1
|
Jin T, Li L, Zhu P, Deng L, Zhang X, Hu C, Shi N, Zhang R, Tan Q, Chen C, Lin Z, Guo J, Yang X, Liu T, Sutton R, Pendharkar S, Phillips AR, Huang W, Xia Q, Windsor JA. Optimising fluid requirements after initial resuscitation: A pilot study evaluating mini-fluid challenge and passive leg raising test in patients with predicted severe acute pancreatitis. Pancreatology 2022; 22:894-901. [PMID: 35927151 DOI: 10.1016/j.pan.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 06/13/2022] [Accepted: 07/05/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The goals and approaches to fluid therapy vary through different stages of resuscitation. This pilot study was designed to test the safety and feasibility of a fluid therapy protocol for the second or optimisation stage of resuscitation in patients with predicted severe acute pancreatitis (SAP). METHODS Spontaneously breathing patients with predicted SAP were admitted after initial resuscitation and studied over a 24-h period in a tertiary hospital ward. Objective clinical assessment (OCA; heart rate, mean arterial pressure, urine output, and haematocrit) was done at 0, 4, 8, 12, 18-20, and 24 h. All patients had mini-fluid challenge (MFC; 250 ml intravenous normal saline within 10 min) at 0 h and repeated at 4 and 8 h if OCA score ≥2. Patients who were fluid responsive (>10% change in stroke volume after MFC) received 5-10 ml/kg/h, otherwise 1-3 ml/kg/h until the next time point. Passive leg raising test (PLRT) was done at each time point and compared with OCA for assessing volume status and predicting fluid responsiveness. RESULTS This fluid therapy protocol based on OCA, MFC, and PLRT and designed for the second stage of resuscitation was safe and feasible in spontaneously breathing predicted SAP patients. The PLRT was superior to OCA (at 0 and 8 h) for predicting fluid responsiveness and guiding fluid therapy. CONCLUSIONS This pilot study found that a protocol for intravenous fluid therapy specifically for the second stage of resuscitation in patients with predicted SAP was safe, feasible, and warrants further investigation.
Collapse
Affiliation(s)
- Tao Jin
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Lan Li
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Zhu
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China; West China Biobanks and Department of Clinical Research Management, West China Hospital, Sichuan University, China
| | - Lihui Deng
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoxin Zhang
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng Hu
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Na Shi
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Ruwen Zhang
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Qingyuan Tan
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Chanjuan Chen
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Ziqi Lin
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Jia Guo
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaonan Yang
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Tingting Liu
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Robert Sutton
- Liverpool Pancreatitis Research Group, Liverpool University Hospitals NHS Foundation Trust and Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Sayali Pendharkar
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Anthony R Phillips
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Wei Huang
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China; West China Biobanks and Department of Clinical Research Management, West China Hospital, Sichuan University, China.
| | - Qing Xia
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China.
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| |
Collapse
|
2
|
Hong A, Villano N, Toppen W, Elizabeth Aquije M, Berlin D, Cannesson M, Barjaktarevic I. Shock Management Without Formal Fluid Responsiveness Assessment: A Retrospective Analysis of Fluid Responsiveness and Its Outcomes. J Acute Med 2021; 11:129-140. [PMID: 35155089 PMCID: PMC8743191 DOI: 10.6705/j.jacme.202112_11(4).0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/22/2021] [Accepted: 04/23/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND In order to quantify fluid administration and evaluate the clinical consequences of conservative fluid management without hemodynamic monitoring in undifferentiated shock, we analyzed previously collected data from a study of carotid Doppler monitoring as a predictor of fluid responsiveness (FR). METHODS This study was a retrospective analysis of data collected from a single tertiary academic center from a previous study. Seventy-four patients were included for post-hoc analysis, and 52 of them were identified as fluid responsive (cardiac output increase > 10% with passive leg raise) according to NICOMTM bioreactance monitoring (Cheetah Medical, Newton Center, MA, USA). Treating teams provided standard of care conservative fluid resuscitation but were blinded to independently performed FR testing results. Outcomes were compared between fluid responsive and fluid non-responsive patients. Primary outcome measures were volume fluids administered and net fluid balance 24- and 72-hour post-FR assessment. Secondary outcome measures included change in vasopressor requirements, mean peak lactate levels, length of hospital/intensive care unit stay, acute respiratory failure, hemodialysis requirement, and durations of vasopressors and mechanical ventilation. RESULTS Mean fluids administered within 72 hours were similar between fluid non-responsive and fluid responsive patients (139 mL/kg [95% confidence interval [CI]: 102.00-175.00] vs. 136 mL/kg [95% CI: 113.00-158.00], p = 0.92, respectively). We observed an insignificant trend toward higher 28-day mortality among fluid non-responsive patients (36% vs. 19%, p = 0.14). Volume of fluids administered significantly correlated with adverse outcomes such as increased hemodialysis requirements (32 patients, 43%), (odds ratio [OR] = 1.7200, p = 0.0018). Subgroup analysis suggested administering ≥ 30 mL/kg fluids to fluid responsive patients had a trend toward increased mortality (25% vs. 0%, p = 0.09) and a significant increase in hemodialysis (55% vs. 17%, p = 0.024). CONCLUSIONS Without formal FR assessment, similar amounts of total fluids were administered in both fluid responsive and non-responsive patients. As greater volumes of intravenous fluids administered were associated with adverse outcomes, we suggest that dedicated FR assessment may be a beneficial utility in early shock resuscitation.
