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Chun EH, Chung MH, Kim JE, Lee HS, Jo Y, Jun JH. Use of stepwise lung recruitment maneuver to predict fluid responsiveness under lung protective ventilation in the operating room. Sci Rep 2024; 14:11649. [PMID: 38773192 PMCID: PMC11109109 DOI: 10.1038/s41598-024-62355-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 05/16/2024] [Indexed: 05/23/2024] Open
Abstract
Recent research has revealed that hemodynamic changes caused by lung recruitment maneuvers (LRM) with continuous positive airway pressure can be used to identify fluid responders. We investigated the usefulness of stepwise LRM with increasing positive end-expiratory pressure and constant driving pressure for predicting fluid responsiveness in patients under lung protective ventilation (LPV). Forty-one patients under LPV were enrolled when PPV values were in a priori considered gray zone (4% to 17%). The FloTrac-Vigileo device measured stroke volume variation (SVV) and stroke volume (SV), while the patient monitor measured pulse pressure variation (PPV) before and at the end of stepwise LRM and before and 5 min after fluid challenge (6 ml/kg). Fluid responsiveness was defined as a ≥ 15% increase in the SV or SV index. Seventeen were fluid responders. The areas under the curve for the augmented values of PPV and SVV, as well as the decrease in SV by stepwise LRM to identify fluid responders, were 0.76 (95% confidence interval, 0.61-0.88), 0.78 (0.62-0.89), and 0.69 (0.53-0.82), respectively. The optimal cut-offs for the augmented values of PPV and SVV were > 18% and > 13%, respectively. Stepwise LRM -generated augmented PPV and SVV predicted fluid responsiveness under LPV.
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Affiliation(s)
- Eun Hee Chun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Mi Hwa Chung
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jung Eun Kim
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Youngbum Jo
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Joo Hyun Jun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
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Kim SJ, Kim SY, Lee HS, Park G, Yoon EJ, Heo S, Koo BN. Ability of dynamic preload indices to predict fluid responsiveness in a high femoral-to-radial arterial pressure gradient: a retrospective study. Anesth Pain Med (Seoul) 2022; 16:360-367. [PMID: 35139617 PMCID: PMC8828628 DOI: 10.17085/apm.21001] [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: 12/31/2020] [Accepted: 07/20/2021] [Indexed: 11/18/2022] Open
Abstract
Background Dynamic preload indices may predict fluid responsiveness in end-stage liver disease. However, their usefulness in patients with altered vascular compliance is uncertain. This study is the first to evaluate whether dynamic indices can reliably predict fluid responsiveness in patients undergoing liver transplantation with a high femoral-to-radial arterial pressure gradient (PG). Methods Eighty liver transplant recipients were retrospectively categorized as having a normal (n = 56) or high (n = 24, difference in systolic pressure ≥ 10 mmHg and/or mean pressure ≥ 5 mmHg) femoral-to-radial arterial PG, measured immediately after radial and femoral arterial cannulation. The ability of dynamic preload indices (stroke volume variation, pulse pressure variation [PPV], pleth variability index) to predict fluid responsiveness was assessed before the surgery. Fluid replacement of 500 ml of crystalloid solution was performed over 15 min. Fluid responsiveness was defined as ≥ 15% increase in the stroke volume index. The area under the receiver-operating characteristic curve (AUC) indicated the prediction of fluid responsiveness. Results Fourteen patients in the normal, and eight in the high PG group were fluid responders. The AUCs for PPV in the normal, high PG groups and total patients were 0.702 (95% confidence interval [CI] 0.553–0.851, P = 0.008), 0.633 (95% CI 0.384–0.881, P = 0.295) and 0.667 (95% CI 0.537–0.798, P = 0.012), respectively. No other index predicted fluid responsiveness. Conclusion PPV can be used as a dynamic index of fluid responsiveness in patients with end-stage liver disease but not in patients with altered vascular compliance.
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Affiliation(s)
- Seon Ju Kim
- Department of Anesthesiology and Pain Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Goeun Park
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Jang Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sungtaik Heo
- Department of Anesthesiology and Pain Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
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Validation of electrical velocimetry in resuscitation of patients undergoing liver transplantation. Observational study. J Clin Monit Comput 2020; 34:271-276. [PMID: 31004273 DOI: 10.1007/s10877-019-00313-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/10/2019] [Indexed: 12/26/2022]
Abstract
Major hemodynamic changes are frequently noted during liver transplantation (LT). We evaluated the performance of electrical velocimetry (EV) as compared to that of TEE in SV optimization during liver transplantation. This was an observational study in 32 patients undergoing LT. We compared SV values measured simultaneously by EV (SVEV) and TEE (SVTEE) at baseline 30 min after induction, at the end of dissection phase, 30 min after anhepatic phase, 30 min after reperfusion. We also evaluated the reliability of EV to track changes In SV before and after 49 fluid challenges. Finally, the SV variation (SVV) and pulse pressure variation (PPV) were tested as predictors for volume responsiveness, defined as an increase in SV ≥ 10% after 250 ml of colloid. For 112 paired SV data, the overall correlation was 0.76 and bias (limits of agreement) 0.3 (- 29 to 29) ml percentage error 62%. The EV was able to track changes in SV with a concordance rate of 97%, and a sensitivity and specificity of 93% to detect a positive fluid challenge. The AUC values (with 95% confidence intervals) for SVV and PPV were 0.68 (0.52-0.83) and 0.72 (0.57-0.86), respectively, indicating low predictive capacity in these setting. The absolute values of SV derived from EV did not agree with SV derived from TEE. However, EV was able to track the direction of changes in SV during hemodynamic management of patients undergoing liver transplantation.Clinical trial registration: Clinicaltrials.gov Identifier: NCT03228329 prospectively Registered on 13-July-2017.
