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A Carotid Doppler Patch Accurately Tracks Stroke Volume Changes During a Preload-Modifying Maneuver in Healthy Volunteers. Crit Care Explor 2020; 2:e0072. [PMID: 32166292 PMCID: PMC7063906 DOI: 10.1097/cce.0000000000000072] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objectives: Detecting instantaneous stroke volume change in response to altered cardiac preload is the physiologic foundation for determining preload responsiveness. Design: Proof-of-concept physiology study. Setting: Research simulation laboratory. Subjects: Twelve healthy volunteers. Interventions: A wireless continuous wave Doppler ultrasound patch was used to measure carotid velocity time integral and carotid corrected flow time during a squat maneuver. The Doppler patch measurements were compared with simultaneous stroke volume measurements obtained from a noninvasive cardiac output monitor. Measurements and Main Results: From stand to squat, stroke volume increased by 24% while carotid velocity time integral and carotid corrected flow time increased by 32% and 9%, respectively. From squat to stand, stroke volume decreased by 13%, while carotid velocity time integral and carotid corrected flow time decreased by 24% and 10%, respectively. Both changes in carotid velocity time integral and corrected flow time were closely correlated with changes in stroke volume (r2 = 0.81 and 0.62, respectively). The four-quadrant plot found a 100% concordance rate between changes in stroke volume and both changes in carotid velocity time integral and changes in corrected flow time. A change in carotid velocity time integral greater than 15% predicted a change in stroke volume greater than 10% with a sensitivity of 95% and a specificity of 92%. A change in carotid corrected flow time greater than 4% predicted a change in stroke volume greater than 10% with a sensitivity of 90% and a specificity of 92%. Conclusions: In healthy volunteers, both carotid velocity time integral and carotid corrected flow time measured by a wireless Doppler patch were useful to track changes in stroke volume induced by a preload-modifying maneuver with high sensitivity and specificity.
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Performance of the Hypotension Prediction Index with non-invasive arterial pressure waveforms in non-cardiac surgical patients. J Clin Monit Comput 2020; 35:71-78. [PMID: 31989416 PMCID: PMC7889685 DOI: 10.1007/s10877-020-00463-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/18/2020] [Indexed: 01/08/2023]
Abstract
An algorithm derived from machine learning uses the arterial waveform to predict intraoperative hypotension some minutes before episodes, possibly giving clinician’s time to intervene and prevent hypotension. Whether the Hypotension Prediction Index works well with noninvasive arterial pressure waveforms remains unknown. We therefore evaluated sensitivity, specificity, and positive predictive value of the Index based on non-invasive arterial waveform estimates. We used continuous hemodynamic data measured from ClearSight (formerly Nexfin) noninvasive finger blood pressure monitors in surgical patients. We re-evaluated data from a trial that included 320 adults ≥ 45 years old designated ASA physical status 3 or 4 who had moderate-to-high-risk non-cardiac surgery with general anesthesia. We calculated sensitivity and specificity for predicting hypotension, defined as mean arterial pressure ≤ 65 mmHg for at least 1 min, and characterized the relationship with receiver operating characteristics curves. We also evaluated the number of hypotensive events at various ranges of the Hypotension Prediction Index. And finally, we calculated the positive predictive value for hypotension episodes when the Prediction Index threshold was 85. The algorithm predicted hypotension 5 min in advance, with a sensitivity of 0.86 [95% confidence interval 0.82, 0.89] and specificity 0.86 [0.82, 0.89]. At 10 min, the sensitivity was 0.83 [0.79, 0.86] and the specificity was 0.83 [0.79, 0.86]. And at 15 min, the sensitivity was 0.75 [0.71, 0.80] and the specificity was 0.75 [0.71, 0.80]. The positive predictive value of the algorithm prediction at an Index threshold of 85 was 0.83 [0.79, 0.87]. A Hypotension Prediction Index of 80–89 provided a median of 6.0 [95% confidence interval 5.3, 6.7] minutes warning before mean arterial pressure decreased to < 65 mmHg. The Hypotension Prediction Index, which was developed and validated with invasive arterial waveforms, predicts intraoperative hypotension reasonably well from non-invasive estimates of the arterial waveform. Hypotension prediction, along with appropriate management, can potentially reduce intraoperative hypotension. Being able to use the non-invasive pressure waveform will widen the range of patients who might benefit. Clinical Trial Number: ClinicalTrials.gov NCT02872896.
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Lee JH, Kwon YL, Na JH, Jang YE, Kim EH, Kim HS, Kim JT. Is dynamic arterial elastance a predictor of an increase in blood pressure after fluid administration in pediatric patients with hypotension? Reanalysis of prospective observational studies. Paediatr Anaesth 2020; 30:34-42. [PMID: 31730254 DOI: 10.1111/pan.13769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/03/2019] [Accepted: 11/12/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Dynamic arterial elastance (Eadyn ) has been proposed to predict an increase in mean arterial pressure (MAP) after volume expansion in hypotensive adults. We aimed to evaluate the clinical usefulness of Eadyn as a predictor of arterial pressure response after fluid loading in pediatric patients with hypotension. METHODS We re-analyzed data of 63 hypotensive children (age, ≤5 years), collected from three previous prospective observational studies about fluid responsiveness. Pulse pressure variation (PPV), stroke volume variation (SVV), and respiratory variation in aortic blood flow velocity (ΔVpeak) were used to calculate Eadyn (PPV/SVV) and modified Eadyn (PPV/ΔVpeak). Preload-dependent patients were defined as those with ΔVpeak ≥12% before fluid loading. Patients were classified as pressure responders, if their MAP increased ≥15% after fluid administration. RESULTS Mean Eadyn (SD) was 1.06 (0.47) in pressure responders (n=39) and 0.99 (0.48) in nonresponders (n = 24) (mean difference, 0.08; 95% confidence interval [CI], -0.19-0.34; P = .567). Additionally, mean modified Eadyn was 1.27 (0.64) in responders and 1.11 (0.43) in nonresponders (mean difference, 0.17; 95% CI, -0.13-0.46; P = 0.269). Both Eadyn (AUC 0.506; 95% confidence interval [CI], 0.337 to 0.675; P = 0.948) and modified Eadyn (AUC 0.498; 95% CI, 0.328-0.669; P = 0.983), as well as other dynamic variables, could not predict pressure responsiveness in children. Sub-group analysis revealed similar findings in both in 39 preload-dependent and hypotensive patients (26 pressure responders and 13 nonpressure responders). CONCLUSION Both Eadyn and modified Eadyn cannot predict whether blood pressure increases with fluid administration in pediatric patients with hypotension.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yea-La Kwon
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Hwan Na
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young-Eun Jang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eun-Hee Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee-Soo Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Tae Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Zaouter C, Oses P, Assatourian S, Labrousse L, Rémy A, Ouattara A. Reduced Length of Hospital Stay for Cardiac Surgery—Implementing an Optimized Perioperative Pathway: Prospective Evaluation of an Enhanced Recovery After Surgery Program Designed for Mini-Invasive Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2019; 33:3010-3019. [DOI: 10.1053/j.jvca.2019.05.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/02/2019] [Accepted: 05/04/2019] [Indexed: 12/21/2022]
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Gonçalves LA, Otsuki DA, Pereira MA, Nagashima JK, Ambrosio AM, Fantoni DT. Comparison of pulse pressure variation versus echocardiography-derived stroke volume variation for prediction of fluid responsiveness in mechanically ventilated anesthetized dogs. Vet Anaesth Analg 2019; 47:28-37. [PMID: 31822378 DOI: 10.1016/j.vaa.2019.08.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 07/31/2019] [Accepted: 08/19/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the ability and accuracy of aortic flow velocity-time integral variation (ΔVTI) and peak aortic velocity variation (ΔVpeak) compared with pulse pressure variation (PPV) to predict fluid responsiveness in mechanically ventilated dogs. STUDY DESIGN Prospective clinical study. ANIMALS A group of 50 mechanically ventilated dogs with spontaneous hypotension during orthopedic or oncologic surgery. METHODS Investigations were performed in the surgery room. When mean arterial pressure (MAP) decreased to <65 mmHg, measurements were performed before and after a fluid challenge (lactated Ringer's solution 5 mL kg-1 over 15 minutes). Responders were defined as a change in stroke volume (SV; transesophageal Doppler) ≥15%. Data were analyzed using paired/unpaired t test or Mann-Whitney/Wilcoxon test when appropriate and receiver operating characteristics (ROC) curves; a p value <0.05 was considered statistically significant. RESULTS After the fluid challenge, 35 (70%) of 50 dogs were responders with significant increases in SV and decreases in PPV; 15 dogs were nonresponders. ΔVTI and ΔVpeak correlated with a 15% increase in SV. The optimum cut-off value for PPV was 15.6% (sensitivity, 88%; specificity, 100%), for ΔVTI was 10.65% (sensitivity, 65%; specificity, 100%) and for ΔVpeak was 10.15% (sensitivity, 80%; specificity, 100%). The area under the ROC curve for PPV was (0.93 ± 0.08) and for ΔVpeak was (0.89 ± 0.09), before fluid challenge. The gray zone area spread from 6.15% to 15.6% for PPV (18 dogs), 2.45% to 10.65% for ΔVTI (22 dogs) and 0.6% to 10.15% for ΔVpeak (25 dogs). CONCLUSIONS When using mechanical ventilation, ΔVTI and ΔVpeak predicted fluid responsiveness with the same ability as PPV, based on the area under the ROC curve analysis. However, PPV showed great accuracy demonstrated by a narrower gray zone that included fewer individuals. CLINICAL RELEVANCE ΔVTI and ΔVpeak can be used as indices of fluid responsiveness in anesthetized dogs.
