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Kenny JES, Prager R, Rola P, McCulloch G, Eibl JK, Haycock K. The effect of gravity-induced preload change on the venous excess ultrasound (VExUS) score and internal jugular vein Doppler in healthy volunteers. Intensive Care Med Exp 2023; 11:19. [PMID: 37055637 PMCID: PMC10102271 DOI: 10.1186/s40635-023-00504-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/20/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND The venous excess ultrasound (VExUS) score is a multi-organ Doppler approach to assess venous congestion. Despite growing use of VExUS in research and clinical practice, other veins can be visualized to assess for venous hypertension, which may overcome acquisition barriers of the VExUS exam. In this pilot, observational study, we used a wearable Doppler ultrasound to assess the relationship between jugular venous Doppler and the VExUS score under different preload conditions. We hypothesized that jugular Doppler morphology would accurately distinguish preload conditions, that it would most closely relate to the hepatic venous Doppler morphology in the fully supine position and that the VExUS score would be influenced by preload condition. RESULTS We recruited 15 healthy volunteers with no cardiovascular history. Preload change was achieved using a tilt-table with three positions: supine, fully upright, and 30-degree head-down tilt. In each position, a VExUS score was performed; furthermore, inferior vena collapsibility and sphericity index were calculated. At the same time, jugular venous Doppler was captured by a novel, wireless, wearable ultrasound system. A continuous jugular venous Doppler morphology was 96% accurate for detecting the low preload condition. The jugular venous Doppler morphology was highly correlated with the hepatic vein, but only in the supine position. Gravitational position did not significantly affect the sphericity index or the VExUS score. CONCLUSIONS The jugular vein Doppler morphology was able to accurately distinguish low from high preload conditions in healthy volunteers. Comparisons between VExUS Doppler morphologies and other veins should occur in the supine position when gravitational pressure gradients are minimized; finally, different preload conditions in healthy subjects did not affect the VExUS score.
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Affiliation(s)
- Jon-Emile S Kenny
- Health Sciences North Research Institute, 56 Walford Rd, Sudbury, ON, P3E 2H2, Canada.
- Flosonics Medical, Toronto, ON, Canada.
| | - Ross Prager
- Division of Critical Care Medicine, Western University, London, ON, Canada
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montreal, QC, Canada
| | | | - Joseph K Eibl
- Health Sciences North Research Institute, 56 Walford Rd, Sudbury, ON, P3E 2H2, Canada
- Flosonics Medical, Toronto, ON, Canada
- Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Korbin Haycock
- Department of Emergency Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
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Garcia-Leal M, Guzman-Lopez S, Verdines-Perez AM, de Leon-Gutierrez H, Fernandez-Rodarte BA, Alvarez-Villalobos NA, Martinez-Garza JH, Quiroga-Garza A, Elizondo-Omaña RE. Trendelenburg position for internal jugular vein catheterization: A systematic review and meta-analysis. J Vasc Access 2023; 24:338-347. [PMID: 34254560 DOI: 10.1177/11297298211031339] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
To determine the effect of Trendelenburg position on the diameter or cross-section area of the internal jugular vein (IJV) a systematic review and metanalysis was performed. Studies that evaluated the cross-sectional area (CSA) and anteroposterior (AP) diameter of the right internal jugular vein (RIJV) with ultrasonography in supine and any degree of head-down tilt (Trendelenburg position) were analyzed. A total of 22 articles (613 study subjects) were included. A >5° Trendelenburg position statistically increases RIJV CSA and AP diameter. Further inclination from 10° does not statistically benefit IJV size. This position should be recommended for CVC placement, when patient conditions allow it, and US-guided cannulation is not available.
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Affiliation(s)
- Mariana Garcia-Leal
- School of Medicine, Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Santos Guzman-Lopez
- Human Anatomy Department, School of Medicine, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | | | - Humberto de Leon-Gutierrez
- School of Medicine, Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | | | - Neri Alejandro Alvarez-Villalobos
- School of Medicine, Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
- Instituto Mexicano del Seguro Social, Delegación de Nuevo Leon, Monterrey, Mexico
| | | | - Alejandro Quiroga-Garza
- Human Anatomy Department, School of Medicine, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
- Instituto Mexicano del Seguro Social, Delegación de Nuevo Leon, Monterrey, Mexico
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Sejersen C, Christiansen T, Secher NH. To identify normovolemia in humans: The stroke volume response to passive leg raising vs. head-down tilt. Physiol Rep 2022; 10:e15216. [PMID: 35854636 PMCID: PMC9296869 DOI: 10.14814/phy2.15216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 06/15/2023] Open
Abstract
Volume responsiveness can be evaluated by tilting maneuvers such as head-down tilt (HDT) and passive leg raising (PLR), but the two procedures use different references (HDT the supine position; PLR the semi-recumbent position). We tested whether the two procedures identify "normovolemia" by evaluating the stroke volume (SV) and cardiac output (CO) responses and whether the peripheral perfusion index (PPI) derived from pulse oximetry provides similar information. In randomized order, 10 healthy men were exposed to both HDT and PLR, and evaluations were made also when the subjects fasted. Central cardiovascular variables were derived by pulse contour analysis and changes in central blood volume assessed by thoracic electrical admittance (TEA). During HDT, SV remained stable (fasted 110 ± 16 vs. 109 ± 16 ml; control 113 ± 16 vs. 111 ± 16 ml, p > 0.05) with no change in CO, TEA, PPI, or SV variation (SVV). In contrast during PLR, SV increased (fasted 108 ± 17 vs. 117 ± 17 ml; control 108 ± 18 vs. 117 ± 18 ml, p < 0.05) followed by an increase in TEA (p < 0.05) and CO increased when subjects fasted (6.7 ± 1.5 vs. 7.1 ± 1.5, p = 0.007) with no change in PPI or SVV. In conclusion, SV has a maximal value for rest in supine men, while PLR restores SV as CBV is reduced in a semi-recumbent position and the procedure thereby makes healthy volunteers seem fluid responsive.
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Affiliation(s)
- Casper Sejersen
- Department of AnaesthesiaInstitute for Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Till Christiansen
- Department of AnaesthesiaInstitute for Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Niels H. Secher
- Department of AnaesthesiaInstitute for Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
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Matsuzono K, Suzuki M, Miura K, Ozawa T, Mashiko T, Koide R, Tanaka R, Fujimoto S. Internal Jugular Vein Velocity and Spontaneous Echo Contrast Correlate with Alzheimer's Disease and Cognitive Function. J Alzheimers Dis 2021; 84:787-796. [PMID: 34602471 DOI: 10.3233/jad-210490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Many issues persist in the today's Alzheimer's disease (AD) screening and the breakthrough method is desired. OBJECTIVE We aim to validate the association between venous reflux and AD, and to develop a new method for AD screening. METHODS We examined spontaneous echo contrast, area, diameter, retrograde velocity, and anterograde velocity of the bilateral cervical internal jugular vein (IJV) using carotid ultrasonography. RESULTS A total of 112 patients participated in this study, with 26 diagnosed as AD. The proportion of both or either IJV spontaneous echo contrast (+) occupied 25 of total 26 AD patients, which showed 96.2%of sensitivity and 98.5%negative predictive value. The IJV velocities also showed significant correlation with AD diagnosis, although the IJV area or diameter did not. CONCLUSION Our results indicate that the validation of the spontaneous echo contrast or velocities of the IJV are convenient AD diagnosis screening methods and that the venous reflux disturbance correlates with AD development.
