Search Results (670)

Background: Eosinophilic granulomatosis with polyangiitis (EGPA), formerly Churg–Strauss syndrome, is a rare necrotizing vasculitis characterized by asthma, eosinophilia, and systemic granulomatosis vasculitis. Perioperative risk is primarily driven by airway hyperreactivity, potential cardiac disease, chronic immunosuppressive therapy, and reported alterations in plasma cholinesterase activity. Evidence specifically addressing anesthetic management remains scarce and largely limited to case-based reports. Methods: A focused narrative review was conducted by searching MEDLINE (via PubMed), Scopus, and Embase from inception to January 2026 for publications reporting perioperative anesthetic management in patients with EGPA/Churg–Strauss syndrome. Case reports and case-based descriptions providing explicit anesthetic details were qualitatively synthesized. Results: Available evidence consists predominantly of isolated case reports across heterogeneous surgical settings, including ENT, abdominal, orthopedic, ambulatory, pediatric, and rare cardiac procedures. Recurring perioperative principles include optimization of bronchial disease and continuation of inhaled therapy; minimization of airway stimulation and avoidance of histamine-releasing drugs; selection of induction agents preserving hemodynamic stability in the presence of myocardial involvement; preference for non-depolarizing neuromuscular blockade with quantitative monitoring (and consideration for sugammadex when appropriate); individualized corticosteroid management and multimodal, opioid-sparing analgesia, often supported by regional techniques. Conclusions: In the absence of dedicated perioperative guidelines, anesthetic care for EGPA should be individualized based on clinical phenotype and organ involvement. A structured approach targeting airway protection, cardiovascular stability, safe neuromuscular management, and opioid-sparing analgesia may represent a pragmatic risk-mitigation framework. These considerations are illustrated by an institutional experience in mitral valve surgery. Full article

Background: Pediatric septic shock remains a major cause of morbidity and mortality and requires timely recognition and management across multiple hospital settings. Although intensive care support is critical, outcomes are also influenced by earlier phases of care, including emergency department recognition, first-hour treatment, inpatient monitoring, and timely escalation to the pediatric intensive care unit (PICU). Objective: We aimed to review pediatric septic shock across the full hospital trajectory, from emergency department recognition to PICU management and outcomes, with emphasis on diagnostic challenges, early treatment, escalation of care, and prognostic assessment. Methods: This narrative review was based on a structured literature search of PubMed/MEDLINE, Scopus, and the Cochrane Library, with emphasis on international guidelines, consensus statements, systematic reviews, and clinically relevant pediatric studies addressing recognition, resuscitation, escalation, intensive care management, and outcomes in pediatric septic shock. Results: Pediatric septic shock is best approached as a dynamic continuum rather than a single event. Early recognition is complicated by age-dependent physiology, nonspecific presentation, and delayed hypotension. Timely antimicrobial therapy, individualized fluid resuscitation, early vasoactive support, and repeated reassessment during the first hours are central to management. Ward surveillance and prompt escalation to PICU are critical, as delayed recognition of deterioration may worsen organ dysfunction and resource use. In the PICU, phenotype-informed hemodynamic support, fluid stewardship, respiratory support, and organ support are essential. Outcomes should be evaluated beyond mortality to include organ dysfunction burden, duration of support, length of stay, and longer-term functional recovery. Conclusions: Pediatric septic shock outcomes are shaped by the entire hospital care pathway rather than PICU treatment alone. A trajectory-based, continuum-of-care approach may improve timely diagnosis, escalation, and short- and longer-term outcomes. Full article

Non-invasive respiratory support (NRS) has become a cornerstone in the management of acute respiratory failure (ARF), offering an alternative or a bridge between conventional oxygen therapy (COT) and invasive mechanical ventilation (iMV). While NRS techniques—including non-invasive ventilation (NIV), continuous positive airway pressure (CPAP), and high-flow nasal oxygen (HFNO)—have demonstrated efficacy in reducing intubation rates and improving outcomes, patient tolerance and synchrony remain critical determinants of success. Analgosedation, the strategic use of analgesics and sedatives, has emerged as an important adjunctive therapy to optimise NRS delivery, reduce patient–ventilator asynchrony, and improve comfort. However, the delicate balance between adequate sedation and the preservation of spontaneous breathing, airway protection, and hemodynamic stability presents unique challenges. This comprehensive narrative review synthesises current evidence on analgosedation strategies during NRS use, examining pharmacological agents, their pharmacokinetic and pharmacodynamic properties, comparative studies, indications, monitoring parameters, clinical settings, and safety considerations. We also review existing guidelines, discuss special considerations in paediatric populations, and propose practical clinical approaches. Understanding the nuanced application of analgosedation is essential for clinicians to maximise therapeutic benefit while minimising risks of NRS treatment failure and adverse outcomes. Full article

