niiden luotettavuudesta on kuitenkin ristiriitaista tietoa. Tämän etenevän menetelmävertailututkimuksen tarkoituksena oli arvioida vähemmän kajoavien sydämen minuuttitilavuuden mittareiden tarkkuutta, täsmällisyyttä ja kykyä havaita muutoksia verrattuna keuhkovaltimokatetrin lämpölaimennusmenetelmään suuren riskin leikkauksissa. Tutkimusmonitoreina olivat täysin kajoamaton bioreaktanssiin perustuva Starling SV, sekä vähän kajoavat FloTrac/EV1000 ja LiDCOrapid, joiden toiminta perustuu valtimopainekäyrän analysointiin. Bioreaktanssi analysoi sydämen toimintaa neljän rintakehän iholle laitettavan elektroditarran avulla, kun taas valtimopainekäyrän analyysia varten tarvitaan valtimokanyyli. Ensimmäisessä osatyössä sydämen minuuttitilavuutta mitattiin potilailla, joille tehtiin sepelvaltimoiden ohitusleikkaus lyövän sydämen tekniikalla. Tutkimusmonitoreina käytetyt bioreaktanssi ja valtimopainekäyrän analyysi (FloTrac/EV1000) olivat tarkkoja mutta eivät täsmällisiä sydämen minuuttitilavuuden mittaamisessa. Niiden kyky havaita muutoksia oli riittämätön. Toisen osatyön potilaille tehtiin sydänleikkaus sydänkeuhkokoneen avulla. Bioreaktanssi oli epätarkka, mutta valtimopainekäyrän analyysi (LiDCOrapid) kalibroituna keuhkovaltimokatetrin avulla oli tarkka. Kumpikaan tutkimusmonitori ei ollut täsmällinen eikä havainnut luotettavasti sydämen minuuttitilavuuden muutoksia. Kolmannessa osatyössä bioreaktanssia ja kalibroimatonta valtimopainekäyrän analyysiä (LiDCOrapid) tutkittiin potilailla, joille tehtiin sytoreduktiivinen vatsan alueen leikkaus ja annettiin hyperterminen vatsak

To determine whether changes in transcranial near-infrared spectroscopy (NIRS) values reflect changes in cardiac index (CI) in adult cardiac surgical patients. Single-center prospective post hoc analysis. University hospital. One hundred and twenty-four adult patients undergoing cardiac surgery. In each patient, several CI measurements were taken, and NIRS values were collected simultaneously. We used a hierarchical linear regression model to assess the association between NIRS values and CI. We calculated a crude model with NIRS as the only factor included, and an adjusted model, where mean arterial pressure, end-tidal CO₂, and oxygen saturation were used as confounding factors. A total of 1301 pairs of NIRS and CI values were collected. The analysis of separate NIRS and CI pairs revealed a poor association, which was not statistically significant when adjusted with the chosen confounders. However, when the changes in NIRS from baseline or from the previous measurement were compared to those of CI, a clinically and statistically significant association between NIRS and CI was observed also in the adjusted model. Compared to the baseline and to the previous measurement, respectively, the regression coefficients with 95% confidence intervals were 0.048 (0.041–0.056) and 0.064 (0.055–0.073) in off-pump coronary artery bypass patients and 0.022 (0.016–0.029) and 0.026 (0.020–0.033) in patients who underwent cardiopulmonary bypass. In an unselected cardiac surgical population, the changes in NIRS values reflect those in CI, especially in off-pump coronary artery bypass patients. In this single-center post hoc analysis of data from a prospectively collected database of cardiac surgery patients, paired measurements of cardiac output and NIRS revealed that while there was a no correlation between individual paired measurements, a small correlation was found in changes in the two measurements from baseline values. This highlights a potential to utilize changes in N

