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Ochagavía A, Palomo-López N, Fraile V, Zapata L. Hemodynamic monitoring and echocardiographic evaluation in cardiogenic shock. Med Intensiva 2024:S2173-5727(24)00177-2. [PMID: 39097480 DOI: 10.1016/j.medine.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 08/05/2024]
Abstract
Cardiogenic shock (CS) is characterized by the presence of a state of tissue hypoperfusion secondary to ventricular dysfunction. Hemodynamic monitoring allows us to obtain information about cardiovascular pathophysiology that will help us make the diagnosis and guide therapy in CS situations. The most used monitoring system in CS is the pulmonary artery catheter since it provides key hemodynamic variables in CS, such as cardiac output, pulmonary artery pressure, and pulmonary artery occlusion pressure. On the other hand, echocardiography makes it possible to obtain, at the bedside, anatomical and hemodynamic data that complement the information obtained through continuous monitoring devices. CS monitoring can be considered multimodal and integrative by including hemodynamic, metabolic, and echocardiographic parameters that allow describing the characteristics of CS and guiding therapeutic interventions during hemodynamic resuscitation.
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Affiliation(s)
- Ana Ochagavía
- Servicio de Medicina Intensiva, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.
| | - Nora Palomo-López
- Servicio de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Virginia Fraile
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Luis Zapata
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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2
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Turquier S, Huot L, Lamkhioued M, Subtil F, Traclet J, Ahmad K, Lestelle F, Chauvelot L, Cottin V, Mornex JF. Bioreactance assessment of cardiac output lacks reliability for the follow-up of patients with pulmonary hypertension. PLoS One 2024; 19:e0298727. [PMID: 38768104 PMCID: PMC11104646 DOI: 10.1371/journal.pone.0298727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/27/2024] [Indexed: 05/22/2024] Open
Abstract
Cardiac output (CO) is one of the primary prognostic factors evaluated during the follow-up of patients treated for pulmonary hypertension (PH). It is recommended that it be measured using the thermodilution technique during right heart catheterization. The difficulty to perform iterative invasive measurements on the same individual led us to consider a non-invasive option. The aims of the present study were to assess the agreement between CO values obtained using bioreactance (Starling™ SV) and thermodilution, and to evaluate the ability of the bioreactance monitor to detect patients whose CO decreased by more than 15% during follow-up and, accordingly, its usefulness for patient monitoring. A prospective cohort study evaluating the performance of the Starling™ SV monitor was conducted in patients with clinically stable PH. Sixty patients referred for hemodynamic assessment were included. CO was measured using both the thermodilution technique and bioreactance during two follow-up visits. A total of 60 PH patients were included. All datasets were available at the baseline visit (V0) and 50 of them were usable during the follow-up visit (V1). Median [IQR] CO was 4.20 l/min [3.60-4.70] when assessed by bioreactance, and 5.30 l/min [4.57-6.20] by thermodilution (p<0.001). The Spearman correlation coefficient was 0.51 [0.36-0.64], and the average deviation on Bland-Altman plot was -1.25 l/min (95% CI [-1.48-1.01], p<0.001). The ability of the monitor to detect a variation in CO of more than 15% between two follow-up measurements, when such variation existed using thermodilution, was insufficient for clinical practice (AUC = 0.54, 95% CI [0.33-0.75]).
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Affiliation(s)
- Ségolène Turquier
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- Lung Physiology Unit, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Laure Huot
- Innovation Department, Health Economic Evaluation Service, Public Health Centre, Hospices Civils de Lyon, Lyon, France
- Research on Healthcare Performance RESHAPE, INSERM U1290, Claude Bernard University, Lyon, France
| | - Medhi Lamkhioued
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- Lung Physiology Unit, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Fabien Subtil
- Biostatistics and Bioinformatics Department, Public Health Centre, Hospices Civils de Lyon, Lyon, France
| | - Julie Traclet
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Kais Ahmad
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - François Lestelle
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Louis Chauvelot
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Vincent Cottin
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- UMR754, INRAE, Claude Bernard University, Lyon, France
| | - Jean-François Mornex
- National Reference Centre for Rare Pulmonary Diseases and Centre for Pulmonary Hypertension, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- UMR754, INRAE, Claude Bernard University, Lyon, France
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3
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Florio KL, Williams EM, White D, Daming T, Hostetter S, Schrufer-Poland T, Gray R, Schmidt L, Grodzinsky A, Lee J, Rader V, Swearingen K, Nelson L, Patel N, Magalski A, Gosch K, Jones P, Fu Z, Spertus JA. Validation of a noninvasive cardiac output monitor in maternal cardiac disease: comparison of NICOM and transthoracic echocardiogram. Am J Obstet Gynecol MFM 2024; 6:101312. [PMID: 38342307 DOI: 10.1016/j.ajogmf.2024.101312] [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: 01/02/2024] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND The physiological changes to the cardiovascular system during pregnancy are considerable and are more pronounced in those with cardiac disease. In the general population, noninvasive hemodynamic monitoring is a valid alternative to pulmonary artery catheterization, which poses risk in the pregnant population. There is limited data on noninvasive cardiac output monitoring in pregnancy as an alternative to pulmonary artery catheterization. OBJECTIVE We sought to compare transthoracic echocardiography with a noninvasive cardiac output monitor (NICOM, Cheetah Medical) in pregnant patients with and without cardiac disease. STUDY DESIGN This was a prospective, open-label validation study that compared 2-dimensional transthoracic echocardiography with NICOM estimations of cardiac output in each trimester of pregnancy and the postpartum period. Participants with and without cardiac disease with a singleton gestation were included. NICOM estimations of cardiac output were derived from thoracic bioreactance and compared with 2-dimensional transthoracic echocardiography for both precision and accuracy. A mean percentage difference of ±30% between the 2 devices was considered acceptable agreement between the 2 measurement techniques. RESULTS A total of 58 subjects were enrolled; 36 did not have cardiac disease and 22 had cardiac disease. Heart rate measurements between the 2 devices were strongly correlated in both groups, whereas stroke volume and cardiac output measurements showed weak correlation. When comparing the techniques, the NICOM device overestimated cardiac output in the control group in all trimesters and the postpartum period (mean percentage differences were 50.3%, 52.7%, 48.1%, and 51.0% in the first, second, and third trimesters and the postpartum period, respectively). In the group with cardiac disease, the mean percentage differences were 31.9%, 29.7%, 19.6%, and 35.2% for the respective timepoints. CONCLUSION The NICOM device consistently overestimated cardiac output when compared with 2-dimensional transthoracic echocardiography at all timepoints in the control group and in the first trimester and postpartum period for the cardiovascular disease group. The physiological changes of pregnancy, specifically the mean chest circumference and total body water, may alter the accuracy of the cardiac output measurement by the NICOM device as they are currently estimated. Although NICOM has been validated for use in the critical care setting, there is insufficient data to support its use in pregnancy.
