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Ostadal P, Belohlavek J. What is cardiogenic shock? New clinical criteria urgently needed. Curr Opin Crit Care 2024; 30:319-323. [PMID: 38841985 PMCID: PMC11224559 DOI: 10.1097/mcc.0000000000001172] [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: 06/07/2024]
Abstract
PURPOSE OF REVIEW Cardiogenic shock is a clinical syndrome with different causes and a complex pathophysiology. Recent evidence from clinical trials evokes the urgent need for redefining clinical diagnostic criteria to be compliant with the definition of cardiogenic shock and current diagnostic methods. RECENT FINDINGS Conflicting results from randomized clinical trials investigating mechanical circulatory support in patients with cardiogenic shock have elicited several extremely important questions. At minimum, it is questionable whether survivors of cardiac arrest should be included in trials focused on cardiogenic shock. Moreover, considering the wide availability of ultrasound and hemodynamic monitors capable of arterial pressure analysis, the current clinical diagnostic criteria based on the presence of hypotension and hypoperfusion have become insufficient. As such, new clinical criteria for the diagnosis of cardiogenic shock should include evidence of low cardiac output and appropriate ventricular filling pressure. SUMMARY Clinical diagnostic criteria for cardiogenic shock should be revised to better define cardiac pump failure as a primary cause of hemodynamic compromise.
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Affiliation(s)
- Petr Ostadal
- Department of Cardiology, Second Faculty of Medicine, Charles University and Motol University Hospital
| | - Jan Belohlavek
- 2nd Department of Medicine – Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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Zhang H, Lian H, Zhang Q, Zhao H, Wang X. Can central venous pressure help identify acute right ventricular dysfunction in mechanically ventilated critically ill patients? Ann Intensive Care 2024; 14:114. [PMID: 39031301 PMCID: PMC11264666 DOI: 10.1186/s13613-024-01352-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 07/09/2024] [Indexed: 07/22/2024] Open
Abstract
OBJECTIVE To investigate the relationship between central venous pressure (CVP) and acute right ventricular (RV) dysfunction in critically ill patients on mechanical ventilation. METHODS This retrospective study enrolled mechanically ventilated critically ill who underwent transthoracic echocardiographic examination and CVP monitoring. Echocardiographic indices including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tricuspid lateral annular systolic velocity wave (S') were collected to assess RV function. Patients were then classified into three groups based on their RV function and presence of systemic venous congestion as assessed by inferior vena cava diameter (IVCD) and hepatic vein (HV) Doppler: normal RV function (TAPSE ≥ 17 mm, FAC ≥ 35% and S' ≥9.5 cm/sec), isolated RV dysfunction (TAPSE < 17 mm or FAC < 35% or S' <9.5 cm/sec with IVCD ≤ 20 mm or HV S ≥ D), and RV dysfunction with congestion (TAPSE < 17 mm or FAC < 35% or S' <9.5 cm/sec with IVCD > 20 mm and HV S < D). RESULTS A total of 518 patients were enrolled in the study, of whom 301 were categorized in normal RV function group, 164 in isolated RV dysfunction group and 53 in RV dysfunction with congestion group. Receiver operating characteristic analysis revealed a good discriminative ability of CVP for identifying patients with RV dysfunction and congestion(AUC 0.839; 95% CI: 0.795-0.883; p < 0.001). The optimal CVP cutoff was 10 mm Hg, with sensitivity of 79.2%, specificity of 69.4%, negative predictive value of 96.7%, and positive predictive value of 22.8%. A large gray zone existed between 9 mm Hg and 12 mm Hg, encompassing 95 patients (18.3%). For identifying all patients with RV dysfunction, CVP demonstrated a lower discriminative ability (AUC 0.616; 95% CI: 0.567-0.665; p < 0.001). Additionally, the gray zone was even larger, ranging from 5 mm Hg to 12 mm Hg, and included 349 patients (67.4%). CONCLUSIONS CVP may be a helpful indicator of acute RV dysfunction patients with systemic venous congestion in mechanically ventilated critically ill, but its accuracy is limited. A CVP less than10 mm Hg can almost rule out RV dysfunction with congestion. In contrast, CVP should not be used to identify general RV dysfunction.
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Affiliation(s)
- Hongmin Zhang
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China.
| | - Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Qing Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Hua Zhao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
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Dimopoulos S, Antonopoulos M. Portal vein pulsatility: An important sonographic tool assessment of systemic congestion for critical ill patients. World J Cardiol 2024; 16:221-225. [PMID: 38817642 PMCID: PMC11135329 DOI: 10.4330/wjc.v16.i5.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/19/2024] [Accepted: 04/01/2024] [Indexed: 05/23/2024] Open
Abstract
In this editorial we comment on the article by Kuwahara et al, published in the recent issue of the World Journal of Cardiology. In this interesting paper, the authors showed a correlation between portal vein pulsatility ratio, examined by bedside ultrasonography, and prognosis of hospitalized patients with acute heart failure. Systemic congestion is being notoriously underdetected in the acutely ill population with conventional methods like clinical examination, biomarkers, central venous pressure estimation and X-rays. However, congestion should be a key therapeutic target due to its deleterious effects to end organ function and subsequently patient prognosis. Doppler flow assessment of the abdominal veins is gaining popularity worldwide, as a valuable tool in estimating comprehensively congestion and giving a further insight into hemodynamics and patient management.
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Affiliation(s)
- Stavros Dimopoulos
- Cardiac Surgery ICU, Onassis Cardiac Surgery Center, Kallithea 17674, Greece.
