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Jang HY, Song IK, Kim SH, Shin WJ. Frequency domain analysis of photoplethysmographic and arterial pressure waveforms for assessing hemodynamics in children with congenital heart surgery. Korean J Anesthesiol 2024; 77:205-216. [PMID: 38204171 PMCID: PMC10982536 DOI: 10.4097/kja.23433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Time-domain parameters are less reliable in children due to increased arterial and chest wall compliance. We assessed the ability of indices derived from frequency analysis of photoplethysmography (PPG) and arterial blood pressure (ABP) waveforms to predict the hemodynamic state in children undergoing congenital heart surgery. METHODS We analyzed waveforms after cardiopulmonary bypass period in 76 children who underwent total repair of congenital heart disease. Amplitude density of baseline and amplitude modulation in PPG and ABP by respiratory frequency were obtained using fast Fourier transform analysis and normalized by cardiac pulse height (representing respiratory modulations in venous blood [PPG-DC%] and in amplitude [PPG-AC%] at respiratory frequency). The ratio of amplitude density of PPG at the cardiac frequency (CF) to ABP-CF was used to assess vascular compliance. We assessed volume replacement (ml/kg) and vasoactive inotropic score (VIS). RESULTS Children requiring volume replacement > 10 ml/kg (15.8%) showed higher PPG-DC% than those not requiring it (median: 52.4%, 95% CI [24.8, 295.1] vs. 36.7% [10.7, 125.7], P = 0.017). In addition, children with a VIS > 7 (22.4%) showed higher PPG-CF/ABP-CF (3.6 [0.91, 10.8] vs. 1.2 [0.27, 5.5], P = 0.008). On receiver operating characteristic curve analysis, PPG-DC% predicted a higher fluid requirement (area under the curve: 0.71, 95% CI [0.604, 0.816], P = 0.009), while PPG-CF/ABP-CF predicted a higher VIS (0.714, [0.599, 0.812], P = 0.004). CONCLUSIONS Frequency domain analysis of PPG and ABP may assess hemodynamic status requiring fluid or vasoactive inotropic therapy after congenital heart surgery.
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Affiliation(s)
- Hwa-Young Jang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Kyung Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won-Jung Shin
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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2
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Giovanni SP, Seitz KP, Hough CL. Fluid Management in Acute Respiratory Failure. Crit Care Clin 2024; 40:291-307. [PMID: 38432697 PMCID: PMC10910130 DOI: 10.1016/j.ccc.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Fluid management in acute respiratory failure is an area of uncertainty requiring a delicate balance of resuscitation and fluid removal to manage hypoperfusion and avoidance of hypoxemia. Overall, a restrictive fluid strategy (minimizing fluid administration) and careful attention to overall fluid balance may be beneficial after initial resuscitation and does not have major side effects. Further studies are needed to improve our understanding of patients who will benefit from a restrictive or liberal fluid management strategy.
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Affiliation(s)
- Shewit P Giovanni
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mailing Code UHN67, Portland, OR 97239, USA.