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Affiliation(s)
- Lucas A Gonçalves
- Department of Surgery, School of Veterinary Medicine and Zootechnics (FMVZ), University of São Paulo, São Paulo, SP, Brazil.
| | - Denise A Otsuki
- Laboratório de Investigação Médica 08 - Anestesiologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, University of São Paulo, São Paulo, SP, Brazil
| | - Marco Aa Pereira
- Department of Surgery, School of Veterinary Medicine and Zootechnics (FMVZ), University of São Paulo, São Paulo, SP, Brazil
| | - Julio K Nagashima
- Department of Surgery, School of Veterinary Medicine and Zootechnics (FMVZ), University of São Paulo, São Paulo, SP, Brazil
| | - Aline M Ambrosio
- Department of Surgery, School of Veterinary Medicine and Zootechnics (FMVZ), University of São Paulo, São Paulo, SP, Brazil
| | - Denise T Fantoni
- Department of Surgery, School of Veterinary Medicine and Zootechnics (FMVZ), University of São Paulo, São Paulo, SP, Brazil
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Teboul JL, Monnet X, Chemla D, Michard F. Arterial Pulse Pressure Variation with Mechanical Ventilation. Am J Respir Crit Care Med 2019; 199:22-31. [PMID: 30138573 DOI: 10.1164/rccm.201801-0088ci] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Fluid administration leads to a significant increase in cardiac output in only half of ICU patients. This has led to the concept of assessing fluid responsiveness before infusing fluid. Pulse pressure variation (PPV), which quantifies the changes in arterial pulse pressure during mechanical ventilation, is one of the dynamic variables that can predict fluid responsiveness. The underlying hypothesis is that large respiratory changes in left ventricular stroke volume, and thus pulse pressure, occur in cases of biventricular preload responsiveness. Several studies showed that PPV accurately predicts fluid responsiveness when patients are under controlled mechanical ventilation. Nevertheless, in many conditions encountered in the ICU, the interpretation of PPV is unreliable (spontaneous breathing, cardiac arrhythmias) or doubtful (low Vt). To overcome some of these limitations, researchers have proposed using simple tests such as the Vt challenge to evaluate the dynamic response of PPV. The applicability of PPV is higher in the operating room setting, where fluid strategies made on the basis of PPV improve postoperative outcomes. In medical critically ill patients, although no randomized controlled trial has compared PPV-based fluid management with standard care, the Surviving Sepsis Campaign guidelines recommend using fluid responsiveness indices, including PPV, whenever applicable. In conclusion, PPV is useful for managing fluid therapy under specific conditions where it is reliable. The kinetics of PPV during diagnostic or therapeutic tests is also helpful for fluid management.
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Affiliation(s)
| | - Xavier Monnet
- 1 Medical Intensive Care Unit, Bicetre Hospital, and
| | - Denis Chemla
- 2 Department of Physiology, Bicetre Hospital, Paris-South University Hospitals, Inserm UMR_S999, Paris-South University, Le Kremlin-Bicêtre, France; and
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Chang BY, Keller SP, Edelman ER. Leveraging Device-Arterial Coupling to Determine Cardiac and Vascular State. IEEE Trans Biomed Eng 2019; 66:2800-2808. [PMID: 30703007 PMCID: PMC6661194 DOI: 10.1109/tbme.2019.2895752] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Limitations in available diagnostic metrics restrict the efficacy of managing therapies for cardiogenic shock. In current clinical practice, cardiovascular state is inferred through measurement of pulmonary capillary wedge pressure and reliance on linear approximations between pressure and flow to estimate peripheral vascular resistance. Mechanical circulatory support devices residing within the left ventricle and aorta provide an opportunity for both determining cardiac and vascular state and offering therapeutic benefit. We leverage the controllable mode of operation and transvalvular position of an indwelling percutaneous ventricular assist device to assess vascular and, in turn, cardiac state through the effects of device-arterial coupling across different levels of device support. METHODS Vascular state is determined by measuring changes in the pressure waveforms induced through intentional variation in the device generated blood flow. We evaluate this impact by applying a lumped parameter model to quantify state-specific vascular resistance and compliance and calculate beat-to-beat stroke volume and cardiac output in both animal models and retrospective patient data without external calibration. RESULTS Vascular state was accurately predicted in patients and animals in both baseline and experimental conditions. In the animal, stroke volume was predicted within a total root mean square error of 3.71 mL (n = 482). CONCLUSION We demonstrate that device-arterial coupling is a powerful tool for evaluating patient and state specific parameters of cardiovascular function. SIGNIFICANCE These insights may yield improved clinical care and support the development of next generation mechanical circulatory support devices that determine and operate in tandem with the supported organ.
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Ultrasound Assessment of the Change in Carotid Corrected Flow Time in Fluid Responsiveness in Undifferentiated Shock. Crit Care Med 2019; 46:e1040-e1046. [PMID: 30134304 DOI: 10.1097/ccm.0000000000003356] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Adequate assessment of fluid responsiveness in shock necessitates correct interpretation of hemodynamic changes induced by preload challenge. This study evaluates the accuracy of point-of-care Doppler ultrasound assessment of the change in carotid corrected flow time induced by a passive leg raise maneuver as a predictor of fluid responsiveness. Noninvasive cardiac output monitoring (NICOM, Cheetah Medical, Newton Center, MA) system based on a bioreactance method was used. DESIGN Prospective, noninterventional study. SETTING ICU at a large academic center. PATIENTS Patients with new, undifferentiated shock, and vasopressor requirements despite fluid resuscitation were included. Patients with significant cardiac disease and conditions that precluded adequate passive leg raising were excluded. INTERVENTIONS Carotid corrected flow time was measured via ultrasound before and after a passive leg raise maneuver. Predicted fluid responsiveness was defined as greater than 10% increase in stroke volume on noninvasive cardiac output monitoring following passive leg raise. Images and measurements were reanalyzed by a second, blinded physician. The accuracy of change in carotid corrected flow time to predict fluid responsiveness was evaluated using receiver operating characteristic analysis. MEASUREMENTS AND MAIN RESULTS Seventy-seven subjects were enrolled with 54 (70.1%) classified as fluid responders by noninvasive cardiac output monitoring. The average change in carotid corrected flow time after passive leg raise for fluid responders was 14.1 ± 18.7 ms versus -4.0 ± 8 ms for nonresponders (p < 0.001). Receiver operating characteristic analysis demonstrated that change in carotid corrected flow time is an accurate predictor of fluid responsiveness status (area under the curve, 0.88; 95% CI, 0.80-0.96) and a 7 ms increase in carotid corrected flow time post passive leg raise was shown to have a 97% positive predictive value and 82% accuracy in detecting fluid responsiveness using noninvasive cardiac output monitoring as a reference standard. Mechanical ventilation, respiratory rate, and high positive end-expiratory pressure had no significant impact on test performance. Post hoc blinded evaluation of bedside acquired measurements demonstrated agreement between evaluators. CONCLUSIONS Change in carotid corrected flow time can predict fluid responsiveness status after a passive leg raise maneuver. Using point-of-care ultrasound to assess change in carotid corrected flow time is an acceptable and reproducible method for noninvasive identification of fluid responsiveness in critically ill patients with undifferentiated shock.
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Conlon TW, Lin EE, Bruins BB, Manrique Espinel AM, Muhly WT, Elliott E, Glau C, Himebauch AS, Johnson G, Fiadjoe JE, Lockman JL, Nishisaki A, Schwartz AJ. Getting to know a familiar face: Current and emerging focused ultrasound applications for the perioperative setting. Paediatr Anaesth 2019; 29:672-681. [PMID: 30839154 DOI: 10.1111/pan.13625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 02/26/2019] [Accepted: 03/03/2019] [Indexed: 12/18/2022]
Abstract
Ultrasound technology is available in many pediatric perioperative settings. There is an increasing number of ultrasound applications for anesthesiologists which may enhance clinical performance, procedural safety, and patient outcomes. This review highlights the literature and experience supporting focused ultrasound applications in the pediatric perioperative setting across varied disciplines including anesthesiology. The review also suggests strategies for building educational and infrastructural systems to translate this technology into clinical practice.
