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Vetrugno L, Biasucci DG, Deana C, Spadaro S, Lombardi FA, Longhini F, Pisani L, Boero E, Cereser L, Cammarota G, Maggiore SM. Lung ultrasound and supine chest X-ray use in modern adult intensive care: mapping 30 years of advancement (1993-2023). Ultrasound J 2024; 16:7. [PMID: 38345653 PMCID: PMC10861418 DOI: 10.1186/s13089-023-00351-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/07/2023] [Indexed: 02/15/2024] Open
Abstract
In critically ill patients with acute respiratory failure, thoracic images are essential for evaluating the nature, extent and progression of the disease, and for clinical management decisions. For this purpose, computed tomography (CT) is the gold standard. However, transporting patients to the radiology suite and exposure to ionized radiation limit its use. Furthermore, a CT scan is a static diagnostic exam for the thorax, not allowing, for example, appreciation of "lung sliding". Its use is also unsuitable when it is necessary to adapt or decide to modify mechanical ventilation parameters at the bedside in real-time. Therefore, chest X-ray and lung ultrasound are today's contenders for shared second place on the podium to acquire a thoracic image, with their specific strengths and limitations. Finally, electrical impedance tomography (EIT) could soon have a role, however, its assessment is outside the scope of this review. Thus, we aim to carry out the following points: (1) analyze the advancement in knowledge of lung ultrasound use and the related main protocols adopted in intensive care units (ICUs) over the latest 30 years, reporting the principal publications along the way, (2) discuss how and when lung ultrasound should be used in a modern ICU and (3) illustrate the possible future development of LUS.
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Affiliation(s)
- Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, 66100, Chieti, Via Dei Vestini, Italy
| | - Daniele Guerino Biasucci
- Department of Clinical Science and Translational Medicine, 'Tor Vergata' University of Rome, Rome, Italy
| | - Cristian Deana
- Anesthesia and Intensive Care 1, Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Piazzale S. M. Della Misericordia 15, 33100, Udine, Italy.
| | - Savino Spadaro
- Department of Translational Medicine, Anesthesia and Intensive Care Unit, University of Ferrara, Ferrara, Italy
| | | | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Luigi Pisani
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Intensive Care Unit, Miulli Regional Hospital, Acquaviva Delle Fonti, Italy
| | - Enrico Boero
- Anesthesia and Intensive Care Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Lorenzo Cereser
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S. Maria Della Misericordia, Azienda Sanitaria-Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Gianmaria Cammarota
- Anesthesia and Intensive Care, Department of Translational Medicine, Eastern Piedmont University, Novara, Italy
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, 66100, Chieti, Via Dei Vestini, Italy
- Department of Innovative Technologies in Medicine and Dentistry, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
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Nikitiuk BE, Rydzewska-Rosołowska A, Kakareko K, Głowińska I, Hryszko T. On Whether Ca-125 Is the Answer for Diagnosing Overhydration, Particularly in End-Stage Kidney Disease Patients-A Systematic Review. Int J Mol Sci 2024; 25:2192. [PMID: 38396869 PMCID: PMC10889175 DOI: 10.3390/ijms25042192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/04/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Overhydration (OH) is a prevalent medical problem that occurs in patients with kidney failure, but a specific marker has still not been found. Patients requiring kidney replacement therapy suffer from a water imbalance, which is correlated with mortality rates in this population. Currently, clinicians employ techniques such as bioimpedance spectroscopy (BIS) and ultrasound (USG) markers of overhydration or markers of heart and kidney function, namely NT-pro-BNP, GFR, or creatinine levels. New serum markers, including but not limited to Ca-125, galectin-3 (Gal-3), adrenomedullin (AMD), and urocortin-2 (UCN-2), are presently under research and have displayed promising results. Ca-125, which is a protein mainly used in ovarian cancer diagnoses, holds great potential to become an OH marker. It is currently being investigated by cardiologists as it corresponds to the volume status in heart failure (HF) and ventricular hypertrophy, which are also associated with OH. The need to ascertain a more precise marker of overhydration is urgent mainly because physical examinations are exceptionally inaccurate. The signs and symptoms of overhydration, such as edema or a gradual increase in body mass, are not always present, notably in patients with chronic kidney disease. Metabolic disruptions and cachexia can give a false picture of the hydration status. This review paper summarizes the existing knowledge on the assessment of a patient's hydration status, focusing specifically on kidney diseases and the role of Ca-125.
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Affiliation(s)
| | - Alicja Rydzewska-Rosołowska
- 2nd Department of Nephrology, Hypertension, and Internal Medicine with Dialysis Unit, Medical University of Bialystok, 15-276 Bialystok, Poland; (B.E.N.); (K.K.); (I.G.); (T.H.)
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53
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Chen R, Gao B, Wang X, Zhao H, Wang X, Liu D. Ultrasonographic assessment of renal microcirculation is a new vision for the treatment of intensive care unit associated acute kidney injury. Eur J Med Res 2024; 29:115. [PMID: 38341556 PMCID: PMC10858548 DOI: 10.1186/s40001-024-01704-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Affiliation(s)
- Rongping Chen
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Beijun Gao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xinchen Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Hua Zhao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
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Ramasco F, Nieves-Alonso J, García-Villabona E, Vallejo C, Kattan E, Méndez R. Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies. J Pers Med 2024; 14:176. [PMID: 38392609 PMCID: PMC10890552 DOI: 10.3390/jpm14020176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/15/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.
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Affiliation(s)
- Fernando Ramasco
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Jesús Nieves-Alonso
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Esther García-Villabona
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Carmen Vallejo
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Eduardo Kattan
- Departamento de Medicina Intensiva del Adulto, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Rosa Méndez
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
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Li ZT, Huang DB, Zhao JF, Li H, Fu SQ, Wang W. Comparison of various surrogate markers for venous congestion in predicting acute kidney injury following cardiac surgery: A cohort study. J Crit Care 2024; 79:154441. [PMID: 37812993 DOI: 10.1016/j.jcrc.2023.154441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/10/2023] [Accepted: 09/27/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Venous congestion has been demonstrated to increase the risk of acute kidney injury (AKI) after cardiac surgery. Although many surrogate markers for venous congestion are currently used in clinical settings, there is no consensus on which marker is most effective in predicting AKI. METHODS We evaluated various markers of venous congestion, including central venous pressure (CVP), inferior vena cava (IVC) diameter, portal pulsatility fraction (PPF), hepatic vein flow pattern (HVF), intra-renal venous flow pattern (IRVF), and venous excess ultrasound grading score (VExUS) in adult patients undergoing cardiac surgery to compare their ability in predicting AKI. RESULTS Among the 230 patients enrolled in our study, 53 (23.0%) developed AKI, and 11 (4.8%) required continuous renal replacement therapy (CRRT). Our multivariate logistic analysis revealed that IRVF, PPF, HVF, and CVP were significantly associated with AKI, with IRVF being the strongest predictor (odds ratio [OR] 2.27; 95% confidence interval [CI], 1.38-3.73). However, we did not observe any association between these markers and CRRT. CONCLUSION Venous congestion is associated with AKI after cardiac surgery, but not necessarily with CRRT. Among the markers tested, IRVF exhibits the strongest correlation with AKI.
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Affiliation(s)
- Zhi-Tao Li
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital, Zhejiang University, School of Medicine, China
| | - Da-Bing Huang
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital, Zhejiang University, School of Medicine, China
| | - Jian-Feng Zhao
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital, Zhejiang University, School of Medicine, China
| | - Hui Li
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital, Zhejiang University, School of Medicine, China
| | - Shui-Qiao Fu
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital, Zhejiang University, School of Medicine, China.
| | - Wei Wang
- Department of Surgical Intensive Care Unit, The First Affiliated Hospital, Zhejiang University, School of Medicine, China.
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Gil-Rodrigo A, Luque-Hernández MJ, Martínez Buendía C, Escribano-Castillo R. Letter to the editor about the article "Role of the femoral vein doppler in acute heart failure patients: results from a prospective multicentric study". Rev Clin Esp 2024; 224:118-119. [PMID: 38228270 DOI: 10.1016/j.rceng.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Affiliation(s)
- A Gil-Rodrigo
- Servicio de Urgencias, Unidad de Corta Estancia y Unidad de Hospitalización a Domicilio, Hospital General Universitario Dr. Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain.
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57
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Di Maria A, Siligato R, Bondanelli M, Fabbian F. Venous Doppler flow patterns, venous congestion, heart disease and renal dysfunction: A complex liaison. World J Cardiol 2024; 16:5-9. [PMID: 38313388 PMCID: PMC10835472 DOI: 10.4330/wjc.v16.i1.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/15/2023] [Accepted: 01/03/2024] [Indexed: 01/19/2024] Open
Abstract
The World Journal of Cardiology published an article written by Kuwahara et al that we take the pleasure to comment on. We focused our attention on venous congestion. In intensive care settings, it is now widely accepted that venous congestion is an important clinical feature worthy of investigation. Evaluating venous Doppler profile abnormalities at multiple sites could suggest adequate treatment and monitor its efficacy. Renal dysfunction could trigger or worsen fluid overload in heart disease, and cardio-renal syndrome is a well-characterized spectrum of disorders describing the complex interactions between heart and kidney diseases. Fluid overload and venous congestion, including renal venous hypertension, are major determinants of acute and chronic renal dysfunction arising in heart disease. Organ congestion from venous hypertension could be involved in the development of organ injury in several clinical situations, such as critical diseases, congestive heart failure, and chronic kidney disease. Ultrasonography and abnormal Doppler flow patterns diagnose clinically significant systemic venous congestion. Cardiologists and nephrologists might use this valuable, non-invasive, bedside diagnostic tool to establish fluid status and guide clinical choices.
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Affiliation(s)
- Alessio Di Maria
- Specialized Medicines, Renal Unit, University Hospital St. Anna of Ferrara, Ferrara I-44124, Italy
| | - Rossella Siligato
- Specialized Medicines, Renal Unit, University Hospital St. Anna of Ferrara, Ferrara I-44124, Italy
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Messina I-98121, Italy
| | - Marta Bondanelli
- Department of Medical Sciences, University of Ferrara, Ferrara I-44124, Italy
| | - Fabio Fabbian
- Department of Medical Sciences, University of Ferrara, Ferrara 44124, Italy.
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58
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Rodríguez-Moguel N, Osuna-Padilla IA, Piekarska KB, Negrete-García MF, Hernández-Muñoz A, Contreras-Marín JA, Montaño-Mattar R, Casas-Aparicio G. Fluid Status Assessment in Critically Ill Patients with COVID-19: A Retrospective Cohort Study. J Clin Med 2024; 13:540. [PMID: 38256674 PMCID: PMC10816646 DOI: 10.3390/jcm13020540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/03/2024] [Accepted: 01/07/2024] [Indexed: 01/24/2024] Open
Abstract
Fluid status (FS) is a diagnostic challenge in critically ill patients with COVID-19. Here, we compared parameters related to FS derived from cumulative fluid balance (CFB), bioelectrical impedance analysis (BIA) and venous congestion assessed by ultrasound (VExUS) to predict mortality. We retrospectively reviewed the medical records of individuals with severe pneumonia due to COVID-19 between July and November 2021 in a single center. Comorbidities, demographic, clinical and laboratory data as well as results from CFB, BIA and VExUS measurements were collected on admission and weekly afterwards for two consecutive evaluations. Seventy-nine patients were included, of which eighteen (14.2%) died. Abnormalities of FS were only identified by BIA. Extracellular water/total body water ratio (ECW/TBW) > 0.394 (overhydrated) by BIA was a good predictor of mortality (AUC = 0.78, 95% CI: 0.067-0.89). Mortality risk was higher in overhydrated patients (OR: 6.2, 95% CI: 1.2-32.6, p = 0.02) and in persistently overhydrated patients (OR: 9.57, 95% CI: 1.18-77.5, p = 0.03) even after adjustment to age, serum albumin and acute kidney injury (AKI) in stages 2-3. Time to death was shorter in overhydrated patients (HR: 2.82, 95% CI: 1.05-7.5, log-rank test p = 0.03). Abnormalities in FS associated with mortality were only identified by BIA in critically ill patients with COVID-19.
