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Denault A, Couture EJ, Perry T, Saade E, Calderone A, Zeng YH, Scherb D, Moses K, Potes C, Hammoud A, Beaubien-Souligny W, Elmi-Sarabi M, Grønlykke L, Lamarche Y, Lebon JS, Rousseau-Saine N, Desjardins G, Rochon A. Continuous Right Ventricular Pressure Monitoring in Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:1673-1682. [PMID: 38862285 DOI: 10.1053/j.jvca.2024.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/10/2024] [Accepted: 04/19/2024] [Indexed: 06/13/2024]
Abstract
OBJECTIVE Right ventricular (RV) dysfunction in cardiac surgery can lead to RV failure, which is associated with increased morbidity and mortality. Abnormal RV function can be identified using RV pressure monitoring. The primary objective of the study is to determine the proportion of patients with abnormal RV early to end-diastole diastolic pressure gradient (RVDPG) and abnormal RV end-diastolic pressure (RVEDP) before initiation and after cardiopulmonary bypass (CPB) separation. The secondary objective is to evaluate if RVDPG before CPB initiation is associated with difficult and complex separation from CPB, RV dysfunction, and failure at the end of cardiac surgery. DESIGN Prospective study. SETTING Tertiary care cardiac institute. PARTICIPANTS Cardiac surgical patients. INTERVENTION Cardiac surgery. MEASUREMENTS AND MAIN RESULTS Automated electronic quantification of RVDPG and RVEDP were obtained. Hemodynamic measurements were correlated with cardiac and extracardiac parameters from transesophageal echocardiography and postoperative complications. Abnormal RVDPG was present in 80% of the patients (n = 105) at baseline, with a mean RVEDP of 14.2 ± 3.9 mmHg. Patients experienced an RVDPG > 4 mmHg for a median duration of 50.2% of the intraoperative period before CPB initiation and 60.6% after CPB separation. A total of 46 (43.8%) patients had difficult/complex separation from CPB, 18 (38.3%) patients had RV dysfunction, and 8 (17%) had RV failure. Abnormal RVDPG before CPB was not associated with postoperative outcome. CONCLUSION Elevated RVDPG and RVEDP are common in cardiac surgery. RVDPG and RVEDP before CPB initiation are not associated with RV dysfunction and failure but can be used to diagnose them.
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Affiliation(s)
- André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Etienne J Couture
- Department of Anesthesiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Tjorvi Perry
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Elena Saade
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Yu Hao Zeng
- Departments of Medicine and of Family Medicine, Jewish General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | | | - Ali Hammoud
- Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | | | - Mahsa Elmi-Sarabi
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Lars Grønlykke
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Yoan Lamarche
- Department of Cardiothoracic Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-Sébastien Lebon
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Nicolas Rousseau-Saine
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Georges Desjardins
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Antoine Rochon
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
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2
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Moll V, Khanna AK, Kurz A, Huang J, Smit M, Swaminathan M, Minear S, Parr KG, Prabhakar A, Zhao M, Malbrain MLNG. Optimization of kidney function in cardiac surgery patients with intra-abdominal hypertension: expert opinion. Perioper Med (Lond) 2024; 13:72. [PMID: 38997752 PMCID: PMC11245849 DOI: 10.1186/s13741-024-00416-5] [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: 12/28/2023] [Accepted: 06/09/2024] [Indexed: 07/14/2024] Open
Abstract
Cardiac surgery-associated acute kidney injury (CSA-AKI) affects up to 42% of cardiac surgery patients. CSA-AKI is multifactorial, with low abdominal perfusion pressure often overlooked. Abdominal perfusion pressure is calculated as mean arterial pressure minus intra-abdominal pressure (IAP). IAH decreases cardiac output and compresses the renal vasculature and renal parenchyma. Recent studies have highlighted the frequent occurrence of IAH in cardiac surgery patients and have linked the role of low perfusion pressure to the occurrence of AKI. This review and expert opinion illustrate current evidence on the pathophysiology, diagnosis, and therapy of IAH and ACS in the context of AKI.
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Affiliation(s)
- Vanessa Moll
- Department of Anesthesiology, Division of Critical Care Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Anesthesiology, Division of Critical Care Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Ashish K Khanna
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Andrea Kurz
- Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Anesthesiology, Emergency Medicine and Intensive Care Medicine, Medical University Graz, Graz, Austria
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Marije Smit
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Madhav Swaminathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Steven Minear
- Department of Anesthesiology, Cleveland Clinic Florida, Weston Hospital, Weston, FL, USA
| | - K Gage Parr
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Amit Prabhakar
- Department of Anesthesiology, Division of Critical Care Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Manxu Zhao
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University Lublin, Lublin, Poland.
- Medical Data Management, Medaman, Geel, Belgium.
- International Fluid Academy, Lovenjoel, Belgium.
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Tanaka K, Matsumoto S, Yoneda N, Hattori Y, Nakamura K. Decrease in the Internal Cerebral Vein Pulsation With Improvement of Patent Ductus Arteriosus in Premature Infants at the Risk of Intraventricular Hemorrhage: Two Interesting Case Reports. Cureus 2024; 16:e65030. [PMID: 39165450 PMCID: PMC11334690 DOI: 10.7759/cureus.65030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2024] [Indexed: 08/22/2024] Open
Abstract
Recently, augmenting the pulsation of the internal cerebral vein (ICV) has been reported to be a predictor of premature intraventricular hemorrhage (IVH); however, prophylaxis for IVH has not yet been established. Venous pulsation is a marker of central venous pressure elevation and may be improved after heart failure treatment. Herein, we report two cases of low-birth-weight infants (29 weeks and 31 weeks of gestational age), who exhibited improvements in ICV pulsation with relief of hemodynamically significant patent ductus arteriosus (hs-PDA) following indomethacin administration. ICV flow patterns were continuously flat early after birth. Thereafter, both patients demonstrated ICV pulsation augmentation with PDA progression and brain natriuretic peptide (BNP) elevation at 52 h and 39 h after birth (in infants born at 29 and 31 weeks of gestational age, respectively). After relieving PDA with indomethacin administration, both infants exhibited an improvement in ICV pulsation with decreased BNP levels. In both cases, ICV pulsation increased when PDA became hemodynamically significant with BNP elevation, and the pulsation improved by reduction in ductal flow with decreasing BNP when PDA was relieved by indomethacin administration. The association between hs-PDA and elevated ICV pulsation indicates that hs-PDA likely leads to heightened central venous pressure. Additionally, indomethacin treatment was effective in reducing the exacerbated ICV pulsation caused by heart failure due to hs-PDA. These cases suggest that treatment for heart failure might improve the augmented ICV pulsation, which is related to the development of premature IVH. However, further studies are needed to confirm this association.
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Torres-Arrese M, Barberá-Rausell P, Li-Zhu JWO, Salas-Dueñas R, Real-Martín AE, Mata-Martínez A, Gonzalo-Moreno B, Núñez JH, Luordo D, Cano JGS, Villén Villegas T, Caurcel-Díaz L, de Casasola-Sánchez GG, Tung-Chen Y. The Cardiac Pulsed Wave Doppler Pattern of the Common Femoral Vein in Diagnosing the Likelihood of Severe Pulmonary Hypertension: Results from a Prospective Multicentric Study. J Clin Med 2024; 13:3860. [PMID: 38999425 PMCID: PMC11242826 DOI: 10.3390/jcm13133860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/05/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024] Open
Abstract
Background and Objectives: Pulmonary hypertension (PH) is a clinical condition with high mortality rates, particularly in patients over 65. Current guidelines recommend assessing the likelihood of pulmonary hypertension (LPH) using advanced echocardiography before proceeding to right heart catheterization. This study proposed using the common femoral vein (CFV), an accessible vein that reflects right atrial pressure, as an alternative method to assess the high likelihood of pulmonary hypertension (H-LPH). Materials and Methods: This prospective observational study included 175 emergency patients from three hospitals. Ultrasound assessed the pulsed wave Doppler (PW-Doppler) morphology of the CFV. This diagnostic yield for H-LPH was evaluated alongside traditional ultrasound parameters (right-to-left ventricular basal diameter ratio greater than 1 (RV > LV), septal flattening, right ventricular outflow acceleration time (RVOT) of less than 105 ms and/or mesosystolic notching, pulmonary artery diameter greater than the aortic root (AR) diameter or over 25 mm, early pulmonary regurgitation maximum velocity > 2.2 m/s; TAPSE/PASP less than 0.55, inferior vena cava (IVC) diameter over 21 mm with decreased inspiratory collapse, and right atrial (RA) area over 18 cm2). Results: The CFV's PW-Doppler cardiac pattern correlated strongly with H-LPH, showing a sensitivity (Sn) of 72% and a specificity (Sp) of 96%. RA dilation and TAPSE/PASP < 0.55 also played significant diagnostic roles. Conclusions: The CFV's PW-Doppler cardiac pattern is an effective indicator of H-LPH, allowing reliable exclusion of this condition when absent. This approach could simplify initial LPH evaluation in emergency settings or where echocardiographic resources are limited.
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Affiliation(s)
- Marta Torres-Arrese
- Department of Emergency Medicine, Hospital Universitario Fundación de Alcorcón, Calle Budapest 1, 28922 Alcorcón, Spain; (R.S.-D.); (A.E.R.-M.); (A.M.-M.); (G.G.d.C.-S.)
- School of Medicine, Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | - Pablo Barberá-Rausell
- Department of Emergency Medicine, Hospital Universitario La Fe, Avenida de Fernando Abril Martorell, 106, 46126 Valencia, Spain;
| | - Jie-Wei Oscar Li-Zhu
- Department of Internal Medicine, Hospital Universitario de Móstoles, Calle del Doctor Luis Montes, s/n, Móstoles, 28935 Madrid, Spain;
- School of Medicine, Universidad Francisco de Vitoria, M-515, Pozuelo de Alarcón, 28223 Madrid, Spain
| | - Rocío Salas-Dueñas
- Department of Emergency Medicine, Hospital Universitario Fundación de Alcorcón, Calle Budapest 1, 28922 Alcorcón, Spain; (R.S.-D.); (A.E.R.-M.); (A.M.-M.); (G.G.d.C.-S.)
| | - Alma Elena Real-Martín
- Department of Emergency Medicine, Hospital Universitario Fundación de Alcorcón, Calle Budapest 1, 28922 Alcorcón, Spain; (R.S.-D.); (A.E.R.-M.); (A.M.-M.); (G.G.d.C.-S.)
| | - Arantzazu Mata-Martínez
- Department of Emergency Medicine, Hospital Universitario Fundación de Alcorcón, Calle Budapest 1, 28922 Alcorcón, Spain; (R.S.-D.); (A.E.R.-M.); (A.M.-M.); (G.G.d.C.-S.)
| | - Begoña Gonzalo-Moreno
- Department of Emergency Medicine, Hospital Universitario Fundación de Alcorcón, Calle Budapest 1, 28922 Alcorcón, Spain; (R.S.-D.); (A.E.R.-M.); (A.M.-M.); (G.G.d.C.-S.)
| | - Joaquín Hernández Núñez
- Department of Emergency Medicine, Hospital Universitario Fundación de Alcorcón, Calle Budapest 1, 28922 Alcorcón, Spain; (R.S.-D.); (A.E.R.-M.); (A.M.-M.); (G.G.d.C.-S.)
| | - Davide Luordo
- Department of Emergency Medicine, Hospital Universitario Infanta Cristina, Avenida Del Nueve de Junio, 2, Parla, 28981 Madrid, Spain
| | - Juan Gabriel Sánchez Cano
- Derpartment of Internal Medicine, Hospital Universitario Fundación Alcorcón, Calle Budapest 1, 28922 Alcorcón, Spain
| | - Tomás Villén Villegas
- School of Medicine, Universidad Francisco de Vitoria, M-515, Pozuelo de Alarcón, 28223 Madrid, Spain
| | - Luis Caurcel-Díaz
- Department of Palliative Care Hospital Universitario 12 de Octubre L.CD. Av. de Córdoba, s/n, 28041 Madrid, Spain
| | - Gonzalo García de Casasola-Sánchez
- Department of Emergency Medicine, Hospital Universitario Fundación de Alcorcón, Calle Budapest 1, 28922 Alcorcón, Spain; (R.S.-D.); (A.E.R.-M.); (A.M.-M.); (G.G.d.C.-S.)
| | - Yale Tung-Chen
- School of Medicine, Universidad Francisco de Vitoria, M-515, Pozuelo de Alarcón, 28223 Madrid, Spain
- Department of Internal Medicine, Hospital Universitario La Paz. Paseo Castellana 241, 28046 Madrid, Spain
- School of Medicine, Universidad Alfonso X, 28691 Madrid, Spain
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Andrei S, Bahr PA, Alissant M, Saccu M, Nguyen M, Popescu BA, Bouhemad B, Guinot PG. Pulsatile Femoral Vein Doppler Pattern is a Parameter of Venous Congestion in ICU Patients. J Cardiothorac Vasc Anesth 2024; 38:1361-1368. [PMID: 38555215 DOI: 10.1053/j.jvca.2023.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/17/2023] [Accepted: 04/20/2023] [Indexed: 04/02/2024]
Abstract
OBJECTIVES The aim of this study was to evaluate if the presence of a pulsatile femoral vein pattern is an indicator of venous congestion in the intensive care unit (ICU). DESIGN Retrospective observational study. SETTING Three medico-surgical university-affiliated ICUs. PARTICIPANTS Adult patients who had an ultrasound evaluation at several time points during their ICU stay: at baseline (within 24 hours of admission to ICU), daily during their ICU stay, and within 24 hours before ICU discharge. INTERVENTIONS At each time point, the hemodynamic, respiratory, and cardiac ultrasound parameters were recorded. The common femoral vein was studied with pulsed-wave Doppler at the level of the femoral trigonum, with high frequency (5-13 MHz) linear array vascular probe and venous vascular mode, in supine patients. MEASUREMENTS AND MAIN RESULTS One hundred eight patients who underwent 400 ultrasound evaluations (3.7 ± 1 ultrasound evaluations per patient) during their ICU stay were included. Seventy-nine of 108 patients (73%) had a pulsatile femoral vein pattern at least at 1 time point. The multivariable mixed effects logistic regression model demonstrated an association among pulsatile femoral vein pattern, body mass index (OR: 0.91[95% CI 0.85-0.96], p = 0.002), inferior vena cava mean diameter (OR: 2.35 [95% CI 1.18-4.66], p = 0.014), portal vein pulsatility (OR: 2.3 [95% CI 1.2-4.4], p = 0.012), and congestive renal vein flow pattern (OR: 4.02 [95% CI 2.01-8.03], p < 0.001). The results were confirmed by principal component analysis. CONCLUSION In the ICU, a pulsatile femoral vein pattern is associated with parameters of venous congestion, independently of the patient's volume status, and ventilatory treatment. These results suggest the femoral vein Doppler pulsatility as a parameter of congestion in ICU patients.
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Affiliation(s)
- Stefan Andrei
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.
| | - Pierre-Alain Bahr
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, Dijon, France
| | - Marine Alissant
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Melissa Saccu
- Vascular Medicine Unit, Dijon University Medical Centre, Dijon, France
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, Dijon, France
| | - Bogdan A Popescu
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania; Department of Cardiology, Euroecolab, Emergency Institute for Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, Dijon, France
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Zhao H, Gao B, Zhang H, Wang X. The Importance of Venous Reflux Status Evaluation in the Intensive Care Unit. Aging Dis 2024; 15:953-964. [PMID: 37611903 PMCID: PMC11081157 DOI: 10.14336/ad.2023.0731] [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: 04/18/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023] Open
Abstract
The current management approach for critically ill patients emphasizes maintaining adequate cardiac output and mean arterial pressure. Recently, researchers have increasingly emphasized the clinical significance of venous reflux. Bedside venous Doppler ultrasonography offers continuous, dynamic, and quantifiable assessment of the venous reflux status. In this review, we explore the pertinent literature on assessing the venous reflux status in critically ill patients. We propose a bedside ultrasonographic evaluation method that starts with the hepatic veins and progresses to the portal, renal and intrarenal, femoral, and pulmonary veins. The clinical significance of venous reflux status evaluation is discussed in terms of its effect on right ventricular function, the functioning of other organs, and the guidance of fluid therapy. Overall, we underscore the importance of venous reflux status evaluation in critically ill patients and highlight the benefits of incorporating bedside ultrasonography for the continuous monitoring of venous return.
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Affiliation(s)
- Hua Zhao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Beijun Gao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Critical Care Ultrasound Study Group
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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7
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Dias NH, Gomes DR, de Oliveira ACT, Pellegrini JAS, Boniatti MM. Prognostic value of Doppler waveform analysis of common femoral vein in septic patients: a prospective cohort study. J Ultrasound 2023; 26:871-877. [PMID: 37603258 PMCID: PMC10632248 DOI: 10.1007/s40477-023-00819-y] [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: 05/30/2023] [Accepted: 07/29/2023] [Indexed: 08/22/2023] Open
Abstract
OBJECTIVES To assess whether there is an association between abnormal common femoral vein (CFV) Doppler waveform and intensive care unit (ICU) mortality in patients with sepsis. METHODS Patients admitted to the ICU with sepsis were included. Pulsed-wave Doppler was performed by examining the CFV in the short axis without angle correction and in the long axis with angle correction. An abnormal CFV Doppler waveform was determined by a retrograde velocity peak (RVP) > 10 cm/s in the long axis or RVP > 50% of the antegrade velocity peak in the short axis. TAPSE < 17 mm was defined as right ventricular (RV) dysfunction. The primary outcome was ICU mortality. RESULTS One hundred and ten patients were included. There was no association between abnormal CFV Doppler waveforms in the long (p = 0.709) and short axes (p = 0.171) and ICU mortality. TAPSE measurements were performed in 16 patients. RV dysfunction was identified in 8 (50.0%) patients. There was no association between the diagnosis of RV dysfunction based on TAPSE measurement and the identification of abnormal CFV Doppler waveforms in the long axis (p = 1.000) and in the short axis (p = 1.000). CONCLUSION Abnormal CFV Doppler waveforms were not associated with ICU mortality in patients with sepsis. Furthermore, in the exploratory analysis, these alterations were not useful in identifying RV dysfunction in these patients.
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Affiliation(s)
- Nathalia Helbig Dias
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil.
- Postgraduate Program in Health Sciences: Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
| | | | | | | | - Márcio Manozzo Boniatti
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Postgraduate Program in Health Sciences: Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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8
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Bhardwaj V, Rola P, Denault A, Vikneswaran G, Spiegel R. Femoral vein pulsatility: a simple tool for venous congestion assessment. Ultrasound J 2023; 15:24. [PMID: 37165284 PMCID: PMC10172460 DOI: 10.1186/s13089-023-00321-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 04/10/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Femoral vein Doppler (FVD) is simpler than the VExUS score which is a multimodal scoring system based on combination of IVC diameter, hepatic venous Doppler, portal vein pulsatility and renal vein Doppler, may be useful in assessing right ventricular overload and signs of venous congestion. There is limited data on the relationship between FVD and VExUS score. RESULTS Adult post-cardiac surgery patients were assessed for venous congestion using the VExUS score and FVD. Agreement between VExUS and FVD was studied using Kappa test, sensitivity, specificity, PPV and NPV for VExUS and FVD was calculated keeping CVP as gold standard. In total, 107 patients were enrolled, with a mean age of 55.67 ± 12.76. The accuracy of VExUS and FVD for detecting venous congestion was 80.37 (95% CI of 71.5 to 87.4) and 74.7 (95% CI of 65.4 to 82.6), respectively. The level of agreement between FVD and VExUS was moderate (Kappa value of 0.62, P < 0.001) while the agreement between FVD and CVP was weak (Kappa value of 0.49, P < 0.001). CONCLUSION FVD has good accuracy for detecting venous congestion and shows moderate agreement with VExUS grading. With potentially easier physical accessibility and a shorter learning curve for novices, it may be a simple and valuable tool for assessing venous congestion.
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Affiliation(s)
- V Bhardwaj
- Critical Care, Narayana Health City, Bangalore, India.
| | - P Rola
- ICU Chief of Service, Santa Cabrini Hospital, Montreal, Canada
| | - A Denault
- Department of Anesthesiology, Monteal Heart Institute, Montreal, Canada
| | - G Vikneswaran
- Clinical Research, Narayana Health City, Bangalore, India
| | - R Spiegel
- Department of Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC, USA
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9
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Koratala A, Taleb Abdellah A, Reisinger N. Nephrologist-performed point-of-care venous excess Doppler ultrasound (VExUS) in the management of acute kidney injury. J Ultrasound 2023; 26:301-306. [PMID: 36617380 PMCID: PMC10063755 DOI: 10.1007/s40477-022-00760-6] [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: 09/25/2022] [Accepted: 11/28/2022] [Indexed: 01/09/2023] Open
Abstract
Acute kidney injury (AKI) is frequently associated with alterations in fluid balance making accurate assessment of hemodynamics a vital component of patient management. Unfortunately, conventional parameters such as history, physical examination, vital signs, weight, natriuretic peptides have limitations in this regard. Point of care ultrasonography (POCUS) is a clinician-performed limited ultrasound study intended to answer focused clinical questions at the bedside. In the past several years, it has evolved as an extension of physical examination in various medical specialties. Herein, we describe a case of AKI where nephrologist-performed multi-organ POCUS aided in accurate diagnosis of fluid overload state. In addition, we describe how venous Doppler (VExUS) evaluation can be used to monitor the efficacy of decongestive therapy in real-time. Nephrologists should adopt a multi-parametric approach integrating all the pieces of hemodynamic puzzle when evaluating patients with AKI and fluid/electrolyte disorders.
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Affiliation(s)
- Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Room A7633, Milwaukee, WI, 53226, USA.
| | - Ahmed Taleb Abdellah
- Division of Nephrology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Room A7633, Milwaukee, WI, 53226, USA
| | - Nathaniel Reisinger
- Division of Renal Electrolyte and Hypertension, University of Pennsylvania Hospital, Philadelphia, USA
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10
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Croquette M, Puyade M, Montani D, Jutant EM, De Géa M, Lanéelle D, Thollot C, Trihan JE. Diagnostic Performance of Pulsed Doppler Ultrasound of the Common Femoral Vein to Detect Elevated Right Atrial Pressure in Pulmonary Hypertension. J Cardiovasc Transl Res 2023; 16:141-151. [PMID: 35604591 DOI: 10.1007/s12265-022-10276-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
Abstract
Right atrial pressure (RAP) is an important prognostic criterion in pulmonary hypertension (PH). The main goals were to evaluate the following: (i) the accuracy of Doppler assessment of common femoral vein flow waveform to detect elevated RAP and (ii) the diagnostic accuracy of RAP assessed by echocardiography (eRAP). Fifty-seven patients, addressed for right heart catheterization, were included in a retrospective cross-sectional study during a 6-month period. Forty-five patients (78.9%) had PH confirmed by RHC. Elevated RAP was defined by RAP ≥ 10 mmHg. Femoral venous stasis index (FVSI) was highly correlated to RAP on both univariate (p < 0.001) and multivariate analysis (p = 0.003), and showed good diagnostic performances to detect elevated RAP (specificity: 92.3% [80.0-99.3], diagnosis accuracy: 90.4 [77.4-97.3], positive likelihood ratio: 12.5 [3.01-51.97]). Diagnosis accuracy of eRAP was only 51.2% (36.2-66.1). FVSI is independently correlated to RAP and a useful tool to predict elevated RAP in PH patients.
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Affiliation(s)
- Magali Croquette
- Vascular Medicine Unit, Cardio-Vascular Center, University Hospital of Poitiers, Poitiers, France
| | - Matthieu Puyade
- Department of Internal Medicine, University Hospital of Poitiers, Poitiers, France
| | - David Montani
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Etienne-Marie Jutant
- Pneumologie, CHU de Poitiers, Poitiers, France.,INSERM CIC 1402, ALIVE Research Group, University of Poitiers, Poitiers, France
| | - Marion De Géa
- Department of Cardiology, CHU de Poitiers, Poitiers, France
| | - Damien Lanéelle
- Vascular Medicine Unit, Centre Hospitalier Universitaire de Caen Normandie, Caen, France.,COMETE Laboratory, INSERM 1075, Université de Caen, 14000, Caen, France
| | - Cécile Thollot
- Vascular Medicine Unit, Cardio-Vascular Center, University Hospital of Poitiers, Poitiers, France
| | - Jean-Eudes Trihan
- Vascular Medicine Unit, Cardio-Vascular Center, University Hospital of Poitiers, Poitiers, France.
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11
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Gourdeau S, Beaubien-Souligny W, Denault AY. Point-of-Care Ultrasound in an Unstable Patient After Cardiac Surgery. Chest 2022; 162:e325-e330. [PMID: 36494134 DOI: 10.1016/j.chest.2021.12.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/31/2021] [Accepted: 12/20/2021] [Indexed: 12/12/2022] Open
Affiliation(s)
- Simon Gourdeau
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - William Beaubien-Souligny
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada; Department of Nephrology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - André Y Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada; Intensive Care Unit, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.
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12
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Koratala A, Reisinger N. Point of Care Ultrasound in Cirrhosis-Associated Acute Kidney Injury: Beyond Inferior Vena Cava. KIDNEY360 2022; 3:1965-1968. [PMID: 36514396 PMCID: PMC9717633 DOI: 10.34067/kid.0005522022] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/20/2022] [Indexed: 12/05/2022]
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13
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De Backer D, Aissaoui N, Cecconi M, Chew MS, Denault A, Hajjar L, Hernandez G, Messina A, Myatra SN, Ostermann M, Pinsky MR, Teboul JL, Vignon P, Vincent JL, Monnet X. How can assessing hemodynamics help to assess volume status? Intensive Care Med 2022; 48:1482-1494. [PMID: 35945344 PMCID: PMC9363272 DOI: 10.1007/s00134-022-06808-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/25/2022] [Indexed: 02/04/2023]
Abstract
In critically ill patients, fluid infusion is aimed at increasing cardiac output and tissue perfusion. However, it may contribute to fluid overload which may be harmful. Thus, volume status, risks and potential efficacy of fluid administration and/or removal should be carefully evaluated, and monitoring techniques help for this purpose. Central venous pressure is a marker of right ventricular preload. Very low values indicate hypovolemia, while extremely high values suggest fluid harmfulness. The pulmonary artery catheter enables a comprehensive assessment of the hemodynamic profile and is particularly useful for indicating the risk of pulmonary oedema through the pulmonary artery occlusion pressure. Besides cardiac output and preload, transpulmonary thermodilution measures extravascular lung water, which reflects the extent of lung flooding and assesses the risk of fluid infusion. Echocardiography estimates the volume status through intravascular volumes and pressures. Finally, lung ultrasound estimates lung edema. Guided by these variables, the decision to infuse fluid should first consider specific triggers, such as signs of tissue hypoperfusion. Second, benefits and risks of fluid infusion should be weighted. Thereafter, fluid responsiveness should be assessed. Monitoring techniques help for this purpose, especially by providing real time and precise measurements of cardiac output. When decided, fluid resuscitation should be performed through fluid challenges, the effects of which should be assessed through critical endpoints including cardiac output. This comprehensive evaluation of the risk, benefits and efficacy of fluid infusion helps to individualize fluid management, which should be preferred over a fixed restrictive or liberal strategy.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Boulevard du Triomphe 201, 1160, Brussels, Belgium.
