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Saugel B, Annecke T, Bein B, Flick M, Goepfert M, Gruenewald M, Habicher M, Jungwirth B, Koch T, Kouz K, Meidert AS, Pestel G, Renner J, Sakka SG, Sander M, Treskatsch S, Zitzmann A, Reuter DA. Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: Guidelines of the German Society of Anaesthesiology and Intensive Care Medicine in collaboration with the German Association of the Scientific Medical Societies. J Clin Monit Comput 2024; 38:945-959. [PMID: 38381359 DOI: 10.1007/s10877-024-01132-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 01/25/2024] [Indexed: 02/22/2024]
Abstract
Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Thorsten Annecke
- Department of Anesthesiology and Intensive Care Medicine, Cologne Merheim Medical Center, Hospital of the University of Witten/Herdecke, Cologne, Germany
| | - Berthold Bein
- Department for Anaesthesiology, Asklepios Hospital Hamburg St. Georg, Hamburg, Germany
| | - Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Goepfert
- Department of Anaesthesiology and Intensive Care Medicine, Alexianer St. Hedwigkliniken Berlin, Berlin, Germany
| | - Matthias Gruenewald
- Department of Anaesthesiology and Intensive Care Medicine, Evangelisches Amalie Sieveking Krankenhaus, Hamburg, Germany
| | - Marit Habicher
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Bettina Jungwirth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Tilo Koch
- Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Marburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Agnes S Meidert
- Department of Anaesthesiology, University Hospital LMU Munich, Munich, Germany
| | - Gunther Pestel
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jochen Renner
- Department of Anesthesiology and Intensive Care Medicine, Municipal Hospital Kiel, Kiel, Germany
| | - Samir G Sakka
- Department of Intensive Care Medicine, Gemeinschaftsklinikum Mittelrhein gGmbH, Academic Teaching Hospital of the Johannes Gutenberg University Mainz, Koblenz, Germany
| | - Michael Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Amelie Zitzmann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
| | - Daniel A Reuter
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
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Hotz E, van Gemmern T, Kriege M. Are We Always Right? Evaluation of the Performance and Knowledge of the Passive Leg Raise Test in Detecting Volume Responsiveness in Critical Care Patients: A National German Survey. J Clin Med 2024; 13:2518. [PMID: 38731046 PMCID: PMC11084342 DOI: 10.3390/jcm13092518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/22/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Background: In hemodynamically unstable patients, the passive leg raise (PLR) test is recommended for use as a self-fluid challenge for predicting preload responsiveness. However, to interpret the hemodynamic effects and reliability of the PLR, the method of performing it is of the utmost importance. Our aim was to determine the current practice of the correct application and interpretation of the PLR in intensive care patients. Methods: After ethical approval, we designed a cross-sectional online survey with a short user-friendly online questionnaire. Using a random sample of 1903 hospitals in Germany, 182 hospitals with different levels of care were invited via an email containing a link to the questionnaire. The online survey was conducted between December 2021 and January 2022. All critical care physicians from different medical disciplines were surveyed. We evaluated the correct points of concern for the PLR, including indication, contraindication, choice of initial position, how to interpret and apply the changes in cardiac output, and the limitations of the PLR. Results: A total of 292 respondents participated in the online survey, and 283/292 (97%) of the respondents completed the full survey. In addition, 132/283 (47%) were consultants and 119/283 (42%) worked at a university medical center. The question about the performance of the PLR was answered correctly by 72/283 (25%) of the participants. The limitations of the PLR, such as intra-abdominal hypertension, were correctly selected by 150/283 (53%) of the participants. The correct effect size (increase in stroke volume ≥ 10%) was correctly identified by 217/283 (77%) of the participants. Conclusions: Our results suggest a considerable disparity between the contemporary practice of the correct application and interpretation of the PLR and the practice recommendations from recently published data at German ICUs.
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Affiliation(s)
| | | | - Marc Kriege
- Department of Anaesthesiology, University Medical Centre, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (E.H.); (T.v.G.)
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Teboul JL, Monnet X, Chemla D, Michard F. Arterial Pulse Pressure Variation with Mechanical Ventilation. Am J Respir Crit Care Med 2019; 199:22-31. [PMID: 30138573 DOI: 10.1164/rccm.201801-0088ci] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Fluid administration leads to a significant increase in cardiac output in only half of ICU patients. This has led to the concept of assessing fluid responsiveness before infusing fluid. Pulse pressure variation (PPV), which quantifies the changes in arterial pulse pressure during mechanical ventilation, is one of the dynamic variables that can predict fluid responsiveness. The underlying hypothesis is that large respiratory changes in left ventricular stroke volume, and thus pulse pressure, occur in cases of biventricular preload responsiveness. Several studies showed that PPV accurately predicts fluid responsiveness when patients are under controlled mechanical ventilation. Nevertheless, in many conditions encountered in the ICU, the interpretation of PPV is unreliable (spontaneous breathing, cardiac arrhythmias) or doubtful (low Vt). To overcome some of these limitations, researchers have proposed using simple tests such as the Vt challenge to evaluate the dynamic response of PPV. The applicability of PPV is higher in the operating room setting, where fluid strategies made on the basis of PPV improve postoperative outcomes. In medical critically ill patients, although no randomized controlled trial has compared PPV-based fluid management with standard care, the Surviving Sepsis Campaign guidelines recommend using fluid responsiveness indices, including PPV, whenever applicable. In conclusion, PPV is useful for managing fluid therapy under specific conditions where it is reliable. The kinetics of PPV during diagnostic or therapeutic tests is also helpful for fluid management.