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Affiliation(s)
- Nadia Rodríguez-Moguel
- Departamento de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, Mexico City 14080, Mexico;
| | - Ivan Armando Osuna-Padilla
- Departamento de Áreas Críticas, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, Mexico City 14080, Mexico;
| | - Karolina Bozena Piekarska
- Departamento de Enseñanza, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, Mexico City 14080, Mexico; (K.B.P.); (M.-F.N.-G.); (J.A.C.-M.); (R.M.-M.)
| | - María-Fernanda Negrete-García
- Departamento de Enseñanza, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, Mexico City 14080, Mexico; (K.B.P.); (M.-F.N.-G.); (J.A.C.-M.); (R.M.-M.)
| | - Andrea Hernández-Muñoz
- Facultad de Nutrición, Universidad Autónoma del Estado de Morelos, Cuernavaca 62209, Mexico;
| | - Julián Andrés Contreras-Marín
- Departamento de Enseñanza, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, Mexico City 14080, Mexico; (K.B.P.); (M.-F.N.-G.); (J.A.C.-M.); (R.M.-M.)
| | - Roberto Montaño-Mattar
- Departamento de Enseñanza, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, Mexico City 14080, Mexico; (K.B.P.); (M.-F.N.-G.); (J.A.C.-M.); (R.M.-M.)
- Facultad de Nutrición, Universidad Autónoma del Estado de Morelos, Cuernavaca 62209, Mexico;
- Departamento de Nefrología, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, Mexico City 14080, Mexico
| | - Gustavo Casas-Aparicio
- Departamento de Nefrología, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, Mexico City 14080, Mexico
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Romero-González G, Argaiz ER, Koratala A, González DA, Vives M, Juega J, Soler-Majoral J, Graterol F, Perezpayá I, Rodriguez-Chitiva N, Lorenzo-Ferris I, Narvaez C, Manrique J, Morales E, Rivera-Gorrín M, Ibeas J, Bover J, Sánchez E, de Sequera P. Towards standardization of POCUS training in Nephrology: the time is NOW. Nefrologia 2024; 44:5-9. [PMID: 38429147 DOI: 10.1016/j.nefroe.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 03/03/2024] Open
Affiliation(s)
- Gregorio Romero-González
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain; International Renal Research Institute of Vicenza, Vicenza, Italy.
| | - Eduardo R Argaiz
- Servicio de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México; Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Spain
| | - Abhilash Koratala
- División de Nefrología, Medical College of Wisconsin, Milwaukee, USA
| | - Duilio Ariel González
- Miembro del Grupo de la Red Española de Ecografía en Cuidado Crítico. Servicio de Anestesiología y Reanimación, Clínica Universidad de Navarra, Pamplona, Spain
| | - Marc Vives
- Copresidente del Grupo de la Red Española de Ecografía en Cuidado Crítico, Servicio de Anestesiología y Reanimación, Clínica Universidad de Navarra, Profesor Asociado, Facultad de Medicina, Universidad de Navarra, Pamplona, Spain
| | - Javier Juega
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Jordi Soler-Majoral
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Fredzzia Graterol
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Inés Perezpayá
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Néstor Rodriguez-Chitiva
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain
| | | | - Carlos Narvaez
- Servicio de Nefrología, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Joaquín Manrique
- Servicio de Nefrología, Hospital Universitario de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Enrique Morales
- Servicio de Nefrología, Hospital 12 de Octubre, Madrid, Spain
| | - Maite Rivera-Gorrín
- Servicio de Nefrología, Hospital Universitario Ramón y Cajal. IRyCis. UAH, Madrid, Spain; Coordinadora del Grupo de Nefrología Diagnóstica e Intervencionista de la Sociedad Española de Nefrología, Spain
| | - José Ibeas
- Servicio de Nefrología, Parc Taulí Hospital Universitari, Institut d´investigació i innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - Jordi Bover
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Emilio Sánchez
- Servicio de Nefrología, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
| | - Patricia de Sequera
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, Spain
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Loosen G, Conrad AM, Essert N, Boesing C, Hagmann M, Thiel M, Luecke T, Rocco PRM, Pelosi P, Krebs J. Preload Responsiveness in Patients With Acute Respiratory Distress Syndrome Managed With Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:53-61. [PMID: 37934718 DOI: 10.1097/mat.0000000000002054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
A restrictive fluid strategy is recommended in patients with acute respiratory distress syndrome (ARDS) managed with venovenous extracorporeal membrane oxygenation (VV ECMO). However, there are no established predictors for preload responsiveness in these patients. In 20 ARDS patients managed with VV ECMO, transesophageal echocardiography was used to repeatedly evaluate dynamic parameters of the left (velocity and stroke volume variation) and right ventricular outflow tract (velocity [respiratory variations of the maximal Doppler velocity in the truncus pulmonalis {ΔV max TP}] and velocity time integral [respiratory variation of the velocity time integral measured in the truncus pulmonalis {ΔVTI_TP}] variation in the truncus pulmonalis), the diameter variation in the superior and inferior vena cava and stroke volume variation measured by pulse contour analysis (SVV_PCA). Patients were categorized as responders and nonresponders according to an increase in stroke volume measured by echocardiography during a Passive Leg Raise Test with a cutoff value ≥10%. The final analysis includes 86 measurements. Predictive values for preload responsiveness were found for ΔV max TP (area under the curve [AUC] of 0.64), ΔVTI_TP (AUC 0.67), and SVV_PCA (AUC 0.74). In conclusion, SVV_PCA and, to a lesser extent, ΔV max TP and ΔVTI_TP are the most accurate parameters to predict preload responsiveness in ARDS patients managed with VV ECMO. Transesophageal echocardiography offers no advantages over pulse contour analysis for predicting preload responsiveness and provides only intermittent monitoring and assessment.
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Affiliation(s)
- Gregor Loosen
- From the Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Alice Marguerite Conrad
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Nils Essert
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Christoph Boesing
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Michael Hagmann
- Department of Computational Linguistics, University of Heidelberg, Heidelberg, Germany
- Interdisciplinary Centre for Scientific Computing, Statistical Natural Language Processing Group, University of Heidelberg, Heidelberg, Germany
| | - Manfred Thiel
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Thomas Luecke
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Department of Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Joerg Krebs
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
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Gómez-Álvarez U, de la Fuente-Mancera JC, Antonio-Villa NE, Álvarez-Sangabriel A, Guizar-Sánchez CA, Tenorio-Bautista F. Experience with the Kosmos ultrasonographic tool in the approach and treatment of ambulatory patients of a heart failure clinic: a single-center cross-sectional study. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2024; 94:79-85. [PMID: 38507324 PMCID: PMC11160521 DOI: 10.24875/acm.22000250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 09/29/2023] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND In Mexico, the epidemiology of heart failure is still not well understood. However, it is known that the primary cause of hospital admissions in patients with heart failure is pulmonary and systemic congestion. OBJECTIVE To estimate congestion status and assess cardiac function using portable ultrasound in patients with heart failure. METHOD A cross-sectional observational study was conducted. Patients who attended the Heart Failure Clinic at the Ignacio Chávez National Cardiology Institute in Mexico City between May and August 2022 were selected. They underwent ultrasonographic evaluation using a portable device to assess pulmonary and systemic congestion, as well as cardiac function and structure. RESULTS One-hundred patients diagnosed with heart failure were prospectively included during the study period; 76% were male, with an average age of 59 years (range: 50-68 years). The recorded LVEF median was 34% (IQR: 27-43.5%). When evaluating pulmonary congestion, 78% of the patients showed a pattern A and 22% a pattern B. Following the VExUS protocol, 92% of the patients were at grade 0, 2% at grade 1, and 6% at grade 2. CONCLUSIONS The use of the portable ultrasound facilitated the quantitative characterization of the echocardiographic features of the studied population. This device could provide better clinical characterization which, in turn, might allow for optimized drug prescription for heart failure and dose adjustments of diuretics based on echocardiographic congestion findings.
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Affiliation(s)
- Ulises Gómez-Álvarez
- Clínica de Insuficiencia Cardiaca y Trasplante, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Juan C. de la Fuente-Mancera
- Clínica de Insuficiencia Cardiaca y Trasplante, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Neftali E. Antonio-Villa
- Clínica de Insuficiencia Cardiaca y Trasplante, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Amada Álvarez-Sangabriel
- Clínica de Insuficiencia Cardiaca y Trasplante, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Carlos A. Guizar-Sánchez
- Clínica de Insuficiencia Cardiaca y Trasplante, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Fernando Tenorio-Bautista
- Clínica de Insuficiencia Cardiaca y Trasplante, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
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62
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Zhou L, Wiley BM. Current and Future Role of Ultrasonography in the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:15-35. [PMID: 37973351 DOI: 10.1016/j.ccc.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
The contemporary practice of ultrasonography in the cardiac intensive care unit integrates the principles of echocardiography with whole-body imaging to create a more expansive paradigm of critical care ultrasonography (CCUS). This article will review the use of CCUS for diagnostic assessment, monitoring, therapeutic guidance, and prognosis.
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Affiliation(s)
- Leon Zhou
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medical Center, Clinic Tower A6E108, 2051 Marengo Street, Los Angeles, CA 90033, USA
| | - Brandon M Wiley
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medical Center, Clinic Tower A6E108, 2051 Marengo Street, Los Angeles, CA 90033, USA.
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Bianchi Bosisio NSM, Romero-González G, De Silvestri A, Husain-Syad F, Ferrari F. Doppler-based evaluation of intrarenal venous flow as a new tool to predict acute kidney injury: A systematic review and meta-analysis. Nefrologia 2023; 43 Suppl 2:57-66. [PMID: 38245439 DOI: 10.1016/j.nefroe.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 03/14/2023] [Indexed: 01/22/2024] Open
Abstract
Congestion is a common complication in the critical care setting, these patients are at increased risk of developing acute kidney injury (AKI). Congestive nephropathy (CN) has recently been described as a mechanism of worsening renal function, and evaluation of renal venous flow by pulsed Doppler (PD) is a useful tool to assess the presence of renal vein congestion. We comprehensively explore the ability of the PD in the evaluation of the intrarenal venous flow (IRVF) to predict the development of AKI in critically ill patients. We searched Pubmed-MEDLINE, Scopus, Embase, and Cochrane Library of Systematic Reviews (to 31th December 2021). We evaluated the association between Doppler-based Intrarenal venous flow demodulation and AKI. CN was defined as the presence of a pulsatile pattern (biphasic or monophasic) in the PD. A total of 4 articles (660 patients) were included in our systematic review, three of these in the metanalysis (413 patients): one study was excluded because its data were inadequate for pooling. Two studies originated in Europe and the other two in the United States. AKI occurrence ranged between 34 and 68%. Patients who developed AKI had a significant difference in PD pattern (continuous vs. pulsatile) in the IRVF (RR=0.46; 95% CI 0.28-0.76). Nevertheless, a large heterogeneity was observed among the studies (I2=68.7%; p=0.04). Albeit preliminary, these findings suggest that the presence of a pulsatile pattern in the PD of the IRVF may be involved in the development of AKI in the critically ill patient. The effect of alterations in the IRVF and renal function warrant further investigation.
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Affiliation(s)
| | - Gregorio Romero-González
- Department of Nephrology, Hospital Germans Trias i Pujol, Badalona, Spain; International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
| | - Annalisa De Silvestri
- Clinical Epidemiology and Biometrics Service, Scientific Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Faeq Husain-Syad
- Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Giessen, Germany; International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
| | - Fiorenza Ferrari
- Anaesthesiology and Intensive Care Unit 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.
