1
|
Jarry S, Couture EJ, Beaubien-Souligny W, Fernandes A, Fortier A, Ben-Ali W, Desjardins G, Huard K, Mailhot T, Denault AY. Clinical relevance of transcranial Doppler in a cardiac surgery setting: embolic load predicts difficult separation from cardiopulmonary bypass. J Cardiothorac Surg 2024; 19:90. [PMID: 38347542 PMCID: PMC10863099 DOI: 10.1186/s13019-024-02591-4] [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: 06/14/2023] [Accepted: 01/30/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND During cardiac surgery, transcranial Doppler (TCD) represents a non-invasive modality that allows measurement of red blood cell flow velocities in the cerebral arteries. TCD can also be used to detect and monitor embolic material in the cerebral circulation. Detection of microemboli is reported as a high intensity transient signal (HITS). The importance of cerebral microemboli during cardiac surgery has been linked to the increased incidence of postoperative renal failure, right ventricular dysfunction, and hemodynamic instability. The objective of this study is to determine whether the embolic load is associated with hemodynamic instability during cardiopulmonary bypass (CPB) separation and postoperative complications. METHODS A retrospective single-centre cohort study of 354 patients undergoing cardiac surgery between December 2015 and March 2020 was conducted. Patients were divided in tertiles, where 117 patients had a low quantity of embolic material (LEM), 119 patients have a medium quantity of microemboli (MEM) and 118 patients who have a high quantity of embolic material (HEM). The primary endpoint was a difficult CPB separation. Multivariate logistic regression was used to determine the potential association between a difficult CPB separation and the number of embolic materials. RESULTS Patients who had a difficult CPB separation had more HITS compared to patients who had a successful CPB separation (p < 0.001). In the multivariate analysis, patients with MEM decreased their odds of having a difficult CPB weaning compared to patients in the HEM group (OR = 0.253, CI 0.111-0.593; p = 0.001). In the postoperative period patients in the HEM group have a higher Time of Persistent Organ Dysfunction (TPOD), a longer stay in the ICU, a longer duration under vasopressor drugs and a higher mortality rate compared to those in the MEM and LEM groups. CONCLUSION The result of this study suggests that a high quantity of cerebral embolic material increases the odds of having a difficult CPB separation. Also, it seems to be associated to more complex surgery, a longer CPB time, a higher TPOD and a longer stay in the ICU. Six out of eight patients who died in this cohort were in the HEM group.
Collapse
Affiliation(s)
- Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada
| | - Etienne J Couture
- Department of Anesthesiology and Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada
| | | | - Armindo Fernandes
- Perfusion Service, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Annik Fortier
- Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Walid Ben-Ali
- Department of Surgery and Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
| | - Georges Desjardins
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada
| | - Karel Huard
- Université de Montréal, Montreal, QC, Canada
| | - Tanya Mailhot
- Research Center, Montreal Heart Institute, and Faculty of Nursing, Université de Montréal, Montreal, QC, Canada
| | - André Y Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada.
| |
Collapse
|
2
|
Galarza Barrachina L, Colinas Fernández L, Martín Bermúdez R, Fernández Galilea A, Martín-Villén L. Abdominal ultrasound and VExUS score in critical care. Med Intensiva 2023; 47:658-667. [PMID: 38783747 DOI: 10.1016/j.medine.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/23/2023] [Indexed: 05/25/2024]
Abstract
The use of ultrasound while caring for critically ill patients has been increasing exponentially in the last two decades and now is an essential component of intensive care practice. Abdominal ultrasound is an established technique in other specialties, but its use in intensive care has lagged behind other ultrasound modalities. However, its potential role in the diagnosis and management of patients will make it an invaluable tool for intensivists. The main use of abdominal ultrasound at the bedside is for free fluid detection in trauma patients. But abdominal ultrasound can also help us diagnose patients with abdominal pain, hypovolemia or anuria, and it can guide us during procedures such as paracentesis or bladder catheter and gastric tube placement.
Collapse
Affiliation(s)
| | | | | | | | - Luis Martín-Villén
- UGC Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| |
Collapse
|
3
|
Couture EJ, Laferrière-Langlois P, Denault A. New Developments in Continuous Hemodynamic Monitoring of the Critically Ill Patient. Can J Cardiol 2023; 39:432-443. [PMID: 36669685 DOI: 10.1016/j.cjca.2023.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/19/2023] Open
Abstract
Hemodynamic monitoring is a cornerstone in the assessment of patients with circulatory shock. Timely recognition of hemodynamic compromise and proper optimisation is essential to ensure adequate tissue perfusion and maintain renal, hepatic, abdominal, and cerebral functions. Hemodynamic monitoring has significantly evolved since the first inception of the pulmonary artery catheter more than 50 years ago. Bedside echocardiography, when combined with noninvasive and minimally invasive technologies, provides tools to monitor and quantify the cardiac output to promptly react and improve hemodynamic management in an acute care setting. Commonly used technologies include noninvasive pulse-wave analysis, pulse-wave transit time, thoracic bioimpedance and bioreactance, esophageal Doppler, minimally invasive pulse-wave analysis, transpulmonary thermodilution, and pulmonary artery catheter. These monitoring strategies are reviewed here, along with detailed analysis of their operating mode, particularities, and limitations. The use of artificial intelligence to enhance performance and effectiveness of hemodynamic monitoring is reviewed to apprehend future possibilities.