| | - Kevin P Seitz
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1215 Medical Center North, 1161 21st Avenue South, Nashville, TN 37232, USA
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mailing Code UHN67, Portland, OR 97239, USA
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3
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De Backer D, Deutschman CS, Hellman J, Myatra SN, Ostermann M, Prescott HC, Talmor D, Antonelli M, Pontes Azevedo LC, Bauer SR, Kissoon N, Loeches IM, Nunnally M, Tissieres P, Vieillard-Baron A, Coopersmith CM. Surviving Sepsis Campaign Research Priorities 2023. Crit Care Med 2024; 52:268-296. [PMID: 38240508 DOI: 10.1097/ccm.0000000000006135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES To identify research priorities in the management, epidemiology, outcome, and pathophysiology of sepsis and septic shock. DESIGN Shortly after publication of the most recent Surviving Sepsis Campaign Guidelines, the Surviving Sepsis Research Committee, a multiprofessional group of 16 international experts representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, convened virtually and iteratively developed the article and recommendations, which represents an update from the 2018 Surviving Sepsis Campaign Research Priorities. METHODS Each task force member submitted five research questions on any sepsis-related subject. Committee members then independently ranked their top three priorities from the list generated. The highest rated clinical and basic science questions were developed into the current article. RESULTS A total of 81 questions were submitted. After merging similar questions, there were 34 clinical and ten basic science research questions submitted for voting. The five top clinical priorities were as follows: 1) what is the best strategy for screening and identification of patients with sepsis, and can predictive modeling assist in real-time recognition of sepsis? 2) what causes organ injury and dysfunction in sepsis, how should it be defined, and how can it be detected? 3) how should fluid resuscitation be individualized initially and beyond? 4) what is the best vasopressor approach for treating the different phases of septic shock? and 5) can a personalized/precision medicine approach identify optimal therapies to improve patient outcomes? The five top basic science priorities were as follows: 1) How can we improve animal models so that they more closely resemble sepsis in humans? 2) What outcome variables maximize correlations between human sepsis and animal models and are therefore most appropriate to use in both? 3) How does sepsis affect the brain, and how do sepsis-induced brain alterations contribute to organ dysfunction? How does sepsis affect interactions between neural, endocrine, and immune systems? 4) How does the microbiome affect sepsis pathobiology? 5) How do genetics and epigenetics influence the development of sepsis, the course of sepsis and the response to treatments for sepsis? CONCLUSIONS Knowledge advances in multiple clinical domains have been incorporated in progressive iterations of the Surviving Sepsis Campaign guidelines, allowing for evidence-based recommendations for short- and long-term management of sepsis. However, the strength of existing evidence is modest with significant knowledge gaps and mortality from sepsis remains high. The priorities identified represent a roadmap for research in sepsis and septic shock.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY
- Sepsis Research Lab, the Feinstein Institutes for Medical Research, Manhasset, NY
| | - Judith Hellman
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Ignacio-Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Leinster, Dublin, Ireland
| | | | - Pierre Tissieres
- Pediatric Intensive Care, Neonatal Medicine and Pediatric Emergency, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Antoine Vieillard-Baron
- Service de Medecine Intensive Reanimation, Hopital Ambroise Pare, Universite Paris-Saclay, Le Kremlin-Bicêtre, France
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4
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Loosen G, Conrad AM, Essert N, Boesing C, Hagmann M, Thiel M, Luecke T, Rocco PRM, Pelosi P, Krebs J. Preload Responsiveness in Patients With Acute Respiratory Distress Syndrome Managed With Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:53-61. [PMID: 37934718 DOI: 10.1097/mat.0000000000002054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
A restrictive fluid strategy is recommended in patients with acute respiratory distress syndrome (ARDS) managed with venovenous extracorporeal membrane oxygenation (VV ECMO). However, there are no established predictors for preload responsiveness in these patients. In 20 ARDS patients managed with VV ECMO, transesophageal echocardiography was used to repeatedly evaluate dynamic parameters of the left (velocity and stroke volume variation) and right ventricular outflow tract (velocity [respiratory variations of the maximal Doppler velocity in the truncus pulmonalis {ΔV max TP}] and velocity time integral [respiratory variation of the velocity time integral measured in the truncus pulmonalis {ΔVTI_TP}] variation in the truncus pulmonalis), the diameter variation in the superior and inferior vena cava and stroke volume variation measured by pulse contour analysis (SVV_PCA). Patients were categorized as responders and nonresponders according to an increase in stroke volume measured by echocardiography during a Passive Leg Raise Test with a cutoff value ≥10%. The final analysis includes 86 measurements. Predictive values for preload responsiveness were found for ΔV max TP (area under the curve [AUC] of 0.64), ΔVTI_TP (AUC 0.67), and SVV_PCA (AUC 0.74). In conclusion, SVV_PCA and, to a lesser extent, ΔV max TP and ΔVTI_TP are the most accurate parameters to predict preload responsiveness in ARDS patients managed with VV ECMO. Transesophageal echocardiography offers no advantages over pulse contour analysis for predicting preload responsiveness and provides only intermittent monitoring and assessment.