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Affiliation(s)
- Kosuke Matsuzono
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Masayuki Suzuki
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kumiko Miura
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Tadashi Ozawa
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Takafumi Mashiko
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Reiji Koide
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Ryota Tanaka
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
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Yamagami Y, Inoue T. Patient Position Affects Venodilation for Peripheral Intravenous Cannulation. Biol Res Nurs 2019; 22:226-233. [PMID: 31835910 DOI: 10.1177/1099800419893027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Larger veins are associated with a higher rate of success of peripheral intravenous cannulation. Although patient position affects venodilation during central venous cannulation, the association between patient position and vein size for peripheral intravenous cannulation remains unclear. PURPOSE We examined the effect of seated versus supine positioning on vein size during peripheral intravenous cannulation before and after tourniquet application. METHODS In the present study, we recruited 81 participants (20-64 years) and included 80 in the analysis. We measured outcomes before and after tourniquet application in the seated and supine positions. The primary outcome was the cross-sectional area of the target forearm vein (ultrasonography by a blinded assessor). Subgroup analysis was used to test the effects of positioning combined with difficult peripheral intravenous cannulation (DPIVC) defined as poor visibility and/or palpability of the target vein. RESULTS Results of paired t tests demonstrated that the venous cross-sectional area significantly increased in the supine position with tourniquet application compared with the seated position with tourniquet application. Subgroup analysis with two-way repeated measures analysis of variance revealed that the venous cross-sectional area was significantly larger in the supine position than in the seated position despite DPIVC. CONCLUSION Vein size during tourniquet application was greater in the supine than in the seated position even in cases of DPIVC. We thus recommend the supine position over the seated position for peripheral intravenous cannulation.
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Affiliation(s)
- Yuki Yamagami
- Department of Epidemiology, School of Medicine, Nara Medical University, Japan.,Department of Health Science, Osaka University Graduate School of Medicine, Japan
| | - Tomoko Inoue
- Department of Health Science, Osaka University Graduate School of Medicine, Japan
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AIUM Practice Parameter for the Use of Ultrasound to Guide Vascular Access Procedures. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:E4-E18. [PMID: 30758889 DOI: 10.1002/jum.14954] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Sonny A, Sessler DI, You J, Kashy BK, Sarwar S, Singh AK, Sale S, Alfirevic A, Duncan AE. The response to Trendelenburg position is minimally affected by underlying hemodynamic conditions in patients with aortic stenosis. J Anesth 2017; 31:692-702. [PMID: 28707021 DOI: 10.1007/s00540-017-2384-5] [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: 04/14/2017] [Accepted: 06/22/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE Trendelenburg positioning is commonly used to temporarily treat intraoperative hypotension. The Trendelenburg position improves cardiac output in normovolemic or anesthetized patients, but not hypovolemic or non-anesthetized patients. Therefore, the response to Trendelenburg positioning may vary depending on patient population or hemodynamic conditions. We thus tested the hypothesis that the effectiveness of the Trendelenburg position, as indicated by an increase in cardiac output, improves after replacement of a stenotic aortic valve. Secondarily, we evaluated whether measurements of left ventricular preload, systolic function, or afterload were associated with the response to Trendelenburg positioning. METHODS This study is a secondary analysis of a clinical trial which included patients having aortic valve replacement (AVR) who were monitored with pulmonary artery catheters (NCT01187329). We examined changes in thermodilution cardiac output with Trendelenburg positioning before and after AVR. We also examined whether echocardiographic and hemodynamic measurements of preload, afterload, and systolic function were associated with changes in cardiac output during Trendelenburg positioning. RESULTS Thirty-seven patients were included. The median [IQR] cardiac output change with Trendelenburg positioning was -3% [-10%, 5%] before AVR versus +4% [-4%, 15%] after AVR. Estimated median difference in cardiac output with Trendelenburg was 5% (95% CI 1, 15%, P = 0.04) greater after AVR. The response to Trendelenburg positioning was largely independent of hemodynamic conditions. CONCLUSION The response to Trendelenburg positioning improved following AVR, but by a clinically unimportant amount. The response to Trendelenburg positioning was independent of hemodynamic conditions.
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Affiliation(s)
- Abraham Sonny
- Division of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA, 02114, USA.
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Jing You
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Babak Kateby Kashy
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Senior Care Physicians, Taylor, MI, USA
| | - Sheryar Sarwar
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Department of Family Medicine, St. Vincent Medical Group, Kokoma, IN, USA
| | - Akhil K Singh
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Shiva Sale
- Division of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH, USA
| | - Andrej Alfirevic
- Division of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH, USA
| | - Andra E Duncan
- Division of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH, USA
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Lieberman P, Nicklas RA, Randolph C, Oppenheimer J, Bernstein D, Bernstein J, Ellis A, Golden DBK, Greenberger P, Kemp S, Khan D, Ledford D, Lieberman J, Metcalfe D, Nowak-Wegrzyn A, Sicherer S, Wallace D, Blessing-Moore J, Lang D, Portnoy JM, Schuller D, Spector S, Tilles SA. Anaphylaxis--a practice parameter update 2015. Ann Allergy Asthma Immunol 2016; 115:341-84. [PMID: 26505932 DOI: 10.1016/j.anai.2015.07.019] [Citation(s) in RCA: 299] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 07/12/2015] [Indexed: 12/12/2022]
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9
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Amorim EDT, Peras VR, de Andrade O, Martins-Pinge MC. Functional evidence of paraventricular nucleus involvement in cardiovascular and autonomic modulation in response to acute microgravity (head-down tilt) in unanesthetized rats. J Neurosci Res 2015; 93:1305-12. [DOI: 10.1002/jnr.23586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/17/2015] [Accepted: 02/26/2015] [Indexed: 11/10/2022]
Affiliation(s)
| | - Vivian Rossi Peras
- Department of Physiological Sciences; State University of Londrina; Londrina Paraná Region Brazil
| | - Ozahyr de Andrade
- Department of Physiological Sciences; State University of Londrina; Londrina Paraná Region Brazil
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10
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Correlation between cross-sectional area of the internal jugular vein and central venous pressure. Eur J Anaesthesiol 2014; 31:50-1. [DOI: 10.1097/eja.0b013e32835f9a50] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Agreement of cardiac output measurement between pulse contour analysis and thermodilution in various body positions: a porcine study. J Surg Res 2013; 181:315-22. [DOI: 10.1016/j.jss.2012.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 06/20/2012] [Accepted: 07/06/2012] [Indexed: 11/22/2022]
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12
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AIUM practice guideline for the use of ultrasound to guide vascular access procedures. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:191-215. [PMID: 23269727 DOI: 10.7863/jum.2013.32.1.191] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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13
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Comprehensive review: is it better to use the Trendelenburg position or passive leg raising for the initial treatment of hypovolemia? J Clin Anesth 2012; 24:668-74. [DOI: 10.1016/j.jclinane.2012.06.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 05/14/2012] [Accepted: 06/02/2012] [Indexed: 11/21/2022]
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Bleeding in Hepatic Surgery: Sorting through Methods to Prevent It. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2012; 2012:169351. [PMID: 23213268 PMCID: PMC3506885 DOI: 10.1155/2012/169351] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 10/23/2012] [Indexed: 12/22/2022]
Abstract
Liver resections are demanding operations which can have life threatening complications although they are performed by experienced liver surgeons. The parameter “Blood Loss” has a central role in liver surgery, and different strategies to minimize it are a key to improve results. Moreover, recently, new technologies are applied in the field of liver surgery, having one goal: safer and easier liver operations. The aim of this paper is to review the different principal solutions to the problem of blood loss in hepatic surgery, focusing on technical aspects of new devices.
