1
|
Solanki SL, Kumar PP, Ambulkar RP. Preoperative "R wave amplitude variation" on electrocardiogram predicts severe hypovolemia. Ann Card Anaesth 2019; 22:340-342. [PMID: 31274504 PMCID: PMC6639896 DOI: 10.4103/aca.aca_70_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Preoperative fasting is essential to prevent aspiration and associated complications. However, quite often patients end up fasting for 12 h or more due to changes in the operating room schedules, delays, and postponements. Preoperative fasting may lead to a fluid deficit, which may contribute to perioperative discomfort and morbidity. We report a case of 44-year-old female posted for total mastectomy with axillary clearance for carcinoma breast, with prolonged fasting where preoperative R wave amplitude variation along with associated changes in the plethysmograph was noticed on the monitor. 500 milliliters of lactated ringer solution was administered before induction of anesthesia, by the time R wave amplitude variation decreased. Variations in plethysmography became normal after 1 L of fluid administration after induction of anesthesia. Gross R wave amplitude variation is not a very common finding and may predict severe hypovolemia in preoperative area in prolonged fasting patients.
Collapse
Affiliation(s)
- Sohan Lal Solanki
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
- Address for correspondence: Dr. Sohan Lal Solanki, Department of Anesthesiology, Critical Care and Pain, 2nd Floor, Main Building, Tata Memorial Centre, Mumbai - 400 012, Maharashtra, India. E-mail:
| | - Pooja P Kumar
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Reshma P Ambulkar
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| |
Collapse
|
2
|
Blendea D, McPherson CA, Pop S, Ruskin JN. Isolated very low QRS voltage in the frontal leads predicts recurrence of neurally mediated syncope. Heart Rhythm 2019; 16:1862-1869. [PMID: 31201963 DOI: 10.1016/j.hrthm.2019.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Indexed: 10/26/2022]
Abstract
BACKGROUND The study was prompted by our observation that some patients with neurally mediated syncope (NMS) have an isolated QRS complex, of very low voltage (≤0.3 mV cutoff), in 1 of the frontal leads on the 12-lead electrocardiogram. OBJECTIVE To prospectively evaluate whether the presence of isolated very low voltage (VLV) predicts recurrence of NMS. METHODS We included 205 patients (aged 50 ± 17 years) with a median of 3 syncopal episodes. Tilt testing was performed in all patients and was positive in 87 (42%). The patients were followed for a median of 14 months. RESULTS VLV in frontal leads was present in 92 patients (45%). During the follow-up period 60 patients experienced recurrence of syncope. The actuarial total syncope recurrence rate at 1 year was 32% (95% confidence interval [CI 23%-44%) in patients with isolated VLV in frontal plane leads, and 14% (95% CI 8%-24%) in patients without VLV (log-rank test P < .0001). The significant relationship between the presence of isolated VLV in the frontal leads and syncope recurrence was retained in Cox multivariate analysis that included the history of presyncope and syncope as well as the left ventricular end-diastolic diameter. The presence of isolated VLV in frontal leads was associated with a 3-fold increase of the risk of recurrent syncope. CONCLUSIONS Isolated very low QRS voltage in the frontal leads predicts recurrence of NMS independent of clinical factors that predict recurrence of syncope in such patients. This phenomenon may help generate new diagnostic tools and insights into the pathogenesis of NMS.
Collapse
Affiliation(s)
- Dan Blendea
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Emergency Clinical County Hospital, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania.