Background: Right ventricular (RV) dysfunction is a key contributor to morbidity and mortality in systemic sclerosis (SSc), emerging from the combined effects of microvascular disease, myocardial fibrosis, interstitial lung involvement, and increasing pulmonary vascular load. Conventional echocardiography frequently fails to detect early RV impairment, prompting growing interest in deformation-based parameters such as RV free-wall longitudinal strain (RV-FWS), global longitudinal strain (RV-GLS), and RV–pulmonary artery (PA) coupling indices. Although natriuretic peptides reflect myocardial stress and are widely used in cardiopulmonary diseases, their integration with advanced RV imaging has been inconsistently reported in SSc. This systematic review synthesizes available evidence on RV strain, RV–PA coupling, and their relationship with clinical outcomes and biomarkers in SSc. Methods: A systematic search was conducted to identify clinical studies evaluating RV strain (RV-FWS, RV-GLS), right atrial strain, or RV–PA coupling indices in adult patients with SSc or SSc-associated pulmonary arterial hypertension (SSc-PAH). Eligible studies included those using speckle-tracking echocardiography or cardiac magnetic resonance feature-tracking. Study selection and data extraction were performed in accordance with PRISMA guidelines. Results: Seven studies met the eligibility criteria. Across unselected SSc cohorts, early disease without pulmonary hypertension (PH), and right-heart-catheterization-confirmed SSc-PAH, RV strain consistently detected myocardial impairment even when conventional echocardiographic indices remained normal. RV-FWS and RV-GLS were commonly reduced, and longitudinal data demonstrated progressive deterioration independent of standard measures. Strain-derived RV–PA coupling, particularly RV-FWS/PASP, significantly improved prognostic stratification when added to established PAH risk models. Two studies identified impaired RV deformation as a predictor of mortality, and CMR-derived right atrial strain provided additional prognostic value. Biomarker integration was limited, with only one study reporting an association between natriuretic peptide elevation (NT-proBNP) and impaired RV–PA coupling suggesting that biomarkers may reflect the hemodynamic load, although evidence remains limited captured by strain abnormalities. Conclusions: RV strain and RV–PA coupling indices are more sensitive than conventional echocardiography for detecting early RV dysfunction, monitoring disease progression, and predicting adverse outcomes in SSc. Although biomarker evidence remains limited, available data suggest that natriuretic peptides may provide complementary information to deformation-based assessment, although current evidence remains limited by reflecting combined myocardial and pulmonary vascular load. Standardized prospective studies including both strain imaging and biomarkers are needed to clarify the integrated diagnostic and prognostic value of advanced RV assessment in SSc. Full article

Background: Lumbar disc herniation (LDH) is the most common etiological cause of low back pain (LBP). Objective and precise pain evaluation is of significant clinical value. Functional near-infrared spectroscopy (fNIRS) as a noninvasive neuroimaging modality, has been increasingly validated to reflect subjective pain perception through hemodynamic correlates. This study aimed to analyze the fNIRS changes in patients with LDH about to receive Unilateral Biportal Endoscopy and to further explore the feasibility of fNIRS as an objective biomarkers for clinical assessment of LDH. Methods: Resting-state fNIRS data were acquired from 67 preoperative LDH patients and 20 healthy controls (HC). Brain functional maps—including z-standardized fractional amplitude of low-frequency fluctuations (zfALFF) and seed-based functional connectivity (FC)—were extracted and quantified. Group-level comparisons were performed between LDH and HC groups across four predefined regions of interest; additionally, correlation analyses were conducted between fNIRS metrics and clinical assessment scores within the LDH cohort. Results: Compared with HC, LDH patients exhibited significantly altered zfALFF in the medial prefrontal cortex (mPFC): decreased amplitude at channel CH12 (t = −2.031, p = 0.045) and increased amplitude at CH21 (t = 2.462, p = 0.016). Whole-brain FC analysis further revealed widespread changes—particularly between the parietal somatosensory cortex and prefrontal regions. Among all tested FC–clinical indicator associations, 56 reached statistical significance after FDR correction (q < 0.05). VAS_ lumbar and SF-36_SF exhibited the highest number of significant connections. Conclusions: LDH patients with LBP exhibit notable alterations in prefrontal resting-state ALFF and FC between the parietal somatosensory cortex and prefrontal cortex relative to HC. Importantly, these neural alterations exhibit significant associations with both pain severity (VAS) and long-term health-related quality of life (SF-36), thereby strengthening their candidacy as neural correlates meriting prospective validation as objective, mechanism-informed biomarkers for clinical evaluation of lumbar disc herniation (LDH). Moreover, these findings highlight candidate neural targets for future longitudinal studies investigating early prognostic prediction and treatment response monitoring in LDH. Full article