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Affiliation(s)
- Karen L Florio
- Department of Obstetrics and Gynecology, University of Missouri, Columbia MO (Dr Florio); Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO (Drs Florio, Williams, Daming, Hostetter, Schrufer-Poland, and Patel); Division of Women's and Children's, Saint Luke's Hospital of Kansas City, Kansas City, MO (Dr Florio, Ms White, Ms Gray, Ms Swearingen, and Ms Nelson).
| | - Emily M Williams
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO (Drs Florio, Williams, Daming, Hostetter, Schrufer-Poland, and Patel)
| | - Darcy White
- Division of Women's and Children's, Saint Luke's Hospital of Kansas City, Kansas City, MO (Dr Florio, Ms White, Ms Gray, Ms Swearingen, and Ms Nelson)
| | - Tara Daming
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO (Drs Florio, Williams, Daming, Hostetter, Schrufer-Poland, and Patel); Department of Maternal-Fetal Medicine, Mercy Hospital of Saint Louis, Saint Louis, MO (Dr Daming)
| | - Sarah Hostetter
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO (Drs Florio, Williams, Daming, Hostetter, Schrufer-Poland, and Patel); Department of Maternal Fetal Medicine, Mercy Hospital of Springfield, Springfield, MO (Dr Hostetter)
| | - Tabitha Schrufer-Poland
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO (Drs Florio, Williams, Daming, Hostetter, Schrufer-Poland, and Patel); AdventHealth High Risk Pregnancy Consultants, Orlando, FL (Dr Schrufer-Poland)
| | - Rebecca Gray
- Division of Women's and Children's, Saint Luke's Hospital of Kansas City, Kansas City, MO (Dr Florio, Ms White, Ms Gray, Ms Swearingen, and Ms Nelson)
| | - Laura Schmidt
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus); Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, Magalski, and Spertus)
| | - Anna Grodzinsky
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus); Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, Magalski, and Spertus)
| | - John Lee
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus); Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, Magalski, and Spertus)
| | - Valerie Rader
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus); Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, Magalski, and Spertus)
| | - Kathleen Swearingen
- Division of Women's and Children's, Saint Luke's Hospital of Kansas City, Kansas City, MO (Dr Florio, Ms White, Ms Gray, Ms Swearingen, and Ms Nelson)
| | - Lynne Nelson
- Division of Women's and Children's, Saint Luke's Hospital of Kansas City, Kansas City, MO (Dr Florio, Ms White, Ms Gray, Ms Swearingen, and Ms Nelson)
| | - Neil Patel
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO (Drs Florio, Williams, Daming, Hostetter, Schrufer-Poland, and Patel); Department of Obstetrics and Gynecology, University of Kentucky, Lexington KY (Dr Patel)
| | - Anthony Magalski
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus); Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, Magalski, and Spertus)
| | - Kensey Gosch
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus)
| | - Philip Jones
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus)
| | - Zhuxuan Fu
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus)
| | - John A Spertus
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus); Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, Magalski, and Spertus)
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Yang Y, Qian QY, Yang XY, Li DS, Chen DS, Shen M. Measurement of non-invasive cardiac output during cycling exercise in ischemic stroke inpatients: A pilot study. Technol Health Care 2024; 32:215-228. [PMID: 37302050 DOI: 10.3233/thc-220823] [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] [Indexed: 06/12/2023]
Abstract
BACKGROUND Cardiac dysfunction accompanies acute ischemic stroke and affects the effective implementation of early rehabilitation interventions. There is a lack of reference hemodynamic data on cardiac function in the subacute phase of ischemic stroke. OBJECTIVE In this study, we aimed to identify appropriate cardiac parameters for exercise training utilizing a pilot study. METHODS We used a transthoracic electrical bioimpedance non-invasive cardiac output measurement (NICOM) device to monitor cardiac function in real time for two groups [i.e., subacute ischemic stroke inpatients group (n= 10) and healthy control group (n= 11)] using a cycling exercise experiment. The parameters of both groups were compared to highlight the cardiac dysfunction in the subacute phase in patients with ischemic stroke. RESULTS We considered stroke volume index (SVI) and systemic vascular resistance index (SVRi) as the primary outcomes, and there was significant intragroup difference (stroke group: P< 0.001; control group: P< 0.001, using one-way ANOVA) and significant intergroup difference at each individual time segment (P< 0.01, using independent t-test). Among the secondary outcomes, i.e., cardiac index (CI), ejection fraction (EF), end-diastolic volume (EDV), and cardiac contraction index (CTI), we found significant intergroup differences in CI, EF, and CTI scores (P< 0.01, using independent t-test). Significant interaction with respect to time and group were seen only in the SVRi and CI scores (P< 0.01, using two-way ANOVA). There was no significant inter- or intra-group differences in EDV scores. CONCLUSION SVRI, SVI, and CI values highlight cardiac dysfunction in stroke patients the most. At the same time, these parameters suggest that cardiac dysfunction in stroke patients may be closely related to the increased peripheral vascular resistance caused by infarction and the limitation of myocardial systolic function.