Collapse
Affiliation(s)
- Andrew Hong
- David Geffen School of Medicine at University of California Department of Medicine Los Angeles, CA USA
| | - Nicholas Villano
- David Geffen School of Medicine at University of California Department of Medicine Los Angeles, CA USA
| | - William Toppen
- David Geffen School of Medicine at University of California Department of Medicine Los Angeles, CA USA
| | - Montoya Elizabeth Aquije
- David Geffen School of Medicine at University of California Department of Medicine Los Angeles, CA USA
| | - David Berlin
- Weill Cornell Medical College Division of Pulmonary and Critical Care New York, NY USA
| | - Maxime Cannesson
- David Geffen School of Medicine at University of California Department of Anesthesiology Los Angeles, CA USA
| | - Igor Barjaktarevic
- David Geffen School of Medicine at University of California Division of Pulmonary and Critical Care Los Angeles, CA USA
| |
Collapse
|
3
|
Abdalazeem ES, Elgazzar AG, Hammad MEMA, Elsawy RE. Role of lung ultrasound in assessment of endpoint of fluid therapy in patients with hypovolemic shock. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1906566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
| | | | - May E. M. A. Hammad
- Critical Care Medicine Departments, Faculty of Medicine, Benha University, Egypt
| | | |
Collapse
|
4
|
Chow RS. Terms, Definitions, Nomenclature, and Routes of Fluid Administration. Front Vet Sci 2021; 7:591218. [PMID: 33521077 PMCID: PMC7844884 DOI: 10.3389/fvets.2020.591218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/02/2020] [Indexed: 12/14/2022] Open
Abstract
Fluid therapy is administered to veterinary patients in order to improve hemodynamics, replace deficits, and maintain hydration. The gradual expansion of medical knowledge and research in this field has led to a proliferation of terms related to fluid products, fluid delivery and body fluid distribution. Consistency in the use of terminology enables precise and effective communication in clinical and research settings. This article provides an alphabetical glossary of important terms and common definitions in the human and veterinary literature. It also summarizes the common routes of fluid administration in small and large animal species.
Collapse
Affiliation(s)
- Rosalind S Chow
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MI, United States
| |
Collapse
|
5
|
Manecke G. Volume Responsiveness: What It Does Not Tell Us. J Cardiothorac Vasc Anesth 2021; 35:1307-1309. [PMID: 33455888 DOI: 10.1053/j.jvca.2020.12.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/23/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Gerard Manecke
- Department of Anesthesiology, University of California San Diego, Veterans Affairs Medical Center San Diego, San Diego, CA.
| |
Collapse
|
6
|
|
7
|
Abstract
Objectives To investigate the effect of albumin exposure in ICU after cardiac surgery on hospital mortality, complications, and costs. Design A retrospective, single-center cohort study with economic evaluation. Setting Cardiothoracic ICU in Australia. Patients Adult patients admitted to the ICU after cardiac surgery. Interventions None. Measurements and Main Results Comparison of outcomes and costs in ICU after cardiac surgery based on 4% human albumin exposure. During the study period, 3,656 patients underwent cardiac surgery. After exclusions, 2,594 patients were suitable for analysis. One-thousand two-hundred sixty-four (48.7%) were exposed to albumin and 19 (1.4%) of those died. The adjusted hospital mortality of albumin exposure compared with no albumin was not significant (odds ratio, 1.24; 95% CI, 0.56-2.79; p = 0.6). More patients exposed to albumin returned to the operating theater for bleeding and/or tamponade (6.1% vs 2.1%; odds ratio, 2.84; 95% CI, 1.81-4.45; p < 0.01) and received packed red cell transfusions (p < 0.001). ICU and hospital lengths of stay were prolonged in those exposed to albumin (mean difference, 18 hr; 95% CI, 10.3-25.6; p < 0.001 and 87.5 hr; 95% CI, 40.5-134.6; p < 0.001). Costs (U.S. dollar) were higher in patients exposed to albumin, compared with those with no albumin exposure (mean difference in ICU costs, $2,728; 95% CI, $1,566-3,890 and mean difference in hospital costs, $5,427; 95% CI, $3,294-7,560). Conclusions There is no increased mortality in patients who are exposed to albumin after cardiac surgery. The patients exposed to albumin had higher illness severity, suffered more complications, and incurred higher healthcare costs. A randomized controlled trial is required to determine whether albumin use is effective and safe in this setting.