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Jun JH, Chung RK, Baik HJ, Chung MH, Hyeon JS, Lee YG, Park SH. The tidal volume challenge improves the reliability of dynamic preload indices during robot-assisted laparoscopic surgery in the Trendelenburg position with lung-protective ventilation. BMC Anesthesiol 2019; 19:142. [PMID: 31390982 PMCID: PMC6686427 DOI: 10.1186/s12871-019-0807-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/18/2019] [Indexed: 12/12/2022] Open
Abstract
Background The reliability of pulse pressure variation (PPV) and stroke volume variation (SVV) is controversial under pneumoperitoneum. In addition, the usefulness of these indices is being called into question with the increasing adoption of lung-protective ventilation using low tidal volume (VT) in surgical patients. A recent study indicated that changes in PPV or SVV obtained by transiently increasing VT (VT challenge) accurately predicted fluid responsiveness even in critically ill patients receiving low VT. We evaluated whether the changes in PPV and SVV induced by a VT challenge predicted fluid responsiveness during pneumoperitoneum. Methods We performed an interventional prospective study in patients undergoing robot-assisted laparoscopic surgery in the Trendelenburg position under lung-protective ventilation. PPV, SVV, and the stroke volume index (SVI) were measured at a VT of 6 mL/kg and 3 min after increasing the VT to 8 mL/kg. The VT was reduced to 6 mL/kg, and measurements were performed before and 5 min after volume expansion (infusing 6% hydroxyethyl starch 6 ml/kg over 10 min). Fluid responsiveness was defined as ≥15% increase in the SVI. Results Twenty-four of the 38 patients enrolled in the study were responders. In the receiver operating characteristic curve analysis, an increase in PPV > 1% after the VT challenge showed excellent predictive capability for fluid responsiveness, with an area under the curve (AUC) of 0.95 [95% confidence interval (CI), 0.83–0.99, P < 0.0001; sensitivity 92%, specificity 86%]. An increase in SVV > 2% after the VT challenge predicted fluid responsiveness, but showed only fair predictive capability, with an AUC of 0.76 (95% CI, 0.60–0.89, P < 0.0006; sensitivity 46%, specificity 100%). The augmented values of PPV and SVV following VT challenge also showed the improved predictability of fluid responsiveness compared to PPV and SVV values (as measured by VT) of 6 ml/kg. Conclusions The change in PPV following the VT challenge has excellent reliability in predicting fluid responsiveness in our surgical population. The change in SVV and augmented values of PPV and SVV following this test are also reliable. Trial registration This trial was registered with Clinicaltrials.gov, NCT03467711, 10th March 2018.
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Affiliation(s)
- Joo-Hyun Jun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, South Korea
| | - Rack Kyung Chung
- Department of Anesthesiology and Pain Medicine, Ewha Womans University, College of Medicine, Anyangcheon-ro, Yangcheon-gu, Seoul, 1071, South Korea.
| | - Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, Ewha Womans University, College of Medicine, Anyangcheon-ro, Yangcheon-gu, Seoul, 1071, South Korea
| | - Mi Hwa Chung
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, South Korea
| | - Joon-Sang Hyeon
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, South Korea
| | - Young-Goo Lee
- Department of Urology, Kangnam Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, South Korea
| | - Sung-Ho Park
- Department of Obstetrics and Gynecology, Kangnam Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, South Korea
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Quantitative Analysis of an Intraoperative Digitalized Esophageal Heart Sound Signal to Speculate on Perturbed Cardiovascular Function. J Clin Med 2019; 8:jcm8050715. [PMID: 31137509 PMCID: PMC6572513 DOI: 10.3390/jcm8050715] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/09/2019] [Accepted: 05/17/2019] [Indexed: 12/21/2022] Open
Abstract
Although visualization of heart sounds, known as phonocardiography, provides valuable information on cardiovascular hemodynamics, its use has not been widely encouraged due to the scarcity of information on its interpretation. In the present study, using the intraoperative phonocardiogram recorded by an esophageal stethoscope, we quantitatively evaluated the time and frequency domains of modulation of the heart sounds components and their association with left ventricular contractility and systemic vascular resistance under the effects of various cardiovascular drugs. We analyzed 29 pairs of intraoperative digitalized phonocardiographic signals and their corresponding hemodynamic data before and after cardiovascular drug administration (ephedrine, esmolol, phenylephrine, and/or nicardipine) in 17 patients who underwent liver transplantation. The S1 and S2 components of the heart sounds (the first and second heart sounds, respectively) were identified and their modulation in time and frequency domains was analyzed. As an index of cardiovascular function, systolic tissue Doppler wave velocity (TDI S'), maximal dP/dt from the arterial waveform, and systemic vascular resistance were simultaneously evaluated. Ephedrine/esmolol and phenylephrine/nicardipine primarily affected the S1 and S2 components of the heart sounds, respectively. This result implies that the intraoperative phonocardiogram may have the potential to be useful in detecting the changes in contractility and afterload that commonly occur in patients receiving anesthesia. In an era of constant need for noninvasive hemodynamic assessment, phonocardiography has the potential for use as a novel and informative tool for monitoring of hemodynamic function.