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Affiliation(s)
- Ying Yang
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
| | - Qiu-Yang Qian
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
| | - Xiao-Yan Yang
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
| | - De-Sheng Li
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
| | - De-Sheng Chen
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
| | - Mei Shen
- Department of Rehabilitation Medicine, People's Hospital of Longhua, Shenzhen, Guangdong, China
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Ladha P, Truong EI, Kanuika P, Allan A, Kishawi S, Ho VP, Claridge JA, Brown LR. Diagnostic Adjunct Techniques in the Assessment of Hypovolemia: A Prospective Pilot Project. J Surg Res 2024; 293:1-7. [PMID: 37690381 PMCID: PMC11334708 DOI: 10.1016/j.jss.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/21/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Measuring the hypovolemic resuscitation end point remains a critical care challenge. Our project compared clinical hypovolemia (CH) with three diagnostic adjuncts: 1) noninvasive cardiac output monitoring (NICOM), 2) ultrasound (US) static IVC collapsibility (US-IVC), and 3) US dynamic carotid upstroke velocity (US-C). We hypothesized US measures would correlate more closely to CH than NICOM. METHODS Adult trauma/surgical intensive care unit patients were prospectively screened for suspected hypovolemia after acute resuscitation, excluding patients with burns, known heart failure, or severe liver/kidney disease. Adjunct measurements were assessed up to twice a day until clinical improvement. Hypovolemia was defined as: 1) NICOM: ≥10% stroke volume variation with passive leg raise, 2) US-IVC: <2.1 cm and >50% collapsibility (nonventilated) or >18% collapsibility (ventilated), 3) US-C: peak systolic velocity increase 15 cm/s with passive leg raise. Previously unknown cardiac dysfunction seen on US was noted. Observation-level data were analyzed with a Cohen's kappa (κ). RESULTS 44 patients (62% male, median age 60) yielded 65 measures. Positive agreement with CH was 47% for NICOM, 37% for US-IVC and 10% for US-C. None of the three adjuncts correlated with CH (κ -0.045 to 0.029). After adjusting for previously unknown cardiac dysfunction present in 10 patients, no adjuncts correlated with CH (κ -0.036 to 0.031). No technique correlated with any other (κ -0.118 to 0.083). CONCLUSIONS None of the adjunct measurements correlated with CH or each other, highlighting that fluid status assessment remains challenging in critical care. US should assess for right ventricular dysfunction prior to resuscitation.
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Affiliation(s)
- Prerna Ladha
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Evelyn I Truong
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Peter Kanuika
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Annie Allan
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Sami Kishawi
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Population Health and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | | | - Laura R Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio.
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Tarras E, Khosla A, Heerdt PM, Singh I. Right Heart Failure in the Intensive Care Unit: Etiology, Pathogenesis, Diagnosis, and Treatment. J Intensive Care Med 2023:8850666231216889. [PMID: 38031338 DOI: 10.1177/08850666231216889] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Right heart (RH) failure carries a high rate of morbidity and mortality. Patients who present with RH failure often exhibit complex aberrant cardio-pulmonary physiology with varying presentations. The treatment of RH failure almost always requires care and management from an intensivist. Treatment options for RH failure patients continue to evolve rapidly with multiple options available, including different pharmacotherapies and mechanical circulatory support devices that target various components of the RH circulatory system. An understanding of the normal RH circulatory physiology, treatment, and support options for the RH failure patients is necessary for all intensivists to improve outcomes. The purpose of this review is to provide clinical guidance on the diagnosis and management of RH failure within the intensive care unit setting, and to highlight the different pathophysiological manifestations of RH failure, its hemodynamics, and treatment options available at the disposal of the intensivist.
