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Jozwiak M, Teboul JL. Heart-Lungs interactions: the basics and clinical implications. Ann Intensive Care 2024; 14:122. [PMID: 39133379 PMCID: PMC11319696 DOI: 10.1186/s13613-024-01356-5] [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: 05/02/2024] [Accepted: 07/24/2024] [Indexed: 08/13/2024] Open
Abstract
Heart-lungs interactions are related to the interplay between the cardiovascular and the respiratory system. They result from the respiratory-induced changes in intrathoracic pressure, which are transmitted to the cardiac cavities and to the changes in alveolar pressure, which may impact the lung microvessels. In spontaneously breathing patients, consequences of heart-lungs interactions are during inspiration an increase in right ventricular preload and afterload, a decrease in left ventricular preload and an increase in left ventricular afterload. In mechanically ventilated patients, consequences of heart-lungs interactions are during mechanical insufflation a decrease in right ventricular preload, an increase in right ventricular afterload, an increase in left ventricular preload and a decrease in left ventricular afterload. Physiologically and during normal breathing, heart-lungs interactions do not lead to significant hemodynamic consequences. Nevertheless, in some clinical settings such as acute exacerbation of chronic obstructive pulmonary disease, acute left heart failure or acute respiratory distress syndrome, heart-lungs interactions may lead to significant hemodynamic consequences. These are linked to complex pathophysiological mechanisms, including a marked inspiratory negativity of intrathoracic pressure, a marked inspiratory increase in transpulmonary pressure and an increase in intra-abdominal pressure. The most recent application of heart-lungs interactions is the prediction of fluid responsiveness in mechanically ventilated patients. The first test to be developed using heart-lungs interactions was the respiratory variation of pulse pressure. Subsequently, many other dynamic fluid responsiveness tests using heart-lungs interactions have been developed, such as the respiratory variations of pulse contour-based stroke volume or the respiratory variations of the inferior or superior vena cava diameters. All these tests share the same limitations, the most frequent being low tidal volume ventilation, persistent spontaneous breathing activity and cardiac arrhythmia. Nevertheless, when their main limitations are properly addressed, all these tests can help intensivists in the decision-making process regarding fluid administration and fluid removal in critically ill patients.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, CHU de Nice Hôpital Archet 1, 151 Route Saint Antoine de Ginestière, 06200, Nice, France.
- UR2CA, Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, 06200, Nice, France.
| | - Jean-Louis Teboul
- Faculté de Médecine Paris-Saclay, Université Paris-Saclay, 94270, Le Kremlin-Bicêtre, France
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Hariri G, Luxey X, Wenger S, Dureau P, Hariri S, Charfeddine A, Lebreton G, Djavidi N, Lancelot A, Duceau B, Bouglé A. Capillary refill time assessment after fluid challenge in patients on venoarterial extracorporeal membrane oxygenation: A retrospective study. J Crit Care 2024; 82:154770. [PMID: 38461658 DOI: 10.1016/j.jcrc.2024.154770] [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: 12/04/2023] [Revised: 01/29/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Monitoring fluid therapy is challenging in patients assisted with Veno-arterial ECMO. The aim of our study was to evaluate the usefulness of capillary refill time to assess the response to fluid challenge in patients assisted with VA-ECMO. METHODS Retrospective monocentric study in a cardiac surgery ICU. We assess fluid responsiveness after a fluid challenge in patients on VA-ECMO. We recorded capillary refill time before and after fluid challenge and the evolution of global hemodynamic parameters. RESULTS A total of 27 patients were included. The main indications for VA-ECMO were post-cardiotomy cardiogenic shock (44%). Thirteen patients (42%) were responders and 14 non-responders (58%). In the responder group, the index CRT decreased significantly (1.7 [1.5; 2.1] vs. 1.2 [1; 1.3] s; p = 0.01), whereas it remained stable in the non-responder group (1.4 [1.1; 2.5] vs. 1.6 [0.9; 1.9] s; p = 0.22). Diagnosis performance of CRT variation to assess response after fluid challenge shows an AUC of 0.68 (p = 0.10) with a sensitivity of 79% [95% CI, 52-92] and a specificity of 69% [95% CI, 42-87], with a threshold at 23%. CONCLUSION In patients treated with VA-ECMO index capillary refill time is a reliable tool to assesses fluid responsiveness. SPECIALTY Critical care, Cardiac surgery, ECMO.
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Affiliation(s)
- Geoffroy Hariri
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France; Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France..
| | - Xavier Luxey
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France
| | - Stefanie Wenger
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
| | - Pauline Dureau
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
| | - Sarah Hariri
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France
| | - Ahmed Charfeddine
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France
| | - Guillaume Lebreton
- Sorbonne Université, AP-HP, Service de Chirurgie Cardiaque, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
| | - Nima Djavidi
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
| | - Aymeric Lancelot
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
| | - Baptiste Duceau
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
| | - Adrien Bouglé
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU DREAM, Département d'anesthésie et réanimation, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Paris F-75013, France.
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Guedra Allais M, Humm K. Intravenous fluid therapy compared to no treatment following blood donation in cats: a randomised controlled. J Small Anim Pract 2024. [PMID: 38988057 DOI: 10.1111/jsap.13760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/18/2024] [Accepted: 05/27/2024] [Indexed: 07/12/2024]
Abstract
OBJECTIVES There is currently no consensus regarding the use of intravenous fluid therapy in feline patients post-blood donation in veterinary medicine. The primary aim of this study was to determine whether blood donation can be performed safely without post-donation intravenous fluid therapy. The secondary aim was to report owner-noted post-donation changes. MATERIALS AND METHODS The study aimed to enrol 100 conscious feline blood donations by client-owned cats performed at a veterinary teaching hospital. Donors were randomised to either receive intravenous compound sodium lactate (twice the volume of blood donated over 2 hours) immediately after blood donation, or to receive no post-blood donation intravenous fluid therapy. Systolic blood pressure was measured non-invasively at 0, 60 and 120 minutes post-donation. Median blood pressures were compared between the two groups using a Shapiro-Wilk test. Owners were called the day following the donation to collect information on changes in their cat post-donation. RESULTS One hundred cats were enrolled and the data of 97 cats were analysed; 46 who received intravenous fluid therapy and 51 who did not. Mean donation volume was 9.95 mL/kg for the intravenous fluid therapy group and 9.72 mL/kg for the non-intravenous fluid therapy group. At each time point, the median blood pressure did not differ significantly between the two groups. The main reported changes in both goups were bruising at the venepuncture site with 27.3% (12/44) in the IVFT group and 23.4% (9/37) in the no-IVFT group, and mild lethargy up to a maximum of 24 hours post donation with 11.4% (5/44) in the IVFT group and 18.9% (7/37) in the no-IVFT group. CLINICAL SIGNIFICANCE This study suggests that the use of intravenous fluid therapy post-feline blood donation may not be necessary. This could mean reduced hospitalisation time for feline donors, possibly decreasing feline stress.
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Affiliation(s)
- M Guedra Allais
- Department of Clinical Science and Services, Queen Mother Hospital for Animals, Royal Veterinary College, Hatfield, UK
| | - K Humm
- Department of Clinical Science and Services, Queen Mother Hospital for Animals, Royal Veterinary College, Hatfield, UK
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Huang W, Huang Y, Ke L, Hu C, Chen P, Hu B. Perspectives for capillary refill time in clinical practice for sepsis. Intensive Crit Care Nurs 2024; 84:103743. [PMID: 38896965 DOI: 10.1016/j.iccn.2024.103743] [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: 01/04/2024] [Revised: 05/11/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Capillary refill time (CRT) is defined as the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. Recent studies demonstrated the benefits of CRT in guiding fluid therapy for sepsis. However, lack of consistency among physicians in how to perform and interpret CRT has led to a low interobserver agreement for this assessment tool, which prevents its availability in sepsis clinical settings. OBJECTIVE To give physicians a concise overview of CRT and explore recent evidence on its reliability and value in the management of sepsis. RESEARCH DESIGN A narrative review. RESULTS This narrative review summarizes the factors affecting CRT values, for example, age, sex, temperature, light, observation techniques, work experience, training level and differences in CRT measurement methods. The methods of reducing the variability of CRT are synthesized. Based on studies with highly reproducible CRT measurements and an excellent inter-rater concordance, we recommend the standardized CRT assessment method. The threshold of normal CRT values is discussed. The application of CRT in different phases of sepsis management is summarized. CONCLUSIONS Recent data confirm the value of CRT in critically ill patients. CRT should be detected by trained physicians using standardized methods and reducing the effect of ambient-related factors. Its association with severe infection, microcirculation, tissue perfusion response, organ dysfunction and adverse outcomes makes this approach a very attractive tool in sepsis. Further studies should confirm its value in the management of sepsis. IMPLICATIONS FOR CLINICAL PRACTICE As a simple assessment, CRT deserves more attention even though it has not been widely applied at the bedside. CRT could provide nursing staff with patient's microcirculatory status, which may help to develop individualized nursing plans and improve the patient's care quality and treatment outcomes.
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Affiliation(s)
- Weipeng Huang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| | - Yiyan Huang
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China.
| | - Li Ke
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| | - Chang Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| | - Pengyu Chen
- Department of Urology, Shenzhen Children's Hospital, Futian District, Shenzhen 518000, Guangdong, China.
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
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Chun EH, Chung MH, Kim JE, Lee HS, Jo Y, Jun JH. Use of stepwise lung recruitment maneuver to predict fluid responsiveness under lung protective ventilation in the operating room. Sci Rep 2024; 14:11649. [PMID: 38773192 PMCID: PMC11109109 DOI: 10.1038/s41598-024-62355-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 05/16/2024] [Indexed: 05/23/2024] Open
Abstract
Recent research has revealed that hemodynamic changes caused by lung recruitment maneuvers (LRM) with continuous positive airway pressure can be used to identify fluid responders. We investigated the usefulness of stepwise LRM with increasing positive end-expiratory pressure and constant driving pressure for predicting fluid responsiveness in patients under lung protective ventilation (LPV). Forty-one patients under LPV were enrolled when PPV values were in a priori considered gray zone (4% to 17%). The FloTrac-Vigileo device measured stroke volume variation (SVV) and stroke volume (SV), while the patient monitor measured pulse pressure variation (PPV) before and at the end of stepwise LRM and before and 5 min after fluid challenge (6 ml/kg). Fluid responsiveness was defined as a ≥ 15% increase in the SV or SV index. Seventeen were fluid responders. The areas under the curve for the augmented values of PPV and SVV, as well as the decrease in SV by stepwise LRM to identify fluid responders, were 0.76 (95% confidence interval, 0.61-0.88), 0.78 (0.62-0.89), and 0.69 (0.53-0.82), respectively. The optimal cut-offs for the augmented values of PPV and SVV were > 18% and > 13%, respectively. Stepwise LRM -generated augmented PPV and SVV predicted fluid responsiveness under LPV.