Collapse
Affiliation(s)
- Etienne J Couture
- Departments of Anaesthesiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada.
| | - Pascal Laferrière-Langlois
- Department of Anaesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, Université de Montréal, Montréal, Québec, Canada
| | - André Denault
- Department of Anaesthesiology, Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| |
Collapse
|
4
|
Effects of changes in position, positive end-expiratory pressure and mean arterial pressure on renal, portal and hepatic Doppler ultrasound perfusion indices: a randomized crossover study in cardiac surgery patients. J Clin Monit Comput 2022; 36:1841-1850. [PMID: 35230558 DOI: 10.1007/s10877-022-00834-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/18/2022] [Indexed: 10/19/2022]
Abstract
Point-of-care ultrasound perfusion indices can be used for detection of AKI and venous congestion. Patients in the postoperative- and intensive care units are frequently exposed to alternating treatment and loading conditions. We aimed to study the effects of changes in preload (patient positioning), positive end-expiratory pressure (PEEP) and afterload (phenylephrine) on renal, portal and hepatic ultrasound indices. We hypothesized that renal resistive index was not influenced by changes in PEEP and patient positioning. This was a single-site, randomized, crossover study. Patients above 18 years scheduled for elective open-heart surgery at Aarhus University Hospital, Denmark, were available for inclusion. Patients were randomized to a sequence of six combinations of PEEP and position in addition to an increase in mean arterial pressure by phenylephrine. Thirty-one patients participated in the study. Resistive index was influenced by positional change (P = 0.007), but not by change in PEEP (P = 0.50) (Table 1). Renal venous stasis index and portal pulsatility fraction increased in the raised legs position (P ≤ 0.019), but not with increases in PEEP. Renal venous flow pattern and hepatic venous flow pattern were affected by position (P ≤ 0.019), but not by PEEP. None of the ultrasound indices were significantly changed by infusion of phenylephrine. Doppler perfusion indices were significantly affected by changes in preload, but not by changes in PEEP or afterload. Although the changes in the Doppler ultrasound indices were significant, they were small in absolute numbers. Therefore, from a clinical perspective, the ultrasound indices were robust.Trial registration Registered at clinicaltrials.com, first posted online June 5th 2020, identifier: NCT04419662.
Collapse
|
5
|
Guo J, Hu Y, Cao S, Feng C, Huang X, Zhou Q. Predictive Value of the Transthoracic Echocardiography Index for Acute Kidney Injury after Cardiac Valve Surgery. J Cardiovasc Dev Dis 2022; 9:jcdd9100316. [PMID: 36286268 PMCID: PMC9604519 DOI: 10.3390/jcdd9100316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/03/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background: We aimed to demonstrate whether the preoperative transthoracic echocardiography index (TTEI) could improve the predictive value of clinical parameters for cardiac valve surgery-associated acute kidney injury (CVS−AKI). Methods: A total of 213 patients who underwent surgical CVS at Renmin Hospital of Wuhan University were consecutively recruited in this retrospective study. TTE assessments were performed within 7 days before surgery and logistic regression was used to determine TTEI. A nomogram was constructed by integrating TTEI and clinical features, and the net reclassification index (NRI) and integrated discrimination improvement (IDI) were applied to evaluate the improvement in TTEI for CVS−AKI. Results: Among them, 66 patients (30.9%) developed CVS−AKI. The TTEI was calculated as follows: −6.579 + 0.068 × pulmonary artery systolic pressure (mmHg) −0.742 × LVEF (>55%, yes or no) + 0.346 × left ventricle posterior wall thickness (mm). The nomogram based on the TEEI and other clinical factors possessed excellent performance (C-index = 0.880), had great calibration and discrimination, and was clinically useful. Furthermore, NRI (0.07, 95% confidence interval, 95%CI, 0.01−0.12, p = 0.02) and IDI (0.08, 95%CI, 0.01−0.20, p = 0.02) indicated that TTEI could significantly improve the predictive value of clinical features for CVS−AKI. Conclusions: As a simple access and cost-effective parameter, the preoperative TTEI may be a reliable and useful factor for CVS−AKI.
Collapse
Affiliation(s)
| | | | | | | | | | - Qing Zhou
- Correspondence: ; Tel.: +86-027-8804-1911
| |
Collapse
|
6
|
Xu L, Wang X, Pu P, Li S, Shao Y, Li Y. Ultrasonic Image Features under the Intelligent Algorithm in the Diagnosis of Severe Sepsis Complicated with Renal Injury. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:2310014. [PMID: 35991127 PMCID: PMC9388266 DOI: 10.1155/2022/2310014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/08/2022] [Accepted: 06/11/2022] [Indexed: 11/18/2022]
Abstract
This research was aimed at analyzing the diagnosis of severe sepsis complicated with acute kidney injury (AKI) by ultrasonic image information based on the artificial intelligence pulse-coupled neural network (PCNN) algorithm and at improving the diagnostic accuracy and efficiency of clinical severe sepsis complicated with AKI. In this research, 50 patients with sepsis complicated with AKI were collected as the observation group and 50 patients with sepsis as the control group. All patients underwent ultrasound examination. The clinical data of the two groups were collected, and the scores of acute physiology and chronic health assessment (APACHE II) and sequential organ failure assessment (SOFA) were compared. The ultrasonic image information enhancement algorithm based on artificial intelligence PCNN is constructed and simulated and is compared with the maximum between-class variance (OSTU) algorithm and the maximum entropy algorithm. The results showed that the PCNN algorithm was superior to the OSTU algorithm and maximum entropy algorithm in the segmentation results of severe sepsis combined with AKI in terms of regional consistency (UM), regional contrast (CM), and shape measure (SM). The acute physiology and chronic health evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores in the observation group were substantially higher than those in the control group (P < 0.05). The interlobular artery resistance index (RI) in the observation group was substantially higher than that in the control group (P < 0.05). Moreover, the mean transit time (mTT) in the observation group was significantly higher than that in the control group (4.85 ± 1.27 vs. 3.42 ± 1.04), and the perfusion index (PI) was significantly lower than that in the control group (134.46 ± 17.29 vs. 168.37 ± 19.28), with statistical significance (P < 0.05). In summary, it can substantially increase ultrasonic image information based on the artificial intelligence PCNN algorithm. The RI, mTT, and PI of the renal interlobular artery level in ultrasound images can be used as indexes for the diagnosis of severe sepsis complicated with AKI.