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Affiliation(s)
- Elizabeth Tarras
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Akhil Khosla
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Paul M Heerdt
- Department of Anesthesiology, Division of Applied Hemodynamics, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
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Waksman R, Pahuja M, van Diepen S, Proudfoot AG, Morrow D, Spitzer E, Nichol G, Weisfeldt ML, Moscucci M, Lawler PR, Mebazaa A, Fan E, Dickert NW, Samsky M, Kormos R, Piña IL, Zuckerman B, Farb A, Sapirstein JS, Simonton C, West NEJ, Damluji AA, Gilchrist IC, Zeymer U, Thiele H, Cutlip DE, Krucoff M, Abraham WT. Standardized Definitions for Cardiogenic Shock Research and Mechanical Circulatory Support Devices: Scientific Expert Panel From the Shock Academic Research Consortium (SHARC). Circulation 2023; 148:1113-1126. [PMID: 37782695 PMCID: PMC11025346 DOI: 10.1161/circulationaha.123.064527] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/31/2023] [Indexed: 10/04/2023]
Abstract
The Shock Academic Research Consortium is a multi-stakeholder group, including representatives from the US Food and Drug Administration and other government agencies, industry, and payers, convened to develop pragmatic consensus definitions useful for the evaluation of clinical trials enrolling patients with cardiogenic shock, including trials evaluating mechanical circulatory support devices. Several in-person and virtual meetings were convened between 2020 and 2022 to discuss the need for developing the standardized definitions required for evaluation of mechanical circulatory support devices in clinical trials for cardiogenic shock patients. The expert panel identified key concepts and topics by performing literature reviews, including previous clinical trials, while recognizing current challenges and the need to advance evidence-based practice and statistical analysis to support future clinical trials. For each category, a lead (primary) author was assigned to perform a literature search and draft a proposed definition, which was presented to the subgroup. These definitions were further modified after feedback from the expert panel meetings until a consensus was reached. This manuscript summarizes the expert panel recommendations focused on outcome definitions, including efficacy and safety.
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Affiliation(s)
- Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W.)
| | - Mohit Pahuja
- Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City (M.P.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.v.D.)
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, London, UK (A.G.P.)
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Germany (A.G.P.)
| | - David Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.M.)
| | - Ernest Spitzer
- Cardialysis, Rotterdam, The Netherlands (E.S.)
- Cardiology Department, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands (E.S.)
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington Harborview Center, Seattle (G.N.)
| | - Myron L Weisfeldt
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD (M.L.W.)
| | - Mauro Moscucci
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital Research Institute, Canada (P.R.L.)
- McGill University Health Centre, Montreal, Canada (P.R.L.)
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (P.R.L.)
| | - Alexandre Mebazaa
- Université Paris Cité, Department of Anesthesiology and Critical Care Medicine, Hôpital Lariboisière, France (A.M.)
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (E.F.)
| | - Neal W Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA (N.W.D.)
| | - Marc Samsky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (M.S.)
| | - Robert Kormos
- Global Medical Affairs Heart Failure, Abbott Laboratories, Austin, TX (R.K.)
| | - Ileana L Piña
- Division of Cardiology, Thomas Jefferson University, Philadelphia, PA (I.L.P.)
| | - Bram Zuckerman
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - Andrew Farb
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - John S Sapirstein
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | | | | | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA (A.A.D.)
| | - Ian C Gilchrist
- Department of Interventional Cardiology/Heart and Vascular Institute, Penn State Health/Hershey Medical Center (I.C.G.)
| | - Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Germany (H.T.)
- Leipzig Heart Science, Germany (H.T.)
| | - Donald E Cutlip
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA (D.E.C.)
| | - Mitchell Krucoff
- Department of Medicine, Duke University School of Medicine, Durham, NC (M.K.)
| | - William T Abraham
- Division of Cardiovascular Medicine and the Davis Heart and Lung Research Institute, The Ohio State University College of Medicine/Ohio State University Wexner Medical Center, Columbus (W.T.A.)
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Teixeira JP, Zeidman A, Beaubien-Souligny W, Cerdá J, Connor MJ, Eggleston K, Juncos LA, da Silva JR, Wells C, Yessayan L, Barker AB, McConville W, Speer R, Wille KM, Neyra JA, Tolwani A. Proceedings of the 2022 UAB CRRT Academy: Non-Invasive Hemodynamic Monitoring to Guide Fluid Removal with CRRT and Proliferation of Extracorporeal Blood Purification Devices. Blood Purif 2023; 52:857-879. [PMID: 37742622 DOI: 10.1159/000533573] [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: 03/22/2023] [Accepted: 06/29/2023] [Indexed: 09/26/2023]
Abstract
In 2022, we celebrated the 15th anniversary of the University of Alabama at Birmingham (UAB) Continuous Renal Replacement Therapy (CRRT) Academy, a 2-day conference attended yearly by an international audience of over 100 nephrology, critical care, and multidisciplinary trainees and practitioners. This year, we introduce the proceedings of the UAB CRRT Academy, a yearly review of select emerging topics in the field of critical care nephrology that feature prominently in the conference. First, we review the rapidly evolving field of non-invasive hemodynamic monitoring and its potential to guide fluid removal by renal replacement therapy (RRT). We begin by summarizing the accumulating data associating fluid overload with harm in critical illness and the potential for harm from end-organ hypoperfusion caused by excessive fluid removal with RRT, underscoring the importance of accurate, dynamic assessment of volume status. We describe four applications of point-of-care ultrasound used to identify patients in need of urgent fluid removal or likely to tolerate fluid removal: lung ultrasound, inferior vena cava ultrasound, venous excess ultrasonography, and Doppler of the left ventricular outflow track to estimate stroke volume. We briefly introduce other minimally invasive hemodynamic monitoring technologies before concluding that additional prospective data are urgently needed to adapt these technologies to the specific task of fluid removal by RRT and to learn how best to integrate them into practical fluid-management strategies. Second, we focus on the growth of novel extracorporeal blood purification devices, starting with brief reviews of the inflammatory underpinnings of multiorgan dysfunction and the specific applications of pathogen, endotoxin, and/or cytokine removal and immunomodulation. Finally, we review a series of specific adsorptive technologies, several of which have seen substantial clinical use during the COVID-19 pandemic, describing their mechanisms of target removal, the limited existing data supporting their efficacy, ongoing and future studies, and the need for additional prospective trials.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology and Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Amanda Zeidman