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64
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Magin JC, Wrobel JR, An X, Acton J, Doyal A, Jia S, Krakowski JC, Schoenherr J, Serrano R, Flynn D, McLean D, Grant SA. Venous Excess Ultrasound (VExUS Grading to Assess Perioperative Fluid Status for Noncardiac Surgeries: a Prospective Observational Pilot Study. POCUS JOURNAL 2023; 8:223-229. [PMID: 38099161 PMCID: PMC10721303 DOI: 10.24908/pocus.v8i2.16792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Objectives: Perioperative fluid administration impacts the rate of complications following surgery. VExUS grading system is a standardized point of care ultrasound (POCUS)-based, comprehensive method to assess volume status. VExUS could serve as a tool to guide fluid management, if validated perioperatively. The primary aim was to assess the success rate of obtaining required windows for VExUS grading , as well as the feasibility within a perioperative setting among noncardiac surgery. Further, this study describes the incidence of perioperative venous congestion and associations with 30-day postoperative complications. Methods: This observational study was conducted in non-critically ill adults undergoing noncardiac surgery. Patients were scanned preoperatively, in the post anesthesia care unit (PACU), and 24 hours postoperatively for venous congestion. Researchers retrospectively captured 30-day complications for multivariate analyses. Results: The cohort included 69 participants. Ninety-one percent of scans over all timepoints were successfully completed. Pre-operatively, 57 (83%) scans were Grade 0, and 11 (16%) were Grade 1. Venous congestion was observed in 29 (44%) patients in the PACU (n=66). 22 (33%) patients were Grade 1, while 7 (11%) were Grade 2. At 24 hours (n=63), 31 patients (49%) had venous congestion: 20 (32%) Grade 1 and 11 (17%) Grade 2. Of the pre-operative Grade 0, 28 (50%) had at least one postoperative scan with venous congestion. No patients were Grade 3 at any timepoint. The 30-day complication rate was 32% (n=22). Eleven (16%) patients developed acute kidney injury (AKI). There was no statistically significant association between VExUS grading and all-cause complications or AKI. Conclusion: This study demonstrates that perioperative VExUS scoring is a feasible tool among a variety of noncardiac surgeries. We highlight that venous congestion is common and increases postoperatively within non-ICU populations. Larger studies are needed to assess the relationship between VExUS grading and postoperative complications.
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Affiliation(s)
- Justin C Magin
- University of North Carolina School of MedicineChapel Hill, NCUSA
| | - Jacob R Wrobel
- University of North Carolina School of MedicineChapel Hill, NCUSA
| | - Xinming An
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Jacob Acton
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Alexander Doyal
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Shawn Jia
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - James C Krakowski
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Jay Schoenherr
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Ricardo Serrano
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - David Flynn
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Duncan McLean
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Stuart A Grant
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
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65
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Tierney DM, Rosborough TK, Sipsey LM, Hanson K, Smith CS, Boland LL, Miner R. Association of Internal Medicine Point of Care Ultrasound (POCUS) with Length of Stay, Hospitalization Costs, and Formal Imaging: a Prospective Cohort Study. POCUS JOURNAL 2023; 8:184-192. [PMID: 38099159 PMCID: PMC10721304 DOI: 10.24908/pocus.v8i2.16791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Background: Point of care ultrasound (POCUS) use has rapidly expanded among internal medicine (IM) physicians in practice and residency training programs. Many benefits have been established; however, studies demonstrating the impact of POCUS on system metrics are few and mostly limited to the emergency department or intensive care setting. The study objective was to evaluate the impact of inpatient POCUS on patient outcomes and hospitalization metrics. Methods: Prospective cohort study of 12,399 consecutive adult admissions to 22 IM teaching attendings, at a quaternary care teaching hospital (7/1/2011-6/30/2015), with or without POCUS available during a given hospitalization. Multivariable regression and propensity score matching (PSM) analyses compared multiple hospital metric outcomes (costs, length of stay, radiology-based imaging, satisfaction, etc.) between the "POCUS available" vs. "POCUS unavailable" groups as well as the "POCUS available" subgroups of "POCUS used" vs. "POCUS not used". Results: Patients in the "POCUS available" vs. "POCUS unavailable" group had lower mean total and per-day hospital costs ($17,474 vs. $21,803, p<0.001; $2,805.88 vs. $3,557.53, p<0.001), lower total and per-day radiology cost ($705.41 vs. $829.12, p<0.001; $163.11 vs. $198.53, p<0.001), fewer total chest X-rays (1.31 vs. 1.55, p=0.01), but more chest CTs (0.22 vs 0.15; p=0.001). Mean length of stay (LOS) was 5.77 days (95% CI = 5.63, 5.91) in the "POCUS available" group vs. 6.08 95% CI (5.66, 6.51) in the "POCUS unavailable" group (p=0.14). Within the "POCUS available" group, cost analysis with a 4:1 PSM (including LOS as a covariate) compared patients receiving POCUS vs. those that could have but did not, and also showed total and per-day cost savings in the "POCUS used" subgroup ($15,082 vs. 15,746; p<0.001 and $2,685 vs. $2,753; p=0.04). Conclusions: Availability and selected use of POCUS was associated with a meaningful reduction in total hospitalization cost, radiology cost, and chest X-rays for hospitalized patients.
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Affiliation(s)
- David M Tierney
- Department of Graduate Medical Education, Abbott Northwestern HospitalMinneapolis, MNUSA
| | - Terry K Rosborough
- Department of Graduate Medical Education, Abbott Northwestern HospitalMinneapolis, MNUSA
| | - Lynn M Sipsey
- Department of Graduate Medical Education, Abbott Northwestern HospitalMinneapolis, MNUSA
| | - Kai Hanson
- Allina Health Care Delivery ResearchMinneapolis, MNUSA
| | | | - Lori L Boland
- Allina Health Care Delivery ResearchMinneapolis, MNUSA
| | - Robert Miner
- Department of Graduate Medical Education, Abbott Northwestern HospitalMinneapolis, MNUSA
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66
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Gargani L, Girerd N, Platz E, Pellicori P, Stankovic I, Palazzuoli A, Pivetta E, Miglioranza MH, Soliman-Aboumarie H, Agricola E, Volpicelli G, Price S, Donal E, Cosyns B, Neskovic AN. Lung ultrasound in acute and chronic heart failure: a clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI). Eur Heart J Cardiovasc Imaging 2023; 24:1569-1582. [PMID: 37450604 PMCID: PMC11032195 DOI: 10.1093/ehjci/jead169] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023] Open
Affiliation(s)
- Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, via Paradisa 2 5614, Pisa, Italy
| | - Nicolas Girerd
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, CHRU de Nancy, INSERM DCAC, F-CRIN INI-CRCT, Nancy, France
| | - Elke Platz
- Cardiovascular Division, Brigham and Women’s Hospital and Harvard Medical School, Boston, USA
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Ivan Stankovic
- Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Serbia
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio-Thoracic and Vascular Department, Le Scotte Hospital, University of Siena, Italy
| | - Emanuele Pivetta
- Medicina d'Urgenza-MECAU, Presidio Molinette, A.O.U. Città della Salute e della Scienza di Torino, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marcelo Haertel Miglioranza
- EcoHaertel - Hospital Mae de Deus, Porto Alegre, Brazil
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Hatem Soliman-Aboumarie
- Department of Cardiothoracic Anaesthesia and Critical Care, Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, King’s College London, UK
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Giovanni Volpicelli
- Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Torino, Italy
| | - Susanna Price
- Departments of Cardiology & Intensive Care, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, Rennes, France
| | - Bernard Cosyns
- Department of Cardiology, Universitair Ziekenhuis Brussel, Jette, Brussels, Belgium
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67
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Liu L, Liu D, Hu Z, Wang X, Chao Y, Wu J, Yin W, Zhang H, Zhang L, He W, Zhu R, Xu Q, Yang R, Huo Y, Zhang Q, Liu H, Zhu W, Zhang Q, Li R. Renal hemodynamic evaluation protocol based on the pathophysiological mechanism of acute kidney injury: Critical Care UltraSound Guided-A (KI)BCDE. Ren Fail 2023; 45:2284842. [PMID: 37994455 PMCID: PMC11001348 DOI: 10.1080/0886022x.2023.2284842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023] Open
Abstract
The multiple etiological characteristics of acute kidney injury (AKI) have brought great challenges to its clinical diagnosis and treatment. Renal injury in critically ill patients always indicates hemodynamic injury. The Critical Care UltraSound Guided (CCUSG)-A(KI)BCDE protocol developed by the Chinese Critical Ultrasound Study Group (CCUSG), respectively, includes A(KI) diagnosis and risk assessment and uses B-mode ultrasound, Color doppler ultrasound, spectral Doppler ultrasound, and contrast Enhanced ultrasound to obtain the hemodynamic characteristics of the kidney so that the pathophysiological mechanism of the occurrence and progression of AKI can be captured and the prognosis of AKI can be predicted combined with other clinical information; therefore, the corresponding intervention and treatment strategies can be formulated to achieve targeted, protocolized, and individualized therapy.
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Affiliation(s)
- Lixia Liu
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Dawei Liu
- Department of Intensive Care Department, Peking Union Medical College Hospital, Beijing, China
| | - Zhenjie Hu
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoting Wang
- Department of Intensive Care Department, Peking Union Medical College Hospital, Beijing, China
| | - Yangong Chao
- Department of Critical Care Medicine, The First Affiliated Hospital of Tsinghua University, Beijing, China
| | - Jun Wu
- Department of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wanhong Yin
- Department of Intensive Care, West China Hospital, Sichuan University, Chengdu, China
| | - Hongmin Zhang
- Department of Intensive Care Department, Peking Union Medical College Hospital, Beijing, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Wei He
- Department of Intensive Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ran Zhu
- Department of Intensive Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Qianghong Xu
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China
| | - Rongli Yang
- Department of Critical Care Medicine, The Central Hospital of Dalian, Dalian, China
| | - Yan Huo
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qian Zhang
- Department of Intensive Care Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Haitao Liu
- Department of Critical Care Medicine, The Fourth Hospital of Harbin Medical University, Harbin, China
| | - Weihua Zhu
- Department of Intensive Care Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Qian Zhang
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Rong Li
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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68
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Kaptein EM, Kaptein MJ. Inferior vena cava ultrasound and other techniques for assessment of intravascular and extravascular volume: an update. Clin Kidney J 2023; 16:1861-1877. [PMID: 37915939 PMCID: PMC10616489 DOI: 10.1093/ckj/sfad156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Indexed: 11/03/2023] Open
Abstract
Goals of volume management are to accurately assess intravascular and extravascular volume and predict response to volume administration, vasopressor support or volume removal. Data are reviewed that support the following: (i) Dynamic parameters reliably guide volume administration and may improve clinical outcomes compared with static parameters, but some are invasive or only validated with mechanical ventilation without spontaneous breathing. (ii) Ultrasound visualization of inferior vena cava (IVC) diameter variations with respiration reliably assesses intravascular volume and predicts volume responsiveness. (iii) Although physiology of IVC respiratory variations differs with mechanical ventilation and spontaneous breathing, the IVC collapsibility index (CI) and distensibility index are interconvertible. (iv) Prediction of volume responsiveness by IVC CI is comparable for mechanical ventilation and spontaneous breathing patients. (v) Respiratory variations of subclavian/proximal axillary and internal jugular veins by ultrasound are alternative sites, with comparable reliability. (vi) Data support clinical applicability of IVC CI to predict hypotension with anesthesia, guide ultrafiltration goals, predict dry weight, predict intra-dialytic hypotension and assess acute decompensated heart failure. (vii) IVC ultrasound may complement ultrasound of heart and lungs, and abdominal organs for venous congestion, for assessing and managing volume overload and deresuscitation, renal failure and shock. (viii) IVC ultrasound has limitations including inadequate visualization. Ultrasound data should always be interpreted in clinical context. Additional studies are required to further assess and validate the role of bedside ultrasonography in clinical care.
