1
|
Evrard B, Woillard JB, Legras A, Bouaoud M, Gourraud M, Humeau A, Goudelin M, Vignon P. Diagnostic, prognostic and clinical value of left ventricular radial strain to identify paradoxical septal motion in ventilated patients with the acute respiratory distress syndrome: an observational prospective multicenter study. Crit Care 2023; 27:424. [PMID: 37919787 PMCID: PMC10623720 DOI: 10.1186/s13054-023-04716-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: 09/01/2023] [Accepted: 10/31/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Acute cor pulmonale (ACP) is prognostic in patients with acute respiratory distress syndrome (ARDS). Identification of paradoxical septal motion (PSM) using two-dimensional echocardiography is highly subjective. We sought to describe feature-engineered metrics derived from LV radial strain changes related to PSM in ARDS patients with ACP of various severity and to illustrate potential diagnostic and prognostic yield. METHODS This prospective bicentric study included patients under protective ventilation for ARDS related to COVID-19 who were assessed using transesophageal echocardiography (TEE). Transgastric short-axis view at mid-papillary level was used to visually grade septal motion, using two-dimensional imaging, solely and combined with LV radial strain: normal (grade 0), transient end-systolic septal flattening (grade 1), prolonged end-systolic septal flattening or reversed septal curvature (grade 2). Inter-observer variability was calculated. Feature engineering was performed to calculate the time-to-peak and area under the strain curve in 6 LV segments. In the subset of patients with serial TEE examinations, a multivariate Cox model analysis accounting for new-onset of PSM as a time-dependent variable was used to identify parameters associated with ICU mortality. RESULTS Overall, 310 TEE examinations performed in 182 patients were analyzed (age: 67 [60-72] years; men: 66%; SAPSII: 35 [29-40]). Two-dimensional assessment identified a grade 1 and grade 2 PSM in 100 (32%) and 48 (15%) examinations, respectively. Inter-rater reliability was weak using two-dimensional imaging alone (kappa = 0.49; 95% CI 0.40-0.58; p < 0.001) and increased with associated LV radial strain (kappa = 0.84, 95% CI 0.79-0.90, p < 0.001). The time-to-peak of mid-septal and mid-lateral segments occurred significantly later in systole and increased with the grade of PSM. Similarly, the area under the strain curve of these segments increased significantly with the grade of PSM, compared with mid-anterior or mid-inferior segments. Severe acute cor pulmonale with a grade 2 PSM was significantly associated with mortality. Requalification in an upper PSM grade using LV radial strain allowed to better identify patients at risk of death (HR: 6.27 [95% CI 2.28-17.2] vs. 2.80 [95% CI 1.11-7.09]). CONCLUSIONS In objectively depicting PSM and quantitatively assessing its severity, TEE LV radial strain appears as a valuable adjunct to conventional two-dimensional imaging.
Collapse
Affiliation(s)
- Bruno Evrard
- Medical-Surgical ICU, Dupuytren Teaching Hospital, 87000, Limoges, France.
- Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France.
- Réanimation Polyvalente, CHU Dupuytren, 87042, Limoges Cedex, France.
| | - Jean-Baptiste Woillard
- Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
- Pharmacology & Transplantation, INSERM U1248, University of Limoges, Limoges, France
- Faculty of Medicine, University of Limoges, 87000, Limoges, France
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, Limoges, France
| | - Annick Legras
- Intensive Care Unit, Tours Teaching Hospital, Tours, France
| | | | - Maeva Gourraud
- Intensive Care Unit, Tours Teaching Hospital, Tours, France
| | - Antoine Humeau
- Pharmacology & Transplantation, INSERM U1248, University of Limoges, Limoges, France
| | - Marine Goudelin
- Medical-Surgical ICU, Dupuytren Teaching Hospital, 87000, Limoges, France
- Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
| | - Philippe Vignon
- Medical-Surgical ICU, Dupuytren Teaching Hospital, 87000, Limoges, France
- Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
- Faculty of Medicine, University of Limoges, 87000, Limoges, France
| |
Collapse
|
2
|
Patidar BS, Mukhopadhyay T, Subramanian A, Aggarwal R, Soni KD, Nischal N, Sahoo D, Surbhi S, Wig N, Pandey RM, Malhotra R, Trikha A. Association between Hypocalcemia and Outcome in COVID-19 Patients: A Retrospective Study. J Lab Physicians 2022. [DOI: 10.1055/s-0042-1757415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Abstract
Background Calcium has been shown to play a vital role in the pathophysiology of severe acute respiratory syndrome-coronavirus-2 and middle east respiratory syndrome coronavirus diseases, but less is known about hypocalcemia in coronavirus disease 2019 (COVID-19) patients and its association with the disease severity and the final outcome. Therefore, this study was conducted with an aim to assess clinical features in COVID-19 patients having hypocalcemia and to observe its impact on COVID-19 disease severity and the final outcome.
