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Crespo-Aznarez S, Campos-Sáenz de Santamaría A, Sánchez-Marteles M, Garcés-Horna V, Josa-Laorden C, Giménez-López I, Pérez-Calvo JI, Rubio-Gracia J. The Association Between Intra-abdominal Pressure and Diuretic Response in Heart Failure. Curr Heart Fail Rep 2023; 20:390-400. [PMID: 37515668 DOI: 10.1007/s11897-023-00617-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 07/31/2023]
Abstract
PURPOSE OF THE REVIEW An efficient diuretic response is vital during cardiac decompensation in heart failure (HF) patients. The increase in intra-abdominal pressure (IAP) could be one of the keys for understanding cardiorenal syndrome and guiding diuretic treatment during hospitalization. In this review, we analyze the relationship between IAP and diuretic response in HF patients. RECENT FINDINGS Increased IAP is associated with worsening renal function (WRF) in patients with advanced HF. Furthermore, the persistence of a rise in IAP after the first 72 h of intravenous diuretic treatment has been correlated with a worse diuretic response, a higher degree of congestion, and an impaired prognosis. The rise in IAP in HF patients has been associated with impaired renal function and a lower diuretic response. Nonetheless, more studies are needed to elucidate the actual role of IAP in congestive nephropathy and whether it may help guide diuretic therapy during acute decompensations.
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Affiliation(s)
- S Crespo-Aznarez
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
| | - A Campos-Sáenz de Santamaría
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
| | - M Sánchez-Marteles
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
| | - V Garcés-Horna
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
| | - C Josa-Laorden
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
| | - I Giménez-López
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
- University of Zaragoza, Zaragoza, Spain
- Aragonese Institute of Health Sciences, Zaragoza, Spain
| | - J I Pérez-Calvo
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain
- University of Zaragoza, Zaragoza, Spain
| | - J Rubio-Gracia
- Internal Medicine Department, Hospital Clínico Universitario "Lozano Blesa", Avda. San Juan Bosco N° 15, 50009, Zaragoza, Spain.
- Aragon Health Research Institute (IIS Aragón), Zaragoza, Spain.
- University of Zaragoza, Zaragoza, Spain.
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102
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Batool A, Chaudhry S, Koratala A. Transcending boundaries: Unleashing the potential of multi-organ point-of-care ultrasound in acute kidney injury. World J Nephrol 2023; 12:93-103. [PMID: 37766842 PMCID: PMC10520752 DOI: 10.5527/wjn.v12.i4.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/24/2023] [Accepted: 09/11/2023] [Indexed: 09/20/2023] Open
Abstract
Acute kidney injury (AKI) is a clinical syndrome characterized by a rapid increase in serum creatinine levels or a decrease in urine output or both. In spite of thorough history-taking, physical examination, and laboratory analysis, there are limitations in the diagnostic process and clinical monitoring of AKI. Point-of-care ultrasonography (POCUS), a limited ultrasound study performed by clinicians at the bedside, has emerged as a valuable tool in different clinical settings. In this discussion, we explore the potential of POCUS performed by nephrologists to address specific questions encountered in the diagnosis and management of AKI patients. POCUS not only aids in excluding hydronephrosis but also provides real-time insights into hemodynamics, enabling formulation of individualized treatment plans. Further studies are required to assess the impact of multi-organ POCUS on pragmatic patient outcomes related to AKI, as well as its potential in risk stratification and identification of different levels of AKI severity and pathophysiological signatures.
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Affiliation(s)
- Aisha Batool
- Department of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - Shahzad Chaudhry
- Department of Family Medicine, Advocate Aurora Healthcare, Milwaukee, WI 53202, United States
| | - Abhilash Koratala
- Department of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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103
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Teixeira JP, Zeidman A, Beaubien-Souligny W, Cerdá J, Connor MJ, Eggleston K, Juncos LA, da Silva JR, Wells C, Yessayan L, Barker AB, McConville W, Speer R, Wille KM, Neyra JA, Tolwani A. Proceedings of the 2022 UAB CRRT Academy: Non-Invasive Hemodynamic Monitoring to Guide Fluid Removal with CRRT and Proliferation of Extracorporeal Blood Purification Devices. Blood Purif 2023; 52:857-879. [PMID: 37742622 DOI: 10.1159/000533573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/29/2023] [Indexed: 09/26/2023]
Abstract
In 2022, we celebrated the 15th anniversary of the University of Alabama at Birmingham (UAB) Continuous Renal Replacement Therapy (CRRT) Academy, a 2-day conference attended yearly by an international audience of over 100 nephrology, critical care, and multidisciplinary trainees and practitioners. This year, we introduce the proceedings of the UAB CRRT Academy, a yearly review of select emerging topics in the field of critical care nephrology that feature prominently in the conference. First, we review the rapidly evolving field of non-invasive hemodynamic monitoring and its potential to guide fluid removal by renal replacement therapy (RRT). We begin by summarizing the accumulating data associating fluid overload with harm in critical illness and the potential for harm from end-organ hypoperfusion caused by excessive fluid removal with RRT, underscoring the importance of accurate, dynamic assessment of volume status. We describe four applications of point-of-care ultrasound used to identify patients in need of urgent fluid removal or likely to tolerate fluid removal: lung ultrasound, inferior vena cava ultrasound, venous excess ultrasonography, and Doppler of the left ventricular outflow track to estimate stroke volume. We briefly introduce other minimally invasive hemodynamic monitoring technologies before concluding that additional prospective data are urgently needed to adapt these technologies to the specific task of fluid removal by RRT and to learn how best to integrate them into practical fluid-management strategies. Second, we focus on the growth of novel extracorporeal blood purification devices, starting with brief reviews of the inflammatory underpinnings of multiorgan dysfunction and the specific applications of pathogen, endotoxin, and/or cytokine removal and immunomodulation. Finally, we review a series of specific adsorptive technologies, several of which have seen substantial clinical use during the COVID-19 pandemic, describing their mechanisms of target removal, the limited existing data supporting their efficacy, ongoing and future studies, and the need for additional prospective trials.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology and Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Amanda Zeidman
- Division of Nephrology, Department of Medicine, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jorge Cerdá
- Department of Medicine, Nephrology, Albany Medical College, Albany, New York, USA
| | - Michael J Connor
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine and Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Luis A Juncos
- Division of Nephrology, Department of Internal Medicine, Central Arkansas Veterans' Healthcare System, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Catherine Wells
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew B Barker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Wendy McConville
- School of Nursing, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Rajesh Speer
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Keith M Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
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Zhi HJ, Cui J, Yuan MW, Zhao YN, Zhao XW, Zhu TT, Jia CM, Li Y. Predictive performance of renal resistive index, semiquantitative power Doppler ultrasound score and renal venous Doppler waveform pattern for acute kidney injury in critically ill patients and prediction model establishment: a prospective observational study. Ren Fail 2023; 45:2258987. [PMID: 37728063 PMCID: PMC10512814 DOI: 10.1080/0886022x.2023.2258987] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/09/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND This study aimed to explore the performance of renal resistive index (RRI), semiquantitative power Doppler ultrasound (PDU) score and renal venous Doppler waveform (RVDW) pattern in predicting acute kidney injury (AKI) in critically ill patients and establish prediction models. METHODS This prospective observational study included 234 critically ill patients. Renal ultrasound was measured within 24 h after intensive care unit admission. The main outcome was the highest AKI stage within 5 days after admission according to the Kidney Disease Improving Global Outcomes criteria. RESULTS Patients in the AKI stage 3 group had significantly higher RRI, RVDW pattern and lower PDU score (p < 0.05). Only lactate, urine volume, serum creatinine (SCr) on admission, PDU score and RVDW pattern were statistically significant predictors (p < 0.05). Model 1 based on these five variables (area under the curve [AUC] = 0.938, 95% confidence interval [CI] 0.899-0.965, p < 0.05) showed the best performance in predicting AKI stage 3, and difference in AUC between it and the clinical model including lactate, urine volume and SCr (AUC = 0.901, 95% CI 0.855-0.936, p < 0.05) was statistically significant (z statistic = 2.224, p = 0.0261). The optimal cut-off point for a nomogram based on Model 1 was ≤127.67 (sensitivity: 95.8%, specificity: 82.3%, Youden's index: 0.781). CONCLUSIONS The nomogram model including SCr, urine volume, lactate, PDU score and RVDW pattern upon admission exhibited a significantly stronger capability for AKI stage 3 than each single indicator and clinical model including SCr, urine volume and lactate.
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Affiliation(s)
- Hai Jun Zhi
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Jie Cui
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Meng Wei Yuan
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Ya Ning Zhao
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Xing Wen Zhao
- Ultrasonic Department, Cangzhou Central Hospital, Cangzhou, China
| | - Ting Ting Zhu
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Chun Mei Jia
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
| | - Yong Li
- Emergency Department, Cangzhou Central Hospital, Cangzhou, China
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105
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Banjade P, Subedi A, Ghamande S, Surani S, Sharma M. Systemic Venous Congestion Reviewed. Cureus 2023; 15:e43716. [PMID: 37724234 PMCID: PMC10505504 DOI: 10.7759/cureus.43716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/20/2023] Open
Abstract
Accurate determination of intravascular volume status is challenging in acutely ill patients. Favorable patient outcome is vital to correctly identify intravascular volume depletion and avoid systemic venous congestion. Most of the conventional means of hemodynamic monitoring in the acute healthcare setting are geared toward addressing the cardiac output and maintaining an optimum mean arterial pressure. While assessing and maintaining cardiac output in an acutely ill patient is very important, a venous congestion cascade is often overlooked, which can negatively affect the intraabdominal end organs. The prospect of using point-of-care ultrasound (POCUS) to determine systemic venous congestion could be a potentially handy tool for clinicians. Venous excess ultrasound score (VExUS) has also been utilized by clinicians as a semi-quantitative assessment tool to assess fluid status. This review aims to discuss the potential role of POCUS and VExUS scores in determining systemic venous congestion through a narrative review of recently published literature.
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Affiliation(s)
- Prakash Banjade
- Department of General Medicine, Manipal College of Medical Sciences, Pokhara, NPL
| | - Ashish Subedi
- Department of Internal Medicine, Gandaki Medical College, Kathmandu, NPL
| | - Shekhar Ghamande
- Department of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott and White Medical Center, Temple, USA
| | - Salim Surani
- Department of Anesthesiology, Mayo Clinic, Rochester, USA
- Department of Medicine, Texas Agricultural and Mechanical (A&M) University, College Station, USA
- Department of Medicine, University of North Texas, Dallas, USA
- Department of Internal Medicine, Pulmonary Associates, Corpus Christi, USA
- Department of Clinical Medicine, University of Houston, Houston, USA
| | - Munish Sharma
- Department of Pulmonary and Critical Care Medicine, Baylor Scott and White Medical Center, Temple, USA
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106
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Huang S, Vieillard-Baron A, Evrard B, Prat G, Chew MS, Balik M, Clau-Terré F, De Backer D, Mekontso Dessap A, Orde S, Morelli A, Sanfilippo F, Charron C, Vignon P. Echocardiography phenotypes of right ventricular involvement in COVID-19 ARDS patients and ICU mortality: post-hoc (exploratory) analysis of repeated data from the ECHO-COVID study. Intensive Care Med 2023; 49:946-956. [PMID: 37436445 DOI: 10.1007/s00134-023-07147-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/18/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Exploratory study to evaluate the association of different phenotypes of right ventricular (RV) involvement and mortality in the intensive care unit (ICU) in patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). METHODS Post-hoc analysis of longitudinal data from the multicenter ECHO-COVID observational study in ICU patients who underwent at least two echocardiography examinations. Echocardiography phenotypes were acute cor pulmonale (ACP, RV cavity dilatation with paradoxical septal motion), RV failure (RVF, RV cavity dilatation and systemic venous congestion), and RV dysfunction (tricuspid annular plane systolic excursion ≤ 16 mm). Accelerated failure time model and multistate model were used for analysis. RESULTS Of 281 patients who underwent 948 echocardiography studies during ICU stay, 189 (67%) were found to have at least 1 type of RV involvements during one or several examinations: ACP (105/281, 37.4%), RVF (140/256, 54.7%) and/or RV dysfunction (74/255, 29%). Patients with all examinations displaying ACP had survival time shortened by 0.479 [0.284-0.803] times when compared to patients with all examinations depicting no ACP (P = 0.005). RVF showed a trend towards shortened survival time by a factor of 0.642 [0.405-1.018] (P = 0.059), whereas the impact of RV dysfunction on survival time was inconclusive (P = 0.451). Multistate analysis showed that patients might transit in and out of RV involvement, and those who exhibited ACP in their last critical care echocardiography (CCE) examination had the highest risk of mortality (hazard ratio (HR) 3.25 [2.38-4.45], P < 0.001). CONCLUSION RV involvement is prevalent in patients ventilated for COVID-19 ARDS. Different phenotypes of RV involvement might lead to different ICU mortality, with ACP having the worst outcome.