- Division of Nephrology, Department of Medicine, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jorge Cerdá
- Department of Medicine, Nephrology, Albany Medical College, Albany, New York, USA
| | - Michael J Connor
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine and Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Luis A Juncos
- Division of Nephrology, Department of Internal Medicine, Central Arkansas Veterans' Healthcare System, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Catherine Wells
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew B Barker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Wendy McConville
- School of Nursing, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Rajesh Speer
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Keith M Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
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9
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Hamzaoui O, Boissier F. Hemodynamic monitoring in cardiogenic shock. JOURNAL OF INTENSIVE MEDICINE 2023; 3:104-113. [PMID: 37188114 PMCID: PMC10175734 DOI: 10.1016/j.jointm.2022.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/09/2022] [Accepted: 10/19/2022] [Indexed: 05/17/2023]
Abstract
Cardiogenic shock (CS) is a life-threatening condition characterized by acute end-organ hypoperfusion due to inadequate cardiac output that can result in multiorgan failure, which may lead to death. The diminished cardiac output in CS leads to systemic hypoperfusion and maladaptive cycles of ischemia, inflammation, vasoconstriction, and volume overload. Obviously, the optimal management of CS needs to be readjusted in view of the predominant dysfunction, which may be guided by hemodynamic monitoring. Hemodynamic monitoring enables (1) characterization of the type of cardiac dysfunction and the degree of its severity, (2) very early detection of associated vasoplegia, (3) detection and monitoring of organ dysfunction and tissue oxygenation, and (4) guidance of the introduction and optimization of inotropes and vasopressors as well as the timing of mechanical support. It is now well documented that early recognition, classification, and precise phenotyping via early hemodynamic monitoring (e.g., echocardiography, invasive arterial pressure, and the evaluation of organ dysfunction and parameters derived from central venous catheterization) improve patient outcomes. In more severe disease, advanced hemodynamic monitoring with pulmonary artery catheterization and the use of transpulmonary thermodilution devices is useful to facilitate the right timing of the indication, weaning from mechanical cardiac support, and guidance on inotropic treatments, thus helping to reduce mortality. In this review, we detail the different parameters relevant to each monitoring approach and the way they can be used to support optimal management of these patients.
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Affiliation(s)
- Olfa Hamzaoui
- Service de Médecine Intensive Réanimation, Hôpital Robert Debré, Université de Reims, Reims 51092, France
- Unité HERVI, Hémostase et Remodelage Vasculaire Post-Ischémie, EA 3801, Reims 51092, France
| | - Florence Boissier
- Médecine Intensive Réanimation, Hôpital Universitaire de Poitiers, Poitiers 90577, France
- INSERM CIC 1402 (ALIVE Group), Université de Poitiers, Poitiers 90577, France
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10
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Ramírez M, Mazwi ML, Bronicki RA, Checchia PA, Ong JSM. Beyond Conventional Hemodynamic Monitoring-Monitoring to Improve Our Understanding of Disease Process and Interventions. Crit Care Clin 2023; 39:243-254. [PMID: 36898771 DOI: 10.1016/j.ccc.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Monitoring the hemodynamic state of patients is a hallmark of any intensive care environment. However, no single monitoring strategy can provide all the necessary data to paint the entire picture of the state of a patient; each monitor has strengths and weaknesses, advantages, and limitations. We review the currently available hemodynamic monitors used in pediatric critical care units using a clinical scenario. This provides the reader with a construct to understand the progression from basic to more advanced monitoring modalities and how they serve to inform the practitioner at the bedside.
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Affiliation(s)
- Michelle Ramírez
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, New York University Langone Medical Center, Hassenfeld Children's Hospital, New York, NY 10016, USA
| | - Mjaye L Mazwi
- Department of Critical Care Medicine, Division of Cardiology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Ronald A Bronicki
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, WT6-006, Houston, TX 77030, USA
| | - Paul A Checchia
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, WT6-006, Houston, TX 77030, USA
| | - Jacqueline S M Ong
- Division of Paediatric Critical Care, Khoo Teck Puat - University Children's Medical Institute, NUHS Tower Block Level 12, 1E Kent Ridge Road, Singapore 119228; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, 21 Lower Kent Ridge Road, Singapore 119077.
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11
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Khariton Y, Hassan OA, Hernandez-Montfort JA. Update on cardiogenic shock: from detection to team management. Curr Opin Cardiol 2023; 38:108-115. [PMID: 36718620 DOI: 10.1097/hco.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW The following review is intended to provide a summary of contemporary cardiogenic shock (CS) profiling and diagnostic strategies, including biomarker and hemodynamic-based (invasive and noninvasive) monitoring, discuss clinical differences in presentation and trajectory between acute myocardial infarction (AMI)-CS and heart failure (HF)-CS, describe transitions to native heart recovery and heart replacement therapies with a focus on tailored management and emerging real-world data, and emphasize trends in team-based initiatives and interventions for cardiogenic shock including the integration of protocol-driven care. RECENT FINDINGS This document provides a broad overview of contemporary scientific consensus statements as well as data derived from randomized controlled clinical trials and observational registry working groups focused on cardiogenic shock management. SUMMARY This review highlights the increasingly important role of pulmonary artery catheterization in AMI-CS and HF-CS cardiogenic shock and advocates for routine application of algorithmic approaches with interdisciplinary care pathways. Cardiogenic shock algorithms facilitate the integration of clinical, hemodynamic, and imaging data to determine the most appropriate patient hemodynamic support platform to achieve adequate organ perfusion and decongestion.