Collapse
|
8
|
El-Nawawy AA, Farghaly PM, Hassouna HM. Accuracy of Passive Leg Raising Test in Prediction of Fluid Responsiveness in Children. Indian J Crit Care Med 2020; 24:344-349. [PMID: 32728327 PMCID: PMC7358867 DOI: 10.5005/jp-journals-10071-23432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Aim To assess the accuracy of the passive leg raising (PLR) test to anticipate fluid responsiveness in critically ill children under age of 5 years. Materials and methods A prospective observational study was conducted, in a university hospital pediatric intensive care unit from June 1, 2017, to January 30, 2018. Hemodynamic parameters including stroke volume using bedside transthoracic echocardiography were assessed at baseline I (45° semi-recumbent position), after PLR, at baseline II, and following fluid challenge. Changes in the stroke volume (delta SV) and in the cardiac index (CI) were recorded after PLR and fluid challenge. Findings Delta SV of 10% after PLR was an excellent discriminator of the fluid responsiveness with an area under ROC (AUC) of 0.81 (95% CI 0.68-0.9) with a sensitivity of 65.38% and a specificity of 100%. The change in CI of 8.7% after PLR was a significant discriminator of fluid responsiveness with an AUC of 0.7 (95% CI 0.56-0.81) with 57.78% sensitivity and 91.67% specificity. Conclusion Passive leg raising can identify nonresponders among seriously ill children under the age of 5 years but it cannot identify all responders with certainty. Clinical significance Passive leg raising is reliable test in under 5 year-old-children if performed appropriately using bedside echocardiography for the measurement of its transient effect. How to cite this article El-Nawawy AA, Farghaly PM, Hassouna HM, Accuracy of Passive Leg Raising Test in Prediction of Fluid Responsiveness in Children. Int J Clin Pediatr Dent 2020;24(5):344-349.
Collapse
Affiliation(s)
- Ahmed A El-Nawawy
- Pediatric Department (PICU), Faculty of Medicine, Alexandria University, Egypt
| | - Passant M Farghaly
- Pediatric Department (PICU), Faculty of Medicine, Alexandria University, Egypt
| | - Hadir M Hassouna
- Pediatric Department (PICU), Faculty of Medicine, Alexandria University, Egypt
| |
Collapse
|
9
|
Assessing Fluid Resuscitation in Adults with Sepsis Who Are Not Mechanically Ventilated: a Systematic Review of Diagnostic Test Accuracy Studies. J Gen Intern Med 2019; 34:1874-1883. [PMID: 31152360 PMCID: PMC6711941 DOI: 10.1007/s11606-019-05073-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/15/2019] [Accepted: 04/19/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Fluid resuscitation is a widely used intervention that is mandated in the management of sepsis. While its use can be life-saving, its overuse is associated with harm. Despite this, the best means of assessing a need for fluid resuscitation in an acute medical setting is unclear. OBJECTIVE To assess studies of diagnostic tests that identify the need for fluid resuscitation in adults with sepsis, as defined by the presence of fluid responsiveness. DESIGN Protocol registration was performed in advance (PROSPERO:CRD42017048651). Research database searches were performed alongside additional searches to identify grey literature. Diagnostic test accuracy studies that assessed any fluid assessment tool were identified independently by two authors, before data extraction and quality assessments were performed. PARTICIPANTS Adults with sepsis, without intensive care organ support, who would be appropriate for admission to an acute medical unit. KEY RESULTS Of the 26,841 articles that were screened, 14 studies were identified for inclusion, involving a combined total of 594 patients. Five categories of index test were identified: inferior vena cava collapsibility index (IVCCI), haemodynamic change with passive leg raise, haemodynamic change with respiration, haemodynamic change with intravenous fluid administration, and static assessment tools. Due to the high level of clinical heterogeneity affecting all aspects of study design, quantitative analysis was not feasible. There was a lack of consensus on reference tests to determine fluid responsiveness. CONCLUSION While fluid resuscitation is considered a key part of the management of sepsis, evidence to support fluid assessment in awake adults is lacking. This review has highlighted a number of research recommendations that should be addressed as a matter of urgency if patient harm is to be avoided.