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Yassen AM. Pressure versus volume indices to guide fluid infusion early after living donor liver transplantation: A prospective randomized controlled trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2012.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Amr M. Yassen
- Department of Anesthesia and Intensive Care, Liver Transplantation Program , Gastroenterology Surgical Center , Mansoura University , Gehan Street , Mansoura, Egypt
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Park YS, Moon YJ, Kim SH, Kim JM, Song JG, Hwang GS. Beat-to-Beat Tracking of Pulse Pressure and Its Respiratory Variation Using Heart Sound Signal in Patients Undergoing Liver Transplantation. J Clin Med 2019; 8:jcm8050593. [PMID: 31052236 PMCID: PMC6572412 DOI: 10.3390/jcm8050593] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 04/23/2019] [Accepted: 04/29/2019] [Indexed: 11/16/2022] Open
Abstract
Purpose: To investigate the possibility of esophageal phonocardiography as a monitor for invasively measured pulse pressure (PP) and its respiratory variation (PPV) in patients undergoing liver transplantation. Methods: In 24 liver transplantation recipients, all hemodynamic parameters, including PP and PPV, were measured during five predetermined surgical phases. Simultaneously, signals of esophageal heart sounds (S1, S2) were identified, and S1–S2 interval (phonocardiographic systolic time, PST) and its respiratory variation (PSV) within a 20-s window were calculated. Beat-to-beat correlation between PP and its corresponding PST was assessed during each time window, according to the surgical phases. To compare PPV and PSV along with 5 phases (a total of 120 data pairs), Pearson correlation was conducted. Results: Beat-to-beat PST values were closely correlated with their corresponding 3360 pairs of PP values (median r = 0.568 [IQR 0.246–0.803]). Compared with the initial phase of surgery, correlation coefficients were significantly lower during the reperfusion period (median r = 0.717 [IQR 0.532–0.886] vs. median r = 0.346 [IQR 0.037–0.677]; p = 0.002). The correlation between PSV and PPV showed similar variation according to the surgical phases (r = 0.576 to 0.689, p < 0.05, for pre-reperfusion; 0.290 to 0.429 for the post-reperfusion period). Conclusions: Continuous monitoring of intraoperative PST with an esophageal stethoscope has the potential to act as an indirect estimator of beat-to-beat arterial PP. Moreover, PSV appears to exhibit a trend similar to that of PPV with moderate accuracy. However, variation according to the surgical phase limits the merit of the current results, thereby necessitating cautious interpretation.
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Messina A, Pelaia C, Bruni A, Garofalo E, Bonicolini E, Longhini F, Dellara E, Saderi L, Romagnoli S, Sotgiu G, Cecconi M, Navalesi P. Fluid Challenge During Anesthesia. Anesth Analg 2018; 127:1353-1364. [DOI: 10.1213/ane.0000000000003834] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Prediction of Fluid Responsiveness by a Non-invasive Respiratory Systolic Time Interval Variation Using Heart Sound Signals in Recipients Undergoing Liver Transplantation. Transplant Proc 2018; 49:1082-1086. [PMID: 28583532 DOI: 10.1016/j.transproceed.2017.03.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The fluid management of cirrhotic patients undergoing liver transplantation (LT) is challenging. Phonocardiography, a graphic recording of heart sounds, provides valuable information concerning heart function and hemodynamic condition. We assessed whether the systolic time interval (STI) and its respiratory variation could predict fluid responsiveness in cirrhotic patients undergoing LT. METHODS Thirty LT recipients who needed volume expansion were included. The fluid challenge consisted of 500 mL 5% albumin administered over a period of 10 minutes. STI was measured as the time interval between the maximal amplitude of each heart sound corrected with the corresponding RR interval (cSTI). The respiratory variation in STI (STV) induced by mechanical ventilation was calculated. Responders were defined as those showing a ≥10% increase in stroke volume index after volume expansion. RESULTS In all, 14 of the 30 patients were responders. Significant increases in cSTI were observed after volume expansion in both responders (P < .001) and non-responders (P = .008). Responders showed significant decreases in STV (11.1% ± 4.3% vs 6.1% ± 2.6%, P < .001) after fluid loading, whereas STV in non-responders remained unchanged (6.4% ± 2.6% vs 6.4% ± 4.2%, P = .86). A cut-off value of ≥7.5% STV from baseline could predict fluid responsiveness with an area under the receiver operating characteristic curve of 0.804 (95% confidence interval, 0.618-0.925). CONCLUSIONS Intra-operative STV can predict fluid responsiveness in patients undergoing LT. Beat-to-beat monitoring of STI and STV may be useful as a non-invasive hemodynamic index and for fluid management.
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Liu Y, Lou JS, Mi WD, Yuan WX, Fu Q, Wang M, Qu J. Pulse pressure variation shows a direct linear correlation with tidal volume in anesthetized healthy patients. BMC Anesthesiol 2016; 16:75. [PMID: 27609188 PMCID: PMC5017055 DOI: 10.1186/s12871-016-0233-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 08/24/2016] [Indexed: 01/20/2023] Open
Abstract
Background The settings of mechanical ventilation, like tidal volume (VT), occasionally need to be adjusted in the process of anesthesia for some special reasons. The aim of this study was therefore to assess the relationship between pulse pressure variations (PPVs) in different settings of VT in anesthetized healthy patients under mechanical ventilation. Methods Sixty nine ASA I-II patients scheduled for gastrointestinal surgery under general anesthesia were included in this prospective study. All the patients were ventilated at a VT of 6, 8 or 10 ml/kg (predicted body weight) with no positive end expiratory pressure (PEEP) in a random order after intubation. PPV, mean arterial blood pressure, and other hemodynamic and respiratory parameters were recorded in each VT setting respectively after Partial Pressure of End-Tidal Expiration Carbon Dioxide (PetCO2) maintained between 30 mmHg and 40 mmHg by changing Respiratory Rate (RR) before incision. Results The values of PPV at different settings of VT showed a tight correlation between each other (6 vs. 8 ml/kg: r = 0.97, P < 0.0001; 6 vs.10 ml/kg: r = 0.95, P < 0.0001; 8 vs. 10 ml/kg: r = 0.98, P < 0.0001, respectively). Conclusion There is a direct linear correlation between PPVs at different tidal volumes in anesthetized ASA I-II patients. PPV in any of the 3 VT settings (6, 8 or 10 ml/kg) can deduce that in any other 2 settings. Further studies are needed to explore the effect of intraoperative confounders for this knowledge to be clinically applied. Trial registration NCT01950949, www.clinicaltrials.gov, July 26, 2013.