| | - Nadia Aissaoui
- Assistance publique des hôpitaux de Paris (APHP), Cochin Hospital, Intensive Care Medicine, médecine interne reanimation, Université de Paris and Paris Cardiovascular Research Center, INSERM U970, 25 rue Leblanc, 75015, Paris, France
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center-IRCCS, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.,Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Ludhmila Hajjar
- Departamento de Cardiopneumologia, InCor, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Antonio Messina
- Humanitas Clinical and Research Center-IRCCS, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jean-Louis Teboul
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Philippe Vignon
- Medical-surgical ICU and Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Univ Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Xavier Monnet
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
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14
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Hammoud A, Saade E, Jarry S, Baelen S, Couture EJ, Beaubien-Souligny W, Denault AY. Pulsatile Femoral Vein Doppler and Congestive Delirium, What Is the Relationship?: A Case Report. A A Pract 2022; 16:e01627. [PMID: 36599030 DOI: 10.1213/xaa.0000000000001627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Delirium is common in patients undergoing cardiac surgery, and venous congestion has been reported as an important risk factor. We report a 69-year-old patient who developed postoperative delirium in the intensive care unit following aortic valve replacement surgery. The postoperative course was complicated by delirium for which echographic signs of venous congestion on the portal and the renal but also the femoral veins and their resolution correlated with the course of delirium. The use of common femoral vein Doppler as a simple bedside technique to predict and identify congestive delirium has not been reported before.
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Affiliation(s)
- Ali Hammoud
- From the Department of Nursing, Université de Montréal, Montreal, Quebec, Canada.,Department of Medicine, Intensive Care Unit and Research Centre, Montreal Heart Institute, Montreal, Quebec, Canada.,Biomedical Science Program
| | - Elena Saade
- Biomedical Science Program.,Department of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.,Pharmacology Program, Université de Montréal, Montreal, Quebec, Canada
| | - Sophie Baelen
- From the Department of Nursing, Université de Montréal, Montreal, Quebec, Canada.,Department of Medicine, Intensive Care Unit and Research Centre, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Etienne J Couture
- Division of Intensive Care Medicine, Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - William Beaubien-Souligny
- Department of Medicine, Nephrology Division, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - André Y Denault
- Department of Medicine, Intensive Care Unit and Research Centre, Montreal Heart Institute, Montreal, Quebec, Canada.,Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.,Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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15
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Perlman H, Lee M, Miles LF. Echo Rounds: Intraoperative Doppler Assessment of Transjugular Intrahepatic Shunt Flow Using Transesophageal Echocardiography. A A Pract 2022; 16:e01607. [DOI: 10.1213/xaa.0000000000001607] [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]
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16
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New developments in the understanding of right ventricular function in acute care. Curr Opin Crit Care 2022; 28:331-339. [PMID: 35653255 DOI: 10.1097/mcc.0000000000000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Right ventricular dysfunction has an important impact on the perioperative course of cardiac surgery patients. Recent advances in the detection and monitoring of perioperative right ventricular dysfunction will be reviewed here. RECENT FINDINGS The incidence of right ventricular dysfunction in cardiac surgery has been associated with unfavorable outcomes. New evidence supports the use of a pulmonary artery catheter in cardiogenic shock. The possibility to directly measure right ventricular pressure by transducing the pacing port has expanded its use to track changes in right ventricular function and to detect right ventricular outflow tract obstruction. The potential role of myocardial deformation imaging has been raised to detect patients at risk of postoperative complications. SUMMARY Perioperative right ventricular function monitoring is based on echocardiographic and extra-cardiac flow evaluation. In addition to imaging modalities, hemodynamic evaluation using various types of pulmonary artery catheters can be achieved to track changes rapidly and quantitatively in right ventricular function perioperatively. These monitoring techniques can be applied during and after surgery to increase the detection rate of right ventricular dysfunction. All this to improve the treatment of patients presenting early signs of right ventricular dysfunction before systemic organ dysfunction ensue.
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17
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Duplex Analysis of Cannulated Vessels in Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation. Medicina (B Aires) 2022; 58:medicina58050671. [PMID: 35630088 PMCID: PMC9143327 DOI: 10.3390/medicina58050671] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/03/2022] [Accepted: 05/12/2022] [Indexed: 11/24/2022] Open
Abstract
Background and objectives: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) cannulas have major repercussions on vascular hemodynamics that can potentially lead to limb ischemia. Duplex ultrasound enables the non-invasive analysis of vascular hemodynamics. This study aims to describe the duplex parameters of the femoral vessels during V-A ECMO support, investigate differences between cannulated and non-cannulated vessels, and analyze the variations in the case of limb ischemia and intra-aortic balloon pumps (IABPs). Methods: Nineteen adults (≥18 years), supported with femoro-femoral V-A ECMO, underwent a duplex analysis of the superficial femoral arteries (SFAs) and veins (FVs). Measured parameters included flow velocities, waveforms, and vessel diameters. Results: 89% of patients had a distal perfusion cannula during duplex analysis and 21% of patients developed limb ischemia. The mean peak systolic flow velocity (PSV) and end-diastolic flow velocity (EDV) of the SFAs on the cannulated side were, respectively, 42.4 and 21.4 cm/s. The SFAs on the non-cannulated side showed a mean PSV and EDV of 87.4 and 19.6 cm/s. All SFAs on the cannulated side had monophasic waveforms, whereas 63% of the SFAs on the non-cannulated side had a multiphasic waveform. Continuous/decreased waveforms were seen in 79% of the FVs on the cannulated side and 61% of the waveforms of the contralateral veins were respirophasic. The mean diameter of the FVs on the cannulated side, in patients who developed limb ischemia, was larger compared to the FVs on the non-cannulated side with a ratio of 1.41 ± 0.12. The group without limb ischemia had a smaller ratio of 1.03 ± 0.25. Conclusions: Femoral cannulas influence flow velocities in the cannulated vessels during V-A ECMO and major waveforms alternations can be seen in all SFAs on the cannulated side and most FVs on the cannulated side. Our data suggest possible venous stasis in the FV on the cannulated side, especially in patients suffering from limb ischemia.