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Bachmann KF, Moller PW, Hunziker L, Maggiorini M, Berger D. Mechanisms maintaining right ventricular contractility-to-pulmonary arterial elastance ratio in VA ECMO: a retrospective animal data analysis of RV-PA coupling. J Intensive Care 2024; 12:19. [PMID: 38734616 PMCID: PMC11088130 DOI: 10.1186/s40560-024-00730-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/14/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND To optimize right ventricular-pulmonary coupling during veno-arterial (VA) ECMO weaning, inotropes, vasopressors and/or vasodilators are used to change right ventricular (RV) function (contractility) and pulmonary artery (PA) elastance (afterload). RV-PA coupling is the ratio between right ventricular contractility and pulmonary vascular elastance and as such, is a measure of optimized crosstalk between ventricle and vasculature. Little is known about the physiology of RV-PA coupling during VA ECMO. This study describes adaptive mechanisms for maintaining RV-PA coupling resulting from changing pre- and afterload conditions in VA ECMO. METHODS In 13 pigs, extracorporeal flow was reduced from 4 to 1 L/min at baseline and increased afterload (pulmonary embolism and hypoxic vasoconstriction). Pressure and flow signals estimated right ventricular end-systolic elastance and pulmonary arterial elastance. Linear mixed-effect models estimated the association between conditions and elastance. RESULTS At no extracorporeal flow, end-systolic elastance increased from 0.83 [0.66 to 1.00] mmHg/mL at baseline by 0.44 [0.29 to 0.59] mmHg/mL with pulmonary embolism and by 1.36 [1.21 to 1.51] mmHg/mL with hypoxic pulmonary vasoconstriction (p < 0.001). Pulmonary arterial elastance increased from 0.39 [0.30 to 0.49] mmHg/mL at baseline by 0.36 [0.27 to 0.44] mmHg/mL with pulmonary embolism and by 0.75 [0.67 to 0.84] mmHg/mL with hypoxic pulmonary vasoconstriction (p < 0.001). Coupling remained unchanged (2.1 [1.8 to 2.3] mmHg/mL at baseline; - 0.1 [- 0.3 to 0.1] mmHg/mL increase with pulmonary embolism; - 0.2 [- 0.4 to 0.0] mmHg/mL with hypoxic pulmonary vasoconstriction, p > 0.05). Extracorporeal flow did not change coupling (0.0 [- 0.0 to 0.1] per change of 1 L/min, p > 0.05). End-diastolic volume increased with decreasing extracorporeal flow (7.2 [6.6 to 7.8] ml change per 1 L/min, p < 0.001). CONCLUSIONS The right ventricle dilates with increased preload and increases its contractility in response to afterload changes to maintain ventricular-arterial coupling during VA extracorporeal membrane oxygenation.
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Affiliation(s)
- Kaspar F Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Per Werner Moller
- Department of Anesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lukas Hunziker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Maggiorini
- Medical Intensive Care Unit, University Hospital Zürich, University of Zürich, Zurich, Switzerland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Zhang H, Zhang D, Lian H, Zhang Q, Chen X, Wang X. Echocardiographic features of right ventricle in septic patients with elevated central venous pressure. BMC Anesthesiol 2024; 24:128. [PMID: 38575875 PMCID: PMC10993580 DOI: 10.1186/s12871-024-02515-8] [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: 10/25/2023] [Accepted: 03/28/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Elevated central venous pressure (CVP) is deemed as a sign of right ventricular (RV) dysfunction. We aimed to characterize the echocardiographic features of RV in septic patients with elevated CVP, and quantify associations between RV function parameters and 30-day mortality. METHODS We retrospectively reviewed a cohort of septic patients with CVP ≥ 8 mmHg in a tertiary hospital intensive care unit. General characteristics and echocardiographic parameters including tricuspid annular plane systolic excursion (TAPSE), pulmonary vascular resistance (PVR) as well as prognostic data were collected. Associations between RV function parameters and 30-day mortality were assessed using Cox regression models. RESULTS Echocardiography was performed in 244 septic patients with CVP ≥ 8 mmHg. Echocardiographic findings revealed that various types of abnormal RV function can occur individually or collectively. Prevalence of RV systolic dysfunction was 46%, prevalence of RV enlargement was 34%, and prevalence of PVR increase was 14%. In addition, we collected haemodynamic consequences and found that prevalence of systemic venous congestion was 16%, prevalence of RV-pulmonary artery decoupling was 34%, and prevalence of low cardiac index (CI) was 23%. The 30-day mortality of the enrolled population was 24.2%. In a Cox regression analysis, TAPSE (HR:0.542, 95% CI:0.302-0.972, p = 0.040) and PVR (HR:1.384, 95% CI:1.007-1.903, p = 0.045) were independently associated with 30-day mortality. CONCLUSIONS Echocardiographic findings demonstrated a high prevalence of RV-related abnormalities (RV enlargement, RV systolic dysfunction and PVR increase) in septic patients with elevated CVP. Among those echocardiographic parameters, TAPSE and PVR were independently associated with 30-day mortality in these patients.
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Affiliation(s)
- Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China.
- Critical Care Ultrasound Study Group, Beijing, China.
| | - Dingding Zhang
- Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Lian
- Critical Care Ultrasound Study Group, Beijing, China
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
- Critical Care Ultrasound Study Group, Beijing, China
| | - Xiukai Chen
- Department of Cardiopulmonary Science, Respiratory Care Division, Rush University, Chicago, IL, USA
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China.
- Critical Care Ultrasound Study Group, Beijing, China.
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Malakan Rad E, Parizadeh N, Radmehr H, Sheykhian T, Gharib B, Zeinaloo A. Correlation between echocardiographic estimation of right atrial pressure and invasive measurement of central venous pressure in postoperative pediatric patients with congenital heart disease: a prospective observational study. Egypt Heart J 2024; 76:25. [PMID: 38381260 PMCID: PMC10881910 DOI: 10.1186/s43044-024-00456-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 02/16/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Right atrial pressure plays a critical role as a hemodynamic parameter in diagnosing pulmonary hypertension and other cardiac diseases, as well as guiding the treatment and prognosis of various cardiac disorders. If there is no obstruction between the inferior or superior vena cava (SVC) as central veins and the right atrium, the pressures in these veins could be considered equal to the right atrial pressure. This study aimed to examine the correlation between echocardiographic methods for estimating right atrial pressure and invasive measurements of central venous pressure (CVPi) in infants and children with congenital heart disease during the 48 h after cardiac surgery and to establish regression equations for echocardiographic estimation of central venous pressure (CVPe). RESULTS We prospectively enrolled 43 infants and children, ranging in age from 6 months to 16 years, including 20 males and 23 females. We found a significant correlation between CVPi and the ratio of the maximal diameter of IVC to the maximal diameter of the descending aorta ratio (IVCmax/DAOmax) (r = 0.529, P < 0.001), SVCS/D velocity ratio (SVCS/D) (r = 0.462, P = 0.006), right atrial vertical diameter (RAVD) (r = 0.409, P = 0.01), area (r = 0.384, P = 0.014), and tricuspid valve A wave acceleration rate (TVAAR) (r = 0.315, P = 0.048). Multiple regression analysis yielded an equation for estimating central venous pressure using four parameters related to the IVC, SVC, tricuspid valve, and right atrium. The equation is as follows: estimated CVP = 4.36 + (2.35 × IVCmax/DAOmax) + (1.06 × SVCS/D) + (0.059 × RAVD) + (0.001 × TVAAR). This equation is strongly correlated with CVPi (Pearson r = 0.698, P = 0.002). CONCLUSIONS The estimation of central venous pressure through a multi-parametric equation that included the ratio of the maximal diameter of the inferior vena cava to the maximal diameter of the descending aorta, the ratio of S to D velocity of the superior vena cava, the vertical diameter of the right atrium, and the acceleration rate of the A wave of the tricuspid valve demonstrated a robust correlation with invasively measured central venous pressure. To assess the accuracy of predicted pressures by this equation, further investigations are required to apply this innovative multi-parametric formula to a prospective population of pediatric patients with congenital heart disease.