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Affiliation(s)
- Elaine M Kaptein
- Departments of Medicine, Divisions of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - Matthew J Kaptein
- Departments of Medicine, Divisions of Nephrology, University of Southern California, Los Angeles, CA, USA
- Loma Linda University Medical Center, Loma Linda, CA, USA
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69
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Galarza Barrachina L, Colinas Fernández L, Martín Bermúdez R, Fernández Galilea A, Martín-Villén L. Abdominal ultrasound and VExUS score in critical care. Med Intensiva 2023; 47:658-667. [PMID: 38783747 DOI: 10.1016/j.medine.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/23/2023] [Indexed: 05/25/2024]
Abstract
The use of ultrasound while caring for critically ill patients has been increasing exponentially in the last two decades and now is an essential component of intensive care practice. Abdominal ultrasound is an established technique in other specialties, but its use in intensive care has lagged behind other ultrasound modalities. However, its potential role in the diagnosis and management of patients will make it an invaluable tool for intensivists. The main use of abdominal ultrasound at the bedside is for free fluid detection in trauma patients. But abdominal ultrasound can also help us diagnose patients with abdominal pain, hypovolemia or anuria, and it can guide us during procedures such as paracentesis or bladder catheter and gastric tube placement.
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Affiliation(s)
| | | | | | | | - Luis Martín-Villén
- UGC Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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70
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Gupta B, Ahluwalia P, Gupta A, Ranjan N, Kakkar K, Aneja P. Utility of VExUS score in the peri-operative care unit, intensive care unit, and emergency setting - A systematic review. Indian J Anaesth 2023; 67:S218-S226. [PMID: 38187971 PMCID: PMC10768914 DOI: 10.4103/ija.ija_475_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/08/2023] [Accepted: 10/31/2023] [Indexed: 01/09/2024] Open
Abstract
Background and Aims The venous excess ultrasound (VExUS) score presents a prospect of valuable clinical utility. The study aimed to systematically review the effectiveness of the VExUS score in detecting venous congestion across emergency, critical care, and peri-operative contexts; assessing its utility in improved patient outcomes; and exploring its relationship with established parameters. Methods This systematic review was registered in the International Prospective Register of Systematic Reviews (CRD42023421034). A comprehensive literature search, employing pre-defined search terms related to the VExUS score in diverse clinical contexts, was conducted on articles published between 2000 and 15 May 2023 across databases- PubMed, PubMed Central, Cochrane, Scopus, Elsevier Clinical Key, and Google Scholar. Bias risk assessment was carried out using the Risk of Bias in Non-Randomised Studies tool. Given the significant heterogeneity across studies concerning participants, interventions, outcomes, and study designs, data pooling for a meaningful meta-analysis was not feasible. Results The review included 15 articles comprising observational studies, case series, and case reports. Most patients exhibited moderate-to-severe venous congestion based on their baseline VExUS scores. Higher VExUS scores correlated with a greater risk of acute kidney injury (AKI) in post-operative patients. The VExUS score strongly correlated with central venous pressure; specific components, such as the intra-renal monophasic pattern, portal-pulsatility, and inferior vena cava diameter, exhibited robust predictive value for venous congestion. Conclusion VExUS score is valuable in assessing and predicting venous congestion, especially regarding AKI prediction risk and guiding interventions. However, its utility in predicting outcomes in acute heart failure patients appears less certain.
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Affiliation(s)
- Bhavna Gupta
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Pallavi Ahluwalia
- Department of Anaesthesiology, Teerthanker Mahaveer Medical College, Moradabad, Uttar Pradesh, India
| | - Anish Gupta
- Department of Cardio Thoracic and Vascular Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Nikhil Ranjan
- Department of Anaesthesiology, Safdarjung Hospital, New Delhi, India
| | - Kamna Kakkar
- Department of Anaesthesiology, Safdarjung Hospital, New Delhi, India
| | - Parag Aneja
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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71
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Rihl MF, Pellegrini JAS, Boniatti MM. VExUS Score in the Management of Patients With Acute Kidney Injury in the Intensive Care Unit: AKIVEX Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2547-2556. [PMID: 37310104 DOI: 10.1002/jum.16288] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/25/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Venous congestion is a potential cause of acute kidney injury (AKI) and venous excess ultrasound (VExUS) score is a potentially useful tool in this scenario. The aim of this study is to verify whether the VExUS score can serve as a guide to decongestion in patients with severe AKI and whether the modification of the score can be associated with an increase in the number of renal replacement therapy (RRT)-free days in 28 days. METHODS This quasi-experimental study was conducted in patients admitted to the intensive care unit who developed severe AKI. The intervention was to suggest to the attending physician the use of diuretic in patients with VExUS >1. After 48 hours, a new VExUS assessment was performed. Primary outcome was RRT-free days at Day 28. RESULTS Ninety patients were included. Patients with a VExUS score >1 (n = 36) at enrollment had a greater use of diuretics in the following 48 hours (75.0%, n = 27) than patients with a VExUS ≤1 (n = 54) at enrollment (38.9%, n = 21), P = .001. Patients who reduced the VExUS score had a significantly greater number of RRT-free days at Day 28 (28.0; 8.0-28.0) when compared with those who did not reduce (15.0; 3.0-27.5), P = .012. CONCLUSIONS We found a higher diuretic use in patients with a higher VExUS score, and patients who reduced the VExUS in 48 hours had significantly more RRT-free days in 28 days.
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Affiliation(s)
- Marcos Frata Rihl
- Postgraduate Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Department of Critical Care, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Márcio Manozzo Boniatti
- Postgraduate Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Department of Critical Care, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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Perry A, Anand Mohan P, Bodker K, Elshennawy M, Taber DJ, Herberth J, Soliman K. Collaborative peri-transplant management of volume status, hypertension, and immunosuppression: enhancing kidney transplants for better outcomes. Ren Fail 2023; 45:2271559. [PMID: 37885261 PMCID: PMC11001351 DOI: 10.1080/0886022x.2023.2271559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023] Open
Affiliation(s)
- Amy Perry
- Medical Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Prince Anand Mohan
- Department of Medicine, Division of Transplant Surgery, Medical University of South Carolina, Lancaster, SC, USA
| | - Kevin Bodker
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | | | - David J. Taber
- Medical Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Johann Herberth
- Medical Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Karim Soliman
- Medical Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA
- Department of Surgery, Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, USA
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73
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Zhang Y, McCurdy MT, Ludmir J. Sepsis Management in the Cardiac Intensive Care Unit. J Cardiovasc Dev Dis 2023; 10:429. [PMID: 37887876 PMCID: PMC10606987 DOI: 10.3390/jcdd10100429] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/28/2023] Open
Abstract
Septic shock management in the cardiac intensive care unit (CICU) is challenging due to the complex interaction of pathophysiology between vasodilatory and cardiogenic shock, complicating how to optimally deploy fluid resuscitation, vasopressors, and mechanical circulatory support devices. Because mixed shock portends high mortality and morbidity, familiarity with quality, contemporary clinical evidence surrounding available therapeutic tools is needed to address the resultant wide range of complications that can arise. This review integrates pathophysiology principles and clinical recommendations to provide an organized, topic-based review of the nuanced intricacies of managing sepsis in the CICU.
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Affiliation(s)
- Yichi Zhang
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Michael T. McCurdy
- Division of Pulmonary & Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Jonathan Ludmir
- Corrigan Minehan Heart Center, Cardiology Division, Massachusetts General Hospital, Boston, MA 02114, USA
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74
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Athanassopoulos GD, Armenis I. A Glimpse for Venous Congestion Management in Pulmonary Hypertension by POCUS of Portal Vein Flow. Am J Cardiol 2023; 205:504-507. [PMID: 37661556 DOI: 10.1016/j.amjcard.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023]
Affiliation(s)
| | - Iakovos Armenis
- Onassis Cardiac Surgery Center Cardiology Section, Athens, Greece
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75
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Guerrero-Gutiérrez MA, García-Guillén FJ, Adame-Encarnación H, Monera-Martínez F, Ñamendys-Silva SA, Córdova-Sánchez BM. Reliability of point-of-care ultrasound to evaluate fluid tolerance performed by critical care residents. Eur J Med Res 2023; 28:431. [PMID: 37828607 PMCID: PMC10571403 DOI: 10.1186/s40001-023-01397-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Patients with hypotension usually receive intravenous fluids, but only 50% will respond to fluid administration. We aimed to assess the intra and interobserver agreement to evaluate fluid tolerance through diverse ultrasonographic methods. METHODS We prospectively included critically ill patients on mechanical ventilation. One trained intensivist and two intensive care residents obtained the left ventricular outflow tract velocity-time integral (VTI) variability, inferior vena cava (IVC) distensibility index, internal jugular vein (IJV) distensibility index, and each component of the venous excess ultrasound (VExUS) system. We obtained the intraclass correlation coefficient (ICC) and Gwet's first-order agreement coefficient (AC1), as appropriate. RESULTS We included 32 patients. In-training observers were unable to assess the VTI-variability in two patients. The interobserver agreement was moderate to evaluate the IJV-distensibility index (AC1 0.54, CI 95% 0.29-0.80), fair to evaluate VTI-variability (AC1 0.39, CI 95% 0.12-0.66), and absent to evaluate the IVC-distensibility index (AC1 0.19, CI 95% - 0.07 to 0.44). To classify patients according to their VExUS grade, the intraobserver agreement was good, and the interobserver agreement was moderate (AC1 0.52, CI 95% 0.34-0.69). CONCLUSIONS Point-of-care ultrasound is frequently used to support decision-making in fluid management. However, we observed that the VTI variability and IVC-distensibility index might require further training of the ultrasound operators to be clinically useful. Our findings suggest that the IJV-distensibility index and the VExUS system have acceptable reproducibility among in-training observers.
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Affiliation(s)
| | | | | | | | - Silvio A Ñamendys-Silva
- Instituto Nacional de Cancerología, San Fernando #22, Tlalpan, Mexico City, Mexico
- Instituto Nacional de Ciencias Medicas y de la Nutricion Salvador Zubiran, Mexico City, Mexico
- Hospital Medica Sur, Mexico City, Mexico
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76
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Patel S, Green A, Ashokumar S, Hoke A, Rachoin JS. Objective Methods of Assessing Fluid Status to Optimize Volume Management in Kidney Disease and Hypertension: The Importance of Ultrasound. J Clin Med 2023; 12:6368. [PMID: 37835014 PMCID: PMC10573183 DOI: 10.3390/jcm12196368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/21/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
Fluid overload, a prevalent complication in patients with renal disease and hypertension, significantly impacts patient morbidity and mortality. The daily clinical challenges that clinicians face include how to identify fluid overload early enough in the course of the disease to prevent adverse outcomes and to guide and potentially reduce the intensity of the diuresis. Traditional methods for evaluating fluid status, such as pitting edema, pulmonary crackles, or chest radiography primarily assess extracellular fluid and do not accurately reflect intravascular volume status or venous congestion. This review explores the rationale, mechanism, and evidence behind more recent methods used to assess volume status, namely, lung ultrasound, inferior vena cava (IVC) ultrasound, venous excess ultrasound score, and basic and advanced cardiac echocardiographic techniques. These methods offer a more accurate and objective assessment of fluid status, providing real-time, non-invasive measures of intravascular volume and venous congestion. The methods we discuss are primarily used in inpatient settings, but, given the increased pervasiveness of ultrasound technology, some could soon expand to the outpatient setting.
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Affiliation(s)
- Sharad Patel
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Adam Green
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Sandhya Ashokumar
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
| | - Andrew Hoke
- Department of Medicine, Cooper University Health Care, Camden, NJ 08103, USA;
| | - Jean-Sebastien Rachoin
- Division of Critical Care Medicine, Cooper University Health Care, Camden, NJ 08103, USA; (S.P.); (A.G.); (S.A.)