Although radiotherapy is a cornerstone in the management of several pediatric malignancies, its administration in children poses unique anesthetic challenges. Unlike adults, pediatric patients, particularly younger children, often require repeated sedation or general anesthesia to ensure immobility and reduce psychological distress during daily treatment sessions that may extend over several weeks. This narrative review summarizes current evidence on anesthetic strategies for children undergoing radiotherapy, focusing on clinical indications, pharmacological approaches, safety considerations, and organizational aspects. We discuss the main sedation and anesthesia techniques used in non-operating room anesthesia (NORA) settings, including deep sedation with midazolam, propofol, ketamine, and dexmedetomidine, as well as general anesthesia with laryngeal mask airway management. Particular attention is given to the cumulative effects of repeated anesthetic exposure, airway management challenges in remote radiation environments, and the risk of respiratory and hemodynamic complications. The review also highlights the importance of individualized, protocol-driven management, rapid recovery strategies, and continuous remote monitoring systems. Non-pharmacological interventions and audiovisual-assisted techniques are also discussed as potential strategies to reduce anesthesia requirements in selected patients. A multidisciplinary approach involving anesthesiologists, radiation oncologists, nurses, psychologists, and technical staff is essential to optimize safety, treatment adherence, and overall quality of care. Tailored anesthetic management, supported by standardized protocols and specialized pediatric expertise, remains crucial to balancing procedural efficacy with short- and long-term safety in this vulnerable population. Full article

Background: Kounis syndrome is an allergic acute coronary syndrome precipitated by coronary vasospasm, plaque destabilization, stent thrombosis, or bypass occlusion. Cardiac surgery represents a uniquely high-risk setting due to cardiopulmonary bypass–associated inflammation and exposure to multiple pharmaceutical agents. Importantly, Kounis syndrome remains underrecognized in this context, as classical signs of anaphylaxis may be masked under general anesthesia and cardiopulmonary bypass, while ischemic manifestations may be misattributed to other perioperative conditions. Methods: A narrative review of PubMed-indexed literature was conducted to synthesize current evidence on the pathophysiology, perioperative triggers, clinical presentation, diagnostic strategies, and management of Kounis syndrome in cardiac surgery, with emphasis on intraoperative recognition and surgical decision-making. Published cases were retrieved involving perioperative cardiac surgery patients with a definite diagnosis of Kounis syndrome. Additionally, cases presenting with severe perioperative anaphylaxis and life-threatening cardiovascular involvement (grade III with cardiovascular collapse and grade IV with cardiac arrest) were included as possible Kounis syndrome, reflecting real-world diagnostic uncertainty in the intraoperative setting. Results: The literature review identified five cases of definite Kounis syndrome and ten cases of possible Kounis syndrome, including three cases with cardiovascular collapse and seven cases with cardiac arrest. Recurrent episodes were reported in several patients, particularly due to re-exposure to the triggering agent. In the context of cardiac surgery, Kounis syndrome is most frequently triggered by chlorhexidine, protamine, antibiotic prophylaxis, and anesthetic agents. The clinical presentation is often subtle during cardiopulmonary bypass. Vasoplegia, pulmonary hypertension, ventricular dysfunction, new regional wall-motion abnormalities, and hyperdynamic ventricles on transesophageal echocardiography commonly precede overt electrocardiographic changes. Diagnosis is primarily clinical and relies on intraoperative ultrasound, hemodynamic monitoring, serum tryptase, serum troponin, and, when indicated, coronary angiography. A dual-pathway approach addressing both anaphylaxis and myocardial ischemia is essential; however, one component may predominate, particularly in perioperative patients with limited clinical information, potentially leading to misdiagnosis. A multidisciplinary approach is therefore required for rapid diagnosis and individualized management. In refractory cases, cardiopulmonary bypass or ventricular assist devices may provide lifesaving support. Conclusions: Kounis syndrome remains underrecognized in cardiac surgery but carries significant morbidity. Increased clinical awareness, multidisciplinary collaboration, structured diagnostic approaches, and preventive strategies are essential to improve outcomes and reduce the risk of recurrence during future procedures. Full article

Euphorbia tirucalli, commonly known as Aveloz, is widely used in Brazilian folk medicine for its purported antibacterial, antiviral, and antitumoral properties. However, scientific evidence regarding its systemic in vivo effects, particularly on the cardiovascular system, remains limited. This study investigated the impact of oral E. tirucalli latex ingestion on cardiac hemodynamics and associated molecular alterations in normotensive Wistar rats. Animals received water (control) or E. tirucalli latex (13.47 mg/kg) by oral gavage for 15 days. Hemodynamic parameters were assessed through noninvasive blood pressure monitoring and direct measurements of left ventricular systolic (LVSP) and end-diastolic pressures (LVEDP), cardiac cycle duration, rates of pressure development (dP/dt_max and dP/dt_min), and the left ventricular relaxation constant (Tau). Oxidative stress and inflammation were evaluated by plasma advanced oxidation protein products (AOPP) and myeloperoxidase (MPO), respectively, while reactive oxygen species production and apoptosis were analyzed in isolated cardiomyocytes. Although systemic blood pressure remained unchanged, E. tirucalli increased LVSP, LVEDP, cardiac cycle duration, and dP/dt_max, while reducing Tau. These alterations were accompanied by elevated AOPP and MPO levels, increased cardiomyocyte hydrogen peroxide, and higher rates of early apoptosis, indicating that E. tirucalli latex alters cardiac hemodynamics and promotes oxidative and inflammatory cardiac injury. Full article

Background: Frail patients undergoing hip and knee revision surgery represent a major anesthetic challenge because of advanced age and multiple comorbidities. Continuous spinal anesthesia (CSA) with titrated low-dose levobupivacaine may offer a potentially useful alternative to general anesthesia or single-shot spinal anesthesia in this high-risk population. Methods: A retrospective review was conducted of ASA II-III patients who underwent complex hip and knee revision surgeries between February and October 2024 under CSA. The technique was performed using a 25-gauge spinal catheter with incremental boluses of 0.25% levobupivacaine (2.5 mg). Hemodynamic parameters, including mean arterial pressure (MAP), stroke volume index (SVI), and cardiac index (CI), were continuously monitored using the EV1000 hemodynamic monitoring system. Postoperative complications were recorded. Results: 37 high-risk patients were included in the study. Catheter placement was successful in all patients, with no conversions to general anesthesia. MAP decreased by a mean of 14.6% after boluses (p < 0.05); 9 patients (24.3%) experienced reductions ≥ 20%, but all remained >65 mmHg and responded to fluid therapy. CI and SVI decreased by 10.1% and 10.5%, respectively (p < 0.05), without clinical instability. No major complications (neurological injury, infection, post-dural puncture headache) were observed. Conclusions: In this retrospective single-center experience, CSA with titrated low-dose levobupivacaine was feasible and associated with stable hemodynamic profiles and a low rate of complications in frail patients undergoing complex lower-limb revision surgery. However, given the absence of a control group and the limited sample size, these findings should be interpreted cautiously. Further prospective comparative studies are needed to better define the role of CSA in high-risk orthopedic patients. Full article