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Affiliation(s)
- Yi Liu
- Anesthesiology and Operation Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Jing-Sheng Lou
- Anesthesiology and Operation Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Wei-Dong Mi
- Anesthesiology and Operation Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Wei-Xiu Yuan
- Anesthesiology and Operation Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Qiang Fu
- Anesthesiology and Operation Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Min Wang
- Department of Anesthesiology, Beijing Tongren hospital, Capital Medical University, Beijing, 100041, China
| | - Jing Qu
- Graduate School, Xuzhou Medical College, Xuzhou, 221004, Jiangsu Province, China
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Predicting stroke volume and arterial pressure fluid responsiveness in liver cirrhosis patients using dynamic preload variables. Eur J Anaesthesiol 2016; 33:645-52. [DOI: 10.1097/eja.0000000000000479] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Konur H, Erdogan Kayhan G, Toprak HI, Bucak N, Aydogan MS, Yologlu S, Durmus M, Yılmaz S. Evaluation of pleth variability index as a predictor of fluid responsiveness during orthotopic liver transplantation. Kaohsiung J Med Sci 2016; 32:373-80. [PMID: 27450027 DOI: 10.1016/j.kjms.2016.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/18/2016] [Accepted: 05/25/2016] [Indexed: 11/17/2022] Open
Abstract
Fluid management is challenging and still remains controversial in orthotopic liver transplantation (OLT). The pleth variability index (PVI) has been shown to be a reliable predictor of fluid responsiveness of perioperative and critically ill patients; however, it has not been evaluated in OLT. This study was designed to examine whether the PVI can reliably predict fluid responsiveness in OLT and to compare PVI with other hemodynamic indexes that are measured using the PiCCO2 monitoring system. Twenty-five patients were enrolled in this study. Each patient was monitored using the noninvasive Masimo and PiCCO2 monitoring system. PVI was obtained with a Masimo pulse oximeter. Cardiac index was obtained using a transpulmonary thermodilution technique (CITPTD). Stroke volume variation (SVV), pulse pressure variation, and systemic vascular resistance index were measured using the PiCCO2 system. Fluid loading (10 mL/kg colloid) was performed at two different phases during the operation, and fluid responsiveness was defined as an increase in CITPTD ≥ 15%. During the dissection phase and the anhepatic phase, respectively, 14 patients (56%) and 18 patients (75%) were classified as responders. There were no differences between the baseline values of the PVI of responders and nonresponders. Area under the curve for PVI was 0.56 (sensitivity 35%, specificity 90%, p = 0.58) at dissection phase, and was 0.55 (sensitivity 55%, specificity 66%, p = 0.58) at anhepatic phase. Of the parameters, a higher area under the curve value was found for SVV. We conclude that PVI was unable to predict fluid responsiveness with sufficient accuracy in patients undergoing OLT, but the SVV parameter was reliable.
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Affiliation(s)
- Huseyin Konur
- Department of Anesthesiology and Reanimation, Goztepe Education and Research Hospital, Medeniyet University, Istanbul, Turkey
| | - Gulay Erdogan Kayhan
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey.
| | - Huseyin Ilksen Toprak
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey
| | - Nizamettin Bucak
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey
| | - Mustafa Said Aydogan
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey
| | - Saim Yologlu
- Department of Biostatistics, Inonu University Medical Faculty, Malatya, Turkey
| | - Mahmut Durmus
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey
| | - Sezai Yılmaz
- Department of General Surgery, Inonu University Medical Faculty, Malatya, Turkey
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Cleland S, Corredor C, Ye JJ, Srinivas C, McCluskey SA. Massive haemorrhage in liver transplantation: Consequences, prediction and management. World J Transplant 2016; 6:291-305. [PMID: 27358774 PMCID: PMC4919733 DOI: 10.5500/wjt.v6.i2.291] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 03/16/2016] [Accepted: 04/11/2016] [Indexed: 02/05/2023] Open
Abstract
From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity (need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both pro- and anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shown improvements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.
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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
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Alvarado-Sánchez JI. Prueba de elevación de piernas pasiva. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: https://doi.org/10.1016/j.rca.2015.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Alvarado-Sánchez JI. The passive leg raising test (PLR). COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2015.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth 2014; 62:158-68. [DOI: 10.1007/s12630-014-0266-y] [Citation(s) in RCA: 161] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 10/28/2014] [Indexed: 12/13/2022] Open
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van Lavieren M, Veelenturf J, Hofhuizen C, van der Kolk M, van der Hoeven J, Pickkers P, Lemson J, Lansdorp B. Dynamic preload indicators decrease when the abdomen is opened. BMC Anesthesiol 2014; 14:90. [PMID: 25337036 PMCID: PMC4203872 DOI: 10.1186/1471-2253-14-90] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 10/03/2014] [Indexed: 01/17/2023] Open
Abstract
Background Optimizing cardiac stroke volume during major surgery is of interest to many as a therapeutic target to decrease the incidence of postoperative complications. Because dynamic preload indicators are strongly correlated with stroke volume, it is suggested that these indices can be used for goal directed fluid therapy. However, threshold values of these indicators depend on many factors that are influenced by surgery, including opening of the abdomen. The aim of this study was therefore to assess the effect of opening the abdomen on arterial pressure variations in patients undergoing abdominal surgery. Methods Blood pressure and bladder pressure were continuously recorded just before and after opening of the abdomen in patients undergoing elective laparotomy. Based on waveform analysis of the non-invasively derived blood pressure, the stroke volume index, pulse pressure variation (PPV) and stroke volume variation (SVV) were calculated off-line. Results Thirteen patients were included. After opening the abdomen, PPV and SVV decreased from 11.5 ± 5.8% to 6.4 ± 2.9% (p < 0.005, a relative decrease of 40 ± 19%) and 12.7 ± 6.1% to 4.8 ± 1.6% (p < 0.05, a relative decrease of 53 ± 26%), respectively. Although mean arterial pressure and stroke volume index tended to increase (41 ± 6 versus 45 ± 4 ml/min/m2, p = 0.14 and 41 ± 6 versus 45 ± 4 ml/min/m2, p = 0.05), and heart rate tended to decrease (73 ± 15 versus 68 ± 11 1/min, p = 0.05), no significant change was found. No significant change was found in respiratory parameter (tidal volume, respiratory rate or inspiratory pressure; p = 0.36, 0.34 and 0.17, respectively) or bladder pressure (6.0 ± 3.7 versus 5.6 ± 2.7 mmHg, p = 0.6) either. Conclusions Opening of the abdomen decreases PPV and SVV. During goal directed therapy, current thresholds for fluid responsiveness should be changed accordingly.