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Affiliation(s)
- Eun Hee Chun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Mi Hwa Chung
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jung Eun Kim
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Youngbum Jo
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Joo Hyun Jun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
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Hotz E, van Gemmern T, Kriege M. Are We Always Right? Evaluation of the Performance and Knowledge of the Passive Leg Raise Test in Detecting Volume Responsiveness in Critical Care Patients: A National German Survey. J Clin Med 2024; 13:2518. [PMID: 38731046 PMCID: PMC11084342 DOI: 10.3390/jcm13092518] [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: 03/13/2024] [Revised: 04/22/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Background: In hemodynamically unstable patients, the passive leg raise (PLR) test is recommended for use as a self-fluid challenge for predicting preload responsiveness. However, to interpret the hemodynamic effects and reliability of the PLR, the method of performing it is of the utmost importance. Our aim was to determine the current practice of the correct application and interpretation of the PLR in intensive care patients. Methods: After ethical approval, we designed a cross-sectional online survey with a short user-friendly online questionnaire. Using a random sample of 1903 hospitals in Germany, 182 hospitals with different levels of care were invited via an email containing a link to the questionnaire. The online survey was conducted between December 2021 and January 2022. All critical care physicians from different medical disciplines were surveyed. We evaluated the correct points of concern for the PLR, including indication, contraindication, choice of initial position, how to interpret and apply the changes in cardiac output, and the limitations of the PLR. Results: A total of 292 respondents participated in the online survey, and 283/292 (97%) of the respondents completed the full survey. In addition, 132/283 (47%) were consultants and 119/283 (42%) worked at a university medical center. The question about the performance of the PLR was answered correctly by 72/283 (25%) of the participants. The limitations of the PLR, such as intra-abdominal hypertension, were correctly selected by 150/283 (53%) of the participants. The correct effect size (increase in stroke volume ≥ 10%) was correctly identified by 217/283 (77%) of the participants. Conclusions: Our results suggest a considerable disparity between the contemporary practice of the correct application and interpretation of the PLR and the practice recommendations from recently published data at German ICUs.
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Affiliation(s)
| | | | - Marc Kriege
- Department of Anaesthesiology, University Medical Centre, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (E.H.); (T.v.G.)
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care 2024; 40:1-37. [PMID: 38040992 PMCID: PMC10861627 DOI: 10.1007/s12028-023-01871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 12/03/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Affiliation(s)
| | | | - Edilberto Amorim
- San Francisco-Weill Institute for Neurosciences, University of California, San Francisco, USA
| | - Mary Kay Bader
- Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
| | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, USA
| | | | | | | | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK
- Royal United Hospital, Bath, UK
| | - Mauro Oddo
- CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | | | - Anezi Uzendu
- St. Luke's Mid America Heart Institute, Kansas City, USA
| | - Brian Walsh
- University of Texas Medical Branch School of Health Sciences, Galveston, USA
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024; 149:e168-e200. [PMID: 38014539 PMCID: PMC10775969 DOI: 10.1161/cir.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Fage N, Moretto F, Rosalba D, Shi R, Lai C, Teboul JL, Monnet X. Effect on capillary refill time of volume expansion and increase of the norepinephrine dose in patients with septic shock. Crit Care 2023; 27:429. [PMID: 37932812 PMCID: PMC10629142 DOI: 10.1186/s13054-023-04714-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Capillary refill time (CRT) has been suggested as a variable to follow during the course of septic shock. We systematically investigated the effects on CRT of volume expansion and norepinephrine. METHODS In 69 septic shock patients, we recorded mean arterial pressure (MAP), cardiac index (CI), and 5 consecutive CRT measurements (video method, standardized pressure applied on the fingertip) before and after a 500-mL saline infusion in 33 patients and before and after an increase of the norepinephrine dose in 36 different patients. Fluid responders were defined by an increase in CI ≥ 15%, and norepinephrine responders by an increase in MAP ≥ 15%. RESULTS The least significant change of CRT was 23%, so that changes in CRT were considered significant if larger than 23%. With volume expansion, CRT remained unchanged on average in patients with baseline CRT < 3 s (n = 7) and in all but one patient with baseline CRT ≥ 3 s in whom fluid increased CI < 15% (n = 13 "fluid non-responders"). In fluid responders with baseline CRT ≥ 3 s (n = 13), CRT decreased in 8 patients and remained unchanged in the others, exhibiting a dissociation between CI and CRT responses. The proportion of patients included > 24 h after starting norepinephrine was higher in patients with such a dissociation than in the other ones (60% vs. 0%, respectively). Norepinephrine did not change CRT significantly (except in one patient) if baseline CRT was ≥ 3 s and the increase in MAP < 15% (n = 6). In norepinephrine responders with prolonged baseline CRT (n = 11), it increased in 4 patients and remained unchanged in the other ones, which exhibited a dissociation between MAP and CRT responses. CONCLUSIONS In septic shock patients with prolonged CRT, CRT very rarely improves with treatment when volume expansion increases cardiac output < 15% and increasing norepinephrine increases MAP < 15%. When the effects of fluid infusion on cardiac output and of norepinephrine on MAP are significant, the response of CRT is variable, as it decreases in some patients and remains stable in others which exhibit a dissociation between changes in macrohemodynamic variables and in CRT. In this regard, CRT behaves as a marker of microcirculation. TRIAL REGISTRATION ClinicalTrial.gov (NCT04870892). Registered January15, 2021. Ethics committee approval CE SRLF 21-25.
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Affiliation(s)
- Nicolas Fage
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France.
- Department of Medical Intensive Care, University Hospital of Angers, Angers, France.
- MITOVASC Laboratory UMR INSERM (French National Institute of Health and Medical Research), 1083-CNRS 6015, University of Angers, Angers, France.
| | - Francesca Moretto
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
| | - Daniela Rosalba
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
| | - Rui Shi
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
| | - Christopher Lai
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
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Combet-Curt J, Pouzot-Nevoret C, Cambournac M, Magnin M, Nectoux A, Bonnet-Garin JM, Goy-Thollot I, Barthélemy A. Ultrasonographic measurement of caudal vena cava to aorta ratio during fluid resuscitation of dogs with spontaneous circulatory shock. J Small Anim Pract 2023; 64:669-679. [PMID: 37452675 DOI: 10.1111/jsap.13654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 06/07/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES To describe the change in the caudal vena cava to aorta ratio (CVC:Ao) ratio during fluid resuscitation of circulatory shock in dogs and compare these results with those of the physical examination and blood lactate. MATERIALS AND METHODS Perfusion parameters and blood lactate were recorded at admission. An abdominal point-of-care ultrasound protocol was performed, during which the caudal vena cava to aorta ratio was measured on the spleno-renal view. Measurements were performed within 5 minutes before and after a 10 mL/kg crystalloid fluid bolus. Investigators were not blinded to therapeutic interventions. RESULTS Twenty-nine dogs with physical signs of circulatory shock were enrolled. Caudal vena cava to aorta ratios were below reference interval in 28 of 29 dogs. After bolus administration, median caudal vena cava diameter increased by 0.14 cm (0.69 to 0.83 cm) and median aorta diameter increased by 0.03 cm (0.87 to 0.90 cm) and caudal vena cava to aorta ratio returned to within reference range in 65% of dogs (13/29). Bolus administration was associated with an increase in median caudal vena cava to aorta ratio of 0.10 (95% CI:0.05 to 0.16, P=0.0005). Blood lactate did not change significantly. Heart rate and capillary refill time decreased significantly after fluid bolus (heart rate: estimate=-19 bpm, 95% CI:-30 to -8, P=0.002; capillary refill time: estimate=-1.0 s, 95% CI:-1.3 to -0.7, P < 0.0001). CLINICAL SIGNIFICANCE In this population of dogs with circulatory shock, the caudal vena cava to aorta ratio significantly increased after a fluid bolus. Future studies that implement blinding of the outcome assessors are warranted to confirm these findings.
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Affiliation(s)
- J Combet-Curt
- Université de Lyon, Intensive care unit (SIAMU), VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
- Université de Lyon, UP 2021.A101 APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
| | - C Pouzot-Nevoret
- Université de Lyon, Intensive care unit (SIAMU), VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
- Université de Lyon, UP 2021.A101 APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
| | - M Cambournac
- Centre hospitalier vétérinaire Fregis, service d'Urgences, Réanimation et Soins-intensifs, 43, avenue Aristide Briand 94110 Arcueil, France
| | - M Magnin
- Université de Lyon, UP 2021.A101 APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
- Université de Lyon, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
| | - A Nectoux
- Université de Lyon, Intensive care unit (SIAMU), VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
- Université de Lyon, UP 2021.A101 APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
| | - J M Bonnet-Garin
- Université de Lyon, UP 2021.A101 APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
- Université de Lyon, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
| | - I Goy-Thollot
- Université de Lyon, Intensive care unit (SIAMU), VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
| | - A Barthélemy
- Université de Lyon, Intensive care unit (SIAMU), VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
- Université de Lyon, UP 2021.A101 APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
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11
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Gao Z, Li C, Chen H, Chen D, Ma S, Xie J, Wu C, Liu L, Yang Y. Association between diastolic blood pressure during the first 24 h and 28-day mortality in patients with septic shock: a retrospective observational study. Eur J Med Res 2023; 28:329. [PMID: 37689707 PMCID: PMC10492407 DOI: 10.1186/s40001-023-01315-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/25/2023] [Indexed: 09/11/2023] Open
Abstract
BACKGROUND Although the mean arterial pressure (MAP) target of 65 mmHg was achieved, diastolic blood pressure (DBP) was still low in some septic shock patients. The effects of DBP on the prognosis and optimal target for patients with septic shock are unclear. We sought to investigate the relationship between DBP and 28-day mortality in septic shock patients. METHODS In this retrospective observational study, we obtained data from the Chinese Database in Intensive Care (CDIC). We included patients with an admission diagnosis of septic shock and shock was controlled. DBP was measured every 1 h, and the mean DBP during the first 24 h (mDBP24h) was recorded. The primary outcome was 28-day mortality. Multivariable logistic regression determined the relationship between mDBP24h and 28-day mortality. RESULTS In total, 1251 patients were finally included. The 28-day mortality of included septic shock patients was 28.3%. The mDBP24h, not mSBP24h, was higher among 28-day survivors compared with non-survivors. 28-day mortality was inversely associated with mDBP24h (unadjusted OR 0.814 per 10 mmHg higher mDBP24h, P = 0.003), with a stepwise increase in 28-day mortality at lower mDBP24h. The 28-day mortality of patients with mDBP24h < 59 mmHg had an absolute risk reduction of 9.4% (P = 0.001). And mDBP24h < 59 mmHg was the remaining high risk factor inversely associated with 28-day mortality after multivariable adjustment (adjusted OR 1.915, 95% CI 1.037-3.536, P = 0.038), while mMAP24h and mSBP24h were not. CONCLUSION In patients with septic shock after initial resuscitation, we observed an inverse association between mDBP24h and 28-day mortality. The poor outcomes in patients with mDBP24h < 59 mmHg provide indirect evidence supporting a further DBP goal of 59 mmHg for patients with septic shock after MAP of 65 mmHg was achieved.
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Affiliation(s)
- Zhiwei Gao
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
- Department of Emergency Intensive Care Unit, The Affiliated Huaian NO. 1 People's Hospital of Nanjing Medical University, Huai'an, 223300, China
| | - Cong Li
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Dongyu Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - ShaoLei Ma
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Changde Wu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China.
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12
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Suh GJ, shin TG, Kwon WY, Kim K, Jo YH, Choi SH, Chung SP, Kim WY. Hemodynamic management of septic shock: beyond the Surviving Sepsis Campaign guidelines. Clin Exp Emerg Med 2023; 10:255-264. [PMID: 37439141 PMCID: PMC10579730 DOI: 10.15441/ceem.23.065] [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: 05/30/2023] [Revised: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 07/14/2023] Open
Abstract
Although the Surviving Sepsis Campaign guidelines provide standardized and generalized guidance, they are less individualized. This review focuses on recent updates in the hemodynamic management of septic shock. Monitoring and intervention for septic shock should be personalized according to the phase of shock. In the salvage phase, fluid resuscitation and vasopressors should be given to provide life-saving tissue perfusion. During the optimization phase, tissue perfusion should be optimized. In the stabilization and de-escalation phases, minimal fluid infusion and safe fluid removal should be performed, respectively, while preserving organ perfusion. There is controversy surrounding the use of restrictive versus liberal fluid strategies after initial resuscitation. Fluid administration after initial resuscitation should depend upon the patient's fluid responsiveness and requires individualized management. A number of dynamic tests have been proposed to monitor fluid responsiveness, which can help clinicians decide whether to give fluid or not. The optimal timing for the initiation of vasopressor agents is unknown. Recent data suggest that early vasopressor initiation should be considered. Inotropes can be considered in patients with decreased cardiac contractility associated with impaired tissue perfusion despite adequate volume status and arterial blood pressure. Venoarterial extracorporeal membrane oxygenation should be considered for refractory septic shock with severe cardiac systolic dysfunction.