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Affiliation(s)
| | - Xavier Monnet
- 1 Medical Intensive Care Unit, Bicetre Hospital, and
| | - Denis Chemla
- 2 Department of Physiology, Bicetre Hospital, Paris-South University Hospitals, Inserm UMR_S999, Paris-South University, Le Kremlin-Bicêtre, France; and
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Cyclic Nonrespiratory Pulse Pressure Oscillations Caused by Atrioventricular Dissociation. Case Rep Crit Care 2018; 2017:7647069. [PMID: 29333300 PMCID: PMC5733209 DOI: 10.1155/2017/7647069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/09/2017] [Indexed: 11/21/2022] Open
Abstract
Dynamic preload assessment tests, especially pulse pressure variation (PPV) and stroke volume variation (SVV), are increasingly acknowledged in mechanically ventilated patients as being predictors of fluid responsiveness. However, the limitations of this method are often neglected or overlooked. One of the prerequisites for PPV and SVV evaluation, in addition to intermittent positive pressure ventilation, is a “regular heart rhythm,” which may be an ambiguous term. We present a case where, despite a regular (paced) rhythm, atrioventricular dissociation was present and resulted in marked PPV elevation, which subsequently disappeared once sinus rhythm returned. Our case indicates that PPV and SVV should be interpreted with caution when atrioventricular dissociation is present.
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Monnet X, Marik PE, Teboul JL. Prediction of fluid responsiveness: an update. Ann Intensive Care 2016; 6:111. [PMID: 27858374 PMCID: PMC5114218 DOI: 10.1186/s13613-016-0216-7] [Citation(s) in RCA: 312] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/08/2016] [Indexed: 12/17/2022] Open
Abstract
In patients with acute circulatory failure, the decision to give fluids or not should not be taken lightly. The risk of overzealous fluid administration has been clearly established. Moreover, volume expansion does not always increase cardiac output as one expects. Thus, after the very initial phase and/or if fluid losses are not obvious, predicting fluid responsiveness should be the first step of fluid strategy. For this purpose, the central venous pressure as well as other “static” markers of preload has been used for decades, but they are not reliable. Robust evidence suggests that this traditional use should be abandoned. Over the last 15 years, a number of dynamic tests have been developed. These tests are based on the principle of inducing short-term changes in cardiac preload, using heart–lung interactions, the passive leg raise or by the infusion of small volumes of fluid, and to observe the resulting effect on cardiac output. Pulse pressure and stroke volume variations were first developed, but they are reliable only under strict conditions. The variations in vena caval diameters share many limitations of pulse pressure variations. The passive leg-raising test is now supported by solid evidence and is more frequently used. More recently, the end-expiratory occlusion test has been described, which is easily performed in ventilated patients. Unlike the traditional fluid challenge, these dynamic tests do not lead to fluid overload. The dynamic tests are complementary, and clinicians should choose between them based on the status of the patient and the cardiac output monitoring technique. Several methods and tests are currently available to identify preload responsiveness. All have some limitations, but they are frequently complementary. Along with elements indicating the risk of fluid administration, they should help clinicians to take the decision to administer fluids or not in a reasoned way.
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Affiliation(s)
- Xavier Monnet
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, Inserm UMR_S999, Paris-Sud University, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.
| | - Paul E Marik
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, Inserm UMR_S999, Paris-Sud University, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
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Fischer MO, Le Manach Y. Perioperative medicine: From theorical guidelines to clinical practice. Anaesth Crit Care Pain Med 2016; 35:241-2. [PMID: 27475829 DOI: 10.1016/j.accpm.2016.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Marc-Olivier Fischer
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France; EA 4650, Université de Caen Basse-Normandie, esplanade de la Paix, CS 14032, 14000 Caen, France.
| | - Yannick Le Manach
- Departments of Anesthesia & Clinical Epidemiology and Biostatistics, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University and the Perioperative Research Group, Population Health Research Institute, Hamilton, Canada.