Methods In this retrospective study, consecutive COVID-19 patients of all age groups were enrolled. Demographical, clinical, and laboratory details were collected and analyzed. On the basis of albumin-corrected calcium levels, patients were classified into normocalcemic (n = 51) and hypocalcemic (n = 110) groups. Death was the primary outcome.
Results The mean age of patients in the hypocalcemic group was significantly lower (p < 0.05). A significantly higher number of hypocalcemic patients had severe COVID-19 infection (92.73%; p < 0.01), had comorbidities (82.73%, p < 0.05), and required ventilator support (39.09%; p < 0.01) compared with normocalcemic patients. The mortality rate was significantly higher in the hypocalcemic patients (33.63%; p < 0.05). Hemoglobin (p < 0.01), hematocrit (p < 0.01), and red cell count (p < 0.01) were significantly lower with higher levels of absolute neutrophil count (ANC; p < 0.05) and neutrophil-to-lymphocyte ratio (NLR; p < 0.01) in the hypocalcemic patients.Albumin-corrected calcium levels had a significant positive correlation with hemoglobin levels, hematocrit, red cell count, total protein, albumin, and albumin-to-globulin ratio and a significant negative correlation with ANC and NLR.
Conclusion The disease severity, ventilator requirement, and mortality were considerably higher in hypocalcemic COVID-19 patients.
Collapse
Affiliation(s)
- Bhagwan Singh Patidar
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Tapasyapreeti Mukhopadhyay
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Arulselvi Subramanian
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Richa Aggarwal
- Department of Anaesthesia, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Kapil Dev Soni
- Department of Anaesthesia, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Neeraj Nischal
- Department of Medicine, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Debasis Sahoo
- Department of Anaesthesia, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Surbhi Surbhi
- Department of Anaesthesia, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Naveet Wig
- Department of Medicine, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra Mohan Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Malhotra
- Department of Orthopedics, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Anjan Trikha
- Department of Laboratory Medicine, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
3
|
Shen ZL, Liu Z, Zhang P, Chen WZ, Dong WX, Chen WH, Lin F, Zang WF, Yan XL, Yu Z. Prognostic significance of postoperative loss of skeletal muscle mass in patients underwent coronary artery bypass grafting. Front Nutr 2022; 9:970729. [PMID: 36118747 PMCID: PMC9478409 DOI: 10.3389/fnut.2022.970729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Increasing life expectancy of coronary artery bypass grafting (CABG) remains to be the major concern of cardiac surgeons. However, few studies have investigated the effect of postoperative skeletal muscle index (SMI) loss on prognosis. This study aims to evaluate the prognostic role of postoperative SMI loss ≥ 5% after CABG, in order to develop a novel nomogram to predict overall survival (OS). Methods Patients underwent CABG via midline sternotomy from December 2015 to March 2021 were recruited in this study. Preoperative and postoperative 3 months chest computed tomography (CT) images were compared to assess changes in SMI at T12 level. Based on this, patients were classified into the presence or absence of SMI loss ≥ 5%. The association between postoperative SMI loss ≥ 5% and OS was then analyzed by the Kaplan-Meier curves and Cox model. A novel nomogram incorporating independent clinical prognostic variables was also developed. Results The study enrolled 506 patients receiving CABG, of whom 98 patients experienced T12 SMI loss ≥ 5% and had a significantly worse OS (P < 0.0001). Multivariate regression analysis showed that T12 SMI per cent change (%T12 SMI-change) was an independent prognostic factor for OS (HR = 0.809, 95% CI = 0.749–0.874). The nomogram incorporating %T12 SMI-change with other variables was accurate for predicting OS. Besides, we also found that postoperative oral nutritional supplement (ONS) can rescue T12 SMI loss. Conclusion Postoperative SMI loss can predict survival outcome after CABG. The nomogram incorporating changes in SMI provides a superior performance than existing systems.