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Affiliation(s)
- Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Tae Gun shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - You Hwan Jo
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - for the Korean Shock Society Investigators
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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13
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Shields AD, Plante LA, Pacheco LD, Louis JM. Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis. Am J Obstet Gynecol 2023; 229:B2-B19. [PMID: 37236495 DOI: 10.1016/j.ajog.2023.05.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Maternal sepsis is a significant cause of maternal morbidity and mortality, and is a potentially preventable cause of maternal death. This Consult aims to summarize what is known about sepsis and provide guidance for the management of sepsis during pregnancy and the postpartum period. Most studies cited are from the nonpregnant population, but where available, pregnancy data are included. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend that clinicians consider the diagnosis of sepsis in pregnant or postpartum patients with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever (GRADE 1C); (2) we recommend that sepsis and septic shock in pregnancy be considered medical emergencies and that treatment and resuscitation begin immediately (Best Practice); (3) we recommend that hospitals and health systems use a performance improvement program for sepsis in pregnancy with sepsis screening tools and metrics (GRADE 1B); (4) we recommend that institutions develop their own procedures and protocols for the detection of maternal sepsis, avoiding the use of a single screening tool alone (GRADE 1B); (5) we recommend obtaining tests to evaluate for infectious and noninfectious causes of life-threatening organ dysfunction in pregnant and postpartum patients with possible sepsis (Best Practice); (6) we recommend that an evaluation for infectious causes in pregnant or postpartum patients in whom sepsis is suspected or identified includes appropriate microbiologic cultures, including blood, before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics (Best Practice); (7) we recommend obtaining a serum lactate level in pregnant or postpartum patients in whom sepsis is suspected or identified (GRADE 1B); (8) in pregnant or postpartum patients with septic shock or a high likelihood of sepsis, we recommend administration of empiric broad-spectrum antimicrobial therapy, ideally within 1 hour of recognition (GRADE 1C); (9) after a diagnosis of sepsis in pregnancy is made, we recommend rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated (Best Practice); (10) we recommend early intravenous administration (within the first 3 hours) of 1 to 2 L of balanced crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (11) we recommend the use of a balanced crystalloid solution as a first-line fluid for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1B); (12) we recommend against the use of starches or gelatin for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1A); (13) we recommend ongoing, detailed evaluation of the patient's response to fluid resuscitation guided by dynamic measures of preload (GRADE 1B); (14) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period with septic shock (GRADE 1C); (15) we suggest using intravenous corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B); (16) because of an increased risk of venous thromboembolism in sepsis and septic shock, we recommend the use of pharmacologic venous thromboembolism prophylaxis in pregnant and postpartum patients in septic shock (GRADE 1B); (17) we suggest initiating insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis (GRADE 2C); (18) if a uterine source for sepsis is suspected or confirmed, we recommend prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age (GRADE 1C); and (19) because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, we recommend ongoing comprehensive support for pregnant and postpartum sepsis survivors and their families (Best Practice).
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14
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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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15
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Munroe ES, Hyzy RC, Semler MW, Shankar-Hari M, Young PJ, Zampieri FG, Prescott HC. Evolving Management Practices for Early Sepsis-induced Hypoperfusion: A Narrative Review. Am J Respir Crit Care Med 2023; 207:1283-1299. [PMID: 36812500 PMCID: PMC10595457 DOI: 10.1164/rccm.202209-1831ci] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/22/2023] [Indexed: 02/24/2023] Open
Abstract
Sepsis causes significant morbidity and mortality worldwide. Resuscitation is a cornerstone of management. This review covers five areas of evolving practice in the management of early sepsis-induced hypoperfusion: fluid resuscitation volume, timing of vasopressor initiation, resuscitation targets, route of vasopressor administration, and use of invasive blood pressure monitoring. For each topic, we review the seminal evidence, discuss the evolution of practice over time, and highlight questions for additional research. Intravenous fluids are a core component of early sepsis resuscitation. However, with growing concerns about the harms of fluid, practice is evolving toward smaller-volume resuscitation, which is often paired with earlier vasopressor initiation. Large trials of fluid-restrictive, vasopressor-early strategies are providing more information about the safety and potential benefit of these approaches. Lowering blood pressure targets is a means to prevent fluid overload and reduce exposure to vasopressors; mean arterial pressure targets of 60-65 mm Hg appear to be safe, at least in older patients. With the trend toward earlier vasopressor initiation, the need for central administration of vasopressors has been questioned, and peripheral vasopressor use is increasing, although it is not universally accepted. Similarly, although guidelines suggest the use of invasive blood pressure monitoring with arterial catheters in patients receiving vasopressors, blood pressure cuffs are less invasive and often sufficient. Overall, the management of early sepsis-induced hypoperfusion is evolving toward fluid-sparing and less-invasive strategies. However, many questions remain, and additional data are needed to further optimize our approach to resuscitation.
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Affiliation(s)
- Elizabeth S. Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Robert C. Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Manu Shankar-Hari
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, United Kingdom
- Department of Intensive Care Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Paul J. Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Fernando G. Zampieri
- Hospital do Coração (HCor) Research Institute, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; and
| | - Hallie C. Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan
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16
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Karlsson J, Hallbäck M, Svedmyr A, Lönnqvist PA, Wallin M. Standardized blood volume changes monitored by capnodynamic hemodynamic variables: An experimental comparative study in pigs. Acta Anaesthesiol Scand 2023. [PMID: 37184945 DOI: 10.1111/aas.14253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/15/2023] [Accepted: 04/11/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND The capnodynamic method, based on Volumetric capnography and differential Fick mathematics, assess cardiac output in mechanically ventilated subjects. Capnodynamic and established hemodynamic monitoring parameters' capability to depict alterations in blood volume were investigated in a model of standardized hemorrhage, followed by crystalloid and blood transfusion. METHODS Ten anesthetized piglets were subjected to controlled hemorrhage (450 mL), followed by isovolemic crystalloid bolus and blood re-transfusion. Intravascular blood volume, and all hemodynamic variables, were determined twice after each intervention. The investigated hemodynamic variables were: cardiac output and stroke volume for capnodynamics and pulse contour analysis, respectively, pulse pressure and stroke volume variability and mean arterial pressure. One-way ANOVA and Tukey's test for multiple comparisons were used to identify significant changes. Trending was assessed by correlation and concordance. RESULT Concordance against intravascular volume changes for capnodynamic cardiac output and stroke volume were 96 and 94%, with correlations r = .78 and .68, (p < .0001) with significant changes for 6 and 5 of the 6 measuring points, respectively. Mean arterial pressure and pulse pressure variation had a concordance of 85% and 87%, r = .67 (p < .0001) and r = -.45 (p < .0001), respectively, and both changed significantly for 3 of 6 measuring points. Pulse contour stroke volume variation, stroke volume and cardiac output, showed concordance and correlation of 76%, r = -.18 (p = .11), 63%, r = .28 (p = .01) and 50%, r = .31 (p = .007), respectively and significant change for 1, 1 and 0 of the measuring points, respectively. CONCLUSION Capnodynamic cardiac output and stroke volume did best depict the changes in intravascular blood volume. Pulse contour parameters did not follow volume changes in a reliable way.
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Affiliation(s)
- Jacob Karlsson
- Department of Paediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology (Fysiologi och Farmakologi [FYFA]), Karolinska Institute, Stockholm, Sweden
| | | | - Anders Svedmyr
- Department of Paediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology (Fysiologi och Farmakologi [FYFA]), Karolinska Institute, Stockholm, Sweden
| | - Per-Arne Lönnqvist
- Department of Paediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology (Fysiologi och Farmakologi [FYFA]), Karolinska Institute, Stockholm, Sweden
| | - Mats Wallin
- Department of Physiology and Pharmacology (Fysiologi och Farmakologi [FYFA]), Karolinska Institute, Stockholm, Sweden
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17
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Huang H, Hu C, Fu Y, Han Z, Cao M, Fu G. THE EFFECTS OF EARLY-PHASE FUROSEMIDE USE ON THE PROGRESSION OF OLIGURIC ACUTE KIDNEY INJURY ACROSS DIFFERENT CENTRAL VENOUS PRESSURE: A RETROSPECTIVE ANALYSIS. Shock 2023; 59:49-57. [PMID: 36377392 DOI: 10.1097/shk.0000000000002045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
ABSTRACT Background: Furosemide is a commonly used loop diuretic in critical care. However, its effect on the progression of oliguric acute kidney injury across different central venous pressure (CVP) remains unknown. This study therefore aims to investigate the association between furosemide 6-12h (defined as the use of furosemide within 6 h after the diagnosis of AKI according to the urine output [UO] criteria set by the Kidney Disease: Improving Global Outcomes [KDIGO] guidelines) and the progression of AKI across different CVP 6-12h (defined as CVP within 6 h after the diagnosis of AKI by the KDIGO UO criteria) levels. Methods: Patients involved in this study were identified from the Medical Information Mart for Intensive Care IV database with the following criteria: (i) adults with UO <0.5 mL/kg per hour for the first 6 h upon admission to the intensive care unit (ICU) (meeting stage 1 AKI by UO) and (ii) CVP 6-12h ranging from 0 to 30 mm Hg. From there on, the target primary outcome would be progression to stage 3 AKI by UO among these chosen patients. The secondary outcome was 28-d mortality since ICU admission. The risks of severe-stage AKI progression and 28-d mortality were respectively examined against furosemide 6-12h (vs. without furosemide 6-12h ) within the full cohort and across different subgroups of CVP 6-12h , using multivariate adjusted logistic regression and inverse probability treatment weighting (IPTW). Sensitivity analyses were performed to assess the robustness of our findings. Results: One thousand one hundred eighty patients were ultimately selected for this study, of whom 643 (54.5%) progressed to stage 3 AKI from stage 1 based on the UO criteria by KDIGO. Multivariate analysis showed that furosemide 6-12h is significantly associated with this severe-stage progression within the full cohort (odds ratio [OR] was 0.62 at 95% confidence interval [CI] of 0.43-0.90, P = 0.011). After dividing the patients into CVP 6-12h subgroups according to their CVP during the early phases, lower risk of AKI progression was observed only in furosemide 6-12h application at CVP 6-12h of ≥12 mm Hg (adjusted OR was 0.40 at 95% CI of 0.25-0.65, P < 0.001), as confirmed by the IPTW analysis (OR was 0.47 at 95% CI of 0.29-0.76, P = 0.002). The robustness of these findings was confirmed by sensitivity analyses. In addition, for patients with CVP 6-12h ≥12 mm Hg, furosemide 6-12h is also significantly associated with lower risk of 28-d mortality (adjusted OR was 0.47 at 95% CI of 0.25-0.92, P = 0.026) in the multivariate logistic regression analysis, and there was a similar trend in the IPTW analysis (adjusted OR was 0.55 at 95% CI of 0.28-1.10, P = 0.092). Conclusions: Among the identified early-stage AKI patients in critical care, the use of furosemide was associated only with lower risk of oliguric AKI progression and 28-d mortality within the high CVP group. These findings suggest the potential of CVP as a guidance or reference point in the usage of furosemide among early-stage oliguric AKI patients in the ICU.