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Affiliation(s)
- Martijn van Lavieren
- University of Twente, MIRA - Institute for Biomedical Technology and Technical Medicine, PO box 217, Enschede, 7500 AE The Netherlands
| | - Jeroen Veelenturf
- University of Twente, MIRA - Institute for Biomedical Technology and Technical Medicine, PO box 217, Enschede, 7500 AE The Netherlands
| | - Charlotte Hofhuizen
- Department of Anaesthesiology, Radboud university medical center, PO Box 9101, Nijmegen, 6500 HB The Netherlands
| | - Marion van der Kolk
- Department of Surgery, Radboud university medical center, PO Box 9101, Nijmegen, 6500 HB The Netherlands
| | - Johannes van der Hoeven
- Department of Intensive Care, Radboud university medical center, PO Box 9101, Nijmegen, 6500 HB The Netherlands
| | - Peter Pickkers
- Department of Intensive Care, Radboud university medical center, PO Box 9101, Nijmegen, 6500 HB The Netherlands
| | - Joris Lemson
- Department of Intensive Care, Radboud university medical center, PO Box 9101, Nijmegen, 6500 HB The Netherlands
| | - Benno Lansdorp
- University of Twente, MIRA - Institute for Biomedical Technology and Technical Medicine, PO box 217, Enschede, 7500 AE The Netherlands ; Department of Intensive Care, Radboud university medical center, PO Box 9101, Nijmegen, 6500 HB The Netherlands
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Pei S, Yuan W, Mai H, Wang M, Hao C, Mi W, Fu Q. Efficacy of dynamic indices in predicting fluid responsiveness in patients with obstructive jaundice. Physiol Meas 2014; 35:369-82. [PMID: 24499723 DOI: 10.1088/0967-3334/35/3/369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Previous studies have shown that the stroke volume variation (SVV), the pulse pressure variation (PPV) and the pleth variability index (PVI) could be successfully used for predicting fluid responsiveness (FR) in surgical patients. The aim of this study was to validate the ability of SVV, PPV and PVI to predict intraoperative FR in mechanically ventilated patients with obstructive jaundice (OJ). Thirty-two patients with OJ (mean serum total bilirubin 190.5 ± 95.3 µmol L(-1)) received intraoperative volume expansion (VE) with 250 ml colloids immediately after an exploratory laparotomy had been completed and after a 5 min period of hemodynamic stability. Hemodynamic variables were recorded before and after VE. FR was defined as an increase in stroke volume index > 10% after VE. The ability of SVV, PPV and PVI to predict FR was assessed by calculation of the area under the receiver operating characteristic curve. Eleven (34%) patients were responders and 21 patients were nonresponders to VE. The PPV was the unique dynamic index that had the moderate ability to predict FR during surgical procedures, the area under the curve was 0.71 (95% CI, 0.523 to 0.856; P = 0.039) and the threshold (sensitivity and specificity) discriminated responders was 7.5% (63.6%/71.4%). The present study concluded that SVV and PVI were not reliable predictors of FR, but PPV has some value predicting FR in patients with OJ intraoperatively.
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Affiliation(s)
- Shujun Pei
- Anesthesia and Operation Center, Chinese People's Liberation Army General Hospital & Medical School of Chinese People's Liberation Army, Beijing 100853, People's Republic of China. Department of Anesthesiology, 251 Hospital of Chinese People's Liberation Army, Zhangjiakou 075000, People's Republic of China
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Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R191. [PMID: 24010849 PMCID: PMC4057030 DOI: 10.1186/cc12885] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 08/02/2013] [Indexed: 12/30/2022]
Abstract
Introduction Several single-center studies and meta-analyses have shown that perioperative goal-directed therapy may significantly improve outcomes in general surgical patients. We hypothesized that using a treatment algorithm based on pulse pressure variation, cardiac index trending by radial artery pulse contour analysis, and mean arterial pressure in a study group (SG), would result in reduced complications, reduced length of hospital stay and quicker return of bowel movement postoperatively in abdominal surgical patients, when compared to a control group (CG). Methods 160 patients undergoing elective major abdominal surgery were randomized to the SG (79 patients) or to the CG (81 patients). In the SG hemodynamic therapy was guided by pulse pressure variation, cardiac index trending and mean arterial pressure. In the CG hemodynamic therapy was performed at the discretion of the treating anesthesiologist. Outcome data were recorded up to 28 days postoperatively. Results The total number of complications was significantly lower in the SG (72 vs. 52 complications, p = 0.038). In particular, infection complications were significantly reduced (SG: 13 vs. CG: 26 complications, p = 0.023). There were no significant differences between the two groups for return of bowel movement (SG: 3 vs. CG: 2 days postoperatively, p = 0.316), duration of post anesthesia care unit stay (SG: 180 vs. CG: 180 minutes, p = 0.516) or length of hospital stay (SG: 11 vs. CG: 10 days, p = 0.929). Conclusions This multi-center study demonstrates that hemodynamic goal-directed therapy using pulse pressure variation, cardiac index trending and mean arterial pressure as the key parameters leads to a decrease in postoperative complications in patients undergoing major abdominal surgery. Trial registration ClinicalTrial.gov, NCT01401283.