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Affiliation(s)
- Elaheh Malakan Rad
- Children's Medical Center (Pediatric Center of Excellence), Affiliated with Tehran University of Medical Sciences, No. 62, Dr. Gharib's Street, End of Keshavarz Boulevard, Tehran, 1419733151, Iran.
| | - Nazli Parizadeh
- Children's Medical Center (Pediatric Center of Excellence), Affiliated with Tehran University of Medical Sciences, No. 62, Dr. Gharib's Street, End of Keshavarz Boulevard, Tehran, 1419733151, Iran
| | - Hassan Radmehr
- Children's Medical Center (Pediatric Center of Excellence), Affiliated with Tehran University of Medical Sciences, No. 62, Dr. Gharib's Street, End of Keshavarz Boulevard, Tehran, 1419733151, Iran
| | - Toktam Sheykhian
- Imam Khoemoeini's Hospital, Affiliated with Tehran University of Medical Sciences, No. 62, Dr. Gharib's Street, End of Keshavarz Boulevard, Next to Children's Medical Center, Tehran, 1419733134, Iran
| | - Behdad Gharib
- Children's Medical Center (Pediatric Center of Excellence), Affiliated with Tehran University of Medical Sciences, No. 62, Dr. Gharib's Street, End of Keshavarz Boulevard, Tehran, 1419733151, Iran
| | - Aliakbar Zeinaloo
- Children's Medical Center (Pediatric Center of Excellence), Affiliated with Tehran University of Medical Sciences, No. 62, Dr. Gharib's Street, End of Keshavarz Boulevard, Tehran, 1419733151, Iran
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Salinas P, Dieiev V. Critical Care Echocardiography: Assessing Left and Right Ventricular Function in the Intensive Care Unit. Semin Ultrasound CT MR 2024; 45:58-73. [PMID: 38097023 DOI: 10.1053/j.sult.2023.12.007] [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: 03/14/2024]
Abstract
In this review we explore Left Ventricular and Right Ventricular parameters that intensivists can use to evaluate, manage, and monitor the critically ill. Understanding these parameters, their clinical relevance, and potential pitfalls, is crucial for thorough and accurate patient assessment and management. Critical Care Echocardiography encompasses all the advanced cardiac and non-cardiac skillset needed to integrate the findings of Left Ventricular and Right Ventricular size and function. We advocate for a physiologic approach to the critically ill patient, tailoring therapy to reverse the etiology while simultaneously supporting circulation based on a sound understanding of left and right ventricular pressures, volumes, and flow.
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Affiliation(s)
- Pedro Salinas
- St. Luke's Medical Center, Aurora Critical Care Service, Milwaukee, WI.
| | - Vladyslav Dieiev
- St. Luke's Medical Center, Aurora Critical Care Service, Milwaukee, WI
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Arrow C, Ward M, Eshraghian J, Dwivedi G. Capturing the pulse: a state-of-the-art review on camera-based jugular vein assessment. BIOMEDICAL OPTICS EXPRESS 2023; 14:6470-6492. [PMID: 38420308 PMCID: PMC10898581 DOI: 10.1364/boe.507418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/02/2023] [Accepted: 11/05/2023] [Indexed: 03/02/2024]
Abstract
Heart failure is associated with a rehospitalisation rate of up to 50% within six months. Elevated central venous pressure may serve as an early warning sign. While invasive procedures are used to measure central venous pressure for guiding treatment in hospital, this becomes impractical upon discharge. A non-invasive estimation technique exists, where the clinician visually inspects the pulsation of the jugular veins in the neck, but it is less reliable due to human limitations. Video and signal processing technologies may offer a high-fidelity alternative. This state-of-the-art review analyses existing literature on camera-based methods for jugular vein assessment. We summarize key design considerations and suggest avenues for future research. Our review highlights the neck as a rich imaging target beyond the jugular veins, capturing comprehensive cardiac signals, and outlines factors affecting signal quality and measurement accuracy. Addressing an often quoted limitation in the field, we also propose minimum reporting standards for future studies.
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Affiliation(s)
- Coen Arrow
- School of Medicine, University of Western Australia, Perth, Australia
- Advanced Clinical and Translational Cardiovascular Imaging, Harry Perkins Institute of Medical Research, University of Western Australia, Perth, Australia
| | - Max Ward
- Department of Computer Science and Software Engineering, University of Western Australia, Perth, Australia
| | - Jason Eshraghian
- Department of Electrical and Computer Engineering, University of California (Santa Cruz), California, USA
| | - Girish Dwivedi
- School of Medicine, University of Western Australia, Perth, Australia
- Advanced Clinical and Translational Cardiovascular Imaging, Harry Perkins Institute of Medical Research, University of Western Australia, Perth, Australia
- Department of Cardiology, Fiona Stanley Hospital, Perth, Australia
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Kim YJ, Seo JH, Lee HC, Kim HS. Pleth variability index during preoxygenation could predict anesthesia-induced hypotension: A prospective, observational study. J Clin Anesth 2023; 90:111236. [PMID: 37639751 DOI: 10.1016/j.jclinane.2023.111236] [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] [Received: 03/28/2023] [Revised: 08/10/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
STUDY OBJECTIVE To determine whether changes in the pleth variability index (PVi) during preoxygenation with forced ventilation for 1 min could predict anesthesia-induced hypotension. DESIGN Prospective, observational study. SETTING A tertiary teaching hospital. PATIENTS Ninety-six patients who underwent general anesthesia using total intravenous anesthesia were enrolled. INTERVENTIONS Upon the patient's arrival at the preoperative waiting area, a PVi sensor was affixed to their fourth fingertip. For preoxygenation, forced ventilation of 8 breaths/min in a 1:2 inspiratory-expiratory ratio was conducted using the guidance of an audio file. One minute after preoxygenation, anesthetic administration was initiated. Blood pressure was measured for the next 15 min. MEASUREMENTS We calculated the difference (dPVi) and percentage of change (%PVi) between the PVi values immediately before and after forced ventilation. Anesthesia-induced hypotension was defined as a mean arterial pressure of <60 mmHg within 15 min after the infusion of anesthetics. MAIN RESULTS Overall, 87 patients were included in the final analysis. Anesthesia-induced hypotension occurred in 31 (35.6%) of the 87 patients. Receiver operating characteristic curve analyses identified a cut-off value of -2 for dPVi, with an area under the curve of 0.691 (95% confidence interval [CI], 0.564-0.818; P < 0.001) and a cut-off value of -7.6% for %PVi, with an area under the curve of 0.711 (95% CI, 0.589-0.832; P < 0.001). Further, multivariate logistic regression analysis showed that a low %PVi with an odds ratio of 9.856 (95% CI, 3.131-31.032; P < 0.001) was a significant determinant of anesthesia-induced hypotension. CONCLUSIONS Hypotension frequently occurs during general anesthesia induction and can impact outcomes. Additionally, the percentage change in the PVi before and after preoxygenation using deep breathing can be used to predict anesthesia-induced hypotension.