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Affiliation(s)
- Stephen Huang
- Intensive Care Medicine, Nepean Hospital, NBMLHD, The University of Sydney, Sydney, Australia
| | - Antoine Vieillard-Baron
- Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France
- INSERM UMR 1018, Clinical Epidemiology Team, CESP, Université de Paris Saclay, Villejuif, France
| | - Bruno Evrard
- Medical-Surgical ICU, Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
| | - Gwenaël Prat
- Service de Médecine Intensive Réanimation, CHU Cavale Blanche Brest, Brest, France
| | - Michelle S Chew
- Department of Anaesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, General University Hospital and 1St Medical Faculty, Charles University, Prague, Czechia
| | - Fernando Clau-Terré
- Department of Anaesthesiology and Critical Care Medicine, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniel De Backer
- CHIREC Hospitals Université Libre de Bruxelles, Brussels, Belgium
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Groupe de Recherche Clinique CARMAS, Inserm U955, Université Paris-Est Créteil, 94000, Créteil, France
| | - Sam Orde
- Intensive Care Medicine, Nepean Hospital, NBMLHD, The University of Sydney, Sydney, Australia
| | - Andrea Morelli
- Department Clinical Internal Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Viale del Policlinico, Rome, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, Policlinico-Vittorio Emanuele University Hospital, Catania, Italy
| | - Cyril Charron
- Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France
- INSERM UMR 1018, Clinical Epidemiology Team, CESP, Université de Paris Saclay, Villejuif, France
| | - Philippe Vignon
- Medical-Surgical ICU, Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France.
- Réanimation Polyvalente, CHU Dupuytren, 2 Ave. Martin Luther King, 87042, Limoges Cedex, France.
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107
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Kenny JÉS, Gibbs SO, Eibl JK, Eibl AM, Yang Z, Johnston D, Munding CE, Elfarnawany M, Lau VC, Kemp BO, Nalla B, Atoui R. Simultaneous venous-arterial Doppler during preload augmentation: illustrating the Doppler Starling curve. Ultrasound J 2023; 15:32. [PMID: 37505318 PMCID: PMC10382420 DOI: 10.1186/s13089-023-00330-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023] Open
Abstract
Providing intravenous (IV) fluids to a patient with signs or symptoms of hypoperfusion is common. However, evaluating the IV fluid 'dose-response' curve of the heart is elusive. Two patients were studied in the emergency department with a wireless, wearable Doppler ultrasound system. Change in the common carotid arterial and internal jugular Doppler spectrograms were simultaneously obtained as surrogates of left ventricular stroke volume (SV) and central venous pressure (CVP), respectively. Both patients initially had low CVP jugular venous Doppler spectrograms. With preload augmentation, only one patient had arterial Doppler measures indicative of significant SV augmentation (i.e., 'fluid responsive'). The other patient manifested diminishing arterial response, suggesting depressed SV (i.e., 'fluid unresponsive') with evidence of ventricular asynchrony. In this short communication, we describe how a wireless, wearable Doppler ultrasound simultaneously tracks surrogates of cardiac preload and output within a 'Doppler Starling curve' framework; implications for IV fluid dosing are discussed.
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Affiliation(s)
- Jon-Émile S Kenny
- Health Sciences North Research Institute, Sudbury, ON, Canada.
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada.
| | | | - Joseph K Eibl
- Health Sciences North Research Institute, Sudbury, ON, Canada
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada
- NOSM University, Sudbury, ON, Canada
| | - Andrew M Eibl
- Health Sciences North Research Institute, Sudbury, ON, Canada
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada
| | - Zhen Yang
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada
| | | | | | | | - Vivian C Lau
- OSF Saint Francis Medical Center, Peoria, IL, USA
| | | | - Bhanu Nalla
- Health Sciences North Research Institute, Sudbury, ON, Canada
- NOSM University, Sudbury, ON, Canada
| | - Rony Atoui
- Health Sciences North Research Institute, Sudbury, ON, Canada
- NOSM University, Sudbury, ON, Canada
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108
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Prager R, Argaiz E, Pratte M, Rola P, Arntfield R, Beaubien-Souligny W, Denault AY, Haycock K, Miralles Aguiar F, Bakker J, Ospina-Tascon G, Orozco N, Rochwerg B, Lewis K, Quazi I, Kattan E, Hernandez G, Basmaji J. Doppler identified venous congestion in septic shock: protocol for an international, multi-centre prospective cohort study (Andromeda-VEXUS). BMJ Open 2023; 13:e074843. [PMID: 37487682 PMCID: PMC10373747 DOI: 10.1136/bmjopen-2023-074843] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
INTRODUCTION Venous congestion is a pathophysiological state where high venous pressures cause organ oedema and dysfunction. Venous congestion is associated with worse outcomes, particularly acute kidney injury (AKI), for critically ill patients. Venous congestion can be measured by Doppler ultrasound at the bedside through interrogation of the inferior vena cava (IVC), hepatic vein (HV), portal vein (PV) and intrarenal veins (IRV). The objective of this study is to quantify the association between Doppler identified venous congestion and the need for renal replacement therapy (RRT) or death for patients with septic shock. METHODS AND ANALYSIS This study is a prespecified substudy of the ANDROMEDA-SHOCK 2 (AS-2) randomised control trial (RCT) assessing haemodynamic resuscitation in septic shock and will enrol at least 350 patients across multiple sites. We will include adult patients within 4 hours of fulfilling septic shock definition according to Sepsis-3 consensus conference. Using Doppler ultrasound, physicians will interrogate the IVC, HV, PV and IRV 6-12 hours after randomisation. Study investigators will provide web-based educational sessions to ultrasound operators and adjudicate image acquisition and interpretation. The primary outcome will be RRT or death within 28 days of septic shock. We will assess the hazard of RRT or death as a function of venous congestion using a Cox proportional hazards model. Sub-distribution HRs will describe the hazard of RRT given the competing risk of death. ETHICS AND DISSEMINATION We obtained ethics approval for the AS-2 RCT, including this observational substudy, from local ethics boards at all participating sites. We will report the findings of this study through open-access publication, presentation at international conferences, a coordinated dissemination strategy by investigators through social media, and an open-access workshop series in multiple languages. TRIAL REGISTRATION NUMBER NCT05057611.
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Affiliation(s)
- Ross Prager
- Division of Critical Care, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Eduardo Argaiz
- Department of Nephrology and Mineral Metabolism, Salvador Zubiran National Institute of Medical Sciences and Nutrition, Ciudad de Mexico, Mexico
- Instituto Tecnológico y de Estudios Superiores de Monterrey Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Michael Pratte
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Philippe Rola
- Intensive Care, Santa Cabrini Hospital, Montreal, Québec, Canada
| | - Robert Arntfield
- Division of Critical Care, Western University, London, Ontario, Canada
| | | | - André Y Denault
- Department of Anesthesiology, Fondation Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | - Korbin Haycock
- Desert Regional Medical Center, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Francisco Miralles Aguiar
- Anesthesia & Surgery Critical Care Service, Hospital Universitario Puerta del Mar, Cadiz, Andalucía, Spain
| | - Jan Bakker
- Department of Intensive Care Adults, Erasmus MC University Medical Center,Netherlands, Rotterdam, The Netherlands
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gustavo Ospina-Tascon
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine, Universidad Icesi, Cali, Colombia
| | - Nicolas Orozco
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Centro de Investigaciones Clínicas, Cali, Colombia
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ibrahim Quazi
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - John Basmaji
- Division of Critical Care, Western University, London, Ontario, Canada
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109
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Hassan Kamel M, Siuba MT. Acute kidney injury in cardiac critical care: bringing the venous circulation out of the shadows. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:420-421. [PMID: 37261945 DOI: 10.1093/ehjacc/zuad058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/03/2023]
Affiliation(s)
- Mohamed Hassan Kamel
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, L2-330A, Cleveland, OH 44195, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, L2-330A, Cleveland, OH 44195, USA
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110
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Syed MKH, Pendleton K, Park J, Weinert C. Physicians' Clinical Behavior During Fluid Evaluation Encounters. Crit Care Explor 2023; 5:e0933. [PMID: 37387710 PMCID: PMC10306425 DOI: 10.1097/cce.0000000000000933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
We sought to identify factors affecting physicians' cognition and clinical behavior when evaluating patients that may need fluid therapy. BACKGROUND Proponents of dynamic fluid responsiveness testing advocate measuring cardiac output or stroke volume after a maneuver to prove that further fluids will increase cardiac output. However, surveys suggest that fluid therapy in clinical practice is often given without prior responsiveness testing. DESIGN Thematic analysis of face-to-face structured interviews. SETTING ICUs and medical-surgical wards in acute care hospitals. SUBJECTS Intensivists and hospitalist physicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We conducted 43 interviews with experienced physicians in 19 hospitals. Hospitalized patients with hypotension, tachycardia, oliguria, or elevated serum lactate are commonly seen by physicians who weigh the risks and benefits of more fluid therapy. Encounters are often with unfamiliar patients and evaluation and decisions are completed quickly without involving other physicians. Dynamic testing for fluid responsiveness is used much less often than static methods and fluid boluses are often ordered with no testing at all. This approach is rationalized by factors that discourage dynamic testing: unavailability of equipment, time to obtain test results, or lack of expertise in obtaining valid data. Two mental calculations are particularly influential: physicians' estimate of the base rate of fluid responsiveness (determined by physical examination, chart review, and previous responses to fluid boluses) and physicians' perception of patient harm if 500 or 1,000 mL fluid boluses are ordered. When the perception of harm is low, physicians use heuristics that rationalize skipping dynamic testing. LIMITATIONS Geographic limitation to hospitals in Minnesota, United States. CONCLUSIONS If dynamic responsiveness testing is to be used more often in routine clinical practice, physicians must be more convinced of the benefits of dynamic testing, that they can obtain valid results quickly and believe that even small fluid boluses harm their patients.