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Affiliation(s)
- Thomas W Conlon
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elaina E Lin
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Benjamin B Bruins
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ana Maria Manrique Espinel
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth Elliott
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christie Glau
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gregory Johnson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John E Fiadjoe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Justin L Lockman
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan Jay Schwartz
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Si X, Cao DY, Chen J, Wu JF, Liu ZM, Xu HL, Chen MY, Liu YJ, Guan XD. Effect of Systolic Cardiac Function on Passive Leg Raising for Predicting Fluid Responsiveness: A Prospective Observational Study. Chin Med J (Engl) 2019; 131:253-261. [PMID: 29363638 PMCID: PMC5798044 DOI: 10.4103/0366-6999.223841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Passive leg raising (PLR) represents a "self-volume expansion (VE)" that could predict fluid responsiveness, but the influence of systolic cardiac function on PLR has seldom been reported. This study aimed to investigate whether systolic cardiac function, estimated by the global ejection fraction (GEF) from transpulmonary-thermodilution, could influence the diagnostic value of PLR. METHODS This prospective, observational study was carried out in the surgical Intensive Care Unit of the First Affiliated Hospital of Sun Yat-sen University from December 2013 to July 2015. Seventy-eight mechanically ventilated patients considered for VE were prospectively included and divided into a low-GEF (<20%) and a near-normal-GEF (≥20%) group. Within each group, baseline hemodynamics, after PLR and after VE (250 ml 5% albumin over 30 min), were recorded. PLR-induced hemodynamic changes (PLR-Δ) were calculated. Fluid responders were defined by a 15% increase of stroke volume (SV) after VE. RESULTS Twenty-five out of 38 patients were responders in the GEF <20% group, compared to 26 out of 40 patients in the GEF ≥20% group. The thresholds of PLR-ΔSV and PLR-Δ cardiac output (PLR-ΔCO) for predicting fluid responsiveness were higher in the GEF ≥20% group than in the GEF <20% group (ΔSV: 12% vs. 8%; ΔCO: 7% vs. 6%), with increased sensitivity (ΔSV: 92% vs. 92%; ΔCO: 81% vs. 80%) and specificity (ΔSV: 86% vs. 70%; ΔCO: 86% vs. 77%), respectively. PLR-Δ heart rate could predict fluid responsiveness in the GEF ≥20% group with a threshold value of -5% (sensitivity 65%, specificity 93%) but could not in the GEF <20% group. The pressure index changes were poor predictors. CONCLUSIONS In the critically ill patients on mechanical ventilation, the diagnostic value of PLR for predicting fluid responsiveness depends on cardiac systolic function. Thus, cardiac systolic function must be considered when using PLR. TRIAL REGISTRATION Chinese Clinical Trial Register, ChiCTR-OCH-13004027; http://www.chictr.org.cn/showproj.aspx?proj=5540.
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Affiliation(s)
- Xiang Si
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Dai-Yin Cao
- Department of Critical Care Medicine, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510655, China
| | - Juan Chen
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Jian-Feng Wu
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Zi-Meng Liu
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Hai-Lin Xu
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Min-Ying Chen
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Yong-Jun Liu
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Xiang-Dong Guan
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
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Jozwiak M, Mercado P, Teboul JL, Benmalek A, Gimenez J, Dépret F, Richard C, Monnet X. What is the lowest change in cardiac output that transthoracic echocardiography can detect? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:116. [PMID: 30971307 PMCID: PMC6458708 DOI: 10.1186/s13054-019-2413-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 03/28/2019] [Indexed: 12/22/2022]
Abstract
Background In critically ill patients, changes in the velocity-time integral (VTI) of the left ventricular outflow tract, measured by transthoracic echocardiography (TTE), are often used to non-invasively assess the response to fluid administration or for performing tests assessing fluid responsiveness. However, the precision of TTE measurements has not yet been investigated in such patients. First, we aimed at assessing how many measurements should be averaged within one TTE examination to reach a sufficient precision for various variables. Second, we aimed at identifying the least significant change (LSC) of these variables between successive TTE examinations. Methods We prospectively included 100 haemodynamically stable patients in whom TTE examination was planned. Three TTE examinations were performed, the first and the third by one operator and the second by another one. We calculated the precision and LSC (1) within one examination depending on the number of averaged measurements and (2) between measurements performed in two successive examinations. Results In patients in sinus rhythm, averaging three measurements within an examination was enough for obtaining an acceptable precision (interquartile range highest value < 10%) for VTI. In patients with atrial fibrillation, averaging five measurements was necessary. The precision of some other common TTE variables depending on the number of measurements is provided. Between two successive examinations performed by the same operator, the LSC was 11 [5–18]% for VTI. If two operators performed the examinations, the LSC for VTI significantly increased to 14 [8–26]%. The LSC between two examinations for other TTE variables is also provided. Conclusions Averaging three measurements within one TTE examination is enough for obtaining precise measurements for VTI in patients in sinus rhythm but not in patients with atrial fibrillation. Between two TTE examinations performed by the same operator, the LSC of VTI is compatible with the assessment of the effects of a 500-mL fluid infusion but is not precise enough for assessing the effects of some tests predicting preload responsiveness. Electronic supplementary material The online version of this article (10.1186/s13054-019-2413-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mathieu Jozwiak
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, APHP, Service de Médecine Intensive-Réanimation et de Surveillance Continue Médicale, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France. .,Inserm UMR S_999, Univ Paris-Sud, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.
| | - Pablo Mercado
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, APHP, Service de Médecine Intensive-Réanimation et de Surveillance Continue Médicale, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.,Inserm UMR S_999, Univ Paris-Sud, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, APHP, Service de Médecine Intensive-Réanimation et de Surveillance Continue Médicale, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.,Inserm UMR S_999, Univ Paris-Sud, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France
| | - Anouar Benmalek
- Faculté de Pharmacie, Université Paris-Sud, 5 rue Jean-Baptiste Clément, F-92290, Châtenay-Malabry, France
| | - Julia Gimenez
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, APHP, Service de Médecine Intensive-Réanimation et de Surveillance Continue Médicale, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.,Inserm UMR S_999, Univ Paris-Sud, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France
| | - François Dépret
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, APHP, Service de Médecine Intensive-Réanimation et de Surveillance Continue Médicale, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.,Inserm UMR S_999, Univ Paris-Sud, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France
| | - Christian Richard
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, APHP, Service de Médecine Intensive-Réanimation et de Surveillance Continue Médicale, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.,Inserm UMR S_999, Univ Paris-Sud, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, APHP, Service de Médecine Intensive-Réanimation et de Surveillance Continue Médicale, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.,Inserm UMR S_999, Univ Paris-Sud, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France
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63
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Zenor L, Anderson CJ. Bridge over Troubled Water. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2018.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Respiratory Variability of Pulmonary Velocity-Time Integral As a New Gauge of Fluid Responsiveness For Mechanically Ventilated Patients in the ICU*. Crit Care Med 2019; 47:e310-e316. [DOI: 10.1097/ccm.0000000000003642] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Pourmand A, Pyle M, Yamane D, Sumon K, Frasure SE. The utility of point-of-care ultrasound in the assessment of volume status in acute and critically ill patients. World J Emerg Med 2019; 10:232-238. [PMID: 31534598 DOI: 10.5847/wjem.j.1920-8642.2019.04.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Volume resuscitation has only been demonstrated to be effective in approximately fifty percent of patients. The remaining patients do not respond to volume resuscitation and may even develop adverse outcomes (such as acute pulmonary edema necessitating endotracheal intubation). We believe that point-of-care ultrasound is an excellent modality by which to adequately predict which patients may benefit from volume resuscitation. DATA RESOURCES We performed a search using PubMed, Scopus, and MEDLINE. The following search terms were used: fluid responsiveness, ultrasound, non-invasive, hemodynamic, fluid challenge, and passive leg raise. Preference was given to clinical trials and review articles that were most relevant to the topic of assessing a patient's cardiovascular ability to respond to intravenous fluid administration using ultrasound. RESULTS Point-of-care ultrasound can be easily employed to measure the diameter and collapsibility of various large vessels including the inferior vena cava, common carotid artery, subclavian vein, internal jugular vein, and femoral vein. Such parameters are closely related to dynamic measures of fluid responsiveness and can be used by providers to help guide fluid resuscitation in critically ill patients. CONCLUSION Ultrasound in combination with passive leg raise is a non-invasive, cost- and time-effective modality that can be employed to assess volume status and response to fluid resuscitation. Traditionally sonographic studies have focused on the evaluation of large veins such as the inferior vena cava, and internal jugular vein. A number of recently published studies also demonstrate the usefulness of evaluating large arteries to predict volume status.