Collapse
Affiliation(s)
- Leiming Xu
- Department of Emergency Medicine, Binhai County People's Hospital, Binhai, 224500 Jiangsu, China
| | - Xin Wang
- Department of Intensive Care Unit, Binhai County People's Hospital, Binhai, 224500 Jiangsu, China
| | - Pu Pu
- Department of Intensive Care Unit, Binhai County People's Hospital, Binhai, 224500 Jiangsu, China
| | - Suhui Li
- Department of Emergency Medicine, Binhai County People's Hospital, Binhai, 224500 Jiangsu, China
| | - Yongzheng Shao
- Department of Intensive Care Unit, Binhai County People's Hospital, Binhai, 224500 Jiangsu, China
| | - Yong Li
- Department of Intensive Care Unit, Binhai County People's Hospital, Binhai, 224500 Jiangsu, China
| |
Collapse
|
7
|
Mao JY, Zhang HM, Liu DW, Wang XT. Visual Rounds Based on Multiorgan Point-of-Care Ultrasound in the ICU. Front Med (Lausanne) 2022; 9:869958. [PMID: 35692540 PMCID: PMC9174546 DOI: 10.3389/fmed.2022.869958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 04/15/2022] [Indexed: 11/20/2022] Open
Abstract
Point-of-care ultrasonography (POCUS) is performed by a treating clinician at the patient's bedside, provides a acquisition, interpretation, and immediate clinical integration based on ultrasonographic imaging. The use of POCUS is not limited to one specialty, protocol, or organ system. POCUS provides the treating clinician with real-time diagnostic and monitoring information. Visual rounds based on multiorgan POCUS act as an initiative to improve clinical practice in the Intensive Care Unit and are urgently needed as part of routine clinical practice.
Collapse
Affiliation(s)
- Jia-Yu Mao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Hong-Min Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Xiao-Ting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
- Department of Health Care, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Xiao-Ting Wang
| |
Collapse
|
8
|
Canaud B, Kooman JP, Selby NM, Taal M, Maierhofer A, Kopperschmidt P, Francis S, Collins A, Kotanko P. Hidden risks associated with conventional short intermittent hemodialysis: A call for action to mitigate cardiovascular risk and morbidity. World J Nephrol 2022; 11:39-57. [PMID: 35433339 PMCID: PMC8968472 DOI: 10.5527/wjn.v11.i2.39] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 10/30/2021] [Accepted: 03/23/2022] [Indexed: 02/06/2023] Open
Abstract
The development of maintenance hemodialysis (HD) for end stage kidney disease patients is a success story that continues to save many lives. Nevertheless, intermittent renal replacement therapy is also a source of recurrent stress for patients. Conventional thrice weekly short HD is an imperfect treatment that only partially corrects uremic abnormalities, increases cardiovascular risk, and exacerbates disease burden. Altering cycles of fluid loading associated with cardiac stretching (interdialytic phase) and then fluid unloading (intradialytic phase) likely contribute to cardiac and vascular damage. This unphysiologic treatment profile combined with cyclic disturbances including osmotic and electrolytic shifts may contribute to morbidity in dialysis patients and augment the health burden of treatment. As such, HD patients are exposed to multiple stressors including cardiocirculatory, inflammatory, biologic, hypoxemic, and nutritional. This cascade of events can be termed the dialysis stress storm and sickness syndrome. Mitigating cardiovascular risk and morbidity associated with conventional intermittent HD appears to be a priority for improving patient experience and reducing disease burden. In this in-depth review, we summarize the hidden effects of intermittent HD therapy, and call for action to improve delivered HD and develop treatment schedules that are better tolerated and associated with fewer adverse effects.