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Affiliation(s)
| | - Kathryn Pendleton
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota Medical School. Minneapolis, MN
| | - John Park
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Craig Weinert
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota Medical School. Minneapolis, MN
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111
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Chalkias A, Adamos G, Mentzelopoulos SD. General Critical Care, Temperature Control, and End-of-Life Decision Making in Patients Resuscitated from Cardiac Arrest. J Clin Med 2023; 12:4118. [PMID: 37373812 DOI: 10.3390/jcm12124118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/02/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Cardiac arrest affects millions of people per year worldwide. Although advances in cardiopulmonary resuscitation and intensive care have improved outcomes over time, neurologic impairment and multiple organ dysfunction continue to be associated with a high mortality rate. The pathophysiologic mechanisms underlying the post-resuscitation disease are complex, and a coordinated, evidence-based approach to post-resuscitation care has significant potential to improve survival. Critical care management of patients resuscitated from cardiac arrest focuses on the identification and treatment of the underlying cause(s), hemodynamic and respiratory support, organ protection, and active temperature control. This review provides a state-of-the-art appraisal of critical care management of the post-cardiac arrest patient.
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Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Georgios Adamos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
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112
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Andrei S, Bahr PA, Nguyen M, Bouhemad B, Guinot PG. Prevalence of systemic venous congestion assessed by Venous Excess Ultrasound Grading System (VExUS) and association with acute kidney injury in a general ICU cohort: a prospective multicentric study. Crit Care 2023; 27:224. [PMID: 37291662 DOI: 10.1186/s13054-023-04524-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/05/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND The importance of assessing venous congestion in ICU patients is widely acknowledged, but its study is hampered by the lack of a practical evaluation tool. The Venous Excess Ultrasound Grading System (VExUS), based on a semi-quantitative combined ultrasound assessment, has been associated with acute kidney injury (AKI) in cardiac ICU patients. The objectives of this study were to assess the prevalence of congestion using VExUS in general ICU patients, and to evaluate the association between VExUS, AKI and death. METHODS This prospective, observational study included adult patients within 24 h of ICU admission. VExUS and hemodynamic parameters were measured four times during the ICU stay: within 24 h of ICU admission, after day 1 (between 24 and 48 h), after day 2 (between 48 and 72 h), and last day of ICU stay. The prevalence of AKI during the first week in ICU and 28-day mortality were assessed. RESULTS Among the 145 patients included, the percentage of patients with a VExUS score of 2 (moderate congestion) and 3 (severe congestion) was 16% and 6%, respectively. The prevalence did not change over the study period. There was no significant association between admission VExUS scores and AKI (p = 0.136) or 28-day mortality (p = 0.594). Admission VExUS ≥ 2 was not associated with AKI (OR 0.499, CI95% 0.21-1.17, p = 0.109) nor 28-day mortality (OR 0.75, CI95% 0.2-2.8, p = 0.669). The results were similar for VExUS scores measured at day 1 and day 2. CONCLUSIONS In general ICU cohort the prevalence of moderate to severe venous congestion was low. Early assessment of systemic venous congestion using VExUS scores was not associated with the development of AKI or with 28-day mortality.
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Affiliation(s)
- Stefan Andrei
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France.
- Department of Anaesthesiology and Critical Care Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.
| | - Pierre-Alain Bahr
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, 21000, Dijon, France
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, 21000, Dijon, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, 21000, Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, 21000, Dijon, France
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113
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Hosokawa T, Tanami Y, Sato Y, Nomura K, Oguma E. Association between the dynamic movement of hyperechoic foci and patients'/sonographic outcomes among pediatric patients with portal venous gas following a cardiac event. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023. [PMID: 37262363 DOI: 10.1002/jcu.23496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/12/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To demonstrate the association between the dynamic movements of hyperechoic foci in portal venous gas (PVG) and patients'/sonographic outcomes after congenital heart disease or cardiac events. METHODS Thirty-one pediatric patients requiring management of congenital heart diseases or cardiac events who had PVG on ultrasound were included in this retrospective study. The patient outcome was prognosis: dead or alive. The sonographic outcome was recovery from PVG, measured as days from PVG detection to when it diminished on ultrasound. The following sonographic findings of hyperechoic foci in PVG were compared between patients: detection within the mesenteric vein, having to-and-fro movements within the intrahepatic portal vein, distribution (left segment or both left and right segments) and shape (line or punctate) in the liver, and detection within the portal and hepatic veins. Comparisons were made using Fisher's exact/Mann-Whitney U test. RESULTS Four patients died without having recovered from PVG. A significant difference was observed in terms of the to-and-fro movement (with/without to-and-fro movement in dead vs. alive patients: 3/1 vs. 1/26, respectively; P = 0.003). Furthermore, a significant difference in sonographic outcomes was observed regarding patients with/without hyperechoic foci within the mesenteric vein (days with vs. without this finding: 2.0 ± 1.24(1-5) vs.1 ± 0(1), respectively; P = 0.011). CONCLUSIONS In our small limited cohort, when PVG was visualized on ultrasound, close evaluation of the dynamic movement of hyperechoic foci, especially their to-and-fro movement within the intrahepatic portal vein and detection of hyperechoic foci within the mesenteric vein, were useful in predicting patients' outcomes and the time to PVG diminishment.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Koji Nomura
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
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Urbani A, Pensotti F, Provera A, Galassi A, Guazzi M, Castini D. Extracorporeal veno-venous ultrafiltration in congestive heart failure: What’s the state of the art? A mini-review. World J Cardiol 2023; 15:205-216. [PMID: 37274372 PMCID: PMC10237006 DOI: 10.4330/wjc.v15.i5.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/19/2023] [Accepted: 04/24/2023] [Indexed: 05/19/2023] Open
Abstract
Hospitalizations for heart failure exceed 1 million per year in both the United States and Europe and more than 90% are due to symptoms and signs of fluid overload. Rates of rehospitalizations or emergency department visit at 60 days are remarkable regardless of whether loop diuretics were administered at low vs high doses or by bolus injection vs continuous infusion. Ultrafiltration (UF) has been considered a promising alternative to stepped diuretic therapy and it consists in the mechanical, adjustable removal of iso-tonic plasma water across a semipermeable membrane with the application of hydrostatic pressure gradient generated by a pump. Fluid removal with ultrafiltration presents several advantages such as elimination of higher amount of sodium with less neurohormonal activation. However, the conflicting results from UF studies highlight that patient selection and fluid removal targets are not completely understood. The best way to assess fluid status and therefore establish the fluid removal target is also still a matter of debate. Herein, we provide an up-to-date systematic review about the role of ultrafiltration among patients with fluid overload and its gaps in daily practice.
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Affiliation(s)
- Andrea Urbani
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Filippo Pensotti
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Andrea Provera
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Andrea Galassi
- Nephrology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Marco Guazzi
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
| | - Diego Castini
- Cardiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan 20142, Italy
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115
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Longino A, Martin K, Leyba K, Siegel G, Gill E, Douglas IS, Burke J. Correlation between the VExUS score and right atrial pressure: a pilot prospective observational study. Crit Care 2023; 27:205. [PMID: 37237315 PMCID: PMC10223840 DOI: 10.1186/s13054-023-04471-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
Venous congestion is an under-recognized contributor to mortality in critically ill patients. Unfortunately, venous congestion is difficult to measure, and right heart catheterization (RHC) has been considered the most readily available means for measuring venous filling pressure. Recently, a novel "Venous Excess Ultrasound (VExUS)" score was developed to noninvasively quantify venous congestion using inferior vena cava (IVC) diameter and Doppler flow through the hepatic, portal, and renal veins. A preliminary retrospective study of post-cardiac surgery patients showed promising results, including a high positive-likelihood ratio of high VExUS grade for acute kidney injury. However, studies have not been reported in broader patient populations, and the relationship between VExUS and conventional measures of venous congestion is unknown. To address these gaps, we prospectively assessed the correlation of VExUS with right atrial pressure (RAP), with comparison to inferior vena cava (IVC) diameter. Patients undergoing RHC at Denver Health Medical Center underwent VExUS examination before their procedure. VExUS grades were assigned before RHC, blinding ultrasonographers to RHC outcomes. After controlling for age, sex, and common comorbidities, we observed a significant positive association between RAP and VExUS grade (P < 0.001, R2 = .68). VExUS had a favorable AUC for prediction of a RAP ≥ 12 mmHg (0.99, 95% CI 0.96-1) compared to IVC diameter (0.79, 95% CI 0.65-0.92). These results suggest a strong correlation between VExUS and RAP in a diverse patient population, and support future studies of VExUS as a tool to assess venous congestion and guide management in a spectrum of critical illnesses.
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Affiliation(s)
- August Longino
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO, USA.
| | - Katharine Martin
- School of Medicine, University of Colorado, University of Colorado, Aurora, CO, USA
| | - Katarina Leyba
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO, USA
| | - Gabriel Siegel
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, CO, USA
| | - Edward Gill
- Department of Cardiology, University of Colorado, Aurora, CO, USA
| | - Ivor S Douglas
- Department of Pulmonary and Critical Care Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Joseph Burke
- Department of Cardiology, Denver Health Medical Center, Denver, CO, USA
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116
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Cheong I, Amador EDO, Gómez RA, Vilariño FMÁ, Furche MA, Tamagnone FM. Evaluating the Utility of Portal Vein Pulsatility Index for Detecting Fluid Unresponsiveness in the Intensive Care Unit. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00346-4. [PMID: 37330331 DOI: 10.1053/j.jvca.2023.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/11/2023] [Accepted: 05/22/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE The primary aim of the authors' study was to evaluate the capacity of the portal vein pulsatility index (PVP) to detect fluid unresponsiveness in patients admitted to intensive care. DESIGN This was a retrospective, diagnostic accuracy study SETTING: At a tertiary medical-surgical intensive care unit in Buenos Aires, Argentina. PARTICIPANTS Patients were included during usual care in the intensive care unit, who were evaluated by ultrasonography for the flow of the portal vein, calculating their PVP prior to fluid expansion. INTERVENTIONS Patients who exhibited an increase of <15% in left ventricle outflow tract velocity-time integral after receiving 500 mL of Ringer Lactate were considered non-responders to fluids. MEASUREMENTS AND MAIN RESULTS The authors included a total of 63 patients between January 2022 and October 2022. The area under the receiver operating characteristic curve for PVP to predict fluid unresponsiveness was 0.708 (95% CI 0.580 to 0.816). A value of the PVP >32% predicted fluid unresponsiveness with a sensitivity of 30.8% (95% CI 17% to 47.6%) and specificity of 100% (95% CI 85.8 to 100). The positive predictive value was 100%, and the negative predictive value was 47.1% (95% CI 41.9% to 52.3%). CONCLUSIONS Although PVP has limited value as the sole indicator for fluid management decisions, it can be used as a stopping rule or combined with other diagnostic tests to improve the accuracy of fluid responsiveness assessment.