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Affiliation(s)
- Gregor Loosen
- From the Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Alice Marguerite Conrad
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Nils Essert
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Christoph Boesing
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Michael Hagmann
- Department of Computational Linguistics, University of Heidelberg, Heidelberg, Germany
- Interdisciplinary Centre for Scientific Computing, Statistical Natural Language Processing Group, University of Heidelberg, Heidelberg, Germany
| | - Manfred Thiel
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Thomas Luecke
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Department of Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Joerg Krebs
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
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Gu H, Yang L. Transesophageal echocardiography combined with ProAQT/PulsioFlex hemodynamic monitoring in anesthetic management of a patient with septic shock associated with septic cardiomyopathy: A case report. Clin Case Rep 2023; 11:e8266. [PMID: 38033696 PMCID: PMC10682247 DOI: 10.1002/ccr3.8266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/07/2023] [Accepted: 11/20/2023] [Indexed: 12/02/2023] Open
Abstract
Patients with septic shock complicated by septic cardiomyopathy (SCM) can be extremely ill and at high risk for mortality. If early assessment of cardiac function is neglected during treatment, sepsis may be further exacerbated. We report a 77-year-old male patient with severe septic shock who underwent intraoperative transesophageal echocardiography (TEE) because of progressive circulatory instability, SCM was diagnosed. Further perioperative treatment to support the circulation was successfully adjusted based on TEE and pulse index continuous cardiac output (CO) by ProAQT/PulsioFlex hemodynamic monitoring. We should consider a diagnosis of SCM in the perioperative period and perform ultrasonography routinely. The use of TEE with ProAQT/PulsioFlex offers a new option for anesthetic management.
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Affiliation(s)
- Hui Gu
- Department of AnesthesiologyWest China Hospital of Sichuan UniversityChengduSichuanChina
| | - Lei Yang
- Department of AnesthesiologyWest China Hospital of Sichuan UniversityChengduSichuanChina
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6
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Messina A, Calabrò L, Pugliese L, Lulja A, Sopuch A, Rosalba D, Morenghi E, Hernandez G, Monnet X, Cecconi M. Fluid challenge in critically ill patients receiving haemodynamic monitoring: a systematic review and comparison of two decades. Crit Care 2022; 26:186. [PMID: 35729632 PMCID: PMC9210670 DOI: 10.1186/s13054-022-04056-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Fluid challenges are widely adopted in critically ill patients to reverse haemodynamic instability. We reviewed the literature to appraise fluid challenge characteristics in intensive care unit (ICU) patients receiving haemodynamic monitoring and considered two decades: 2000–2010 and 2011–2021.
Methods
We assessed research studies and collected data regarding study setting, patient population, fluid challenge characteristics, and monitoring. MEDLINE, Embase, and Cochrane search engines were used. A fluid challenge was defined as an infusion of a definite quantity of fluid (expressed as a volume in mL or ml/kg) in a fixed time (expressed in minutes), whose outcome was defined as a change in predefined haemodynamic variables above a predetermined threshold.
Results
We included 124 studies, 32 (25.8%) published in 2000–2010 and 92 (74.2%) in 2011–2021, overall enrolling 6,086 patients, who presented sepsis/septic shock in 50.6% of cases. The fluid challenge usually consisted of 500 mL (76.6%) of crystalloids (56.6%) infused with a rate of 25 mL/min. Fluid responsiveness was usually defined by a cardiac output/index (CO/CI) increase ≥ 15% (70.9%). The infusion time was quicker (15 min vs 30 min), and crystalloids were more frequent in the 2011–2021 compared to the 2000–2010 period.
Conclusions
In the literature, fluid challenges are usually performed by infusing 500 mL of crystalloids bolus in less than 20 min. A positive fluid challenge response, reported in 52% of ICU patients, is generally defined by a CO/CI increase ≥ 15%. Compared to the 2000–2010 decade, in 2011–2021 the infusion time of the fluid challenge was shorter, and crystalloids were more frequently used.