| | - Craig A McPherson
- Bridgeport Hospital, Yale University School of Medicine, Bridgeport, Connecticut
| | - Sorin Pop
- Emergency Clinical County Hospital, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Jeremy N Ruskin
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
3
|
Park HS, Kim SH, Park YS, Thiele RH, Shin WJ, Hwang GS. Respiratory Variations in Electrocardiographic R-Wave Amplitude during Acute Hypovolemia Induced by Inferior Vena Cava Clamping in Patients Undergoing Liver Transplantation. J Clin Med 2019; 8:jcm8050717. [PMID: 31137521 PMCID: PMC6572700 DOI: 10.3390/jcm8050717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/14/2019] [Accepted: 05/17/2019] [Indexed: 12/05/2022] Open
Abstract
The aim of this study was to analyze whether the respiratory variation in electrocardiogram (ECG) standard lead II R-wave amplitude (ΔRDII) could be used to assess intravascular volume status following inferior vena cava (IVC) clamping. This clamping causes an acute decrease in cardiac output during liver transplantation (LT). We retrospectively compared ΔRDII and related variables before and after IVC clamping in 34 recipients. Receiver operating characteristic (ROC) curve and area under the curve (AUC) analyses were used to derive a cutoff value of ΔRDII for predicting pulse pressure variation (PPV). After IVC clamping, cardiac output significantly decreased while ΔRDII significantly increased (p = 0.002). The cutoff value of ΔRDII for predicting a PPV >13% was 16.9% (AUC: 0.685) with a sensitivity of 57.9% and specificity of 77.6% (95% confidence interval 0.561 – 0.793, p = 0.015). Frequency analysis of ECG also significantly increased in the respiratory frequency band (p = 0.016). Although significant changes in ΔRDII during vena cava clamping were found at norepinephrine doses <0.1 µg/kg/min (p = 0.032), such changes were not significant at norepinephrine doses >0.1 µg/kg/min (p = 0.093). ΔRDII could be a noninvasive dynamic parameter in LT recipients presenting with hemodynamic fluctuation. Based on our data, we recommended cautious interpretation of ΔRDII may be requisite according to vasopressor administration status.
Collapse
Affiliation(s)
- Hee-Sun Park
- Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, 05505 Seoul, Korea.
| | - Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, 05505 Seoul, Korea.
| | - Yong-Seok Park
- Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, 05505 Seoul, Korea.
| | - Robert H Thiele
- Departments of Anesthesiology and Biomedical Engineering, University of Virginia School of Medicine, Charlottesville, VA 22903, USA.
| | - Won-Jung Shin
- Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, 05505 Seoul, Korea.
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, 05505 Seoul, Korea.
| |
Collapse
|
4
|
Toscani L, Aya HD, Antonakaki D, Bastoni D, Watson X, Arulkumaran N, Rhodes A, Cecconi M. What is the impact of the fluid challenge technique on diagnosis of fluid responsiveness? A systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:207. [PMID: 28774325 PMCID: PMC5543539 DOI: 10.1186/s13054-017-1796-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 07/12/2017] [Indexed: 12/21/2022]
Abstract
Background The fluid challenge is considered the gold standard for diagnosis of fluid responsiveness. The objective of this study was to describe the fluid challenge techniques reported in fluid responsiveness studies and to assess the difference in the proportion of ‘responders,’ (PR) depending on the type of fluid, volume, duration of infusion and timing of assessment. Methods Searches of MEDLINE and Embase were performed for studies using the fluid challenge as a test of cardiac preload with a description of the technique, a reported definition of fluid responsiveness and PR. The primary outcome was the mean PR, depending on volume of fluid, type of fluids, rate of infusion and time of assessment. Results A total of 85 studies (3601 patients) were included in the analysis. The PR were 54.4% (95% CI 46.9–62.7) where <500 ml was administered, 57.2% (95% CI 52.9–61.0) where 500 ml was administered and 60.5% (95% CI 35.9–79.2) where >500 ml was administered (p = 0.71). The PR was not affected by type of fluid. The PR was similar among patients administered a fluid challenge for <15 minutes (59.2%, 95% CI 54.2–64.1) and for 15–30 minutes (57.7%, 95% CI 52.4–62.4, p = 1). Where the infusion time was ≥30 minutes, there was a lower PR of 49.9% (95% CI 45.6–54, p = 0.04). Response was assessed at the end of fluid challenge, between 1 and 10 minutes, and >10 minutes after the fluid challenge. The proportions of responders were 53.9%, 57.7% and 52.3%, respectively (p = 0.47). Conclusions The PR decreases with a long infusion time. A standard technique for fluid challenge is desirable. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1796-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Laura Toscani
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Cristo Re Hospital, Via delle Calasanziane 25, 00167, Rome, Italy
| | - Hollmann D Aya
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK. .,Anaesthetic Department, East Surrey Hospital, Surrey & Sussex Healthcare Trust, Canada Avenue, Redhill, Surrey, RH1 5 RH, UK.