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Affiliation(s)
- Issac Cheong
- Department of critical care medicine, Sanatorio De los Arcos, Buenos Aires, Argentina; Argentinian Critical Care Ultrasonography Association, Buenos Aires, Argentina.
| | - Elías Daniel Olarte Amador
- Argentinian Critical Care Ultrasonography Association, Buenos Aires, Argentina; Department of critical care medicine, Clínica Pediátrica Sanitas, Bogotá, Colombia
| | - Raúl Alejandro Gómez
- Department of critical care medicine, Sanatorio De los Arcos, Buenos Aires, Argentina
| | | | - Mariano Andrés Furche
- Department of critical care medicine, Sanatorio De los Arcos, Buenos Aires, Argentina
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117
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Bhardwaj V, Rola P, Denault A, Vikneswaran G, Spiegel R. Femoral vein pulsatility: a simple tool for venous congestion assessment. Ultrasound J 2023; 15:24. [PMID: 37165284 PMCID: PMC10172460 DOI: 10.1186/s13089-023-00321-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 04/10/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Femoral vein Doppler (FVD) is simpler than the VExUS score which is a multimodal scoring system based on combination of IVC diameter, hepatic venous Doppler, portal vein pulsatility and renal vein Doppler, may be useful in assessing right ventricular overload and signs of venous congestion. There is limited data on the relationship between FVD and VExUS score. RESULTS Adult post-cardiac surgery patients were assessed for venous congestion using the VExUS score and FVD. Agreement between VExUS and FVD was studied using Kappa test, sensitivity, specificity, PPV and NPV for VExUS and FVD was calculated keeping CVP as gold standard. In total, 107 patients were enrolled, with a mean age of 55.67 ± 12.76. The accuracy of VExUS and FVD for detecting venous congestion was 80.37 (95% CI of 71.5 to 87.4) and 74.7 (95% CI of 65.4 to 82.6), respectively. The level of agreement between FVD and VExUS was moderate (Kappa value of 0.62, P < 0.001) while the agreement between FVD and CVP was weak (Kappa value of 0.49, P < 0.001). CONCLUSION FVD has good accuracy for detecting venous congestion and shows moderate agreement with VExUS grading. With potentially easier physical accessibility and a shorter learning curve for novices, it may be a simple and valuable tool for assessing venous congestion.
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Affiliation(s)
- V Bhardwaj
- Critical Care, Narayana Health City, Bangalore, India.
| | - P Rola
- ICU Chief of Service, Santa Cabrini Hospital, Montreal, Canada
| | - A Denault
- Department of Anesthesiology, Monteal Heart Institute, Montreal, Canada
| | - G Vikneswaran
- Clinical Research, Narayana Health City, Bangalore, India
| | - R Spiegel
- Department of Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC, USA
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118
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Kenny JES, Prager R, Rola P, McCulloch G, Eibl JK, Haycock K. The effect of gravity-induced preload change on the venous excess ultrasound (VExUS) score and internal jugular vein Doppler in healthy volunteers. Intensive Care Med Exp 2023; 11:19. [PMID: 37055637 PMCID: PMC10102271 DOI: 10.1186/s40635-023-00504-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/20/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND The venous excess ultrasound (VExUS) score is a multi-organ Doppler approach to assess venous congestion. Despite growing use of VExUS in research and clinical practice, other veins can be visualized to assess for venous hypertension, which may overcome acquisition barriers of the VExUS exam. In this pilot, observational study, we used a wearable Doppler ultrasound to assess the relationship between jugular venous Doppler and the VExUS score under different preload conditions. We hypothesized that jugular Doppler morphology would accurately distinguish preload conditions, that it would most closely relate to the hepatic venous Doppler morphology in the fully supine position and that the VExUS score would be influenced by preload condition. RESULTS We recruited 15 healthy volunteers with no cardiovascular history. Preload change was achieved using a tilt-table with three positions: supine, fully upright, and 30-degree head-down tilt. In each position, a VExUS score was performed; furthermore, inferior vena collapsibility and sphericity index were calculated. At the same time, jugular venous Doppler was captured by a novel, wireless, wearable ultrasound system. A continuous jugular venous Doppler morphology was 96% accurate for detecting the low preload condition. The jugular venous Doppler morphology was highly correlated with the hepatic vein, but only in the supine position. Gravitational position did not significantly affect the sphericity index or the VExUS score. CONCLUSIONS The jugular vein Doppler morphology was able to accurately distinguish low from high preload conditions in healthy volunteers. Comparisons between VExUS Doppler morphologies and other veins should occur in the supine position when gravitational pressure gradients are minimized; finally, different preload conditions in healthy subjects did not affect the VExUS score.
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Affiliation(s)
- Jon-Emile S Kenny
- Health Sciences North Research Institute, 56 Walford Rd, Sudbury, ON, P3E 2H2, Canada.
- Flosonics Medical, Toronto, ON, Canada.
| | - Ross Prager
- Division of Critical Care Medicine, Western University, London, ON, Canada
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montreal, QC, Canada
| | | | - Joseph K Eibl
- Health Sciences North Research Institute, 56 Walford Rd, Sudbury, ON, P3E 2H2, Canada
- Flosonics Medical, Toronto, ON, Canada
- Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Korbin Haycock
- Department of Emergency Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
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Bellido D, García-García C, Talluri A, Lukaski HC, García-Almeida JM. Future lines of research on phase angle: Strengths and limitations. Rev Endocr Metab Disord 2023; 24:563-583. [PMID: 37043140 PMCID: PMC10090740 DOI: 10.1007/s11154-023-09803-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/13/2023]
Abstract
Bioelectrical impedance analysis (BIA) is the most widely used technique in body composition analysis. When we focus the use of phase sensitive BIA on its raw parameters Resistance (R), Reactance (Xc) and Phase Angle (PhA), we eliminate the bias of using predictive equations based on reference models. In particular PhA, have demonstrated their prognostic utility in multiple aspects of health and disease. In recent years, as a strong association between prognostic and diagnostic factors has been observed, scientific interest in the utility of PhA has increased. In the different fields of knowledge in biomedical research, there are different ways of assessing the impact of a scientific-technical aspect such as PhA. Single frequency with phase detection bioimpedance analysis (SF-BIA) using a 50 kHz single frequency device and tetrapolar wrist-ankle electrode placement is the most widely used bioimpedance approach for characterization of whole-body composition. However, the incorporation of vector representation of raw bioelectrical parameters and direct mathematical calculations without the need for regression equations for the analysis of body compartments has been one of the most important aspects for the development of research in this area. These results provide new evidence for the validity of phase-sensitive bioelectrical measurements as biomarkers of fluid and nutritional status. To enable the development of clinical research that provides consistent results, it is essential to establish appropriate standardization of PhA measurement techniques. Standardization of test protocols will facilitate the diagnosis and assessment of the risk associated with reduced PhA and the evaluation of changes in response to therapeutic interventions. In this paper, we describe and overview the value of PhA in biomedical research, technical and instrumental aspects of PhA research, analysis of Areas of clinical research (cancer patients, digestive and liver diseases, critical and surgical patients, Respiratory, infectious, and COVID-19, obesity and metabolic diseases, Heart and kidney failure, Malnutrition and sarcopenia), characterisation of the different research outcomes, Morphofunctional assessment in disease-related malnutrition and other metabolic disorders: validation of PhA with reference clinical practice techniques, strengths and limitations. Based on the detailed study of the measurement technique, some of the key issues to be considered in future PhA research. On the other hand, it is important to assess the clinical conditions and the phenotype of the patients, as well as to establish a disease-specific clinical profile. The appropriate selection of the most critical outcomes is another fundamental aspect of research.
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Affiliation(s)
- Diego Bellido
- Department of Endocrinology and Nutrition, Complejo Hospitalario de Ferrol, 15405, Ferrol, A Coruña, Spain
| | - Cristina García-García
- PhD Program in Biomedicine, Translational Research and New Health Technologies, Faculty of Medicine, Málaga University, 29010, Málaga, Spain
| | | | - Henry C Lukaski
- Department of Kinesiology and Public Health Education, University of North Dakota, Grand Forks, ND, 58202, USA
| | - José Manuel García-Almeida
- Department of Endocrinology and Nutrition, Virgen de La Victoria Hospital, Malaga University, 29010, Malaga, Spain.
- Centro de Investigación Biomédica en Red de La Fisiopatología de La Obesidad Y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), 29010, Malaga, Spain.
- Málaga University, 29010, Málaga, Spain.
- Department of Endocrinology and Nutrition, Quironsalud Málaga Hospital, 29004, Málaga, Spain.
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Melo RH, dos Santos MHC, Ramos FJDS. Beyond fluid responsiveness: the concept of fluid tolerance and its potential implication in hemodynamic management. CRITICAL CARE SCIENCE 2023; 35:226-229. [PMID: 37712813 PMCID: PMC10406410 DOI: 10.5935/2965-2774.20230012-en] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/12/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Rafael Hortêncio Melo
- Adult Intensive Care Unit, Hospital Municipal Vila Santa Catarina -
São Paulo (SP), Brazil
| | | | - Fernando José da Silva Ramos
- Department of Anesthesiology, Pain and Intensive Care, Universidade
Federal de São Paulo - São Paulo (SP), Brazil
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121
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Dabrowski W, Rola P, Malbrain MLNG. Intra-abdominal pressure monitoring in cardiac surgery: is this the canary in the coalmine for kidney injury? J Clin Monit Comput 2023; 37:351-358. [PMID: 36550345 PMCID: PMC10068659 DOI: 10.1007/s10877-022-00933-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/11/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Wojciech Dabrowski
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, CEMTL, Montreal, Canada
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland.
- Medical Data Management, Medaman, Geel, Belgium.
- International Fluid Academy, Lovenjoel, Belgium.
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Girard M, Deschamps J, Razzaq S, Lavoie N, Denault A, Beaubien-Souligny W. Emerging Applications of Extracardiac Ultrasound in Critically Ill Cardiac Patients. Can J Cardiol 2023; 39:444-457. [PMID: 36509177 DOI: 10.1016/j.cjca.2022.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/21/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Abstract
Point-of-care ultrasound has evolved as an invaluable diagnostic modality and procedural guidance tool in the care of critically ill cardiac patients. Beyond focused cardiac ultrasound, additional extracardiac ultrasound modalities may provide important information at the bedside. In addition to new uses of existing modalities, such as pulsed-wave Doppler ultrasound, the development of new applications is fostered by the implementation of additional features in mid-range ultrasound machines commonly acquired for intensive care units, such as tissue elastography, speckle tracking, and contrast-enhanced ultrasound quantification software. This review explores several areas in which ultrasound imaging technology may transform care in the future. First, we review how lung ultrasound in mechanically ventilated patients can enable the personalization of ventilator parameters and help to liberate them from mechanical ventilation. Second, we review the role of venous Doppler in the assessment of organ congestion and how tissue elastography may complement this application. Finally, we explore how contrast-enhanced ultrasound could be used to assess changes in organ perfusion.
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Affiliation(s)
- Martin Girard
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Department of Anaesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Jean Deschamps
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - André Denault
- Department of Anaesthesiology, Montréal Heart Institute, Montréal, Québec, Canada
| | - William Beaubien-Souligny
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada; Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
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123
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Bhasin-Chhabra B, Koratala A. Point of care ultrasonography in onco-nephrology: A stride toward better physical examination. World J Nephrol 2023; 12:29-39. [PMID: 37035508 PMCID: PMC10075017 DOI: 10.5527/wjn.v12.i2.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/27/2023] [Accepted: 03/09/2023] [Indexed: 03/21/2023] Open
Abstract
Onco-Nephrology is an emerging subspecialty of Nephrology that focuses on a broad spectrum of renal disorders that can arise in patients with cancer. It encompasses acute kidney injury (AKI), complex fluid, electrolyte, and acid-base disorders, as well as chronic kidney disease caused or exacerbated by cancer and/or its treatment. In many such scenarios including AKI and hyponatremia, objective evaluation of hemodynamics is vital for appropriate management. Point of care ultrasonography (POCUS) is a limited ultrasound exam performed at the bedside and interpreted by the treating physician intended to answer focused clinical questions and guide therapy. Compared to conventional physical examination, POCUS offers substantially higher diagnostic accuracy for various structural and hemodynamic derangements. In this narrative review, we provide an overview of the utility of POCUS enhanced physical examination for the Onconephrologist supported by the current evidence and our experience-based opinion.