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de Souza TB, Rubio AJ, Carioca FDL, Ferraz IDS, Brandão MB, Nogueira RJN, de Souza TH. Carotid doppler ultrasonography as a method to predict fluid responsiveness in mechanically ventilated children. Paediatr Anaesth 2022; 32:1038-1046. [PMID: 35748620 DOI: 10.1111/pan.14513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/31/2022] [Accepted: 06/19/2022] [Indexed: 11/26/2022]
Abstract
AIMS The aim of this study was to investigate whether respiratory variations in carotid and aortic blood flows measured by Doppler ultrasonography could accurately predict fluid responsiveness in critically ill children. METHODS This was a prospective single-center study including mechanically ventilated children who underwent fluid replacement at the discretion of the attending physician. Response to fluid load was defined by a stroke volume increase of more than 15%. Maximum and minimum values of velocity peaks were determined over one controlled respiratory cycle before and after volume expansion. Respiratory changes in velocity peak of the carotid (∆Vpeak_Ca) and aortic (∆Vpeak_Ao) blood flows were calculated as the difference between the maximum and minimum values divided by the mean of the two values and were expressed as a percentage. RESULTS A total of 30 patients were included, of which twelve (40%) were fluid responders and 18 (60%) non-responders. Before volume expansion, both ∆Vpeak_Ca and ∆Vpeak_Ao were higher in responders than in non-responders (17.1% vs 4.4%; p < .001 and 22.8% vs 6.4%; p < .001, respectively). ∆Vpeak_Ca could effectively predict fluid responsiveness (AUC 1.00, 95% CI 0.88-1.00), as well as ∆Vpeak_Ao (AUC 0.94, 95% CI 0.80-0.99). The best cutoff values were 10.6% for ∆Vpeak_Ca (sensitivity, specificity, positive predictive value and negative predictive value of 100%) and 18.2% for ∆Vpeak_Ao (sensitivity, 91.7%; specificity, 88.9%; positive predictive value, 84.6%; negative predictive value, 94.1%). Volume expansion-induced changes in stroke volume correlated with the ∆Vpeak_Ca and ∆Vpeak_Ao before volume expansion (ρ of 0.70 and 0.61, respectively; p < .001 for both). CONCLUSIONS Analysis of respiratory changes in carotid and aortic blood flows are accurate methods for predicting fluid responsiveness in children under invasive mechanical ventilation.
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Affiliation(s)
- Thalita Belato de Souza
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Aline Junqueira Rubio
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Fernando de Lima Carioca
- Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Isabel de Siqueira Ferraz
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Marcelo Barciela Brandão
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Roberto José Negrão Nogueira
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Tiago Henrique de Souza
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, SP, Brazil
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Lin EE, Glau C, Conlon TW, Chen AE, Kaplan SL, Posada A, Nishisaki A. The association between carotid flow time and fluid responsiveness in children under general anesthesia. Paediatr Anaesth 2022; 32:1047-1053. [PMID: 35735131 DOI: 10.1111/pan.14510] [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: 04/27/2022] [Revised: 06/04/2022] [Accepted: 06/16/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Fluid administration in children undergoing surgery requires precision, however, determining fluid responsiveness can be challenging. Ultrasound has been used widely in the emergency department and intensive care units as a noninvasive, bedside manner of determining volume status, but the intraoperative period presents unique challenges as often the chest and abdomen are inaccessible for ultrasound. We investigate whether carotid artery ultrasound, specifically carotid flow time, can be used to determine fluid responsiveness in children under general anesthesia. METHODS Prospective observational study of 87 children ages 1-12 years who were scheduled for elective noncardiac surgery. Ultrasound of the carotid artery and heart was performed at three time points: (1) after inhalational induction of anesthesia with the subject spontaneously breathing, (2) during positive pressure ventilation through endotracheal tube or supraglottic airway with tidal volume set at 8 ml/kg with PEEP of 10 cmH2 O, and (3) after a 10 ml/kg fluid bolus. Carotid flow time and cardiac output were measured from saved images. RESULTS Corrected carotid flow time (FTc) increased with initiation of positive pressure ventilation in both fluid responders and nonresponders (352.7 vs. 365.3 msec, p = .005 in fluid responders; 348.3 vs. 365.2 msec, p = .001 in nonresponders). FTc increased after fluid bolus in both responders and nonresponders (365.3 vs. 397.6 msec, p < .001 in fluid responders; 365.2 vs. 397.2 msec, p < .001 in nonresponders). However, baseline FTc during spontaneous ventilation or positive pressure ventilation prior to fluid bolus was not associated with fluid responsiveness. DISCUSSION Flow time increases with initiation of positive pressure ventilation and after administration of a fluid bolus. FTc may serve as an indicator of fluid status but does not predict fluid responsiveness in children under general anesthesia.