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA
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77
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Lintner Rivera M, Prager R, Gushu MB, June S, Phiri T, Salameh JP, Johnson HC, Taylor T, O'Brien NF. Point-of-care Ultrasound to Assess Hemodynamic Contributors to Acute Kidney Injury in Pediatric Patients With Cerebral Malaria: A Pilot Study. Pediatr Infect Dis J 2023; 42:844-850. [PMID: 37409812 DOI: 10.1097/inf.0000000000004021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
BACKGROUND Acute kidney injury is common in severe malaria and is independently associated with mortality. The pathogenesis of acute kidney injury (AKI) in severe malaria remains incompletely understood. Ultrasound-based tools such as point-of-care ultrasound (POCUS), ultrasound cardiac output monitors (USCOMs) and renal arterial resistive index (RRI) can be used to detect hemodynamic and renal blood flow abnormalities contributing to AKI in malaria. METHODS We conducted a prospective study of Malawian children with cerebral malaria to determine the feasibility of using POCUS and USCOM to characterize hemodynamic contributors to severe AKI (Kidney Disease: Improving Global Outcomes stage 2 or 3). The primary outcome was feasibility (completion rate of study procedures). We also assessed for differences in POCUS and hemodynamic variables for patients with or without severe AKI. RESULTS We enrolled 27 patients who had admission cardiac and renal ultrasounds and USCOM. Completion rates were high for cardiac (96%), renal (100%) and USCOM studies (96%). Severe AKI occurred in 13 of 27 patients (48%). No patients had ventricular dysfunction. Only 1 patient in the severe AKI group was determined to be hypovolemic ( P = 0.64). No significant differences in USCOM, RRI or venous congestion parameters were detected among patients with and without severe AKI. Mortality was 11% (3/27) with the 3 deaths occurring in the severe AKI group ( P = 0.056). CONCLUSIONS Ultrasound-based cardiac, hemodynamic and renal blood flow measurements appear to be feasible in pediatric patients with cerebral malaria. We were unable to detect hemodynamic or renal blood flow abnormalities contributing to severe AKI in cerebral malaria. Larger studies are needed to corroborate these findings.
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Affiliation(s)
- Michael Lintner Rivera
- From the Department of Pediatrics, Division of Critical Care Medicine, University of Maryland Children's Hospital, Baltimore, MD
| | - Ross Prager
- Critical Care Medicine, Schulich Medicine and Dentistry, Western University, London Health Sciences Center, London, Ontario, Canada
| | | | - Sylvester June
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, Blantyre, Malawi
| | - Tusekile Phiri
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, Blantyre, Malawi
| | - Jean-Paul Salameh
- Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Hunter C Johnson
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Terrie Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, E. Lansing, MI
| | - Nicole F O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
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78
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Ahluwalia P, Gupta B. Clinical utility of VExUS score for anaesthesiologists. Indian J Anaesth 2023; 67:941-942. [PMID: 38044918 PMCID: PMC10691597 DOI: 10.4103/ija.ija_230_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 12/05/2023] Open
Affiliation(s)
- Pallavi Ahluwalia
- Department of Anaesthesiology, Teerthanker Mahaveer Medical College, Moradabad, Uttar Pradesh, India
| | - Bhavna Gupta
- Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
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79
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Crespo-Aznarez S, Campos-Sáenz de Santamaría A, Sánchez-Marteles M, Garcés-Horna V, Josa-Laorden C, Giménez-López I, Pérez-Calvo JI, Rubio-Gracia J. The Association Between Intra-abdominal Pressure and Diuretic Response in Heart Failure. Curr Heart Fail Rep 2023; 20:390-400. [PMID: 37515668 DOI: 10.1007/s11897-023-00617-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 07/31/2023]
Abstract
PURPOSE OF THE REVIEW An efficient diuretic response is vital during cardiac decompensation in heart failure (HF) patients. The increase in intra-abdominal pressure (IAP) could be one of the keys for understanding cardiorenal syndrome and guiding diuretic treatment during hospitalization. In this review, we analyze the relationship between IAP and diuretic response in HF patients. RECENT FINDINGS Increased IAP is associated with worsening renal function (WRF) in patients with advanced HF. Furthermore, the persistence of a rise in IAP after the first 72 h of intravenous diuretic treatment has been correlated with a worse diuretic response, a higher degree of congestion, and an impaired prognosis. The rise in IAP in HF patients has been associated with impaired renal function and a lower diuretic response. Nonetheless, more studies are needed to elucidate the actual role of IAP in congestive nephropathy and whether it may help guide diuretic therapy during acute decompensations.
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Affiliation(s)
- S Crespo-Aznarez
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
| | - A Campos-Sáenz de Santamaría
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
| | - M Sánchez-Marteles
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
| | - V Garcés-Horna
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
| | - C Josa-Laorden
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
| | - I Giménez-López
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
- University of Zaragoza, Zaragoza, Spain
- Aragonese Institute of Health Sciences, Zaragoza, Spain
| | - J I Pérez-Calvo
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
- University of Zaragoza, Zaragoza, Spain
| | - J Rubio-Gracia
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain.
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain.
- University of Zaragoza, Zaragoza, Spain.
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80
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Batool A, Chaudhry S, Koratala A. Transcending boundaries: Unleashing the potential of multi-organ point-of-care ultrasound in acute kidney injury. World J Nephrol 2023; 12:93-103. [PMID: 37766842 PMCID: PMC10520752 DOI: 10.5527/wjn.v12.i4.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/24/2023] [Accepted: 09/11/2023] [Indexed: 09/20/2023] Open
Abstract
Acute kidney injury (AKI) is a clinical syndrome characterized by a rapid increase in serum creatinine levels or a decrease in urine output or both. In spite of thorough history-taking, physical examination, and laboratory analysis, there are limitations in the diagnostic process and clinical monitoring of AKI. Point-of-care ultrasonography (POCUS), a limited ultrasound study performed by clinicians at the bedside, has emerged as a valuable tool in different clinical settings. In this discussion, we explore the potential of POCUS performed by nephrologists to address specific questions encountered in the diagnosis and management of AKI patients. POCUS not only aids in excluding hydronephrosis but also provides real-time insights into hemodynamics, enabling formulation of individualized treatment plans. Further studies are required to assess the impact of multi-organ POCUS on pragmatic patient outcomes related to AKI, as well as its potential in risk stratification and identification of different levels of AKI severity and pathophysiological signatures.
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Affiliation(s)
- Aisha Batool
- Department of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - Shahzad Chaudhry
- Department of Family Medicine, Advocate Aurora Healthcare, Milwaukee, WI 53202, United States
| | - Abhilash Koratala
- Department of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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81
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Teixeira JP, Zeidman A, Beaubien-Souligny W, Cerdá J, Connor MJ, Eggleston K, Juncos LA, da Silva JR, Wells C, Yessayan L, Barker AB, McConville W, Speer R, Wille KM, Neyra JA, Tolwani A. Proceedings of the 2022 UAB CRRT Academy: Non-Invasive Hemodynamic Monitoring to Guide Fluid Removal with CRRT and Proliferation of Extracorporeal Blood Purification Devices. Blood Purif 2023; 52:857-879. [PMID: 37742622 DOI: 10.1159/000533573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/29/2023] [Indexed: 09/26/2023]
Abstract
In 2022, we celebrated the 15th anniversary of the University of Alabama at Birmingham (UAB) Continuous Renal Replacement Therapy (CRRT) Academy, a 2-day conference attended yearly by an international audience of over 100 nephrology, critical care, and multidisciplinary trainees and practitioners. This year, we introduce the proceedings of the UAB CRRT Academy, a yearly review of select emerging topics in the field of critical care nephrology that feature prominently in the conference. First, we review the rapidly evolving field of non-invasive hemodynamic monitoring and its potential to guide fluid removal by renal replacement therapy (RRT). We begin by summarizing the accumulating data associating fluid overload with harm in critical illness and the potential for harm from end-organ hypoperfusion caused by excessive fluid removal with RRT, underscoring the importance of accurate, dynamic assessment of volume status. We describe four applications of point-of-care ultrasound used to identify patients in need of urgent fluid removal or likely to tolerate fluid removal: lung ultrasound, inferior vena cava ultrasound, venous excess ultrasonography, and Doppler of the left ventricular outflow track to estimate stroke volume. We briefly introduce other minimally invasive hemodynamic monitoring technologies before concluding that additional prospective data are urgently needed to adapt these technologies to the specific task of fluid removal by RRT and to learn how best to integrate them into practical fluid-management strategies. Second, we focus on the growth of novel extracorporeal blood purification devices, starting with brief reviews of the inflammatory underpinnings of multiorgan dysfunction and the specific applications of pathogen, endotoxin, and/or cytokine removal and immunomodulation. Finally, we review a series of specific adsorptive technologies, several of which have seen substantial clinical use during the COVID-19 pandemic, describing their mechanisms of target removal, the limited existing data supporting their efficacy, ongoing and future studies, and the need for additional prospective trials.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology and Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Amanda Zeidman
- Division of Nephrology, Department of Medicine, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jorge Cerdá
- Department of Medicine, Nephrology, Albany Medical College, Albany, New York, USA
| | - Michael J Connor
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine and Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Luis A Juncos
- Division of Nephrology, Department of Internal Medicine, Central Arkansas Veterans' Healthcare System, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Catherine Wells
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew B Barker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Wendy McConville
- School of Nursing, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Rajesh Speer
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Keith M Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
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82
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Zhi HJ, Cui J, Yuan MW, Zhao YN, Zhao XW, Zhu TT, Jia CM, Li Y. Predictive performance of renal resistive index, semiquantitative power Doppler ultrasound score and renal venous Doppler waveform pattern for acute kidney injury in critically ill patients and prediction model establishment: a prospective observational study. Ren Fail 2023; 45:2258987. [PMID: 37728063 PMCID: PMC10512814 DOI: 10.1080/0886022x.2023.2258987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/09/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND This study aimed to explore the performance of renal resistive index (RRI), semiquantitative power Doppler ultrasound (PDU) score and renal venous Doppler waveform (RVDW) pattern in predicting acute kidney injury (AKI) in critically ill patients and establish prediction models. METHODS This prospective observational study included 234 critically ill patients. Renal ultrasound was measured within 24 h after intensive care unit admission. The main outcome was the highest AKI stage within 5 days after admission according to the Kidney Disease Improving Global Outcomes criteria. RESULTS Patients in the AKI stage 3 group had significantly higher RRI, RVDW pattern and lower PDU score (p < 0.05). Only lactate, urine volume, serum creatinine (SCr) on admission, PDU score and RVDW pattern were statistically significant predictors (p < 0.05). Model 1 based on these five variables (area under the curve [AUC] = 0.938, 95% confidence interval [CI] 0.899-0.965, p < 0.05) showed the best performance in predicting AKI stage 3, and difference in AUC between it and the clinical model including lactate, urine volume and SCr (AUC = 0.901, 95% CI 0.855-0.936, p < 0.05) was statistically significant (z statistic = 2.224, p = 0.0261). The optimal cut-off point for a nomogram based on Model 1 was ≤127.67 (sensitivity: 95.8%, specificity: 82.3%, Youden's index: 0.781). CONCLUSIONS The nomogram model including SCr, urine volume, lactate, PDU score and RVDW pattern upon admission exhibited a significantly stronger capability for AKI stage 3 than each single indicator and clinical model including SCr, urine volume and lactate.