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Assessment of changes in cardiac index with calibrated pulse contour analysis in cardiac surgery: A prospective observational study. Anaesth Crit Care Pain Med 2016; 35:261-7. [PMID: 27083307 DOI: 10.1016/j.accpm.2015.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 12/02/2015] [Accepted: 12/14/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To assess the trending ability of calibrated pulse contour cardiac index (CIPC) monitoring during haemodynamic changes (passive leg raising [PLR] and fluid loading) compared with transpulmonary thermodilution CI (CITD). METHOD Seventy-eight mechanically-ventilated patients admitted to intensive care with calibrated pulse contour following cardiac surgery were prospectively included and investigated during PLR, and after fluid loading. Fluid responsiveness was defined as a≥15% CITD increase after a 500ml bolus. Areas under the empiric receiver operating characteristic curves (ROCAUC) for changes in CIPC (ΔCIPC) during PLR to predict fluid responsiveness and after fluid challenge to predict an increase at least 15% in CITD after fluid loading were calculated. RESULTS Fifty-five patients (71%) were classified as responders, 23 (29%) as non-responders. ROCAUC for ΔCIPC during PLR in predicting fluid responsiveness, its sensitivity, specificity, and percentage of patients within the inconclusive class of response were 0.67 (95% CI=0.55-0.77), 0.76 (95% CI=0.63-0.87), 0.57 (95% CI=0.34-0.77) and 68%, respectively. Bias, precision and limits of agreements and percentage error between CIPC and CITD after fluid challenge were 0.14 (95% CI: 0.08-0.20), 0.26, -0.37 to 0.64 l min(-1)m(-2), and 20%, respectively. The concordance rate was 97% and the polar concordance at 30° was 91%. ROCAUC for ΔCIPC in predicting an increase of at least 15% in CITD after fluid loading was 0.85 (95% CI: 0.76-0.92). CONCLUSION Although ΔCIPC after fluid loading could track the direction of changes of CITD and was interchangeable with bolus transpulmonary thermodilution, PLR could not predict fluid responsiveness in cardiac surgery patients.
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Fischer MO, Cannesson M. The veno-ventricular-arterial coupling during anaesthesia. Anaesth Crit Care Pain Med 2015; 34:315-6. [DOI: 10.1016/j.accpm.2015.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Preau S, Dewavrin F, Demaeght V, Chiche A, Voisin B, Minacori F, Poissy J, Boulle-Geronimi C, Blazejewski C, Onimus T, Durocher A, Saulnier F. The use of static and dynamic haemodynamic parameters before volume expansion: A prospective observational study in six French intensive care units. Anaesth Crit Care Pain Med 2015; 35:93-102. [PMID: 26603329 DOI: 10.1016/j.accpm.2015.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 08/31/2015] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The aim of the present study was to determine the use of static and dynamic haemodynamic parameters for predicting fluid responsiveness prior to volume expansion (VE) in intensive care unit (ICU) patients with systemic inflammatory response syndrome (SIRS). METHODS We conducted a prospective, multicentre, observational study in 6 French ICUs in 2012. ICU physicians were audited concerning their use of static and dynamic haemodynamic parameters before each VE performed in patients with SIRS for 6 consecutive weeks. RESULTS The median volume of the 566 VEs administered to patients with SIRS was 1000mL [500-1000mL]. Although at least one static or dynamic haemodynamic parameter was measurable before 99% (95% CI, 99%-100%) of VEs, at least one them was used in only 38% (95% CI, 34%-42%) of cases: static parameters in 11% of cases (95% CI, 10%-12%) and dynamic parameters in 32% (95% CI, 30%-34%). Static parameters were never used when uninterpretable. For 15% of VEs (95% CI, 12%-18%), a dynamic parameter was measured in the presence of contraindications. Among dynamic parameters, respiratory variations in arterial pulse pressure (PPV) and passive leg raising (PLR) were measurable and interpretable before 17% and 90% of VEs, respectively. CONCLUSIONS Haemodynamic parameters are underused for predicting fluid responsiveness in current practice. In contrast to static parameters, dynamic parameters are often incorrectly used in the presence of contraindications. PLR is more frequently valid than PPV for predicting fluid responsiveness in ICU patients.
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Affiliation(s)
- Sébastien Preau
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000 Lille, France.
| | - Florent Dewavrin
- Intensive Care Unit, General Hospital of Valenciennes, 59300 Valenciennes, France.
| | - Vincent Demaeght
- Intensive Care Unit, General Hospital of Valenciennes, 59300 Valenciennes, France.
| | - Arnaud Chiche
- Intensive Care Unit, General Hospital of Tourcoing, 59200 Tourcoing, France.
| | - Benoît Voisin
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000 Lille, France.
| | - Franck Minacori
- Intensive Care Unit, University Hospital of Lomme, 59160 Lomme, France.
| | - Julien Poissy
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000 Lille, France.
| | | | - Caroline Blazejewski
- Intensive Care Unit, Salengro Hospital, University Hospital of Lille, 59000 Lille, France.
| | - Thierry Onimus
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000 Lille, France.
| | - Alain Durocher
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000 Lille, France.
| | - Fabienne Saulnier
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000 Lille, France.
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