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Affiliation(s)
- Elaina E Lin
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine and the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christie Glau
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine and the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas W Conlon
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine and the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aaron E Chen
- Perelman School of Medicine and the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Pediatric Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Summer L Kaplan
- Perelman School of Medicine and the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Adriana Posada
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine and the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Monnet X, Shi R, Teboul JL. Prediction of fluid responsiveness. What’s new? Ann Intensive Care 2022; 12:46. [PMID: 35633423 PMCID: PMC9148319 DOI: 10.1186/s13613-022-01022-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023] Open
Abstract
AbstractAlthough the administration of fluid is the first treatment considered in almost all cases of circulatory failure, this therapeutic option poses two essential problems: the increase in cardiac output induced by a bolus of fluid is inconstant, and the deleterious effects of fluid overload are now clearly demonstrated. This is why many tests and indices have been developed to detect preload dependence and predict fluid responsiveness. In this review, we take stock of the data published in the field over the past three years. Regarding the passive leg raising test, we detail the different stroke volume surrogates that have recently been described to measure its effects using minimally invasive and easily accessible methods. We review the limits of the test, especially in patients with intra-abdominal hypertension. Regarding the end-expiratory occlusion test, we also present recent investigations that have sought to measure its effects without an invasive measurement of cardiac output. Although the limits of interpretation of the respiratory variation of pulse pressure and of the diameter of the vena cava during mechanical ventilation are now well known, several recent studies have shown how changes in pulse pressure variation itself during other tests reflect simultaneous changes in cardiac output, allowing these tests to be carried out without its direct measurement. This is particularly the case during the tidal volume challenge, a relatively recent test whose reliability is increasingly well established. The mini-fluid challenge has the advantage of being easy to perform, but it requires direct measurement of cardiac output, like the classic fluid challenge. Initially described with echocardiography, recent studies have investigated other means of judging its effects. We highlight the problem of their precision, which is necessary to evidence small changes in cardiac output. Finally, we point out other tests that have appeared more recently, such as the Trendelenburg manoeuvre, a potentially interesting alternative for patients in the prone position.
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10
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Comparison of vena cava distensibility index and pulse pressure variation for the evaluation of intravascular volume in critically ill children. J Pediatr (Rio J) 2022; 98:99-103. [PMID: 34052225 PMCID: PMC9432067 DOI: 10.1016/j.jped.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE In this study, the authors aimed to evaluate the effectiveness of the vena cava distensibility index and pulse pressure variation as dynamic parameters for estimating intravascular volume in critically ill children. METHODS Patients aged 1 month to 18 years, who were hospitalized in the present study's pediatric intensive care unit, were included in the study. The patients were divided into two groups according to central venous pressure: hypovolemic (< 8 mmHg) and non-hypovolemic (central venous pressure ≥ 8 mmHg) groups. In both groups, vena cava distensibility index was measured using bedside ultrasound and pulse pressure variation. Measurements were recorded and evaluated under arterial monitoring. RESULTS In total, 19 (47.5%) of the 40 subjects included in the study were assigned to the central venous pressure ≥ 8 mmHg group, and 21 (52.5%) to the central venous pressure < 8 mmHg group. A moderate positive correlation was found between pulse pressure variation and vena cava distensibility index (r = 0.475, p < 0.01), while there were strong negative correlations of central venous pressure with pulse pressure variation and vena cava distensibility index (r = -0.628, p < 0.001 and r = -0.760, p < 0.001, respectively). In terms of predicting hypovolemia, the predictive power for vena cava distensibility index was > 16% (sensitivity, 90.5%; specificity, 94.7%) and that for pulse pressure variation was > 14% (sensitivity, 71.4%; specificity, 89.5%). CONCLUSION Vena cava distensibility index has higher sensitivity and specificity than pulse pressure variation for estimating intravascular volume, along with the advantage of non-invasive bedside application.