Collapse
Affiliation(s)
- Bernard Canaud
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
- Department of Nephrology, Montpellier University, Montpellier 34000, France
| | - Jeroen P Kooman
- Department of Internal Medicine, Maastricht University, Maastricht 6229 HX, Netherlands
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Maarten Taal
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Derby DE22 3DT, United Kingdom
| | - Andreas Maierhofer
- Global Research Development, Fresenius Medical Care, Schweinfurt 97424, Germany
| | | | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham NG7 2RD, United Kingdom
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Bad Homburg 61352, Germany
| | - Peter Kotanko
- Renal Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10065, United States
| |
Collapse
|
9
|
Utility of bedside ultrasound derived hepatic and renal parenchymal flow patterns to guide management of acute kidney injury. Curr Opin Crit Care 2021; 27:587-592. [PMID: 34636777 DOI: 10.1097/mcc.0000000000000899] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE OF REVIEW Ideal fluid management of critically ill patients is maintaining an adequate perfusion pressure but avoiding venous congestion. Venous excess ultrasound score (VExUS) quantifies venous congestion to guide the management of fluid balance. RECENT FINDINGS VExUS of abdominal veins measures fluid tolerance and helps clinicians avoid congestion. VExUS scoring predicts the development of acute kidney injury (AKI) that is a common hospital problem resulting in higher mortality and morbidity. VExUS can predict patients at risk of developing AKI post cardiac surgery. VExUS has been associated with an increase in adverse outcomes in a general intensive care population. Hepatic vein ultrasound can manifest as a sequela of right heart failure and pulmonary hypertension. Intrarenal congestion suggests poorer prognosis in heart failure patients. VExUS score has been used in decision-making to remove fluid in patients with cardiorenal syndrome. VExUS scoring may help curtail overly aggressive fluid resuscitation for patients with septic shock and help avoid iatrogenic 'salt water drowning'. SUMMARY We summarize the technique and clinical practice of VExUS to help guide fluid balance across different populations of critically ill patients.
Collapse
|
10
|
Yaport MA, Denault A. The Science and Innovation Behind Google Maps and Renal-Resistive Index. J Cardiothorac Vasc Anesth 2021; 35:3826-3828. [PMID: 34538744 DOI: 10.1053/j.jvca.2021.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 08/23/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Miguel A Yaport
- Department of Anesthesiology, Tufts University School of Medicine, Boston, MA.
| | - Andre Denault
- Department of Anesthesiology, Faculté de médecine de l'Université de Montréal, Montréal, Quebec
| |
Collapse
|
11
|
Gudsoorkar P, Langote A, Vaidya P, Meraz-Muñoz AY. Acute Kidney Injury in Patients With Cancer: A Review of Onconephrology. Adv Chronic Kidney Dis 2021; 28:394-401.e1. [PMID: 35190106 DOI: 10.1053/j.ackd.2021.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 11/11/2022]
Abstract
Over the past 2 decades, significant research and advancements have been made in oncology and its therapeutics. Thanks to novel diagnostic methods, treatments, and supportive measures, patients with cancer live longer and have a better quality of life. However, an unforeseen consequence of this progress has been increasing medical complications, including acute kidney injury. The purpose of this review is to provide an overview of the epidemiology and most common causes of acute kidney injury in patients with cancer unrelated to oncological treatment.
Collapse
|
12
|
Pettey G, Hermansen JL, Nel S, Moutlana HJ, Muteba M, Juhl-Olsen P, Tsabedze N, Chakane PM. Ultrasound Hepatic Vein Ratios Are Associated With the Development of Acute Kidney Injury After Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:1326-1335. [PMID: 34419361 DOI: 10.1053/j.jvca.2021.07.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/15/2021] [Accepted: 07/22/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The authors investigated the use of hepatic venous and right-heart ultrasound parameters in predicting cardiac surgery-associated acute kidney injury (AKI). DESIGN This was a prospective, contextual, descriptive two-center study. Blood tests,clinical and ultrasound data were obtained preoperatively, and postoperative day one, and day four. The hepatic vein, inferior vena cava, and right-heart Doppler ultrasound parameters were obtained and analyzed. SETTING The sites of the study were Johannesburg, South Africa, and Aarhus, Denmark. PARTICIPANTS Adult patients who satisfied inclusion criteria, between August 2019 and January 2020, were included, with a total of 152 participants. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The median (interquartile range) age of patients was 68 (55-73) years, predominantly male, and the majority were hypertensive. Of 152 patients analyzed, 54 (35%) patients developed AKI. Among these, 37 (69%) were classified as Kidney Disease: Improving Global Outcomes (KDIGO) stage I, 11 (20%) as stage II, while six (11%) were stage III. Age (adjusted odds ratio [AOR] 1.05, 95% confidence interval [CI] 1.00-1.10 p = 0.031), The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (AOR 1.43, 95% CI 1.14-1.80, p = 0.005], and preoperative serum creatinine (AOR 1.04, 95% CI 1.01-1.08, p = 0.013) were predictive of AKI. Those who developed AKI had experienced longer cardiopulmonary bypass (CPB) times (p < 0.001). Preoperatively, hepatic vein S-wave measurements were significantly higher in patients with AKI (p < 0.05). On postoperative day one (D1), the hepatic vein flow ratios of patients with AKI were significantly decreased, driven by low S waves and high D waves, and accompanied by significantly elevated central venous pressure (CVP) levels. CVP levels on D1 postoperatively were predictive of AKI (AOR 1.31, 95% CI 1.11-1.55, p = 0.001). Measurements of right ventricular (RV) base, tricuspid annular plane excursion (TAPSE), and inferior vena cava were not associated with the development of AKI (p > 0.05). CONCLUSION There was an association between the development of AKI and a decrease in hepatic flow ratios on D1, driven by low S-wave and high D-wave velocities. The presence of venous congestion was reflected by significantly elevated CVP values, which were independently associated with AKI on D1. RV base and TAPSE measurements were, however, not associated with AKI. These parameters may reflect perioperative circumstances, including prolonged CPB times and potential fluid management, which can be modified in this period.