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12
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Abstract
PURPOSE OF REVIEW The purpose of this article is to review various contemporary cardiac output (CO) measurement technologies available and their utility in critically ill patients. RECENT FINDINGS CO measurement devices can be invasive, minimally invasive, or noninvasive depending upon their method of CO measurement. All devices have pros and cons, with pulmonary artery catheter (PAC) being the gold standard. The invasive techniques are more accurate; however, their invasiveness can cause more complications. The noninvasive devices predict CO via mathematical modeling with several assumptions and are thus prone to errors in clinical situations. Recently, PAC has made a comeback into clinical practice especially in cardiac intensive care units (ICUs). Critical care echocardiography (CCE) is an upcoming tool that not only provides CO but also helps in differential diagnosis. Lack of proper training and nonavailability of equipment are the main hindrances to the wide adoption of CCE. SUMMARY PAC thermodilution for CO measurement is still gold standard and most suitable in patients with cardiac pathology and with experienced user. CCE offers an alternative to thermodilution and is suitable for all ICUs; however, structural training is required.
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Affiliation(s)
- Virendra K Arya
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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13
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Rali AS, Butcher A, Tedford RJ, Sinha SS, Mekki P, Van Spall HGC, Sauer AJ. Contemporary Review of Hemodynamic Monitoring in the Critical Care Setting. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hemodynamic assessment remains the most valuable adjunct to physical examination and laboratory assessment in the diagnosis and management of shock. Through the years, multiple modalities to measure and trend hemodynamic indices have evolved with varying degrees of invasiveness. Pulmonary artery catheter (PAC) has long been considered the gold standard of hemodynamic assessment in critically ill patients and in recent years has been shown to improve clinical outcomes among patients in cardiogenic shock. The invasive nature of PAC is often cited as its major limitation and has encouraged development of less invasive technologies. In this review, the authors summarize the literature on the mechanism and validation of several minimally invasive and noninvasive modalities available in the contemporary intensive care unit. They also provide an update on the use of focused bedside echocardiography.
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Amy Butcher
- Department of Cardiovascular Anesthesia and Critical Care, Baylor College of Medicine, Houston, TX
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Shashank S Sinha
- Division of Cardiology, Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | - Pakinam Mekki
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Harriette GC Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Andrew J Sauer
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS
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Kashani K, Omer T, Shaw AD. The Intensivist's Perspective of Shock, Volume Management, and Hemodynamic Monitoring. Clin J Am Soc Nephrol 2022; 17:706-716. [PMID: 35379765 PMCID: PMC9269574 DOI: 10.2215/cjn.14191021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
One of the primary reasons for intensive care admission is shock. Identifying the underlying cause of shock (hypovolemic, distributive, cardiogenic, and obstructive) may lead to entirely different clinical pathways for management. Among patients with hypovolemic and distributive shock, fluid therapy is one of the leading management strategies. Although an appropriate amount of fluid administration might save a patient's life, inadequate (or excessive) fluid use could lead to more complications, including organ failure and mortality due to either hypovolemia or volume overload. Currently, intensivists have access to a wide variety of information sources and tools to monitor the underlying hemodynamic status, including medical history, physical examination, and specific hemodynamic monitoring devices. Although appropriate and timely assessment and interpretation of this information can promote adequate fluid resuscitation, misinterpretation of these data can also lead to additional mortality and morbidity. This article provides a narrative review of the most commonly used hemodynamic monitoring approaches to assessing fluid responsiveness and fluid tolerance. In addition, we describe the benefits and disadvantages of these tools.
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Affiliation(s)
- Kianoush Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Tarig Omer
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio
| | - Andrew D. Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio
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15
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Ott S, Leser L, Lanmüller P, Just IA, Leistner DM, Potapov E, O’Brien B, Klages J. Cardiogenic Shock Management and Research: Past, Present, and Future Outlook. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Although great strides have been made in the pathophysiological understanding, diagnosis and management of cardiogenic shock (CS), morbidity and mortality in patients presenting with the condition remain high. Acute MI is the commonest cause of CS; consequently, most existing literature concerns MI-associated CS. However, there are many more phenotypes of patients with acute heart failure. Medical treatment and mechanical circulatory support are well-established therapeutic options, but evidence for many current treatment regimens is limited. The issue is further complicated by the fact that implementing adequately powered, randomized controlled trials are challenging for many reasons. In this review, the authors discuss the history, landmark trials, current topics of medical therapy and mechanical circulatory support regimens, and future perspectives of CS management.