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11
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Su L, Pan P, He H, Liu D, Long Y. PPV May Be a Starting Point to Achieve Circulatory Protective Mechanical Ventilation. Front Med (Lausanne) 2021; 8:745164. [PMID: 34926495 PMCID: PMC8674583 DOI: 10.3389/fmed.2021.745164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/20/2021] [Indexed: 11/16/2022] Open
Abstract
Pulse pressure variation (PPV) is a mandatory index for hemodynamic monitoring during mechanical ventilation. The changes in pleural pressure (Ppl) and transpulmonary pressure (PL) caused by mechanical ventilation are the basis for PPV and lead to the effect of blood flow. If the state of hypovolemia exists, the effect of the increased Ppl during mechanical ventilation on the right ventricular preload will mainly affect the cardiac output, resulting in a positive PPV. However, PL is more influenced by the change in alveolar pressure, which produces an increase in right heart overload, resulting in high PPV. In particular, if spontaneous breathing is strong, the transvascular pressure will be extremely high, which may lead to the promotion of alveolar flooding and increased RV flow. Asynchronous breathing and mediastinal swing may damage the pulmonary circulation and right heart function. Therefore, according to the principle of PPV, a high PPV can be incorporated into the whole respiratory treatment process to monitor the mechanical ventilation cycle damage/protection regardless of the controlled ventilation or spontaneous breathing. Through the monitoring of PPV, the circulation-protective ventilation can be guided at bedside in real time by PPV.
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Affiliation(s)
- Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Pan Pan
- College of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Dawei Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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12
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Vallabhajosyula S, Shankar A, Vojjini R, Cheungpasitporn W, Sundaragiri PR, DuBrock HM, Sekiguchi H, Frantz RP, Cajigas HR, Kane GC, Oh JK. Impact of Right Ventricular Dysfunction on Short-term and Long-term Mortality in Sepsis. Chest 2021; 159:2254-2263. [DOI: 10.1016/j.chest.2020.12.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 11/27/2020] [Accepted: 12/04/2020] [Indexed: 12/12/2022] Open
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13
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Graessler MF, Wodack KH, Pinnschmidt HO, Nishimoto S, Behem CR, Reuter DA, Trepte CJC. Assessing volume responsiveness using right ventricular dynamic indicators of preload. J Anesth 2021; 35:488-494. [PMID: 33950295 PMCID: PMC8096889 DOI: 10.1007/s00540-021-02937-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 04/18/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Dynamic indicators of preload currently only do reflect preload requirements of the left ventricle. To date, no dynamic indicators of right ventricular preload have been established. The aim of this study was to calculate dynamic indicators of right ventricular preload and assess their ability to predict ventricular volume responsiveness. MATERIALS AND METHODS The study was designed as experimental trial in 20 anaesthetized pigs. Micro-tip catheters and ultrasonic flow probes were used as experimental reference to enable measurement of right ventricular stroke volume and pulse pressure. Hypovolemia was induced (withdrawal of blood 20 ml/kg) and thereafter three volume-loading steps were performed. ROC analysis was performed to assess the ability of dynamic right ventricular parameters to predict volume response. RESULTS ROC analysis revealed an area under the curve (AUC) of 0.82 (CI 95% 0.73-0.89; p < 0.001) for right ventricular stroke volume variation (SVVRV), an AUC of 0.72 (CI 95% 0.53-0.85; p = 0.02) for pulmonary artery pulse pressure variation (PPVPA) and an AUC of 0.66 (CI 95% 0.51-0.79; p = 0.04) for pulmonary artery systolic pressure variation (SPVPA). CONCLUSIONS In our experimental animal setting, calculating dynamic indicators of right ventricular preload is possible and appears promising in predicting volume responsiveness.
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Affiliation(s)
- Michael F Graessler
- Department of Anesthesiology, Centre for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Karin H Wodack
- Department of Anesthesiology, Centre for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hans O Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Nishimoto
- Department of Anesthesiology, Centre for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | | | - Daniel A Reuter
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany
| | - Constantin J C Trepte
- Department of Anesthesiology, Centre for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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14
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Comments on "Right ventricular failure in septic shock: characterization, incidence and impact on fluid responsiveness": which parameter to assess right ventricular failure and venous congestion? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:136. [PMID: 33836816 PMCID: PMC8034069 DOI: 10.1186/s13054-021-03473-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/13/2021] [Indexed: 11/21/2022]
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15
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Respiratory Variation in Aortic Blood Flow Velocity in Hemodynamically Unstable, Ventilated Neonates: A Pilot Study of Fluid Responsiveness. