Dual veno-arterial extra-corporeal membrane oxygenation support in a patient with refractory hyperdynamic septic shock: a case report

The hypodynamic septic shock appears to be a promising indication to veno-arterial membrane oxygenation (VA-ECMO) support of a patient with insufficient cardiac output. With cardiac recovery most of those patients progress into a hyperdynamic septic shock with cardiac output, which may not match critically low systemic vascular resistance to maintain perfusion pressures. Such refractory distributive shock represents a challenging indication to VA-ECMO. We report a rare case of a 27-year old patient who developed severe refractory hypodynamic septic shock due to the bilateral staphylococcal pneumonia and had to be initially rescued by femoro-femoral VA-ECMO. Despite extensive measures, he remained in intractable hypotension and profound tissue hypoperfusion with imminent multiorgan failure. The commencement of a second jugulo-axillary VA ECMO secured a total blood flow of 14.3 L/min, which restored perfusion pressure and successfully bridged patient over the period of critical haemodynamic instability and ultimately may have facilitated recovery.

69 Effects of supplementing heifers with dietary quercetin during late-gestation

Introduction of antioxidants, such as quercetin, into the diets of livestock species have become a new and revolutionary field of study. The objective was to examine effects of dietary supplementation of quercetin in beef heifers. Assessments were evaluated based on uterine artery hemodynamics and maternal hormone concentrations during late-gestation, as well as calf morphometric parameters. Eleven pregnant, Angus x Brahman heifers were randomly assigned to receive one of two dietary treatments: 1) quercetin (250 mg/day; Liftmode.com, Synaptent LLC, Chicago, IL, USA) supplemented group (QR; n = 6) or 2) no quercetin supplemented group (CON; n = 5). Dietary treatments were applied daily from d 190 of gestation until calving in a Calan System (American Calan, Inc., Northwood, NH) with 3.63 kg of a commodity grain and approximately 8.16 kg of hay per head per day. Both groups were subject to ultrasound scanning via rectal ultrasonography of the uterine artery using Color Doppler on d 190, 220, 250, and 270 of gestation. Blood samples were also collected via coccygeal venipuncture for hormone analysis. Data were analyzed using the ANOVA method within the Proc Mixed procedure of SAS 9.4. Total blood flow was greater (P < 0.05) on d 248 and even greater (P < 0.05) on d 270 of gestation as compared to d 190 and 220. Contralateral Pulsatility Index (PI) was greater (P < 0.05) in QR treated heifers as compared to CON. Additionally, QR heifers yielded a greater serum progesterone concentration (P < 0.05) as compared to CON but no differences (P > 0.05) between treatments regarding serum estrogen concentrations. Calf birth weight was not different (P > 0.05), but calves from quercetin supplemented dams resulted in greater wither and hip height (P < 0.05). Future research with antioxidant supplementation could lead to further fetal programming implications.

Are there differences in auscultatory pulse in total blood flow restriction between positions, limbs and body segments?

Verification of the auscultatory pulse in total blood flow restriction (BFR) has been a limiting factor in studies due to the way in which it is evaluated and prescribed, as hemodynamic measurements can be directly affected by gravity. The aim of the present study was to compare the auscultatory pulse in BFR between positions, genders, limbs and body segments in healthy young individuals. A total of 156 subjects participated in the study, 76 of whom were male and 80 of whom were female (23.9±3.7 years, 66.5±11.5 kg, 1.67±0.07 m). After filling in registration data, anthropometry was evaluated, and BFR pressure was determined. BFR was evaluated in a randomized manner in both limbs (upper and lower) and in both segments (right and left) in the following positions: a) lying in the supine position; B) sitting with knees and trunk at 90°; and c) standing in the anatomical position. Significant differences were observed between the lying, sitting and standing positions (p<0.05), between genders (p<0.05), between limbs (p<0.05) and between the right and left segments in the lower limb in both genders [males (p=0.014) and females (p=0.009)] in the lying position. However, no significant differences were observed between the right and left segments in the upper limbs (p>0.05). The BFR point appears to differ between positions, genders, lower limbs and segments. Therefore, it is recommended that health professionals should check the BFR point in the position relating to the exercise that will be performed, taking into account gender, lower limbs and body segments.

Normal physiology of the hepatic system

Hepatic blood inflow is from two sources—high-pressure, well-oxygenated blood from the hepatic artery and low-pressure, partly deoxygenated blood from the portal vein. Hepatic inflow is maintained by variation in flows in these two systems. Although less than a third of total blood flow is delivered via the hepatic artery, it is responsible for the majority of hepatic oxygen supply. The liver can be subdivided into eight functionally independent segments, each with its own vascular inflow, outflow, and biliary drainage. The tri-dimensional hepatic microstructure is complex with geographic heterogeneity of hepatocellular function, and resistance to toxic, ischaemic, and metabolic damage. The liver is central to a wide variety of synthetic, metabolic, and detoxification functions. The overall balance of activity may be altered rapidly in response to systemic inflammatory stimuli.