Purpose: Various malignancies with peritoneal carcinomatosis are treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). The hemodynamic instability resulting from fluid balance alterations during the procedure necessitates reliable hemodynamic monitoring. The aim of the study was to compare the accuracy, precision and trending ability of two less invasive hemodynamic monitors, bioreactance-based Starling SV and pulse power device LiDCOrapid with bolus thermodilution technique with pulmonary artery catheter in the setting of cytoreductive surgery with HIPEC. Methods: Thirty-one patients scheduled for cytoreductive surgery were recruited. Twenty-three of them proceeded to HIPEC and were included to the study. Altogether 439 and 430 intraoperative bolus thermodilution injections were compared to simultaneous cardiac index readings obtained with Starling SV and LiDCOrapid, respectively. Bland-Altman method, four-quadrant plots and error grids were used to assess the agreement of the devices. Results: Comparing Starling SV with bolus thermodilution, the bias was acceptable (0.13 l min⁻¹ m⁻², 95% CI 0.05 to 0.20), but the limits of agreement were wide (− 1.55 to 1.71 l min⁻¹ m⁻²) and the percentage error was high (60.0%). Comparing LiDCOrapid with bolus thermodilution, the bias was acceptable (− 0.26 l min⁻¹ m⁻², 95% CI − 0.34 to − 0.18), but the limits of agreement were wide (− 1.99 to 1.39 l min⁻¹ m⁻²) and the percentage error was high (57.1%). Trending ability was inadequate with both devices. Conclusion: Starling SV and LiDCOrapid were not interchangeable with bolus thermodilution technique limiting their usefulness in the setting of cytoreductive surgery with HIPEC.

Objectives: Less-invasive and continuous cardiac output monitors recently have been developed to monitor patient hemodynamics. The aim of this study was to compare the accuracy, precision, and trending ability of noninvasive bioreactance-based Starling SV and miniinvasive pulse-power device LiDCOrapid to bolus thermodilution technique with a pulmonary artery catheter (TDCO) when measuring cardiac index in the setting of cardiac surgery with cardiopulmonary bypass (CPB). Design: A prospective method-comparison study. Setting: Oulu University Hospital, Finland. Participants: Twenty patients undergoing cardiac surgery with CPB. Interventions: Cardiac index measurements were obtained simultaneously with TDCO intraoperatively and postoperatively, resulting in 498 measurements with Starling SV and 444 with LiDCOrapid. Measurements and Main Results: The authors used the Bland-Altman method to investigate the agreement between the devices and four-quadrant plots with error grids to assess the trending ability. The agreement between TDCO and Starling SV was qualified with a bias of 0.43 L/min/m² (95% confidence interval [CI], 0.37‐0.50), wide limits of agreement (LOA, –1.07 to 1.94 L/min/m²), and a percentage error (PE) of 66.3%. The agreement between TDCO and LiDCOrapid was qualified, with a bias of 0.22 L/min/m² (95% CI 0.16‐0.27), wide LOA (–0.93 to 1.43), and a PE of 53.2%. With both devices, trending ability was insufficient. Conclusions: The reliability of bioreactance-based Starling SV and pulse-power analyzer LiDCOrapid was not interchangeable with TDCO, thus limiting their usefulness in cardiac surgery with CPB.

Background: Low postoperative mixed venous oxygen saturation (SvO₂) values have been linked to poor outcomes after cardiac surgery. The present study was designed to assess whether SvO₂ values of < 60% at intensive care unit (ICU) admission and 4 h after admission are associated with increased mortality after cardiac surgery. Methods: During the years 2007–2020, 7046 patients (74.4% male; median age, 68 years [interquartile range, 60–74]) underwent cardiac surgery at an academic medical center in Finland. All patients were monitored with a pulmonary artery catheter. SvO₂ values were obtained at ICU admission and 4 h later. Patients were divided into four groups for analyses: SvO₂ ≥ 60% at ICU admission and 4 h later; SvO₂ ≥ 60% at admission but < 60% at 4 h; SvO₂ < 60% at admission but ≥ 60% at 4 h; and SvO₂ < 60% at both ICU admission and 4 h later. Kaplan–Meier survival curves, Cox regression models, and receiver operating characteristic curve analysis were used to assess differences among groups in 30-day and 1-year mortality. Results: In the overall cohort, 52.9% underwent coronary artery bypass grafting (CABG), 29.1% valvular surgery, 12.1% combined CABG and valvular procedures, 3.5% surgery of the ascending aorta or aortic dissection, and 2.4% other cardiac surgery. The 1-year crude mortality was 4.3%. The best outcomes were associated with SvO₂ ≥ 60% at both ICU admission and 4 h later. Hazard ratios for 1-year mortality were highest among patients with SvO₂ <60% at both ICU admission and 4 h later, regardless of surgical subgroup. Conclusions: SvO₂ values < 60% at ICU admission and 4 h after admission are associated with increased 30-day and 1-year mortality after cardiac surgery. Goal-directed therapy protocols targeting SvO₂ ≥ 60% may be beneficial. Prospective studies are needed to confirm these observational findings.

