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Using Transesophageal Echocardiography in Liver Transplantation with Veno-Venous Bypass Is a Tool with Many Applications: A Case Series from an Italian Transplant Center. J Cardiovasc Dev Dis 2023; 10:jcdd10010032. [PMID: 36661927 PMCID: PMC9866160 DOI: 10.3390/jcdd10010032] [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: 12/05/2022] [Revised: 12/30/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Hemodynamic instability (HDI) is common during liver transplantation (LT); veno-venous bypass (VVB) is a tool used in selected cases to ensure hemodynamic stability and for surgical needs. Transesophageal echocardiography (TEE) allows the transplant team to identify the causes of HDI and to guide therapies. We present a case series of four patients showing the valuable role of TEE during LT in VVB. METHODS We report four explicative cases of TEE use in LT with VVB performed at IRCCS Azienda Ospedaliero-Universitaria di Bologna. Four transplants were performed between 2016 and 2022. RESULTS Many authors have highlighted the diagnostic value of TEE during LT in the case of HDI. However, its specific role during LT with VVB is poorly described. This paper illustrates multiple potential uses of TEE in LT with VVB: TEE as a guide for catheterization and optimal cannula positioning, TEE as a tool for intraoperative Patent Foramen Ovale management, TEE as help for anticoagulation therapy and finally, TEE as support when evaluating bypass efficiency and correcting hypovolemia. CONCLUSION TEE is a useful instrument during LT with VVB. However, further studies are needed to assess the suitable applications of TEE during LT in patients with HDI requiring VVB. TEE should be part of the anesthetist's cultural background.
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Michels G, Horn R, Helfen A, Hagendorff A, Jung C, Hoffmann B, Jaspers N, Kinkel H, Greim CA, Knebel F, Bauersachs J, Busch HJ, Kiefl D, Spiel AO, Marx G, Dietrich CF. [Standardized contrast-enhanced ultrasound (CEUS) in clinical acute and emergency medicine and critical care (CEUS Acute) : Consensus statement of DGIIN, DIVI, DGINA, DGAI, DGK, ÖGUM, SGUM and DEGUM]. Med Klin Intensivmed Notfmed 2022; 117:1-23. [PMID: 35006320 DOI: 10.1007/s00063-021-00891-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The present document describes the possible applications of contrast-enhanced ultrasound (CEUS) in emergency examinations. Guidelines on contrast medium ultrasound in acute and emergency care and intensive care medicine have not yet been published. Evidence-based CEUS guidelines were first provided by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and the World Federation for Ultrasound in Medicine and Biology (WFUMB). The presented recommendations describe the possible applications and protocols of CEUS in acute care.
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Affiliation(s)
- Guido Michels
- Klinik für Akut- und Notfallmedizin, St.-Antonius-Hospital gGmbH, Eschweiler, Deutschland. .,Klinik für Akut- und Notfallmedizin, St.-Antonius-Hospital gGmbH, Akademisches Lehrkrankenhaus der RWTH Aachen, Dechant-Deckers-Str. 8, 52249, Eschweiler, Deutschland.
| | - Rudolf Horn
- Center da sandà Val Müstair, Notfallmedizin, Sta. Maria Val Müstair, Schweiz
| | - Andreas Helfen
- St.-Marien-Hospital Lünen, Medizinische Klinik I, Katholisches Klinikum Lünen Werne GmbH, Lünen, Deutschland
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Christian Jung
- Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Beatrice Hoffmann
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Natalie Jaspers
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Köln, Köln, Deutschland
| | - Horst Kinkel
- Praxis für Gastroenterologie, Düren, Deutschland
| | - Clemens-Alexander Greim
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Klinikum Fulda, Pacelliallee 4, 36043, Fulda, Deutschland
| | - Fabian Knebel
- Klinik für Innere Medizin, Sana Klinikum Lichtenberg, Berlin, Deutschland
| | - Johann Bauersachs
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Hans-Jörg Busch
- Universitätsklinikum, Universitäts-Notfallzentrum, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Daniel Kiefl
- Klinik für Interdisziplinäre Notfallmedizin, Sana Klinikum Offenbach, Offenbach am Main, Deutschland
| | - Alexander O Spiel
- Klinik Ottakring, Zentrale Notaufnahme, Wiener Gesundheitsverbund, Wien, Österreich
| | - Gernot Marx
- Klinik für operative Intensivmedizin, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Christoph F Dietrich
- Department für Allgemeine Innere Medizin Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Schweiz. .,Department Allgemeine Innere Medizin DAIM, Schänzlihalde 11, 3013, Bern, Schweiz.
