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Tang X, Chen Q, Huang Z, Liang J, An R, Liu H. Comparison of the carotid corrected flow time and tidal volume challenge for assessing fluid responsiveness in robot-assisted laparoscopic surgery. J Robot Surg 2023; 17:2763-2772. [PMID: 37707743 DOI: 10.1007/s11701-023-01710-y] [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: 07/24/2023] [Accepted: 09/01/2023] [Indexed: 09/15/2023]
Abstract
We aimed to compare the ability of carotid corrected flow time assessed by ultrasound and the changes in dynamic preload indices induced by tidal volume challenge predicting fluid responsiveness in patients undergoing robot-assisted laparoscopic gynecological surgery in the modified head-down lithotomy position. This prospective single-center study included patients undergoing robot-assisted laparoscopic surgery in the modified head-down lithotomy position. Carotid Doppler parameters and hemodynamic data, including corrected flow time, pulse pressure variation, stroke volume variation, and stroke volume index at a tidal volume of 6 mL/kg predicted body weight and after increasing the tidal volume to 8 mL/kg predicted body weight (tidal volume challenge), respectively, were measured. Fluid responsiveness was defined as a stroke volume index ≥ 10% increase after volume expansion. Among the 52 patients included, 26 were classified as fluid responders and 26 as non-responders based on the stroke volume index. The area under the receiver operating characteristic curve measured to predict the fluid responsiveness to corrected flow time and changes in pulse pressure variation (ΔPPV6-8) after tidal volume challenge were 0.82 [95% confidence interval (CI) 0.71-0.94; P < 0.0001] and 0.85 (95% CI 0.74-0.96; P < 0.0001), respectively. The value for pulse pressure variation at a tidal volume of 8 mL/kg was 0.79 (95% CI 0.67-0.91; P = 0.0003). The optimal cut-off values for corrected flow time and ΔPPV6-8 were 357 ms and > 1%, respectively. Both the corrected flow time and Changes in pulse pressure variation after tidal volume challenge reliably predicted fluid responsiveness in patients undergoing robot-assisted laparoscopic gynecological surgery in the modified head-down lithotomy position. And pulse pressure variation at a tidal volume of 8 mL/kg maybe also a useful predictor.Trial registration: Chinese Clinical Trial Register (CHiCTR2200060573, Principal investigator: Hongliang Liu, Date of registration: 05/06/2022).
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Affiliation(s)
- Xixi Tang
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, China
| | - Qi Chen
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, China
| | - Zejun Huang
- Department of Ultrasound, Chongqing University Cancer Hospital, Chongqing, China
| | - Jingqiu Liang
- Chongqing Cancer Multi-Omics Big Data Application Engineering Research Center, Chongqing University Cancer Hospital, Chongqing, China
| | - Ran An
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, China
| | - Hongliang Liu
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, China.
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Hrdy O, Duba M, Dolezelova A, Roskova I, Hlavaty M, Traj R, Bönisch V, Smrcka M, Gal R. Effects of goal-directed fluid management guided by a non-invasive device on the incidence of postoperative complications in neurosurgery: a pilot and feasibility randomized controlled trial. Perioper Med (Lond) 2023; 12:32. [PMID: 37408018 DOI: 10.1186/s13741-023-00321-3] [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: 03/02/2022] [Accepted: 06/28/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND The positive effects of goal-directed hemodynamic therapy (GDHT) on patient-orientated outcomes have been demonstrated in various clinical scenarios; however, the effects of fluid management in neurosurgery remain unclear. Therefore, this study was aimed at assessing the safety and feasibility of GDHT using non-invasive hemodynamic monitoring in elective neurosurgery. The incidence of postoperative complications was compared between GDHT and control groups. METHODS We conducted a single-center randomized pilot study with an enrollment target of 34 adult patients scheduled for elective neurosurgery. We randomly assigned the patients equally into control and GDHT groups. The control group received standard therapy during surgery and postoperatively, whereas the GDHT group received therapy guided by an algorithm based on non-invasive hemodynamic monitoring. In the GDHT group, we aimed to achieve and sustain an optimal cardiac index by using non-invasive hemodynamic monitoring and bolus administration of colloids and vasoactive drugs. The number of patients with adverse events, feasibility criteria, perioperative parameters, and incidence of postoperative complications was compared between groups. RESULTS We successfully achieved all feasibility criteria. The GDHT protocol was safe, because no patients in either group had unsatisfactory brain tissue relaxation after surgery or brain edema requiring therapy during surgery or 24 h after surgery. Major complications occurred in two (11.8%) patients in the GDHT group and six (35.3%) patients in the control group (p = 0.105). CONCLUSIONS Our results suggested that a large randomized trial evaluating the effects of GDHT on the incidence of postoperative complications in elective neurosurgery should be safe and feasible. The rate of postoperative complications was comparable between groups. TRIAL REGISTRATION Trial registration: ClininalTrials.gov, registration number: NCT04754295, date of registration: February 15, 2021.
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Affiliation(s)
- Ondrej Hrdy
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Milos Duba
- Department of Neurosurgery, University Hospital Brno, Brno, Czech Republic.
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Andrea Dolezelova
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ivana Roskova
- Department of Neurosurgery, University Hospital Brno, Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Hlavaty
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Rudolf Traj
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Vit Bönisch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Smrcka
- Department of Neurosurgery, University Hospital Brno, Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Roman Gal
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno, Brno, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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The Impact of Individualized Hemodynamic Management on Intraoperative Fluid Balance and Hemodynamic Interventions during Spine Surgery in the Prone Position: A Prospective Randomized Trial. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58111683. [PMID: 36422222 PMCID: PMC9698539 DOI: 10.3390/medicina58111683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/07/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022]
Abstract
Background and Objectives: The effect of individualized hemodynamic management on the intraoperative use of fluids and other hemodynamic interventions in patients undergoing spinal surgery in the prone position is controversial. This study aimed to evaluate how the use of individualized hemodynamic management based on extended continuous non-invasive hemodynamic monitoring modifies intraoperative hemodynamic interventions compared to conventional hemodynamic monitoring with intermittent non-invasive blood pressure measurements. Methods: Fifty adult patients (American Society of Anesthesiologists physical status I−III) who underwent spinal procedures in the prone position and were then managed with a restrictive fluid strategy were prospectively randomized into intervention and control groups. In the intervention group, individualized hemodynamic management followed a goal-directed protocol based on continuously non-invasively measured blood pressure, heart rate, cardiac output, systemic vascular resistance, and stroke volume variation. In the control group, patients were monitored using intermittent non-invasive blood pressure monitoring, and the choice of hemodynamic intervention was left to the discretion of the attending anesthesiologist. Results: In the intervention group, more hypotensive episodes (3 (2−4) vs. 1 (0−2), p = 0.0001), higher intraoperative dose of ephedrine (0 (0−10) vs. 0 (0−0) mg, p = 0.0008), and more positive fluid balance (680 (510−937) vs. 270 (196−377) ml, p < 0.0001) were recorded. Intraoperative norepinephrine dose and postoperative outcomes did not differ between the groups. Conclusions: Individualized hemodynamic management based on data from extended non-invasive hemodynamic monitoring significantly modified intraoperative hemodynamic management and was associated with a higher number of hemodynamic interventions and a more positive fluid balance.
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Reliability of stroke volume or pulse pressure variation as dynamic predictors of fluid responsiveness in laparoscopic surgery: a systematic review. J Clin Monit Comput 2022; 37:379-387. [PMID: 36399217 DOI: 10.1007/s10877-022-00939-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/25/2022] [Indexed: 11/19/2022]
Abstract
The reliability of stroke volume variation (SVV) and pulse pressure variation (PPV) in predicting fluid responsiveness during laparoscopic surgery remains unclear. We conducted the present systematic review to summarize the current evidence. We reviewed studies that investigated the reliability of SVV and PPV in laparoscopic surgery. Seven studies were included in the final analysis. Two studies demonstrated that the area under the receiver operating characteristic curve (AUROC) for SVV was less than 0.8, and five studies reported that the AUROC was > 0.8. The pooled AUROC for SVV and PPV was more than 0.8 with high heterogeneities between the included studies. Most individual studies have suggested that SVV and PPV are sufficiently reliable for predicting fluid responsiveness during laparoscopic surgery. However, the limited number of patients, varied apparatus used to define fluid responsiveness, diverse definitions of fluid responsiveness, and different fluids used to perform fluid challenges in the included studies render firm conclusions about SVV's and PPV's reliability impossible.
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Nakano H, Hashimoto H, Mochizuki M, Naraba H, Takahashi Y, Sonoo T, Nakamura K. Evaluation of Intravascular Volume Using the Internal Jugular Vein Cardiac Collapse Index in the Emergency Department: A Preliminary Prospective Observational Study. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1169-1178. [PMID: 35370023 DOI: 10.1016/j.ultrasmedbio.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 01/17/2022] [Accepted: 02/08/2022] [Indexed: 06/14/2023]
Abstract
A non-invasive method for assessment of intravascular volume for optimal fluid administration is needed. We here conducted a preliminary study to confirm whether cardiac variation in the internal jugular vein (IJV), evaluated by ultrasound, predicts fluid responsiveness in patients in the emergency department. Patients who presented to the emergency department between August 2019 and March 2020 and required infusions were enrolled. We recorded a short-axis video of the IJV, respiratory variability in the inferior vena cava and stroke volume variations using the ClearSight System (Edwards Lifesciences, Irvine, CA, USA) before infusion of 500 mL of crystalloid fluid. Cardiac variations in the cross-sectional area of the IJV were measured by speckle tracking. Among the 148 patients enrolled, 105 were included in the final analysis. Fluid responsiveness did not correlate with the cardiac collapse index (13.6% vs. 16.8%, p = 0.24), but correlated with stroke volume variations (12.5% vs. 15.6%, p = 0.026). Although it is a simple correction, the cardiac collapse index correlated with stroke volume corrected by age (r = 0.25, p = 0.01), body surface area (r = 0.33, p = 0.002) and both (r = 0.35, p = 0.001). Cardiac variations in the IJV did not predict fluid responsiveness in the emergency department, but may reflect stroke volume.
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Affiliation(s)
- Hidehiko Nakano
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan.
| | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Masaki Mochizuki
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Hiromu Naraba
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Yuji Takahashi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Tomohiro Sonoo
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
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Liu Y, Chen G, Gao J, Chi M, Mao M, Shi Y, Ji Z, Fu Q, Zhang H, Xu Z. Effect of different levels of stroke volume variation on the endothelial glycocalyx of patients undergoing colorectal surgery: A randomized clinical trial. Exp Physiol 2021; 106:2124-2132. [PMID: 34347918 DOI: 10.1113/ep089348] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/03/2021] [Indexed: 12/28/2022]
Abstract
NEW FINDINGS What is the central question of this study? Massive infusion can destroy the endothelial glycocalyx. We compared the serum concentrations of endothelial glycocalyx components and atrial natriuretic peptide and the outcomes of patients with different levels of stroke volume variation (SVV). What is the main finding and its importance? With a decrease in SVV, the serum concentrations of endothelial glycocalyx components and atrial natriuretic peptide increased, whereas the oxygenation index decreased. When the intraoperative SVV was maintained at 7-10%, the patients had better postoperative recovery and shorter postoperative hospital stays. Therefore, it is advisable to maintain the SVV between 7 and 10%. ABSTRACT Dynamic haemodynamic parameters, such as stroke volume variation (SVV), can be used for blood volume monitoring. However, studies have determined the SVV threshold but not the optimal level. The endothelial glycocalyx (EG) plays an important role in maintaining vascular permeability. Moreover, rapid and massive infusion can lead to the degradation, shedding and destruction of the EG. We aimed to explore the effects of different SVV values (11-14, 7-10 or 3-6%) on the EG in 54 patients who were scheduled for elective colorectal tumour surgery and to identify the optimal peri-operative fluid therapy strategy. The concentrations of EG degradation products (heparin sulphate, hyaluronic acid and syndecan-1) and atrial natriuretic peptide were higher when the SVV was maintained between 3 and 6% after fluid therapy compared with pre-infusion (P < 0.05). Comparison of postoperative complications and hospitalization time among the three SVV levels was not statistically significant (P > 0.05). The postoperative hospitalization time in patients with SVV of 7-10% was shorter than that in patients with SVV of 3-6%. Infusion of a large volume of fluid, with increasing EG degeneration and atrial natriuretic peptide concentrations, might be related to postoperative outcomes.
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Affiliation(s)
- Yi Liu
- Department of Anesthesiology, The Third Medical Center of Chinese PLA General Hospital, No. 69 Yongding Road, Beijing, 100039, China.,Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Gang Chen
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Jie Gao
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Menglin Chi
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Mengmeng Mao
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Yizheng Shi
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Zexuan Ji
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Qiang Fu
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Hong Zhang
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Zhipeng Xu
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
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de Keijzer IN, Scheeren TWL. Perioperative Hemodynamic Monitoring: An Overview of Current Methods. Anesthesiol Clin 2021; 39:441-456. [PMID: 34392878 DOI: 10.1016/j.anclin.2021.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Perioperative hemodynamic monitoring is an essential part of anesthetic care. In this review, we aim to give an overview of methods currently used in the clinical routine and experimental methods under development. The technical aspects of the mentioned methods are discussed briefly. This review includes methods to monitor blood pressures, for example, arterial pressure, mean systemic filling pressure and central venous pressure, and volumes, for example, global end-diastolic volume (GEDV) and extravascular lung water. In addition, monitoring blood flow (cardiac output) and fluid responsiveness (preload) will be discussed.
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Affiliation(s)
- Ilonka N de Keijzer
- Department of Anesthesiology, University Medical Center Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB Groningen, The Netherlands.
| | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB Groningen, The Netherlands
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Heart rate variability and haemodynamic factors associated with hypotension during spinal anaesthesia for caesarean delivery: A case-control study. Eur J Anaesthesiol 2021; 39:219-226. [PMID: 34101716 DOI: 10.1097/eja.0000000000001551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Hypotension frequently occurs during spinal anaesthesia for caesarean delivery, with potential adverse effects. OBJECTIVE To investigate heart rate variability and haemodynamic factors associated with spinal anaesthesia-induced hypotension. DESIGN Secondary case-control analysis of a randomised study. SETTING Single obstetric centre. PATIENTS Data were obtained from 230 healthy term singleton parturients who underwent elective caesarean delivery under spinal anaesthesia. INTERVENTION With parturients at rest, continuous haemodynamic measurements were recorded using a Nexfin cardiac monitor. Baseline pre-operative values were defined as the average of five minutes of continuous measurements. After initiation of standardised spinal anaesthesia, vasopressors were administered to maintain SBP within 10% of pre-operative values. Hypotension was defined as any 10 seconds average SBP less than 80% of pre-operative values from initiation of spinal anaesthesia to foetal delivery. Parturients were classified into cases (hypotensive) or controls (normotensive), and both univariate and multivariable logistic regression models were used to identify independent factors associated with hypotension. MAIN OUTCOME MEASURES Pre-operative standard deviation of the interbeat interval (SDNN), root mean square of successive interbeat difference, low-frequency to high-frequency ratio, SD1, SD2, approximate entropy, sample entropy, mean arterial pressure, SBP, stroke volume variation and systemic vascular resistance index were recorded, as were sensory block height, intravenous fluid volume and vasopressor use between spinal anaesthesia and foetal delivery. RESULTS Of 230 parturients, 113 (49.1%) experienced hypotension. Pre-operative lower SDNN [odds ratio (OR) 0.87, 95% confidence interval (CI) 0.78 to 0.97], higher SD2 (OR 25.06, 95% CI 2.41 to 261.06), and lower SBP (OR 0.98, 95% CI 0.97 to 1.00) were independently associated with hypotension. Between spinal anaesthesia to foetal delivery, lower sensory block height (OR 0.76, 95% CI 0.65 to 0.90) and higher intravenous fluid volume (OR 0.98, 95% CI 0.96 to 0.99 per 15 ml change) were associated with a lower incidence of hypotension. Area under the receiver operating characteristic curve was 0.701. CONCLUSION Pre-operative higher SD2, lower SDNN and lower SBP were associated with hypotension during spinal anaesthesia for caesarean delivery. TRIAL REGISTRATION NCT02277730.
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Sasaki K, Yamamoto S, Mutoh T. Noninvasive assessment of fluid responsiveness for emergency abdominal surgery in dogs with pulmonary hypertension: Insights into high-risk companion animal anesthesia. PLoS One 2020; 15:e0241234. [PMID: 33095826 PMCID: PMC7584187 DOI: 10.1371/journal.pone.0241234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 10/11/2020] [Indexed: 11/19/2022] Open
Abstract
Objective Optimizing cardiac stroke volume during high-risk surgical anesthesia is of particular interest with regard to a therapeutic target to reduce the incidence of postoperative complications. However, intensive fluid management in critically ill small animals with pulmonary hypertension (PH) has been empirically performed, and thus it can be challenging. Stroke volume variation (SVV) has been used as a dynamic preload predictor of fluid responsiveness. We hypothesized that if SVV exhibited robust reliability in the setting of hemodynamically unstable condition, it would provide more precise information on fluid resuscitation to translate it into veterinary anesthesia. Thus the aim of this study was to investigate the utility of SVV measured by the electrical velocimetry (EV) method for predicting fluid responsiveness in dogs with PH. Methods Sixteen dogs undergoing emergency abdominal surgery and diagnosed with PH secondary to myxomatous mitral valve disease (MMVD) on preoperative transthoracic echocardiogram were included. Dogs were randomly assigned to 2 groups with and without inotropic cardiac support with dobutamine. Hemodynamic measurements including stroke volume and SVV derived from the EV device were performed under general anesthesia before (baseline) and after surgery (fluid challenge with a colloid solution defined by a SV increase of ≥ 10%). Results In both groups, SVV elevated significantly after abdominal surgery compared with baseline. In dobutamine infused group, the SVV values decreased significantly after fluid challenge (P < 0.05) with a greater number of responders than saline infused control group (P < 0.01). Receiver operating curve analysis of SVV confirmed high positive predictive value for dogs during dobutamine infusion (P < 0.05; cut-off value of 15%; specificity 90%, sensitivity 82%). Conclusions Noninvasive EV monitoring may be useful for the prediction of fluid responsiveness in critically ill dogs with left-sided heart failure-related PH. This normalization of dynamic preload indices, which could be achieved more precisely under inotropic support, may prevent further detrimental consequence of fluid loading.
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Affiliation(s)
- Kazumasu Sasaki
- Small Animal Emergency and Critical Care Service, Sendai Animal Care and Research Center, Sendai, Japan
- Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Shuzo Yamamoto
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Tatsushi Mutoh
- Small Animal Emergency and Critical Care Service, Sendai Animal Care and Research Center, Sendai, Japan
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
- * E-mail:
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Weinberg L, Mackley L, Ho A, Mcguigan S, Ianno D, Yii M, Banting J, Muralidharan V, Tan CO, Nikfarjam M, Christophi C. Impact of a goal directed fluid therapy algorithm on postoperative morbidity in patients undergoing open right hepatectomy: a single centre retrospective observational study. BMC Anesthesiol 2019; 19:135. [PMID: 31366327 PMCID: PMC6668127 DOI: 10.1186/s12871-019-0803-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/12/2019] [Indexed: 12/27/2022] Open
Abstract
Background Right hepatectomy is a complex procedure that carries inherent risks of perioperative morbidity. To evaluate outcome differences between a low central venous pressure fluid intervention strategy and a goal directed fluid therapy (GDFT) cardiac output algorithm we performed a retrospective observational study. We hypothesized that a GDFT protocol would result in less intraoperative fluid administration, reduced complications and a shorter length of hospital stay. Methods Patients undergoing hepatectomy using an established enhanced recovery after surgery (ERAS) programme between 2010 and 2017 were extracted from a prospectively managed electronic hospital database. Inclusion criteria included adult patients, undergoing open right (segments V-VIII) or extended right (segments IV-VIII) hepatectomy. Primary outcome: amount of intraoperative fluid administration used between the two groups. Secondary outcomes: type and amount of vasoactive medications used, the development of predefined postoperative complications, hospital length of stay, and 30-day mortality. Complications were defined by the European Perioperative Clinical Outcome definitions and graded according to Clavien-Dindo classification. The association between GDFT and the amount of fluid and vasoactive medication used was investigated using logistic and linear regression models. Results Fifty-eight consecutive patients were identified. 26 patients received GDFT and 32 received Usual care. There were no significant differences in baseline patient characteristics. Less intraoperative fluid was used in the GDFT group: median (IQR) 2000 ml (1175 to 2700) vs. 2750 ml (2000 to 4000) in the Usual care group; p = 0.03. There were no significant differences in the use of vasoactive medications. Postoperative complications were similar: 9 patients (35%) in the GDFT group vs. 18 patients (56%) in the Usual care group; p = 0.10, OR: 0.41; (95%CI: 0.14 to 1.20). Median (IQR) length of stay for patients in the GDFT group was 7 days (6:8) vs. 9 days (7:13) in the Usual care group; incident rate ratio 0.72 (95%CI: 0.56 to 0.93); p = 0.012. There was no difference in perioperative mortality. Conclusions In patients undergoing open right hepatectomy with an established ERAS programme, use of GDFT was associated with less intraoperative fluid administration and reduced hospital length of stay when compared to Usual care. There were no significant differences in postoperative complications or mortality. Trial registration Australian New Zealand Clinical Trials Registry: no12619000558123 on 10/4/19.
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Affiliation(s)
- Laurence Weinberg
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia. .,Department of Surgery, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia.
| | - Lois Mackley
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Alexander Ho
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Steven Mcguigan
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Damian Ianno
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Matthew Yii
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Jonathan Banting
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | | | - Chong Oon Tan
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Chris Christophi
- Department of Surgery, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
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11
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Weinberg L, Ianno D, Churilov L, Mcguigan S, Mackley L, Banting J, Shen SH, Riedel B, Nikfarjam M, Christophi C. Goal directed fluid therapy for major liver resection: A multicentre randomized controlled trial. Ann Med Surg (Lond) 2019; 45:45-53. [PMID: 31360460 PMCID: PMC6642079 DOI: 10.1016/j.amsu.2019.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 06/30/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background The effect a restrictive goal directed therapy (GDT) fluid protocol combined with an enhanced recovery after surgery (ERAS) programme on hospital stay for patients undergoing major liver resection is unknown. Methods We conducted a multicentre randomized controlled pilot trial evaluating whether a patient-specific, surgery-specific intraoperative restrictive fluid optimization algorithm would improve duration of hospital stay and reduce perioperative fluid related complications. Results Forty-eight participants were enrolled. The median (IQR) length of hospital stay was 7.0 days (7.0:8.0) days in the restrictive fluid optimization algorithm group (Restrict group) vs. 8.0 days (6.0:10.0) in the conventional care group (Conventional group) (Incidence rate ratio 0.85; 95% Confidence Interval 0.71:1.1; p = 0.17). No statistically significant difference in expected number of complications per patient between groups was identified (IRR 0.85; 95%CI: 0.45–1.60; p = 0.60). Patients in the Restrict group had lower intraoperative fluid balances: 808 mL (571:1565) vs. 1345 mL (900:1983) (p = 0.04) and received a lower volume of fluid per kg/hour intraoperatively: 4.3 mL/kg/hr (2.6:5.8) vs. 6.0 mL/kg/hr (4.2:7.6); p = 0.03. No significant differences in the proportion of patients who received vasoactive drugs intraoperatively (p = 0.56) was observed. Conclusion In high-volume hepatobiliary surgical units, the addition of a fluid restrictive intraoperative cardiac output-guided algorithm, combined with a standard ERAS protocol did not significantly reduce length of hospital stay or fluid related complications. Our findings are hypothesis-generating and a larger confirmatory study may be justified. Major liver resection is a complex procedure with up to 40% patients experiencing complications. Optimisation of perfusion and oxygen delivery to all organs remain the cornerstone of best hemodynamic care. Traditionally, a low central venous pressure strategy during major liver resection has been used to reduce venous bleeding. The impact of a restrictive cardiac output fluid optimisation algorithm during major liver surgery is unknown. After major hepatobiliary surgery, a fluid restrictive algorithm did not reduce length of hospital stay or complications.
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Affiliation(s)
- Laurence Weinberg
- Director of Anesthesia, Austin Hospital; and A/Professor, Department of Surgery, Austin Health, The University of Melbourne, Victoria, Australia
| | - Damian Ianno
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Leonid Churilov
- Statistics and Decision Analysis Academic Platform, The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Victoria, Australia.,Department of Medicine (Austin Health), Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Steven Mcguigan
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Lois Mackley
- Department of Anesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Jonathan Banting
- Department of Anesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Shi Hong Shen
- Department of Anesthesia, Peter MacCallum Cancer Hospital, Victoria, Australia
| | - Bernhard Riedel
- Department of Anesthesia, Peter MacCallum Cancer Hospital, Victoria, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, Austin Hospital, The University of Melbourne, Victoria, Australia
| | - Chris Christophi
- Department of Surgery, Austin Hospital, The University of Melbourne, Victoria, Australia
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12
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Bubenek-Turconi ŞI, Hendy A, Băilă S, Drăgan A, Chioncel O, Văleanu L, Moroșanu B, Iliescu VA. The value of a superior vena cava collapsibility index measured with a miniaturized transoesophageal monoplane continuous echocardiography probe to predict fluid responsiveness compared to stroke volume variations in open major vascular surgery: a prospective cohort study. J Clin Monit Comput 2019; 34:491-499. [PMID: 31278544 PMCID: PMC7223808 DOI: 10.1007/s10877-019-00346-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 06/27/2019] [Indexed: 11/28/2022]
Abstract
Superior vena cava collapsibility index (SVC-CI) and stroke volume variation (SVV) have been shown to predict fluid responsiveness. SVC-CI has been validated only with conventional transoesophageal echocardiography (TEE) in the SVC long axis, on the basis of SVC diameter variations, but not in the SVC short axis or by SVC area variations. SVV was not previously tested in vascular surgery patients. Forty consecutive adult patients undergoing open major vascular surgical procedures received 266 intraoperative volume loading tests (VLTs), with 500 ml of gelatine over 10 min. The hSVC-CI was measured using a miniaturized transoesophageal echocardiography probe (hTEE). The SVV and cardiac index (CI) were measured using Vigileo-FloTrac technology. VLTs were considered 'positive' (≥ 11% increase in CI) or 'negative' (< 11% increase in CI). We compared SVV and hSVC-CI measurements in the SVC short axis to predict fluid responsiveness. Areas under the receiver operating characteristic curves for hSVC-CI and SVV were not significantly different (P = 0.56), and both showed good predictivity at values of 0.92 (P < 0.001) and 0.89 (P < 0.001), respectively. The cutoff values for hSVC-CI and SVV were 37% (sensitivity 90%, specificity of 83%) and 15% (sensitivity 78%, specificity of 100%), respectively. Our study validated the value of the SVC-CI measured as area variations in the SVC short axis to predict fluid responsiveness in anesthetized patients. An hTEE probe was used to monitor and measure the hSVC-CI but conventional TEE may also offer this new dynamic parameter. In our cohort of significant preoperative hypovolemic patients undergoing major open vascular surgery, hSVC-CI and SVV cutoff values of 37% and 15%, respectively, predicted fluid responsiveness with good accuracy.
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Affiliation(s)
- Şerban-Ion Bubenek-Turconi
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Bulevardul Eroii Sanitari Nr. 8, 050474, Bucharest, Romania. .,1-st Department of Cardiovascular Anaesthesiology and Intensive Care, "Prof. C. C. Iliescu" Emergency Institute for Cardiovascular Diseases, Șos. Fundeni Nr. 258, 022328, Bucharest, Romania.
| | - Adham Hendy
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Bulevardul Eroii Sanitari Nr. 8, 050474, Bucharest, Romania
| | - Sorin Băilă
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Bulevardul Eroii Sanitari Nr. 8, 050474, Bucharest, Romania.,Department of Cardiovascular Surgery, "Prof. C. C. Iliescu" Emergency Institute for Cardiovascular Diseases, Șos. Fundeni Nr. 258, 022328, Bucharest, Romania
| | - Anca Drăgan
- 1-st Department of Cardiovascular Anaesthesiology and Intensive Care, "Prof. C. C. Iliescu" Emergency Institute for Cardiovascular Diseases, Șos. Fundeni Nr. 258, 022328, Bucharest, Romania
| | - Ovidiu Chioncel
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Bulevardul Eroii Sanitari Nr. 8, 050474, Bucharest, Romania.,1-st Department of Cardiology, "Prof. C. C. Iliescu" Emergency Institute for Cardiovascular Diseases, Șos. Fundeni Nr. 258, 022328, Bucharest, Romania
| | - Liana Văleanu
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Bulevardul Eroii Sanitari Nr. 8, 050474, Bucharest, Romania.,1-st Department of Cardiovascular Anaesthesiology and Intensive Care, "Prof. C. C. Iliescu" Emergency Institute for Cardiovascular Diseases, Șos. Fundeni Nr. 258, 022328, Bucharest, Romania
| | - Bianca Moroșanu
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Bulevardul Eroii Sanitari Nr. 8, 050474, Bucharest, Romania.,1-st Department of Cardiovascular Anaesthesiology and Intensive Care, "Prof. C. C. Iliescu" Emergency Institute for Cardiovascular Diseases, Șos. Fundeni Nr. 258, 022328, Bucharest, Romania
| | - Vlad-Anton Iliescu
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Bulevardul Eroii Sanitari Nr. 8, 050474, Bucharest, Romania.,Department of Cardiovascular Surgery, "Prof. C. C. Iliescu" Emergency Institute for Cardiovascular Diseases, Șos. Fundeni Nr. 258, 022328, Bucharest, Romania
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13
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Ultrasound assessment of the inferior vena cava for fluid responsiveness: easy, fun, but unlikely to be helpful. Can J Anaesth 2019; 66:633-638. [PMID: 30919234 DOI: 10.1007/s12630-019-01357-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 12/18/2018] [Accepted: 12/19/2018] [Indexed: 02/06/2023] Open
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14
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Renner J, Gruenewald M, Hill M, Mangelsdorff L, Aselmann H, Ilies C, Steinfath M, Broch O. Non-invasive assessment of fluid responsiveness using CNAP™ technology is interchangeable with invasive arterial measurements during major open abdominal surgery. Br J Anaesth 2018; 118:58-67. [PMID: 28039242 DOI: 10.1093/bja/aew399] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Dynamic variables of fluid responsiveness (FR), such as pulse pressure variation (PPV), have been shown to predict the response to a fluid challenge accurately. A recently introduced non-invasive technology based on the volume-clamp method (CNAP™) offers the ability to measure PPV continuously (PPVCNAP). However, the accuracy regarding the prediction of FR in the operating room has to be proved. METHODS We compared PPVCNAP with an invasive approach measuring PPV using the PiCCO technology (PPVPiCCO). We studied 47 patients undergoing major open abdominal surgery before and after a passive leg-raising manoeuvre and i.v. fluid resuscitation. A positive response to a volume challenge was defined as ≥15% increase in stroke volume index obtained with transpulmonary thermodilution. Bootstrap methodology was used with the grey zone approach to determine the area of inconsistency regarding the ability of PPVPiCCO and PPVCNAP to predict FR. RESULTS In response to the passive leg-raising manoeuvre, PPVPiCCO predicted FR with a sensitivity of 81% and a specificity of 72% [area under the curve (AUC) 0.86] compared with a sensitivity of 76% and a specificity of 72% (AUC 0.78) for PPVCNAP Regarding the volume challenge in the operating room, PPVPiCCO predicted FR with a sensitivity of 87% and a specificity of 100% (AUC 0.97) compared with a sensitivity of 91% and specificity of 93% (AUC 0.97) for PPVCNAP The grey zone approach identified a range of PPVPiCCO values (11-13%) and PPVCNAP values (7-11%) for which FR could not be predicted reliably. CONCLUSIONS Non-invasive assessment of FR using PPVCNAP seems to be interchangeable with PPVPiCCO in patients undergoing major open abdominal surgery. CLINICAL TRIAL REGISTRATION NCT02166580.
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Affiliation(s)
- J Renner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - M Gruenewald
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - M Hill
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - L Mangelsdorff
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - H Aselmann
- Department of General and Thoracic Surgery, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - C Ilies
- Department of Anaesthesiology and Intensive Care Medicine, Marienhospital Stuttgart, Stuttgart, Germany
| | - M Steinfath
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - O Broch
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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15
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Sasaki K, Mutoh T, Yamamoto S, Taki Y, Kawashima R. Comparison of Noninvasive Dynamic Indices of Fluid Responsiveness Among Different Ventilation Modes in Dogs Recovering from Experimental Cardiac Surgery. Med Sci Monit 2018; 24:7736-7741. [PMID: 30372425 PMCID: PMC6216474 DOI: 10.12659/msm.910135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Fluid resuscitation is a cornerstone of minimizing morbidity and mortality in critically ill patients, but the techniques for predicting fluid responsiveness is still a matter of debate. In this study, we aimed to evaluate the utility of noninvasive stroke volume variation (SVV), pulse pressure variation (PPV), and systolic pressure variation (SPV) as a dynamic predictor for assessing fluid responsiveness during different ventilation modes in anaesthetized, intubated dogs recovering from cardiac surgery. Material/Methods Thirty-six adult Beagle dogs undergoing experimental surgery for isolated right ventricular failure were monitored for SVV, PPV, and SPV simultaneously using electrical velocimetry device. The relationships between each indicator and SVI before and after volume loading were compared in 3 ventilatory modes: assist control (A/C), synchronized intermittent mandatory ventilation (SIMV), and continuous positive airway pressure (CPAP). Responders were defined as those whose stroke volume index increased by ≥10%. Results In all of the indices, the baseline values were greater in responders than in nonresponders (P<0.01) under A/C and SIMV. Receiver operating curve analysis confirmed the best predictive value during A/C [area under the curve (AUC): SVV, 0.90; PPV, 0.88; SPV, 0.85; P<0.05] followed by SIMV (AUC: SVV, 0.86; PPV, 0.83; CPAP, 0.80; P<0.05), with their sensitivities and specificities of ≥7 5%. By contrast, no statistically significance detected in any parameter during CPAP (AUC: SVV, 0.71; PPV, 0.66; CPAP, 0.65; P>0.05). Conclusions SVV, PPV, and SVV are all useful to predict cardiac response to fluid loading in dogs during A/C and SIMV, while their reliabilities during CPAP are poor.
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Affiliation(s)
- Kazumasu Sasaki
- Small Animal Emergency and Critical Care Service, Sendai Animal Care and Research Center (SACRC), Sendai, Miyagi, Japan.,Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Tatsushi Mutoh
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Shuzo Yamamoto
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Yasuyuki Taki
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Ryuta Kawashima
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
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16
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Gholami B, Haddad WM, Bailey JM, Geist B, Ueyama Y, Muir WW. A pilot study evaluating adaptive closed-loop fluid resuscitation during states of absolute and relative hypovolemia in dogs. J Vet Emerg Crit Care (San Antonio) 2018; 28:436-446. [PMID: 30117659 DOI: 10.1111/vec.12753] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 04/02/2018] [Accepted: 05/09/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate and determine the performance of a partially automated as well as a fully automated closed-loop fluid resuscitation system during states of absolute and relative hypovolemia. DESIGN Prospective experimental trial. SETTING Research laboratory. ANIMALS Five adult Beagle dogs. METHODS Isoflurane anesthetized mechanically ventilated dogs were subjected to absolute hypovolemia (controlled: 2 trials; uncontrolled: 3 trials), relative hypovolemia (2 trials), and the combination of relative and absolute controlled hypovolemia (2 trials). Controlled and uncontrolled hypovolemia were produced by withdrawing blood from the carotid or femoral artery. Relative hypovolemia was produced by increasing the isoflurane concentration (1 trial) or by infusion of intravenous sodium nitroprusside (1 trial). Relative hypovolemia combined with controlled absolute hypovolemia was produced by increasing the isoflurane concentration (1 trial) and infusion of IV sodium nitroprusside (1 trial). Hemodynamic parameters including stroke volume variation (SVV) were continuously monitored and recorded in all dogs. A proprietary closed-loop fluid administration system based on fluid distribution and compartmental dynamical systems administered a continuous infusion of lactated Ringers solution in order to restore and maintain SVV to a predetermined target value. MEASUREMENTS AND MAIN RESULTS A total of 9 experiments were performed on 5 dogs. Hemodynamic parameters deteriorated and SVV increased during controlled or uncontrolled hypovolemia, relative hypovolemia, and during relative hypovolemia combined with controlled hypovolemia. Stroke volume variation was restored to baseline values during closed-loop fluid infusion. CONCLUSIONS Closed-loop fluid administration based on IV fluid distribution and compartmental dynamical systems can be used to provide goal directed fluid therapy during absolute or relative hypovolemia in mechanically ventilated isoflurane anesthetized dogs.
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Affiliation(s)
| | - Wassim M Haddad
- School of Aerospace Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - James M Bailey
- The Northeast Georgia Medical Center, Gainsville, GA, USA
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17
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Figueiredo S, Taconet C, Harrois A, Hamada S, Gauss T, Raux M, Duranteau J. How useful are hemoglobin concentration and its variations to predict significant hemorrhage in the early phase of trauma? A multicentric cohort study. Ann Intensive Care 2018; 8:76. [PMID: 29980953 PMCID: PMC6035120 DOI: 10.1186/s13613-018-0420-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/21/2018] [Indexed: 12/15/2022] Open
Abstract
Background The diagnostic value of hemoglobin (Hb) for detecting a significant hemorrhage (SH) in the early phase of trauma remains controversial. The present study aimed to assess the abilities of Hb measurements taken at different times throughout trauma management to identify patients with SH. Methods All consecutive adult trauma patients directly admitted to six French level-1 trauma centers with at least one prehospital Hb measurement were analyzed. The abilities of the following variables to identify SH (≥ 4 units of red blood cells in the first 6 h and/or death related to uncontrolled bleeding within 24 h) were determined and compared to that of shock index (SI): Hb as measured with a point-of-care (POC) device by the prehospital team on scene (POC-Hbprehosp) and upon patient’s admission to the hospital (POC-Hbhosp), the difference between POC-Hbhosp and POC-Hbprehosp (DeltaPOC-Hb) and Hb as measured by the hospital laboratory on admission (Hb-Labhosp). Results A total of 6402 patients were included, 755 with SH and 5647 controls (CL). POC-Hbprehosp significantly predicted SH with an area under ROC curve (AUC) of 0.72 and best cutoff values of 12 g/dl for women and 13 g/dl for men. POC-Hbprehosp < 12 g/dl had 90% specificity to predict of SH. POC-Hbhosp and Hb-Labhosp (AUCs of 0.92 and 0.89, respectively) predicted SH better than SI (AUC = 0.77, p < 0.001); best cutoff values of POC-Hbhosp were 10 g/dl for women and 12 g/dl for men. DeltaPOC-Hb also predicted SH with an AUC of 0.77, a best cutoff value of − 2 g/dl irrespective of the gender. For a same prehospital fluid volume infused, DeltaPOC-Hb was significantly larger in patients with significant hemorrhage than in controls. Conclusions Challenging the classical idea that early Hb measurement is not meaningful in predicting SH, POC-Hbprehosp was able, albeit modestly, to predict significant hemorrhage. POC-Hbhosp had a greater ability to predict SH when compared to shock index. For a given prehospital fluid volume infused, the magnitude of the Hb drop was significantly higher in patients with significant hemorrhage than in controls. Electronic supplementary material The online version of this article (10.1186/s13613-018-0420-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S Figueiredo
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France. .,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France.
| | - C Taconet
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France
| | - A Harrois
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France
| | - S Hamada
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France
| | - T Gauss
- Department of Anaesthesia and Critical Care, Beaujon Hospital, Hôpitaux Universitaires Paris-Nord Val-de-Seine, Assistance Publique - Hôpitaux de Paris, Clichy, France
| | - M Raux
- SSPI - Accueil des Polytraumatisés, Hôpital Universitaire Pitié Salpêtrière - Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France.,INSERM UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Université Pierre et Marie Curie, Paris, France
| | - J Duranteau
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France
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18
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Ganter MT, Geisen M, Hartnack S, Dzemali O, Hofer CK. Prediction of fluid responsiveness in mechanically ventilated cardiac surgical patients: the performance of seven different functional hemodynamic parameters. BMC Anesthesiol 2018; 18:55. [PMID: 29788919 PMCID: PMC5964892 DOI: 10.1186/s12871-018-0520-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/10/2018] [Indexed: 02/06/2023] Open
Abstract
Background Functional hemodynamic parameters such as stroke volume and pulse pressure variation (SVV and PPV) have been shown to be reliable predictors of fluid responsiveness in mechanically ventilated patients. Today, different minimally- and non-invasive hemodynamic monitoring systems measure functional hemodynamic parameters. Although some of these parameters are described by the same name, they differ in their measurement technique and thus may provide different results. We aimed to test the performance of seven functional hemodynamic parameters simultaneously in the same clinical setting. Methods Hemodynamic measurements were done in 30 cardiac surgery patients that were mechanically ventilated. Before and after a standardized intravenous fluid bolus, hemodynamics were measured by the following monitoring systems: PiCCOplus (SVVPiCCO, PPVPiCCO), LiDCOrapid (SVVLiDCO, PPVLiDCO), FloTrac (SVVFloTrac), Philips Intellivue (PPVPhilips) and Masimo pulse oximeter (pleth variability index, PVI). Prediction of fluid responsiveness was tested by calculation of receiver operating characteristic (ROC) curves including a gray zone approach and compared using Fisher’s Z-Test. Results Fluid administration resulted in an increase in cardiac output, while all functional hemodynamic parameters decreased. A wide range of areas under the ROC-curve (AUC’s) was observed: AUC-SVVPiCCO = 0.91, AUC-PPVPiCCO = 0.88, AUC-SVVLiDCO = 0.78, AUC-PPVLiDCO = 0.89, AUC-SVVFloTrac = 0.87, AUC-PPVPhilips = 0.92 and AUC-PVI = 0.68. Optimal threshold values for prediction of fluid responsiveness ranged between 9.5 and 17.5%. Lowest threshold values were observed for SVVLiDCO, highest for PVI. Conclusion All functional hemodynamic parameters tested except for PVI showed that their use allows a reliable identification of potential fluid responders. PVI however, may not be suitable after cardiac surgery to predict fluid responsiveness. Trial registration NCT02571465, registered on October 7th, 2015 (retrospectively registered).
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Affiliation(s)
- Michael T Ganter
- Institute of Anesthesiology, Kantonsspital Winterthur, Brauerstr. 15, 8401, Winterthur, Switzerland
| | - Martin Geisen
- Institute of Anesthesiology and Intensive Care Medicine, Triemli City Hospital Zurich, Birmensdorferstr. 497, 8063, Zurich, Switzerland
| | - Sonja Hartnack
- Section of Epidemiology, Vetsuisse Faculty, University of Zurich, Winterthurerstr. 270, 8057, Zurich, Switzerland
| | - Omer Dzemali
- Division of Cardiac Surgery, Triemli City Hospital Zurich, Birmensdorferstr. 497, 8063, Zurich, Switzerland
| | - Christoph K Hofer
- Institute of Anesthesiology and Intensive Care Medicine, Triemli City Hospital Zurich, Birmensdorferstr. 497, 8063, Zurich, Switzerland.
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19
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Vos JJ, Kalmar AF, Hendriks HGD, Bakker J, Scheeren TWL. The effect of fluid resuscitation on the effective circulating volume in patients undergoing liver surgery: a post-hoc analysis of a randomized controlled trial. J Clin Monit Comput 2018; 32:73-80. [PMID: 28210935 PMCID: PMC5750327 DOI: 10.1007/s10877-017-9990-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 01/23/2017] [Indexed: 12/23/2022]
Abstract
To assess the significance of an analogue of the mean systemic filling pressure (Pmsa) and its derived variables, in providing a physiology based discrimination between responders and non-responders to fluid resuscitation during liver surgery. A post-hoc analysis of data from 30 patients undergoing major hepatic surgery was performed. Patients received 15 ml kg-1 fluid in 30 min. Fluid responsiveness (FR) was defined as an increase of 20% or greater in cardiac index, measured by FloTrac-Vigileo®. Dynamic preload variables (pulse pressure variation and stroke volume variation: PPV, SVV) were recorded additionally. Pvr, the driving pressure for venous return (=Pmsa-central venous pressure) and heart performance (EH; Pvr/Pmsa) were calculated according to standard formula. Pmsa increased following fluid administration in responders (n = 18; from 13 ± 3 to 17 ± 4 mmHg, p < 0.01) and in non-responders (n = 12; from 14 ± 4 to 17 ± 4 mmHg, p < 0.01). Pvr, which was lower in responders before fluid administration (6 ± 1 vs. 7 ± 1 mmHg; p = 0.02), increased after fluid administration only in responders (from 6 ± 1 to 8 ± 1 mmHg; p < 0.01). EH only decreased in non-responders (from 0.56 ± 0.17 to 0.45 ± 0.12; p < 0.05). The area under the receiver operating characteristics curve of Pvr, PPV and SVV for predicting FR was 0.75, 0.73 and 0.72, respectively. Changes in Pmsa, Pvr and EH reflect changes in effective circulating volume and heart performance following fluid resuscitation, providing a physiologic discrimination between responders and non-responders. Also, Pvr predicts FR equivalently compared to PPV and SVV, and might therefore aid in predicting FR in case dynamic preload variables cannot be used.
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Affiliation(s)
- Jaap Jan Vos
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700RB, Groningen, Netherlands.
| | - A F Kalmar
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700RB, Groningen, Netherlands
- Department of Anesthesia and Critical Care Medicine, Maria Middelares Hospital, Ghent, Belgium
| | - H G D Hendriks
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700RB, Groningen, Netherlands
| | - J Bakker
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - T W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700RB, Groningen, Netherlands
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Wu C, Lin Y, Tseng H, Cheng H, Lee T, Lin P, Chou W, Cheng Y. Comparison of two stroke volume variation-based goal-directed fluid therapies for supratentorial brain tumour resection: a randomized controlled trial. Br J Anaesth 2017; 119:934-942. [DOI: 10.1093/bja/aex189] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2017] [Indexed: 11/13/2022] Open
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21
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Weinberg L, Ianno D, Churilov L, Chao I, Scurrah N, Rachbuch C, Banting J, Muralidharan V, Story D, Bellomo R, Christophi C, Nikfarjam M. Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial. PLoS One 2017; 12:e0183313. [PMID: 28880931 PMCID: PMC5589093 DOI: 10.1371/journal.pone.0183313] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 07/31/2017] [Indexed: 12/16/2022] Open
Abstract
We aimed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy with or without a cardiac output goal directed therapy (GDT) algorithm. We conducted a multicentre randomised controlled trial in four high volume hepatobiliary-pancreatic surgery centres. We evaluated whether the additional impact of a intraoperative fluid optimisation algorithm would influence the amount of fluid delivered, reduce fluid related complications, and improve length of hospital stay. Fifty-two consecutive adult patients were recruited. The median (IQR) duration of surgery was 8.6 hours (7.1:9.6) in the GDT group vs. 7.8 hours (6.8:9.0) in the usual care group (p = 0.2). Intraoperative fluid balance was 1005mL (475:1873) in the GDT group vs. 3300mL (2474:3874) in the usual care group (p<0.0001). Total volume of fluid administered intraoperatively was also lower in the GDT group: 2050mL (1313:2700) vs. 4088mL (3400:4525), p<0.0001 and vasoactive medications were used more frequently. There were no significant differences in proportions of patients experiencing overall complications (p = 0.179); however, fewer complications occurred in the GDT group: 44 vs. 92 (Incidence Rate Ratio: 0.41; 95%CI 0.24 to 0.69, p = 0.001). Median (IQR) length of hospital stay was 9.5 days (IQR: 7.0, 14.3) in the GDT vs. 12.5 days in the usual care group (IQR: 9.0, 22.3) for an Incidence Rate Ratio 0.64 (95% CI 0.48 to 0.85, p = 0.002). In conclusion, using a surgery-specific, patient-specific goal directed restrictive fluid therapy algorithm in this cohort of patients, can justify using enough fluid without causing oedema, yet as little fluid as possible without causing hypovolaemia i.e. “precision” fluid therapy. Our findings support the use of a perioperative haemodynamic optimization plan that prioritizes preservation of cardiac output and organ perfusion pressure by judicious use of fluid therapy, rational use of vasoactive drugs and timely application of inotropic drugs. They also suggest the need for further larger studies to confirm its findings.
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Affiliation(s)
- Laurence Weinberg
- Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia
- Anaesthesia and Perioperative and Pain Medicine Unit, The University of Melbourne, Parkville, Victoria, Australia
- * E-mail:
| | - Damian Ianno
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- Statistics and Decision Analysis Academic Platform, The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Victoria, Australia
| | - Ian Chao
- Department of Anaesthesia, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Nick Scurrah
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Clive Rachbuch
- Department of Anaesthesia, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Jonathan Banting
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Vijaragavan Muralidharan
- Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia
| | - David Story
- Anaesthesia and Perioperative and Pain Medicine Unit, The University of Melbourne, Parkville, Victoria, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Chris Christophi
- Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, Austin Hospital, The University of Melbourne, Heidelberg, Victoria, Australia
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Arterial Pressure Variation in Elective Noncardiac Surgery: Identifying Reference Distributions and Modifying Factors. Anesthesiology 2017; 126:249-259. [PMID: 27906705 DOI: 10.1097/aln.0000000000001460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Assessment of need for intravascular volume resuscitation remains challenging for anesthesiologists. Dynamic waveform indices, including systolic and pulse pressure variation, are demonstrated as reliable measures of fluid responsiveness for mechanically ventilated patients. Despite widespread use, real-world reference distributions for systolic and pulse pressure variation values have not been established for euvolemic intraoperative patients. The authors sought to establish systolic and pulse pressure variation reference distributions and assess the impact of modifying factors. METHODS The authors evaluated adult patients undergoing general anesthetics for elective noncardiac surgery. Median systolic and pulse pressure variations during a 50-min postinduction period were noted for each case. Modifying factors including body mass index, age, ventilator settings, positioning, and hemodynamic management were studied via univariate and multivariable analyses. For systolic pressure variation values, effects of data entry method (manually entered vs. automated recorded) were similarly studied. RESULTS Among 1,791 cases, per-case median systolic and pulse pressure variation values formed nonparametric distributions. For each distribution, median values, interquartile ranges, and reference intervals (2.5th to 97.5th percentile) were, respectively, noted: these included manually entered systolic pressure variation (6.0, 5.0 to 7.0, and 3.0 to 11.0 mmHg), automated systolic pressure variation (4.7, 3.9 to 6.0, and 2.2 to 10.4 mmHg), and automated pulse pressure variation (7.0, 5.0 to 9.0, and 2.0 to 16.0%). Nonsupine positioning and preoperative β blocker were independently associated with altered systolic and pulse pressure variations, whereas ventilator tidal volume more than 8 ml/kg ideal body weight and peak inspiratory pressure more than 16 cm H2O demonstrated independent associations for systolic pressure variation only. CONCLUSIONS This study establishes real-world systolic and pulse pressure variation reference distributions absent in the current literature. Through a consideration of reference distributions and modifying factors, the authors' study provides further evidence for assessing intraoperative volume status and fluid management therapies.
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Høiseth LØ, Hagemo JS. Predicting fluid responsiveness in whom? A simulated example of patient spectrum influencing the receiver operating characteristics curve. J Clin Monit Comput 2017; 32:215-219. [PMID: 28432561 DOI: 10.1007/s10877-017-0019-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 04/17/2017] [Indexed: 11/26/2022]
Abstract
The influence of patient spectrum on the sensitivities and specificities of diagnostic methods has been termed spectrum bias or spectrum effect. Receiver operating characteristics curves are often used to assess the ability of diagnostic methods to predict fluid responsiveness. As a receiver operating characteristics curve is a presentation of sensitivity and specificity, the purpose of the present manuscript was to explore if patient spectrum could affect areas under receiver operating characteristics curves and their gray zones. Relationships between stroke volume variation and change in stroke volume in two different patient populations using simulated data. Simulated patient populations with stroke volume variation values between 5 and 15 or 3 and 25% had median (2.5th-97.5th percentiles) areas under receiver operating characteristics curves of 0.79 (0.65-0.90) and 0.93 (0.85-0.99), respectively. The gray zones indicating range of diagnostic uncertainty were also affected. The patient spectrum can affect common statistics from receiver operating characteristics curves, indicating the need for considering patient spectrum when evaluating the abilities of different methods to predict fluid responsiveness.
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Affiliation(s)
- Lars Øivind Høiseth
- Division of Emergencies and Critical Care, Department of Anesthesiology, Oslo University Hospital, Kirkeveien 166, 0368, Oslo, Norway.
- Section of Vascular Investigations, Division of Cardiovascular and Pulmonary Diseases, Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway.
| | - Jostein S Hagemo
- Norwegian Air Ambulance Foundation, Drøbak, Norway
- Division of Prehospital Care, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
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Sasaki K, Mutoh T, Mutoh T, Taki Y, Kawashima R. Noninvasive stroke volume variation using electrical velocimetry for predicting fluid responsiveness in dogs undergoing cardiac surgery. Vet Anaesth Analg 2017; 44:719-726. [PMID: 28803717 DOI: 10.1016/j.vaa.2016.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 10/29/2016] [Accepted: 11/06/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the ability of a noninvasive cardiac output monitoring system with electrical velocimetry (EV) for predicting fluid responsiveness in dogs undergoing cardiac surgery. STUDY DESIGN Prospective experimental trial. ANIMALS A total of 30 adult Beagle dogs. METHODS Stroke volume (SV), stroke volume variation (SVV) and cardiac index were measured using the EV device in sevoflurane-anaesthetized, mechanically ventilated dogs undergoing thoracotomies for experimental creation of right ventricular failure. The dogs were considered fluid responsive if stroke volume (SVI; indexed to body weight), measured using pulmonary artery thermodilution, increased by 10% or more after volume loading (10 mL kg-1). Relationships of SVV, central venous pressure (CVP) and pulmonary artery occlusion pressure (PAOP) with SVI were analysed to estimate fluid responsiveness. RESULTS Better prediction of fluid responsiveness, with a significant area under the receiver operating characteristic curve, was observed for SVV (0.85±0.07; p=0.0016) in comparison with CVP (0.65±0.11; p=0.17) or PAOP (0.60±0.12; p=0.35), with a cut-off value of 13.5% (84% specificity and 73% sensitivity). CONCLUSIONS AND CLINICAL RELEVANCE SVV derived from EV is useful for identification of dogs that are likely to respond to fluids, providing valuable information on volume status under cardiothoracic anaesthesia.