Coagulation factor XII (FXII) is a plasma serine protease that belongs to the contact activation complex responsible for initiating the intrinsic coagulation pathway. FXII deficiency is a rare congenital disorder that is not associated with an increased tendency for bleeding. However, as contact activation is impaired in FXII deficiency, both the celite- and kaolin-initiated activated clotting time (ACT) measurements are prolonged markedly, which poses a challenge for anticoagulation monitoring in patients undergoing cardiac surgery. The authors successfully have used the standard Hemochron Jr. ACT+ test, which is activated by silica and phospholipid in addition to kaolin, to monitor anticoagulation for cardiopulmonary bypass in two patients with severe FXII deficiency. The ACT+ test showed low baseline values, increased adequately in response to heparin, and decreased to baseline after protamine. Importantly, there was no abnormal intra- or postoperative bleeding nor any thrombotic complications. Furthermore, in vitro dose-response ACT+ testing of FXII-deficient blood with increasing heparin concentrations supports the use of ACT+ in FXII deficiency.

Objective: To determine whether central venous oxygen saturation (ScvO2) measurements could be used interchangeably with mixed venous oxygen saturation (SvO2) measurements in adult cardiac surgery patients. Design: A single-center prospective observational study. Setting: A university hospital. Participants: Eighty-five adult patients undergoing cardiac surgery. Interventions: The study authors compared the oxygen saturations in 590 pairs of venous blood samples drawn from the pulmonary artery catheter (PAC) at three different time points during surgery and four different time points in the intensive care unit. They compared samples obtained from the distal pulmonary artery line (SvO2) to those drawn from the proximal central venous line of the PAC (ScvO2) with the Bland-Altman test and the four-quadrant method. Measurements and main results: The mean bias between SvO2 and ScvO2 was –1.9 (95% confidence interval [CI], –2.3 to –1.5) and the limits of agreement (LOA) were –11.5 to 7.6 (95% CI, –12.5 to –10.7 and 6.8–8.5, respectively). The percentage error (PE) was 13.2%. Based on the four-quadrant plot, only 50% of the measurement pairs were in agreement, indicating deficient trending ability. Conclusion: ScvO2 values showed acceptable accuracy as the mean bias was low. The precision was inadequate; although the PE was acceptable, the LOA were wide. Trending ability was inadequate. The authors cannot recommend the use of ScvO2 values interchangeably with SvO2 measurements in the management of adult cardiac surgery patients.

The pulmonary artery catheter (PAC) is considered the gold standard for cardiac index monitoring. Recently new and less invasive methods to assess cardiac performance have been developed. The aim of our study was to assess the reliability of a non-invasive monitor utilizing bioreactance (Starling SV) and a non-calibrated mini-invasive pulse contour device (FloTrac/EV1000, fourth-generation software) compared to bolus thermodilution technique with PAC (TDCO) during off-pump coronary artery bypass surgery (OPCAB). In this prospective study, 579 simultaneous intra- and postoperative cardiac index measurements obtained with Starling SV, FloTrac/EV1000 and TDCO were compared in 20 patients undergoing OPCAB. The agreement of data was investigated by Bland–Altman plots, while trending ability was assessed by four-quadrant plots with error grids. In comparison with TDCO, Starling SV was associated with a bias of 0.13 L min−1 m−2 (95% confidence interval, 95% CI, 0.07 to 0.18), wide limits of agreement (LOA, − 1.23 to 1.51 L min−1 m−2), a percentage error (PE) of 60.7%, and poor trending ability. In comparison with TDCO, FloTrac was associated with a bias of 0.01 L min−1 m−2 (95% CI − 0.05 to 0.06), wide LOA (− 1.27 to 1.29 L min−1 m−2), a PE of 56.8% and poor trending ability. Both Starling SV and fourth-generation FloTrac showed acceptable mean bias but imprecision due to wide LOA and high PE, and poor trending ability. These findings indicate limited reliability in monitoring cardiac index in patients undergoing OPCAB.

Background: The delay of percutaneous coronary intervention increases the risk of heart failure and mortality in STEMI. The aim of this study was to examine the time intervals of EMS and the factors associated with the time delay to angiography in patients with STEMI. Methods: The present study was conducted in Northern Ostrobothnia, Finland in 2014–2016. All patients transported to the hospital by EMS who were diagnosed with STEMI and underwent a primary angiography within 24 h of arrival were included. Angiography was defined as delayed if it was performed over 120 min of the first medical contact (FMC). Results: 310 patients met the inclusion criteria during the study period. Time from the FMC to angiography was less than 120 min in 231 patients (74.5%). In multivariate analysis, the factors associated with delayed angiography were the absence of chest pain (OR 2.46 (1.18–5.13),p = 0.016), dyspnea (OR 3.11 (1.54–6.28),p = 0.002), the treatment protocol violations by EMS (OR 2.41 (0.99–5.80),p = 0.050), treatment initiation at a primary health care center (OR 3.64 (1.39–9.48),p = 0.008), and the distance to hospital of over 100 km (OR 11.87 (6.14–22.93),p < 0.001). Conclusion: In our study, treatment protocol violations, non-specific symptoms, and the distance to hospital of over 100 km were associated with primary angiography in patients with STEMI transported to the hospital by EMS.

A drop in arterial oxygen content activates fetal chemoreflex including an increase in sympathetic activity leading to peripheralvasoconstriction and redistribution of bloodflow to protect the brain, myocardium, and adrenal glands. By using a chronicallyinstrumented fetal sheep model with intact placental circulation at near-term gestation, we investigated the relationship betweenperipheral chemoreflex activation induced by hypoxemia and central hemodynamics. A total of 17 Åland landrace sheep fetusesat 115–128/145 gestational days were instrumented. Carotid artery was catheterized in 10 fetuses and descending aorta in 7fetuses. After a 4-day recovery, baseline measurements of fetal arterial blood pressures, blood gas values, and fetal cardiovascu-lar hemodynamics by pulsed Doppler ultrasonography were obtained under isoflurane anesthesia. Comparable data to baselinewere collected 10 min (acute hypoxemia) and 60 min (prolonged hypoxemia) after maternal hypo-oxygenation to saturation levelof 70%–80% was achieved. During prolonged hypoxemia, pH and base excess (BE) were lower and lactate levels were higher inthe descending aorta than in the carotid artery. During hypoxemia mean arterial blood pressure (MAP) in the descending aortaincreased, whereas in the carotid artery, MAP decreased. In addition, right pulmonary artery pulsatility index values increased,and the diastolic component in the aortic isthmus bloodflow velocity waveform became more retrograde, thus decreasing theaortic isthmus antegrade/retrograde bloodflow (AoI Net Flow) ratio. Both fetal ventricular cardiac outputs were maintained evenduring prolonged hypoxemia when significant fetal metabolic acidemia developed. Fetal chemoreflex activation induced by hy-poxemia decreased the perfusion pressure in the cerebral circulation. Fetal weight-indexed left ventricular cardiac output (LVCO)or AoI Net Flow ratio did not correlate with a drop in carotid artery blood pressure.

Thromboelastography (TEG) provides information on clotting kinetics by measuring the viscoelastic properties of whole blood. Despite its widespread use in operating theatres, TEG has not been standardized or validated in the manner that conventional coagulation tests (CCTs) have. The aim of this study was to evaluate TEG as an analysis method; particularly the effect of sample site and citrate storage on TEG analyses. Further studies investigated the role of TEG in diagnosing the hypercoagulable state in obesity and cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). The following TEG parameters can demonstrate hypercoagulation: short reaction time (R), broad angle (α), elevated clot strength (G) and maximum amplitude (MA). Study I was a methodological validation study. Simultaneously drawn venous and arterial samples were compared to each other. The effect of citrate storage was assessed at 30 min, 60 min and 120 min after collection. The mean bias between arterial and venous samples was low; -0.4 min for R and 0.3 mm for MA. Sample storage up to 120 min had no impact on TEG analyses. In study II, the TEG parameters R, α, G and MA and high-sensitivity C-reactive protein (hsCRP) were determined before and six months after obesity surgery. The median MA (71.3 mm), G (12 403.3 d/sc) and hsCRP (3.5 mg/l) exceeded their upper normal limits preoperatively. The hsCRP declined to within its normal range six months after surgery, while MA and G remained elevated, indicating hypercoagulation. The mean weight loss during the study period was 19.6 kg. Studies III and IV assessed blood coagulation during (study III) and after CRS and HIPEC (study IV). The median MA (69.3 mm) was elevated preoperatively, while other TEG parameters were within normal limits. Towards the end of the operation, the median R was reduced (p < 0.005) and α increased (p = 0.005). These changes had reverted by the first postoperative morning. At, Tiivistelmä Tromboelastografia (TEG) kuvaa kokonaisvaltaisesti veren hyytymisen kinetiikkaa mittaamalla veren viskoelastisia ominaisuuksia. Huolimatta laajasta käytöstä leikkaussaleissa, TEG:a ei ole standardoitu eikä validoitu kuten perinteisiä hyytymis-kokeita. Tutkimuksen tarkoituksena oli selvittää verinäytteen ottotavan ja säilytyksen vaikutusta TEG-tuloksiin ja TEG:n mahdollisuuksia tunnistaa lihavuuteen ja sytoreduktiiviseen kirurgiaan liittyvä hyperkoagulaatiotila. TEG-arvoista lyhyt R-aika, laaja α-kulma, korkea hyytymän vahvuus (G) ja maksimiamplitudi (MA) viittaavat hyperkoagulaatioon. Ensimmäinen osatyö oli menetelmän validointityö. Samanaikaisesti laskimosta ja valtimosta otettuja näytteitä vertailtiin toisiinsa. Sitraattisäilytyksen vaikutusta selvitettiin analysoimalla näytteet 30 min, 60 min ja 120 min kuluttua näytteenotosta. Laskimo- ja valtimonäytteiden välinen ero oli vähäinen; R-ajan suhteen -0.4 min ja MA:n suhteen 0.3 mm. Säilytyksellä 120 min saakka ei ollut vaikutusta TEG-tuloksiin. Toisessa osatyössä R, α, G ja MA sekä inflammaatiota kuvaava hsCRP määritettiin lihavuusleikkausta edeltävästi ja 6 kk leikkauksen jälkeen. Preoperatiivisesti MA, G ja hsCRP olivat yli viitevälin. Leikkauksen jälkeen hsCRP normaalistui mutta MA ja G jäivät koholle viitaten hyperkoagulaatioon. Keskimääräinen painon lasku tutkimusjakson aikana oli 19.6 kg. Kolmannessa ja neljännessä osatyössä veren hyytymistä tutkittiin sytoreduktiivisen leikkauksen ja hypertermisen intaperitoneaalisen kemoterapian (HIPEK) aikana (osatyö III) ja jälkeen (osatyö IV). Ennen leikkausta MA oli koholla, muut TEG-arvot viiteväleissä. Leikkauksen loppua kohden R-aika lyheni (p < 0.005) ja α-kulma nousi (p = 0.005). Nämä muutokset korjaantuivat seuraavaan aamuun mennessä. Kotiutusvaiheessa MA (p < 0.001), α-kulma (p = 0002) ja perinteisistä hyytymiskokeista verihiutaleiden määrä (p < 0.001), fibrinogeeni (p < 0.001) ja fibrinogeenin D-dimeeri (p < 0.

Background and Objectives: Postoperative thromboembolism is a significant cause of prolonged recovery in patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Thromboelastography (TEG) can detect hypercoagulable states and predict thromboembolic complications after surgery. This study assessed the impact of CRS and HIPEC on TEG values. Methods: TEG parameters reaction time (R), kinetics time (K), angle (α), maximum amplitude (MA), and lysis percent at 60 min (LY60) were determined preoperatively, and at the end of CRS, during HIPEC, and at the end of the operation using blood samples from 15 HIPEC patients. Platelets, P-TT, and aPTT were also determined before and after CRS. Results: A total of 75 samples were analyzed. During CRS, there was a significant reduction in the mean MA (3.06 mm, p = 0.001). The mean P-TT declined by 32% (p < 0.001) and mean platelets by 55 × 10⁹/L (p < 0.001). During HIPEC, the mean R and K shortened by 1.04 min (p = 0.015) and 0.18 min (p = 0.018), respectively, whereas α increased by 2.48° (p = 0.005). Conclusions: During CRS, both TEG and conventional laboratory tests indicated hypocoagulation. During HIPEC, however, the initiation of coagulation and the kinetics of thrombin formation were accelerated.