Collapse
Affiliation(s)
- Zi-Le Shen
- Department of Gastrointestinal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhang Liu
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Peng Zhang
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wei-Zhe Chen
- Department of Gastrointestinal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen-Xi Dong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wen-Hao Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Feng Lin
- Department of Gastrointestinal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wang-Fu Zang
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Wang-Fu Zang,
| | - Xia-Lin Yan
- Department of Colorectal Anal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Xia-Lin Yan,
| | - Zhen Yu
- Department of Gastrointestinal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhen Yu,
| |
Collapse
|
4
|
Evrard B, Lakatos BK, Goudelin M, Tősér Z, Merkely B, Vignon P, Kovács A. Assessment of Right Ventricular Mechanics by 3D Transesophageal Echocardiography in the Early Phase of Acute Respiratory Distress Syndrome. Front Cardiovasc Med 2022; 9:861464. [PMID: 35592398 PMCID: PMC9110691 DOI: 10.3389/fcvm.2022.861464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/12/2022] [Indexed: 11/25/2022] Open
Abstract
Aim To compare global and axial right ventricular ejection fraction in ventilated patients for moderate-to-severe acute respiratory distress syndrome (ARDS) secondary to early SARS-CoV-2 pneumonia or to other causes, and in ventilated patients without ARDS used as reference. Methods Retrospective single-center cross-sectional study including 64 ventilated patients: 21 with ARDS related to SARS-CoV-2 (group 1), 22 with ARDS unrelated to SARS-CoV-2 (group 2), and 21 without ARDS (control group). Real-time three-dimensional transesophageal echocardiography was performed for hemodynamic assessment within 24 h after admission. Contraction pattern of the right ventricle was decomposed along the three anatomically relevant axes. Relative contribution of each spatial axis was evaluated by calculating ejection fraction along each axis divided by the global right ventricular ejection fraction. Results Global right ventricular ejection fraction was significantly lower in group 2 than in both group 1 and controls [median: 43% (25–75th percentiles: 40–57) vs. 58% (55–62) and 65% (56–68), respectively: p < 0.001]. Longitudinal shortening had a similar relative contribution to global right ventricular ejection fraction in all groups [group 1: 32% (28–39), group 2: 29% (24–40), control group: 31% (28–38), p = 0.6]. Radial shortening was lower in group 2 when compared to both group 1 and controls [45% (40–53) vs. 57% (51–62) and 56% (50–60), respectively: p = 0.005]. The relative contribution of right ventricular shortening along the anteroposterior axis was not statistically different between groups [group 1: 51% (41–55), group 2: 56% (46–63), control group; 56% (50–64), p = 0.076]. Conclusion During early hemodynamic assessment, the right ventricular systolic function appears more impaired in ARDS unrelated to SARS-CoV-2 when compared to early stage SARS-CoV-2 ARDS. Radial shortening appears more involved than longitudinal and anteroposterior shortening in patients with ARDS unrelated to SARS-CoV-2 and decreased right ventricular ejection fraction.
Collapse
Affiliation(s)
- Bruno Evrard
- Medical-Surgical ICU, Limoges University Hospital, Limoges, France
- Inserm CIC 1435, Limoges, France
- *Correspondence: Bruno Evrard,
| | | | - Marine Goudelin
- Medical-Surgical ICU, Limoges University Hospital, Limoges, France
- Inserm CIC 1435, Limoges, France
| | - Zoltán Tősér
- Argus Cognitive, Inc., Lebanon, NH, United States
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Philippe Vignon
- Medical-Surgical ICU, Limoges University Hospital, Limoges, France
- Inserm CIC 1435, Limoges, France
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| |
Collapse
|
5
|
Hockstein MA, Haycock K, Wiepking M, Lentz S, Dugar S, Siuba M. Transthoracic Right Heart Echocardiography for the Intensivist. J Intensive Care Med 2021; 36:1098-1109. [PMID: 33853435 DOI: 10.1177/08850666211003475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The impact of critical illness on the right ventricle (RV) can be profound and RV dysfunction is associated with mortality. Intensivists are becoming more facile with bedside echocardiography, however, pedagogy has largely focused on left ventricular function. Here we review measurements of right heart function by way of echocardiographic modalities and list clinical scenarios where the RV dysfunction is a salient feature. MAIN RV dysfunction is heterogeneously defined across many domains and its diagnosis is not always clinically apparent. The RV is affected by conditions commonly seen in the ICU such as acute respiratory distress syndrome, pulmonary embolism, RV ischemia, and pulmonary hypertension. Basic ultrasonographic modalities such as 2D imaging, M-mode, tissue Doppler, pulsed-wave Doppler, and continuous Doppler provide clinicians with metrics to assess RV function and response to therapy. CONCLUSION The right ventricle is impacted by various critical illnesses with substantial mortality and mortality. Focused bedside echocardiographic exams with attention to the right heart may provide intensivists insight into RV function and provide guidance for patient management.