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Halm MA. Trendelenburg position: "put to bed" or angled toward use in your unit? Am J Crit Care 2012; 21:449-52. [PMID: 23117908 DOI: 10.4037/ajcc2012657] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Margo A. Halm
- Margo A. Halm is the director of nursing research, professional practice, and Magnet at Salem Hospital in Salem, Oregon
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La posición de Trendelenburg en el tratamiento urgente del paciente hipotenso: empirismo versus racionalismo. ENFERMERIA CLINICA 2012; 22:114. [DOI: 10.1016/j.enfcli.2011.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 11/24/2011] [Indexed: 11/19/2022]
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17
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Zorko N, Mekiš D, Kamenik M. The influence of the Trendelenburg position on haemodynamics: comparison of anaesthetized patients with ischaemic heart disease and healthy volunteers. J Int Med Res 2011; 39:1084-9. [PMID: 21819742 DOI: 10.1177/147323001103900343] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study compared the influence of the Trendelenburg position on haemodynamics in non-anaesthetized spontaneously breathing healthy volunteers and anaesthetized, mechanically ventilated patients with ischaemic heart disease scheduled for coronary artery bypass graft (CABG) surgery. Placing the anaesthetized patients scheduled for CABG surgery in the Trendelenburg position resulted in a significant increase in cardiac output and mean arterial pressure and a non-significant decrease in heart rate. In contrast, in the non-anaesthetized healthy volunteers, heart rate increased significantly but both cardiac output and mean arterial pressure changed non-significantly. Further studies will be needed to evaluate the haemodynamics of the Trendelenburg position.
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Affiliation(s)
- N Zorko
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Maribor, Slovenia
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SAND L, RIZELL M, HOULTZ E, KARLSEN K, WIKLUND J, ODENSTEDT HERGÈS H, STENQVIST O, LUNDIN S. Effect of patient position and PEEP on hepatic, portal and central venous pressures during liver resection. Acta Anaesthesiol Scand 2011; 55:1106-12. [PMID: 22092208 DOI: 10.1111/j.1399-6576.2011.02502.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2011] [Indexed: 12/29/2022]
Abstract
BACKGROUND It has been suggested that blood loss during liver resection may be reduced if central venous pressure (CVP) is kept at a low level. This can be achieved by changing patient position but it is not known how position changes affect portal (PVP) and hepatic (HVP) venous pressures. The aim of the study was to assess if changes in body position result in clinically significant changes in these pressures. METHODS We studied 10 patients undergoing liver resection. Mean arterial pressure (MAP) and CVP were measured using fluid-filled catheters, PVP and HVP with tip manometers. Measurements were performed in the horizontal, head up and head down tilt position with two positive end expiratory pressure (PEEP) levels. RESULTS A 10° head down tilt at PEEP 5 cm H(2) O significantly increased CVP (11 ± 3 to 15 ± 3 mmHg) and MAP (72 ± 8 to 76 ± 8 mmHg) while head up tilt at PEEP 5 cm H(2) O decreased CVP (11 ± 3 to 6 ± 4 mmHg) and MAP (72 ± 8 to 63 ± 7 mmHg) with minimal changes in transhepatic venous pressures. Increasing PEEP from 5 to 10 resulted in small increases, around 1 mmHg in CVP, PVP and HVP. There was no significant correlation between changes in CVP vs. PVP and HVP during head up tilt and only a weak correlation between CVP and HVP by head down tilt. CONCLUSIONS Changes of body position resulted in marked changes in CVP but not in HVPs. Head down or head up tilt to reduce venous pressures in the liver may therefore not be effective measures to reduce blood loss during liver surgery.
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Affiliation(s)
- L. SAND
- Department of Anaesthesiology; University of Gothenburg; Gothenburg; Sweden
| | - M. RIZELL
- Department of Intensive Care Medicine, Transplantation and Liver Surgery; Institutes of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg; Sweden
| | - E. HOULTZ
- Department of Anaesthesiology; University of Gothenburg; Gothenburg; Sweden
| | - K. KARLSEN
- Department of Anaesthesiology; University of Gothenburg; Gothenburg; Sweden
| | - J. WIKLUND
- Department of Anaesthesiology; University of Gothenburg; Gothenburg; Sweden
| | | | - O. STENQVIST
- Department of Anaesthesiology; University of Gothenburg; Gothenburg; Sweden
| | - S. LUNDIN
- Department of Anaesthesiology; University of Gothenburg; Gothenburg; Sweden
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The head-down tilt position decreases vasopressor requirement during hypotension following induction of anaesthesia in patients undergoing elective coronary artery bypass graft and valvular heart surgeries. Eur J Anaesthesiol 2011; 28:45-50. [DOI: 10.1097/eja.0b013e3283408a0f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Suk EH, Kim DH, Kil HK, Kweon TD. Effects of skin traction on cross-sectional area of the internal jugular vein in infants and young children. Anaesth Intensive Care 2010; 38:342-5. [PMID: 20369769 DOI: 10.1177/0310057x1003800235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Internal jugular veins (IJV) are commonly used to obtain central venous access. However percutaneous cannulation of the IJVis difficult in infants and young children because of its diminutive size. The aim of this study was to evaluate the effect of skin traction on the cross-sectional area of the IJV in anaesthetised infants (younger than one year) and young children (one to six years) using ultrasound. Sixty-seven subjects undergoing general anaesthesia were studied. The cross-sectional area of the IJV was measured at the junction of the two heads of the sternocleidomastoid using ultrasound. Skin traction was performed by stretching the skin over the puncture point with pieces of surgical tape in both cephalad and caudad directions. The measurements were made after the induction of anaesthesia with patients in the supine position and with positive pressure ventilation. Skin traction increased the maximum cross-sectional area of the IJV by 39.9 +/- 29.6% in infants and by 33.8 +/- 21.9% in children (P < 0.01). This increase might facilitate easier and safer IJV cannulation in infants and children.
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Affiliation(s)
- E H Suk
- Department of Anaesthesiology and Pain Medicine, Severance Hospital, Seoul, Korea
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Dennis A, Arhanghelschi I, Simmons S, Royse C. Prospective observational study of serial cardiac output by transthoracic echocardiography in healthy pregnant women undergoing elective caesarean delivery. Int J Obstet Anesth 2010; 19:142-8. [DOI: 10.1016/j.ijoa.2009.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 04/28/2009] [Accepted: 06/25/2009] [Indexed: 11/15/2022]
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22
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Bellazzini MA, Rankin PM, Gangnon RE, Bjoernsen LP. Ultrasound validation of maneuvers to increase internal jugular vein cross-sectional area and decrease compressibility. Am J Emerg Med 2009; 27:454-9. [DOI: 10.1016/j.ajem.2008.03.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Revised: 03/21/2008] [Accepted: 03/23/2008] [Indexed: 10/20/2022] Open
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Sturgess DJ, Joyce C, Marwick TH, Venkatesh B. A clinician's guide to predicting fluid responsiveness in critical illness: applied physiology and research methodology. Anaesth Intensive Care 2007; 35:669-78. [PMID: 17933152 DOI: 10.1177/0310057x0703500504] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intravenous fluid administration is often used in critical care with the goal of improving haemodynamics and consequently tissue perfusion and oxygen delivery. While inotropic and vasoactive drugs are often necessary to correct haemodynamic instability, resuscitation usually begins with fluid therapy. As fluid challenge can result in clinical deterioration, the ability to predict haemodynamic response is desirable. In this way it might be possible to avoid unnecessary volume replacement in critically ill patients. Cardiac preload is a concept that accounts for the relationship between ventricular filling and stroke volume. It has been challenging to apply this concept to clinical practice. For this reason, the study of fluid responsiveness is of increasing research and clinical interest. The clinical application of predicting fluid responsiveness requires an understanding of relevant physiological principles. Furthermore, an improved understanding of these principles should assist the clinician in appraising published data, which has been characterised by significant methodological differences. This review aims to assist the clinician by detailing the physiological principles that underlie the prediction of fluid responsiveness in the critically ill. In addition, the potential importance of methodological differences in the cutrent literature will be considered.
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Affiliation(s)
- D J Sturgess
- School of Medicine, University of Queensland, Princess Alexandra Hospital, Wolloongabba, Queensland, Australia
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Choi YS, Bang SO, Shim JK, Chung KY, Kwak YL, Hong YW. Effects of head-down tilt on intrapulmonary shunt fraction and oxygenation during one-lung ventilation in the lateral decubitus position. J Thorac Cardiovasc Surg 2007; 134:613-8. [PMID: 17723807 DOI: 10.1016/j.jtcvs.2007.05.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2007] [Revised: 04/24/2007] [Accepted: 05/11/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVE During one-lung ventilation, surgical positions significantly affect deterioration of oxygenation, and the lateral decubitus position is superior in preventing dangerous hypoxemia compared with the supine position. However, additional head-down tilt causes more compression of the dependent ventilated lung by the abdominal contents and may result in dangerous hypoxemia, as occurs in the supine position. Therefore, we evaluated the effect of head-down tilt on intrapulmonary shunt and oxygenation during one-lung ventilation in the lateral decubitus position. METHODS Thirty-four patients requiring one-lung ventilation were randomly allocated to the control group (n = 17) or the head-down tilt group (n = 17). Hemodynamic and respiratory variables were measured 15 minutes after one-lung ventilation in the lateral decubitus position (baseline), 5 and 10 minutes after a 10-degree head-down tilt (T5 and T10, respectively), and 10 minutes after the patient was returned to a horizontal position (T20) in the head-down tilt group. Measurements were done at the same time points in the control group without head-down tilting. RESULTS In the head-down tilt group, cardiac filling pressures were increased after head-down tilt without any changes in cardiac index. Percent change of shunt to baseline value was significantly increased at T10 and T20 in the head-down tilt group. Percent change of arterial oxygen tension to baseline value was significantly decreased at T5, T10, and T20 in the head-down tilt group, whereas it was decreased only at T20 in the control group. CONCLUSION Head-down tilt during one-lung ventilation in the lateral decubitus position caused a significant increase in shunt and a decrease in percent change of arterial oxygen tension, without causing dangerous hypoxemia.
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Affiliation(s)
- Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, South Korea
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Affiliation(s)
- Amber Shammas
- University of Texas at Austin School of Nursing, Red River, Austin, TX 78701, USA
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Choi SH, Ban SY, Jun NH, Jun DB, Nam SH, Kil HK, Kim KS. Central Venous Pressure and Its Effect on Blood Loss during Hepatic Lobectomy. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.52.6.663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Seung Ho Choi
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - So Young Ban
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Na Hyung Jun
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Byeong Jun
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Soon Ho Nam
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hae Keum Kil
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Sik Kim
- Department of General Surgery, Yonsei University College of Medicine, Seoul, Korea
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Kardos A, Földesi C, Nagy A, Sáringer A, Kiss A, Kiss G, Marschalkó P, Szabó M. Trendelenburg positioning does not prevent a decrease in cardiac output after induction of anaesthesia with propofol in children. Acta Anaesthesiol Scand 2006; 50:869-74. [PMID: 16879471 DOI: 10.1111/j.1399-6576.2006.01073.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE Induction of anaesthesia may cause decreased cardiac output and blood pressure. Head-down tilt is often the first clinical step to treat hypotension. The objective of this randomized single centre study was to determine, with the use of impedance cardiography (ICG), whether Trendelenburg positioning modifies the haemodynamic response to propofol/fentanyl induction of anaesthesia in ASA I children. METHODS Thirty ASA I children aged between 7 and 16 years scheduled for elective minor orthopaedic surgery were included. After intravenous induction with propofol and fentanyl in the head-down group (HDG, n = 15), 5 min of 20 degrees head-down tilt was applied. In the supine group (SG, n = 15), no change in the supine position was made. Heart rate (HR), mean arterial blood pressure (MABP), end-tidal carbon dioxide (ETCO(2)), stroke volume index (SVI), cardiac index (CI), systemic vascular resistance index (SVRI) and Heather index (HI) were recorded before (B), at 3 (A(3)), 5 (A(5)) and 8 (A(8)) minutes after induction in each group. RESULTS After induction, a significant decrease in CI, MABP, HR and HI was recorded in both groups. In the study group, significantly lower values of HR (66 vs. 78 beat/min) and higher values of SVI (42.9 vs. 40.6 ml/min/m(2)) were measured at A(3) compared with the control group. After induction, no difference in CI and SVRI was found between the two groups. CONCLUSION The present study shows that cardiac performance is not improved by Trendelenburg positioning after propofol/fentanyl induction of anaesthesia in children.
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Affiliation(s)
- A Kardos
- Paediatric Intensive Care Unit, Heim Pál Children's Hospital, Ullöi Str. 89, 1086 Budapest, Hungary.
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Stone MB, Price DD, Anderson BS. Ultrasonographic investigation of the effect of Reverse Trendelenburg on the cross-sectional area of the femoral vein. J Emerg Med 2006; 30:211-3. [PMID: 16567260 DOI: 10.1016/j.jemermed.2005.05.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2005] [Accepted: 05/25/2005] [Indexed: 10/24/2022]
Abstract
Emergency physicians often obtain central venous access via the femoral vein in critically ill patients or patients with difficult peripheral access due to chronic intravenous drug use. Previous studies using two-dimensional ultrasonography have demonstrated that the Trendelenburg position increases the cross-sectional area of the internal jugular vein. This study is designed to determine the effect of the Reverse Trendelenburg position on femoral vein dimensions using bedside ED ultrasonography. A prospective, non-randomized observational study was conducted that enrolled subjects at an urban Level I Trauma Center and an affiliated School of Medicine over a 2-month period. Informed consent was obtained from 52 adult subjects with no history of deep venous thrombosis or vascular surgery in the lower limbs. Using two-dimensional ultrasound with a 7.5-MHz linear transducer, femoral vein cross-sectional areas on the right and left sides were measured with subjects supine, and in approximately 15 degrees reverse Trendelenburg. The data was analyzed using a two-tailed Student's t test. The mean cross-sectional area of the femoral vein with subjects supine was 0.85 cm(2) (SD +/- 0.41 cm(2)), and 1.22 cm(2) (SD +/- 0.51 cm(2)) with subjects in reverse Trendelenberg. The cross-sectional area of the femoral vein increased significantly (p < 0.001) with the reverse Trendelenburg position [55.2% +/- 9.1% (95% CI)]. In conclusion, a significant increase in femoral vein cross-sectional area can be achieved with the reverse Trendelenburg position. This maneuver may increase the rate of successful femoral vein catheterization.
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Affiliation(s)
- Michael B Stone
- Department of Emergency Medicine, Alameda County Medical Center, Highland Campus, Oakland, California 94602, USA
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Campbell AE, Turley A, Wilkes AR, Hall JE. Cricoid yoke: the effect of surface area and applied force on discomfort experienced by conscious volunteers. Eur J Anaesthesiol 2003; 20:52-5. [PMID: 12553388 DOI: 10.1017/s0265021503000097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE The application of cricoid force is central to techniques that reduce the risk of gastric regurgitation and the subsequent pulmonary aspiration associated with obstetric and emergency anaesthesia. The discomfort associated with cricoid force in awake preoperative patients increases the incidence of coughing, struggling and pain during induction of anaesthesia. This study determined if increasing the surface area of a cricoid yoke reduced the associated discomfort in volunteers. METHODS Fifty volunteers participated in a randomized single-blinded study. The cricoid yoke was positioned using standard anatomical landmarks and forces of 10, 20, 30 and 40 N were applied in a random order for 20s, using two different yoke attachments with surface areas of 3 and 10 cm2. A rest of 30s was allowed between the application of forces. Discomfort was graded by volunteers on a scale from 0 to 10 (0: no discomfort; 10: worse discomfort imaginable). A score of 10 was allocated if the volunteers could not tolerate the applied force for 20s. RESULTS Median scores for the small yoke were always higher than those for the large yoke at each force. There were significant differences between the scores for the small and large yokes at 10 and 20 N (P < 0.001) and 30 N (P = 0.0233), but there was no significant difference at 40 N. CONCLUSIONS The larger yoke was tolerated better by volunteers when clinically relevant cricoid forces were applied.
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Affiliation(s)
- A E Campbell
- University of Wales College of Medicine, Department of Anaesthetics and Intensive Care Medicine, Cardiff, UK
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Browne I, Byrne H, Briggs L. Sickle cell disease in pregnancy. Eur J Anaesthesiol 2003; 20:75-6. [PMID: 12553395 DOI: 10.1017/s0265021503240138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Gaszyński T, Gaszyński W, Strzelczyk J. General anaesthesia with remifentanil and cisatracurium for a superobese patient. Eur J Anaesthesiol 2003; 20:77-8. [PMID: 12553396 DOI: 10.1017/s0265021503250134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Erhan E, Ugur G, Alper I, Gunusen I, Ozyar B. Tracheal intubation without muscle relaxants: remifentanil or alfentanil in combination with propofol. Eur J Anaesthesiol 2003; 20:37-43. [PMID: 12557834 DOI: 10.1017/s0265021503000073] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE In some situations, the use of muscle relaxants (neuromuscular blocking drugs) are undesirable or contraindicated. We compared intubating conditions without muscle relaxants in premedicated patients receiving either alfentanil 40 microg kg(-1) or remifentanil 2, 3 or 4 microg kg(-1) followed by propofol 2 mg kg(-1). METHODS In a randomized, double-blind study, 80 healthy patients were assigned to one of four groups (n = 20). After intravenous atropine, alfentanil 40 microg kg(-1) or remifentanil 2, 3 or 4 microg kg(-1) were injected over 90 s followed by propofol 2 mg kg(-1). Ninety seconds after administration of the propofol, laryngoscopy and tracheal intubation were attempted. Intubating conditions were assessed as excellent, good or poor on the basis of ease of lung ventilation, jaw relaxation, laryngoscopy, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff. RESULTS Seven patients who received remifentanil 2 microg kg(-1) and one patient who received remifentanil 3 microg kg(-1) could not be intubated at the first attempts. Excellent intubating conditions (jaw relaxed, vocal cords open and no movement in response to tracheal intubation and cuff inflation) were observed in those who received either alfentanil 40 microg kg(-1) (45% of patients) or remifentanil in doses of 2 microg kg(-1) (20%), 3 microg kg(-1) (75%) or 4 microg kg(-1) (95%). Overall, intubating conditions were significantly better (P < 0.05), and the number of patients showing excellent conditions were significantly higher (P < 0.05) in patients who received remifentanil 4 microg kg(-1) compared with those who received alfentanil 40 microg kg(-1) or remifentanil 2 microg kg(-1). No patient needed treatment for hypotension or bradycardia. CONCLUSIONS Remifentanil 4 microg kg(-1) and propofol 2 mg kg(-1) administered in sequence intravenously provided good or excellent conditions for tracheal intubation in all patients without the use of muscle relaxants.
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Affiliation(s)
- E Erhan
- Ege University, Department of Anaesthesiology and Reanimation, Faculty of Medicine, Izmir, Turkey.
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Brimacombe J, Keller C. Stability of the LMA-ProSeal and standard laryngeal mask airway in different head and neck positions: a randomized crossover study. Eur J Anaesthesiol 2003; 20:65-9. [PMID: 12553391 DOI: 10.1017/s0265021503000127] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE The LMA-ProSeal laryngeal mask airway is a new laryngeal mask airway with a modified cuff and drainage tube. We compared oropharyngeal leak pressure, intracuff pressure and anatomical position (assessed fibreoptically) for the Size 5 LMA-ProSeal laryngeal mask airway and the classic laryngeal mask airway in different head-neck positions and using different intracuff inflation volumes. METHODS Thirty paralysed anaesthetized adult male patients were studied. The LMA-ProSeal laryngeal mask airway and the classic laryngeal mask airway were inserted into each patient in random order. The oropharyngeal leak pressure, intracuff pressure, and anatomical position of the airway tube and drainage tube (LMA-ProSeal laryngeal mask airway only) were documented in four head and neck positions (neutral first, then flexion, extension and rotation in random order), and at 0-40 mL cuff volumes in the neutral position in 10 mL increments. RESULTS Compared with the neutral position, the oropharyngeal leak pressure for both the LMA-ProSeal laryngeal mask airway and the classic laryngeal mask airway was higher in flexion and rotation (all P < or = 0.02), but lower in extension (all P < or = 0.01). Changes in head-neck position did not alter the anatomical position of the airway tube or the drainage tube. The oropharyngeal leak pressure was always higher for the LMA-ProSeal laryngeal mask airway (all P < or = 0.005) and anatomical position better for the classic laryngeal mask airway (all P < or = 0.04). CONCLUSIONS The anatomical position of the LMA-ProSeal and the classic laryngeal mask airway is stable in different head-neck positions, but head-neck flexion and rotation are associated with an increase, and head-neck extension a decrease, in oropharyngeal leak pressure and intracuff pressure. The Size 5 LMA-ProSeal laryngeal mask airway is capable of forming a more effective seal than the Size 5 classic laryngeal mask airway in males.
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Affiliation(s)
- J Brimacombe
- University of Queensland James Cook University, Department of Anaesthesia and Intensive Care, Cairns Base Hospital, The Esplanade, Australia.
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Kuhlen R, Max M, Dembinski R, Terbeck S, Jürgens E, Rossaint R. Breathing pattern and workload during automatic tube compensation, pressure support and T-piece trials in weaning patients. Eur J Anaesthesiol 2003; 20:10-6. [PMID: 12553382 DOI: 10.1017/s0265021503000024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Automatic tube compensation has been designed as a new ventilatory mode to compensate for the non-linear resistance of the endotracheal tube. The study investigated the effects of automatic tube compensation compared with breathing through a T-piece or pressure support during a trial of spontaneous breathing used for weaning patients from mechanical ventilation of the lungs. METHODS Twelve patients were studied who were ready for weaning after prolonged mechanical ventilation (10.2 +/- 8.4 days) due to acute respiratory failure. Patients with chronic obstructive pulmonary disease were excluded. Thirty minutes of automatic tube compensation were compared with 30 min periods of 7 cmH2O pressure support and T-piece breathing. Breathing patterns and workload indices were measured at the end of each study period. RESULTS During T-piece breathing, the peak inspiratory flow rate (0.65 +/- 0.20 L s(-1)) and minute ventilation (8.9 +/- 2.7L min(-1)) were lower than during either pressure support (peak inspiratory flow rate 0.81 +/- 0.25 L s(-1) minute ventilation 10.2 +/- 2.3 L min(-1), respectively) or automatic tube compensation (peak inspiratory flow rate 0.75 +/- 0.26L s(-1); minute ventilation 10.8 +/- 2.7 L min(-1)). The pressure-time product as well as patients' work of breathing were comparable during automatic tube compensation (pressure-time product 214.5 +/- 104.6 cmH2O s(-1) min(-1), patient work of breathing 1.1 +/- 0.4 J L(-1)) and T-piece breathing (pressure-time product 208.3 +/- 121.6 cmH2O s(-1) min(-1), patient work of breathing 1.1 +/- 0.4 J L(-1)), whereas pressure support resulted in a significant decrease in workload indices (pressure-time product 121.2 +/- 64.1 cmH2O s(-1) min(-1), patient work of breathing 0.7 +/- 0.4 J L(-1)). CONCLUSIONS In weaning from mechanical lung ventilation, patients' work of breathing during spontaneous breathing trials is clearly reduced by the application of pressure support 7 cmH2O, whereas the workload during automatic tube compensation corresponded closely to the values during trials of breathing through a T-piece.
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Affiliation(s)
- R Kuhlen
- University of Aachen Medical School, Department of Anesthesiology, Aachen, Germany.
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Abstract
This study reports a review of all comparative published studies of adult day case anaesthesia in the English language up to December 2000. Ten databases were searched using appropriate keywords and data were extracted in a standardized fashion. One hundred-and-one published studies were examined. Recovery measurements were grouped as early, intermediate, late, psychomotor and adverse effects. With respect to induction of anaesthesia, propofol was superior to methohexital, etomidate and thiopental, but equal to sevoflurane and desflurane. Desflurane and sevoflurane were both superior to thiopental. There was no detectable difference between sevoflurane and isoflurane. With respect to the maintenance of anaesthesia, isoflurane and halothane were the worst. There were no significant differences between propofol, desflurane, sevoflurane and enflurane. Propofol is the induction agent of choice in day case patients. The use of a propofol infusion and avoidance of nitrous oxide may help to reduce postoperative nausea and vomiting.
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Abstract
BACKGROUND AND OBJECTIVE Preoperative bedside screening tests for difficult tracheal intubation may be neither sensitive nor specific enough for clinical use. The aim was to investigate if a combination of the Mallampati classification of the oropharyngeal view with either the thyromental or sternomental distance measurement improved the predictive value. METHODS A total of 212 (109 male, 103 female) non-obstetric surgical patients, aged >18 yr, undergoing elective surgical procedures requiring tracheal intubation were assessed preoperatively with respect to the oropharyngeal (modified Mallampati) classification, thyromental and sternomental distances. An experienced anaesthetist, blinded to the preoperative airway assessment, performed laryngoscopy and graded the view according to Cormack and Lehane's classification. RESULTS Twenty tracheal intubations (9%) were difficult as defined by a Cormack and Lehane Grade 3 or 4, or the requirement for a bougie in patients with Cormack and Lehane Grade 2. Used alone, the Mallampati oropharyngeal view, and thyromental and sternomental distances were associated with poor sensitivity, specificity and positive predictive values. Combining the Mallampati Class III or IV with either a thyromental distance <6.5cm or a sternomental distance <12.5cm decreased the sensitivity (from 40 to 25 and 20%, respectively), but maintained a negative predictive value of 93%. The specificity and positive predictive values increased from 89 and 27% respectively for Mallampati alone to 100%. CONCLUSIONS The findings suggest that the Mallampati classification, in conjunction with measurement of the thyromental and sternomental distances, may be a useful routine screening test for preoperative prediction of difficult tracheal intubation.
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Affiliation(s)
- G Iohom
- Beaumont Hospital, Department of Anaesthesia and Intensive Care, Dublin, Ireland.
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Alper I, Erhan E, Ugur G, Ozyar B. Remifentanil versus alfentanil in total intravenous anaesthesia for day case surgery. Eur J Anaesthesiol 2003; 20:61-4. [PMID: 12553390 DOI: 10.1017/s0265021503000115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE We assessed the intraoperative haemodynamic responses and recovery profiles of total intravenous anaesthesia with remifentanil and alfentanil for outpatient surgery. METHODS Patients in Group 1 (n = 20) received alfentanil 20 microg kg(-1) followed by 2 microg kg(-1) min(-1) intravenously; patients in Group 2 (n = 20) received remifentanil 1 microg kg(-1) followed by 0.5 microg kg(-1) min(-1) intravenously. Both groups then received propofol 2 mg kg(-1) followed by 9 mg kg(-1) h(-1) intravenously. Five minutes after skin incision, infusion rates were decreased, and at the end of surgery, all infusions were discontinued. Early recovery was assessed by the Aldrete score, whereas intermediate recovery was assessed with the postanaesthetic discharge scoring system (PADS). RESULTS Perioperative arterial pressure was similar in both groups; heart rate was lower in Group 2 (P < 0.05). The times to spontaneous and adequate respiration, response to verbal commands, extubation and times for Aldrete score > or = 9 were shorter in Group 2 patients (P < 0.05). Pain scores were higher in Group 2 patients (P < 0.05). Overall times for postanaesthetic discharge scores > or = 9 were similar. CONCLUSIONS Early recovery of patients after day surgery is significantly shorter after total intravenous anaesthesia with remifentanil compared with that with alfentanil but postoperative pain management must be planned ahead.
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Affiliation(s)
- I Alper
- Ege University, Department of Anaesthesiology and Reanimation, Faculty of Medicine, Bornova, Izmir, Turkey.
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Turhanoğlu S, Kararmaz A, Ozyilmaz MA, Kaya S, Tok D. Effects of different doses of oral ketamine for premedication of children. Eur J Anaesthesiol 2003; 20:56-60. [PMID: 12553389 DOI: 10.1017/s0265021503000103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE A need exists for a safe and effective oral preanaesthetic medication for use in children undergoing elective surgery. The study sought to define the dose of oral ketamine that would facilitate induction of anaesthesia without causing significant side-effects. METHODS We studied 80 children undergoing elective surgery under general anaesthesia who received oral ketamine 4, 6 or 8 mg kg(-1) in a prospective, randomized, double-blind placebo controlled study. We compared the reaction to separation from parents, transport to the operating room, the response to intravenous cannula insertion and application of an anaesthetic facemask, the induction of anaesthesia and recovery from anaesthesia. RESULTS In the group receiving ketamine 8 mg kg(-1), the children were significantly calmer than those of the other groups, and anaesthesia induction was more comfortable. Recovery from anaesthesia was longer in the group receiving ketamine 8 mg kg(-1) compared with the other groups, but no differences between the groups were observed after 2 h in the recovery room. CONCLUSIONS It is concluded that oral ketamine 8 mg kg(-1) is an effective oral premedication in inpatient children undergoing elective surgery.
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Affiliation(s)
- S Turhanoğlu
- Dicle University Hospital, Department of Anaesthesiology, Diyarbakir, Turkey.
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Reuter DA, Felbinger TW, Schmidt C, Moerstedt K, Kilger E, Lamm P, Goetz AE. Trendelenburg positioning after cardiac surgery: effects on intrathoracic blood volume index and cardiac performance. Eur J Anaesthesiol 2003; 20:17-20. [PMID: 12553383 DOI: 10.1017/s0265021503000036] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE The efficacy of the Trendelenburg position, a common first step to treat suspected hypovolaemia, remains controversial. We evaluated its haemodynamic effects on cardiac preload and performance in patients after cardiac surgery. METHODS Twelve patients undergoing mechanical ventilation of the lungs who demonstrated left ventricular 'kissing papillary muscles' by transoesophageal echocardiography, thus suggesting hypovolaemia, were positioned 30 degrees head down for 15 min immediately after cardiac surgery. Cardiac output by thermodilution, central venous pressure, pulmonary artery occlusion pressure, left ventricular end-diastolic area by transoesophageal echocardiography and intrathoracic blood volume by thermo- and dye dilution were determined before, during and after this Trendelenburg manoeuvre. RESULTS Trendelenburg's manoeuvre was associated with increases in central venous pressure (9 +/- 2 to 12 +/- 3 mmHg) and pulmonary artery occlusion pressure (8 +/- 2 to 11 +/- 3 mmHg). The intrathoracic blood volume index increased slightly (dye dilution from 836 +/- 129 to 872 +/- 112 mL m(-2); thermodilution from 823 +/- 129 to 850 +/- 131 mL m(-2)) as did the left ventricular end-diastolic area index (7.5 +/- 2.1 to 8.1 +/- 1.7 cm2 m(-2)), whereas mean arterial pressure and the cardiac index did not change significantly. After supine repositioning, the cardiac index decreased significantly below baseline (3.0 +/- 0.6 versus 3.5 +/- 0.8 L min(-1) m(-2)) as did mean arterial pressure (76 +/- 12 versus 85 +/- 11 mmHg), central venous pressure (8 +/- 2 mmHg) and pulmonary artery occlusion pressure (6 +/- 4 mmHg). The intrathoracic blood volume index and left ventricular end-diastolic area index did not differ significantly from baseline. CONCLUSIONS Trendelenburg's manoeuvre caused only a slight increase of preload volume, despite marked increases in cardiac-filling pressures, without significantly improving cardiac performance.
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Affiliation(s)
- D A Reuter
- Ludwig-Maximilians-University, Department of Anaesthesiology, Munich, Germany
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Reisli R, Celik J, Tuncer S, Yosunkaya A, Otelcioglu S. Anaesthetic and haemodynamic effects of continuous spinal versus continuous epidural anaesthesia with prilocaine. Eur J Anaesthesiol 2003; 20:26-30. [PMID: 12553385 DOI: 10.1017/s026502150300005x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE To compare, using prilocaine, the effects of continuous spinal anaesthesia (CSA) and continuous epidural anaesthesia (CEA) on haemodynamic stability as well as the quality of anaesthesia and recovery in patients undergoing transurethral resection of the prostate gland. METHODS Thirty patients (>60 yr) were randomized into two groups. Prilocaine, 2% 40 mg, was given to patients in the CSA group, and prilocaine 1% 150mg was given to patients in the CEA group. Incremental doses were given if the level of sensory block was lower than T10 or if needed during surgery. RESULTS There was a significant decrease in mean arterial pressure in Group CEA compared with Group CSA (P < 0.01). The decrease in heart rate in Group CSA occurred 10 min after the first local anaesthetic administration and continued through the operation (P < 0.05). The level of sensory anaesthesia was similar in both groups. The times to reach the level of T10 and the upper level of sensory blockade (Tmax) were 18.0 +/- 4.7 and 25.3 +/- 7.0 min in Groups CSA and CEA, respectively, and were significantly longer in Group CEA. The duration of anaesthesia was 76.8 +/- 4min and was shorter in Group CSA (P < 0.01). CONCLUSIONS Spinal or epidural anaesthesia administered continuously was reliable in elderly patients undergoing transurethral resection of the prostate. Continuous spinal anaesthesia had a more rapid onset of action, produced more effective sensory and motor blockade and had a shorter recovery period. Prilocaine appeared to be a safe local anaesthetic for use with either continuous spinal anaesthesia or continuous epidural anaesthesia.
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Affiliation(s)
- R Reisli
- University of Selcuk, Faculty of Medicine, Department of Anaesthesiology, Konya, Turkey.