Collapse
|
10
|
Marques NR, De Riese J, Yelverton BC, McQuitty C, Jupiter D, Willmann K, Salter M, Kinsky M, Johnston WE. Diastolic Function and Peripheral Venous Pressure as Indices for Fluid Responsiveness in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2019; 33:2208-2215. [PMID: 30738752 DOI: 10.1053/j.jvca.2019.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Identifying fluid responsiveness is critical to optimizing perfusion while preventing fluid overload. An experimental study of hypovolemic shock resuscitation showed the importance of ventricular compliance and peripheral venous pressure (PVP) on fluid responsiveness. The authors tested the hypothesis that reduced ventricular compliance measured using transesophageal echocardiography results in decreased fluid responsiveness after a fluid bolus. DESIGN Prospective observational study. SETTING Two-center, university hospital study. PARTICIPANTS The study comprised 29 patients undergoing elective coronary revascularization. INTERVENTION Albumin 5%, 7 mL/kg, was infused over 10 minutes to characterize fluid responders (>15% increase in stroke volume) from nonresponders. MEASUREMENTS AND MAIN RESULTS Invasive hemodynamics and the ratio of mitral inflow velocity (E-wave)/annular relaxation (e'), or E/e' ratio, were measured using transesophageal echocardiography to assess left ventricular (LV) compliance at baseline and after albumin infusion. Fifteen patients were classified as responders and 14 as nonresponders. The E/e' ratio in responders was 7.4 ± 1.9 at baseline and 7.1 ± 1.8 after bolus. In contrast, E/e' was significantly higher in nonresponders at baseline (10.7 ± 4.6; p = 0.04) and further increased after bolus (12.6 ± 5.5; p = 0.002). PVP was significantly greater in the nonresponders at baseline (14 ± 4 mmHg v 11 ± 3 mmHg; p = 0.02) and increased in both groups after albumin infusion. Fluid responsiveness was tested using the area under the receiver operating characteristic curve and was 0.74 for the E/e' ratio (95% confidence interval 0.55-0.93; p = 0.029) and 0.72 for the PVP (95% confidence interval 0.52-0.92; p = 0.058). CONCLUSION Fluid responders had normal LV compliance and lower PVP at baseline. In contrast, nonresponders had reduced LV compliance, which worsened after fluid bolus. E/e,' more than PVP, may be a useful clinical index to predict fluid responsiveness.
Collapse
|
11
|
Abstract
Intravenous fluids are commonly prescribed but uncertainty remains about how to assess when fluids are required and how much to give, particularly in our multimorbid, polymedicated and ageing population. Furthermore, studies have noted that fluid resuscitation can be harmful even if clinical evidence of hypervolaemia is not present. Two recent guidelines have acknowledged a limited evidence base to guide fluid assessment. A recommended means to assess hypovolaemia includes assessment of fluid responsiveness. Fluid responsiveness is a rise in stroke volume following an increase in preload, achieved using a fluid challenge or a passive leg raise. However, the means of defining fluid responsiveness and its ability to identify patients who would benefit from fluid resuscitation is currently unclear. This review discusses the current guidelines about, and the evidence base for the provision of, intravenous fluids in the acutely unwell medical patient. It highlights how little evidence is available to guide medical practice.
Collapse
Affiliation(s)
- Adam Seccombe
- Acute Medicinal Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| |
Collapse
|
12
|
Martin-Flores M, Cisternas AF, Gleed RD. Changes in blood volume indicators and dynamic indicators measured with transpulmonary ultrasound velocity during blood depletion and repletion in a neonatal swine model. Paediatr Anaesth 2017; 27:1136-1141. [PMID: 29030937 DOI: 10.1111/pan.13232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Dynamic indicators such as pulse pressure and stroke volume variations can be measured to track changes in preload during hemorrhage, and evaluate fluid therapy. However, these dynamic indicators require mechanical ventilation, and might be affected by cardiac dysrhythmias and changes in vascular tone. Blood volume indicators may offer alternatives for assessing changes in volume status. AIMS The aims of this study were to measure changes in blood volume indicators and dynamic indicators during removal of blood in two stages and subsequent blood replacement in anesthetized, mechanically ventilated, neonatal pigs. METHODS In eight anesthetized, mechanically ventilated piglets (5-6 weeks old), cardiac index, stroke volume index, total end-diastolic volume, central blood volume, active circulating volume, pulse pressure variation, and stroke volume variation were measured during blood removal in two stages (15 mL kg-1 each stage) and blood replacement (30 mL kg-1 ). Values after each intervention were measured for each parameter. RESULTS All indicators differed from baseline after removal of 15 mL kg-1 of blood, except for stroke volume variation. Differences between both stages of hemorrhage were only observed for indexed stroke volume, total end-diastolic volume, central blood volume, and pulse pressure variation. CONCLUSION Total end-diastolic volume and central blood volume changed during blood depletion and repletion, and differed between stages of hemorrhage. These indicators might be useful for assessing volume status instead of, or in addition to cardiac index and dynamic indicators.
Collapse
Affiliation(s)
- Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Alvaro F Cisternas
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Robin D Gleed
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| |
Collapse
|
13
|
Pickett JD, Bridges E, Kritek PA, Whitney JD. Passive Leg-Raising and Prediction of Fluid Responsiveness: Systematic Review. Crit Care Nurse 2017; 37:32-47. [PMID: 28365648 DOI: 10.4037/ccn2017205] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Fluid boluses are often administered with the aim of improving tissue hypoperfusion in shock. However, only approximately 50% of patients respond to fluid administration with a clinically significant increase in stroke volume. Fluid overload can exacerbate pulmonary edema, precipitate respiratory failure, and prolong mechanical ventilation. Therefore, it is important to predict which hemodynamically unstable patients will increase their stroke volume in response to fluid administration, thereby avoiding deleterious effects. Passive leg-raising (lowering the head and upper torso from a 45° angle to lying supine [flat] while simultaneously raising the legs to a 45° angle) is a transient, reversible autotransfusion that simulates a fluid bolus and is performed to predict a response to fluid administration. The article reviews the accuracy, physiological effects, and factors affecting the response to passive-leg raising to predict fluid responsiveness in critically ill patients.