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Affiliation(s)
- Haoquan Huang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Cavaliere F, Biancofiore G, Bignami E, DE Robertis E, Giannini A, Grasso S, McCREDIE VA, Piastra M, Scolletta S, Taccone FS, Terragni P. A year in review in Minerva Anestesiologica 2022: critical care. Minerva Anestesiol 2023; 89:115-124. [PMID: 36745125 DOI: 10.23736/s0375-9393.22.17211-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Franco Cavaliere
- IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Gianni Biancofiore
- Department of Transplant Anesthesia and Critical Care, University School of Medicine, Pisa, Italy
| | - Elena Bignami
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Edoardo DE Robertis
- Section of Anesthesia, Analgesia and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, Children's Hospital - ASST Spedali Civili di Brescia, Brescia, Italy
| | - Salvatore Grasso
- Section of Anesthesiology and Intensive Care, Department of Emergency and Organ Transplantation, Polyclinic Hospital, Aldo Moro University, Bari, Italy
| | - Victoria A McCREDIE
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Marco Piastra
- Unit of Pediatric Intensive Care and Trauma Center, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Sabino Scolletta
- Department of Emergency-Urgency and Organ Transplantation, Anesthesia and Intensive Care, University Hospital of Siena, Siena, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Pierpaolo Terragni
- Division of Anesthesia and General Intensive Care, Department of Medical, Surgical and Experimental Sciences, University Hospital of Sassari, University of Sassari, Sassari, Italy
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De Backer D, Cecconi M, Chew MS, Hajjar L, Monnet X, Ospina-Tascón GA, Ostermann M, Pinsky MR, Vincent JL. A plea for personalization of the hemodynamic management of septic shock. Crit Care 2022; 26:372. [PMID: 36457089 PMCID: PMC9714237 DOI: 10.1186/s13054-022-04255-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/25/2022] [Indexed: 12/02/2022] Open
Abstract
Although guidelines provide excellent expert guidance for managing patients with septic shock, they leave room for personalization according to patients' condition. Hemodynamic monitoring depends on the evolution phase: salvage, optimization, stabilization, and de-escalation. Initially during the salvage phase, monitoring to identify shock etiology and severity should include arterial pressure and lactate measurements together with clinical examination, particularly skin mottling and capillary refill time. Low diastolic blood pressure may trigger vasopressor initiation. At this stage, echocardiography may be useful to identify significant cardiac dysfunction. During the optimization phase, echocardiographic monitoring should be pursued and completed by the assessment of tissue perfusion through central or mixed-venous oxygen saturation, lactate, and carbon dioxide veno-arterial gradient. Transpulmonary thermodilution and the pulmonary artery catheter should be considered in the most severe patients. Fluid therapy also depends on shock phases. While administered liberally during the resuscitation phase, fluid responsiveness should be assessed during the optimization phase. During stabilization, fluid infusion should be minimized. In the de-escalation phase, safe fluid withdrawal could be achieved by ensuring tissue perfusion is preserved. Norepinephrine is recommended as first-line vasopressor therapy, while vasopressin may be preferred in some patients. Essential questions remain regarding optimal vasopressor selection, combination therapy, and the most effective and safest escalation. Serum renin and the angiotensin I/II ratio may identify patients who benefit most from angiotensin II. The optimal therapeutic strategy for shock requiring high-dose vasopressors is scant. In all cases, vasopressor therapy should be individualized, based on clinical evaluation and blood flow measurements to avoid excessive vasoconstriction. Inotropes should be considered in patients with decreased cardiac contractility associated with impaired tissue perfusion. Based on pharmacologic properties, we suggest as the first test a limited dose of dobutamine, to add enoximone or milrinone in the second line and substitute or add levosimendan if inefficient. Regarding adjunctive therapies, while hydrocortisone is nowadays advised in patients receiving high doses of vasopressors, patients responding to corticosteroids may be identified in the future by the analysis of selected cytokines or specific transcriptomic endotypes. To conclude, although some general rules apply for shock management, a personalized approach should be considered for hemodynamic monitoring and support.
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Affiliation(s)
- Daniel De Backer
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Boulevard du Triomphe 201, 1160 Brussels, Belgium
| | - Maurizio Cecconi
- grid.417728.f0000 0004 1756 8807Humanitas Clinical and Research Center – IRCCS, Rozzano, MI Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI Italy
| | - Michelle S. Chew
- grid.5640.70000 0001 2162 9922Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ludhmila Hajjar
- grid.11899.380000 0004 1937 0722Departamento de Cardiopneumologia, InCor, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Xavier Monnet
- grid.460789.40000 0004 4910 6535AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Gustavo A. Ospina-Tascón
- grid.477264.4Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia ,grid.440787.80000 0000 9702 069XTranslational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Marlies Ostermann
- grid.420545.20000 0004 0489 3985Department of Intensive Care, King’s College London, Guy’s & St Thomas’ Hospital, London, UK
| | - Michael R. Pinsky
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Dept of Intensive Care, Erasme Univ Hospital, Université Libre de Bruxelles, Brussels, Belgium
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20
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Shi R, Ayed S, Moretto F, Azzolina D, De Vita N, Gavelli F, Carelli S, Pavot A, Lai C, Monnet X, Teboul JL. Tidal volume challenge to predict preload responsiveness in patients with acute respiratory distress syndrome under prone position. Crit Care 2022; 26:219. [PMID: 35850771 PMCID: PMC9294836 DOI: 10.1186/s13054-022-04087-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Prone position is frequently used in patients with acute respiratory distress syndrome (ARDS), especially during the Coronavirus disease 2019 pandemic. Our study investigated the ability of pulse pressure variation (PPV) and its changes during a tidal volume challenge (TVC) to assess preload responsiveness in ARDS patients under prone position.
Methods
This was a prospective study conducted in a 25-bed intensive care unit at a university hospital. We included patients with ARDS under prone position, ventilated with 6 mL/kg tidal volume and monitored by a transpulmonary thermodilution device. We measured PPV and its changes during a TVC (ΔPPV TVC6–8) after increasing the tidal volume from 6 to 8 mL/kg for one minute. Changes in cardiac index (CI) during a Trendelenburg maneuver (ΔCITREND) and during end-expiratory occlusion (EEO) at 8 mL/kg tidal volume (ΔCI EEO8) were recorded. Preload responsiveness was defined by both ΔCITREND ≥ 8% and ΔCI EEO8 ≥ 5%. Preload unresponsiveness was defined by both ΔCITREND < 8% and ΔCI EEO8 < 5%.
Results
Eighty-four sets of measurements were analyzed in 58 patients. Before prone positioning, the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen was 104 ± 27 mmHg. At the inclusion time, patients were under prone position for 11 (2–14) hours. Norepinephrine was administered in 83% of cases with a dose of 0.25 (0.15–0.42) µg/kg/min. The positive end-expiratory pressure was 14 (11–16) cmH2O. The driving pressure was 12 (10–17) cmH2O, and the respiratory system compliance was 32 (22–40) mL/cmH2O. Preload responsiveness was detected in 42 cases. An absolute change in PPV ≥ 3.5% during a TVC assessed preload responsiveness with an area under the receiver operating characteristics (AUROC) curve of 0.94 ± 0.03 (sensitivity: 98%, specificity: 86%) better than that of baseline PPV (0.85 ± 0.05; p = 0.047). In the 56 cases where baseline PPV was inconclusive (≥ 4% and < 11%), ΔPPV TVC6–8 ≥ 3.5% still enabled to reliably assess preload responsiveness (AUROC: 0.91 ± 0.05, sensitivity: 97%, specificity: 81%; p < 0.01 vs. baseline PPV).
Conclusion
In patients with ARDS under low tidal volume ventilation during prone position, the changes in PPV during a TVC can reliably assess preload responsiveness without the need for cardiac output measurements.
Trial registration: ClinicalTrials.gov (NCT04457739). Registered 30 June 2020 —Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04457739
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21
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Clinical presentation and outcomes of acute heart failure in the critically ill patient: A prospective, observational, multicentre study. MEDICINA INTENSIVA (ENGLISH EDITION) 2022; 47:221-231. [PMID: 36272910 DOI: 10.1016/j.medine.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/03/2022] [Indexed: 11/06/2022]
Abstract
AIMS To assess the clinical profile and factors associated with 30-day mortality in patients with acute heart failure (AHF) admitted to the intensive care unit (ICU). DESIGN Prospective, multicentre cohort study. SCOPE Thirty-two Spanish ICUs. PATIENTS Adult patients admitted to the ICU between April and June 2017. INTERVENTION Patients were classified into three groups according to AHF status: without AHF (no AHF); AHF as the primary reason for ICU admission (primary AHF); and AHF developed during the ICU stay (secondary AHF). MAIN VARIABLES OF INTEREST Incidence of AHF and 30-day mortality. RESULTS A total of 4330 patients were included. Of these, 627 patients (14.5%) had primary (n=319; 7.4%) or secondary (n=308; 7.1%) AHF. Among the main precipitating factors, fluid overload was more common in the secondary AHF group than in the primary group (12.9% vs 23.4%, p<0.001). Patients with AHF had a higher risk of 30-day mortality than those without AHF (OR 2.45; 95% CI: 1.93-3.11). APACHE II, cardiogenic shock, left ventricular ejection fraction, early inotropic therapy, and diagnostic delay were independently associated with 30-day mortality in AHF patients. Diagnostic delay was associated with a significant increase in 30-day mortality in the secondary group (OR 6.82; 95% CI 3.31-14.04). CONCLUSIONS The incidence of primary and secondary AHF was similar in this cohort of ICU patients. The risk of developing AHF in ICU patients can be reduced by avoiding modifiable precipitating factors, particularly fluid overload. Diagnostic delay was associated with significantly higher mortality rates in patients with secondary AHF.
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22
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Hultman TM, Boysen SR, Owen R, Yozova ID. Ultrasonographically derived caudal vena cava parameters acquired in a standing position and lateral recumbency in healthy, lightly sedated cats: a pilot study. J Feline Med Surg 2022; 24:1039-1045. [PMID: 34904481 PMCID: PMC10812311 DOI: 10.1177/1098612x211064697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES The aim of this study was to determine the feasibility of ultrasonographically measuring the caudal vena cava (CVC) at the subxiphoid view of healthy, lightly sedated cats in a standing position and lateral recumbency. METHODS This was a prospective, observational, experimental single-centre study. Twenty healthy research-purposed cats were enrolled. Two trained operators scanned each cat in two positions - standing and lateral recumbency - in a randomised order. CVC diameter was measured at the narrowest diameter during inspiration and at the widest diameter during expiration, at two anatomical locations along the CVC - where the CVC crosses the diaphragm (base) and 2 mm caudal to the diaphragm. The CVC collapsibility index (CVC-CI) was calculated for each site. Normalcy was assessed with a Shapiro-Wilk test. A one-way ANOVA with post-hoc Tukey's test was used to compare inspiratory with expiratory values within and between groups. A paired t-test compared the CVC-CI between groups (P ⩽0.05 indicated statistical significance). Spearman's correlation and Bland-Altman analysis assessed inter-operator variability. RESULTS All ultrasonographic data passed normalcy and were reported as mean ± SD. When compared with each other, inspiratory and expiratory values were statistically different for position, location and operator (all P <0.0001). There was no statistically significant difference between lateral recumbency or standing position for inspiratory, expiratory and CVC-CI values. Inter-operator variability was substantial, with operator 2 consistently obtaining smaller measurements than operator 1. The mean CVC-CI in lateral recumbency at the base was 24% for operator 1 and 37% for operator 2. For the same site in standing position, CVC-CI was 27% and 41% for operators 1 and 2, respectively. CONCLUSIONS AND RELEVANCE This pilot study demonstrates that it is possible to ultrasonographically measure the CVC diameter in both lateral recumbency and a standing position in healthy, lightly sedated cats. However, measurements obtained are operator dependent with variability between individuals. Further studies are needed to determine if ultrasonographic CVC assessment will prove helpful in estimating intravascular volume status in cats.