Collapse
Affiliation(s)
- Maxwell A Hockstein
- Departments of Emergency Medicine and Critical Care, 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Korbin Haycock
- Department of Emergency Medicine, 4608Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Matthew Wiepking
- Department of Emergency Medicine and Surgery, 12223University of Southern California-Keck School of Medicine, Los Angeles, CA, USA
| | - Skyler Lentz
- Division of Emergency Medicine and Pulmonary Disease & Critical Care Medicine, Department of Surgery and Medicine, Larner College of 12352Medicine-University of Vermont, Burlington, VT, USA
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Siuba
- Department of Critical Care Medicine, Respiratory Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
6
|
Maile MD, Mathis MR, Habib RH, Schwann TA, Engoren MC. Association of Both High and Low Left Ventricular Ejection Fraction With Increased Risk After Coronary Artery Bypass Grafting. Heart Lung Circ 2021; 30:1091-1099. [PMID: 33516659 DOI: 10.1016/j.hlc.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/20/2020] [Accepted: 11/05/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND While reduced left ventricular ejection fraction (LVEF) is a known risk factor for complications after coronary artery bypass grafting (CABG), the relevance of higher LVEF values has not been established. Currently, most risk stratification tools consider LVEF values above a certain point as normal. However, since this does not account for insufficient ventricular filling or increased adrenergic tone, higher values may have clinical significance. To improve our understanding of this situation, we investigated the relationship of preoperative LVEF values with short- and long-term outcomes after CABG using a strategy that allowed for the identification of nonlinear relationships. We hypothesised that both higher and lower values are independently associated with increased postoperative complications and death in this population. METHODS We performed a single-centre retrospective cohort study of patients undergoing isolated CABG surgery. All patients had a preoperative measurement of their LVEF. Surgery involving mitral valve repair was excluded in order to eliminate the impact of mitral regurgitation. The primary outcome was long-term mortality; secondary outcomes included atrial fibrillation, operative mortality, and a composite outcome including any postoperative adverse event. Fractional polynomial equations were used to model the relationship between LVEF and outcomes so we could account for nonlinear relationships if present. Adjustments for confounders were made using multivariable logistic regression and Cox models. RESULTS A total of 7,932 subjects were included in the study. After adjusting for patient and surgical characteristics, LVEF remained associated with the primary outcome as well as the composite outcome of any postoperative adverse event. Both these relationships were best described by a J-shaped curve given that higher LVEF values were associated with increased risk, albeit not as high has lower values. Regarding long-term mortality, individuals with a preoperative LVEF of 60% demonstrated the longest survival. A statistically significant relationship was not found between LVEF and operative mortality or atrial fibrillation after adjustment for confounders. CONCLUSIONS Higher preoperative LVEF values may be associated with increased risk for patients undergoing CABG surgery. Future studies are needed to better characterise this phenotype.
Collapse
Affiliation(s)
- Michael D Maile
- Division of Critical Care Medicine, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA. https://twitter.com/MikeMaile_MD
| | - Michael R Mathis
- Division of Adult Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, IL, USA
| | - Thomas A Schwann
- Division of Cardiac Surgery, Department of Surgery, University of Massachusetts, University of Massachusetts-Baystate, Springfield, MA, USA
| | - Milo C Engoren
- Division of Critical Care Medicine, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
7
|
Vignon P. Continuous cardiac output assessment or serial echocardiography during septic shock resuscitation? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:797. [PMID: 32647722 PMCID: PMC7333154 DOI: 10.21037/atm.2020.04.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Septic shock is the leading cause of cardiovascular failure in the intensive care unit (ICU). Cardiac output is a primary component of global oxygen delivery to organs and a sensitive parameter of cardiovascular failure. Any mismatch between oxygen delivery and rapidly varying metabolic demand may result in tissue dysoxia, hence organ dysfunction. Since the intricate alterations of both vascular and cardiac function may rapidly and widely change over time, cardiac output should be measured repeatedly to characterize the type of shock, select the appropriate therapeutic intervention, and evaluate patient's response to therapy. Among the numerous techniques commercially available for measuring cardiac output, transpulmonary thermodilution (TPT) provides a continuous monitoring with external calibration capability, whereas critical care echocardiography (CCE) offers serial hemodynamic assessments. CCE allows early identification of potential sources of inaccuracy of TPT, including right ventricular failure, severe tricuspid or left-sided regurgitations, intracardiac shunt, very low flow states, or dynamic left ventricular outflow tract obstruction. In addition, CCE has the unique advantage of depicting the distinct components generating left ventricular stroke volume (large cavity size vs. preserved contractility), providing information on left ventricular diastolic properties and filling pressures, and assessing pulmonary artery pressure. Since inotropes may have deleterious effects if misused, their initiation should be based on the documentation of a cardiac dysfunction at the origin of the low flow state by CCE. Experts widely advocate using CCE as a first-line modality to initially evaluate the hemodynamic profile associated with shock, as opposed to more invasive techniques. Repeated assessments of both the efficacy (amplitude of the positive response) and tolerance (absence of side-effect) of therapeutic interventions are required to best guide patient management. Overall, TPT allowing continuous tracking of cardiac output variations and CCE appear complementary rather than mutually exclusive in patients with septic shock who require advanced hemodynamic monitoring.