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Intraoperative predictors of short-term mortality in living donor liver transplantation due to acute liver failure. Transplant Proc 2013; 45:236-40. [PMID: 23375307 DOI: 10.1016/j.transproceed.2012.06.077] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 05/23/2012] [Accepted: 06/19/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Acute liver failure (ALF) is a rare and fatal disease with rapidly deteriorating clinical features. Many predictive models for ALF outcomes have been tested, but none have been adopted as definitive guidelines for prognosis because of inconsistencies in accuracy. Most prognostic models for ALF are based on preoperative patient conditions, thus ignoring various specific intraoperative features relevant to postoperative outcomes. We investigated whether intraoperative factors predicted short-term mortality due to ALF in living donor liver transplantations (LDLT). METHODS We retrospectively collected intraoperative data, including surgical time, fluctuations in mean blood pressure (MBP) and heart rate, mean pulmonary arterial pressure (PAP), central venous pressure (CVP), urine output, laboratory data, oxygen indices (PaO(2)/FiO(2)), administered drugs, and transfusion of packed red blood cells (PRBCs) from 101 patients with ALF who underwent LDLT. After simple relationships of individual intraoperative variables with 1-month posttransplant mortality were analyzed, we examined potentially significant intraoperative variables (P < .10) by a multivariate adjustment process with preoperative indicators of ALF prognosis. RESULTS Intraoperative MBP fluctuations, first mean PAP and CVP, last oxygen index, administered calcium chloride, and PRBC transfusion showed individual associations with posttransplant mortality of ALF patients (P < .05). After multivariate adjustment, PRBC transfusion of ≥ 10 pints (odds ratio 4.73; 95% confidence interval [CI] 1.06-21.16) and MBP fluctuations (odds ratio 1.26; 95% CI 1.00-1.58) were identified to be independent predictors of 1-month posttransplant mortality, together with preoperative factors, including severe hepatic encephalopathy, and a Model for End-stage Liver Disease score ≥ 30 points (area under the curve 0.82, P < .001). CONCLUSION MBP fluctuations and large blood transfusions were intraoperative predictors of short-term mortality after LDLT due to ALF. Increased attention to intraoperative manifestations should provide valuable prognostic information for ALF.
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Effect of pulse pressure on the predictability of stroke volume variation for fluid responsiveness in patients with coronary disease. J Crit Care 2013; 28:318.e1-7. [DOI: 10.1016/j.jcrc.2012.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 09/03/2012] [Accepted: 09/07/2012] [Indexed: 01/08/2023]
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Gouveia V, Marcelino P, Reuter DA. The role of transesophageal echocardiography in the intraoperative period. Curr Cardiol Rev 2013; 7:184-96. [PMID: 22758616 PMCID: PMC3263482 DOI: 10.2174/157340311798220511] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 02/18/2011] [Accepted: 02/21/2011] [Indexed: 12/17/2022] Open
Abstract
The goal of hemodynamic monitoring and management during major surgery is to guarantee adequate organ perfusion, a major prerequisite for adequate tissue oxygenation and thus, end-organ function. Further, hemodynamic monitoring should serve to prevent, detect, and to effectively guide treatment of potentially life-threatening hemodynamic events, such as severe hypovolemia due to hemorrhage, or cardiac failure. The ideal monitoring device does not exist, but some conditions must be met: it should be easy and operator-independently to use; it should provide adequate, reproducible information in real time. In this review we discuss in particular the role of intraoperative use of transesophageal echocardiography (TOE). Although TOE has gained special relevance in cardiac surgery, its role in major non cardiac surgery is still to be determined. We particularly focus on its ability to provide measurements of cardiac output (CO), and its role to guide fluid therapy. Within the last decade, concepts oriented on optimizing stroke volume and cardiac output mainly by fluid administration and guided by continuous monitoring of cardiac output or so called functional parameters of cardiac preload gained particular attention. Although they are potentially linked to an increased amount of fluid infusion, recent data give evidence that such pre-emptive concepts of hemodynamic optimization result in a decrease in morbidity and mortality. As TOE allows a real time direct visualization of cardiac structures, other potentially important advantages of its use also outside the cardiac surgery operation room can be postulated, namely the ability to evaluate the anatomical and functional integrity of the left and the right heart chambers. Finally, a practical approach to TOE monitoring is presented, based on a local experience.
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Affiliation(s)
- Veronica Gouveia
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Itzehoe, Germany.
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Perel A, Habicher M, Sander M. Bench-to-bedside review: functional hemodynamics during surgery - should it be used for all high-risk cases? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:203. [PMID: 23356477 PMCID: PMC4056316 DOI: 10.1186/cc11448] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The administration of a fluid bolus is done frequently in the perioperative period to increase the cardiac output. Yet fluid loading fails to increase the cardiac output in more than 50% of critically ill and surgical patients. The assessment of fluid responsiveness (the slope of the left ventricular function curve) prior to fluid administration may thus not only help in detecting patients in need of fluids but may also prevent unnecessary and harmful fluid overload. Unfortunately, commonly used hemodynamic parameters, including the cardiac output itself, are poor predictors of fluid responsiveness, which is best assessed by functional hemodynamic parameters. These dynamic parameters reflect the response of cardiac output to a preload-modifying maneuver (for example, a mechanical breath or passive leg-raising), thus providing information about fluid responsiveness without the actual administration of fluids. All dynamic parameters, which include the respiratory variations in systolic blood pressure, pulse pressure, stroke volume and plethysmographic waveform, have been repeatedly shown to be superior to commonly used static preload parameters in predicting the response to fluid loading. Within their respective limitations, functional hemodynamic parameters should be used to guide fluid therapy as part of or independently of goal-directed therapy strategies in the perioperative period.