Collapse
Affiliation(s)
- Gabriela Pettey
- Department of Anaesthesiology, University of the Witwatersrand, Johannesburg, South Africa.
| | - Johan Lyngklip Hermansen
- Department of Cardiothoracic- and Vascular Surgery, Anaesthesia section, Aarhus University Hospital, Denmark
| | - Samantha Nel
- Department of Cardiology, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Michel Muteba
- Department of Anaesthesiology, University of the Witwatersrand, Johannesburg, South Africa
| | - Peter Juhl-Olsen
- Department of Cardiothoracic- and Vascular Surgery, Anaesthesia section, Aarhus University Hospital, Denmark
| | - Nqoba Tsabedze
- Department of Cardiology, University of the Witwatersrand, Johannesburg, South Africa
| | | |
Collapse
|
13
|
Denault AY, Roberts M, Cios T, Malhotra A, Paquin SC, Tan S, Cavayas YA, Desjardins G, Klick J. Transgastric Abdominal Ultrasonography in Anesthesia and Critical Care: Review and Proposed Approach. Anesth Analg 2021; 133:630-647. [PMID: 34086617 DOI: 10.1213/ane.0000000000005537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The use of transesophageal echocardiography (TEE) in the operating room and intensive care unit can provide invaluable information on cardiac as well as abdominal organ structures and function. This approach may be particularly useful when the transabdominal ultrasound examination is not possible during intraoperative procedures or for anatomical reasons. This review explores the role of transgastric abdominal ultrasonography (TGAUS) in perioperative medicine. We describe several reported applications using 10 views that can be used in the diagnosis of relevant abdominal conditions associated with organ dysfunction and hemodynamic instability in the operating room and the intensive care unit.
Collapse
Affiliation(s)
- André Y Denault
- From the Department of Anesthesiology and Critical Care Medicine, Montreal Heart Institute, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, Quebec, Canada
| | - Michael Roberts
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, Milton S. Hershey Penn State Medical Center, Penn State University School of Medicine, Hershey, Pennsylvania
| | - Theodore Cios
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, Milton S. Hershey Penn State Medical Center, Penn State University School of Medicine, Hershey, Pennsylvania
| | - Anita Malhotra
- From the Department of Anesthesiology and Critical Care Medicine, Montreal Heart Institute, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, Quebec, Canada
| | - Sarto C Paquin
- Department of Medicine, Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal (CHUM)
| | - Stéphanie Tan
- Department of Radiology, Montreal Heart Institute, Université de Montréal
| | - Yiorgos Alexandros Cavayas
- Department of Medicine and Intensive Care Unit, Montreal Sacré-Coeur Hospital and Department of Medicine and Intensive Care Unit, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Georges Desjardins
- From the Department of Anesthesiology and Critical Care Medicine, Montreal Heart Institute, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, Quebec, Canada
| | - John Klick
- Department of Anesthesiology, University of Vermont Medical Center, Larner College of Medicine, University of Vermont, Burlington, Vermont
| |
Collapse
|
14
|
Meraz-Munoz A, Langote A, Jhaveri KD, Izzedine H, Gudsoorkar P. Acute Kidney Injury in the Patient with Cancer. Diagnostics (Basel) 2021; 11:611. [PMID: 33805529 PMCID: PMC8065801 DOI: 10.3390/diagnostics11040611] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 01/18/2023] Open
Abstract
Over the last three decades, advancements in the diagnosis, treatment, and supportive care of patients with cancer have significantly improved their overall survival. However, these advancements have also led to a higher rate of cancer-related complications. Acute kidney injury (AKI) and chronic kidney disease (CKD) are highly prevalent in patients with cancer, and they are associated with an increased risk of all-cause mortality. This bidirectional interplay between cancer and kidney, termed "the kidney-cancer connection" has become a very active area of research. This review aims to provide an overview of some of the most common causes of AKI in patients with cancer. Cancer therapy-associated AKI is beyond the scope of this review and will be discussed separately.
Collapse
Affiliation(s)
- Alejandro Meraz-Munoz
- Division of Nephrology, Department of Medicine, St Michael’s Hospital, Toronto, ON M5B 1W8, Canada;
| | - Amit Langote
- Consultant Nephrologist, Apollo Hospital, Navi Mumbai, Maharashtra 400614, India;
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine, Great Neck, NY 11021, USA;
| | - Hassane Izzedine
- Department of Nephrology, Peupliers Private Hospital, Ramsay Générale de Santé, 75013 Paris, France;
| | - Prakash Gudsoorkar
- Division of Nephrology & Kidney Clinical Advancement, Research & Education Program, University of Cincinnati, Cincinnati, OH 45267, USA
| |
Collapse
|
15
|
Calderone A, Hammoud A, Jarry S, Denault A, Couture EJ. Femoral Vein Pulsatility: What Does It Mean? J Cardiothorac Vasc Anesth 2021; 35:2521-2527. [PMID: 33985881 DOI: 10.1053/j.jvca.2021.03.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
In this report, the clinical evolution of a 72-year-old patient transferred to the surgical intensive care unit after cardiac surgery is described. The presence of a pulsatile Doppler signal of the common femoral vein was noted after surgery. On postoperative day 5, diuretics in addition to a combination of inhaled epoprostenol and milrinone were associated with normalization of femoral vein pulsatility. The observations seen in peripheral venous flow reinforce the hypothesis that pulsatility of the common femoral vein represents an associated echocardiographic sign of right ventricular dysfunction and may be used to monitor systemic venous congestion. Pulsatility in the venous system may be improved by reducing volume overload and improving right ventricular function.