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Affiliation(s)
- Hai Jun Zhi
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Jie Cui
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Meng Wei Yuan
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Ya Ning Zhao
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Xing Wen Zhao
- Ultrasonic Department, Cangzhou Central Hospital, Cangzhou, China
| | - Ting Ting Zhu
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Chun Mei Jia
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Yong Li
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
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83
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Banjade P, Subedi A, Ghamande S, Surani S, Sharma M. Systemic Venous Congestion Reviewed. Cureus 2023; 15:e43716. [PMID: 37724234 PMCID: PMC10505504 DOI: 10.7759/cureus.43716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/20/2023] Open
Abstract
Accurate determination of intravascular volume status is challenging in acutely ill patients. Favorable patient outcome is vital to correctly identify intravascular volume depletion and avoid systemic venous congestion. Most of the conventional means of hemodynamic monitoring in the acute healthcare setting are geared toward addressing the cardiac output and maintaining an optimum mean arterial pressure. While assessing and maintaining cardiac output in an acutely ill patient is very important, a venous congestion cascade is often overlooked, which can negatively affect the intraabdominal end organs. The prospect of using point-of-care ultrasound (POCUS) to determine systemic venous congestion could be a potentially handy tool for clinicians. Venous excess ultrasound score (VExUS) has also been utilized by clinicians as a semi-quantitative assessment tool to assess fluid status. This review aims to discuss the potential role of POCUS and VExUS scores in determining systemic venous congestion through a narrative review of recently published literature.
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Affiliation(s)
- Prakash Banjade
- Department of General Medicine, Manipal College of Medical Sciences, Pokhara, NPL
| | - Ashish Subedi
- Department of Internal Medicine, Gandaki Medical College, Kathmandu, NPL
| | - Shekhar Ghamande
- Department of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott and White Medical Center, Temple, USA
| | - Salim Surani
- Department of Anesthesiology, Mayo Clinic, Rochester, USA
- Department of Medicine, Texas Agricultural and Mechanical (A&M) University, College Station, USA
- Department of Medicine, University of North Texas, Dallas, USA
- Department of Internal Medicine, Pulmonary Associates, Corpus Christi, USA
- Department of Clinical Medicine, University of Houston, Houston, USA
| | - Munish Sharma
- Department of Pulmonary and Critical Care Medicine, Baylor Scott and White Medical Center, Temple, USA
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84
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Huang S, Vieillard-Baron A, Evrard B, Prat G, Chew MS, Balik M, Clau-Terré F, De Backer D, Mekontso Dessap A, Orde S, Morelli A, Sanfilippo F, Charron C, Vignon P. Echocardiography phenotypes of right ventricular involvement in COVID-19 ARDS patients and ICU mortality: post-hoc (exploratory) analysis of repeated data from the ECHO-COVID study. Intensive Care Med 2023; 49:946-956. [PMID: 37436445 DOI: 10.1007/s00134-023-07147-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/18/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Exploratory study to evaluate the association of different phenotypes of right ventricular (RV) involvement and mortality in the intensive care unit (ICU) in patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). METHODS Post-hoc analysis of longitudinal data from the multicenter ECHO-COVID observational study in ICU patients who underwent at least two echocardiography examinations. Echocardiography phenotypes were acute cor pulmonale (ACP, RV cavity dilatation with paradoxical septal motion), RV failure (RVF, RV cavity dilatation and systemic venous congestion), and RV dysfunction (tricuspid annular plane systolic excursion ≤ 16 mm). Accelerated failure time model and multistate model were used for analysis. RESULTS Of 281 patients who underwent 948 echocardiography studies during ICU stay, 189 (67%) were found to have at least 1 type of RV involvements during one or several examinations: ACP (105/281, 37.4%), RVF (140/256, 54.7%) and/or RV dysfunction (74/255, 29%). Patients with all examinations displaying ACP had survival time shortened by 0.479 [0.284-0.803] times when compared to patients with all examinations depicting no ACP (P = 0.005). RVF showed a trend towards shortened survival time by a factor of 0.642 [0.405-1.018] (P = 0.059), whereas the impact of RV dysfunction on survival time was inconclusive (P = 0.451). Multistate analysis showed that patients might transit in and out of RV involvement, and those who exhibited ACP in their last critical care echocardiography (CCE) examination had the highest risk of mortality (hazard ratio (HR) 3.25 [2.38-4.45], P < 0.001). CONCLUSION RV involvement is prevalent in patients ventilated for COVID-19 ARDS. Different phenotypes of RV involvement might lead to different ICU mortality, with ACP having the worst outcome.
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Affiliation(s)
- Stephen Huang
- Intensive Care Medicine, Nepean Hospital, NBMLHD, The University of Sydney, Sydney, Australia
| | - Antoine Vieillard-Baron
- Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France
- INSERM UMR 1018, Clinical Epidemiology Team, CESP, Université de Paris Saclay, Villejuif, France
| | - Bruno Evrard
- Medical-Surgical ICU, Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
| | - Gwenaël Prat
- Service de Médecine Intensive Réanimation, CHU Cavale Blanche Brest, Brest, France
| | - Michelle S Chew
- Department of Anaesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, General University Hospital and 1St Medical Faculty, Charles University, Prague, Czechia
| | - Fernando Clau-Terré
- Department of Anaesthesiology and Critical Care Medicine, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniel De Backer
- CHIREC Hospitals Université Libre de Bruxelles, Brussels, Belgium
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Groupe de Recherche Clinique CARMAS, Inserm U955, Université Paris-Est Créteil, 94000, Créteil, France
| | - Sam Orde
- Intensive Care Medicine, Nepean Hospital, NBMLHD, The University of Sydney, Sydney, Australia
| | - Andrea Morelli
- Department Clinical Internal Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Viale del Policlinico, Rome, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, Policlinico-Vittorio Emanuele University Hospital, Catania, Italy
| | - Cyril Charron
- Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France
- INSERM UMR 1018, Clinical Epidemiology Team, CESP, Université de Paris Saclay, Villejuif, France
| | - Philippe Vignon
- Medical-Surgical ICU, Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France.
- Réanimation Polyvalente, CHU Dupuytren, 2 Ave. Martin Luther King, 87042, Limoges Cedex, France.
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85
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Kenny JÉS, Gibbs SO, Eibl JK, Eibl AM, Yang Z, Johnston D, Munding CE, Elfarnawany M, Lau VC, Kemp BO, Nalla B, Atoui R. Simultaneous venous-arterial Doppler during preload augmentation: illustrating the Doppler Starling curve. Ultrasound J 2023; 15:32. [PMID: 37505318 PMCID: PMC10382420 DOI: 10.1186/s13089-023-00330-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023] Open
Abstract
Providing intravenous (IV) fluids to a patient with signs or symptoms of hypoperfusion is common. However, evaluating the IV fluid 'dose-response' curve of the heart is elusive. Two patients were studied in the emergency department with a wireless, wearable Doppler ultrasound system. Change in the common carotid arterial and internal jugular Doppler spectrograms were simultaneously obtained as surrogates of left ventricular stroke volume (SV) and central venous pressure (CVP), respectively. Both patients initially had low CVP jugular venous Doppler spectrograms. With preload augmentation, only one patient had arterial Doppler measures indicative of significant SV augmentation (i.e., 'fluid responsive'). The other patient manifested diminishing arterial response, suggesting depressed SV (i.e., 'fluid unresponsive') with evidence of ventricular asynchrony. In this short communication, we describe how a wireless, wearable Doppler ultrasound simultaneously tracks surrogates of cardiac preload and output within a 'Doppler Starling curve' framework; implications for IV fluid dosing are discussed.
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Affiliation(s)
- Jon-Émile S Kenny
- Health Sciences North Research Institute, Sudbury, ON, Canada.
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada.
| | | | - Joseph K Eibl
- Health Sciences North Research Institute, Sudbury, ON, Canada
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada
- NOSM University, Sudbury, ON, Canada
| | - Andrew M Eibl
- Health Sciences North Research Institute, Sudbury, ON, Canada
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada
| | - Zhen Yang
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada
| | | | | | | | - Vivian C Lau
- OSF Saint Francis Medical Center, Peoria, IL, USA
| | | | - Bhanu Nalla
- Health Sciences North Research Institute, Sudbury, ON, Canada
- NOSM University, Sudbury, ON, Canada
| | - Rony Atoui
- Health Sciences North Research Institute, Sudbury, ON, Canada
- NOSM University, Sudbury, ON, Canada
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86
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Prager R, Argaiz E, Pratte M, Rola P, Arntfield R, Beaubien-Souligny W, Denault AY, Haycock K, Miralles Aguiar F, Bakker J, Ospina-Tascon G, Orozco N, Rochwerg B, Lewis K, Quazi I, Kattan E, Hernandez G, Basmaji J. Doppler identified venous congestion in septic shock: protocol for an international, multi-centre prospective cohort study (Andromeda-VEXUS). BMJ Open 2023; 13:e074843. [PMID: 37487682 PMCID: PMC10373747 DOI: 10.1136/bmjopen-2023-074843] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
INTRODUCTION Venous congestion is a pathophysiological state where high venous pressures cause organ oedema and dysfunction. Venous congestion is associated with worse outcomes, particularly acute kidney injury (AKI), for critically ill patients. Venous congestion can be measured by Doppler ultrasound at the bedside through interrogation of the inferior vena cava (IVC), hepatic vein (HV), portal vein (PV) and intrarenal veins (IRV). The objective of this study is to quantify the association between Doppler identified venous congestion and the need for renal replacement therapy (RRT) or death for patients with septic shock. METHODS AND ANALYSIS This study is a prespecified substudy of the ANDROMEDA-SHOCK 2 (AS-2) randomised control trial (RCT) assessing haemodynamic resuscitation in septic shock and will enrol at least 350 patients across multiple sites. We will include adult patients within 4 hours of fulfilling septic shock definition according to Sepsis-3 consensus conference. Using Doppler ultrasound, physicians will interrogate the IVC, HV, PV and IRV 6-12 hours after randomisation. Study investigators will provide web-based educational sessions to ultrasound operators and adjudicate image acquisition and interpretation. The primary outcome will be RRT or death within 28 days of septic shock. We will assess the hazard of RRT or death as a function of venous congestion using a Cox proportional hazards model. Sub-distribution HRs will describe the hazard of RRT given the competing risk of death. ETHICS AND DISSEMINATION We obtained ethics approval for the AS-2 RCT, including this observational substudy, from local ethics boards at all participating sites. We will report the findings of this study through open-access publication, presentation at international conferences, a coordinated dissemination strategy by investigators through social media, and an open-access workshop series in multiple languages. TRIAL REGISTRATION NUMBER NCT05057611.
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Affiliation(s)
- Ross Prager
- Division of Critical Care, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Eduardo Argaiz
- Department of Nephrology and Mineral Metabolism, Salvador Zubiran National Institute of Medical Sciences and Nutrition, Ciudad de Mexico, Mexico
- Instituto Tecnológico y de Estudios Superiores de Monterrey Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Michael Pratte
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Philippe Rola
- Intensive Care, Santa Cabrini Hospital, Montreal, Québec, Canada
| | - Robert Arntfield
- Division of Critical Care, Western University, London, Ontario, Canada
| | | | - André Y Denault
- Department of Anesthesiology, Fondation Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | - Korbin Haycock
- Desert Regional Medical Center, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Francisco Miralles Aguiar
- Anesthesia & Surgery Critical Care Service, Hospital Universitario Puerta del Mar, Cadiz, Andalucía, Spain
| | - Jan Bakker
- Department of Intensive Care Adults, Erasmus MC University Medical Center,Netherlands, Rotterdam, The Netherlands
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gustavo Ospina-Tascon
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine, Universidad Icesi, Cali, Colombia
| | - Nicolas Orozco
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Centro de Investigaciones Clínicas, Cali, Colombia
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ibrahim Quazi
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - John Basmaji
- Division of Critical Care, Western University, London, Ontario, Canada
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87
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Hassan Kamel M, Siuba MT. Acute kidney injury in cardiac critical care: bringing the venous circulation out of the shadows. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:420-421. [PMID: 37261945 DOI: 10.1093/ehjacc/zuad058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/03/2023]
Affiliation(s)
- Mohamed Hassan Kamel
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, L2-330A, Cleveland, OH 44195, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, L2-330A, Cleveland, OH 44195, USA
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88
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Syed MKH, Pendleton K, Park J, Weinert C. Physicians' Clinical Behavior During Fluid Evaluation Encounters. Crit Care Explor 2023; 5:e0933. [PMID: 37387710 PMCID: PMC10306425 DOI: 10.1097/cce.0000000000000933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
We sought to identify factors affecting physicians' cognition and clinical behavior when evaluating patients that may need fluid therapy. BACKGROUND Proponents of dynamic fluid responsiveness testing advocate measuring cardiac output or stroke volume after a maneuver to prove that further fluids will increase cardiac output. However, surveys suggest that fluid therapy in clinical practice is often given without prior responsiveness testing. DESIGN Thematic analysis of face-to-face structured interviews. SETTING ICUs and medical-surgical wards in acute care hospitals. SUBJECTS Intensivists and hospitalist physicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We conducted 43 interviews with experienced physicians in 19 hospitals. Hospitalized patients with hypotension, tachycardia, oliguria, or elevated serum lactate are commonly seen by physicians who weigh the risks and benefits of more fluid therapy. Encounters are often with unfamiliar patients and evaluation and decisions are completed quickly without involving other physicians. Dynamic testing for fluid responsiveness is used much less often than static methods and fluid boluses are often ordered with no testing at all. This approach is rationalized by factors that discourage dynamic testing: unavailability of equipment, time to obtain test results, or lack of expertise in obtaining valid data. Two mental calculations are particularly influential: physicians' estimate of the base rate of fluid responsiveness (determined by physical examination, chart review, and previous responses to fluid boluses) and physicians' perception of patient harm if 500 or 1,000 mL fluid boluses are ordered. When the perception of harm is low, physicians use heuristics that rationalize skipping dynamic testing. LIMITATIONS Geographic limitation to hospitals in Minnesota, United States. CONCLUSIONS If dynamic responsiveness testing is to be used more often in routine clinical practice, physicians must be more convinced of the benefits of dynamic testing, that they can obtain valid results quickly and believe that even small fluid boluses harm their patients.