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Affiliation(s)
- Yoon Jung Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, 03080 Seoul, South Korea.
| | - Jeong-Hwa Seo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, 03080 Seoul, South Korea.
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, 03080 Seoul, South Korea.
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, 03080 Seoul, South Korea.
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Magder S, Piazza N. Severe Tricuspid Regurgitation and the Potential for a Spiral of Death. JACC Cardiovasc Interv 2023; 16:2259-2261. [PMID: 37758381 DOI: 10.1016/j.jcin.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Sheldon Magder
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada; Department of Critical Care, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Nicolo Piazza
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
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Berger D, Werner Moller P, Bachmann KF. Cardiopulmonary interactions-which monitoring tools to use? Front Physiol 2023; 14:1234915. [PMID: 37621761 PMCID: PMC10445648 DOI: 10.3389/fphys.2023.1234915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/18/2023] [Indexed: 08/26/2023] Open
Abstract
Heart-lung interactions occur due to the mechanical influence of intrathoracic pressure and lung volume changes on cardiac and circulatory function. These interactions manifest as respiratory fluctuations in venous, pulmonary, and arterial pressures, potentially affecting stroke volume. In the context of functional hemodynamic monitoring, pulse or stroke volume variation (pulse pressure variation or stroke volume variability) are commonly employed to assess volume or preload responsiveness. However, correct interpretation of these parameters requires a comprehensive understanding of the physiological factors that determine pulse pressure and stroke volume. These factors include pleural pressure, venous return, pulmonary vessel function, lung mechanics, gas exchange, and specific cardiac factors. A comprehensive knowledge of heart-lung physiology is vital to avoid clinical misjudgments, particularly in cases of right ventricular (RV) failure or diastolic dysfunction. Therefore, when selecting monitoring devices or technologies, these factors must be considered. Invasive arterial pressure measurements of variations in breath-to-breath pressure swings are commonly used to monitor heart-lung interactions. Echocardiography or pulmonary artery catheters are valuable tools for differentiating preload responsiveness from right ventricular failure, while changes in diastolic function should be assessed alongside alterations in airway or pleural pressure, which can be approximated by esophageal pressure. In complex clinical scenarios like ARDS, combined forms of shock or right heart failure, additional information on gas exchange and pulmonary mechanics aids in the interpretation of heart-lung interactions. This review aims to describe monitoring techniques that provide clinicians with an integrative understanding of a patient's condition, enabling accurate assessment and patient care.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per Werner Moller
- Department of Anaesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kaspar F. Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
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Magder S, Slobod D, Assanangkornchai N. Right Ventricular Limitation: A Tale of Two Elastances. Am J Respir Crit Care Med 2023; 207:678-692. [PMID: 36257049 DOI: 10.1164/rccm.202106-1564so] [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: 11/16/2022] Open
Abstract
Right ventricular (RV) dysfunction is a commonly considered cause of low cardiac output in critically ill patients. Its management can be difficult and requires an understanding of how the RV limits cardiac output. We explain that RV stroke output is caught between the passive elastance of the RV walls during diastolic filling and the active elastance produced by the RV in systole. These two elastances limit RV filling and stroke volume and consequently limit left ventricular stroke volume. We emphasize the use of the term "RV limitation" and argue that limitation of RV filling is the primary pathophysiological process by which the RV causes hemodynamic instability. Importantly, RV limitation can be present even when RV function is normal. We use the term "RV dysfunction" to indicate that RV end-systolic elastance is depressed or diastolic elastance is increased. When RV dysfunction is present, RV limitation occurs at lowerpulmonary valve opening pressures and lower stroke volume, but stroke volume and cardiac output still can be maintained until RV filling is limited. We use the term "RV failure" to indicate the condition in which RV output is insufficient for tissue needs. We discuss the physiological underpinnings of these terms and implications for clinical management.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Nawaporn Assanangkornchai
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
- Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand
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Chen H, Gong SR, Shang XL, Li J, Yu RG. The magnitude, but not the duration of elevated central venous pressure is associated with mortality in sepsis patients: An analysis of the MIMIC-IV database. PLoS One 2023; 18:e0281549. [PMID: 36753503 PMCID: PMC9907836 DOI: 10.1371/journal.pone.0281549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/25/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND It is unclear whether the magnitude and duration of elevated central venous pressure (ECVP) greater than ten mmHg has the same impact on mortality in sepsis patients. METHODS Critically ill patients with sepsis were identified from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The duration and the magnitude of ECVP were calculated. Normalized ECVP load was defined as the ECVP load (the sum of ECVP value times its duration) divided by the total duration of ECVP. The primary endpoint was 28-day mortality. Kaplan-Meier survival analysis was used to compare survival between patients with high or low normalized ECVP load. RESULTS A total of 1071 sepsis patients were included. Higher normalized ECVP load was associated with higher mortality rate; in contrast, the duration of ECVP was not associated with mortality. A linear relationship between normalized ECVP load and mortality was identified. Patients with higher normalized ECVP load had less urine output and more positive fluid balance. CONCLUSION The magnitude, but not the duration of ECVP, is associated with mortality in sepsis patients. ECVP should be considered as a valuable and easily accessible safety parameter during fluid resuscitation.