Collapse
Affiliation(s)
- Joya D Pickett
- Joya D. Pickett completed her doctoral degree at the University of Washington, School of Nursing, and practices as a critical care clinical nurse specialist at Swedish Medical Center in Seattle, Washington. .,Elizabeth Bridges is an associate professor at the University of Washington School of Nursing and the clinical nurse researcher at the University of Washington Medical Center, Seattle, Washington. .,Patricia (Trish) A. Kritek is the medical director of Critical Care at the University of Washington Medical Center. .,JoAnne D. Whitney is a professor of nursing at the University of Washington, School of Nursing, and a nurse scientist at Harborview Medical Center, Seattle, Washington.
| | - Elizabeth Bridges
- Joya D. Pickett completed her doctoral degree at the University of Washington, School of Nursing, and practices as a critical care clinical nurse specialist at Swedish Medical Center in Seattle, Washington.,Elizabeth Bridges is an associate professor at the University of Washington School of Nursing and the clinical nurse researcher at the University of Washington Medical Center, Seattle, Washington.,Patricia (Trish) A. Kritek is the medical director of Critical Care at the University of Washington Medical Center.,JoAnne D. Whitney is a professor of nursing at the University of Washington, School of Nursing, and a nurse scientist at Harborview Medical Center, Seattle, Washington
| | - Patricia A Kritek
- Joya D. Pickett completed her doctoral degree at the University of Washington, School of Nursing, and practices as a critical care clinical nurse specialist at Swedish Medical Center in Seattle, Washington.,Elizabeth Bridges is an associate professor at the University of Washington School of Nursing and the clinical nurse researcher at the University of Washington Medical Center, Seattle, Washington.,Patricia (Trish) A. Kritek is the medical director of Critical Care at the University of Washington Medical Center.,JoAnne D. Whitney is a professor of nursing at the University of Washington, School of Nursing, and a nurse scientist at Harborview Medical Center, Seattle, Washington
| | - JoAnne D Whitney
- Joya D. Pickett completed her doctoral degree at the University of Washington, School of Nursing, and practices as a critical care clinical nurse specialist at Swedish Medical Center in Seattle, Washington.,Elizabeth Bridges is an associate professor at the University of Washington School of Nursing and the clinical nurse researcher at the University of Washington Medical Center, Seattle, Washington.,Patricia (Trish) A. Kritek is the medical director of Critical Care at the University of Washington Medical Center.,JoAnne D. Whitney is a professor of nursing at the University of Washington, School of Nursing, and a nurse scientist at Harborview Medical Center, Seattle, Washington
| |
Collapse
|
14
|
Aronson S, Nisbet P, Bunke M. Fluid resuscitation practices in cardiac surgery patients in the USA: a survey of health care providers. Perioper Med (Lond) 2017; 6:15. [PMID: 29075482 PMCID: PMC5649061 DOI: 10.1186/s13741-017-0071-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 09/17/2017] [Indexed: 02/07/2023] Open
Abstract
Background Fluid resuscitation during cardiac surgery is common with significant variability in clinical practice. Our goal was to investigate current practice patterns of fluid volume expansion in patients undergoing cardiac surgeries in the USA. Methods We conducted a cross-sectional online survey of 124 cardiothoracic surgeons, cardiovascular anesthesiologists, and perfusionists. Survey questions were designed to assess clinical decision-making patterns of intravenous (IV) fluid utilization in cardiovascular surgery for five types of patients who need volume expansion: (1) patients undergoing cardiopulmonary bypass (CPB) without bleeding, (2) patients undergoing CPB with bleeding, (3) patients undergoing acute normovolemic hemodilution (ANH), (4) patients requiring extracorporeal membrane oxygenation (ECMO) or use of a ventricular assist device (VAD), and (5) patients undergoing either off-pump coronary artery bypass graft (OPCABG) surgery or transcatheter aortic valve replacement (TAVR). First-choice fluid used in fluid boluses for these five patient types was requested. Descriptive statistics were performed using Kruskal-Wallis test and follow-up tests, including t tests, to evaluate differences among respondent groups. Results The most commonly preferred indicators of volume status were blood pressure, urine output, cardiac output, central venous pressure, and heart rate. The first choice of fluid for patients needing volume expansion during CPB without bleeding was