Collapse
Affiliation(s)
- Philippe Vignon
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching hospital, Limoges, France.,Inserm CIC 1435, Dupuytren Teaching hospital, Limoges, France.,Faculty of Medicine, University of Limoges, Limoges, France
| |
Collapse
|
8
|
Goudelin M, Champy P, Amiel JB, Evrard B, Fedou AL, Daix T, François B, Vignon P. Left ventricular overloading identified by critical care echocardiography is key in weaning-induced pulmonary edema. Intensive Care Med 2020; 46:1371-1381. [PMID: 32377766 PMCID: PMC7223421 DOI: 10.1007/s00134-020-06061-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/17/2020] [Indexed: 01/15/2023]
Abstract
Purpose To assess the role of left ventricular overload and cumulated fluid balance in the development weaning-induced pulmonary edema (WIPO). Methods Ventilated patients in sinus rhythm with COPD and/or heart failure (ejection fraction ≤ 40%) were studied. Echocardiography was performed immediately before and during a 30-min spontaneous breathing trial (SBT) using a T-tube. Patients who failed were treated according to echocardiography results before undergoing a second SBT. Results Twelve of 59 patients failed SBT, all of them developing WIPO. Patients who succeeded SBT had lower body weight (− 2.5 kg [− 4.8; − 1] vs. + 0.75 kg [− 2.95; + 5.57]: p = 0.02) and cumulative fluid balance (− 2326 ml [− 3715; + 863] vs. + 143 ml [− 2654; + 4434]: p = 0.007) than those who developed WIPO. SBT-induced central hemodynamic changes were more pronounced in patients who developed WIPO, with higher E wave velocity (122 cm/s [92; 159] vs. 93 cm/s [74; 109]: p = 0.017) and E/A ratio (2.1 [1.2; 3.6] vs. 0.9 [0.8; 1.4]: p = 0.001), and shorter E wave deceleration time (85 ms [72; 125] vs. 147 ms [103; 175]: p = 0.004). After echocardiography-guided treatment, all patients who failed the first SBT were successfully extubated. Fluid balance was then negative (− 2224 ml [− 7056; + 100] vs. + 146 ml [− 2654; + 4434]: p = 0.005). Left ventricular filling pressures were lower (E/E′: 7.3 [5; 10.4] vs. 8.9 [5.9; 13.1]: p = 0.028); SBT-induced increase in E wave velocity (+ 10.6% [− 2.7/ + 18] vs. + 25.6% [+ 12.7/ + 49]: p = 0.037) and of mitral regurgitation area were significantly smaller. Conclusion In high-risk patients, WIPO appears related to overloaded left ventricle associated with excessive fluid balance. SBT-induced central hemodynamic changes monitored by CCE help in guiding therapy for successful weaning. Electronic supplementary material The online version of this article (10.1007/s00134-020-06061-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Marine Goudelin
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Pauline Champy
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Jean-Bernard Amiel
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Bruno Evrard
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Anne-Laure Fedou
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Thomas Daix
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Bruno François
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, 87000-Limoges, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, 87000-Limoges, France. .,Inserm CIC 1435, Dupuytren Teaching Hospital, 87000-Limoges, France. .,Faculty of Medicine, University of Limoges, 87000-Limoges, France. .,Réanimation Polyvalente, CHU Dupuytren, 2 Avenue Martin Luther king, 87000, Limoges, France.
| |
Collapse
|