| | - Dimitra Antonakaki
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Cardiology Department, Broomfield Hospital, Mid-Essex Healthcare Trust, Court Road, Broomfield, Chelmsford, CM1 7ET, UK
| | - Davide Bastoni
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Dipartimento di Medicina Sperimentale, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Ximena Watson
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Nish Arulkumaran
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Andrew Rhodes
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Maurizio Cecconi
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| |
Collapse
|
6
|
Giraud R, Siegenthaler N, Morel DR, Romand JA, Brochard L, Bendjelid K. Respiratory change in ECG-wave amplitude is a reliable parameter to estimate intravascular volume status. J Clin Monit Comput 2012; 27:107-11. [PMID: 23117586 DOI: 10.1007/s10877-012-9405-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Accepted: 10/12/2012] [Indexed: 11/30/2022]
Abstract
Electrocardiogram (ECG) is a standard type of monitoring in intensive care medicine. Several studies suggest that changes in ECG morphology may reflect changes in volume status. The "Brody effect", a theoretical analysis of left ventricular (LV) chamber size influence on QRS-wave amplitude, is the key element of this phenomenon. It is characterised by an increase in QRS-wave amplitude that is induced by an increase in ventricular preload. This study investigated the influence of changes in intravascular volume status on respiratory variations of QRS-wave amplitudes (ΔECG) compared with respiratory pulse pressure variations (ΔPP), considered as a reference standard. In 17 pigs, ECG and arterial pressure were recorded. QRS-wave amplitude was measured from the Biopac recording to ensure that in all animals ECG electrodes were always at the same location. Maximal QRS amplitude (ECGmax) and minimal QRS amplitude (ECGmin) were determined over one respiratory cycle. ΔECG was calculated as 100 × [(ECGmax - ECGmin)/(ECGmax + ECGmin)/2]. ΔECG and ΔPP were simultaneously recorded. Measurements were performed at different time points: during normovolemic conditions, after haemorrhage (25 mL/kg), and following re-transfusion (25 mL/kg) with constant tidal volume (10 mL/kg) and respiration rate (15 breath/min). At baseline, ΔPP and ΔECG were both <12 %. ΔPP were significantly correlated with ΔECG (r(2) = 0.89, p < 0.001). Volume loss induced by haemorrhage increased significantly ΔPP and ΔECG. Moreover, during this state, ΔPP were significantly correlated with ΔECG (r(2) = 0.86, p < 0.001). Re-transfusion significantly decreased ΔPP and ΔECG, and ΔPP were significantly correlated with ΔECG (r(2) = 0.90, p < 0.001). The observed correlations between ΔPP and ΔECG at each time point of the study suggest that ΔECG is a reliable parameter to estimate the changes in intravascular volume status and provide experimental confirmation of the "Brody effect."
Collapse
Affiliation(s)
- Raphaël Giraud
- Intensive Care Service, Geneva University Hospitals, 4 Rue Gabrielle Perret-Gentil, 1211, Geneva 14, Switzerland.
| | | | | | | | | | | |
Collapse
|
7
|
Lorne E, Mahjoub Y, Guinot PG, Fournier Y, Detave M, Pila C, Ben Ammar A, Labont B, Zogheib E, Dupont H. Respiratory variations of R-wave amplitude in lead II are correlated with stroke volume variations evaluated by transesophageal Doppler echocardiography. J Cardiothorac Vasc Anesth 2012; 26:381-6. [PMID: 22459928 DOI: 10.1053/j.jvca.2012.01.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The authors hypothesized that variations in electrocardiographically derived R-wave amplitude might be correlated with mechanical ventilation-induced variations in stroke volume as determined by transesophageal echocardiography. DESIGN Observational prospective study. SETTING Single university hospital. PARTICIPANTS Thirty-four patients undergoing coronary artery bypass surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Respiratory R-wave variations in lead II (ΔRII) were correlated with aortic velocity time integral variations (r = 0.82, p < 0.0001). Respiratory R-wave variations in leads III and aVF and pulse pressure variation also were correlated with aortic velocity time integral variations (r = 0.49, p = 0.015; r = 0.61, p = 0.0016; and r = 0.72, p < 0.0001, respectively). R-wave respiratory variations in lead V(5) were not correlated with aortic velocity time integral variations. ΔRII was correlated with pulse pressure variation (r = 0.71, p < 0.0001). A ΔRII cutoff value of 15% accurately predicted stroke volume variations >15%, with a specificity of 92%, a sensitivity of 86%, a positive likelihood ratio of 11.1, a negative likelihood ratio of 0.15, a positive predictive value of 95%, and a negative predictive value of 80%. CONCLUSIONS ΔRII is correlated with stroke volume variations as determined by transesophageal echocardiography in mechanically ventilated patients and can identify the stroke volume variation cutoff of 15%, previously determined to be the cutoff for volume responsiveness.
Collapse
Affiliation(s)
- Emmanuel Lorne
- Pôle Anesthésie-Réanimation, CHU d'Amiens, Amiens, France.
| | | | | | | | | | | | | | | | | | | |
Collapse
|