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Affiliation(s)
- Bhavna Bhasin-Chhabra
- Division of Nephrology and Hypertension, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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124
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Magder S, Slobod D, Assanangkornchai N. Right Ventricular Limitation: A Tale of Two Elastances. Am J Respir Crit Care Med 2023; 207:678-692. [PMID: 36257049 DOI: 10.1164/rccm.202106-1564so] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Right ventricular (RV) dysfunction is a commonly considered cause of low cardiac output in critically ill patients. Its management can be difficult and requires an understanding of how the RV limits cardiac output. We explain that RV stroke output is caught between the passive elastance of the RV walls during diastolic filling and the active elastance produced by the RV in systole. These two elastances limit RV filling and stroke volume and consequently limit left ventricular stroke volume. We emphasize the use of the term "RV limitation" and argue that limitation of RV filling is the primary pathophysiological process by which the RV causes hemodynamic instability. Importantly, RV limitation can be present even when RV function is normal. We use the term "RV dysfunction" to indicate that RV end-systolic elastance is depressed or diastolic elastance is increased. When RV dysfunction is present, RV limitation occurs at lowerpulmonary valve opening pressures and lower stroke volume, but stroke volume and cardiac output still can be maintained until RV filling is limited. We use the term "RV failure" to indicate the condition in which RV output is insufficient for tissue needs. We discuss the physiological underpinnings of these terms and implications for clinical management.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Nawaporn Assanangkornchai
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
- Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand
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125
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Inferior Vena Cava Ultrasonography for Volume Status Evaluation: An Intriguing Promise Never Fulfilled. J Clin Med 2023; 12:jcm12062217. [PMID: 36983218 PMCID: PMC10053997 DOI: 10.3390/jcm12062217] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023] Open
Abstract
The correct determination of volume status is a fundamental component of clinical evaluation as both hypovolaemia (with hypoperfusion) and hypervolaemia (with fluid overload) increase morbidity and mortality in critically ill patients. As inferior vena cava (IVC) accounts for two-thirds of systemic venous return, it has been proposed as a marker of volaemic status by indirect assessment of central venous pressure or fluid responsiveness. Although ultrasonographic evaluation of IVC is relatively easy to perform, correct interpretation of the results may not be that simple and multiple pitfalls hamper its wider application in the clinical setting. In the present review, the basic elements of the pathophysiology of IVC behaviour, potential applications and limitations of its evaluation are discussed.
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126
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Turk M, Robertson T, Koratala A. Point-of-care ultrasound in diagnosis and management of congestive nephropathy. World J Crit Care Med 2023; 12:53-62. [PMID: 37034023 PMCID: PMC10075049 DOI: 10.5492/wjccm.v12.i2.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/08/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
Congestive nephropathy is kidney dysfunction caused by the impact of elevated venous pressures on renal hemodynamics. As a part of cardiorenal syndrome, the diagnosis is usually made based on history and physical examination, with findings such as jugular venous distension, a third heart sound, and vital signs as supporting findings. More recently, however, these once though objective measures have come under scrutiny for their accuracy. At the same time, bedside ultrasound has increased in popularity and is routinely being used by clinicians to take some of the guess work out of making the diagnosis of volume overload and venous congestion. In this mini-review, we will discuss some of the traditional methods used to measure venous congestion, describe the role of point-of-care ultrasound and how it can ameliorate a clinician’s evaluation, and offer a description of venous excess ultrasound score, a relatively novel scoring technique used to objectively quantify congestion. While there is a paucity of published large scale clinical trials evaluating the potential benefit of ultrasonography in venous congestion compared to gold standard invasive measurements, more study is underway to solidify the role of this objective measure in daily clinical practice.
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Affiliation(s)
- Michael Turk
- Department of Medicine, Allegheny Health Network, Pittsburgh, PA 15222, United States
| | - Thomas Robertson
- Department of Medicine, Allegheny Health Network, Pittsburgh, PA 15222, United States
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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127
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Benes J, Kasperek J, Smekalova O, Tegl V, Kletecka J, Zatloukal J. Individualizing Fluid Management in Patients with Acute Respiratory Distress Syndrome and with Reduced Lung Tissue Due to Surgery—A Narrative Review. J Pers Med 2023; 13:jpm13030486. [PMID: 36983668 PMCID: PMC10056120 DOI: 10.3390/jpm13030486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023] Open
Abstract
Fluids are the cornerstone of therapy in all critically ill patients. During the last decades, we have made many steps to get fluid therapy personalized and based on individual needs. In patients with lung involvement—acute respiratory distress syndrome—finding the right amount of fluids after lung surgery may be extremely important because lung tissue is one of the most vulnerable to fluid accumulation. In the current narrative review, we focus on the actual perspectives of fluid therapy with the aim of showing the possibilities to tailor the treatment to a patient’s individual needs using fluid responsiveness parameters and other therapeutic modalities.
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Affiliation(s)
- Jan Benes
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
- Biomedical Centre, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Correspondence:
| | - Jiri Kasperek
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Fachkrankenhaus Coswig GmbH, Zentrum für Pneumologie, Allergologie, Beatmungsmedizin, Thoraxchirurgie, 01640 Coswig, Germany
| | - Olga Smekalova
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
| | - Vaclav Tegl
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
- Biomedical Centre, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
| | - Jakub Kletecka
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
| | - Jan Zatloukal
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
- Biomedical Centre, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
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128
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Sohal S, Uppal D, Mathai SV, Wats K, Uppal NN. Acute Cardiorenal Syndrome: An Update. Cardiol Rev 2023; Publish Ahead of Print:00045415-990000000-00074. [PMID: 36883827 DOI: 10.1097/crd.0000000000000532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
The complex dynamic pathophysiological interplay between the heart and kidney causes a vicious cycle of worsening renal and/or cardiovascular function. Acute decompensated heart failure causing worsening renal function defines Type 1 cardiorenal syndrome (CRS). Altered hemodynamics coupled with a multitude of nonhemodynamic factors namely pathological activation of the renin angiotensin aldosterone system and systemic inflammatory pathways mechanistically incite CRS type 1. A multipronged diagnostic approach utilizing laboratory markers, noninvasive and/or invasive modalities must be implemented to enable timely initiation of effective treatment strategies. In this review, we discuss the pathophysiology, diagnosis, and emerging treatment options for CRS type 1.
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Affiliation(s)
- Sumit Sohal
- From the Division of Cardiovascular Diseases, Department of Medicine, RWJ-BH Newark Beth Israel Medical Center, Newark, NJ
| | - Dipan Uppal
- Department of Cardiovascular Diseases, Cleveland Clinic Florida, Weston, FL
| | | | - Karan Wats
- Division of Cardiovascular Diseases, Department of Medicine, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Nupur N Uppal
- Division of Kidney Diseases and Hypertension, Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
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129
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Koratala A, Taleb Abdellah A, Reisinger N. Nephrologist-performed point-of-care venous excess Doppler ultrasound (VExUS) in the management of acute kidney injury. J Ultrasound 2023; 26:301-306. [PMID: 36617380 PMCID: PMC10063755 DOI: 10.1007/s40477-022-00760-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/28/2022] [Indexed: 01/09/2023] Open
Abstract
Acute kidney injury (AKI) is frequently associated with alterations in fluid balance making accurate assessment of hemodynamics a vital component of patient management. Unfortunately, conventional parameters such as history, physical examination, vital signs, weight, natriuretic peptides have limitations in this regard. Point of care ultrasonography (POCUS) is a clinician-performed limited ultrasound study intended to answer focused clinical questions at the bedside. In the past several years, it has evolved as an extension of physical examination in various medical specialties. Herein, we describe a case of AKI where nephrologist-performed multi-organ POCUS aided in accurate diagnosis of fluid overload state. In addition, we describe how venous Doppler (VExUS) evaluation can be used to monitor the efficacy of decongestive therapy in real-time. Nephrologists should adopt a multi-parametric approach integrating all the pieces of hemodynamic puzzle when evaluating patients with AKI and fluid/electrolyte disorders.
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Affiliation(s)
- Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Room A7633, Milwaukee, WI, 53226, USA.
| | - Ahmed Taleb Abdellah
- Division of Nephrology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Room A7633, Milwaukee, WI, 53226, USA
| | - Nathaniel Reisinger
- Division of Renal Electrolyte and Hypertension, University of Pennsylvania Hospital, Philadelphia, USA
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130
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Ruiz Sada P, Palacios García L, Echeverria Echeverria A. Respuesta a las consideraciones sobre la ecografía clínica en pacientes con insuficiencia cardíaca atendidos en hospitalización a domicilio. Med Clin (Barc) 2023:S0025-7753(23)00110-0. [PMID: 37005124 DOI: 10.1016/j.medcli.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/15/2023] [Accepted: 02/21/2023] [Indexed: 04/03/2023]
Affiliation(s)
- Pablo Ruiz Sada
- Servicio de Medicina Interna, Hospital Reina Sofía, Tudela, Navarra, España.
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131
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Devangam S, Sigakis M, Palmer LJ, Goeddel L, Fiza B. Point-of-Care Ultrasound: A Moving Picture Is Worth a Thousand Tests. Anesthesiol Clin 2023; 41:231-248. [PMID: 36872001 DOI: 10.1016/j.anclin.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
The effective utilization of point-of-care ultrasound may decrease the utilization of conventional diagnostic modalities. This review describes the various pathologies that can be effectively and rapidly identified with point-of-care cardiac, lung, abdominal, vascular airway, and ocular ultrasonography.
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Affiliation(s)
- Suhas Devangam
- Department of Anesthesiology, Division of Critical Care, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA
| | - Matthew Sigakis
- Department of Anesthesiology, Division of Critical Care, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA
| | - Louisa J Palmer
- Department of Anesthesiology, Division of Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston MA 02115, USA
| | - Lee Goeddel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Bloomberg 6320, 1800 Orleans Street, Baltimore, MD, USA 21287
| | - Babar Fiza
- Department of Anesthesiology, Division of Critical Care Medicine, Emory School of Medicine, 1364 Clifton Road Northeast, Atlanta, GA 30322, USA.
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132
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Pulmonary Artery Systolic Pressure and Cava Vein Status in Acute Heart Failure with Preserved Ejection Fraction: Clinical and Prognostic Implications. Diagnostics (Basel) 2023; 13:diagnostics13040692. [PMID: 36832179 PMCID: PMC9955829 DOI: 10.3390/diagnostics13040692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Peak tricuspid regurgitation (TR) velocity and inferior cava vein (ICV) distention are two recognized features of increased pulmonary artery pressure (PASP) and right atrial pressure, respectively. Both parameters are related to pulmonary and systemic congestion and adverse outcomes. However, few data exist about the assessment of PASP and ICV in acute patients affected by heart failure with preserved ejection fraction (HFpEF). Thus, we investigated the relationship existing among clinical and echocardiographic features of congestion, and we analyzed the prognostic impact of PASP and ICV in acute HFpEF patients. METHODS AND RESULTS We analyzed clinical congestion PASP and ICV value in consecutive patients admitted in our ward by echocardiographic examination using peak Doppler velocity tricuspid regurgitation and ICV diameter and collapse for the assessment of PASP and ICV dimension, respectively. A total of 173 HFpEF patients were included in the analysis. The median age was 81 and median left ventricular ejection fraction (LVEF) was 55% [50-57]. Mean values of PASP was 45 mmHg [35-55] and mean ICV was 22 [20-24] mm. Patients with adverse events during follow-up showed significantly higher values of PASP (50 [35-55] vs. 40 [35-48] mmHg, (p = 0.005) and increased values of ICV (24 [22-25] vs. 22 [20-23] mm, p < 0.001). Multivariable analysis showed prognostic power of ICV dilatation (HR 3.22 [1.58-6.55], p = 0.001) and clinical congestion score ≥ 2 (HR 2.35 [1.12-4.93], p = 0.023), but PASP increase did not reach statistical significance (p = 0.874). The combination of PASP > 40 mmHg and ICV > 21 mm was capable of identifying patients with increased events (45% vs. 20%). CONCLUSIONS ICV dilatation provides additional prognostic information with respect to PASP in patients with acute HFpEF. A combined model adding PASP and ICV assessment to clinical evaluation is a useful tool for predicting HF related events.