Collapse
Affiliation(s)
- Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Ali Hammoud
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Faculty of Nursing Graduate Studies, Université de Montréal, Montreal, Quebec, Canada
| | - Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada; Department of Cardiac Surgery and Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Etienne J Couture
- Department of Anesthesiology, Department of Medicine, Division of Intensive Care Medicine, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Canada
| |
Collapse
|
16
|
Bianco JC, Stang MV, Denault AY, Marenchino RG, Belziti CA, Musso CG. Acute Kidney Injury After Heart Transplant: The Importance of Pulmonary Hypertension. J Cardiothorac Vasc Anesth 2020; 35:2052-2062. [PMID: 33414071 DOI: 10.1053/j.jvca.2020.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine whether relative pulmonary hypertension (PH), defined as the ratio of mean arterial pressure to mean pulmonary artery pressure, is associated with severe acute kidney injury (AKI) after heart transplant (HT). DESIGN An institutional review board-approved retrospective observational study. SETTING Tertiary care university hospital. PARTICIPANTS A total of 184 consecutive adult patients who underwent HT between January 2009 and December 2017 were included, and were followed up through December 2019. Using the Kidney Disease: Improving Global Outcomes classification, recipients were categorized into two groups: patients who developed stage 3 AKI (severe AKI) and those with minor or without AKI (nonsevere AKI) within seven days after transplant. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the included patients, 83.2% developed AKI, in whom 40.8%, 19.6%, and 22.8% were stage 1, 2, and 3, respectively. With use of the multivariate logistic regression analysis, independent risk factors for stage 3 AKI post-HT included preoperative relative PH (odds ratio [OR]: 1.62, 95% confidence interval [95% CI]: 1.05-2.49, p = 0.028), central venous-to-pulmonary capillary wedge pressure ratio ≥0.86 (OR: 3.59, 95% CI: 1.13-11.43, p = 0.030), and postoperative right ventricular dysfunction (OR: 3.63, 95% CI: 1.50-8.75, p = 0.004). Conversely, preoperative estimated glomerular filtration rate (OR: 0.99, 95% CI: 0.97-1.00, p = 0.143) was not related to the development of stage 3 AKI post-HT. CONCLUSIONS Preoperative relative PH, central venous-to-pulmonary capillary wedge pressure ratio, and postoperative right ventricular failure by echocardiographic assessment were associated with severe AKI post-HT.
Collapse
Affiliation(s)
- Juan C Bianco
- Department of Anesthesiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - María V Stang
- Department of Anesthesiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - André Y Denault
- Department of Anesthesiology and Intensive Care Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Ricardo G Marenchino
- Department of Cardiovascular Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - César A Belziti
- Department of Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carlos G Musso
- Department of Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Facultad de Ciencias de la Salud. Universidad Simón Bolivar, Barranquilla, Colombia
| |
Collapse
|
17
|
Canaud B, Kooman JP, Selby NM, Taal MW, Francis S, Maierhofer A, Kopperschmidt P, Collins A, Kotanko P. Dialysis-Induced Cardiovascular and Multiorgan Morbidity. Kidney Int Rep 2020; 5:1856-1869. [PMID: 33163709 PMCID: PMC7609914 DOI: 10.1016/j.ekir.2020.08.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
Hemodialysis has saved many lives, albeit with significant residual mortality. Although poor outcomes may reflect advanced age and comorbid conditions, hemodialysis per se may harm patients, contributing to morbidity and perhaps mortality. Systemic circulatory "stress" resulting from hemodialysis treatment schedule may act as a disease modifier, resulting in a multiorgan injury superimposed on preexistent comorbidities. New functional intradialytic imaging (i.e., echocardiography, cardiac magnetic resonance imaging [MRI]) and kinetic of specific cardiac biomarkers (i.e., Troponin I) have clearly documented this additional source of end-organ damage. In this context, several factors resulting from patient-hemodialysis interaction and/or patient management have been identified. Intradialytic hypovolemia, hypotensive episodes, hypoxemia, solutes, and electrolyte fluxes as well as cardiac arrhythmias are among the contributing factors to systemic circulatory stress that are induced by hemodialysis. Additionally, these factors contribute to patients' symptom burden, impair cognitive function, and finally have a negative impact on patients' perception and quality of life. In this review, we summarize the adverse systemic effects of current intermittent hemodialysis therapy, their pathophysiologic consequences, review the evidence for interventions that are cardioprotective, and explore new approaches that may further reduce the systemic burden of hemodialysis. These include improved biocompatible materials, smart dialysis machines that automatically may control the fluxes of solutes and electrolytes, volume and hemodynamic control, health trackers, and potentially disruptive technologies facilitating a more personalized medicine approach.