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Affiliation(s)
- Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Matthew Pyle
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - David Yamane
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Kazi Sumon
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sarah E Frasure
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Predicting fluid responsiveness: A review of literature and a guide for the clinician. Am J Emerg Med 2018; 36:2093-2102. [DOI: 10.1016/j.ajem.2018.08.037] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/27/2018] [Accepted: 08/13/2018] [Indexed: 01/04/2023] Open
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Jozwiak M, Monnet X, Teboul JL. Prediction of fluid responsiveness in ventilated patients. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:352. [PMID: 30370279 DOI: 10.21037/atm.2018.05.03] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Fluid administration is the first-line therapy in patients with acute circulatory failure. The main goal of fluid administration is to increase the cardiac output and ultimately the oxygen delivery. Nevertheless, the decision to administer fluids or not should be carefully considered, since half of critically ill patients are fluid unresponsive, and the deleterious effects of fluid overload clearly documented. Thus, except at the initial phase of hypovolemic or septic shock, where hypovolemia is constant and most of the patients responsive to the initial fluid resuscitation, it is of importance to test fluid responsiveness before administering fluids in critically ill patients. The static markers of cardiac preload cannot reliably predict fluid responsiveness, although they have been used for decades. To address this issue, some dynamic tests have been developed over the past years. All these tests consist in measuring the changes in cardiac output in response to the transient changes in cardiac preload that they induced. Most of these tests are based on the heart-lung interactions. The pulse pressure or stroke volume respiratory variations were first described, following by the respiratory variations of the vena cava diameter or of the internal jugular vein diameter. Nevertheless, all these tests are reliable only under strict conditions limiting their use in many clinical situations. Other tests such as passive leg raising or end-expiratory occlusion act as an internal volume challenge. To reliably predict fluid responsiveness, physicians must choose among these different dynamic tests, depending on their respective limitations and on the cardiac output monitoring technique which is used. In this review, we will summarize the most recent findings regarding the prediction of fluid responsiveness in ventilated patients.
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Affiliation(s)
- Mathieu Jozwiak
- Hôpitaux Universitaires Paris-Sud, Assistance Publique - Hôpitaux de Paris, Hôpital de Bicêtre, service de réanimation médicale, Le Kremlin-Bicêtre, France.,Inserm UMR S_999, Univ Paris-Sud, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Hôpitaux Universitaires Paris-Sud, Assistance Publique - Hôpitaux de Paris, Hôpital de Bicêtre, service de réanimation médicale, Le Kremlin-Bicêtre, France.,Inserm UMR S_999, Univ Paris-Sud, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Hôpitaux Universitaires Paris-Sud, Assistance Publique - Hôpitaux de Paris, Hôpital de Bicêtre, service de réanimation médicale, Le Kremlin-Bicêtre, France.,Inserm UMR S_999, Univ Paris-Sud, Le Kremlin-Bicêtre, France
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68
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Hrishi AP, Sethuraman M, Menon G. Quest for the holy grail: Assessment of echo-derived dynamic parameters as predictors of fluid responsiveness in patients with acute aneurysmal subarachnoid hemorrhage. Ann Card Anaesth 2018; 21:243-248. [PMID: 30052209 PMCID: PMC6078021 DOI: 10.4103/aca.aca_141_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Acute aneurysmal subarachnoid hemorrhage (aSAH) is a potentially devastating event often presenting with a plethora of hemodynamic fluctuations requiring meticulous fluid management. The aim of this study was to assess the utility of newer dynamic predictors of fluid responsiveness such as Delta down (DD), superior vena cava collapsibility index (SVCCI), and aortic velocity time integral variability (VTIAoV) in patients with SAH undergoing neurosurgery. Materials and Methods: Fifteen individuals with SAH undergoing surgery for intracranial aneurysmal clipping were enrolled in this prospective study. Postinduction, vitals, anesthetic parameters, and the study variables were recorded as the baseline. Following this, patients received a fluid bolus of 10 ml/kg of colloid over 20 min, and measurements were repeated postfluid loading. Continuous variables were expressed as mean ± standard deviation and compared using Student's t-test, with a P < 0.05 considered statistically significant. The predictive ability of variables for fluid responsiveness was determined using Pearson's coefficient analysis (r). Results: There were 12 volume responders and 3 nonresponders (NR). DD >5 mm Hg was efficient in differentiating the responders from NR (P < 0.05) with a sensitivity and specificity of 90% and 85%, respectively, with a good predictive ability to identify fluid responders and NR; r = 0.716. SVCCI of >38% was 100% sensitive and 95% specific in detecting the volume status and in differentiating the responders from NR (P < 0.05) and is an excellent predictor of fluid responsive status; r = 0.906. VTIAoV >20% too proved to be a good predictor of fluid responsiveness, with a sensitivity and specificity of 100% and 90%, respectively, with a predictive power; r = 0.732. Conclusion: Our study showed that 80% of patients presenting with aSAH for intracranial aneurysm clipping were fluid responders with normal hemodynamic parameters such as heart rate and blood pressure. Among the variables, SVCCI >38% appears to be an excellent predictor followed by VTIAoV >20% and DD >5 mmHg in assessing the fluid status in this population.
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Affiliation(s)
- Ajay Prasad Hrishi
- Department of Anesthesiology, Division of Neuroanesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Manikandan Sethuraman
- Department of Anesthesiology, Division of Neuroanesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Udupi, Karnataka, India
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69
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The importance of sensor contacting force for predicting fluid responsiveness in children using respiratory variations in pulse oximetry plethysmographic waveform. J Clin Monit Comput 2018; 33:393-401. [DOI: 10.1007/s10877-018-0183-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/10/2018] [Indexed: 12/14/2022]
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70
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Unluer EE, Evrin T, Katipoglu B, Bayata S. A bedside ultrasound technique for fluid therapy monitoring in severe hypovolemia: Tissue Doppler imaging of the right ventricle. Interv Med Appl Sci 2018; 9:212-214. [PMID: 29951288 PMCID: PMC6016210 DOI: 10.1556/1646.9.2017.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Fluid therapy is one of the main issues for hemodynamic resuscitation. Tissue Doppler imaging (TDI) of the right ventricle (RV) with bedside ultrasound (BUS) technique is a new dynamic method to identify fluid responsiveness in patients with hypotension. Here, we present the case of a hypotensive patient monitored with TDI measurements of RV. A 75-year-old male patient was admitted to the emergency department (ED) with the complaint of diarrhea. He was in severe hypovolemia, with hypotension, tachycardia, and tachypnea. His laboratory results were normal. BUS was performed on the patient by the ED physician. The velocity of the excursion of the tricuspid valve measured at presentation was 14.47 cm/s and, together with collapsed inferior vena cava (IVC), this finding led to the decision to begin fluid therapy immediately. The patient underwent 2 L of fluid therapy with 0.9% NaCl in a 2-h period. Control BUS after fluid therapy revealed decreased TDI velocity of tricuspid annulus to 11.81 cm/s and dilated IVC not collapsing sufficiently with respiration. The patient received his maintenance therapy after admission to the internal medicine department and was discharged from the service after 3 days. TDI in fluid responsiveness may find a clinical role in the future by the clinical studies.
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Affiliation(s)
- Erden Erol Unluer
- Department of Emergency Medicine, Usak University Medical Faculty, Usak, Turkey
| | - Togay Evrin
- Department of Emergency Medicine, Ufuk University Medical Faculty, Dr Ridvan Ege Education and Research Hospital, Ankara, Turkey
| | - Burak Katipoglu
- Department of Emergency Medicine, Ankara Education and Research Hospital, Ankara, Turkey
| | - Serdar Bayata
- Department of Cardiology, Izmir Katip Çelebi University, Ataturk Research and Training Hospital, Izmir, Turkey
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Abstract
PURPOSE OF REVIEW The objective was to define the role of ultrasound in the diagnosis and the management of circulatory shock by critical appraisal of the literature. RECENT FINDINGS Assessment of any patient's hemodynamic profile based on clinical examination can be sufficient in several cases, but many times unclarities remain. Arterial catheters and central venous lines are commonly used in critically ill patients for practical reasons, and offer an opportunity for advanced hemodynamic monitoring. Critical care ultrasonography may add to the understanding of the hemodynamic profile at hand. Improvements in ultrasound techniques, for example, smaller devices and improved image quality, may reduce limitations and increase its value as a complementary tool. Critical care ultrasonography has great potential to guide decisions in the management of shock, but operators should be aware of limitations and pitfalls as well. Current evidence comes from cohort studies with heterogeneous design and outcomes. SUMMARY Use of ultrasonography for hemodynamic monitoring in critical care expands, probably because of absence of procedure-related adverse events. Easy applicability and the capacity of distinguishing different types of shock add to its increasing role, further supported by consensus statements promoting ultrasound as the preferred tool for diagnostics in circulatory shock.