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Affiliation(s)
- Han Chen
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Shu-Rong Gong
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Xiu-Ling Shang
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Jun Li
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Rong-Guo Yu
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, Fujian, China,* E-mail: ,
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Manavi T, Ijaz M, O’Grady H, Nagy M, Martina J, Finucane C, Sharif F, Zafar H. Design and Haemodynamic Analysis of a Novel Anchoring System for Central Venous Pressure Measurement. SENSORS (BASEL, SWITZERLAND) 2022; 22:8552. [PMID: 36366251 PMCID: PMC9659073 DOI: 10.3390/s22218552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/28/2022] [Accepted: 11/02/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND/OBJECTIVE In recent years, treatment of heart failure patients has proved to benefit from implantation of pressure sensors in the pulmonary artery (PA). While longitudinal measurement of PA pressure profoundly improves a clinician's ability to manage HF, the full potential of central venous pressure as a clinical tool has yet to be unlocked. Central venous pressure serves as a surrogate for the right atrial pressure, and thus could potentially predict a wider range of heart failure conditions. However, it is unclear if current sensor anchoring methods, designed for the PA, are suitable to hold pressure sensors safely in the inferior vena cava. The purpose of this study was to design an anchoring system for accurate apposition in inferior vena cava and evaluate whether it is a potential site for central venous pressure measurement. MATERIALS AND METHODS A location inferior to the renal veins was selected as an optimal site based on a CT scan analysis. Three anchor designs, a 10-strut anchor, and 5-struts with and without loops, were tested on a custom-made silicone bench model of Vena Cava targeting the infra-renal vena cava. The model was connected to a pulsatile pump system and a heated water bath that constituted an in-vitro simulation unit. Delivery of the inferior vena cava implant was accomplished using a preloaded introducer and a dilator as a push rod to deploy the device at the target area. The anchors were subjected to manual compression tests to evaluate their stability against dislodgement. Computational Fluid Dynamics (CFD) analysis was completed to characterize blood flow in the anchor's environment using pressure-based transient solver. Any potential recirculation zones or disturbances in the blood flow caused by the struts were identified. RESULTS We demonstrated successful anchorage and deployment of the 10-strut anchor in the Vena Cava bench model. The 10-strut anchor remained stable during several compression attempts as compared with the other two 5-strut anchor designs. The 10-strut design provided the maximum number of contact points with the vessel in a circular layout and was less susceptible to movement or dislodgement during compression tests. Furthermore, the CFD simulation provided haemodynamic analysis of the optimum 10-strut anchor design. CONCLUSIONS This study successfully demonstrated the design and deployment of an inferior vena cava anchoring system in a bench test model. The 10-strut anchor is an optimal design as compared with the two other 5-strut designs; however, substantial in-vivo experiments are required to validate the safety and accuracy of such implants. The CFD simulation enabled better understanding of the haemodynamic parameters and any disturbances in the blood flow due to the presence of the anchor. The ability to place a sensor technology in the vena cava could provide a simple and minimally invasive approach for heart failure patients.
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Affiliation(s)
- Tejaswini Manavi
- Cardiovascular Research & Innovation Centre, University of Galway, H91 TK33 Galway, Ireland
- Lambe Institute for Translational Research, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Masooma Ijaz
- Cardiovascular Research & Innovation Centre, University of Galway, H91 TK33 Galway, Ireland
- Lambe Institute for Translational Research, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Helen O’Grady
- Cardiovascular Research & Innovation Centre, University of Galway, H91 TK33 Galway, Ireland
- Lambe Institute for Translational Research, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | | | | | - Ciaran Finucane
- Department of Medical Physics and Bioengineering, Mercer’s Institute for Successful Ageing, St James’s Hospital Dublin, D08 NHY1 Dublin, Ireland
| | - Faisal Sharif
- Cardiovascular Research & Innovation Centre, University of Galway, H91 TK33 Galway, Ireland
- Lambe Institute for Translational Research, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
- Department of Cardiology, University Hospital Galway, H91 YR71 Galway, Ireland
- BioInnovate, H91 TK33 Galway, Ireland
| | - Haroon Zafar
- Cardiovascular Research & Innovation Centre, University of Galway, H91 TK33 Galway, Ireland
- Lambe Institute for Translational Research, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
- College of Science and Engineering, University of Galway, H91 TK33 Galway, Ireland
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15
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Argaiz ER, Rola P, Haycock KH, Verbrugge FH. Fluid management in acute kidney injury: from evaluating fluid responsiveness towards assessment of fluid tolerance. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:786-793. [PMID: 36069621 DOI: 10.1093/ehjacc/zuac104] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
Despite the widespread use of intravenous fluids in acute kidney injury (AKI), solid evidence is lacking. Intravenous fluids mainly improve AKI due to true hypovolaemia, which is difficult to discern at the bedside unless it is very pronounced. Empiric fluid resuscitation triggered only by elevated serum creatinine levels or oliguria is frequently misguided, especially in the presence of fluid intolerance syndromes such as increased extravascular lung water, capillary leak, intra-abdominal hypertension, and systemic venous congestion. While fluid responsiveness tests clearly identify patients who will not benefit from fluid administration (i.e. those without an increase in cardiac output), the presence of fluid responsiveness does not guarantee that fluid therapy is indicated or even safe. This review calls for more attention to the concept of fluid tolerance, incorporating it into a practical algorithm with systematic venous Doppler ultrasonography assessment to use at the bedside, thereby lowering the risk of detrimental kidney congestion in AKI.
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Affiliation(s)
- Eduardo R Argaiz
- Department of Nephrology and Mineral Metabolism, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montréal, QC, Canada
| | - Korbin H Haycock
- Department of Emergency Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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Valeanu L, Bubenek-Turconi SI, Ginghina C, Balan C. Hemodynamic Monitoring in Sepsis-A Conceptual Framework of Macro- and Microcirculatory Alterations. Diagnostics (Basel) 2021; 11:1559. [PMID: 34573901 PMCID: PMC8469937 DOI: 10.3390/diagnostics11091559] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/22/2021] [Accepted: 08/26/2021] [Indexed: 12/29/2022] Open
Abstract
Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.
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Affiliation(s)
- Liana Valeanu
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Serban-Ion Bubenek-Turconi
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Carmen Ginghina
- 3rd Department of Cardiology, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania;
- Department of Cardiology, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Cosmin Balan
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
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17
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De Blasi RA, Finazzi S. Validation of the mean systemic filling pressure assessment with preserved arterial blood flow by comparing two methods of calculation. Sci Rep 2021; 11:15844. [PMID: 34349219 PMCID: PMC8338930 DOI: 10.1038/s41598-021-95350-7] [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: 02/14/2021] [Accepted: 07/22/2021] [Indexed: 11/28/2022] Open
Abstract
We developed a method for measuring in vivo venular volumes and the mean systemic filling pressure in the limbs using near-infrared spectroscopy (NIRS). We aimed to validate the NIRS methodology by comparing two independent methods of calculation based on different physiological approaches. Pressure–volumes (P–V) curves were recorded following graded venous occlusion on the forearm. Values from a P–V curves analysis model (method 1) were compared with data derived from a resistor-capacitance calculation model (method 2) based on arterial pressure and venous compliance. We tested these methods on 10 healthy participants at rest and during exercise and on 6 severely ill patients. Results from method 1 were comparable with those calculated by method 2. Venular volumes calculated using method 1 correlated linearly with those calculated using method 2 both in participants (R2 = 0.98) and in patients (R2 = 0.94). A good agreement between methods was shown with few values out of the range of ± 1.96 standard deviation. Our findings added mathematical consistency for the NIRS methodology validation in the venular P–V assessment with no flow interruption. Further research will be required to confirm the relevance of the methodology in the clinical setting.