crystalloids, whereas 5% albumin was the most preferred first choice of fluid for bleeding patients. For volume expansion during ECMO or VAD, the respondents were equally likely to prefer 5% albumin or crystalloids as a first choice of IV fluid, with 5% albumin being the most frequently used adjunct fluid to crystalloids. Surgeons, as a group, more often chose starches as an adjunct fluid to crystalloids for patients needing volume expansion during CPB without bleeding. Surgeons were also more likely to use 25% albumin as an adjunct fluid than were anesthesiologists. While most perfusionists reported using crystalloids to prime the CPB circuit, one third preferred a mixture of 25% albumin and crystalloids. Less interstitial edema and more sustained volume expansion were considered the most important colloid traits in volume expansion. Conclusions Fluid utilization practice patterns in the USA varied depending on patient characteristics and clinical specialties of health care professionals. Electronic supplementary material The online version of this article (10.1186/s13741-017-0071-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Solomon Aronson
- Department of Anesthesiology, Duke University, 201 Trent Drive, 101 Baker House, Durham, NC 27710 USA
| | - Paul Nisbet
- One Research, LLC, 1150 Hungryneck Blvd. Suite C-303, Mt. Pleasant, SC 29464 USA
| | - Martin Bunke
- Department of Medical Affairs, Grifols, 79 T.W. Alexander Drive, 4101 Research Commons, Research Triangle Park, Raleigh, NC 27709 USA
| |
Collapse
|
15
|
Kinsky M, Ribeiro N, Cannesson M, Deyo D, Kramer G, Salter M, Khan M, Ju H, Johnston WE. Peripheral Venous Pressure as an Indicator of Preload Responsiveness During Volume Resuscitation from Hemorrhage. Anesth Analg 2017; 123:114-22. [PMID: 27314691 DOI: 10.1213/ane.0000000000001297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Fluid resuscitation of hypovolemia presumes that peripheral venous pressure (PVP) increases more than right atrial pressure (RAP), so the net pressure gradient for venous return (PVP-RAP) rises. However, the heart and peripheral venous system function under different compliances that could affect their respective pressures during fluid infusion. In a porcine model of hemorrhage resuscitation, we examined whether RAP increases more than PVP, thereby reducing the venous return pressure gradient and blood flow. METHODS Anesthetized pigs (n = 8) were bled to a mean arterial blood pressure of 40 mm Hg and resuscitated with stored blood and albumin for pulmonary artery occlusion pressures (PAOPs) of 5, 10, 15, and 20 mm Hg. Venous pressures, inferior vena cava blood flow (ultrasonic flowprobe), and left ventricular diastolic compliance (Doppler echocardiography) were measured. Stroke volume variability was calculated. RESULTS With volume resuscitation, the slope of RAP exceeded PVP (P ≤ 0.0001) when PAOP is 10 to 20 mm Hg, causing the pressure gradient for venous return to progressively decrease. Inferior vena cava blood flow did not further increase after PAOP > 10 mm Hg. The E/e' ratio increased (P = 0.001) during resuscitation indicating reduced diastolic compliance. A significant curvilinear relationship was found between PVP and stroke volume variability (R = 0.62; P < 0.001), where fluid responders had PVP < 15 mm Hg. CONCLUSIONS Fluid resuscitation above a PAOP 10 mm Hg reduces myocardial compliance and reduces the venous return pressure gradient. The hemodynamic response to fluid resuscitation becomes limited by diastolic properties of the heart. PVP measurement during hemorrhage resuscitation may predict fluid responsiveness and nonresponsiveness.
Collapse
Affiliation(s)
- Michael Kinsky
- From the *Department of Anesthesiology, The University of Texas Medical Branch at Galveston, Galveston, Texas; †Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; ‡Department of Respiratory Care and §Department of Biostatistics, The University of Texas Medical Branch at Galveston, Galveston, Texas; and ‖Baylor Scott & White Healthcare, Texas A&M University School of Medicine, Temple, Texas
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Ripollés-Melchor J, Chappell D, Aya HD, Espinosa Á, Mhyten MG, Abad-Gurumeta A, Bergese SD, Casans-Francés R, Calvo-Vecino JM. Fluid therapy recommendations for major abdominal surgery. Via RICA recommendations revisited. Part II: Goal directed hemodynamic therapy. Rationale for optimising intravascular volume. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:339-347. [PMID: 28343684 DOI: 10.1016/j.redar.2017.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 06/06/2023]
Affiliation(s)
- J Ripollés-Melchor
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España.