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Affiliation(s)
- Sascha Ott
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Laura Leser
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
| | - Pia Lanmüller
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Isabell A Just
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - David Manuel Leistner
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Evgenij Potapov
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Benjamin O’Brien
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany; William Harvey Research Institute, London, UK
| | - Jan Klages
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
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16
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Non-invasive cardiac output monitoring (NICOM) in adult congenital heart disease patients with Fontan palliation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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17
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Kittleson MM, Prestinenzi P, Potena L. Right Heart Catheterization in Patients with Advanced Heart Failure: When to Perform? How to Interpret? Heart Fail Clin 2021; 17:647-660. [PMID: 34511212 DOI: 10.1016/j.hfc.2021.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Right heart catheterization is an established cornerstone of advanced heart failure management, as a clear understanding of the patient's hemodynamic status offers insight into diagnosis, prognosis, and management. In this review, the authors will describe the role of right heart catheterization in the diagnosis and management of shock, in the context of left ventricular assist devices, in the assessment of heart transplant candidacy, and also explore future directions of implantable monitoring devices for pulmonary artery and left atrial pressure monitoring.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA, USA
| | - Paola Prestinenzi
- Heart Failure and Heart Transplant Program, IRCCS Policlinico di Sant'Orsola, Building 25 via Massarenti, 9, 40138 Bologna, Italy
| | - Luciano Potena
- Heart Failure and Heart Transplant Program, IRCCS Policlinico di Sant'Orsola, Building 25 via Massarenti, 9, 40138 Bologna, Italy.
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Abstract
PURPOSE OF REVIEW Cardiogenic shock remains a major cause of mortality today. With recent advancements in invasive mechanical support strategies, reperfusion practice, and a new classification scheme is proposed for cardiogenic shock, an updated review of the latest hemodynamic monitoring techniques is important. RECENT FINDINGS Multiple recent studies have emerged supporting the use of pulmonary artery catheters in the cardiogenic shock population. Data likewise continues to emerge on the use of echocardiography and biomarker measurement in the care of these patients. SUMMARY The integration of multiple forms of hemodynamic monitoring, spanning noninvasive and invasive modalities, is important in the diagnosis, staging, initial treatment, and subsequent management of the cardiogenic shock patient.
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19
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Wise ES, Hocking KM, Polcz ME, Beilman GJ, Brophy CM, Sobey JH, Leisy PJ, Kiberenge RK, Alvis BD. Hemodynamic Parameters in the Assessment of Fluid Status in a Porcine Hemorrhage and Resuscitation Model. Anesthesiology 2021; 134:607-616. [PMID: 33635950 PMCID: PMC7946734 DOI: 10.1097/aln.0000000000003724] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Measuring fluid status during intraoperative hemorrhage is challenging, but detection and quantification of fluid overload is far more difficult. Using a porcine model of hemorrhage and over-resuscitation, it is hypothesized that centrally obtained hemodynamic parameters will predict volume status more accurately than peripherally obtained vital signs. METHODS Eight anesthetized female pigs were hemorrhaged at 30 ml/min to a blood loss of 400 ml. After each 100 ml of hemorrhage, vital signs (heart rate, systolic blood pressure, mean arterial pressure, diastolic blood pressure, pulse pressure, pulse pressure variation) and centrally obtained hemodynamic parameters (mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure, cardiac output) were obtained. Blood volume was restored, and the pigs were over-resuscitated with 2,500 ml of crystalloid, collecting parameters after each 500-ml bolus. Hemorrhage and resuscitation phases were analyzed separately to determine differences among parameters over the range of volume. Conformity of parameters during hemorrhage or over-resuscitation was assessed. RESULTS During the course of hemorrhage, changes from baseline euvolemia were observed in vital signs (systolic blood pressure, diastolic blood pressure, and mean arterial pressure) after 100 ml of blood loss. Central hemodynamic parameters (mean pulmonary artery pressure and pulmonary capillary wedge pressure) were changed after 200 ml of blood loss, and central venous pressure after 300 ml of blood loss. During the course of resuscitative volume overload, changes were observed from baseline euvolemia in mean pulmonary artery pressure and central venous pressure after 500-ml resuscitation, in pulmonary capillary wedge pressure after 1,000-ml resuscitation, and cardiac output after 2,500-ml resuscitation. In contrast to hemorrhage, vital sign parameters did not change during over-resuscitation. The strongest linear correlation was observed with pulmonary capillary wedge pressure in both hemorrhage (r2 = 0.99) and volume overload (r2 = 0.98). CONCLUSIONS Pulmonary capillary wedge pressure is the most accurate parameter to track both hemorrhage and over-resuscitation, demonstrating the unmet clinical need for a less invasive pulmonary capillary wedge pressure equivalent. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Eric S Wise
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kyle M Hocking
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Monica E Polcz
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Colleen M Brophy
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jenna H Sobey
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Philip J Leisy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Roy K Kiberenge
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Bret D Alvis
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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20
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Garan AR, Kanwar M, Hernandez-Montfort J, Mahr C, Sinha SS, Burkhoff D, Kapur NK. Reply: Pulmonary Artery Catheter in Cardiogenic Shock: Will the Benefits Finally Outweigh the Costs and Complications? JACC-HEART FAILURE 2021; 9:323-324. [PMID: 33795125 DOI: 10.1016/j.jchf.2020.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 12/31/2020] [Indexed: 11/28/2022]
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21
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Lopez CN, Sulaica EM, Donahue KR, Wanat MA. Updates in Hemodynamic Monitoring: A Review for Pharmacists. J Pharm Pract 2021; 35:762-768. [PMID: 33769132 DOI: 10.1177/08971900211003436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Vital signs are regularly monitored in hospitalized patients. In the intensive care unit (ICU), traditional non-invasive blood pressure monitoring and telemetry may not provide enough information to determine the etiology of hemodynamic instability or guide intervention. Arterial catheters remain the gold-standard for continuous blood pressure monitoring and are commonly used in ICU patients. Pulmonary artery catheters and central venous catheters are beneficial in select patient populations and provide more advanced and specific information about a patient's hemodynamics. However, neither are benign and can increase risk of complications such as infection, arrhythmias, pneumothorax and vascular or valvular damage. In the past 10 years, the development of reliable non-invasive (NICOM), or minimally-invasive (MICOM), cardiac output monitoring devices has accelerated. The MICOM devices require an arterial catheter to obtain hemodynamic values, whereas NICOM devices do not require any arterial or venous access. These devices have emerged to be particularly useful in evaluating and managing patients with suspected mixed shock. As these devices become more prevalent, it is imperative that clinical pharmacists become familiar with interpreting this data as it may have a substantial impact on medication selection and optimization. This review will discuss the basics of NICOM and MICOM devices, limitations with these methods of monitoring, and clinical application for pharmacists.