The foramen ovale (FO) accounts for the majority of fetal left ventricular (LV) output. Increased right ventricular afterload can cause a redistribution of combined cardiac output between the ventricles. To understand the capability of the FO to increase its volume blood flow and thus LV output, we mechanically occluded the main pulmonary artery in seven chronically instrumented near‐term sheep fetuses. We hypothesized that FO volume blood flow and LV output would increase during main pulmonary artery occlusion. Fetal cardiac function and haemodynamics were assessed by pulsed and tissue Doppler at baseline, 15 and 60 min after occlusion of the main pulmonary artery and 15 min after occlusion was released. Fetal ascending aorta and central venous pressures and blood gas values were monitored. Main pulmonary artery occlusion initially increased fetal heart rate (P < 0.05) from [mean (SD)] 158 (7) to 188 (23) beats min⁻¹ and LV cardiac output (P < 0.0001) from 629 (198) to 776 (283) ml min⁻¹. Combined cardiac output fell (P < 0.0001) from 1524 (341) to 720 (273) ml min⁻¹. During main pulmonary artery occlusion, FO volume blood flow increased (P < 0.001) from 507 (181) to 776 (283) ml min⁻¹. This increase was related to fetal tachycardia, because LV stroke volume did not change. Fetal ascending aortic blood pressure remained stable. Central venous pressure was higher (P < 0.05) during the occlusion than after it was released. During the occlusion, fetal pH decreased and PCO₂ increased. Left ventricular systolic dysfunction developed while LV diastolic function was preserved. Right ventricular systolic and diastolic function deteriorated after the occlusion. In conclusion, the FO has a limited capacity to increase its volume blood flow at near‐term gestation.

Purpose: Obesity causes a prothrombotic state and is known as a predisposing factor for thromboembolic events. In this pilot study, we assessed the impact of surgery for obesity and the subsequent weight loss on blood coagulation using traditional coagulation tests and thromboelastography (TEG). Material and Methods: We studied blood samples from 18 patients receiving bariatric surgery. Besides traditional blood coagulation tests and high-sensitivity C-reactive protein (hsCRP) as a marker of inflammation, the TEG parameters reaction time (R), kinetics time (K), angle (α), maximum amplitude (MA), clot strength (G), and lysis percent at 60 min (LY60) were determined preoperatively and on the first postoperative day and 6 months after surgery. Results: Altogether, 54 samples were analyzed. The median MA (71.3 mm), G (12,403.3 d/sc), and hsCRP (3.5 mg/l) were elevated preoperatively. The median hsCRP further increased on the first day postoperatively, but declined to the normal range 6 months after surgery, while MA and G remained elevated. In traditional coagulation tests, there was an increase in median fibrinogen and D-dimer postoperatively. D-dimer normalized (0.4 mg/l) during the study period, while the fibrinogen level (4.1 g/l) remained above the upper limit of normal. Conclusions: Measured by TEG, patients receiving bariatric surgery have hemostatic abnormalities indicating hypercoagulation at the 6-month follow-up visit, suggesting an elevated risk for thromboembolic events for at least 6 months after surgery.

Knowledge of the effects of maternally administered vasopressors on human fetal and placental haemodynamics is sparse and limited to elective Caesarean deliveries in uncomplicated pregnancies. We hypothesized that, after short-term fetal hypoxaemia, which activates fetal cardiovascular compensatory mechanisms, treatment of maternal hypotension with ephedrine or phenylephrine results in divergent responses in fetal and placental haemodynamics. Chronically instrumented near-term sheep fetuses with either normal placental function or increased placental vascular resistance following placental embolization were exposed to two subsequent periods of decreased fetal oxygenation caused by maternal hypoxaemia and epidural-induced hypotension. The fetuses that underwent placental embolization were also chronically hypoxaemic. Fetal and placental haemodynamics were assessed by invasive techniques and by noninvasive Doppler ultrasonography. Our results show that umbilical artery blood flow velocity waveforms cannot be used to derive information of fetal cardiac function. Furthermore, the changes in placental volume blood flows and vascular resistances caused by maternal vasopressor treatment cannot be reliably recognized based on uterine and umbilical artery pulsatility index values. In response to acute hypoxaemia, a fetus with normal placental function redistributes its right ventricular cardiac output from the pulmonary to the systemic circulation and is able to increase its combined cardiac output, with a concomitant relative decrease in the net forward flow through the aortic isthmus. However, fetal haemodynamic responses to subsequent hypoxaemic insults may vary. Furthermore, the compensatory responses of fetuses with increased placental vascular resistance differ from those of normal fetuses. In these fetuses, repeated episodes of a further decrease in oxygenation lead to lactataemia. The effects of ephedrine on uteroplacental and umbilicoplacental circulations