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Affiliation(s)
- Roberto Alberto De Blasi
- Dipartimento di Scienze Medico-Chirurgiche e Medicina Traslazionale, Università degli studi di Roma Sapienza, Via di Grottarossa 1035, 00189, Rome, Italy.
| | - Stefano Finazzi
- Laboratorio di Clinical Data Science, Dipartimento di Salute Pubblica, Istituto di Ricerche farmacologiche Mario Negri IRCCS, Ranica, BG, Italy
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18
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Munsterman AS, Gillen AM, Coleridge MOD, Hanson RR. Evaluation of the effects of intraabdominal hypertension on equine central venous pressure. J Vet Emerg Crit Care (San Antonio) 2020; 30:653-659. [PMID: 32929882 DOI: 10.1111/vec.13001] [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] [Received: 03/20/2018] [Revised: 12/17/2018] [Accepted: 02/18/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the effect of changes in intraabdominal pressure (IAP) on central venous pressure (CVP) in normal horses. DESIGN Experimental, in vivo study. SETTING University Teaching Hospital. ANIMALS Convenience sample of 7 mixed breed horses-5 geldings and 2 mares. INTERVENTIONS Pneumoperitoneum was induced in horses under standing sedation with carbon dioxide gas using a laparoscopic insufflator for a total of 60 minutes to simulate clinical elevation in IAP. Pressure was increased stepwise to 20 mm Hg over 30 minutes, and maintained at that pressure for 30 minutes to evaluate the effect of sustained intraabdominal hypertension. CVP was obtained from the cranial vena cava, concurrent with pressure obtained from the peritoneal cavity. MEASUREMENTS AND MAIN RESULTS CVP increased as IAP increased up to 12 mm Hg, and declined as IAP increased further. The changes in CVP over time were significantly different (P < 0.03). Repeated measures correlation was positive, and highest, for mean CVP as IAP increased from 0 to 12 mm Hg (r = .70; 95% CI, .43-.85; P < 0.0001). Correlation of mean CVP with insufflation pressure became negative as IAP increased further from 15 to 20 mm Hg (r = -.47; 95% CI, -.66 to -.21; P = 0.0006). CONCLUSIONS This report provides preliminary data demonstrating a biphasic trend in equine CVP caused by changes in IAP, similar to that observed in other species. Further investigations are needed to evaluate this trend and to confirm these results in clinical patients.
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Affiliation(s)
- Amelia S Munsterman
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan
| | - Alexandra M Gillen
- The Philip Leverhulme Equine Hospital, University of Liverpool, Chester High Road, Neston, Cheshire, UK
| | | | - R Reid Hanson
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL
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19
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Chen H, Zhu Z, Zhao C, Guo Y, Chen D, Wei Y, Jin J. Central venous pressure measurement is associated with improved outcomes in septic patients: an analysis of the MIMIC-III database. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:433. [PMID: 32665010 PMCID: PMC7358999 DOI: 10.1186/s13054-020-03109-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 06/26/2020] [Indexed: 12/15/2022]
Abstract
Purpose Measurement of central venous pressure (CVP) can be a useful clinical tool. However, the formal utility of CVP measurement in preventing mortality in septic patients has never been proven. Methods The Medical Information Mart for Intensive Care III (MIMIC-III) database was searched to identify septic patients with and without CVP measurements. The primary outcome was 28-day mortality. Multivariate regression was used to elucidate the relationship between CVP measurement and 28-day mortality, and propensity score matching (PSM) and an inverse probability of treatment weighing (IPTW) were employed to validate our findings. Results A total of 10,275 patients were included in our study, of which 4516 patients (44%) underwent CVP measurement within 24 h of intensive care unit (ICU) admission. The risk of 28-day mortality was reduced in the CVP group (OR 0.60 (95% CI 0.51–0.70; p < 0.001)). Patients in the CVP group received more fluid on day 1 and had a shorter duration of mechanical ventilation and vasopressor use, and the reduction in serum lactate was greater than that in the no CVP group. The mediating effect of serum lactate reduction was significant for the whole cohort (p = 0.04 for the average causal mediation effect (ACME)) and patients in the CVP group with an initial CVP level below 8 mmHg (p = 0.04 for the ACME). Conclusion CVP measurement was associated with decreased risk-adjusted 28-day mortality among patients with sepsis and was proportionally mediated through serum lactate reduction.
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Affiliation(s)
- Hui Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215000, Jiangsu, China
| | - Zhu Zhu
- Department of General Surgery, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou, 215000, Jiangsu, China
| | - Chenyan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215000, Jiangsu, China
| | - Yanxia Guo
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215000, Jiangsu, China
| | - Dongyu Chen
- Department of Intensive Care Medicine, Yancheng City No.1 People's Hospital, Yancheng, 224000, Jiangsu, China
| | - Yao Wei
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215000, Jiangsu, China. .,Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215000, Jiangsu, China.
| | - Jun Jin
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215000, Jiangsu, China. .,Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215000, Jiangsu, China.
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20
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Totally Implanted Port May Be an Alternative to Centrally Inserted Central Catheter for Measurement of Central Venous Pressure. JOURNAL OF HEALTHCARE ENGINEERING 2020; 2020:9180856. [PMID: 32676177 PMCID: PMC7346251 DOI: 10.1155/2020/9180856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 05/29/2020] [Accepted: 06/15/2020] [Indexed: 11/17/2022]
Abstract
Background A conventional centrally inserted central catheter (CICC) is frequently used to measure central venous pressure (CVP) to monitor the cardiocirculatory status of patients. The tip of the totally implanted port (TIP) is inserted at the same location in the superior vena cava as that of a CICC, and the TIP has been implanted in many patients with cancer. Measurements of CVP using CICC (CICCP) and TIP (TIPP) may be closely related. Material and Methods. Ten patients with TIPs in an intensive care unit were prospectively studied, and 121 records of 4536 paired CICCP and TIPP measurements were collected. A bench test in a static or dynamic setting was performed, and 598 paired measurements taken using CICC and TIP were recorded. Results The measurement of TIPP was highly correlated with that of CICCP in patients with cancer, especially those in a calm state. Patients with a calm state and ≥3 consecutive identical TIPP were recorded (≥30 seconds), and 90% of the mean difference between CICCP and TIPP was ≤2 mmHg. The pressure measurements recorded using CICC and TIP were identical in both the static and dynamic bench tests. Conclusions TIP may be an alternative to CICC for measuring CVP.