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Abstract
PURPOSE OF REVIEW It has recently become evident that administration of intravenous fluids following initial resuscitation has a greater probability of producing tissue edema and hypoxemia than of increasing oxygen delivery. Therefore, it is essential to have a rational approach to assess the adequacy of volume resuscitation. Here we review passive leg raising (PLR) and respiratory variation in hemodynamics to assess fluid responsiveness. RECENT FINDINGS The use of ultrasound enhances the clinician's ability to detect and predict fluid responsiveness, whereas enthusiasm for this modality must be tempered by recent evidence that it is only reliable in apneic patients. SUMMARY The best predictor of fluid response for hypotensive patients not on vasopressors is a properly conducted passive leg raise maneuver. For more severely ill patients who are apneic, mechanically ventilated and on vasopressors, point of care echocardiography is the best choice. Increases in vena caval diameter induced by controlled positive pressure breaths are insensitive to arrhythmias and can be performed with relatively brief training. Most challenging are patients who are awake and on vasopressors; we suggest that the best method to discriminate fluid responders is PLR measuring changes in cardiac output.
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73
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Desai N, Garry D. Assessing dynamic fluid-responsiveness using transthoracic echocardiography in intensive care. BJA Educ 2018; 18:218-226. [PMID: 33456836 DOI: 10.1016/j.bjae.2018.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2018] [Indexed: 11/19/2022] Open
Affiliation(s)
- N Desai
- Northwick Park Hospital, London, UK
| | - D Garry
- John Radcliffe Hospital, Oxford, UK
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74
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Noel-Morgan J, Muir WW. Anesthesia-Associated Relative Hypovolemia: Mechanisms, Monitoring, and Treatment Considerations. Front Vet Sci 2018; 5:53. [PMID: 29616230 PMCID: PMC5864866 DOI: 10.3389/fvets.2018.00053] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/02/2018] [Indexed: 12/14/2022] Open
Abstract
Although the utility and benefits of anesthesia and analgesia are irrefutable, their practice is not void of risks. Almost all drugs that produce anesthesia endanger cardiovascular stability by producing dose-dependent impairment of cardiac function, vascular reactivity, and compensatory autoregulatory responses. Whereas anesthesia-related depression of cardiac performance and arterial vasodilation are well recognized adverse effects contributing to anesthetic risk, far less emphasis has been placed on effects impacting venous physiology and venous return. The venous circulation, containing about 65–70% of the total blood volume, is a pivotal contributor to stroke volume and cardiac output. Vasodilation, particularly venodilation, is the primary cause of relative hypovolemia produced by anesthetic drugs and is often associated with increased venous compliance, decreased venous return, and reduced response to vasoactive substances. Depending on factors such as patient status and monitoring, a state of relative hypovolemia may remain clinically undetected, with impending consequences owing to impaired oxygen delivery and tissue perfusion. Concurrent processes related to comorbidities, hypothermia, inflammation, trauma, sepsis, or other causes of hemodynamic or metabolic compromise, may further exacerbate the condition. Despite scientific and technological advances, clinical monitoring and treatment of relative hypovolemia still pose relevant challenges to the anesthesiologist. This short perspective seeks to define relative hypovolemia, describe the venous system’s role in supporting normal cardiovascular function, characterize effects of anesthetic drugs on venous physiology, and address current considerations and challenges for monitoring and treatment of relative hypovolemia, with focus on insights for future therapies.
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Affiliation(s)
- Jessica Noel-Morgan
- Center for Cardiovascular & Pulmonary Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - William W Muir
- QTest Labs, Columbus, OH, United States.,College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
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75
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Georges D, de Courson H, Lanchon R, Sesay M, Nouette-Gaulain K, Biais M. End-expiratory occlusion maneuver to predict fluid responsiveness in the intensive care unit: an echocardiographic study. Crit Care 2018; 22:32. [PMID: 29415773 PMCID: PMC5804059 DOI: 10.1186/s13054-017-1938-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 12/27/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In mechanically ventilated patients, an increase in cardiac index during an end-expiratory-occlusion test predicts fluid responsiveness. To identify this rapid increase in cardiac index, continuous and instantaneous cardiac index monitoring is necessary, decreasing its feasibility at the bedside. Our study was designed to investigate whether changes in velocity time integral and in peak velocity obtained using transthoracic echocardiography during an end-expiratory-occlusion maneuver could predict fluid responsiveness. METHODS This single-center, prospective study included 50 mechanically ventilated critically ill patients. Velocity time integral and peak velocity were assessed using transthoracic echocardiography before and at the end of a 12-sec end-expiratory-occlusion maneuver. A third set of measurements was performed after volume expansion (500 mL of saline 0.9% given over 15 minutes). Patients were considered as responders if cardiac output increased by 15% or more after volume expansion. RESULTS Twenty-eight patients were responders. At baseline, heart rate, mean arterial pressure, cardiac output, velocity time integral and peak velocity were similar between responders and non-responders. End-expiratory-occlusion maneuver induced a significant increase in velocity time integral both in responders and non-responders, and a significant increase in peak velocity only in responders. A 9% increase in velocity time integral induced by the end-expiratory-occlusion maneuver predicted fluid responsiveness with sensitivity of 89% (95% CI 72% to 98%) and specificity of 95% (95% CI 77% to 100%). An 8.5% increase in peak velocity induced by the end-expiratory-occlusion maneuver predicted fluid responsiveness with sensitivity of 64% (95% CI 44% to 81%) and specificity of 77% (95% CI 55% to 92%). The area under the receiver operating curve generated for changes in velocity time integral was significantly higher than the one generated for changes in peak velocity (0.96 ± 0.03 versus 0.70 ± 0.07, respectively, P = 0.0004 for both). The gray zone ranged between 6 and 10% (20% of the patients) for changes in velocity time integral and between 1 and 13% (62% of the patients) for changes in peak velocity. CONCLUSIONS In mechanically ventilated and sedated patients in the neuro Intensive Care Unit, changes in velocity time integral during a 12-sec end-expiratory-occlusion maneuver were able to predict fluid responsiveness and perform better than changes in peak velocity.
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Affiliation(s)
- Delphine Georges
- Department of Anesthesiology and Critical Care Pellegrin, Bordeaux University Hospital, F-33000 Bordeaux, France
| | - Hugues de Courson
- Department of Anesthesiology and Critical Care Pellegrin, Bordeaux University Hospital, F-33000 Bordeaux, France
| | - Romain Lanchon
- Department of Anesthesiology and Critical Care Pellegrin, Bordeaux University Hospital, F-33000 Bordeaux, France
| | - Musa Sesay
- Department of Anesthesiology and Critical Care Pellegrin, Bordeaux University Hospital, F-33000 Bordeaux, France
| | - Karine Nouette-Gaulain
- Department of Anesthesiology and Critical Care Pellegrin, Bordeaux University Hospital, F-33000 Bordeaux, France
- INSERM, U12-11, Laboratoire de Maladies Rares: Génétique et Métabolisme (MRGM), Bordeaux, France
- University of Bordeaux, Bordeaux, F-33600 France
| | - Matthieu Biais
- Department of Anesthesiology and Critical Care Pellegrin, Bordeaux University Hospital, F-33000 Bordeaux, France
- University of Bordeaux, Bordeaux, F-33600 France
- INSERM, U1034, Biology of Cardiovascular Diseases, F-33600 Pessac, France
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Singh Y, Katheria AC, Vora F. Advances in Diagnosis and Management of Hemodynamic Instability in Neonatal Shock. Front Pediatr 2018; 6:2. [PMID: 29404312 PMCID: PMC5780410 DOI: 10.3389/fped.2018.00002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 01/05/2018] [Indexed: 01/20/2023] Open
Abstract
Shock in newborn infants has unique etiopathologic origins that require careful assessment to direct specific interventions. Early diagnosis is key to successful management. Unlike adults and pediatric patients, shock in newborn infants is often recognized in the uncompensated phase by the presence of hypotension, which may be too late. The routine methods of evaluation used in the adult and pediatric population are often invasive and less feasible. We aim to discuss the pathophysiology in shock in newborn infants, including the transitional changes at birth and unique features that contribute to the challenges in early identification. Special emphasis has been placed on bedside focused echocardiography/focused cardiac ultrasound, which can be used as an additional tool for early, neonatologist driven, ongoing evaluation and management. An approach to goal oriented management of shock has been described and how bed side functional echocardiography can help in making a logical choice of intervention (fluid therapy, inotropic therapy or vasopressor therapy) in infants with shock.