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133
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Torres-Arrese M, Mata-Martínez A, Luordo-Tedesco D, García-Casasola G, Alonso-González R, Montero-Hernández E, Cobo-Marcos M, Sánchez-Sauce B, Cuervas-Mons V, Tung-Chen Y. Usefulness of Systemic Venous Ultrasound Protocols in the Prognosis of Heart Failure Patients: Results from a Prospective Multicentric Study. J Clin Med 2023; 12:jcm12041281. [PMID: 36835816 PMCID: PMC9966251 DOI: 10.3390/jcm12041281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/21/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
Mortality and re-admission rates for decompensated acute heart failure (AHF) is increasing overall and risk stratification might be challenging. We sought to evaluate the prognostic role of systemic venous ultrasonography in patients hospitalized for AHF. We prospectively recruited 74 AHF patients with a NT-proBNP level above 500 pg/mL. Then, multi-organ ultrasound assessments (lung, inferior vena cava (IVC), pulsed-wave Doppler (PW-Doppler) of hepatic, portal, intra-renal and femoral veins) were performed at admission, discharge, and follow-up (for 90 days). We also calculated the Venous Excess Ultrasound System (VExUS), a new score of systemic congestion based on IVC dilatation and pulsed-wave Doppler morphology of hepatic, portal and intra-renal veins. An intra-renal monophasic pattern (area under the curve (AUC) 0.923, sensitivity (Sn) 90%, specificity (Sp) 81%, positive predictive value (PPV) 43%, and negative predictive value (NPV) 98%), a portal pulsatility > 50% (AUC 0.749, Sn 80%, Sp 69%, PPV 30%, NPV 96%) and a VExUS score of 3 corresponding to severe congestion (AUC 0.885, Sn 80%, Sp 75%, PPV 33%, and NPV 96%) predicted death during hospitalization. An IVC above 2 cm (AUC 0.758, Sn 93.l% and Sp 58.3) and the presence of an intra-renal monophasic pattern (AUC 0. 834, sensitivity 0.917, specificity 67.4%) in the follow-up visit predicted AHF-related re-admission. Additional scans during hospitalization or the calculation of a VExUS score probably adds unnecessary complexity to the assessment of AHF patients. In conclusion, VExUS score does not contribute to the guidance of therapy or the prediction of complications, compared with the presence of an IVC greater than 2 cm, a venous monophasic intra-renal pattern or a pulsatility > 50% of the portal vein in AHF patients. Early and multidisciplinary follow-up visits remain necessary for the improvement of the prognosis of this highly prevalent disease.
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Affiliation(s)
- Marta Torres-Arrese
- Department of Emergency Medicine, Hospital Universitario Fundación de Alcorcón, Calle Budapest 1, 28922 Alcorcón, Spain
| | - Arantzazu Mata-Martínez
- Department of Emergency Medicine, Hospital Universitario Fundación de Alcorcón, Calle Budapest 1, 28922 Alcorcón, Spain
| | - Davide Luordo-Tedesco
- Department of Emergency Medicine, Hospital Universitario Infanta Cristina, Avenida 9 de Junio 2, 28981 Parla, Spain
| | - Gonzalo García-Casasola
- Department of Emergency Medicine, Hospital Universitario Fundación de Alcorcón, Calle Budapest 1, 28922 Alcorcón, Spain
| | - Rodrigo Alonso-González
- Department of Radiology, Hospital Universitario Severo Ochoa, M-402, s/n, 28914 Leganés, Spain
| | - Esther Montero-Hernández
- Department of Internal Medicine, Hospital Universitario Puerta de Hierro–Majadahonda, Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Joaquín Rodrigo 1, 28222 Majadahonda, Spain
| | - Marta Cobo-Marcos
- Department of Cardiology, Hospital Universitario Puerta de Hierro–Majadahonda, Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Joaquín Rodrigo 1, 28222 Majadahonda, Spain
| | - Beatriz Sánchez-Sauce
- Department of Internal Medicine, Hospital Universitario Fundación de Alcorcón, Calle Budapest 1, 28922 Alcorcón, Spain
| | - Valentín Cuervas-Mons
- Department of Internal Medicine, Hospital Universitario Puerta de Hierro–Majadahonda, Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Joaquín Rodrigo 1, 28222 Majadahonda, Spain
| | - Yale Tung-Chen
- Department of Internal Medicine, Hospital Universitario La Paz, Paseo Castellana 241, 28046 Madrid, Spain
- Department of Medicine, Universidad Alfonso X, 28691 Madrid, Spain
- Correspondence: ; Tel.: +34-676-030-131
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134
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Romero-González G, Manrique J, Slon-Roblero MF, Husain-Syed F, De la Espriella R, Ferrari F, Bover J, Ortiz A, Ronco C. PoCUS in nephrology: a new tool to improve our diagnostic skills. Clin Kidney J 2023; 16:218-229. [PMID: 36755847 PMCID: PMC9900589 DOI: 10.1093/ckj/sfac203] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Indexed: 11/14/2022] Open
Abstract
Point-of-Care Ultrasonography (PoCUS) aims to include a fifth pillar (insonation) in the classical physical examination in order to obtain images to answer specific questions by the clinician at the patient's bedside, allowing rapid identification of structural or functional abnormalities, enabling more accurate volume assessment and supporting diagnosis, as well as guiding procedures. In recent years, PoCUS has started becoming a valuable tool in day-to-day clinical practice, adopted by healthcare professionals from various medical specialties, never replacing physical examination but improving patient and medical care and experience. Renal patients represent a wide range of diseases, which lends PoCUS a special role as a valuable tool in different scenarios, not only for volume-related information but also for the assessment of a wide range of acute and chronic conditions, enhancing the sensitivity of conventional physical examination in nephrology. PoCUS in the hands of a nephrologist is a precision medicine tool.
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Affiliation(s)
- Gregorio Romero-González
- Nephrology Department, University Hospital Germans Trias I Pujol, Badalona, Spain
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
- International Renal Research Institute of Vicenza, Vicenza, Italy
| | - Joaquin Manrique
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
- Nephrology Department, University Hospital of Navarra, Pamplona, Spain
| | - María F Slon-Roblero
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
- Nephrology Department, University Hospital of Navarra, Pamplona, Spain
| | - Faeq Husain-Syed
- Department of Medicine, University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, USA
- Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Klinikstrasse, Giessen, Germany
| | | | | | - Jordi Bover
- Nephrology Department, University Hospital Germans Trias I Pujol, Badalona, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IISFundacion Jimenez Diaz UAM, Madrid, Spain
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Vicenza, Italy
- Professor of Medicine - University of Padova, Padova, Italy
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
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135
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Yu Y, Li C, Zhu S, Jin L, Hu Y, Ling X, Miao C, Guo K. Diagnosis, pathophysiology and preventive strategies for cardiac surgery-associated acute kidney injury: a narrative review. Eur J Med Res 2023; 28:45. [PMID: 36694233 PMCID: PMC9872411 DOI: 10.1186/s40001-023-00990-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/03/2023] [Indexed: 01/25/2023] Open
Abstract
Acute kidney injury (AKI) is a common and serious complication of cardiac surgery and is associated with increased mortality and morbidity, accompanied by a substantial economic burden. The pathogenesis of cardiac surgery-associated acute kidney injury (CSA-AKI) is multifactorial and complex, with a variety of pathophysiological theories. In addition to the existing diagnostic criteria, the exploration and validation of biomarkers is the focus of research in the field of CSA-AKI diagnosis. Prevention remains the key to the management of CSA-AKI, and common strategies include maintenance of renal perfusion, individualized blood pressure targets, balanced fluid management, goal-directed oxygen delivery, and avoidance of nephrotoxins. This article reviews the pathogenesis, definition and diagnosis, and pharmacological and nonpharmacological prevention strategies of AKI in cardiac surgical patients.
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Affiliation(s)
- Ying Yu
- Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Chenning Li
- Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Shuainan Zhu
- Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Lin Jin
- Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Yan Hu
- Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Xiaomin Ling
- Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Changhong Miao
- Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Kefang Guo
- Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
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D’Andrea A, Del Giudice C, Fabiani D, Caputo A, Sabatella F, Cante L, Palermi S, Desiderio A, Tagliamonte E, Liccardo B, Russo V. The Incremental Role of Multiorgan Point-of-Care Ultrasounds in the Emergency Setting. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2088. [PMID: 36767456 PMCID: PMC9915087 DOI: 10.3390/ijerph20032088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 06/18/2023]
Abstract
Point-of-care ultrasonography (POCUS) represents a goal-directed ultrasound examination performed by clinicians directly involved in patient healthcare. POCUS has been widely used in emergency departments, where US exams allow physicians to make quick diagnoses and to recognize early life-threatening conditions which require prompt interventions. Although initially meant for the real-time evaluation of cardiovascular and respiratory pathologies, its use has been extended to a wide range of clinical applications, such as screening for deep-vein thrombosis and trauma, abdominal ultrasonography of the right upper quadrant and appendix, and guidance for invasive procedures. Moreover, recently, bedside ultrasounds have been used to evaluate the fluid balance and to guide decongestive therapy in acutely decompensated heart failure. The aim of the present review was to discuss the most common applications of POCUS in the emergency setting.
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Affiliation(s)
- Antonello D’Andrea
- Department of Cardiology and Intensive Coronary Care, Umberto I Hospital, 84014 Nocera Inferiore, Italy
| | - Carmen Del Giudice
- Division of Cardiology, Department of Traslational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Dario Fabiani
- Division of Cardiology, Department of Traslational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Adriano Caputo
- Division of Cardiology, Department of Traslational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Francesco Sabatella
- Division of Cardiology, Department of Traslational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Luigi Cante
- Division of Cardiology, Department of Traslational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Stefano Palermi
- Public Health Department, University of Naples Federico II, 80131 Naples, Italy
| | - Alfonso Desiderio
- Department of Cardiology and Intensive Coronary Care, Umberto I Hospital, 84014 Nocera Inferiore, Italy
| | - Ercole Tagliamonte
- Department of Cardiology and Intensive Coronary Care, Umberto I Hospital, 84014 Nocera Inferiore, Italy
| | - Biagio Liccardo
- Division of Cardiology, Department of Traslational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Vincenzo Russo
- Division of Cardiology, Department of Traslational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
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Soliman-Aboumarie H, Denault AY. How to assess systemic venous congestion with point of care ultrasound. Eur Heart J Cardiovasc Imaging 2023; 24:177-180. [PMID: 36464836 DOI: 10.1093/ehjci/jeac239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022] Open
Affiliation(s)
- Hatem Soliman-Aboumarie
- Department of Anaesthetics and Cardiothoracic Critical Care, Harefield Hosputal, Hill End Road, Uxbridge, UB9 6JH London, UK.,School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, Denmark Hill, London SE5 9RS, UK
| | - André Y Denault
- Anaesthetist and Intensivist, Institut de Cardiologie de Montreal, 5000 Rue Bélanger, Montréal QC H1T 1C8, Canada.,Professeur titulaire de clinique, Directeur du programme de Fellowship en échographie ciblée, Département d'Anesthésiologie, Département de Pharmacologie, Affilié au département de Médecine, Institut de Cardiologie de Montréal
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Ruben M, Molinas MS, Paladini H, Khalife W, Barbagelata A, Perrone S, Kaplinsky E. Emerging concepts in heart failure management and treatment: focus on point-of-care ultrasound in cardiogenic shock. Drugs Context 2023; 12:dic-2022-5-8. [PMID: 36660015 PMCID: PMC9828879 DOI: 10.7573/dic.2022-5-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/26/2022] [Indexed: 01/04/2023] Open
Abstract
Point-of-care ultrasound (POCUS) plays a strategic role in the diagnostic and therapeutic evaluation of critically ill patients and, especially, in those who are haemodynamically unstable. In this context, POCUS allows a more precise identification of the cause, its differential diagnosis, the eventual coexistence with another entity and, finally, guiding of the therapeutic approach. It implies a portable use of ultrasound in acute settings covering different specified protocols, such as echocardiography, vascular, lung or abdominal ultrasound. This article reviews POCUS application in the emergency department or the intensive care unit, focused on severely compromised patients with cardiogenic shock with an emergent bedside assessment. Considering the high mortality rate of this entity, POCUS provides the intensivist/clinician with an appropriate tool for accurate diagnoses and a timely management plan. The authors propose practical algorithms for the diagnosis of patients using POCUS in these settings. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.