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18
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Jarry S, Calderone A, Dion D, Bouchard D, Couture ÉJ, Denault A. Acute Cardiointestinal Syndrome Resulting From Postoperative Acute Biventricular Heart Failure. J Cardiothorac Vasc Anesth 2022; 36:2220-2227. [PMID: 35331631 DOI: 10.1053/j.jvca.2022.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/08/2022] [Indexed: 01/16/2023]
Affiliation(s)
- Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Daniel Dion
- Department of Pathology and Cell Biology, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Denis Bouchard
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Étienne J Couture
- Department of Anesthesiology and Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Canada
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada; Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Canada.
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19
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Torres-Arrese M, García de Casasola-Sánchez G, Méndez-Bailón M, Montero-Hernández E, Cobo-Marcos M, Rivas-Lasarte M, Caurcel-Díaz L, Rodríguez-Fuertes P, Villén-Villegas T, Tung-Chen Y. Usefulness of Serial Multiorgan Point-of-Care Ultrasound in Acute Heart Failure: Results from a Prospective Observational Cohort. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:124. [PMID: 35056432 PMCID: PMC8780545 DOI: 10.3390/medicina58010124] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
Background and Objectives: Acute heart failure (AHF) is a common disease and a cause of high morbidity and mortality, constituting a major health problem. The main purpose of this study was to determine the impact of multiorgan ultrasound in identifying pulmonary hypertension (PH), a major prognostic factor in patients admitted due to AHF, and assess whether there are significant changes in the venous excess ultrasonography (VE × US) score or femoral vein Doppler at discharge. Materials and Methods: Patients were evaluated with a standard protocol of lung ultrasound, echocardiography, inferior vena cava (IVC) and hepatic, portal, intra-renal and femoral vein Doppler flow patterns at admission and on the day of discharge. Results: Thirty patients were enrolled during November 2021. The mean age was seventy-nine years (Standard Deviation-SD 13.4). Seven patients (23.3%) had a worsening renal function during hospitalization. Regarding ultrasound findings, VE × US score was calculated at admission and at discharge, unexpectedly remaining unchanged or even worsened (21 patients, 70.0%). The area under the curve for the lung score was 83.9% (p = 0.008), obtaining a cutoff value of 10 that showed a sensitivity of 82.6% and a specificity of 71.4% in the identification of intermediate and high PH. It was possible to monitor significant changes between both exams on the lung score (16.5 vs. 9.3; p < 0.001), improvement in the hepatic vein Doppler pattern (2.4 vs. 2.1; p = 0.002), improvement in portal vein Doppler pattern (1.7 vs. 1.4; p = 0.023), without significant changes in the intra-renal vein Doppler pattern (1.70 vs. 1.57; p = 0.293), VE × US score (1.3 vs. 1.1; p = 0.501), femoral vein Doppler pattern (2.4 vs. 2.1; p = 0.161) and IVC collapsibility (2.0 vs. 2.1; p = 0.420). Conclusions: Our study results suggest that performing serial multiorgan Point-of-Care ultrasound can help us to better identify high and intermediate probability of PH patients with AHF. Currently proposed multi-organ, venous Doppler scanning protocols, such as the VE × US score, should be further studied before expanding its use in AHF patients.
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Affiliation(s)
- Marta Torres-Arrese
- Department of Emergency Medicine, Hospital Universitario Fundación de Alcorcón, 28922 Madrid, Spain; (M.T.-A.); (G.G.d.C.-S.)
| | | | - Manuel Méndez-Bailón
- Department of Internal Medicine, Hospital Clínico San Carlos, 28040 Madrid, Spain;
| | - Esther Montero-Hernández
- Department of Internal Medicine, Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain;
| | - Marta Cobo-Marcos
- Department of Cardiology, Hospital Universitario Puerta de Hierro, CIBERCV, Majadahonda, 28222 Madrid, Spain; (M.C.-M.); (M.R.-L.)
| | - Mercedes Rivas-Lasarte
- Department of Cardiology, Hospital Universitario Puerta de Hierro, CIBERCV, Majadahonda, 28222 Madrid, Spain; (M.C.-M.); (M.R.-L.)
| | - Luis Caurcel-Díaz
- Department of Palliative Medicine, Hospital 12 de Octubre, 28041 Madrid, Spain;
| | | | | | - Yale Tung-Chen
- Department of Internal Medicine, Hospital Universitario Puerta de Hierro Majadahonda, 28222 Madrid, Spain;
- Department of Medicine, Universidad Alfonso X, 28691 Madrid, Spain
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20
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Galindo P, Gasca C, Argaiz ER, Koratala A. Point of care venous Doppler ultrasound: Exploring the missing piece of bedside hemodynamic assessment. World J Crit Care Med 2021; 10:310-322. [PMID: 34888157 PMCID: PMC8613717 DOI: 10.5492/wjccm.v10.i6.310] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/28/2021] [Accepted: 09/30/2021] [Indexed: 02/06/2023] Open
Abstract
Accurate assessment of the hemodynamic status is vital for appropriate management of patients with critical illness. As such, there has been a constant quest for reliable and non-invasive bedside tools to assess and monitor circulatory status in order to ensure end-organ perfusion. In the recent past, point of care ultrasonography (POCUS) has emerged as a valuable adjunct to physical examination in various specialties, which basically is a clinician-performed bedside ultrasound to answer focused questions. POCUS allows visualization of the internal anatomy and flow dynamics in real time, guiding apt interventions. While both arterial (forward flow) and venous (organ outflow or afterload) limbs of hemodynamic circuit are important for tissue perfusion, the venous side remains relatively under-explored. With recent data underscoring the deleterious consequences of iatrogenic volume overload, objective evaluation of venous congestion is gaining attention. Bedside Doppler ultrasound serves this purpose and aids in diagnosing and monitoring the congestion/venous blood flow pattern. In this article, we summarize the rationale for integrating this technology into routine care of patients with volume-related disorders, discuss the normal and abnormal waveforms, limitations, and future directions.