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Affiliation(s)
- Yogen Singh
- Department of Pediatric Cardiology and Neonatal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- University of Cambridge Clinical School of Medicine, Cambridge, United Kingdom
| | - Anup C. Katheria
- Department of Neonatology, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
- Department of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Farha Vora
- Department of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, United States
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77
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Abstract
Background Fluid resuscitation is not only used to prevent acute kidney injury (AKI) but fluid management is also a cornerstone of treatment for patients with established AKI and renal failure. Ultrafiltration removes volume initially from the intravascular compartment inducing a relative degree of hypovolemia. Normal reflex mechanisms attempt to sustain blood pressure constant despite marked changes in blood volume and cardiac output. Thus, compensated shock with a normal blood pressure is a major cause of AKI or exacerbations of AKI during ultrafiltration. Methods We undertook a systematic review of the literature using MEDLINE, Google Scholar and PubMed searches. We determined a list of key questions and convened a 2-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated clinical practice recommendations and/or directions for future research. Results We defined three aspects of fluid monitoring: i) normal and pathophysiological cardiovascular mechanisms; ii) measures of volume responsiveness and impending cardiovascular collapse during volume removal, and; iii) measured indices of each using non-invasive and minimally invasive continuous and intermittent monitoring techniques. The evidence documents that AKI can occur in the setting of normotensive hypovolemia and that under-resuscitation represents a major cause of both AKI and mortality ion critically ill patients. Traditional measures of intravascular volume and ventricular filling do not predict volume responsiveness whereas dynamic functional hemodynamic markers, such as pulse pressure or stroke volume variation during positive pressure breathing or mean flow changes with passive leg raising are highly predictive of volume responsiveness. Numerous commercially-available devices exist that can acquire these signals. Conclusions Prospective clinical trials using functional hemodynamic markers in the diagnosis and management of AKI and volume status during ultrafiltration need to be performed. More traditional measure of preload be abandoned as marked of volume responsiveness though still useful to assess overall volume status.
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Affiliation(s)
- M.R. Pinsky
- Bioengineering, Cardiovascular Diseases and Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA - USA
| | - P. Brophy
- Division of Pediatric Nephrology, Hypertension, Dialysis and Transplantation, University of Iowa, Children's Hospital, Iowa City, Iowa - USA
| | - J. Padilla
- Universidad de Iberoamerica, San Jose - Costa Rica
| | - E. Paganini
- Division of Nephrology, Cleveland Clinic Foundation, Cleveland, OH - USA
| | - N. Pannu
- Division of Nephrology and CCM, University of Alberta, Edmonton, Alberta - Canada
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Yonis H, Bitker L, Aublanc M, Perinel Ragey S, Riad Z, Lissonde F, Louf-Durier A, Debord S, Gobert F, Tapponnier R, Guérin C, Richard JC. Change in cardiac output during Trendelenburg maneuver is a reliable predictor of fluid responsiveness in patients with acute respiratory distress syndrome in the prone position under protective ventilation. Crit Care 2017; 21:295. [PMID: 29208025 PMCID: PMC5718075 DOI: 10.1186/s13054-017-1881-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/31/2017] [Indexed: 11/10/2022] Open
Abstract
Background Predicting fluid responsiveness may help to avoid unnecessary fluid administration during acute respiratory distress syndrome (ARDS). The aim of this study was to evaluate the diagnostic performance of the following methods to predict fluid responsiveness in ARDS patients under protective ventilation in the prone position: cardiac index variation during a Trendelenburg maneuver, cardiac index variation during an end-expiratory occlusion test, and both pulse pressure variation and change in pulse pressure variation from baseline during a tidal volume challenge by increasing tidal volume (VT) to 8 ml.kg-1. Methods This study is a prospective single-center study, performed in a medical intensive care unit, on ARDS patients with acute circulatory failure in the prone position. Patients were studied at baseline, during a 1-min shift to the Trendelenburg position, during a 15-s end-expiratory occlusion, during a 1-min increase in VT to 8 ml.kg-1, and after fluid administration. Fluid responsiveness was deemed present if cardiac index assessed by transpulmonary thermodilution increased by at least 15% after fluid administration. Results There were 33 patients included, among whom 14 (42%) exhibited cardiac arrhythmia at baseline and 15 (45%) were deemed fluid-responsive. The area under the receiver operating characteristic (ROC) curve of the pulse contour-derived cardiac index change during the Trendelenburg maneuver and the end-expiratory occlusion test were 0.90 (95% CI, 0.80–1.00) and 0.65 (95% CI, 0.46–0.84), respectively. An increase in cardiac index ≥ 8% during the Trendelenburg maneuver enabled diagnosis of fluid responsiveness with sensitivity of 87% (95% CI, 67–100), and specificity of 89% (95% CI, 72–100). The area under the ROC curve of pulse pressure variation and change in pulse pressure variation during the tidal volume challenge were 0.52 (95% CI, 0.24–0.80) and 0.59 (95% CI, 0.31–0.88), respectively. Conclusions Change in cardiac index during a Trendelenburg maneuver is a reliable test to predict fluid responsiveness in ARDS patients in the prone position, while neither change in cardiac index during end-expiratory occlusion, nor pulse pressure variation during a VT challenge reached acceptable predictive performance to predict fluid responsiveness in this setting. Trial registration ClinicalTrials.gov, NCT01965574. Registered on 16 October 2013. The trial was registered 6 days after inclusion of the first patient. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1881-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hodane Yonis
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Laurent Bitker
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Mylène Aublanc
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Sophie Perinel Ragey
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Zakaria Riad
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Floriane Lissonde
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Aurore Louf-Durier
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Sophie Debord
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Florent Gobert
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Romain Tapponnier
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France.,IMRB, INSERM 955Eq13, Créteil, France
| | - Jean-Christophe Richard
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. .,Université de Lyon, Université LYON I, Lyon, France. .,CREATIS INSERM 1044 CNRS 5220, Villeurbanne, France.
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79
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Jaffee W, Hodgins S, McGee WT. Tissue Edema, Fluid Balance, and Patient Outcomes in Severe Sepsis: An Organ Systems Review. J Intensive Care Med 2017; 33:502-509. [DOI: 10.1177/0885066617742832] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Severe sepsis and septic shock remain among the deadliest diseases managed in the intensive care unit. Fluid resuscitation has been a mainstay of early treatment, but the deleterious effects of excessive fluid administration leading to tissue edema are becoming clearer. A positive fluid balance at 72 hours is associated with significantly increased mortality, yet ongoing fluid administration beyond a durable increase in cardiac output is common. We review the pathophysiologic and clinical data showing the negative effects of edema on pulmonary, renal, central nervous, hepatic, and cardiovascular systems. We discuss data showing increased morbidity and mortality following nonjudicious fluid administration and challenge the assumption that patients who are fluid responsive are also likely to benefit from that fluid. The distinctions between fluid requirement, responsiveness, and tolerance are central to newer concepts of resuscitation. We summarize data in each organ system showing a predictable increase in morbidity and mortality with nonbeneficial fluid administration, providing a better framework for precision in volume management of the patient with severe sepsis.
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Affiliation(s)
- Will Jaffee
- Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA, USA
| | - Spencer Hodgins
- Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA, USA
| | - William T. McGee
- Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA, USA
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80
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Orde S, Slama M, Hilton A, Yastrebov K, McLean A. Pearls and pitfalls in comprehensive critical care echocardiography. Crit Care 2017; 21:279. [PMID: 29149863 PMCID: PMC5693549 DOI: 10.1186/s13054-017-1866-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 10/23/2017] [Indexed: 01/08/2023] Open
Abstract
Critical care echocardiography is developing rapidly with an increasing number of specialists now performing comprehensive studies using Doppler and other advanced techniques. However, this imaging can be challenging, interpretation is far from simple in the complex critically ill patient and mistakes can be easy to make. We aim to address clinically relevant areas where potential errors may occur and suggest methods to hopefully improve accuracy of imaging and interpretation.
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Affiliation(s)
- Sam Orde
- Intensive Care Unit, Nepean Hospital, Kingswood, Sydney, NSW Australia
| | - Michel Slama
- Medical Intensive Care Unit, Amiens University Hospital, Amiens, France
| | - Andrew Hilton
- Intensive Care Unit, Austin Hospital, Heidelberg, Melbourne, VIC Australia
| | | | - Anthony McLean
- Intensive Care Unit, Nepean Hospital, Kingswood, Sydney, NSW Australia
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81
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Predicting Fluid Responsiveness in Critically Ill Patients by Using Combined End-Expiratory and End-Inspiratory Occlusions With Echocardiography. Crit Care Med 2017; 45:e1131-e1138. [DOI: 10.1097/ccm.0000000000002704] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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82
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Bilgili B, Haliloglu M, Tugtepe H, Umuroglu T. The Assessment of Intravascular Volume with Inferior Vena Cava and Internal Jugular Vein Distensibility Indexes in Children Undergoing Urologic Surgery. J INVEST SURG 2017; 31:523-528. [PMID: 28952826 DOI: 10.1080/08941939.2017.1364806] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this work is to assess the predictive value, for fluid responsiveness (FR), of the inferior vena cava distensibility index (IVC-DI) and internal jugular vein distensibility index (IJV-DI) in pediatric surgical patients. MATERIAL AND METHODS Prior to being placed under general anesthesia, 24 surgical patients were enrolled. Baseline parameters were recorded with the patient in the semirecumbent position (Stage 1). Next, the passive leg raising (PLR) maneuver was carried out and a second measurement was recorded (Stage 2). Patients with an increase in the cardiac index (CI) of >10%, induced by PLR, were considered to be responders (R), otherwise they were classified as nonresponders (NR). At both stages, CI and DI of the IVC and IJV were measured. RESULTS Responders had higher IVC-DI and IVJ-DI than NR in stage 1 (both p <.001). In stage 2, IVC-DI and IJV-DI were not different in R and NR groups (p =.164, p =.201). Utilizing cut-off values of > 22.7% for IVC-DI and > 25% for IJV-DI, these parameters had positive correlation coefficients, both in R and NR of, respectively, 0.626 and 0.929. CONCLUSIONS The IVC-DI predicts FR in anesthetized pediatric patients and correlates well with the IJV-DI; both may be used as prediction markers of FR in children.