Collapse
Affiliation(s)
- Bernard Canaud
- Montpellier University, Montpellier, France
- GMO, FMC, Bad Homburg, Germany
| | - Jeroen P. Kooman
- Maastricht University Medical Centre, Department of Internal Medicine, Maastricht, Netherlands
| | - Nicholas M. Selby
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, UK
| | - Maarten W. Taal
- Centre for Kidney Research and Innovation, Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, UK
| | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, UK
| | | | | | | | - Peter Kotanko
- Renal Research Institute, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
18
|
Montrief T, Alerhand S, Denault A, Scott J. Point-of-care echocardiography for the evaluation of right-to-left cardiopulmonary shunts: a narrative review. Can J Anaesth 2020; 67:1824-1838. [PMID: 32944839 DOI: 10.1007/s12630-020-01813-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/10/2020] [Accepted: 06/10/2020] [Indexed: 12/19/2022] Open
Abstract
Right-to-left pulmonary and cardiac shunts (RLS) are important causes of refractory hypoxia in the critically-ill perioperative patient. Using a point-of-care ultrasound (POCUS) agitated saline bubble study for an early diagnosis allows patients with clinically significant RLSs to receive expedited therapy. This narrative review discusses the principles of agitated saline ultrasonography as well as the role of POCUS in detecting the most common RLS types seen in the intensive care unit, including patent foramen ovale, atrial septal defects, and pulmonary arterio-venous malformations. An illustrated discussion of the procedure, as well as shunt-enhancing maneuvers (Valsalva or lung recruitment maneuver with subsequent rapid release) is provided. With the wide dissemination of bedside ultrasound within the perioperative and critical care arena, POCUS practitioners should be knowledgeable of the potential pitfalls leading to both false-positive and false-negative studies. False-positive studies may be due to congenital abnormalities, mischaracterization of intrapulmonary shunts as intracardiac shunts (and vice versa), or evidence of the Valsalva effect. False negatives are typically due to respiratory-phasic variation, performing an inadequate shunt-enhancing maneuver, inadequate injection of agitated saline, or pathophysiologic states of elevated left atrial pressure. Finally, alternative POCUS methods for determining presence of an RLS in patients with poor echocardiographic windows are discussed, with a focus on pulsed-wave Doppler interrogation of arterial signals.
Collapse
Affiliation(s)
- Tim Montrief
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - André Denault
- Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada.
| | - Jeffrey Scott
- Division of Cardiothoracic and Transplant Critical Care, Jackson Health System, Miami Transplant Institute, Miami, FL, USA
| |
Collapse
|
19
|
Augoustides JG. Perioperative Echocardiography During the Coronavirus Crisis: Considerations in Pediatrics and Congenital Heart Disease. J Cardiothorac Vasc Anesth 2020; 34:2303-2306. [PMID: 32387016 PMCID: PMC7165086 DOI: 10.1053/j.jvca.2020.04.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/11/2020] [Indexed: 12/22/2022]
Affiliation(s)
- John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
20
|
Fernando RJ, Marchant BE, Jao GT, Royster RL. Renal Function and Heart Failure: Assessment, Goals, and Perioperative Implications. J Cardiothorac Vasc Anesth 2020; 34:3175-3179. [PMID: 32739089 DOI: 10.1053/j.jvca.2020.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Rohesh J Fernando
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Bryan E Marchant
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Geoffrey T Jao
- Department of Cardiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Roger L Royster
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
| |
Collapse
|
21
|
Augoustides JG. Perioperative Echocardiography: Key Considerations During the Coronavirus Pandemic. J Cardiothorac Vasc Anesth 2020; 34:1416-1418. [PMID: 32249075 PMCID: PMC7138190 DOI: 10.1053/j.jvca.2020.03.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 02/08/2023]
Affiliation(s)
- John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
22
|
A proposed lung ultrasound and phenotypic algorithm for the care of COVID-19 patients with acute respiratory failure. Can J Anaesth 2020; 67:1393-1404. [PMID: 32440906 PMCID: PMC7241588 DOI: 10.1007/s12630-020-01704-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 01/08/2023] Open
Abstract
Pulmonary complications are the most common clinical manifestations of coronavirus disease (COVID-19). From recent clinical observation, two phenotypes have emerged: a low elastance or L-type and a high elastance or H-type. Clinical presentation, pathophysiology, pulmonary mechanics, radiological and ultrasound findings of these two phenotypes are different. Consequently, the therapeutic approach also varies between the two. We propose a management algorithm that combines the respiratory rate and oxygenation index with bedside lung ultrasound examination and monitoring that could help determine earlier the requirement for intubation and other surveillance of COVID-19 patients with respiratory failure.