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Affiliation(s)
- Mariela Ruben
- Catholic University Argentina, Buenos Aires, Argentina,Cardiology Service, MIT Group, Santa Fe, Argentina
| | - María Sol Molinas
- Catholic University Argentina, Buenos Aires, Argentina,Cardiology Service, MIT Group, Santa Fe, Argentina
| | - Hugo Paladini
- Medical Images Service, MIT Group, Santa Fe, Argentina
| | - Wissam Khalife
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Alejandro Barbagelata
- Catholic University Argentina, Buenos Aires, Argentina,Duke University School of Medicine, Durham, NC, USA
| | - Sergio Perrone
- Catholic University Argentina, Buenos Aires, Argentina,Fleni Institute, Buenos Aires, Argentina
| | - Edgardo Kaplinsky
- Cardiology Unit, Medicine Department, Hospital Municipal de Badalona, Spain
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Thota RS, Ramkiran S, Ramanjulu R. Time to FOCUS - 'Palliative Medicine Point-of-Care Ultrasound'. Indian J Palliat Care 2023; 29:36-45. [PMID: 36846289 PMCID: PMC9945239 DOI: 10.25259/ijpc_274_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 12/13/2022] [Indexed: 01/15/2023] Open
Abstract
Point-of-care diagnosis has become the need of the hour and along with its guided interventions, ultrasound could be utilised bedside in a palliative care patient. Point-of-care ultrasound (POCUS) in palliative care medicine is fast emerging and has varied applications ranging from performing bedside diagnostic evaluation to the performance of interventional paracentesis, thoracocentesis and chronic pain interventions. Handheld ultrasound devices have transformed the application of POCUS and should revolutionise the future of home-based palliative care. Palliative care physicians should be enabled to carry out bedside ultrasounds at home care and hospice setting for achieving rapid symptom relief. The aim of POCUS in palliative care medicine should be adequate training of palliative care physicians, transforming the applicability of this technology to OPD as well as community driven to achieve home outreach. The goal is towards empowering technology by reaching out to the community rather than the terminally ill patient transported for the hospital admission. Palliative care physicians should receive mandatory training in POCUS to enable diagnostic proficiency and early triaging. The inclusion of ultrasound machine in an outpatient palliative care clinic brings about value addition in rapid diagnosis. Limiting POCUS application to certain selected sub-specialities such as emergency medicine, internal medicine and critical care medicine should be overcome. This would need acquiring higher training as well as improvised skill sets to perform bedside interventions. Ultrasonography competency among palliative care providers proposed as palliative medicine point-of-care ultrasound (PM-POCUS) could be achieved by imparting dedicated POCUS training within the core curriculum.
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Affiliation(s)
| | - Seshadri Ramkiran
- Department of Anaesthesia and Critical Care, HCG Cancer Hospital, Bengaluru, Karnataka, India
| | - Raghavendra Ramanjulu
- Department of Pain and Palliative Care, Aster Hospitals, Bengaluru, Karnataka, India
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Deschamps J, Denault A, Galarza L, Rola P, Ledoux-Hutchinson L, Huard K, Gebhard CE, Calderone A, Canty D, Beaubien-Souligny W. Venous Doppler to Assess Congestion: A Comprehensive Review of Current Evidence and Nomenclature. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:3-17. [PMID: 36207224 DOI: 10.1016/j.ultrasmedbio.2022.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/29/2022] [Accepted: 07/21/2022] [Indexed: 06/16/2023]
Abstract
Organ congestion from venous hypertension is an important pathophysiological mechanism mediating organ injury in several clinical contexts including critical illness, congestive heart failure and end-stage chronic kidney disease. However, the practical evaluation of venous congestion is often challenging at the bedside because of the limitations of traditional methods. Point-of-care ultrasound (POCUS) enables the clinician to assess venous velocity profiles during the cardiac cycle using Doppler modalities. Venous Doppler profile abnormalities at multiple sites are detected when elevated venous pressure results in hemodynamic changes within the systemic venous circulation. The detection of these abnormal Doppler profiles may identify patients with clinically significant systemic venous congestion. These patients have been reported to be at increased risk of medical complications. Improving the evaluation of venous congestion may lead to individualized treatment and improved patient outcomes. In this review, we describe the physiologic principles necessary to understand venous Doppler assessment. We also propose a nomenclature for the description of venous Doppler profiles. Finally, we provide a narrative review of the current clinical evidence related to use of venous Doppler assessment in various clinical contexts.
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Affiliation(s)
- Jean Deschamps
- Division of Intensive Care, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - André Denault
- Department of Anesthesiology and Intensive Care, Montreal Heart Institute, Montréal, Canada
| | - Laura Galarza
- Department of Intensive Care, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - Philippe Rola
- Division of Intensive Care, Hôpital Santa-Cabrini, Montréal, Canada
| | | | | | | | | | - David Canty
- Department of Surgery (Royal Melbourne Hospital), University of Melbourne, Parkville, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Australia; Department of Medicine and Nursing (Monash Medical Centre), Monash University, Clayton, Australia
| | - William Beaubien-Souligny
- Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Innovation Hub, Centre de Recherche du CHUM, Montréal, Canada.
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Blanco JB, Esquinas A. Commentary on "Integrated ultrasound protocol in predicting weaning success and extubation failure: a prospective observational study". Anaesthesiol Intensive Ther 2023; 55:136-137. [PMID: 37587883 PMCID: PMC10415599 DOI: 10.5114/ait.2023.129315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
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142
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Menéndez-Suso JJ, Rodríguez-Álvarez D, Sánchez-Martín M. Feasibility and Utility of the Venous Excess Ultrasound Score to Detect and Grade Central Venous Pressure Elevation in Critically Ill Children. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:211-220. [PMID: 35811405 DOI: 10.1002/jum.16057] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/06/2022] [Accepted: 06/23/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES The Venous Excess Ultrasound (VExUS) score has been described as a useful tool to estimate the degree of venous congestion in adult patients. The present study aimed to analyze the feasibility and usefulness of the VExUS score to detect and grade central venous pressure (CVP) elevation in critically ill children. METHODS A cross-sectional pilot study was conducted in a tertiary-care pediatric intensive care unit between November 2020 and June 2021. All children in whom CVP was monitored, were enrolled. At the time of central venous catheter placement, CVP and VExUS score grade were determined, analyzing the inferior vena cava (IVC) diameter and the hepatic (HVD), portal (PVD), and intrarenal (IRVD) venous Doppler waveforms. RESULTS A total of 33 children were studied (median age 12.2 [interquartile range (IQR) 4.1-100.6] months old; median weight 8.5 [IQR 5.6-35] kg; 20 [60.6%] males). The VExUS score was successfully obtained in 100% of the patients and its severity was strongly associated with the CVP levels (P < .001). Analyzing the VExUS score components separately, IVC dilation (P < .001) and severe HVD (P = .026), mild IRVD (P = .005), and severe IRVD (P = .025) patterns were associated with elevated CVP. After adjustment for confounding factors, IRVD pattern remained the only independent variable associated with elevated CVP. CONCLUSIONS The VExUS score appears to be a feasible and potentially useful bedside noninvasive monitoring tool for the detection and grading of CVP elevation in critically ill children. Among all its components, IRVD assessment seems most associated with high CVP in this population.
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Romano M, Viana E, Martins JD, Corga Da Silva R. Evaluation Of Congestion Levels in Septic Patients Admitted to Critical Care Units with a Combined Venous Excess-Lung Ultrasound Score (VExLUS) - a Research Protocol. POCUS JOURNAL 2023; 8:93-98. [PMID: 37152345 PMCID: PMC10155730 DOI: 10.24908/pocus.v8i1.16188] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection with a high mortality rate. Septic shock is a subset of sepsis with manifest circulatory dysfunction (use of vasopressors and persistent elevation of lactic acid) . As stated in literature, in addition to the use of empiric antibiotics and control of the infectious focus, intravenous fluid therapy is an essential intervention to promote hemodynamic stabilization. However, the literature also describes harmful outcomes related to fluid overload. Hemodynamic management in critically ill patients has traditionally focused on maintaining adequate cardiac output and arterial blood pressure by relying on fluid administration and/or vasopressor/inotropic support. However, organ perfusion is affected by other important factors, such as venous pressure, which can be overlooked. The evaluation of lung congestion with point of care ultrasound (POCUS), as a signal of extravascular fluid, and, more recently, a venous excess Doppler ultrasound (VExUS) grading system, are parameters for the assessment of the fluid status of the patient and organ congestion. Our main hypothesis is that adding a modified lung ultrasound score to the VExUS protocol could provide higher sensitivity and earlier identification of fluid overload, guiding the clinician in the decision of fluid administration in patients with sepsis.
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Affiliation(s)
- Miguel Romano
- School of Medicine, Minho UniversityBragaPortugal
- Internal Medicine, Unidade Local de Saúde do Alto MinhoViana do CasteloPortugal
| | | | - José Diogo Martins
- Internal Medicine, Unidade Local de Saúde do Alto MinhoViana do CasteloPortugal
| | - Rogério Corga Da Silva
- School of Medicine, Minho UniversityBragaPortugal
- Intensive Care Unit, Unidade Local de Saúde do Alto MinhoViana do CasteloPortugal
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Pastore MC, Ilardi F, Stefanini A, Mandoli GE, Palermi S, Bandera F, Benfari G, Esposito R, Lisi M, Pasquini A, Santoro C, Valente S, D’Andrea A, Cameli M. Bedside Ultrasound for Hemodynamic Monitoring in Cardiac Intensive Care Unit. J Clin Med 2022; 11:jcm11247538. [PMID: 36556154 PMCID: PMC9785677 DOI: 10.3390/jcm11247538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/03/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Thanks to the advances in medical therapy and assist devices, the management of patients hospitalized in cardiac intensive care unit (CICU) is becoming increasingly challenging. In fact, Patients in the cardiac intensive care unit are frequently characterized by dynamic and variable diseases, which may evolve into several clinical phenotypes based on underlying etiology and its complexity. Therefore, the use of noninvasive tools in order to provide a personalized approach to these patients, according to their phenotype, may help to optimize the therapeutic strategies towards the underlying etiology. Echocardiography is the most reliable and feasible bedside method to assess cardiac function repeatedly, assisting clinicians not only in characterizing hemodynamic disorders, but also in helping to guide interventions and monitor response to therapies. Beyond basic echocardiographic parameters, its application has been expanded with the introduction of new tools such as lung ultrasound (LUS), the Venous Excess UltraSound (VexUS) grading system, and the assessment of pulmonary hypertension, which is fundamental to guide oxygen therapy. The aim of this review is to provide an overview on the current knowledge about the pathophysiology and echocardiographic evaluation of perfusion and congestion in patients in CICU, and to provide practical indications for the use of echocardiography across clinical phenotypes and new applications in CICU.