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Affiliation(s)
- Kazumasu Sasaki
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan; Sendai Animal Care and Research Center, Sendai, Japan
| | - Tatsushi Mutoh
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan.
| | - Tomoko Mutoh
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Yasuyuki Taki
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Ryuta Kawashima
- Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
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[Anaesthesia procedures and invasive vascular access in severely injured patients at trauma room admission in Germany : An online survey]. Anaesthesist 2017; 66:100-108. [PMID: 28078374 DOI: 10.1007/s00101-016-0258-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 10/12/2016] [Accepted: 10/18/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND The continuous monitoring of vital parameters and subsequent therapy belong to the core duties of anaesthetists during acute trauma resuscitation in the trauma room. Important procedures may include placement of arterial lines and central venous catheters (CVCs). Knowledge of indication, performance and localization of invasive catheterisation of trauma care in Germany is scarce. METHODS After approval of the German Society of Anaesthesiology and Intensive Care Medicine we conducted an online survey about arterial and central venous catheterisation of severely injured patients with consideration of common practice used by anaesthetists in German trauma rooms. Data are presented in a descriptive manner. RESULTS Of 843 hospitals invited for the survey, 72 (8.5%) had complete and valid data and were thus included in the analysis. Of these, 47% were supra-regional (level 1) trauma centres, 38% regional trauma centres and 15% local trauma centres. The annual mean injury severity score (ISS) of admitted patients to these hospitals was 21 ± 10. In the trauma room, the responding hospitals place CVCs (49%) and arterial lines (59%) only in haemodynamically unstable patients, whereas 24% (CVC) and 39% (arterial line) do when pathological laboratory tests were confirmed. Standard operating procedures (SOPs) merely exist for placement of either arterial lines (25%) or CVCs (22%) in multiple trauma resuscitation. The decision to perform CVC or arterial line placement is usually (79%) at the discretion of the attending anaesthetist. The preferred anatomical access site for CVCs is the right internal jugular vein (46%) and for arterial lines the radial artery (without side preference) (57%), respectively. Of the responding hospitals, 49% prefer landmark-guided CVC-puncture (91% of arterial lines) instead of 43% using sonographic guidance (9% of arterial lines). Intravascular electrocardiography monitoring for CVC tip detection is used by 36%. CONCLUSION In Germany, medical indication and schedule of invasive vascular catheterisation of severely injured patients in the trauma room is rarely regulated by SOPs and often performed at the discretion of the attending trauma team. Sonographic assistance during vascular puncture and electrocardiography for CVC tip detection is not as common as in non-emergency anaesthesia. Further studies are required to explore the real necessity and safety of invasive vascular catheterisation in multiple trauma patients in order to improve trauma care.
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Meng L, Heerdt P. Perioperative goal-directed haemodynamic therapy based on flow parameters: a concept in evolution. Br J Anaesth 2016; 117:iii3-iii17. [DOI: 10.1093/bja/aew363] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Emerging Methodology of Intraoperative Hemodynamic Monitoring Research. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0176-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sundaram SC, Salins SR, Kumar AN, Korula G. Intra-Operative Fluid Management in Adult Neurosurgical Patients Undergoing Intracranial Tumour Surgery: Randomised Control Trial Comparing Pulse Pressure Variance (PPV) and Central Venous Pressure (CVP). J Clin Diagn Res 2016; 10:UC01-5. [PMID: 27437329 PMCID: PMC4948505 DOI: 10.7860/jcdr/2016/18377.7850] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 04/02/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Fluid management in neurosurgery presents specific challenges to the anaesthesiologist. Dynamic para-meters like Pulse Pressure Variation (PPV) have been used successfully to guide fluid management. AIM To compare PPV against Central Venous Pressure (CVP) in neurosurgical patients to assess hemodynamic stability and perfusion status. MATERIALS AND METHODS This was a single centre prospective randomised control trial at a tertiary care centre. A total of 60 patients undergoing intracranial tumour excision in supine and lateral positions were randomised to two groups (Group 1, CVP n=30), (Group 2, PPV n=30). Intra-operative fluid management was titrated to maintain baseline CVP in Group 1(5-10cm of water) and in Group 2 fluids were given to maintain PPV less than 13%. Acid base status, vital signs and blood loss were monitored. RESULTS Although intra-operative hypotension and acid base changes were comparable between the groups, the patients in the CVP group had more episodes of hypotension requiring fluid boluses in the first 24 hours post surgery. {CVP group median (25, 75) 2400ml (1850, 3110) versus PPV group 2100ml (1350, 2200) p=0.03} The patients in the PPV group received more fluids than the CVP group which was clinically significant. {2250 ml (1500, 3000) versus 1500ml (1200, 2000) median (25, 75) (p=0.002)}. The blood loss was not significantly different between the groups The median blood loss in the CVP group was 600ml and in the PPV group was 850 ml; p value 0.09. CONCLUSION PPV can be used as a reliable index to guide fluid management in neurosurgical patients undergoing tumour excision surgery in supine and lateral positions and can effectively augment CVP as a guide to fluid management. Patients in PPV group had better hemodynamic stability and less post operative fluid requirement.
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Affiliation(s)
| | - Serina Ruth Salins
- Assistant Professor, Department of Anaesthesia, Christian Medical College, Vellore, India
| | - Amar Nandha Kumar
- Consultant Anaesthetist, Department of Anaesthesia, Kovai Medical Center And Hospital, Coimbatore, India
| | - Grace Korula
- Professor Emeritus, Department of Anaesthesia, Christian Medical College, Vellore, India
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Hendy A, Bubenek Ş. Pulse waveform hemodynamic monitoring devices: recent advances and the place in goal-directed therapy in cardiac surgical patients. Rom J Anaesth Intensive Care 2016; 23:55-65. [PMID: 28913477 DOI: 10.21454/rjaic.7518.231.wvf] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Hemodynamic monitoring has evolved and improved greatly during the past decades as the medical approach has shifted from a static to a functional approach. The technological advances have led to innovating calibrated or not, but minimally invasive and noninvasive devices based on arterial pressure waveform (APW) analysis. This systematic clinical review outlines the physiologic rationale behind these recent technologies. We describe the strengths and the limitations of each method in terms of accuracy and precision of measuring the flow parameters (stroke volume, cardiac output) and dynamic parameters which predict the fluid responsiveness. We also analyzed the place of the APW monitoring devices in goal-directed therapy (GDT) protocols in cardiac surgical patients. According to the data from the three GDT-randomized control trials performed in cardiac surgery (using two types of APW techniques PiCCO and FloTrac/Vigileo), these devices did not demonstrate that they played a role in decreasing mortality, but only decreasing the ventilation time and the ICU and hospital length of stay.
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Affiliation(s)
- Adham Hendy
- Carol Davila University of Medicine and Pharmacy, Bucharest, 1 Department of Cardiovascular Anaesthesia and Intensive Care, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
| | - Şerban Bubenek
- Carol Davila University of Medicine and Pharmacy, Bucharest, 1 Department of Cardiovascular Anaesthesia and Intensive Care, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
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Cannesson M. The “grey zone” or how to avoid the binary constraint of decision-making. Can J Anaesth 2015; 62:1139-42. [DOI: 10.1007/s12630-015-0465-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/16/2015] [Indexed: 12/01/2022] Open
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