Collapse
|
23
|
Renberg M, Kilhamn N, Lund K, Hertzberg D, Rimes-Stigare C, Bell M. Feasibility of renal resistive index measurements performed by an intermediate and novice sonographer in a volunteer population. Ultrasound J 2020; 12:28. [PMID: 32430724 PMCID: PMC7237552 DOI: 10.1186/s13089-020-00175-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/11/2020] [Indexed: 01/13/2023] Open
Abstract
Background The Doppler-derived renal resistive index (RRI) is emerging as a promising bedside tool for assessing renal perfusion and risk of developing acute kidney injury in critically ill patients. It is not known what level of ultrasonography competence is needed to obtain reliable RRI values. Objective The aim of this study was to evaluate the feasibility of RRI measurements by an intermediate and novice sonographer in a volunteer population. Methods After a focused teaching session, an intermediate (resident), novice (medical student) and expert sonographer performed RRI measurements in 23 volunteers consecutively and blinded to the results of one another. Intraclass correlation coefficients and Bland–Altman plots were used to evaluate interobserver reliability, bias and precision. Results Both non-experts were able to obtain RRI values in all volunteers. Median RRI in the population measured by the expert was 0.58 (interquartile range 0.52–0.62). The intraclass correlation coefficient was 0.96 (95% confidence interval 0.90–0.98) for the intermediate and expert, and 0.85 (95% confidence interval 0.69–0.94) for the novice and expert. In relation to the measurements of the expert, both non-experts showed negligible bias (mean difference 0.002 [95% confidence interval − 0.005 to 0.009, p = 0.597] between intermediate and expert, mean difference 0.002 [95% confidence interval − 0.011 to 0.015, p = 0.752] between novice and expert) and clinically acceptable precision (95% limits of agreement − 0.031 to 0.035 for the intermediate, 95% limits of agreement − 0.056 to 0.060 for the novice). Conclusions RRI measurements by both an intermediate and novice sonographer in a volunteer population were reliable, accurate and precise after a brief course. RRI is easy to learn and feasible within the scope of point-of-care ultrasound.
Collapse
Affiliation(s)
- Mårten Renberg
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden. .,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
| | - Naima Kilhamn
- Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden
| | - Kent Lund
- Department of Clinical Physiology, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Daniel Hertzberg
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden
| | - Claire Rimes-Stigare
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden
| | - Max Bell
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
24
|
Pettey G, Motshabi P. Novel modalities for the diagnosis of cardiac surgery associated acute kidney injury : a narrative review of the literature. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.2.2305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
25
|
Canaud B, Collins A, Maddux F. The renal replacement therapy landscape in 2030: reducing the global cardiovascular burden in dialysis patients. Nephrol Dial Transplant 2020; 35:ii51-ii57. [PMID: 32162663 PMCID: PMC7066547 DOI: 10.1093/ndt/gfaa005] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Indexed: 12/15/2022] Open
Abstract
Despite the significant progress made in understanding chronic kidney disease and uraemic pathophysiology, use of advanced technology and implementation of new strategies in renal replacement therapy, the clinical outcomes of chronic kidney disease 5 dialysis patients remain suboptimal. Considering residual suboptimal medical needs of short intermittent dialysis, it is our medical duty to revisit standards of dialysis practice and propose new therapeutic options for improving the overall effectiveness of dialysis sessions and reduce the burden of stress induced by the therapy. Several themes arise to address the modifiable components of the therapy that are aimed at mitigating some of the cardiovascular risks in patients with end-stage kidney disease. Among them, five are of utmost importance and include: (i) enhancement of treatment efficiency and continuous monitoring of dialysis performances; (ii) prevention of dialysis-induced stress; (iii) precise handling of sodium and fluid balance; (iv) moving towards heparin-free dialysis; and (v) customizing electrolyte prescriptions. In summary, haemodialysis treatment in 2030 will be substantially more personalized to the patient, with a clear focus on cardioprotection, volume management, arrhythmia surveillance, avoidance of anticoagulation and the development of more dynamic systems to align the fluid and electrolyte needs of the patient on the day of the treatment to their particular circumstances.
Collapse
Affiliation(s)
- Bernard Canaud
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
- School of Medicine, Montpellier University, Montpellier, France
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| | - Frank Maddux
- Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| |
Collapse
|
26
|
|
27
|
Denault A, Canty D, Azzam M, Amir A, Gebhard CE. Whole body ultrasound in the operating room and intensive care unit. Korean J Anesthesiol 2019; 72:413-428. [PMID: 31159535 PMCID: PMC6781205 DOI: 10.4097/kja.19186] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/23/2019] [Indexed: 12/14/2022] Open
Abstract
Whole body ultrasound can be used to improve the speed and accuracy of evaluation of an increasing number of organ systems in the critically ill. Cardiac and abdominal ultrasound can be used to identify the mechanisms and etiology of hemodynamic instability. In hypoxemia or hypercarbia, lung ultrasound can rapidly identify the etiology of the condition with an accuracy that is equivalent to that of computed tomography. For encephalopathy, ocular ultrasound and transcranial Doppler can identify elevated intracranial pressure and midline shift. Renal and bladder ultrasound can identify the mechanisms and etiology of renal failure. Ultrasound can also improve the accuracy and safety of percutaneous procedures and should be currently used routinely for central vein catheterization and percutaneous tracheostomy.
Collapse
Affiliation(s)
- André Denault
- Department of Anesthesiology and Critical Care Medicine, Faculté de Médecine, Université de Montréal, Institut de Cardiologie de Montréal, and Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - David Canty
- Department of Surgery, University of Melbourne, Australia.,Department of Medicine, Monash Medical Centre, Monash University, Clayton, Melbourne, and Department of Anesthesia, Monash Medical Centre and Royal Melbourne Hospital, Victoria, Australia
| | - Milène Azzam
- Department of Anesthesiology, Jewish General Hospital, McGill University Faculty of Medicine, Montreal, QC, Canada
| | - Alexander Amir
- Department of Anesthesiology, Montreal General Hospital, McGill University Faculty of Medicine, Montreal, QC, Canada
| | - Caroline E Gebhard
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| |
Collapse
|