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Affiliation(s)
- Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
- Correspondence: (M.C.P.); (M.C.); Tel.: +39-057-758-5377 (M.C.P.)
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
- Mediterranea Cardiocentro, 80122 Naples, Italy
| | - Andrea Stefanini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Stefano Palermi
- Public Health Department, University of Naples Federico II, 80131 Naples, Italy
| | - Francesco Bandera
- Cardiology University Department, Heart Failure Unit, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
- Department of Biomedical Sciences for Health, University of Milano, 20122 Milan, Italy
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, 37129 Verona, Italy
| | - Roberta Esposito
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Matteo Lisi
- Department of Cardiovascular Disease—AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, 48121 Ravenna, Italy
| | - Annalisa Pasquini
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 20123 Rome, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
| | - Serafina Valente
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Antonello D’Andrea
- Department of Cardiology, Umberto I Hospital, 84014 Nocera Inferiore, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
- Correspondence: (M.C.P.); (M.C.); Tel.: +39-057-758-5377 (M.C.P.)
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Eke C, Szabó A, Nagy Á, Szécsi B, Szentgróti R, Dénes A, Kertai MD, Fazekas L, Kovács A, Lakatos B, Hartyánszky I, Benke K, Merkely B, Székely A. Association between Hepatic Venous Congestion and Adverse Outcomes after Cardiac Surgery. Diagnostics (Basel) 2022; 12:diagnostics12123175. [PMID: 36553182 PMCID: PMC9777079 DOI: 10.3390/diagnostics12123175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/03/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Hepatic venous flow patterns reflect pressure changes in the right ventricle and are also markers of systemic venous congestion. Fluid management is crucial in patients undergoing cardiac surgery. METHODS Our goal was to determine which factors are associated with the increased congestion of the liver as measured by Doppler ultrasound in patients undergoing cardiac surgery. This prospective, observational study included 41 patients without preexisting liver disease who underwent cardiac surgery between 1 January 2021 and 30 September 2021 at a tertiary heart center. In addition to routine echocardiographic examination, we recorded the maximal velocity and velocity time integral (VTI) of the standard four waves seen in the common hepatic vein (flow profile) using Doppler ultrasound preoperatively and at the 20-24th hour of the postoperative period. The ratios of the retrograde and anterograde hepatic venous waves were calculated, and the waveforms were compared to the baseline value and expressed as a delta ratio. Demographic data, pre- and postoperative echocardiographic parameters, intraoperative variables (procedure, cardiopulmonary bypass time), postoperative factors (fluid balance, vasoactive medication requirement, ventilation time and parameters) and perioperative laboratory parameters (liver and kidney function tests, albumin) were used in the analysis. RESULTS Of the 41 patients, 20 (48.7%) were males, and the median age of the patients was 65.9 years (IQR: 59.8-69.9 years). Retrograde VTI growth showed a correlation with positive fluid balance (0.89 (95% CI 0.785-0.995) c-index. After comparing the postoperative echocardiographic parameters of the two subgroups, right ventricular and atrial diameters were significantly greater in the "retrograde VTI growth" group. The ejection fraction and decrement in ejection fraction to preoperative parameters were significantly different between the two groups. (p = 0.001 and 0.003). Ventilation times were longer in the retrograde VTI group. The postoperative vs. baseline delta VTI ratio of the hepatic vein correlated with positive fluid balance, maximum central venous pressure, and ejection fraction. (B = -0.099, 95% CI = -0.022-0.002, p = 0.022, B = 0.011, 95% CI = 0.001-0.021, p = 0.022, B = 0.091, 95% CI = 0.052-0.213, p = 0.002, respectively.) Conclusion: The increase of the retrograde hepatic flow during the first 24 h following cardiac surgery was associated with positive fluid balance and the decrease of the right ventricular function. Measurement of venous congestion or venous abdominal insufficiency seems to be a useful tool in guiding fluid therapy and hemodynamic management.
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Affiliation(s)
- Csaba Eke
- Rácz Károly School of PhD Studies, Semmelweis University, Ulloi Ut 26, 1085 Budapest, Hungary
| | - András Szabó
- Rácz Károly School of PhD Studies, Semmelweis University, Ulloi Ut 26, 1085 Budapest, Hungary
| | - Ádám Nagy
- Rácz Károly School of PhD Studies, Semmelweis University, Ulloi Ut 26, 1085 Budapest, Hungary
| | - Balázs Szécsi
- Rácz Károly School of PhD Studies, Semmelweis University, Ulloi Ut 26, 1085 Budapest, Hungary
| | - Rita Szentgróti
- Rácz Károly School of PhD Studies, Semmelweis University, Ulloi Ut 26, 1085 Budapest, Hungary
| | - András Dénes
- Faculty of Medicine, Semmelweis University, Ulloi Ut 26, 1085 Budapest, Hungary
| | - Miklós D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212, USA
| | - Levente Fazekas
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, 1123 Budapest, Hungary
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, 1123 Budapest, Hungary
| | - Bálint Lakatos
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, 1123 Budapest, Hungary
| | - István Hartyánszky
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, 1123 Budapest, Hungary
| | - Kálmán Benke
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, 1123 Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, 1123 Budapest, Hungary
| | - Andrea Székely
- Heart and Vascular Center, Semmelweis University, Varosmajor Utca 68, 1123 Budapest, Hungary
- Faculty of Health Sciences, Semmelweis University, Vas Utca 17, 1088 Budapest, Hungary
- Correspondence:
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Buxbaum JL, Bolado F, de-Madaria E. Aggressive or Moderate Fluids in Acute Pancreatitis. Reply. N Engl J Med 2022; 387:2199-2200. [PMID: 36477046 DOI: 10.1056/nejmc2213440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Gourdeau S, Beaubien-Souligny W, Denault AY. Point-of-Care Ultrasound in an Unstable Patient After Cardiac Surgery. Chest 2022; 162:e325-e330. [PMID: 36494134 DOI: 10.1016/j.chest.2021.12.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/31/2021] [Accepted: 12/20/2021] [Indexed: 12/12/2022] Open
Affiliation(s)
- Simon Gourdeau
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - William Beaubien-Souligny
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada; Department of Nephrology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - André Y Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada; Intensive Care Unit, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.
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148
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Effects of changes in position, positive end-expiratory pressure and mean arterial pressure on renal, portal and hepatic Doppler ultrasound perfusion indices: a randomized crossover study in cardiac surgery patients. J Clin Monit Comput 2022; 36:1841-1850. [PMID: 35230558 DOI: 10.1007/s10877-022-00834-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/18/2022] [Indexed: 10/19/2022]
Abstract
Point-of-care ultrasound perfusion indices can be used for detection of AKI and venous congestion. Patients in the postoperative- and intensive care units are frequently exposed to alternating treatment and loading conditions. We aimed to study the effects of changes in preload (patient positioning), positive end-expiratory pressure (PEEP) and afterload (phenylephrine) on renal, portal and hepatic ultrasound indices. We hypothesized that renal resistive index was not influenced by changes in PEEP and patient positioning. This was a single-site, randomized, crossover study. Patients above 18 years scheduled for elective open-heart surgery at Aarhus University Hospital, Denmark, were available for inclusion. Patients were randomized to a sequence of six combinations of PEEP and position in addition to an increase in mean arterial pressure by phenylephrine. Thirty-one patients participated in the study. Resistive index was influenced by positional change (P = 0.007), but not by change in PEEP (P = 0.50) (Table 1). Renal venous stasis index and portal pulsatility fraction increased in the raised legs position (P ≤ 0.019), but not with increases in PEEP. Renal venous flow pattern and hepatic venous flow pattern were affected by position (P ≤ 0.019), but not by PEEP. None of the ultrasound indices were significantly changed by infusion of phenylephrine. Doppler perfusion indices were significantly affected by changes in preload, but not by changes in PEEP or afterload. Although the changes in the Doppler ultrasound indices were significant, they were small in absolute numbers. Therefore, from a clinical perspective, the ultrasound indices were robust.Trial registration Registered at clinicaltrials.com, first posted online June 5th 2020, identifier: NCT04419662.
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149
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Zeuthen E, Wichmann S, Schønemann-Lund M, Järvisalo MJ, Rubenson-Wahlin R, Sigurðsson MI, Holen E, Bestle MH. Nordic survey on assessment and treatment of fluid overload in intensive care. Front Med (Lausanne) 2022; 9:1067162. [PMID: 36507497 PMCID: PMC9732460 DOI: 10.3389/fmed.2022.1067162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Fluid overload in patients in the intensive care unit (ICU) is associated with higher mortality. There are few randomized controlled trials to guide physicians in treating patients with fluid overload in the ICU, and no guidelines exist. We aimed to elucidate how ICU physicians from Nordic countries define, assess, and treat fluid overload in the ICU. Materials and methods We developed an online questionnaire with 18 questions. The questions were pre-tested and revised by specialists in intensive care medicine. Through a network of national coordinators. The survey was distributed to a wide range of Nordic ICU physicians. The distribution started on January 5th, 2022 and ended on May 6th, 2022. Results We received a total of 1,066 responses from Denmark, Norway, Finland, Sweden, and Iceland. When assessing fluid status, respondents applied clinical parameters such as clinical examination findings, cumulative fluid balance, body weight, and urine output more frequently than cardiac/lung ultrasound, radiological appearances, and cardiac output monitoring. A large proportion of the respondents agreed that a 5% increase or more in body weight from baseline supported the diagnosis of fluid overload. The preferred de-resuscitation strategy was diuretics (91%), followed by minimization of maintenance (76%) and resuscitation fluids (71%). The majority declared that despite mild hypotension, mild hypernatremia, and ongoing vasopressor, they would not withhold treatment of fluid overload and would continue diuretics. The respondents were divided when it came to treating fluid overload with loop diuretics in patients receiving noradrenaline. Around 1% would not administer noradrenaline and diuretics simultaneously and 35% did not have a fixed upper limit for the dosage. The remaining respondents 63% reported different upper limits of noradrenaline infusion (0.05-0.50 mcg/kg/min) when administering loop diuretics. Conclusion Self-reported practices among Nordic ICU physicians when assessing, diagnosing, and treating fluid overload reveals variability in the practice. A 5% increase in body weight was considered a minimum to support the diagnosis of fluid overload. Clinical examination findings were preferred for assessing, diagnosing and treating fluid overload, and diuretics were the preferred treatment modality.
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Affiliation(s)
- Emilie Zeuthen
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Denmark,*Correspondence: Emilie Zeuthen,
| | - Sine Wichmann
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Denmark
| | - Martin Schønemann-Lund
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Denmark
| | - Mikko J. Järvisalo
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland,Kidney Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Rebecka Rubenson-Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden,Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Martin I. Sigurðsson
- Department of Anesthesia and Critical Care, Landspitali – The National University Hospital of Iceland, Reykjavík, Iceland,Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Erling Holen
- Department of Anesthesia and Intensive Care, Helse Stavanger University Hospital, Stavanger, Norway
| | - Morten H. Bestle
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Mohammad A, Karamat S, Majeed Y, Silvet H, Abramov D. Echo-Based Hemodynamics to Help Guide Care in Cardiogenic Shock: a Review. CURRENT CARDIOVASCULAR IMAGING REPORTS 2022. [DOI: 10.1007/s12410-022-09572-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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