| | - D Chappell
- Departamento de Anestesia, Hospital Universitario LMU de Múnich, Múnich, Alemania
| | - H D Aya
- Departamento de Cuidados Intensivos, St George's University Hospitals, NHS Foundation Trust, Londres, Reino Unido
| | - Á Espinosa
- Departamento de Anestesia Cardiovascular y Torácica, y Cuidados Intensivos, Bahrain Defence Force Hospital, Riffa, Reino de Baréin
| | - M G Mhyten
- University College London Hospital, National Institute for Health Research, Biomedical Research Centre, Londres, Reino Unido
| | - A Abad-Gurumeta
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España
| | - S D Bergese
- Departamento de Anestesia y Neurocirugía, Wexner Medical Center, The Ohio State University, Columbus, OH, Estados Unidos
| | - R Casans-Francés
- Departamento de Anestesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J M Calvo-Vecino
- Departamento de Anestesia, Complejo Asistencial Universitario de Salamanca, Universidad de Salamanca (CAUSA), Salamanca, España
| |
Collapse
|
17
|
Elwan MH, Roshdy A, Elsharkawy EM, Eltahan SM, Coats TJ. The haemodynamic dilemma in emergency care: Is fluid responsiveness the answer? A systematic review. Scand J Trauma Resusc Emerg Med 2017; 25:25. [PMID: 28264700 PMCID: PMC5339987 DOI: 10.1186/s13049-017-0370-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 02/23/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Fluid therapy is a common and crucial treatment in the emergency department (ED). While fluid responsiveness seems to be a promising method to titrate fluid therapy, the evidence for its value in ED is unclear. We aim to synthesise the existing literature investigating fluid responsiveness in ED. METHODS MEDLINE, Embase and the Cochrane library were searched for relevant peer-reviewed studies published from 1946 to present. RESULTS A total of 249 publications were retrieved of which 22 studies underwent full-text review and eight relevant studies were identified. Only 3 studies addressed clinical outcomes - including 2 randomised controlled trials and one feasibility study. Five articles evaluated the diagnostic accuracy of fluid responsiveness techniques in ED. Due to marked heterogeneity, it was not possible to combine results in a meta-analysis. CONCLUSION High quality, adequately powered outcome studies are still lacking, so the place of fluid responsiveness in ED remains undefined. Future studies should have standardisation of patient groups, the target response and the underpinning theoretic concept of fluid responsiveness. The value of a fluid responsiveness based fluid resuscitation protocol needs to be established in a clinical trial.
Collapse
Affiliation(s)
- Mohammed H. Elwan
- Department of Emergency Medicine, Alexandria University, Alexandria, Egypt
- Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, Level G Jarvis Building RMO, Infirmary Square, LE1 5WW Leicester, UK
| | - Ashraf Roshdy
- Department of Critical Care Medicine, Alexandria University, Alexandria, Egypt
- General Intensive Care Unit, Broomfield hospital, Mid Essex NHS Trust, Chelmsford, UK
| | | | - Salah M. Eltahan
- Department of Cardiology, Alexandria University, Alexandria, Egypt
| | - Timothy J. Coats
- Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, Level G Jarvis Building RMO, Infirmary Square, LE1 5WW Leicester, UK
| |
Collapse
|
18
|
Cherpanath TGV, Geerts BF, Maas JJ, de Wilde RBP, Groeneveld AB, Jansen JR. Ventilator-induced central venous pressure variation can predict fluid responsiveness in post-operative cardiac surgery patients. Acta Anaesthesiol Scand 2016; 60:1395-1403. [PMID: 27624218 DOI: 10.1111/aas.12811] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 05/30/2016] [Accepted: 08/23/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Ventilator-induced dynamic hemodynamic parameters such as stroke volume variation (SVV) and pulse pressure variation (PPV) have been shown to predict fluid responsiveness in contrast to static hemodynamic parameters such as central venous pressure (CVP). We hypothesized that the ventilator-induced central venous pressure variation (CVPV) could predict fluid responsiveness. METHODS Twenty-two elective cardiac surgery patients were studied post-operatively on the intensive care unit during mechanical ventilation with tidal volumes of 6-8 ml/kg without spontaneous breathing efforts or cardiac arrhythmia. Before and after administration of 500mL hydroxyethyl starch, SVV and PPV were measured using pulse contour analysis by modified Modelflow® , while CVP was obtained from a central venous catheter positioned in the superior vena cava. CVPV was calculated as 100 × (CVPmax -CVPmin )/[(CVPmax + CVPmin) /2]. RESULTS Nineteen patients (86%) were fluid responders defined as an increase in cardiac output of ≥ 15% after fluid administration. CVPV decreased upon fluid loading in responders, but not in non-responders. Baseline CVP values showed no correlation with a change in cardiac output in contrast to baseline SVV (r = 0.60, P = 0.003), PPV (r = 0.58, P = 0.005), and CVPV (r = 0.63, P = 0.002). Baseline values of SVV > 9% and PPV > 8% could predict fluid responsiveness with a sensitivity of 89% and 95%, respectively, both with a specificity of 100%. Baseline CVPV could identify all fluid responders and non-responders correctly at a cut-off value of 12%. There was no difference between the area under the receiver operating characteristic curves of SVV, PPV, and CVPV. CONCLUSION The use of ventilator-induced CVPV could predict fluid responsiveness similar to SVV and PPV in post-operative cardiac surgery patients.