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Affiliation(s)
- Tove M Hultman
- Veterinary Teaching Hospital, School of Veterinary Science, Massey University, Palmerston North, New Zealand
| | - Søren R Boysen
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Rebecca Owen
- Veterinary Teaching Hospital, School of Veterinary Science, Massey University, Palmerston North, New Zealand
| | - Ivayla D Yozova
- Veterinary Teaching Hospital, School of Veterinary Science, Massey University, Palmerston North, New Zealand
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23
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Mallat J, Fischer MO, Granier M, Vinsonneau C, Jonard M, Mahjoub Y, Baghdadi FA, Préau S, Poher F, Rebet O, Bouhemad B, Lemyze M, Marzouk M, Besnier E, Hamed F, Rahman N, Abou-Arab O, Guinot PG. Passive leg raising-induced changes in pulse pressure variation to assess fluid responsiveness in mechanically ventilated patients: a multicentre prospective observational study. Br J Anaesth 2022; 129:308-316. [PMID: 35842352 DOI: 10.1016/j.bja.2022.04.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/15/2022] [Accepted: 04/17/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Passive leg raising-induced changes in cardiac index can be used to predict fluid responsiveness. We investigated whether passive leg raising-induced changes in pulse pressure variation (ΔPPVPLR) can also predict fluid responsiveness in mechanically ventilated patients. METHODS In this multicentre prospective observational study, we included 270 critically ill patients on mechanical ventilation in whom volume expansion was indicated because of acute circulatory failure. We did not include patients with cardiac arrythmias. Cardiac index and PPV were measured before/during a passive leg raising test and before/after volume expansion. A volume expansion-induced increase in cardiac index of >15% defined fluid responsiveness. To investigate whether ΔPPVPLR can predict fluid responsiveness, we determined areas under the receiver operating characteristic curves (AUROCs) and grey zones for relative and absolute ΔPPVPLR. RESULTS Of the 270 patients, 238 (88%) were on controlled mechanical ventilation with no spontaneous breathing activity and 32 (12%) were on pressure support ventilation. The median tidal volume was 7.1 (inter-quartile range [IQR], 6.6-7.6) ml kg-1 ideal body weight. One hundred sixty-four patients (61%) were fluid responders. Relative and absolute ΔPPVPLR predicted fluid responsiveness with an AUROC of 0.92 (95% confidence interval [95% CI], 0.88-0.95; P<0.001) each. The grey zone for relative and absolute ΔPPVPLR included 4.8% and 22.6% of patients, respectively. These results were not affected by ventilatory mode and baseline characteristics (type of shock, centre, vasoactive treatment). CONCLUSIONS Passive leg raising-induced changes in pulse pressure variation accurately predict fluid responsiveness with a small grey zone in critically ill patients on mechanical ventilation. CLINICAL TRIAL REGISTRATION NCT03225378.
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Affiliation(s)
- Jihad Mallat
- Department of Critical Care Medicine, Arras Hospital, Arras, France; Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Normandy University, UNICAEN, Ecole Doctorale NBISE 497, Caen, France.
| | - Marc-Olivier Fischer
- Normandy University, UNICAEN, CHU de Caen Normandie, Ecole Doctorale NBISE 497, Service d'Anesthésie Réanimation, Caen, France
| | - Maxime Granier
- Department of Critical Care Medicine, Arras Hospital, Arras, France
| | | | - Marie Jonard
- Department of Critical Care Medicine, Amiens University Medical Centre, Amiens, France
| | - Yazine Mahjoub
- Cardiac Vascular Thoracic and Respiratory Intensive Care Unit, Department of Anesthesia and Intensive Care, Amiens University Medical Centre, Amiens, France
| | - Fawzi Ali Baghdadi
- Department of Critical Care Medicine, Intensive Care Unit, Centre Hospitalier de Cambrai, Cambrai, France
| | - Sébastien Préau
- Division of Intensive Care, Inserm, Institut Pasteur de Lille, U1167, University of Lille, CHU Lille, Lille, France
| | - Fabien Poher
- Intensive Care Unit, Centre Hospitalier de Boulogne Sur Mer, Boulogne Sur Mer, France
| | - Olivier Rebet
- Cardiac Vascular Intensive Care Unit, Schaffner Hospital, Lens, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Malcolm Lemyze
- Department of Critical Care Medicine, Arras Hospital, Arras, France
| | - Mehdi Marzouk
- Intensive Care Unit, Hôpital de Béthune, Beuvry, France
| | - Emmanuel Besnier
- Department of Anesthesiology and Critical Care, Rouen University Hospital, Rouen, France
| | - Fadi Hamed
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Nadeem Rahman
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Osama Abou-Arab
- Anesthesia and Critical Care department, Amiens Hospital University, Amiens, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, Dijon, France
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24
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Zapata L, Guía C, Gómez R, García-Paredes T, Colinas L, Portugal-Rodriguez E, Rodado I, Leache I, Fernández-Ferreira A, Hermosilla-Semikina I, Roche-Campo F. Clinical presentation and outcomes of acute heart failure in the critically ill patient: A prospective, observational, multicentre study. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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25
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Rali AS, Butcher A, Tedford RJ, Sinha SS, Mekki P, Van Spall HGC, Sauer AJ. Contemporary Review of Hemodynamic Monitoring in the Critical Care Setting. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hemodynamic assessment remains the most valuable adjunct to physical examination and laboratory assessment in the diagnosis and management of shock. Through the years, multiple modalities to measure and trend hemodynamic indices have evolved with varying degrees of invasiveness. Pulmonary artery catheter (PAC) has long been considered the gold standard of hemodynamic assessment in critically ill patients and in recent years has been shown to improve clinical outcomes among patients in cardiogenic shock. The invasive nature of PAC is often cited as its major limitation and has encouraged development of less invasive technologies. In this review, the authors summarize the literature on the mechanism and validation of several minimally invasive and noninvasive modalities available in the contemporary intensive care unit. They also provide an update on the use of focused bedside echocardiography.
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Amy Butcher
- Department of Cardiovascular Anesthesia and Critical Care, Baylor College of Medicine, Houston, TX
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Shashank S Sinha
- Division of Cardiology, Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | - Pakinam Mekki
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Harriette GC Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Andrew J Sauer
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS
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Mallat J, Rahman N, Hamed F, Hernandez G, Fischer MO. Pathophysiology, mechanisms, and managements of tissue hypoxia. Anaesth Crit Care Pain Med 2022; 41:101087. [PMID: 35462083 DOI: 10.1016/j.accpm.2022.101087] [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: 12/29/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 11/01/2022]
Abstract
Oxygen is needed to generate aerobic adenosine triphosphate and energy that is required to support vital cellular functions. Oxygen delivery (DO2) to the tissues is determined by convective and diffusive processes. The ability of the body to adjust oxygen extraction (ERO2) in response to changes in DO2 is crucial to maintain constant tissue oxygen consumption (VO2). The capability to increase ERO2 is the result of the regulation of the circulation and the effects of the simultaneous activation of both central and local factors. The endothelium plays a crucial role in matching tissue oxygen supply to demand in situations of acute drop in tissue oxygenation. Tissue oxygenation is adequate when tissue oxygen demand is met. When DO2 is severely compromised, a critical DO2 value is reached below which VO2 falls and becomes dependent on DO2, resulting in tissue hypoxia. The different mechanisms of tissue hypoxia are circulatory, anaemic, and hypoxic, characterised by a diminished DO2 but preserved capacity of increasing ERO2. Cytopathic hypoxia is another mechanism of tissue hypoxia that is due to impairment in mitochondrial respiration that can be observed in septic conditions with normal overall DO2. Sepsis induces microcirculatory alterations with decreased functional capillary density, increased number of stopped-flow capillaries, and marked heterogeneity between the areas with large intercapillary distance, resulting in impairment of the tissue to extract oxygen and to satisfy the increased tissue oxygen demand, leading to the development of tissue hypoxia. Different therapeutic approaches exist to increase DO2 and improve microcirculation, such as fluid therapy, transfusion, vasopressors, inotropes, and vasodilators. However, the effects of these agents on microcirculation are quite variable.
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Affiliation(s)
- Jihad Mallat
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Normandy University, UNICAEN, ED 497, Caen, France.
| | - Nadeem Rahman
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Fadi Hamed
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontifcia Universidad Católica de Chile, Santiago, Chile
| | - Marc-Olivier Fischer
- Department of Anaesthesiology-Resuscitation and Perioperative Medicine, Normandy University, UNICAEN, Caen University Hospital, Normandy, Caen, France
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27
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Del Río-Carbajo L, Nieto-Del Olmo J, Fernández-Ugidos P, Vidal-Cortés P. [Resuscitation strategy for patients with sepsis and septic shock]. Med Intensiva 2022; 46 Suppl 1:60-71. [PMID: 38341261 DOI: 10.1016/j.medine.2022.02.025] [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: 01/07/2022] [Accepted: 02/11/2022] [Indexed: 02/12/2024]
Abstract
Fluid and vasopressor resuscitation is, along with antimicrobial therapy and control of the focus of infection, a basic issue of the treatment of sepsis and septic shock. There is currently no accepted protocol that we can follow for the resuscitation of these patients and the Surviving Sepsis Campaign proposes controversial measures and without sufficient evidence support to establish firm recommendations. We propose a resuscitation strategy adapted to the situation of each patient: in the patient in whom community sepsis is suspected, we consider that the early administration of 30mL/kg of crystalloids is effective and safe; in the patient with nosocomial sepsis, we must carry out a more in-depth evaluation before initiating aggressive resuscitation. In patients who do not respond to initial resuscitation, it is necessary to increase monitoring level and, depending on the hemodynamic profile, administer more fluids, a second vasopressor or inotropes.
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Affiliation(s)
- L Del Río-Carbajo
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense. Ourense, España
| | - J Nieto-Del Olmo
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense. Ourense, España
| | - P Fernández-Ugidos
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense. Ourense, España
| | - P Vidal-Cortés
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense. Ourense, España.