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Raymondos K, Münte S, Krauss T, Grouven U, Piepenbrock S. Cortical activity assessed by Narcotrend in relation to haemodynamic responses to tracheal intubation at different stages of cortical suppression and reflex control. Eur J Anaesthesiol 2003; 20:44-51. [PMID: 12553387 DOI: 10.1017/s0265021503000085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Many anaesthesiologists still interpret haemodynamic responses as signs of insufficient cortical suppression. The aim was to illustrate how haemodynamics may only poorly reflect the level of cortical suppression and that electroencephalographic monitoring could indicate different relationships between cortical effects and haemodynamics. METHODS Anaesthesia was induced with thiopental (7 mg kg(-1)), and fentanyl (2 microg kg(-1)) with succinylcholine (1.5 mg kg(-1)) for neuromuscular blockade in the 11 patients of Group 1. In Group 2 (n = 15), thiopental (7 mg kg(-1)) and succinylcholine (1.5 mg kg(-1)) were given. In Group 3, the patients (n = 13) received thiopental (7 mg kg(-1)), fentanyl (2 microg kg(-1)) and cisatracurium (0.1 mg kg(-1)), and they were intubated 3 min later than the patients in Groups 1 and 2. We determined conventional electroencephalographic (EEG) variables and classified 14 EEG stages in real-time ranging from A (= 1), indicating full wakefulness, to F1 (= 14), at profound cortical suppression. RESULTS All groups had profound cortical suppression 45 s after thiopental administration, which rapidly decreased (EEG stage, 11 (6-13) versus 7 (2-13) at 4 min, P < 0.0001). Decreasing EEG stages were associated with increasing SEF 95, relative alpha and beta power and decreasing relative delta power. During tracheal intubation, profound cortical suppression remained unchanged in Groups 1 and 2. In Group 3, cortical suppression had decreased before laryngoscopy (P < 0.005). In Group 2, 11 patients had heart rate responses to tracheal intubation, whereas only two responded in Group 1 (P = 0.015) and three in Group 3 (P = 0.02). Thirteen patients in Group 2 had arterial pressure responses, and five in Group 1 (P = 0.038). Circulatory responses did not differ between Groups 1 and 3. CONCLUSIONS Electroencephalographic monitoring was suitable to indicate in real-time that haemodynamics only poorly reflect rapidly changing levels of cortical suppression, and how haemodynamics and cortical activity depend on the applied combination of hypnotic and analgesic drugs during anaesthesia induction with thiopental.
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Affiliation(s)
- K Raymondos
- Medical School of Hannover, Department of Anaesthesiology, Hannover, Germany.
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Ogawa-Okamoto C, Saito S, Nishihara F, Yuki N, Goto F. Blood pressure control with glyceryl trinitrate during electroconvulsive therapy in a patient with cerebral aneurysm. Eur J Anaesthesiol 2003; 20:70-2. [PMID: 12553392 DOI: 10.1017/s0265021503210139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Haltiavaara KM, Laitinen JO, Kaukinen S, Viljakka TJ, Laippala PJ, Luukkaala TH. Failure of interscalene brachial plexus blockade to produce pre-emptive analgesia after shoulder surgery. Eur J Anaesthesiol 2003; 20:72-3. [PMID: 12553393 DOI: 10.1017/s0265021503220135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Trendelenburg positioning after cardiac surgery: effects on intrathoracic blood volume index and cardiac performance. Eur J Anaesthesiol 2003. [DOI: 10.1097/00003643-200301000-00003] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Krenn H, Deusch E, Balogh B, Jellinek H, Oczenski W, Plainer-Zöchling E, Fitzgerald RD. Increasing the injection volume by dilution improves the onset of motor blockade, but not sensory blockade of ropivacaine for brachial plexus block. Eur J Anaesthesiol 2003; 20:21-5. [PMID: 12553384 DOI: 10.1017/s0265021503000048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Ropivacaine used for axillary plexus block provides effective motor and sensory blockade. Varying clinical dosage recommendations exist. Increasing the dosage by increasing the concentration showed no improvement in onset. We compared the behaviour of a constant dose of ropivacaine 150 mg diluted in a 30, 40 or 60 mL injection volume for axillary (brachial) plexus block. METHODS A prospective, randomized, observer-blinded study on patients undergoing elective hand surgery was conducted in a community hospital. Three groups of patients with a constant dose of ropivacaine 150 mg, diluted in 30,40 or 60 mL NaCl 0.9%, for axillary plexus blockade were compared for onset times of motor and sensory block onset by assessing muscle strength, two-point discrimination and constant-touch sensation. RESULTS Increasing the injection volume of ropivacaine 150 mg to 60 mL led to a faster onset of motor block, but not of sensory block, in axillary plexus block, compared with 30 or 40 mL volumes of injection. CONCLUSIONS The data show that the onset of motor, but not of sensory block, is accelerated by increasing the injection volume to 60 mL using ropivacaine 150 mg for axillary plexus block. This may be useful for a more rapid determination of whether the brachial plexus block is effective. However, when performing surgery in the area of the block, sensory block onset seems more important.
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Affiliation(s)
- H Krenn
- Department of Anaesthesia and Critical Care, City Hospital, Lainz, Vienna, Austria.
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Schreiber SJ, Lambert UKW, Doepp F, Valdueza JM. Effects of prolonged head-down tilt on internal jugular vein cross-sectional area. Br J Anaesth 2002. [DOI: 10.1093/bja/89.5.769] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Verghese ST, Nath A, Zenger D, Patel RI, Kaplan RF, Patel KM. The Effects of the Simulated Valsalva Maneuver, Liver Compression, and/or Trendelenburg Position on the Cross-Sectional Area of the Internal Jugular Vein in Infants and Young Children. Anesth Analg 2002. [DOI: 10.1213/00000539-200202000-00004] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Verghese ST, Nath A, Zenger D, Patel RI, Kaplan RF, Patel KM. The effects of the simulated Valsalva maneuver, liver compression, and/or Trendelenburg position on the cross-sectional area of the internal jugular vein in infants and young children. Anesth Analg 2002; 94:250-4, table of contents. [PMID: 11812678 DOI: 10.1097/00000539-200202000-00004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
UNLABELLED We calculated the effects of the simulated Valsalva (V), liver (L) compression, and Trendelenburg (T) position on the cross-sectional area (CSA) of the right internal jugular vein by using planimetry (Aloka ultrasound machine) in 84 infants and young children. Eight combinations of positions and interventions were studied for each patient, with the patient supine, in the T position, during the simulated V maneuver, with L compression and a combination of maneuvers. Data were analyzed by using Friedman's chi(2) test and Wilcoxon's signed rank test. An increase of >25% in the CSA of the internal jugular vein was considered significant. In infants, the maximal mean increase achieved with the combination of all 3 maneuvers was only 17.4% +/- 16.1%. As a single maneuver, the simulated V was the most effective (11.6% +/- 11.5%). In children, the combination of all 3 maneuvers performed simultaneously produced a mean 65.9% (SD +/- 44.7%) increase in the CSA, which was larger than the increase by all other maneuvers alone or in a single combination (Friedman's test, P < 0.001 and Wilcoxon's test, P < 0.002). As a single maneuver, V produced the most increase (40.4% +/- 32.2%) compared with L compression (14.3% +/- 18.9%) or T position (24.3% +/- 27.1%). IMPLICATIONS The combinations of simulated Valsalva, liver compression, and Trendelenburg maneuvers produce the maximal mean increase in the size of the internal jugular vein in infants and young children, with the Valsalva maneuver being the most effective single maneuver. This increase is significant in young children, but negligible in infants.
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Affiliation(s)
- Susan T Verghese
- Department of Anesthesiology, Children's National Medical Center and George Washington University Medical Center, Washington, DC 20010, USA.
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Affiliation(s)
- K C Fink
- Lakeside Memorial Hospital, Brockport, NY, USA
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