Hemorrhagic shock remains a leading cause of preventable death in trauma, yet traditional vital signs may fail to reflect early blood loss before physiological compensatory mechanisms are no longer able to maintain hemodynamic stability. The Compensatory Reserve Measurement (CRM) algorithm offers early detection capability using physiological waveforms but requires testing with emerging wearable sensor technologies for operational deployment. This study tested the Epicore Epidermal Patch for Imperceptible Care (EPIC) wearable healthcare device (WHD) for CRM-based hemodynamic monitoring during progressive central hypovolemia induced by lower-body negative pressure (LBNP) to simulate hemorrhage. Twenty participants underwent progressive LBNP while photoplethysmography (PPG) signals were recorded from EPIC sensors placed at the clavicle and triceps alongside a clinical-grade finger pulse oximeter for reference. Signal quality, heart-rate accuracy, and CRM predictions were evaluated across multiple filtering approaches. The triceps placement achieved signal quality comparable to the pulse oximeter reference when Chebyshev Type II filtering was applied, as well as high heart-rate accuracy. CRM derived from the EPIC sensor placed at the triceps tracked compensatory trends during progressive hypovolemia, but prediction magnitudes were inaccurate compared to calculated CRM values. In contrast, the clavicle placement consistently performed poorly across all measurements, regardless of the signal-processing approach. These findings support the feasibility of soft, flexible wearable sensors for continuous hemorrhage monitoring at the triceps location in operational environments where traditional finger-based pulse oximetry is impractical. Full article

Concurrent with the rising consumption of ultra-processed, high-calorie diets and the decline in physical activity, obesity and related cardiovascular conditions among young adults have continued to increase, becoming an important global public health concern. This study integrates non-invasive Internet of Things (IoT) sensing devices, including the TERUMO ES-P2000 blood pressure monitor (Terumo Corp., Tokyo, Japan) and the PhysioFlow PF07 Enduro cardiac hemodynamic analyzer (Manatec Biomedical, Poissy, France), with an artificial neural network (ANN) for cardiac index (CI) prediction. Through appropriate data preprocessing and model training strategies, the generalization ability and stability of the proposed CI prediction model were significantly enhanced. Experimental results demonstrate that, when using three physiological parameters as input, the ANN achieved a classification accuracy of 97.78%, substantially outperforming traditional approaches. Even under two-parameter input conditions, the model maintained strong predictive performance. These findings confirm the effectiveness and practical potential of the proposed framework for real-time, non-invasive CI assessment. Moreover, this research has received rigorous assessment and approval from the Institutional Review Board (IRB) under application number 202501987B0. Full article

Background/Objective: Continuous blood pressure (BP) monitoring is essential in clinical settings, where rapid hemodynamic changes influence patient management. While intra-arterial measurement remains the reference standard, non-invasive volume-clamp systems offer a potential alternative. We assessed the accuracy of finger-cuff-based continuous BP monitoring compared to invasive measurement in patients with pulmonary hypertension (PH). Methods: This post hoc analysis from a crossover RCT included PH patients who underwent repetitive hemodynamic assessments at rest and during exercise. The participants had simultaneous invasive BP monitoring via the radial artery and a non-invasive finger-cuff device (Finapres^® NOVA Basic). The mean blood pressure (mBP) was compared at rest, 50% of the maximal workload, and at the end of exercise using Bland–Altman and Taffé analysis. Results: In the study, 24 patients (seven female; 59 ± 14 years) contributed 385 paired mBP measurements. The invasive and non-invasive methods showed similar values at rest (96.1 ± 16.7 vs. 96.4 ± 17.2 mmHg) and during maximal exercise (106.8 ± 18.6 vs. 111.8 ± 21.6 mmHg). The overall Bland–Altman bias was 2.8 mmHg with wide limits of agreement (−39.6 to 45.3 mmHg), which remained broad across all exercise intensities. The Taffé analysis revealed a non-uniform, directionally dependent bias: the non-invasive system overestimated the mBP at low pressures and underestimated it at higher pressures. The measurement variability was substantially greater for the non-invasive method than for the invasive reference. Conclusions: In PH patients, finger-cuff-based continuous BP monitoring demonstrated acceptable group-level agreement but insufficient individual-level accuracy for clinical decision-making. Full article