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28
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Gillespie J, Hansen M, Samatham R, Baker SD, Filer S, Sheridan DC. Capillary Refill Technology to Enhance the Accuracy of Peripheral Perfusion Evaluation in Sepsis. J Intensive Care Med 2022; 37:1159-1164. [DOI: 10.1177/08850666221087685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Monitoring of capillary refill time (CRT) is a common bedside assessment used to ascertain peripheral perfusion in a patient for a vast array of conditions. The literature has shown that a change in CRT can be used to recognize life-threatening conditions that cause decreased perfusion, such as sepsis, and aid in resuscitation. The current practice for calculating CRT invites subjectivity and produces a highly variable result. Innovative technology may be able to standardize this process and provide a reliable and accurate value for use in diagnostics and treatment. This study aimed to assess a new technology (DCR by ProMedix Inc.) for rapid, bedside, and noninvasive detection of CRT. Methods: This was a secondary analysis of a prospective observational study evaluating the accuracy of new technology towards CRT-guided diagnosis of sepsis. It was carried out in the adult emergency departments (ED) of an academic tertiary care medical center. Patients seeking care in the ED were determined eligible if they were > 18 years in age and exhibited chief complaints suggestive of possible sepsis. The CRT produced by the technology was compared to the gold standard manual waveform assessment. Results: 218 consecutive subject enrollments were included and multiple measurements were made on each patient. Data with irregular waveforms were excluded. A total of 692 waveforms were evaluated for CRT values by a pair of trained PhD biomedical engineers. The average age of the cohort was 50.62 and 51.4% female. Results showed a Pearson correlation coefficient of 0.91 for the device CRT compared to the CRT gold standard. The Pearson correlation coefficient for the two independent engineering review of the waveform data was 0.98. This device produces accurate, consistent results and eliminates the subjectivity of CRT measurements that is in practice currently.
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Affiliation(s)
- Jordan Gillespie
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Matthew Hansen
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Ravi Samatham
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | - David C. Sheridan
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Yatabe T, Egi M, Ogura H. New avenues of sepsis research: obtaining perspective by analyzing and comparing SSCG 2021 and J-SSCG 2020. J Intensive Care 2022; 10:11. [PMID: 35255989 PMCID: PMC8900396 DOI: 10.1186/s40560-022-00606-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/27/2022] [Indexed: 11/29/2022] Open
Abstract
Recently, revisions of two sepsis guidelines, namely, the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 and the Surviving Sepsis Campaign Guidelines 2021, were published. Although both guidelines were created in accordance with the Grading of Recommendations, Assessment, Development and Evaluation approach, the evidence-to-decision tables differed between them. In addition, certain recommendations may differ between these guidelines for similar clinical questions because of differences in the “PICO” criteria. Other differences in recommendations between the two guidelines are due to unclear evidence, and these ambiguities may provide the basis for further sepsis research. We hope that these two guidelines will contribute to the creation of new clinical evidence in addition to supporting treatment of patients with sepsis.
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30
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Estrategia integral de reanimación del paciente con sepsis y shock séptico. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ocampo-Quintero N, Vidal-Cortés P, Del Río Carbajo L, Fdez-Riverola F, Reboiro-Jato M, Glez-Peña D. Enhancing sepsis management through machine learning techniques: A review. Med Intensiva 2022; 46:140-156. [PMID: 35221003 DOI: 10.1016/j.medine.2020.04.015] [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: 11/29/2019] [Accepted: 04/05/2020] [Indexed: 06/14/2023]
Abstract
Sepsis is a major public health problem and a leading cause of death in the world, where delay in the beginning of treatment, along with clinical guidelines non-adherence have been proved to be associated with higher mortality. Machine Learning is increasingly being adopted in developing innovative Clinical Decision Support Systems in many areas of medicine, showing a great potential for automatic prediction of diverse patient conditions, as well as assistance in clinical decision making. In this context, this work conducts a narrative review to provide an overview of how specific Machine Learning techniques can be used to improve sepsis management, discussing the main tasks addressed, the most popular methods and techniques, as well as the obtained results, in terms of both intelligent system accuracy and clinical outcomes improvement.
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Affiliation(s)
- N Ocampo-Quintero
- ESEI - Escuela Superior de Ingeniería Informática, Universidad de Vigo, Ourense, Spain
| | - P Vidal-Cortés
- Intensive Care Unit, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - L Del Río Carbajo
- Intensive Care Unit, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - F Fdez-Riverola
- ESEI - Escuela Superior de Ingeniería Informática, Universidad de Vigo, Ourense, Spain; CINBIO - Centro de Investigaciones Biomédicas, Universidad de Vigo, Vigo, Spain; SING Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Spain
| | - M Reboiro-Jato
- ESEI - Escuela Superior de Ingeniería Informática, Universidad de Vigo, Ourense, Spain; CINBIO - Centro de Investigaciones Biomédicas, Universidad de Vigo, Vigo, Spain; SING Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Spain
| | - D Glez-Peña
- ESEI - Escuela Superior de Ingeniería Informática, Universidad de Vigo, Ourense, Spain; CINBIO - Centro de Investigaciones Biomédicas, Universidad de Vigo, Vigo, Spain; SING Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Spain.
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Barthélémy R, Kindermans M, Delval P, Collet M, Gaugain S, Cecconi M, Mebazaa A, Chousterman BG. Accuracy of cumulative volumes of fluid challenge to assess fluid responsiveness in critically ill patients with acute circulatory failure: a pharmacodynamic approach. Br J Anaesth 2021; 128:236-243. [PMID: 34895718 DOI: 10.1016/j.bja.2021.10.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The relationship between the dose (volume of fluid) and the effect (increase of stroke volume [SV]) has been poorly described. We hypothesised that the analysis of the dynamic response of SV during fluid challenge (FC) helps to determine the optimal volume of FC, along with its diagnostic accuracy parameters for fluid responsiveness. METHODS A prospective observational study was conducted in critically ill patients with circulatory failure. Patients monitored with oesophageal Doppler and assigned to an FC of 500 ml of crystalloid were included. The areas under the curve (AUC) and 95% confidence intervals (CI95) of the receiver operating characteristic curves for cumulative volumes from 50 to 450 ml were determined for fluid responsiveness (SV increase ≥15% from baseline) along with other parameters of diagnostic accuracy. In the pharmacodynamic analysis, dose-effect and dose-response models were constructed, with determination of median and 90% effective dose (ED50 and ED90). RESULTS Forty-five patients were included. The AUC increased with cumulative volumes of FC up to 250 ml (AUC250 0.93 [CI95: 0.85-1.00]), followed by a plateau above 0.95 of AUC. The optimal volume was 250 ml, associated with a specificity of 0.89 [CI95: 0.78-1.00], a sensitivity of 0.92 [CI95: 0.69-1.00], and a threshold of 9.6% increase in SV. The ED50 was 156 [CI95: 136-177] ml and the ED90 was 312 [CI95: 269-352] ml. CONCLUSIONS A volume of FC of 250 ml with a threshold of 9.6% increase in SV showed the highest accuracy in detecting fluid responsiveness in critically ill patients with shock. CLINICAL TRIAL REGISTRATION .
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Affiliation(s)
- Romain Barthélémy
- AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, Paris, France.
| | - Manuel Kindermans
- AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, Paris, France
| | - Paul Delval
- AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, Paris, France
| | - Magalie Collet
- AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, Paris, France
| | - Samuel Gaugain
- AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alexandre Mebazaa
- Université de Paris, AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, MASCOT UMRS 942, Inserm, Paris, France
| | - Benjamin G Chousterman
- Université de Paris, AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, MASCOT UMRS 942, Inserm, Paris, France
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33
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 894] [Impact Index Per Article: 298.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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34
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Messina A, Sotgiu G, Saderi L, Cammarota G, Capuano L, Colombo D, Bennett V, Payen D, DE Backer D, Navalesi P, Cecconi M. Does the definition of fluid responsiveness affect passive leg raising reliability? A methodological ancillary analysis from a multicentric study. Minerva Anestesiol 2021; 88:272-281. [PMID: 34709017 DOI: 10.23736/s0375-9393.21.15944-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fluid challenge (FC) is often adopted as gold standard used to assess the reliability of passive leg raising (PLR) in predicting fluid responsiveness in the intensive care unit (ICU). This study aimed to address the impact of the different definitions and timings used to assess FC response on PLR reliability. METHODS Ancillary study from a data set of a multicentric study in 85 ICU patient with acute circulatory failure who received a FC (500 mL of crystalloids in 10 minutes) within the first 48h of ICU admission, preceded by PLR in 30 patients. FC response was assessed considering the changes in cardiac index (CI) and stroke volume index (SVI) using different thresholds and at different timepoints. RESULTS The definitions of fluid responsiveness by using CI or SVI with a 15% increase after 10 minutes were associated to the best performances of the PLR [AUC (95% CI) 0.94 (0.83-1.01); vs. AUC (95% CI) 0.95 (0.87-1.02)]. The sensitivity of the PLR by adopting the CI or the SVI as reference variable ranged from 54.1% to 67.6% and from 81.5% to 100.0%; the specificity from 65.9% to 78.0% and from 79.5% to 100.0%, respectively. Considering all the subgroups, the number of responders 10 minutes after FC administration was higher as compared to 15 and 30 minutes (140 vs. 120 and 125, respectively, p < 0.05). CONCLUSIONS The reliability of the PLR test to predict fluid responsiveness depends on the definition of FC adopted. The timing of FC outcome assessment affected the overall fluid responsiveness.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy - .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy -
| | - Giovanni Sotgiu
- Research, Medical Education and Professional Development Unit, AOU Sassari, Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Laura Saderi
- Research, Medical Education and Professional Development Unit, AOU Sassari, Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | | | - Lorenzo Capuano
- Dipartimento di Medicina e Chirurgia, Università di Perugia, Perugia, Italy
| | - Davide Colombo
- Anesthesia and Intensive Care Medicine, Ospedale Ss. Trinità, Borgomanero, Novara, Italy
| | - Victoria Bennett
- Department of Intensive Care Medicine, St George's University Hospital NHS Foundation Trust, London, UK
| | | | - Daniel DE Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Paolo Navalesi
- Section of Anesthesiology and Intensive Care, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
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35
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1459] [Impact Index Per Article: 486.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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Left ventricular longitudinal strain variations assessed by speckle-tracking echocardiography after a passive leg raising maneuver in patients with acute circulatory failure to predict fluid responsiveness: A prospective, observational study. PLoS One 2021; 16:e0257737. [PMID: 34591884 PMCID: PMC8483378 DOI: 10.1371/journal.pone.0257737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 09/08/2021] [Indexed: 01/22/2023] Open
Abstract
Background An association was reported between the left ventricular longitudinal strain (LV-LS) and preload. LV-LS reflects the left cardiac function curve as it is the ratio of shortening over diastolic dimension. The aim of this study was to determine the sensitivity and specificity of LV-LS variations after a passive leg raising (PLR) maneuver to predict fluid responsiveness in intensive care unit (ICU) patients with acute circulatory failure (ACF). Methods Patients with ACF were prospectively included. Preload-dependency was defined as a velocity time integral (VTI) variation greater than 10% between baseline (T0) and PLR (T1), distinguishing the preload-dependent (PLD+) group and the preload-independent (PLD-) group. A 7-cycles, 4-chamber echocardiography loop was registered at T0 and T1, and strain analysis was performed off-line by a blind clinician. A general linear model for repeated measures was used to compare the LV-LS variation (T0 to T1) between the two groups. Results From June 2018 to August 2019, 60 patients (PLD+ = 33, PLD- = 27) were consecutively enrolled. The VTI variations after PLR were +21% (±8) in the PLD+ group and -1% (±7) in the PLD- group (p<0.01). Mean baseline LV-LS was -11.3% (±4.2) in the PLD+ group and -13.0% (±4.2) in the PLD- group (p = 0.12). LV-LS increased in the whole population after PLR +16.0% (±4.0) (p = 0.04). The LV-LS variations after PLR were +19.0% (±31) (p = 0.05) in the PLD+ group and +11.0% (±38) (p = 0.25) in the PLD- group, with no significant difference between the two groups (p = 0.08). The area under the curve for the LV-LS variations between T0 and T1 was 0.63 [0.48–0.77]. Conclusion Our study confirms that LV-LS is load-dependent; however, the variations in LV-LS after PLR is not a discriminating criterion to predict fluid responsiveness of ICU patients with ACF in this cohort.