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HØISETH LØ, HOFF IE, MYRE K, LANDSVERK SA, KIRKEBØEN KA. Dynamic variables of fluid responsiveness during pneumoperitoneum and laparoscopic surgery. Acta Anaesthesiol Scand 2012; 56:777-86. [PMID: 22288953 DOI: 10.1111/j.1399-6576.2011.02641.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2011] [Indexed: 01/02/2023]
Abstract
BACKGROUND Few data exist on dynamic variables predicting fluid responsiveness during laparoscopic surgery. The aim of this study was to explore the effects of laparoscopy on four dynamic variables: respiratory variations in pulse pressure (ΔPP), stroke volume variation by Vigileo/FloTrac (SVV (Vigileo) ), pleth variability index (PVI) and respiratory variations in pulse oximetry plethysmography waveform amplitude (ΔPOP), and their relation to fluid challenges during laparoscopic surgery. METHODS ΔPP, SVV (Vigileo) , PVI and ΔPOP were studied in 20 adult patients before and during pneumoperitoneum (10-12 mmHg). During ongoing laparoscopic surgery, relations between the dynamic variables and changes in stroke volume oesophageal Doppler, (SV(OD) ) after fluid challenges (250 ml colloid) were evaluated. RESULTS Pneumoperitoneum changed the dynamic variables as follows {mean [95% confidence interval (CI)]}: ΔPP 0.5 (-1.3, 2.3)%, P = 0.53; SVV (Vigileo) 0.6 (-1.3, 2.5)%, P = 0.52; PVI 2.9 (0.4, 5.3)%, P = 0.025. For ΔPOP, median difference (95% CI) was 2.5 (-0.15, 6.7)%, P = 0.058. During laparoscopic surgery, areas under receiver operating characteristics curves (95% CI) were ΔPP 0.53 (0.31-0.75), SVV (Vigileo) 0.74 (0.51-0.90), PVI 0.61 (0.38-0.81), ΔPOP 0.63 (0.40-0.82). Correlation coefficients (P-values) between changes in dynamic variables and changes in SV(OD) were ΔPP r = -0.65, P = 0.009; SVV (Vigileo) r = -0.73, P = 0.002; PVI r = -0.22, P = 0.44; ΔPOP r = -0.32, P = 0.24. CONCLUSION ΔPP and SVV (Vigileo) did not change as pneumoperitoneum was established, whereas PVI increased and ΔPOP tended to increase. All four dynamic variables predicted fluid responsiveness relatively poor during ongoing laparoscopic surgery. ΔPP and SVV (Vigileo) tracked changes in stroke volume induced by fluid challenges during ongoing laparascopic surgery, whereas ΔPOP and PVI did not.
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Affiliation(s)
| | | | - K. MYRE
- Department of Anaesthesiology; Oslo University Hospital; Oslo; Norway
| | - S. A. LANDSVERK
- Department of Anaesthesiology; Oslo University Hospital; Oslo; Norway
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Rinehart J, Islam T, Boud R, Nguyen A, Alexander B, Canales C, Cannesson M. Visual estimation of pulse pressure variation is not reliable: a randomized simulation study. J Clin Monit Comput 2012; 26:191-6. [PMID: 22491961 DOI: 10.1007/s10877-012-9359-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 03/28/2012] [Indexed: 01/28/2023]
Abstract
Pulse pressure variation (PPV) can be monitored several ways, but according to recent survey data it is most often visually estimated ("eyeballed") by practitioners. It is not known how accurate visual estimation of PPV is, or whether eyeballing of PPV in goal-directed fluid therapy studies may limit the ability to blind the control group to PPV value. The goal of this study was to test the accuracy of visual estimation of PPV. Using a simulator program designed by the authors that runs on a PC, 20 residents and 19 attendings were shown five arterial pressure waveforms each with different PPV values (range 1-30 %) moving at one of three sweep speeds (6.25, 12.5, or 25 mm/s) and asked to determine the PPV. There was a weak but significant relationship between true PPV and eyeball PPV (r (2) = 0.22; p < 0.01). The agreement between true PPV and eyeball PPV was 3.3 ± 8.7 %. The mean percent error was 122 %. The rate of correct response group classification was 65 %. Mean percent error was higher the faster the waveform sweep speed (130 % at 25 mm/s vs. 117 % at 6.25 mm/s), and correct responsiveness classification lower (58 % at 25 mm/s vs. 69 % at 6.25 mm/s). The results from this study show that eyeballing the arterial pressure waveform in order to evaluate pulse pressure variation is not accurate.
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Affiliation(s)
- Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, CA 92868, USA.
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Woo YC. What is your strategy for fluid management? Korean J Anesthesiol 2012; 62:307-8. [PMID: 22558494 PMCID: PMC3337374 DOI: 10.4097/kjae.2012.62.4.307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Young-Cheol Woo
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, Seoul, Korea
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Cannesson M, de Backer D, Hofer CK. Using arterial pressure waveform analysis for the assessment of fluid responsiveness. Expert Rev Med Devices 2012; 8:635-46. [PMID: 22026628 DOI: 10.1586/erd.11.30] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Predicting the effects of volume expansion on cardiac output and oxygen delivery is of major importance in different clinical scenarios. Functional hemodynamic parameters based on pulse waveform analysis, which are relying on the effects of mechanical ventilation on stroke volume and its surrogates, have been shown to be reliable predictors of fluid responsiveness during anesthesia and intensive care unit treatment, as demonstrated by several clinical studies and meta-analyses. However, different limitations of these parameters have to be considered when they are used in clinical practice. Today, they can be continuously and automatically monitored by a variety of commercially available devices. These parameters have been introduced into the concept of perioperative fluid management and hemodynamic optimization - an approach that may positively impact postoperative patients' outcomes. In this article, technical aspects of the assessment of the functional hemodynamic parameters derived from pulse waveform analysis are summarized, emphasizing their advantages, limitations and potential applications, primarily in a perioperative setting in order to improve patient outcome.
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Affiliation(s)
- Maxime Cannesson
- Department of Anesthesiology & Perioperative Care, School of Medicine, University of California, Irvine, CA, USA.