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Affiliation(s)
- Beliz Bilgili
- a Marmara University, School of Medicine , Department of Anesthesiology and Reanimation , Pendik, Istanbul , Turkey
| | - Murat Haliloglu
- a Marmara University, School of Medicine , Department of Anesthesiology and Reanimation , Pendik, Istanbul , Turkey
| | - Halil Tugtepe
- b Marmara University, School of Medicine , Department of Pediatric Surgery , Pendik, Istanbul , Turkey
| | - Tumay Umuroglu
- a Marmara University, School of Medicine , Department of Anesthesiology and Reanimation , Pendik, Istanbul , Turkey
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83
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Exploring the best predictors of fluid responsiveness in patients with septic shock. Am J Emerg Med 2017; 35:1258-1261. [DOI: 10.1016/j.ajem.2017.03.052] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/15/2017] [Accepted: 03/21/2017] [Indexed: 12/21/2022] Open
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84
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Garijo JM, Mashari A, Meineri M. Role of Transesophageal Echocardiography in General Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0221-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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85
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Bucci M, Rabozzi R, Guglielmini C, Franci P. Respiratory variation in aortic blood peak velocity and caudal vena cava diameter can predict fluid responsiveness in anaesthetised and mechanically ventilated dogs. Vet J 2017; 227:30-35. [PMID: 29031327 DOI: 10.1016/j.tvjl.2017.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 08/01/2017] [Accepted: 08/10/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND M&MS Dynamic preload indices, such as systolic pressure variation (SPV), aortic flow peak velocity variation (ΔVpeak) and distensibility index of the caudal vena cava (CVCDI), are reliable indices for predicting fluid responsiveness in humans. This study aimed to investigate the ability of these indices to predict fluid response in 24 healthy dogs undergoing general anaesthesia and mechanical ventilation. Aortic flow peak velocity variation (∆Vpeak), CVCDI, and SPV were calculated before volume expansion (5mL/kg bolus of lactated Ringer's solution). The aortic velocity time integral (VTI) was measured before and after volume expansion as a surrogate of stroke volume. Dogs were considered responders (n=9) when the VTI increase was ≥15% and non-responders (n=15) when the increase was <15%. RESULTS AND CONCLUSIONS Before volume expansion, ΔVpeak, CVCDI and SPV were higher in responders than in non-responders (P=0.0009, P=0.0003, and P=0.0271, respectively). Receiver operating characteristic (ROC) curves were plotted for the three indices. The areas under the ROC curves for SPV, ΔVpeak, and CVCDI were 0.91 (CI 0.73-0.99; P=0.0001), 0.95 (CI 0.77-1; P=0.0001), and 0.78 (CI 0.56-0.92; P=0.015), respectively. The best cut-offs were 6.7% for SPV (sensitivity, 77.78%; specificity, 93.33%), 9.4% for ΔVpeak (sensitivity, 88.89%; specificity, 100%), and 24% for CVCDI (sensitivity, 77.78%; specificity, 73.33). In conclusion, ΔVpeak, CVCDI, and SPV are reliable predictors of fluid responsiveness in healthy dogs undergoing general anaesthesia and mechanical ventilation.
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Affiliation(s)
- M Bucci
- Department of Animal Medicine, Production and Health, University of Padua, Viale dell'Università, 16, Legnaro 35020, Italy.
| | - R Rabozzi
- Clinica Veterinaria Roma Sud, Via Pilade Mazza, Rome 00173, Italy
| | - C Guglielmini
- Department of Animal Medicine, Production and Health, University of Padua, Viale dell'Università, 16, Legnaro 35020, Italy
| | - P Franci
- Department of Animal Medicine, Production and Health, University of Padua, Viale dell'Università, 16, Legnaro 35020, Italy
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86
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Nedel WL, Simas DM, Marin LG, Morais VD, Friedman G. Respiratory Variation in Femoral Vein Diameter Has Moderate Accuracy as a Marker of Fluid Responsivity in Mechanically Ventilated Septic Shock Patients. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:2713-2717. [PMID: 28756901 DOI: 10.1016/j.ultrasmedbio.2017.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 06/13/2017] [Accepted: 06/19/2017] [Indexed: 12/16/2022]
Abstract
Ultrasound (US) is considered the first step in evaluation of patients with shock; respiratory variation of the inferior vena cava (inferior vena cava collapsibility [IVCc]) is an important measurement in this scenario that can be impaired by patient condition or technical skills. The main objective of this study was to evaluate if respiratory variation of the femoral vein (femoral vein collapsibility [FVc]), which is easier to visualize, can adequately predict fluid responsiveness in septic shock patients. Forty-five mechanically ventilated septic shock patients in a mixed clinical-surgical, 30-bed intensive care unit were enrolled in this study. All patients underwent assessments of FVc, IVCc and cardiac output using a portable US device. The passive leg raising test was used to evaluate fluid responsiveness. FVc presented an area under the receiver operating characteristic curve of 0.678 (95% confidence interval: 0.519-0.837, p = 0.044) with a cutoff point of 17%, yielding a sensitivity of 62% and specificity of 65% in predicting fluid responsiveness. IVCc had greater diagnostic accuracy compared with FVc, with an area under the receiver operating characteristic curve of 0.733 (95% confidence interval: 0.563-0.903, p = 0.024) and a cutoff point of 29%, yielding a sensitivity of 47% and specificity of 86%. In conclusion, FVc has moderate accuracy when employed as an indicator of fluid responsiveness in spontaneously mechanically ventilated septic shock patients.
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Affiliation(s)
- Wagner Luis Nedel
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil.
| | | | - Luiz Gustavo Marin
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
| | | | - Gilberto Friedman
- Postgraduate Program in Pneumological Sciences, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS), Brazil
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87
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Audimoolam VK, McPhail MJW, Willars C, Bernal W, Wendon JA, Cecconi M, Auzinger G. Predicting Fluid Responsiveness in Acute Liver Failure: A Prospective Study. Anesth Analg 2017; 124:480-486. [PMID: 27984249 DOI: 10.1213/ane.0000000000001585] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The profound hemodynamic changes seen in acute liver failure (ALF) resemble the hyperdynamic state found in the later stages of septic shock. Vasopressor support frequently is required after initial volume therapy. Markers of preload dependency have not been studied in this patient group. Dynamic maneuvers such as passive leg raising or end-expiratory hold, which have shown good predictive accuracy in a general intensive care unit population, cannot be considered safe in this cohort because of the concerns of intracranial hypertension. METHODS Mechanically ventilated patients with ALF admitted to a tertiary specialist intensive care unit in shock and multiorgan failure were enrolled. Markers of fluid responsiveness derived from transpulmonary thermodilution, pulse contour analysis, and echocardiography were compared between responders (cardiac index ≥15%) and nonresponders to a colloid fluid challenge (5 mL/kg predicted body weight). The ability to predict fluid responsiveness of stroke volume variation, pulse pressure variation (PPV), and respiratory change in peak (delta V peak) left ventricular outflow tract velocity for preload dependency were analyzed. RESULTS Thirty-five patients (mean ± SD age, 38 [14] years, 13 male, 22 female]) were assessed after a single fluid challenge. Ten patients (29%) were fluid responders. Changes in cardiac index and stroke volume index in the cohort of 35 patients were correlated (R = 0.726 [99% confidence interval, 0.401-0.910]; P < .001). PPV predicted fluid responsiveness (area under the receiver operating characteristic curve [AUROC], 0.752 [95% confidence interval, 0.565-0.889]; P = .005; cutoff >9%). The AUROC for stroke volume variation was 0.678 ([95% confidence interval, 0.499-0.825]; P = .084; cutoff >11%). The AUROC for [delta] V peak before fluid bolus was 0.637 (95% confidence interval, 0.413-0.825; P = .322). CONCLUSIONS PPV based on pulse contour analysis predicted fluid responsiveness in ALF.
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Affiliation(s)
- Vinod Kumar Audimoolam
- From the *Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London, UK; †Liver and Anti-viral Centre, St. Mary's Hospital, Imperial College London, Paddington, London, UK; and ‡Anaesthesia and Intensive Care, St. George's Hospital London and St. George's University of London, London, UK
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88
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Abstract
Intravenous fluid management of trauma patients is fraught with complex decisions that are often complicated by coagulopathy and blood loss. This review discusses the fluid management in trauma patients from the perspective of the developing world. In addition, the article describes an approach to specific circumstances in trauma fluid decision-making and provides recommendations for the resource-limited environment.