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21
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Monaco F, Di Prima AL, Kim JH, Plamondon MJ, Yavorovskiy A, Likhvantsev V, Lomivorotov V, Hajjar LA, Landoni G, Riha H, Farag A, Gazivoda G, Silva F, Lei C, Bradic N, El-Tahan M, Bukamal N, Sun L, Wang C. Management of Challenging Cardiopulmonary Bypass Separation. J Cardiothorac Vasc Anesth 2020; 34:1622-1635. [DOI: 10.1053/j.jvca.2020.02.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 11/11/2022]
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Magder S. Diastolic pressure should be used to guide management of patients in shock: PRO. J Crit Care 2020; 51:241-243. [PMID: 31126439 DOI: 10.1016/j.jcrc.2018.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/30/2018] [Accepted: 09/04/2018] [Indexed: 01/08/2023]
Abstract
Based primarily on the rational that adequate diastolic pressure is needed to maintain sufficient coronary blood for myocardial needs, diastolic pressure has been proposed as a treatment target for patients in shock. To date, clinical evidence supporting this is limited to observational data. Key points are that what is important for tissues is flow not pressure; the coronary circulation has very large flow reserves and can maintain flow with a low pressure; raising arterial pressure by only increasing vascular resistance does not alter tissue perfusion and could even increase myocardial oxygen demand. Targeting diastolic pressure can lead to over use of vasopressors, which studies have associated with worse outcome. Pressor management in shock should include assessment of indicators of tissue perfusion and changes in flow if possible.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care, McGill University Health Centre, 1001 Decarie Blvd, Montreal, Quebec H4A 3J1, Canada..
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23
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Dubo S, Valenzuela ED, Aquevedo A, Jibaja M, Berrutti D, Labra C, Lagos R, García MF, Ramírez V, Tobar M, Picoita F, Peláez C, Carpio D, Alegría L, Hidalgo C, Godoy K, Bruhn A, Hernández G, Bakker J, Castro R. Early rise in central venous pressure during a spontaneous breathing trial: A promising test to identify patients at high risk of weaning failure? PLoS One 2019; 14:e0225181. [PMID: 31805071 PMCID: PMC6894783 DOI: 10.1371/journal.pone.0225181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 10/30/2019] [Indexed: 11/19/2022] Open
Abstract
Background The spontaneous breathing trial (SBT) assesses the risk of weaning failure by evaluating some physiological responses to the massive venous return increase imposed by discontinuing positive pressure ventilation. This trial can be very demanding for some critically ill patients, inducing excessive physical and cardiovascular stress, including muscle fatigue, heart ischemia and eventually cardiac dysfunction. Extubation failure with emergency reintubation is a serious adverse consequence of a failed weaning process. Some data suggest that as many as 50% of patients that fail weaning do so because of cardiac dysfunction. Unfortunately, monitoring cardiovascular function at the time of the SBT is complex. The aim of our study was to explore if central venous pressure (CVP) changes were related to weaning failure after starting an SBT. We hypothesized that an early rise on CVP could signal a cardiac failure when handling a massive increase on venous return following a discontinuation of positive pressure ventilation. This CVP rise could identify a subset of patients at high risk for extubation failure. Methods Two-hundred and four mechanically ventilated patients in whom an SBT was decided were subjected to a monitoring protocol that included blinded assessment of CVP at baseline, and at 2 minutes after starting the trial (CVP-test). Weaning failure was defined as reintubation within 48-hours following extubation. Comparisons between two parametric or non-parametric variables were performed with student T test or Mann Whitney U test, respectively. A logistic multivariate regression was performed to determine the predictive value on extubation failure of usual clinical variables and CVP at 2-min after starting the SBT. Results One-hundred and sixty-five patients were extubated after the SBT, 11 of whom were reintubated within 48h. Absolute CVP values at 2-minutes, and the change from baseline (dCVP) were significantly higher in patients with extubation failure as compared to those successfully weaned. dCVP was an early predictor for reintubation (OR: 1.70 [1.31,2.19], p<0.001). Conclusions An early rise in CVP after starting an SBT was associated with an increased risk of extubation failure. This might represent a warning signal not captured by usual SBT monitoring and could have relevant clinical implications.
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Affiliation(s)
- Sebastián Dubo
- Departamento de Kinesiología, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
- Programa de Doctorado en Ciencias Médicas, Universidad de la Frontera, Temuco, Chile
| | - Emilio Daniel Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Andrés Aquevedo
- Unidad de Pacientes Críticos, Hospital Dr. Sótero del Río, Santiago, Chile
| | - Manuel Jibaja
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador
- Escuela de Medicina, Universidad Internacional de Ecuador, Quito, Ecuador
| | - Dolores Berrutti
- Centro de Terapia Intensiva, Hospital de Clínicas, Universidad de la Republica de Uruguay, Montevideo, Uruguay
| | - Christian Labra
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rossana Lagos
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Vanessa Ramírez
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador
| | - Milton Tobar
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador
| | - Fabricio Picoita
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador
| | - Cristian Peláez
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Quito, Ecuador
| | - David Carpio
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Programa de Doctorado en Ciencias Médicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carolina Hidalgo
- Unidad de Cuidados Intensivos Cardioquirúrgicos, Hospital Guillermo Grant Benavente, Concepción, Chile
| | - Karen Godoy
- Unidad de Cuidados Intensivos Neuroquirúrgicos, Hospital Guillermo Grant Benavente, Concepción, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Pulmonary and Critical Care, Columbia University College of Physicians and Surgeons, New York, New York, United States of America
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Pulmonary and Critical Care, New York University Medical Center, New York, New York, United States of America
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- * E-mail:
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Werner-Moller P, Sondergaard S, Jakob SM, Takala J, Berger D. Effect of volume status on the estimation of mean systemic filling pressure. J Appl Physiol (1985) 2019; 126:1503-1513. [PMID: 30817243 DOI: 10.1152/japplphysiol.00897.2018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Various methods for indirect assessment of mean systemic filling pressure (MSFP) produce controversial results compared with MSFP at zero blood flow. We recently reported that the difference between MSFP at zero flow measured by right atrial balloon occlusion (MSFPRAO) and MSFP estimated using inspiratory holds depends on the volume status. We now compare three indirect estimates of MSFP with MSFPRAO in euvolemia, bleeding, and hypervolemia in a model of anesthetized pigs (n = 9) with intact circulation. MSFP was estimated using instantaneous beat-to-beat venous return during tidal ventilation (MSFPinst_VR), right atrial pressure-flow data pairs at flow nadir during inspiratory holds (MSFPnadir_hold), and a dynamic model analog adapted to pigs (MSFPa). MSFPRAO was underestimated by MSFPnadir_hold and MSFPa in all volume states. Volume status modified the difference between MSFPRAO and all indirect methods (method × volume state interaction, P ≤ 0.020). All methods tracked changes in MSFPRAO concordantly, with the lowest bias seen for MSFPa [bias (confidence interval): -0.4 (-0.7 to -0.0) mmHg]. We conclude that indirect estimates of MSFP are unreliable in this experimental setup. NEW & NOTEWORTHY For indirect estimations of MSFP using inspiratory hold maneuvers, instantaneous beat-to-beat venous return, or a dynamic model analog, the accuracy was affected by the underlying volume state. All methods investigated tracked changes in MSFPRAO concordantly.