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Rando K, Niemann CU, Taura P, Klinck J. Optimizing cost-effectiveness in perioperative care for liver transplantation: a model for low- to medium-income countries. Liver Transpl 2011; 17:1247-78. [PMID: 21837742 DOI: 10.1002/lt.22405] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although liver transplantation (LT) is a highly effective treatment, it has been considered too costly for publicly funded health systems in many countries with low to medium average incomes. However, with economic growth and improving results, some governments are reconsidering this position. Cost-effectiveness data for LT are limited, especially in perioperative care, and the techniques and costs vary widely between centers without overt differences in outcomes. Anesthesiologists working in new programs find it difficult to determine which modalities are essential, which are needed only in exceptional circumstances, and which may be omitted without effects on outcomes. We investigated key elements of preoperative evaluations, intraoperative management, and early postoperative care that might significantly affect costs in order to develop a best-value approach for new programs in resource-limited health systems. We identified all modalities of care commonly used in anesthesia and perioperative care for adult LT along with their costs. Those considered to be universally accepted as minimum requirements for safe care were excluded from the analysis, and so were those considered to be safe and low-cost, even when evidence of efficacy was lacking. The remaining items were, therefore, those with uncertain or context-restricted value and significant costs. A systematic review of the published evidence, practice surveys, and institutional guidelines was performed, and the evidence was graded and summarized. With respect to costs and benefits, each modality was then cited as strongly recommended, recommended or optional, or no recommendation was made because of insufficient evidence. Sixteen modalities, which included preoperative cardiovascular imaging, venovenous bypass, pulmonary artery catheterization, high-flow fluid warming devices, drug therapies for hemostasis, albumin, cell salvage, anesthetic drugs, personnel (staffing) requirements, and early extubation, were assessed. Only high-flow fluid warming was strongly recommended. The recommended modalities included preoperative echocardiography, cell salvage, tranexamic acid and early extubation. Six others were rated optional, and there was insufficient evidence for 5 modalities. We conclude that some costly techniques and treatments can be omitted without adverse effects on outcomes.
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Affiliation(s)
- Karina Rando
- Department of Hepatic Diseases, Military Hospital, Montevideo, Uruguay
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HØISETH LØ, HOFF IE, SKARE Ø, KIRKEBØEN KA, LANDSVERK SA. Photoplethysmographic and pulse pressure variations during abdominal surgery. Acta Anaesthesiol Scand 2011; 55:1221-30. [PMID: 22092127 DOI: 10.1111/j.1399-6576.2011.02527.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2011] [Indexed: 01/21/2023]
Abstract
BACKGROUND Respiratory variations in pulse pressure (ΔPP) predict fluid responsiveness during mechanical ventilation. Variations in pulse oximetry plethysmography amplitude (ΔPOP) are proposed as a non-invasive alternative. Large variations in ΔPOP and poor agreement between ΔPP and ΔPOP are found in intensive care unit patients. General anaesthesia is suggested to reduce variability of ΔPOP and improve agreement between the variables. We evaluated the variability of the agreement between and the diagnostic values of ΔPP and ΔPOP during ongoing open abdominal surgery. The variability of diagnostic methods in specific clinical conditions is important, as this reflects the stability over time during which clinical decisions are made. METHODS Observational study during open abdominal surgery in general anaesthesia. ΔPP and ΔPOP were calculated semi-automatically from recording periods of approximately 5 min both before and after fluid challenges. Fluid responsiveness was evaluated by changes in stroke volume (oesophageal Doppler) after 250 ml colloid. RESULTS Thirty-four fluid challenges were performed in 25 patients. Variance both within registration periods and between patients were significantly larger for ΔPOP than for ΔPP (54.1% vs. 22.1% and 69.6% vs. 22.6%, respectively, both P < 0.001). Limits of agreement with a regression-based correction were ± 13.9%. Areas under receiver operating characteristics curves for fluid responsiveness were 0.67 for ΔPP and 0.72 for ΔPOP. CONCLUSIONS Analysis of raw signals during open abdominal surgery documents that the variance of ΔPOP is larger than of ΔPP, with wide limits of agreement between ΔPP and ΔPOP. The diagnostic values of ΔPP and ΔPOP are relatively poor.
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Affiliation(s)
| | - I. E. HOFF
- Department of Anaesthesiology; Oslo University Hospital; Oslo; Norway
| | | | | | - S. A. LANDSVERK
- Department of Anaesthesiology; Oslo University Hospital; Oslo; Norway
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Shin YH, Ko JS, Gwak MS, Kim GS, Lee JH, Lee SK. Utility of uncalibrated femoral stroke volume variation as a predictor of fluid responsiveness during the anhepatic phase of liver transplantation. Liver Transpl 2011; 17:53-9. [PMID: 21254345 DOI: 10.1002/lt.22186] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
We evaluated the value of the stroke volume variation (SVV) calculated with the Vigileo monitor, which recently has been increasingly advocated for fluid management, as a predictor of fluid responsiveness during the anhepatic phase of liver transplantation (LT). We also compared SVV to the central venous pressure (CVP) and pulmonary arterial occlusion pressure (PAOP) in patients. Thirty-three adult recipients scheduled for elective living donor LT were enrolled in this study. Twenty minutes after the start of the anhepatic phase, the CVP, PAOP, approximate inferior vena caval pressure, femoral SVV, and cardiac output values were measured before and 12 minutes after fluid loading. Fluid loading was performed with a 6% hydroxyethyl starch solution (10 mL/kg). The responders were defined as patients whose cardiac index increased ≥ 15% after fluid loading. Receiver operating characteristic (ROC) analysis showed that only femoral SVV (area under the curve = 0.894, P = 0.0001) could be used to predict fluid responsiveness during the anhepatic phase of LT. The area under the ROC curve for femoral SVV was 0.894 (P = 0.0001), and it was significantly larger than those for CVP (area under the curve = 0.576, P = 0.004) and PAOP (area under the curve = 0.670, P = 0.021). Femoral SVV >8% identified the responders with a sensitivity of 89% and a specificity of 80%. Our results suggest that femoral SVV derived with the Vigileo monitor would be useful for fluid management during the anhepatic phase in LT recipients.
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Affiliation(s)
- Young Hee Shin
- Department of Anesthesiology and Pain Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
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Cannesson M, Vallet B, Michard F. Pulse pressure variation and stroke volume variation: from flying blind to flying right? Br J Anaesth 2009; 103:896-7; author reply 897-9. [DOI: 10.1093/bja/aep321] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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