Collapse
Affiliation(s)
- T. G. V. Cherpanath
- Department of Intensive Care Medicine; Academic Medical Centre; Amsterdam The Netherlands
| | - B. F. Geerts
- Department of Anaesthesiology; Academic Medical Centre; Amsterdam The Netherlands
| | - J. J. Maas
- Department of Intensive Care Medicine; Leiden University Medical Centre; Leiden The Netherlands
| | - R. B. P. de Wilde
- Department of Intensive Care Medicine; Leiden University Medical Centre; Leiden The Netherlands
| | - A. B. Groeneveld
- Department of Intensive Care Medicine; Erasmus Medical Centre; Rotterdam The Netherlands
| | - J. R. Jansen
- Department of Intensive Care Medicine; Leiden University Medical Centre; Leiden The Netherlands
| |
Collapse
|
19
|
|
20
|
Miller TE, Bunke M, Nisbet P, Brudney CS. Fluid resuscitation practice patterns in intensive care units of the USA: a cross-sectional survey of critical care physicians. Perioper Med (Lond) 2016; 5:15. [PMID: 27313844 PMCID: PMC4910257 DOI: 10.1186/s13741-016-0035-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/09/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Fluid resuscitation is a cornerstone of intensive care treatment, yet there is a lack of agreement on how various types of fluids should be used in critically ill patients with different disease states. Therefore, our goal was to investigate the practice patterns of fluid utilization for resuscitation of adult patients in intensive care units (ICUs) within the USA. METHODS We conducted a cross-sectional online survey of 502 physicians practicing in medical and surgical ICUs. Survey questions were designed to assess clinical decision-making processes for 3 types of patients who need volume expansion: (1) not bleeding and not septic, (2) bleeding but not septic, (3) requiring resuscitation for sepsis. First-choice fluid used in fluid boluses for these 3 patient types was requested from the respondents. Descriptive statistics were performed using a Kruskal-Wallis test to evaluate differences among the physician groups. Follow-up tests, including t tests, were conducted to evaluate differences between ICU types, hospital settings, and bolus volume. RESULTS Fluid resuscitation varied with respect to preferences for the factors to determine volume status and preferences for fluid types. The 3 most frequently preferred volume indicators were blood pressure, urine output, and central venous pressure. Regardless of the patient type, the most preferred fluid type was crystalloid, followed by 5 % albumin and then 6 % hydroxyethyl starches (HES) 450/0.70 and 6 % HES 600/0.75. Surprisingly, up to 10 % of physicians still chose HES as the first choice of fluid for resuscitation in sepsis. The clinical specialty and the practice setting of the treating physicians also influenced fluid choices. CONCLUSIONS Practice patterns of fluid resuscitation varied in the USA, depending on patient characteristics, clinical specialties, and practice settings of the treating physicians.
Collapse
Affiliation(s)
- Timothy E Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710 USA
| | - Martin Bunke
- Department of Medical Affairs, Grifols, 79 TW Alexander Dr. Bldg. 4101, Research Triangle Park, NC 27709 USA
| | - Paul Nisbet
- One Research, LLC, 1150 Hungry Neck Blvd., Suite C-303, Charleston, SC 29464 USA
| | - Charles S Brudney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710 USA
| |
Collapse
|
21
|
|
22
|
Maurer C, Wagner JY, Schmid RM, Saugel B. Assessment of volume status and fluid responsiveness in the emergency department: a systematic approach. Med Klin Intensivmed Notfmed 2015; 112:326-333. [PMID: 26676240 DOI: 10.1007/s00063-015-0124-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/13/2015] [Accepted: 10/29/2015] [Indexed: 01/10/2023]
Abstract
When treating acutely ill patients in the emergency department (ED), the successful management of a variety of medical conditions, such as sepsis, acute kidney injury, and pancreatitis, is highly dependent on the correct assessment and optimization of a patient's intravascular volume status. Therefore, it is crucial that the ED physician knows and uses available means to assess intravascular volume status to adequately guide fluid therapy. This review focuses on techniques for volume status assessment that are available in the ED including basic clinical and laboratory findings, apparatus-based tests such as sonography and chest x-ray, and functional tests to evaluate fluid responsiveness. Furthermore, we provide an outlook on promising innovative, noninvasive technologies that might be used for advanced hemodynamic monitoring in the ED.
Collapse
Affiliation(s)
- C Maurer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Strasse 22, 81675, München, Germany
| | - J Y Wagner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - R M Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Strasse 22, 81675, München, Germany
| | - B Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| |
Collapse
|
23
|
Ansari BM, Zochios V, Falter F, Klein AA. Physiological controversies and methods used to determine fluid responsiveness: a qualitative systematic review. Anaesthesia 2015; 71:94-105. [DOI: 10.1111/anae.13246] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2015] [Indexed: 11/29/2022]
Affiliation(s)
- B. M. Ansari
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
| | - V. Zochios
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
| | - F. Falter
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
| | - A. A. Klein
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
| |
Collapse
|