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Affiliation(s)
- Per Werner-Moller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland.,Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Ostra, Gothenburg , Sweden
| | - Soren Sondergaard
- Centre of Elective Surgery, Silkeborg Regional Hospital , Silkeborg , Denmark
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
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Magder S. Heart-Lung interaction in spontaneous breathing subjects: the basics. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:348. [PMID: 30370275 DOI: 10.21037/atm.2018.06.19] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Heart-lung interactions occur primarily because of two components of lung inflation, changes in pleural pressure and changes in transpulmonary pressure. Of these, changes in pleural pressure dominate during spontaneous breathing. Because the heart is surrounded by pleural pressure, during inspiration the environment of the heart falls relative to the rest of the body. This alters inflow into the right heart and outflow from the left heart. Alterations in transpulmonary pressure can alter the outflow from the right heart and the inflow to the left heart. These interactions are modified by the cardiac and respiratory frequency, ventricular function and magnitude of the respiratory efforts.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care, McGill University Health Centre, Montreal, Quebec, Canada
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Mizunoya K, Saito H, Morimoto Y. Evaluation of external reference levels for central venous pressure measurements of severely obese patients in the supine position. J Anesth 2018; 32:558-564. [DOI: 10.1007/s00540-018-2513-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/23/2018] [Indexed: 10/14/2022]
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Noel-Morgan J, Muir WW. Anesthesia-Associated Relative Hypovolemia: Mechanisms, Monitoring, and Treatment Considerations. Front Vet Sci 2018; 5:53. [PMID: 29616230 PMCID: PMC5864866 DOI: 10.3389/fvets.2018.00053] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/02/2018] [Indexed: 12/14/2022] Open
Abstract
Although the utility and benefits of anesthesia and analgesia are irrefutable, their practice is not void of risks. Almost all drugs that produce anesthesia endanger cardiovascular stability by producing dose-dependent impairment of cardiac function, vascular reactivity, and compensatory autoregulatory responses. Whereas anesthesia-related depression of cardiac performance and arterial vasodilation are well recognized adverse effects contributing to anesthetic risk, far less emphasis has been placed on effects impacting venous physiology and venous return. The venous circulation, containing about 65–70% of the total blood volume, is a pivotal contributor to stroke volume and cardiac output. Vasodilation, particularly venodilation, is the primary cause of relative hypovolemia produced by anesthetic drugs and is often associated with increased venous compliance, decreased venous return, and reduced response to vasoactive substances. Depending on factors such as patient status and monitoring, a state of relative hypovolemia may remain clinically undetected, with impending consequences owing to impaired oxygen delivery and tissue perfusion. Concurrent processes related to comorbidities, hypothermia, inflammation, trauma, sepsis, or other causes of hemodynamic or metabolic compromise, may further exacerbate the condition. Despite scientific and technological advances, clinical monitoring and treatment of relative hypovolemia still pose relevant challenges to the anesthesiologist. This short perspective seeks to define relative hypovolemia, describe the venous system’s role in supporting normal cardiovascular function, characterize effects of anesthetic drugs on venous physiology, and address current considerations and challenges for monitoring and treatment of relative hypovolemia, with focus on insights for future therapies.
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Affiliation(s)
- Jessica Noel-Morgan
- Center for Cardiovascular & Pulmonary Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - William W Muir
- QTest Labs, Columbus, OH, United States.,College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
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Reply to: the central venous pressure, and 'a plea for some common-sense'. Eur J Anaesthesiol 2018; 35:322-323. [PMID: 29485459 DOI: 10.1097/eja.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Limited value of end-expiratory inferior vena cava diameter to predict fluid responsiveness impact of intra-abdominal pressure. Intensive Care Med 2018; 44:197-203. [PMID: 29356854 DOI: 10.1007/s00134-018-5067-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/13/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE We sought to determine the diagnostic ability of the end-expiratory inferior vena cava diameter (IVCEE) to predict fluid responsiveness (FR) and the potential confounding effect of intra-abdominal pressure (IAP). METHODS In this multicenter study, 540 consecutive ventilated patients with shock of various origins underwent an echocardiographic assessment by experts. The IVCEE, velocity time integral (VTI) of the left ventricular outflow tract (LVOT) and intra-abdominal pressure (IAP) were measured. Passive leg raising (PLR) was then systematically used to perform a reversible central blood volume expansion. FR was defined by an increase in LVOT VTI ≥ 10% after 1 min of PLR. RESULTS Since IVCEE was not obtained in 117 patients (22%), 423 were studied (septic shock: 56%), 129 of them (30%) having elevated IAP (≥ 12 mmHg) and 172 of them (41%) exhibiting FR. IVCEE ≤ 13 mm predicted FR with a specificity of at least 80% in 62 patients (15%), while IVCEE ≥ 25 mm predicted the absence of FR with a specificity of at least 80% in 61 patients (14%). In the remaining 300 patients (71%), the intermediate value of IVCEE did not allow predicting FR. An adjusted relationship between IVCEE and FR was observed while this relationship was less pronounced in patients with IAP ≥ 12 mmHg. CONCLUSIONS Measurement of IVCEE in ventilated patients is moderately feasible and poorly predicts FR, with IAP acting as a confounding factor. IVCEE might add some value to guide fluid therapy but should not be used alone for fluid prediction purposes.
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Right Atrial Myxoma with Cannon A Waves. Anesthesiology 2017; 128:143. [PMID: 28837433 DOI: 10.1097/aln.0000000000001850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text.
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