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37
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Gavelli F, Castello LM, Avanzi GC. Management of sepsis and septic shock in the emergency department. Intern Emerg Med 2021; 16:1649-1661. [PMID: 33890208 PMCID: PMC8354945 DOI: 10.1007/s11739-021-02735-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/30/2021] [Indexed: 12/19/2022]
Abstract
Early management of sepsis and septic shock is crucial for patients' prognosis. As the Emergency Department (ED) is the place where the first medical contact for septic patients is likely to occur, emergency physicians play an essential role in the early phases of patient management, which consists of accurate initial diagnosis, resuscitation, and early antibiotic treatment. Since the issuing of the Surviving Sepsis Campaign guidelines in 2016, several studies have been published on different aspects of sepsis management, adding a substantial amount of new information on the pathophysiology and treatment of sepsis and septic shock. In light of this emerging evidence, the present narrative review provides a comprehensive account of the recent advances in septic patient management in the ED.
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Affiliation(s)
- Francesco Gavelli
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Via Solaroli 17, Novara, Italy.
- Emergency Medicine Department, AOU Maggiore Della Carità, Corso Mazzini 18, Novara, Italy.
| | - Luigi Mario Castello
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Via Solaroli 17, Novara, Italy
- Emergency Medicine Department, AOU Maggiore Della Carità, Corso Mazzini 18, Novara, Italy
| | - Gian Carlo Avanzi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Via Solaroli 17, Novara, Italy
- Emergency Medicine Department, AOU Maggiore Della Carità, Corso Mazzini 18, Novara, Italy
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38
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Schell CO, Khalid K, Wharton-Smith A, Oliwa J, Sawe HR, Roy N, Sanga A, Marshall JC, Rylance J, Hanson C, Kayambankadzanja RK, Wallis LA, Jirwe M, Baker T. Essential Emergency and Critical Care: a consensus among global clinical experts. BMJ Glob Health 2021; 6:e006585. [PMID: 34548380 PMCID: PMC8458367 DOI: 10.1136/bmjgh-2021-006585] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/19/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19. METHODS In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC's Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements. RESULTS The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19. CONCLUSION The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide.
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Affiliation(s)
- Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Internal Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Karima Khalid
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Alexandra Wharton-Smith
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jacquie Oliwa
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics & Child Health, University of Nairobi, Nairobi, Kenya
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Nobhojit Roy
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- The George Institute for Global Health India, New Delhi, India
- WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, BARC Hospital, Mumbai, India
| | - Alex Sanga
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, United Republic of Tanzania
| | - John C Marshall
- Departments of Surgery and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jamie Rylance
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK
| | - Raphael K Kayambankadzanja
- Department of Anaesthesia and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Maria Jirwe
- Department of Health Sciences, The Red Cross University College, Huddinge, Sweden
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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39
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Hamzaoui O, Shi R, Carelli S, Sztrymf B, Prat D, Jacobs F, Monnet X, Gouëzel C, Teboul JL. Changes in pulse pressure variation to assess preload responsiveness in mechanically ventilated patients with spontaneous breathing activity: an observational study. Br J Anaesth 2021; 127:532-538. [PMID: 34246460 DOI: 10.1016/j.bja.2021.05.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/03/2021] [Accepted: 05/28/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Pulse pressure variation (PPV) is not reliable in predicting preload responsiveness in patients receiving mechanical with spontaneous breathing (SB) activity. We hypothesised that an increase in PPV after a tidal volume (VT) challenge (TVC) or a decrease in PPV during passive leg raising (PLR) can predict preload responsiveness in such cases. METHODS This prospective observational study was performed in two ICUs and included patients receiving mechanical ventilation with SB, for whom the treating physician decided to test preload responsiveness. Transthoracic echocardiography was used to measure the velocity-time integral (VTI) of the left ventricular outflow tract. Patients exhibiting an increase in VTI ≥12% during PLR were defined as PLR+ patients (or preload responders). Then, a TVC was performed by increasing VT by 2 ml kg-1 predicted body weight (PBW) for 1 min. PPV was recorded at each step. RESULTS Fifty-four patients (Simplified Acute Physiology Score II: 60 (25) ventilated with a VT of 6.5 (0.8) ml kg-1 PBW, were included. Twenty-two patients were PLR+. The absolute decrease in PPV during PLR and the absolute increase in PPV during TVC discriminated between PLR+ and PLR- patients with area under the receiver operating characteristic (AUROC) curve of 0.78 and 0.73, respectively, and cut-off values of -1% and +2%, respectively. Those AUROC curve values were similar but were significantly different from that of baseline PPV (0.61). CONCLUSION In patients undergoing mechanical ventilation with SB activity, PPV does not predict preload responsiveness. However, the decrease in PPV during PLR and the increase in PPV during a TVC help discriminate preload responders from non-responders with moderate accuracy. CLINICAL TRIAL REGISTRATION NCT04369027 (ClinicalTrials.gov).
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Affiliation(s)
- Olfa Hamzaoui
- Service de réanimation Polyvalente, Hôpital Antoine Béclère, AP-HP Université Paris-Saclay, Clamart, France.
| | - Rui Shi
- Université Paris-Saclay, AP-HP, Service de Médecine Intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Le Kremlin-Bicêtre, France; INSERM-UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Simone Carelli
- Université Paris-Saclay, AP-HP, Service de Médecine Intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Le Kremlin-Bicêtre, France
| | - Benjamin Sztrymf
- Service de réanimation Polyvalente, Hôpital Antoine Béclère, AP-HP Université Paris-Saclay, Clamart, France; INSERM-UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Dominique Prat
- Service de réanimation Polyvalente, Hôpital Antoine Béclère, AP-HP Université Paris-Saclay, Clamart, France
| | - Frederic Jacobs
- Service de réanimation Polyvalente, Hôpital Antoine Béclère, AP-HP Université Paris-Saclay, Clamart, France
| | - Xavier Monnet
- Université Paris-Saclay, AP-HP, Service de Médecine Intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Le Kremlin-Bicêtre, France; INSERM-UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Corentin Gouëzel
- Service de réanimation Polyvalente, Hôpital Antoine Béclère, AP-HP Université Paris-Saclay, Clamart, France
| | - Jean-Louis Teboul
- Université Paris-Saclay, AP-HP, Service de Médecine Intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Le Kremlin-Bicêtre, France; INSERM-UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
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40
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Ortolani JM, Bellis TJ. Evaluation of the quick sequential organ failure assessment score plus lactate in critically ill dogs. J Small Anim Pract 2021; 62:874-880. [PMID: 34110024 DOI: 10.1111/jsap.13381] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 02/17/2021] [Accepted: 05/12/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To apply the quick sequential organ failure assessment (qSOFA) score to dogs admitted to a veterinary ICU, and evaluate whether the addition of lactate increased the predictive ability of the score. MATERIALS AND METHODS A quick sequential organ failure assessment score of 0, 1, 2, or 3 was assigned to each dog based on the following criteria: respiratory rate >22 breaths per minute, altered mentation, systolic blood pressure <100 mmHg. Lactate was added to quick sequential organ failure assessment in an LqSOFA model and assigned to each patient. Disease processes evaluated included sepsis, congestive heart failure, pneumonia and pancreatitis. RESULTS Two hundred and sixty-seven client-owned dogs met the inclusion criteria. There was no significant difference in quick sequential organ failure assessment score between survivors and non-survivors. The use of lactate >3, 4, and 5 mmol/L incorporated into the quick sequential organ failure assessment score (L3qSOFA, L4qSOFA, L5qSOFA) distinguished between survival and non-survival (AUC=0.62; AUC=0.64; AUC=0.62, respectively). Lactate alone distinguished between survival and non-survival (AUC=0.63). Lactate concentration was significantly lower in survivors. CLINICAL SIGNIFICANCE In this study, quick sequential organ failure assessment was not able to predict survival in a general population of critically ill patients. The addition of lactate to the quick sequential organ failure assessment score slightly increased the predictive ability of the score.
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Affiliation(s)
- J M Ortolani
- BluePearl Specialty and Emergency Pet Hospital, Critical Care Department, New York, NY, 10019, USA
| | - T J Bellis
- BluePearl Specialty and Emergency Pet Hospital, Critical Care Department, New York, NY, 10019, USA
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41
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Boysen SR, Gommeren K. Assessment of Volume Status and Fluid Responsiveness in Small Animals. Front Vet Sci 2021; 8:630643. [PMID: 34124213 PMCID: PMC8193042 DOI: 10.3389/fvets.2021.630643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/29/2021] [Indexed: 12/30/2022] Open
Abstract
Intravenous fluids are an essential component of shock management in human and veterinary emergency and critical care to increase cardiac output and improve tissue perfusion. Unfortunately, there are very few evidence-based guidelines to help direct fluid therapy in the clinical setting. Giving insufficient fluids and/or administering fluids too slowly to hypotensive patients with hypovolemia can contribute to continued hypoperfusion and increased morbidity and mortality. Similarly, giving excessive fluids to a volume unresponsive patient can contribute to volume overload and can equally increase morbidity and mortality. Therefore, assessing a patient's volume status and fluid responsiveness, and monitoring patient's response to fluid administration is critical in maintaining the balance between meeting a patient's fluid needs vs. contributing to complications of volume overload. This article will focus on the physiology behind fluid responsiveness and the methodologies used to estimate volume status and fluid responsiveness in the clinical setting.
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Affiliation(s)
- Søren R. Boysen
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Kris Gommeren
- Department of Companion Animals, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
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42
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43
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Langston C, Gordon D. Effects of IV Fluids in Dogs and Cats With Kidney Failure. Front Vet Sci 2021; 8:659960. [PMID: 33959654 PMCID: PMC8093391 DOI: 10.3389/fvets.2021.659960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/18/2021] [Indexed: 12/25/2022] Open
Abstract
Intravenous fluid therapy has long been the mainstay of treatment of kidney disease, including acute kidney injury and uremic crisis associated with chronic kidney disease. Careful management of fluid dose is critical, as animals with kidney disease may have marked derangements in their ability to regulate fluid homeostasis and acid-base status. Understanding of the physiology of renal fluid handling is necessary, along with repeated attention to parameters of fluid status, electrolytes, and acid-base balance, to achieve optimal hydration status and avoid further damage or decrease in function from dehydration or overhydration.
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Affiliation(s)
- Cathy Langston
- The Ohio State University College of Veterinary Medicine, Columbus, OH, United States
| | - Daniel Gordon
- The Ohio State University College of Veterinary Medicine, Columbus, OH, United States
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Lat I, Coopersmith CM, De Backer D. The Surviving Sepsis Campaign: Fluid Resuscitation and Vasopressor Therapy Research Priorities in Adult Patients. Crit Care Med 2021; 49:623-635. [PMID: 33731607 PMCID: PMC7963440 DOI: 10.1097/ccm.0000000000004864] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Expand upon the priorities of fluid resuscitation and vasopressor therapy research priorities identified by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. DATA SOURCES Original article, literature search. STUDY SELECTION Several members of the original task force with expertise specific to the area of fluid resuscitation and vasopressor therapy. DATA EXTRACTION None. DATA SYNTHESIS None. CONCLUSION In the second of a series of manuscripts subsequent to the original article, members with expertise in the subjects expound upon the three identified priorities related to fluid resuscitation and vasopressor therapies. This analysis summarizes what is known and what were identified as ongoing and future research.