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Affiliation(s)
- Pablo Galindo
- Department of Nephrology, Centro Médico ISSEMYM, Ecatepec 55000, Mexico
| | - Carlos Gasca
- Department of Critical Care, Hospital Juárez de México, Mexico City 07760, Mexico
| | - Eduardo R Argaiz
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Wauwatosa, WI 53226, United States
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21
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Gonzalez C, Chamberland ME, Aldred MP, Couture E, Beaubien-Souligny W, Calderone A, Lamarche Y, Denault A. Constrictive pericarditis: portal, splenic, and femoral venous Doppler pulsatility: a case series. Can J Anaesth 2021; 69:119-128. [PMID: 34739707 DOI: 10.1007/s12630-021-02126-8] [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: 01/05/2021] [Revised: 04/12/2021] [Accepted: 09/09/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Pulsatile flow of the portal vein has been implicated as an indicator of right ventricular dysfunction in cardiac patients. In patients with significantly elevated right atrial pressure, pulsatile venous flow may be transmitted to the portal, splenic, renal, and femoral veins. We describe the evolution of these echocardiographic findings in four patients with constrictive pericarditis (CP) undergoing pericardiectomy with simultaneous hemodynamic waveform and cerebral oximetry monitoring in the operating room and in the intensive care unit. CLINICAL FEATURES Patient 1 presented classic signs of CP, including equalization of left and right diastolic pressures, a "square root" sign on the diastolic portion of the right ventricular pressure curve, and elevated right atrial pressure. Preoperative transesophageal echocardiography showed a hyperdynamic left ventricle and dilated right ventricle with abnormal pulsatile waveforms in the portal and splenic veins. Surgical decompression of the pericardium gradually normalized the Doppler waveforms. Increased venous return following pericardiectomy during surgery in patients 2 and 3 and during the postoperative period in patient 4 resulted in right ventricular (RV) failure due to significantly increased preload. Venous pulsatility was also observed in the portal, splenic, and femoral veins. CONCLUSION In patients with CP, changes in hemodynamic and echocardiographic signs of RV dysfunction are rapidly reflected by changes in peripheral venous velocities. Identifying signs of splanchnic and peripheral vascular venous congestion could help identify patients at higher risk of developing postoperative complications following pericardiectomy.
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Affiliation(s)
- Céline Gonzalez
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada
| | - Marie-Eve Chamberland
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada
| | - Matthew P Aldred
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada
| | - Etienne Couture
- Department of Anesthesiology and Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie, Quebec, QC, Canada
| | - William Beaubien-Souligny
- Department of Medicine, Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Alexander Calderone
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada
| | - Yoan Lamarche
- Department of Cardiac Surgery and Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada. .,Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.
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22
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Argaiz ER. VExUS Nexus: Bedside Assessment of Venous Congestion. Adv Chronic Kidney Dis 2021; 28:252-261. [PMID: 34906310 DOI: 10.1053/j.ackd.2021.03.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/02/2021] [Accepted: 03/09/2021] [Indexed: 12/19/2022]
Abstract
Organ dysfunction in the setting of heart failure is mainly determined by backward transmission of increased right atrial pressure. Although traditional point-of-care ultrasound applications such as inferior vena cava and lung ultrasound have been increasingly incorporated in the clinical care of congestive heart failure, they do not directly evaluate the hemodynamic consequences of high right atrial pressure on organ blood flow. Congestion induces alterations in the venous flow patterns of abdominal organs that can be readily assessed using Doppler imaging. These alterations have been consistently associated with congestive organ dysfunction and adverse clinical outcomes. In this article, we provide a comprehensive overview of the bedside assessment of venous congestion using Doppler imaging. The review focuses mainly on the normal and abnormal Doppler patterns of the hepatic, portal, and intrarenal veins along with clinical examples of how to incorporate this tool in the management of patients with venous congestion.
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Malinovska A, Arslani K, Zellweger N, Gebhard C, Beaubien-Souligny W, Calderone A, Siegemund M, Aschwanden M, Denault A, Gebhard CE. Femoral and popliteal venous Doppler during prone and supine position in COVID-19 patients: a potential diagnostic tool to detect abnormal right ventricular function. Can J Anaesth 2021; 68:737-739. [PMID: 33532997 PMCID: PMC7853706 DOI: 10.1007/s12630-021-01918-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Alexandra Malinovska
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Ketina Arslani
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Núria Zellweger
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Catherine Gebhard
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - William Beaubien-Souligny
- Nephrology Division, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | - Martin Siegemund
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Markus Aschwanden
- Department of Angiology, University Hospital Basel, Basel, Switzerland
| | - André Denault
- Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Montreal, QC, Canada
| | - Caroline E Gebhard
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland.
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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.
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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
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