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Affiliation(s)
- Chelsea N Lopez
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Elisabeth M Sulaica
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Kevin R Donahue
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Matthew A Wanat
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA.,Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
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22
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Sengupta SP, Mungulmare K, Okwose NC, MacGowan GA, Jakovljevic DG. Comparison of cardiac output estimates by echocardiography and bioreactance at rest and peak dobutamine stress test in heart failure patients with preserved ejection fraction. Echocardiography 2020; 37:1603-1609. [PMID: 32949037 DOI: 10.1111/echo.14836] [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: 06/15/2020] [Revised: 07/25/2020] [Accepted: 08/02/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To assess the agreement between cardiac output estimated by two-dimensional echocardiography and bioreactance methods at rest and during dobutamine stress test in heart failure patients with preserved left ventricular ejection fraction (HFpEF). METHODS Hemodynamic measurements were assessed in 20 stable HFpEF patients (12 females; aged 61 ± 7 years) using echocardiography and bioreactance methods during rest and dobutamine stress test at increment dosages of 5, 10, 15, and 20 μg/kg/min until maximal dose was achieved or symptoms and sign occurred, that is, chest pain, abnormal blood pressure elevation, breathlessness, ischemic changes, or arrhythmia. RESULTS Resting cardiac output and cardiac index estimated by bioreactance and echocardiography were not significantly different. At peak dobutamine stress test, cardiac output and cardiac index estimated by echocardiography and bioreactance were significantly different (7.06 ± 1.43 vs 5.71 ± 1.59 L/min, P < .01; and 4.27 ± 0.67 vs 3.43 ± 0.87 L/m2 /min; P < .01) due to the significant differences in stroke volume. There was a strong positive relationship between cardiac outputs obtained by the two methods at peak dobutamine stress (r = .79, P < .01). The mean difference (lower and upper limits of agreement) between bioreactance and echocardiography cardiac outputs at rest and peak dobutamine stress was -0.45 (1.71 to -2.62) L/min and -1.35 (0.60 to -3.31) L/min, respectively. CONCLUSION Bioreactance and echocardiography methods provide different cardiac output values at rest and during stress thus cannot be used interchangeably. Ability to continuously monitor key hemodynamic variables such as cardiac output, stroke volume, and heart rate is the major advantage of bioreactance method.
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Affiliation(s)
- Shantanu P Sengupta
- Cardiology, Sengupta Hospital and Research Institute, Ravinagar Nagpur, Maharashtra, India.,Faculty of Medical Sciences, Cardiovascular Research Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Kunda Mungulmare
- Cardiology, Sengupta Hospital and Research Institute, Ravinagar Nagpur, Maharashtra, India
| | - Nduka C Okwose
- Faculty of Medical Sciences, Cardiovascular Research Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Guy A MacGowan
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Faculty of Medical Sciences, Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Djordje G Jakovljevic
- Faculty of Medical Sciences, Cardiovascular Research Translational and Clinical Research Institute, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Faculty of Health and Life Sciences, Coventry University, Coventry, UK
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Hankinson SJ, Williams CH, Ton VK, Gottlieb SS, Hong CC. Should we overcome the resistance to bioelectrical impedance in heart failure? Expert Rev Med Devices 2020; 17:785-794. [PMID: 32658589 PMCID: PMC8356137 DOI: 10.1080/17434440.2020.1791701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Heart failure is associated with increased neurohormonal activation that results in changes in body composition including volume overload and the loss of skeletal muscle, body fat, and bone density. Bioelectrical impedance measures body composition based on the conduction of electrical current through body fluids. AREAS COVERED The PubMed and Scopus databases were reviewed up to the third week of June 2020. Cross-sectional studies, retrospective observational studies, prospective observational studies, and randomized controlled trials have examined numerous bioelectrical impedance monitoring strategies to guide the diagnosis, prognosis, and treatment of heart failure. These monitoring strategies include intrathoracic impedance, lung impedance, bioelectrical impedance vector analysis, leg bioelectrical impedance, and thoracic bioreactance. EXPERT COMMENTARY Based on the current evidence, more studies are needed to validate bioelectrical impedance in heart failure. Lung impedance appears to be useful for guiding heart failure treatment in patients with ST-elevation myocardial infarction and improving outcomes in outpatients with heart failure. Furthermore, bioelectrical impedance has potential as a noninvasive, quantitative heart failure variable for population-based research.
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Affiliation(s)
- Stephen J. Hankinson
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Charles H. Williams
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Van-Khue Ton
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Harvard Medical School, Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen S. Gottlieb
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Charles C. Hong
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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