Cirrhosis is no longer viewed solely as an isolated hepatic disorder but rather as a complex multisystemic disease that affects cardiovascular, renal, pulmonary, metabolic, and immune systems. One of its most clinically relevant but under-recognized consequences is cardiac dysfunction, manifesting as cirrhotic cardiomyopathy, portopulmonary hypertension, right ventricular (RV) failure, and impaired myocardial strain. Oxidative stress (OS) has recently emerged as a fundamental mechanistic link between hepatic fibrogenesis and myocardial remodeling, acting through mitochondrial injury, NADPH oxidase activation, nitric oxide dysregulation, iron-mediated ferroptosis, and inflammatory cytokines. These alterations lead to diastolic dysfunction, autonomic imbalance, myocardial fibrosis, electrophysiological abnormalities (including QTc prolongation), and impaired RV–pulmonary artery coupling. Redox biomarkers such as malondialdehyde (MDA), NOX2-derived peptides, GSH/GSSG ratio, sST2, NT-proBNP, and 8-isoprostanes hold promise in detecting early subclinical cardiac involvement in cirrhosis. Novel antioxidant therapies, including mitochondrial-targeted molecules, NOX inhibitors, and ferroptosis blockers, may improve myocardial remodeling and hemodynamic stability. This review explores the central role of redox imbalance in the cardiohepatic syndrome and its potential utility in diagnosis, monitoring, and therapy. Full article

Background: Reactive hyperemia (RH) is used to assess microcirculatory function in vivo and has traditionally been interpreted as a local, ischemia-driven vasodilatory response following arterial occlusion. However, perfusion changes consistently observed in contralateral, non-challenged limbs question the exclusively local nature of RH. Objective: This study aimed to characterize reactive hyperemic responses elicited by subsystolic cuff pressures, below arterial occlusion pressure (AOP), and to investigate their effects on glabrous and non-glabrous skin microcirculation and on global hemodynamics. Methods: Seven healthy women underwent a standardized protocol consisting of baseline stabilization, a 2 min subsystolic cuff inflation (70–80% of resting AOP) in one arm, and a recovery period. Microvascular perfusion was simultaneously assessed in both hands using laser Doppler flowmetry (LDF) on glabrous skin and polarized light spectroscopy (PSp) on non-glabrous dorsal skin. Hemodynamic indicators were continuously monitored using CNAP (Continuous Non-invasive Arterial Pressure) technology. Ipsilateral and contralateral responses were compared across experimental phases. Results: Subsystolic cuff inflation induced significant perfusion changes not only in the challenged limb but also in the contralateral limb, despite the absence of a complete arterial occlusion. Conclusions: These findings confirm the adaptive nature of RH emphasizing the major role for the sympathetic nervous system in glabrous skin. In glabrous (palmar) skin, a similar perfusion profile is shown in both hands but significant differences could only be found in the ipsilateral hand. In contrast, non-glabrous (dorsal) skin demonstrated region-specific increases in perfusion, again evident in the ipsilateral hand, suggesting venous stasis. No changes in global hemodynamic variables were observed throughout the protocol. Further studies in larger, more diverse populations are needed to confirm these observations and refine the mechanistic understanding of reactive hyperemia. Full article

Hemorrhagic shock remains one of the leading causes of preventable death for both civilian and military trauma. Fluid resuscitation is the primary treatment but requires constant monitoring, particularly for volume non-responsive patients susceptible to fluid overload, pulmonary edema, and other life-threatening conditions. To overcome fluid non-responsiveness, vasoactive drugs or vasopressors can be necessary adjuvants to fluid therapy but require tedious titrations that can be difficult to manage during mass-casualty situations. This study developed and evaluated automated closed-loop vasopressor controllers for hemorrhage scenarios. Ten physiological closed-loop controller (PCLC) configurations with different underlying functionalities were tuned to be either more aggressive or conservative to reach the target mean arterial pressure. A hardware-in-loop test platform with fluid-pressure responsiveness, derived from animal data, tested each controller across three different starting pressure scenarios. The platform successfully differentiated controller designs based on performance metrics. While some configurations overshot the target and others could not reach the target pressure, strong-performing PCLCs consistently reached and maintained the target quickly. Three candidate PCLCs outperformed the rest and will be evaluated across wider scenarios to develop a robust controller design. This work accelerates PCLC-driven vasopressor administration development, providing a necessary fluid resuscitation adjuvant for precise hemodynamic management in hemorrhagic trauma. Full article