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Affiliation(s)
| | - Kathryn Pendleton
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota Medical School. Minneapolis, MN
| | - John Park
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Craig Weinert
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota Medical School. Minneapolis, MN
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89
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Chalkias A, Adamos G, Mentzelopoulos SD. General Critical Care, Temperature Control, and End-of-Life Decision Making in Patients Resuscitated from Cardiac Arrest. J Clin Med 2023; 12:4118. [PMID: 37373812 DOI: 10.3390/jcm12124118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/02/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Cardiac arrest affects millions of people per year worldwide. Although advances in cardiopulmonary resuscitation and intensive care have improved outcomes over time, neurologic impairment and multiple organ dysfunction continue to be associated with a high mortality rate. The pathophysiologic mechanisms underlying the post-resuscitation disease are complex, and a coordinated, evidence-based approach to post-resuscitation care has significant potential to improve survival. Critical care management of patients resuscitated from cardiac arrest focuses on the identification and treatment of the underlying cause(s), hemodynamic and respiratory support, organ protection, and active temperature control. This review provides a state-of-the-art appraisal of critical care management of the post-cardiac arrest patient.
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Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Georgios Adamos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
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90
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Andrei S, Bahr PA, Nguyen M, Bouhemad B, Guinot PG. Prevalence of systemic venous congestion assessed by Venous Excess Ultrasound Grading System (VExUS) and association with acute kidney injury in a general ICU cohort: a prospective multicentric study. Crit Care 2023; 27:224. [PMID: 37291662 DOI: 10.1186/s13054-023-04524-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/05/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND The importance of assessing venous congestion in ICU patients is widely acknowledged, but its study is hampered by the lack of a practical evaluation tool. The Venous Excess Ultrasound Grading System (VExUS), based on a semi-quantitative combined ultrasound assessment, has been associated with acute kidney injury (AKI) in cardiac ICU patients. The objectives of this study were to assess the prevalence of congestion using VExUS in general ICU patients, and to evaluate the association between VExUS, AKI and death. METHODS This prospective, observational study included adult patients within 24 h of ICU admission. VExUS and hemodynamic parameters were measured four times during the ICU stay: within 24 h of ICU admission, after day 1 (between 24 and 48 h), after day 2 (between 48 and 72 h), and last day of ICU stay. The prevalence of AKI during the first week in ICU and 28-day mortality were assessed. RESULTS Among the 145 patients included, the percentage of patients with a VExUS score of 2 (moderate congestion) and 3 (severe congestion) was 16% and 6%, respectively. The prevalence did not change over the study period. There was no significant association between admission VExUS scores and AKI (p = 0.136) or 28-day mortality (p = 0.594). Admission VExUS ≥ 2 was not associated with AKI (OR 0.499, CI95% 0.21-1.17, p = 0.109) nor 28-day mortality (OR 0.75, CI95% 0.2-2.8, p = 0.669). The results were similar for VExUS scores measured at day 1 and day 2. CONCLUSIONS In general ICU cohort the prevalence of moderate to severe venous congestion was low. Early assessment of systemic venous congestion using VExUS scores was not associated with the development of AKI or with 28-day mortality.
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Affiliation(s)
- Stefan Andrei
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France.
- Department of Anaesthesiology and Critical Care Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.
| | - Pierre-Alain Bahr
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, 21000, Dijon, France
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, 21000, Dijon, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, 21000, Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, 21000, Dijon, France
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91
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Hosokawa T, Tanami Y, Sato Y, Nomura K, Oguma E. Association between the dynamic movement of hyperechoic foci and patients'/sonographic outcomes among pediatric patients with portal venous gas following a cardiac event. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023. [PMID: 37262363 DOI: 10.1002/jcu.23496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/12/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To demonstrate the association between the dynamic movements of hyperechoic foci in portal venous gas (PVG) and patients'/sonographic outcomes after congenital heart disease or cardiac events. METHODS Thirty-one pediatric patients requiring management of congenital heart diseases or cardiac events who had PVG on ultrasound were included in this retrospective study. The patient outcome was prognosis: dead or alive. The sonographic outcome was recovery from PVG, measured as days from PVG detection to when it diminished on ultrasound. The following sonographic findings of hyperechoic foci in PVG were compared between patients: detection within the mesenteric vein, having to-and-fro movements within the intrahepatic portal vein, distribution (left segment or both left and right segments) and shape (line or punctate) in the liver, and detection within the portal and hepatic veins. Comparisons were made using Fisher's exact/Mann-Whitney U test. RESULTS Four patients died without having recovered from PVG. A significant difference was observed in terms of the to-and-fro movement (with/without to-and-fro movement in dead vs. alive patients: 3/1 vs. 1/26, respectively; P = 0.003). Furthermore, a significant difference in sonographic outcomes was observed regarding patients with/without hyperechoic foci within the mesenteric vein (days with vs. without this finding: 2.0 ± 1.24(1-5) vs.1 ± 0(1), respectively; P = 0.011). CONCLUSIONS In our small limited cohort, when PVG was visualized on ultrasound, close evaluation of the dynamic movement of hyperechoic foci, especially their to-and-fro movement within the intrahepatic portal vein and detection of hyperechoic foci within the mesenteric vein, were useful in predicting patients' outcomes and the time to PVG diminishment.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Koji Nomura
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
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Urbani A, Pensotti F, Provera A, Galassi A, Guazzi M, Castini D. Extracorporeal veno-venous ultrafiltration in congestive heart failure: What’s the state of the art? A mini-review. World J Cardiol 2023; 15:205-216. [PMID: 37274372 PMCID: PMC10237006 DOI: 10.4330/wjc.v15.i5.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/19/2023] [Accepted: 04/24/2023] [Indexed: 05/19/2023] Open
Abstract
Hospitalizations for heart failure exceed 1 million per year in both the United States and Europe and more than 90% are due to symptoms and signs of fluid overload. Rates of rehospitalizations or emergency department visit at 60 days are remarkable regardless of whether loop diuretics were administered at low vs high doses or by bolus injection vs continuous infusion. Ultrafiltration (UF) has been considered a promising alternative to stepped diuretic therapy and it consists in the mechanical, adjustable removal of iso-tonic plasma water across a semipermeable membrane with the application of hydrostatic pressure gradient generated by a pump. Fluid removal with ultrafiltration presents several advantages such as elimination of higher amount of sodium with less neurohormonal activation. However, the conflicting results from UF studies highlight that patient selection and fluid removal targets are not completely understood. The best way to assess fluid status and therefore establish the fluid removal target is also still a matter of debate. Herein, we provide an up-to-date systematic review about the role of ultrafiltration among patients with fluid overload and its gaps in daily practice.
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Affiliation(s)
- Andrea Urbani
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Filippo Pensotti
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Andrea Provera
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Andrea Galassi
- Nephrology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Marco Guazzi
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Diego Castini
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
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93
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Longino A, Martin K, Leyba K, Siegel G, Gill E, Douglas IS, Burke J. Correlation between the VExUS score and right atrial pressure: a pilot prospective observational study. Crit Care 2023; 27:205. [PMID: 37237315 PMCID: PMC10223840 DOI: 10.1186/s13054-023-04471-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
Venous congestion is an under-recognized contributor to mortality in critically ill patients. Unfortunately, venous congestion is difficult to measure, and right heart catheterization (RHC) has been considered the most readily available means for measuring venous filling pressure. Recently, a novel "Venous Excess Ultrasound (VExUS)" score was developed to noninvasively quantify venous congestion using inferior vena cava (IVC) diameter and Doppler flow through the hepatic, portal, and renal veins. A preliminary retrospective study of post-cardiac surgery patients showed promising results, including a high positive-likelihood ratio of high VExUS grade for acute kidney injury. However, studies have not been reported in broader patient populations, and the relationship between VExUS and conventional measures of venous congestion is unknown. To address these gaps, we prospectively assessed the correlation of VExUS with right atrial pressure (RAP), with comparison to inferior vena cava (IVC) diameter. Patients undergoing RHC at Denver Health Medical Center underwent VExUS examination before their procedure. VExUS grades were assigned before RHC, blinding ultrasonographers to RHC outcomes. After controlling for age, sex, and common comorbidities, we observed a significant positive association between RAP and VExUS grade (P < 0.001, R2 = .68). VExUS had a favorable AUC for prediction of a RAP ≥ 12 mmHg (0.99, 95% CI 0.96-1) compared to IVC diameter (0.79, 95% CI 0.65-0.92). These results suggest a strong correlation between VExUS and RAP in a diverse patient population, and support future studies of VExUS as a tool to assess venous congestion and guide management in a spectrum of critical illnesses.
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Affiliation(s)
- August Longino
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO, USA.
| | - Katharine Martin
- School of Medicine, University of Colorado, University of Colorado, Aurora, CO, USA
| | - Katarina Leyba
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO, USA
| | - Gabriel Siegel
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, CO, USA
| | - Edward Gill
- Department of Cardiology, University of Colorado, Aurora, CO, USA
| | - Ivor S Douglas
- Department of Pulmonary and Critical Care Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Joseph Burke
- Department of Cardiology, Denver Health Medical Center, Denver, CO, USA
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94
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Cheong I, Amador EDO, Gómez RA, Vilariño FMÁ, Furche MA, Tamagnone FM. Evaluating the Utility of Portal Vein Pulsatility Index for Detecting Fluid Unresponsiveness in the Intensive Care Unit. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00346-4. [PMID: 37330331 DOI: 10.1053/j.jvca.2023.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/11/2023] [Accepted: 05/22/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE The primary aim of the authors' study was to evaluate the capacity of the portal vein pulsatility index (PVP) to detect fluid unresponsiveness in patients admitted to intensive care. DESIGN This was a retrospective, diagnostic accuracy study SETTING: At a tertiary medical-surgical intensive care unit in Buenos Aires, Argentina. PARTICIPANTS Patients were included during usual care in the intensive care unit, who were evaluated by ultrasonography for the flow of the portal vein, calculating their PVP prior to fluid expansion. INTERVENTIONS Patients who exhibited an increase of <15% in left ventricle outflow tract velocity-time integral after receiving 500 mL of Ringer Lactate were considered non-responders to fluids. MEASUREMENTS AND MAIN RESULTS The authors included a total of 63 patients between January 2022 and October 2022. The area under the receiver operating characteristic curve for PVP to predict fluid unresponsiveness was 0.708 (95% CI 0.580 to 0.816). A value of the PVP >32% predicted fluid unresponsiveness with a sensitivity of 30.8% (95% CI 17% to 47.6%) and specificity of 100% (95% CI 85.8 to 100). The positive predictive value was 100%, and the negative predictive value was 47.1% (95% CI 41.9% to 52.3%). CONCLUSIONS Although PVP has limited value as the sole indicator for fluid management decisions, it can be used as a stopping rule or combined with other diagnostic tests to improve the accuracy of fluid responsiveness assessment.