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Affiliation(s)
- Ishaq Lat
- Department of Pharmacy, Shirley Ryan AbilityLab, Chicago, IL
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA
| | - Daniel De Backer
- Department of Intensive Care, Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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45
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Kenny JES, Barjaktarevic I. Letter to the Editor: Stroke volume is the key measure of fluid responsiveness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:104. [PMID: 33722261 PMCID: PMC7962206 DOI: 10.1186/s13054-021-03498-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/08/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Jon-Emile S Kenny
- Health Sciences North Research Institute, 56 Walford Rd, Sudbury, ON, P3E 2H2, Canada.
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine At UCLA, Los Angeles, CA, USA
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46
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Schulz L, Geri G, Vieillard‐Baron A, Vignon P, Parkin G, Aneman A. Volume status and volume responsiveness in postoperative cardiac surgical patients: An observational, multicentre cohort study. Acta Anaesthesiol Scand 2021; 65:320-328. [PMID: 33169357 DOI: 10.1111/aas.13735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The best strategy to identify patients in whom fluid loading increases cardiac output (CO) following cardiac surgery remains debated. This study examined the utility of a calculated mean systemic filling pressure analogue (Pmsa ) and derived variables to explain the response to a fluid bolus. METHODS The Pmsa was calculated using retrospective, observational cohort data in the early postoperative period between admission to the intensive care unit and extubation within 6 hours. The venous return pressure gradient (VRdP) was calculated as Pmsa - central venous pressure. Concurrent changes induced by a fluid bolus in the ratio of the VRdP over Pmsa , the volume efficiency (Evol ), were studied to assess fluid responsiveness. Changes between Pmsa and derived variables and CO were analysed by Wilcoxon rank-sum test, hierarchial clustering and multiple linear regression. RESULTS Data were analysed for 235 patients who received 489 fluid boluses. The Pmsa increased with consecutive fluid boluses (median difference [range] 1.3 [0.5-2.4] mm Hg, P = .03) with a corresponding increase in VRdP (median difference 0.4 [0.2-0.6] mm Hg, P = .04). Hierarchical cluster analysis only identified Evol and the change in CO within one cluster. The multiple linear regression between Pmsa and its derived variables and the change in CO (overall r2 = .48, P < .001) demonstrated the best partial regression between the continuous change in CO and the concurrent Evol (r = .55, P < .001). CONCLUSION The mean systemic filling Pmsa enabled a comprehensive interpretation of fluid responsiveness with volume efficiency useful to explain the change in CO as a continuous phenomenon.
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Affiliation(s)
- Luis Schulz
- Intensive Care Unit Liverpool Hospital South Western Sydney Local Health District Liverpool NSW Australia
| | - Guillaume Geri
- Intensive Care Unit Assistance Publique‐Hôpitaux de Paris University Hospital Ambroise Paré Boulogne‐Billancourt France
- INSERM U‐1018 CESP Team 5 University of Versailles Saint‐Quentin en Yvelines Villejuif France
- Faculty of Medicine Paris Ile‐de‐France Ouest University of Versailles Saint‐Quentin en Yvelines Villejuif France
| | - Antoine Vieillard‐Baron
- Intensive Care Unit Assistance Publique‐Hôpitaux de Paris University Hospital Ambroise Paré Boulogne‐Billancourt France
- INSERM U‐1018 CESP Team 5 University of Versailles Saint‐Quentin en Yvelines Villejuif France
- Faculty of Medicine Paris Ile‐de‐France Ouest University of Versailles Saint‐Quentin en Yvelines Villejuif France
| | - Philippe Vignon
- Medical‐surgical Intensive Care Unit Limoges University Hospital Limoges France
- INSERM CIC 1435 Limoges University Hospital Limoges France
- Faculty of Medicine University of Limoges Limoges France
| | - Geoffrey Parkin
- Intensive Care Unit Monash Medical Centre Clayton Vic. Australia
| | - Anders Aneman
- Intensive Care Unit Liverpool Hospital South Western Sydney Local Health District Liverpool NSW Australia
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia
- Faculty of Medicine and Health Sciences Macquarie University Sydney NSW Australia
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47
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Lat I, Coopersmith CM, De Backer D, Coopersmith CM. The surviving sepsis campaign: fluid resuscitation and vasopressor therapy research priorities in adult patients. Intensive Care Med Exp 2021; 9:10. [PMID: 33644843 PMCID: PMC7917035 DOI: 10.1186/s40635-021-00369-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To expand upon the priorities of fluid resuscitation and vasopressor therapy research priorities identified by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. DATA SOURCES Original paper and literature search. STUDY SELECTION Several members of the original task force with expertise specific to the area of fluid resuscitation and vasopressor therapy. DATA EXTRACTION None. DATA SYNTHESIS None. CONCLUSION In the second of a series of manuscripts subsequent to the original paper, members with expertise in the subjects expound upon the three identified priorities related to fluid resuscitation and vasopressor therapies. This analysis summarizes what is known and what were identified as ongoing and future research.
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Affiliation(s)
- Ishaq Lat
- Department of Pharmacy, Shirley Ryan Abilitylab, Chicago, IL, USA.
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Daniel De Backer
- Department of Intensive Care, Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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48
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Virág M, Leiner T, Rottler M, Ocskay K, Molnar Z. Individualized Hemodynamic Management in Sepsis. J Pers Med 2021; 11:157. [PMID: 33672267 PMCID: PMC7926902 DOI: 10.3390/jpm11020157] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/13/2021] [Accepted: 02/18/2021] [Indexed: 02/06/2023] Open
Abstract
Hemodynamic optimization remains the cornerstone of resuscitation in the treatment of sepsis and septic shock. Delay or inadequate management will inevitably lead to hypoperfusion, tissue hypoxia or edema, and fluid overload, leading eventually to multiple organ failure, seriously affecting outcomes. According to a large international survey (FENICE study), physicians frequently use inadequate indices to guide fluid management in intensive care units. Goal-directed and "restrictive" infusion strategies have been recommended by guidelines over "liberal" approaches for several years. Unfortunately, these "fixed regimen" treatment protocols neglect the patient's individual needs, and what is shown to be beneficial for a given population may not be so for the individual patient. However, applying multimodal, contextualized, and personalized management could potentially overcome this problem. The aim of this review was to give an insight into the pathophysiological rationale and clinical application of this relatively new approach in the hemodynamic management of septic patients.
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Affiliation(s)
- Marcell Virág
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Szent György University Teaching Hospital of Fejér County, 8000 Székesfehérvár, Hungary
| | - Tamas Leiner
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Anaesthetic Department, North West Anglia NHS Foundation Trust, Hinchingbrooke Hospital, Huntingdon PE29 6NT, UK
| | - Mate Rottler
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Szent György University Teaching Hospital of Fejér County, 8000 Székesfehérvár, Hungary
| | - Klementina Ocskay
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
| | - Zsolt Molnar
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, 61-701 Poznan, Poland
- Department of Anesthesiology and Intensive Therapy, Markusovszky Teaching Hospital, 9700 Szombathely, Hungary
- Multidisciplinary Doctoral School, University of Szeged, 6720 Szeged, Hungary
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Ostermann M, Bellomo R, Burdmann EA, Doi K, Endre ZH, Goldstein SL, Kane-Gill SL, Liu KD, Prowle JR, Shaw AD, Srisawat N, Cheung M, Jadoul M, Winkelmayer WC, Kellum JA. Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference. Kidney Int 2020; 98:294-309. [PMID: 32709292 PMCID: PMC8481001 DOI: 10.1016/j.kint.2020.04.020] [Citation(s) in RCA: 232] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/31/2020] [Accepted: 04/09/2020] [Indexed: 12/19/2022]
Abstract
In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) published a guideline on the classification and management of acute kidney injury (AKI). The guideline was derived from evidence available through February 2011. Since then, new evidence has emerged that has important implications for clinical practice in diagnosing and managing AKI. In April of 2019, KDIGO held a controversies conference entitled Acute Kidney Injury with the following goals: determine best practices and areas of uncertainty in treating AKI; review key relevant literature published since the 2012 KDIGO AKI guideline; address ongoing controversial issues; identify new topics or issues to be revisited for the next iteration of the KDIGO AKI guideline; and outline research needed to improve AKI management. Here, we present the findings of this conference and describe key areas that future guidelines may address.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St. Thomas' Hospital, King's College London, London, UK.
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emmanuel A Burdmann
- Laboratório de Investigação Médica 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Zoltan H Endre
- Prince of Wales Hospital and Clinical School, University of New South Wales, Randwick, NSW, Australia
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Kathleen D Liu
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, California, USA; Department of Anesthesia, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California, USA
| | - John R Prowle
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Academy of Science, Royal Society of Thailand, Bangkok, Thailand
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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50
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Hamzaoui O, Gouëzel C, Jozwiak M, Millereux M, Sztrymf B, Prat D, Jacobs F, Monnet X, Trouiller P, Teboul JL. Increase in Central Venous Pressure During Passive Leg Raising Cannot Detect Preload Unresponsiveness. Crit Care Med 2020; 48:e684-e689. [PMID: 32697509 DOI: 10.1097/ccm.0000000000004414] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE By analogy with the classical central venous pressure rules to assess a fluid challenge, we hypothesized that an increase in central venous pressure greater than or equal to 5 cm H2O (i.e., 4 mm Hg) during passive leg raising can predict preload unresponsiveness diagnosed by the absence of increase in velocity-time integral of the left ventricular outflow tract greater than or equal to 10% during the test (negative passive leg raising test). DESIGN AND SETTINGS Velocity-time integral was measured by transthoracic echocardiography. Central venous pressure and velocity-time integral were measured before and during passive leg raising. PATIENTS Critically ill patients for whom the physician decided to test preload responsiveness by passive leg raising were prospectively included. MEASUREMENT AND MAIN RESULTS Fifty-seven set of measurements were performed in 50 patients. Preload unresponsiveness (negative passive leg raising test) was observed in 32 cases. The changes in central venous pressure during passive leg raising did not differ between positive passive leg raising cases (positive passive leg raising test) and negative passive leg raising test cases (3 ± 2 vs 3 ± 2 mm Hg, respectively) and thus did not predict preload unresponsiveness (area under the receiver-operating characteristic curve of 0.59). An increase in central venous pressure greater than or equal to 4 mm Hg during passive leg raising was observed in 10 cases of positive passive leg raising test and in 11 cases of negative passive leg raising test. Taking an increase in central venous pressure greater than or equal to 3 or greater than or equal to 5 mm Hg rather than greater than or equal to 4 mm Hg during passive leg raising did not better allow one to identify negative passive leg raising test. CONCLUSIONS Marked increase in central venous pressure during passive leg raising cannot identify negative passive leg raising test cases and thus preload unresponsiveness. Measurements of cardiac output (or its surrogates) during passive leg raising are, thus, mandatory to appropriately interpret this test.
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Affiliation(s)
- Olfa Hamzaoui
- Service de Réanimation Polyvalente, Hôpital Antoine Béclère, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Clamart, France
| | - Corentin Gouëzel
- Service de Réanimation Polyvalente, Hôpital Antoine Béclère, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Clamart, France
| | - Mathieu Jozwiak
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Maude Millereux
- Service de Réanimation Polyvalente, Hôpital Antoine Béclère, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Clamart, France
| | - Benjamin Sztrymf
- Service de Réanimation Polyvalente, Hôpital Antoine Béclère, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Clamart, France
| | - Dominique Prat
- Service de Réanimation Polyvalente, Hôpital Antoine Béclère, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Clamart, France
| | - Frederic Jacobs
- Service de Réanimation Polyvalente, Hôpital Antoine Béclère, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Clamart, France
| | - Xavier Monnet
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Pierre Trouiller
- Service de Réanimation Polyvalente, Hôpital Antoine Béclère, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Clamart, France
| | - Jean-Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
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