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Intracardiac Right-to-Left Shunt Impeding Liberation From Veno-Venous Extracorporeal Membrane Oxygenation: Two Case Studies. Crit Care Med 2017; 44:e583-6. [PMID: 26807685 DOI: 10.1097/ccm.0000000000001619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Veno-venous extracorporeal membrane oxygenation is an increasingly used form of advanced respiratory support, but its effects on the physiology of the right heart are incompletely understood. We seek to illustrate the impact of veno-venous extracorporeal membrane oxygenation return blood flow upon the right atrium by considering the physiologic effects during interatrial shunting. PATIENTS Two veno-venous extracorporeal membrane oxygenation patients in whom an extracorporeal membrane oxygenation induced right-to-left interatrial shunt appears to have created a barrier to liberation from extracorporeal support. CONCLUSIONS Veno-venous extracorporeal membrane oxygenation return flow generates a high-pressure jet that has potential to exert focal pressure upon the intra-atrial septum. In patients with potential for interatrial flow, this may lead to a right-to-left shunt, which becomes physiologically apparent only when sweep gas flow is ceased.
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Lui JK, Banauch GI. Diagnostic Bedside Ultrasonography for Acute Respiratory Failure and Severe Hypoxemia in the Medical Intensive Care Unit: Basics and Comprehensive Approaches. J Intensive Care Med 2016; 32:355-372. [PMID: 27402396 DOI: 10.1177/0885066616658475] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Bedside goal-directed ultrasound is a powerful tool for rapid differential diagnosis and monitoring of cardiopulmonary disease in the critically ill patient population. The bedside intensivist is in a unique position to integrate ultrasound findings with the overall clinical situation. Medically critically ill patients who require urgent bedside diagnostic assessment fall into 2 categories: (1) acute respiratory failure and (2) hemodynamic derangements. The first portion of this review outlines the diagnostic role of bedside ultrasound in the medically critically ill patient population for the diagnosis and treatment of acute respiratory failure, acute respiratory distress, and severe hypoxemia. The second portion will focus on the diagnostic role of ultrasound for the evaluation and treatment of shock states, as well as describe protocolized approaches for evaluation of shock during cardiopulmonary resuscitation. Different respiratory system pathologies that result in acute respiratory failure (such as increased interstitial fluid, alveolar consolidation, pleural effusion) cause characteristic ultrasonographic findings; diaphragmatic assessment may also add information. Intracardiac shunting can cause severe hypoxemia. Protocolized approaches for the evaluation of patients with acute respiratory failure or distress are discussed.
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Affiliation(s)
- Justin K Lui
- 1 Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Gisela I Banauch
- 1 Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.,2 Division of Pulmonary Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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Prevalence and prognosis of shunting across patent foramen ovale during acute respiratory distress syndrome. Crit Care Med 2010; 38:1786-92. [PMID: 20601861 DOI: 10.1097/ccm.0b013e3181eaa9c8] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Right-to-left shunting across a patent foramen ovale may occur in acute respiratory distress syndrome as a result of pulmonary hypertension and positive-pressure mechanical ventilation. The shunt may worsen the hypoxemia. The objective of our study was to determine the prevalence, clinical implications, and prognosis of patent foramen ovale shunting during acute respiratory distress syndrome. DESIGN Prospective study. SETTING Medical intensive care unit of a university hospital in Créteil, France. PATIENTS Two hundred three consecutive patients with acute respiratory distress syndrome. INTERVENTIONS Patent foramen ovale shunting was detected by using transesophageal echocardiography with modified gelatin contrast. Moderate-to-large shunting was defined as right-to-left passage of at least 10 bubbles through a valve-like structure within three cardiac cycles after complete opacification of the right atrium. In 85 patients without and 31 with shunting, the influence of the positive end-expiratory pressure level on shunting was studied. MEASUREMENTS AND RESULTS The prevalence of moderate-to-large patent foramen ovale shunting was 19.2% (39 patients). Compared to those in the group without shunting, the patients in group with shunting had larger right ventricle dimensions, higher pulmonary artery systolic pressure, and a higher prevalence of cor pulmonale. Compared to patients without shunting, patients with shunting had a poorer Pa(O(2))/Fi(O(2)) ratio response to positive end-expiratory pressure, more often required prone positioning and nitric oxide as adjunctive interventions, and had fewer ventilator-free and intensive care unit-free days within the first 28 days. CONCLUSIONS Moderate-to-large patent foramen ovale shunting occurred in 19.2% of patients with acute respiratory distress syndrome, in keeping with findings from autopsy studies. Patent foramen ovale was associated with a poor oxygenation response to positive end-expiratory pressure, greater use of adjunctive interventions, and a longer intensive care unit stay.
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Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Groeneveld J, Hedenstierna G, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Metnitz P, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine, 2007. II. Haemodynamics, pneumonia, infections and sepsis, invasive and non-invasive mechanical ventilation, acute respiratory distress syndrome. Intensive Care Med 2008; 34:405-22. [PMID: 18236026 DOI: 10.1007/s00134-008-1009-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 01/07/2008] [Indexed: 01/14/2023]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anaesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168 Rome, Italy.
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