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89
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Monitoring and End-Points of Trauma Resuscitation. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0089-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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90
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Alvarado Sánchez JI, Amaya Zúñiga WF, Monge García MI. Predictors to Intravenous Fluid Responsiveness. J Intensive Care Med 2017. [DOI: https://doi.org/10.1177/0885066617709434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Management with intravenous fluids can improve cardiac output in some surgical patients. Management with static preload indicators, such as central venous pressure and pulmonary artery occlusion pressure, has not demonstrated a suitable relationship with changes in the cardiac output induced by intravenous fluid therapy. Dynamic indicators, such as the variability of arterial pulse pressure or stroke volume variation, have demonstrated a suitable relationship. Since improvement in cardiac output does not guarantee an adequate perfusion pressure, in patients with hypotension, it is also necessary to know whether arterial pressure will also increase with intravenous fluid therapy. In this regard, the functional assessment of arterial load by dynamic arterial elastance could help to determine which patients will improve not only their cardiac output but also their mean arterial pressure.
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Affiliation(s)
- Jorge Iván Alvarado Sánchez
- Department of Physiology, Universidad Nacional De Colombia, Bogota, Colombia
- Department of Anesthesiology, Centro Policlínico del Olaya, Bogota, Colombia
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91
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Alvarado Sánchez JI, Amaya Zúñiga WF, Monge García MI. Predictors to Intravenous Fluid Responsiveness. J Intensive Care Med 2017; 33:227-240. [PMID: 28506136 DOI: 10.1177/0885066617709434] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Management with intravenous fluids can improve cardiac output in some surgical patients. Management with static preload indicators, such as central venous pressure and pulmonary artery occlusion pressure, has not demonstrated a suitable relationship with changes in the cardiac output induced by intravenous fluid therapy. Dynamic indicators, such as the variability of arterial pulse pressure or stroke volume variation, have demonstrated a suitable relationship. Since improvement in cardiac output does not guarantee an adequate perfusion pressure, in patients with hypotension, it is also necessary to know whether arterial pressure will also increase with intravenous fluid therapy. In this regard, the functional assessment of arterial load by dynamic arterial elastance could help to determine which patients will improve not only their cardiac output but also their mean arterial pressure.
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Affiliation(s)
- Jorge Iván Alvarado Sánchez
- 1 Department of Physiology, Universidad Nacional De Colombia, Bogota, Colombia.,2 Department of Anesthesiology, Centro Policlínico del Olaya, Bogota, Colombia
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92
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Lanspa MJ. Echocardiography is a feasible tool for assessing volume responsiveness. J Thorac Dis 2017; 9:E477-E479. [PMID: 28616314 DOI: 10.21037/jtd.2017.03.182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Michael J Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center and University of Utah, Salt Lake City, USA
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93
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Vignon P, Repessé X, Bégot E, Léger J, Jacob C, Bouferrache K, Slama M, Prat G, Vieillard-Baron A. Comparison of Echocardiographic Indices Used to Predict Fluid Responsiveness in Ventilated Patients. Am J Respir Crit Care Med 2017; 195:1022-1032. [DOI: 10.1164/rccm.201604-0844oc] [Citation(s) in RCA: 151] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Philippe Vignon
- Medical-Surgical Intensive Care Unit and
- INSERM CIC 1435, Limoges University Hospital, Limoges, France
- Faculty of Medicine, University of Limoges, Limoges, France
| | - Xavier Repessé
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Boulogne-Billancourt, France
| | - Emmanuelle Bégot
- Medical-Surgical Intensive Care Unit and
- INSERM CIC 1435, Limoges University Hospital, Limoges, France
| | - Julie Léger
- INSERM CIC 1415, Tours University Hospital, Tours, France
| | - Christophe Jacob
- Medical Intensive Care Unit, Brest University Hospital, Brest, France
| | | | - Michel Slama
- Medical Intensive Care Unit, Amiens University Hospital, Amiens, France
| | - Gwenaël Prat
- Medical Intensive Care Unit, Brest University Hospital, Brest, France
| | - Antoine Vieillard-Baron
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Boulogne-Billancourt, France
- Faculty of Medicine Paris Ile-de-France Ouest, University of Versailles Saint-Quentin en Yvelines, Saint-Quentin en Yvelines, France; and
- INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
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94
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Lazzeri C, Peris A. Fluid responsiveness raises many questions-echocardiography may be the answer. J Thorac Dis 2017; 9:946-949. [PMID: 28523144 DOI: 10.21037/jtd.2017.03.146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit and Regional ECMO Referral centre, Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral centre, Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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95
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Laher AE, Watermeyer MJ, Buchanan SK, Dippenaar N, Simo NCT, Motara F, Moolla M. A review of hemodynamic monitoring techniques, methods and devices for the emergency physician. Am J Emerg Med 2017; 35:1335-1347. [PMID: 28366285 DOI: 10.1016/j.ajem.2017.03.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 03/15/2017] [Accepted: 03/16/2017] [Indexed: 02/07/2023] Open
Abstract
The emergency department (ED) is frequently the doorway to the intensive care unit (ICU) for a significant number of critically ill patients presenting to the hospital. Hemodynamic monitoring (HDM) which is a key component in the effective management of the critically ill patient presenting to the ED, is primarily concerned with assessing the performance of the cardiovascular system and determining the correct therapeutic intervention to optimise end-organ oxygen delivery. The spectrum of hemodynamic monitoring ranges from simple clinical assessment and routine bedside monitoring to point of care ultrasonography and various invasive monitoring devices. The clinician must be aware of the range of available techniques, methods, interventions and technological advances as well as possess a sound approach to basic hemodynamic monitoring prior to selecting the optimal modality. This article comprises an in depth discussion of an approach to hemodynamic monitoring techniques and principles as well as methods of predicting fluid responsiveness as it applies to the ED clinician. We review the role, applicability and validity of various methods and techniques that include; clinical assessment, passive leg raising, blood pressure, finger based monitoring devices, the mini-fluid challenge, the end-expiratory occlusion test, central venous pressure monitoring, the pulmonary artery catheter, ultrasonography, bioreactance and other modern invasive hemodynamic monitoring devices.
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Affiliation(s)
- Abdullah E Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, South Africa.
| | - Matthew J Watermeyer
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Sean K Buchanan
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Nicole Dippenaar
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | | | - Feroza Motara
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Muhammed Moolla
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, South Africa
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96
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Schmidt GA. POINT: Should Acute Fluid Resuscitation Be Guided Primarily by Inferior Vena Cava Ultrasound for Patients in Shock? Yes. Chest 2017; 151:531-532. [DOI: 10.1016/j.chest.2016.11.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 11/08/2016] [Indexed: 12/12/2022] Open
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97
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Franchi F, Vetrugno L, Scolletta S. Echocardiography to guide fluid therapy in critically ill patients: check the heart and take a quick look at the lungs. J Thorac Dis 2017; 9:477-481. [PMID: 28449449 DOI: 10.21037/jtd.2017.02.94] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Federico Franchi
- Department of Medical Biotechnologies, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, Siena, Italy
| | - Luigi Vetrugno
- Department of Medical and Biological Sciences, Anesthesia and Intensive Care Unit, University of Udine, Piazzale Santa Maria della Misericordia 15, Udine, Italy
| | - Sabino Scolletta
- Department of Medical Biotechnologies, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, Siena, Italy
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98
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Monitorage hémodynamique par échocardiographie des patients en état de choc. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1256-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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99
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Lanspa MJ, Briggs BJ, Hirshberg EL, Pratt CM, Grissom CK, Brown SM. Data availability and feasibility of various techniques to predict response to volume expansion in critically ill patients. Int J Crit Illn Inj Sci 2017; 7:163-165. [PMID: 28971030 PMCID: PMC5613408 DOI: 10.4103/2229-5151.214412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: The accuracy of various techniques to predict response to volume expansion in shock has been studied, but less well known is how feasible these techniques are in the ICU. Methods: This is a prospective observation single-center study of inpatients from a mixed profile ICU who received volume expansion. At time of volume expansion, we determined whether a particular technique to predict response was feasible, according to rules developed from available literature and nurse assessment. Results: We studied 214 volume expansions in 97 patients. The most feasible technique was central venous pressure (50%), followed by vena cava collapsibility, (47%) passive leg raise (42%), and stroke volume variation (22%). Aortic velocity variation, and pulse pressure variation, and were rarely feasible (1% each). In 37% of volume expansions, no technique that we assessed was feasible. Conclusions: Techniques to predict response to volume expansion are infeasible in many patients in shock.
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Affiliation(s)
- Michael J Lanspa
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Benjamin J Briggs
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Eliotte L Hirshberg
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Cristina M Pratt
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Colin K Grissom
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Mukherjee V, Brosnahan SB, Bakker J. How to Use Fluid Responsiveness in Sepsis. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2017. [DOI: 10.1007/978-3-319-51908-1_6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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