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Affiliation(s)
- Issac Cheong
- Department of critical care medicine, Sanatorio De los Arcos, Buenos Aires, Argentina; Argentinian Critical Care Ultrasonography Association, Buenos Aires, Argentina.
| | - Elías Daniel Olarte Amador
- Argentinian Critical Care Ultrasonography Association, Buenos Aires, Argentina; Department of critical care medicine, Clínica Pediátrica Sanitas, Bogotá, Colombia
| | - Raúl Alejandro Gómez
- Department of critical care medicine, Sanatorio De los Arcos, Buenos Aires, Argentina
| | | | - Mariano Andrés Furche
- Department of critical care medicine, Sanatorio De los Arcos, Buenos Aires, Argentina
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95
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Bhardwaj V, Rola P, Denault A, Vikneswaran G, Spiegel R. Femoral vein pulsatility: a simple tool for venous congestion assessment. Ultrasound J 2023; 15:24. [PMID: 37165284 PMCID: PMC10172460 DOI: 10.1186/s13089-023-00321-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 04/10/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Femoral vein Doppler (FVD) is simpler than the VExUS score which is a multimodal scoring system based on combination of IVC diameter, hepatic venous Doppler, portal vein pulsatility and renal vein Doppler, may be useful in assessing right ventricular overload and signs of venous congestion. There is limited data on the relationship between FVD and VExUS score. RESULTS Adult post-cardiac surgery patients were assessed for venous congestion using the VExUS score and FVD. Agreement between VExUS and FVD was studied using Kappa test, sensitivity, specificity, PPV and NPV for VExUS and FVD was calculated keeping CVP as gold standard. In total, 107 patients were enrolled, with a mean age of 55.67 ± 12.76. The accuracy of VExUS and FVD for detecting venous congestion was 80.37 (95% CI of 71.5 to 87.4) and 74.7 (95% CI of 65.4 to 82.6), respectively. The level of agreement between FVD and VExUS was moderate (Kappa value of 0.62, P < 0.001) while the agreement between FVD and CVP was weak (Kappa value of 0.49, P < 0.001). CONCLUSION FVD has good accuracy for detecting venous congestion and shows moderate agreement with VExUS grading. With potentially easier physical accessibility and a shorter learning curve for novices, it may be a simple and valuable tool for assessing venous congestion.
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Affiliation(s)
- V Bhardwaj
- Critical Care, Narayana Health City, Bangalore, India.
| | - P Rola
- ICU Chief of Service, Santa Cabrini Hospital, Montreal, Canada
| | - A Denault
- Department of Anesthesiology, Monteal Heart Institute, Montreal, Canada
| | - G Vikneswaran
- Clinical Research, Narayana Health City, Bangalore, India
| | - R Spiegel
- Department of Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC, USA
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96
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Kenny JES, Prager R, Rola P, McCulloch G, Eibl JK, Haycock K. The effect of gravity-induced preload change on the venous excess ultrasound (VExUS) score and internal jugular vein Doppler in healthy volunteers. Intensive Care Med Exp 2023; 11:19. [PMID: 37055637 PMCID: PMC10102271 DOI: 10.1186/s40635-023-00504-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/20/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND The venous excess ultrasound (VExUS) score is a multi-organ Doppler approach to assess venous congestion. Despite growing use of VExUS in research and clinical practice, other veins can be visualized to assess for venous hypertension, which may overcome acquisition barriers of the VExUS exam. In this pilot, observational study, we used a wearable Doppler ultrasound to assess the relationship between jugular venous Doppler and the VExUS score under different preload conditions. We hypothesized that jugular Doppler morphology would accurately distinguish preload conditions, that it would most closely relate to the hepatic venous Doppler morphology in the fully supine position and that the VExUS score would be influenced by preload condition. RESULTS We recruited 15 healthy volunteers with no cardiovascular history. Preload change was achieved using a tilt-table with three positions: supine, fully upright, and 30-degree head-down tilt. In each position, a VExUS score was performed; furthermore, inferior vena collapsibility and sphericity index were calculated. At the same time, jugular venous Doppler was captured by a novel, wireless, wearable ultrasound system. A continuous jugular venous Doppler morphology was 96% accurate for detecting the low preload condition. The jugular venous Doppler morphology was highly correlated with the hepatic vein, but only in the supine position. Gravitational position did not significantly affect the sphericity index or the VExUS score. CONCLUSIONS The jugular vein Doppler morphology was able to accurately distinguish low from high preload conditions in healthy volunteers. Comparisons between VExUS Doppler morphologies and other veins should occur in the supine position when gravitational pressure gradients are minimized; finally, different preload conditions in healthy subjects did not affect the VExUS score.
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Affiliation(s)
- Jon-Emile S Kenny
- Health Sciences North Research Institute, 56 Walford Rd, Sudbury, ON, P3E 2H2, Canada.
- Flosonics Medical, Toronto, ON, Canada.
| | - Ross Prager
- Division of Critical Care Medicine, Western University, London, ON, Canada
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montreal, QC, Canada
| | | | - Joseph K Eibl
- Health Sciences North Research Institute, 56 Walford Rd, Sudbury, ON, P3E 2H2, Canada
- Flosonics Medical, Toronto, ON, Canada
- Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Korbin Haycock
- Department of Emergency Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
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97
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Bellido D, García-García C, Talluri A, Lukaski HC, García-Almeida JM. Future lines of research on phase angle: Strengths and limitations. Rev Endocr Metab Disord 2023; 24:563-583. [PMID: 37043140 PMCID: PMC10090740 DOI: 10.1007/s11154-023-09803-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/13/2023]
Abstract
Bioelectrical impedance analysis (BIA) is the most widely used technique in body composition analysis. When we focus the use of phase sensitive BIA on its raw parameters Resistance (R), Reactance (Xc) and Phase Angle (PhA), we eliminate the bias of using predictive equations based on reference models. In particular PhA, have demonstrated their prognostic utility in multiple aspects of health and disease. In recent years, as a strong association between prognostic and diagnostic factors has been observed, scientific interest in the utility of PhA has increased. In the different fields of knowledge in biomedical research, there are different ways of assessing the impact of a scientific-technical aspect such as PhA. Single frequency with phase detection bioimpedance analysis (SF-BIA) using a 50 kHz single frequency device and tetrapolar wrist-ankle electrode placement is the most widely used bioimpedance approach for characterization of whole-body composition. However, the incorporation of vector representation of raw bioelectrical parameters and direct mathematical calculations without the need for regression equations for the analysis of body compartments has been one of the most important aspects for the development of research in this area. These results provide new evidence for the validity of phase-sensitive bioelectrical measurements as biomarkers of fluid and nutritional status. To enable the development of clinical research that provides consistent results, it is essential to establish appropriate standardization of PhA measurement techniques. Standardization of test protocols will facilitate the diagnosis and assessment of the risk associated with reduced PhA and the evaluation of changes in response to therapeutic interventions. In this paper, we describe and overview the value of PhA in biomedical research, technical and instrumental aspects of PhA research, analysis of Areas of clinical research (cancer patients, digestive and liver diseases, critical and surgical patients, Respiratory, infectious, and COVID-19, obesity and metabolic diseases, Heart and kidney failure, Malnutrition and sarcopenia), characterisation of the different research outcomes, Morphofunctional assessment in disease-related malnutrition and other metabolic disorders: validation of PhA with reference clinical practice techniques, strengths and limitations. Based on the detailed study of the measurement technique, some of the key issues to be considered in future PhA research. On the other hand, it is important to assess the clinical conditions and the phenotype of the patients, as well as to establish a disease-specific clinical profile. The appropriate selection of the most critical outcomes is another fundamental aspect of research.
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Affiliation(s)
- Diego Bellido
- Department of Endocrinology and Nutrition, Complejo Hospitalario de Ferrol, 15405, Ferrol, A Coruña, Spain
| | - Cristina García-García
- PhD Program in Biomedicine, Translational Research and New Health Technologies, Faculty of Medicine, Málaga University, 29010, Málaga, Spain
| | | | - Henry C Lukaski
- Department of Kinesiology and Public Health Education, University of North Dakota, Grand Forks, ND, 58202, USA
| | - José Manuel García-Almeida
- Department of Endocrinology and Nutrition, Virgen de La Victoria Hospital, Malaga University, 29010, Malaga, Spain.
- Centro de Investigación Biomédica en Red de La Fisiopatología de La Obesidad Y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), 29010, Malaga, Spain.
- Málaga University, 29010, Málaga, Spain.
- Department of Endocrinology and Nutrition, Quironsalud Málaga Hospital, 29004, Málaga, Spain.
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98
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Melo RH, dos Santos MHC, Ramos FJDS. Beyond fluid responsiveness: the concept of fluid tolerance and its potential implication in hemodynamic management. CRITICAL CARE SCIENCE 2023; 35:226-229. [PMID: 37712813 PMCID: PMC10406410 DOI: 10.5935/2965-2774.20230012-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/12/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Rafael Hortêncio Melo
- Adult Intensive Care Unit, Hospital Municipal Vila Santa Catarina -
São Paulo (SP), Brazil
| | | | - Fernando José da Silva Ramos
- Department of Anesthesiology, Pain and Intensive Care, Universidade
Federal de São Paulo - São Paulo (SP), Brazil
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99
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Dabrowski W, Rola P, Malbrain MLNG. Intra-abdominal pressure monitoring in cardiac surgery: is this the canary in the coalmine for kidney injury? J Clin Monit Comput 2023; 37:351-358. [PMID: 36550345 PMCID: PMC10068659 DOI: 10.1007/s10877-022-00933-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/11/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Wojciech Dabrowski
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, CEMTL, Montreal, Canada
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland.
- Medical Data Management, Medaman, Geel, Belgium.
- International Fluid Academy, Lovenjoel, Belgium.
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100
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Girard M, Deschamps J, Razzaq S, Lavoie N, Denault A, Beaubien-Souligny W. Emerging Applications of Extracardiac Ultrasound in Critically Ill Cardiac Patients. Can J Cardiol 2023; 39:444-457. [PMID: 36509177 DOI: 10.1016/j.cjca.2022.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/21/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Abstract
Point-of-care ultrasound has evolved as an invaluable diagnostic modality and procedural guidance tool in the care of critically ill cardiac patients. Beyond focused cardiac ultrasound, additional extracardiac ultrasound modalities may provide important information at the bedside. In addition to new uses of existing modalities, such as pulsed-wave Doppler ultrasound, the development of new applications is fostered by the implementation of additional features in mid-range ultrasound machines commonly acquired for intensive care units, such as tissue elastography, speckle tracking, and contrast-enhanced ultrasound quantification software. This review explores several areas in which ultrasound imaging technology may transform care in the future. First, we review how lung ultrasound in mechanically ventilated patients can enable the personalization of ventilator parameters and help to liberate them from mechanical ventilation. Second, we review the role of venous Doppler in the assessment of organ congestion and how tissue elastography may complement this application. Finally, we explore how contrast-enhanced ultrasound could be used to assess changes in organ perfusion.
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Affiliation(s)
- Martin Girard
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Department of Anaesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Jean Deschamps
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - André Denault
- Department of Anaesthesiology, Montréal Heart Institute, Montréal, Québec, Canada
| | - William Beaubien-Souligny
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
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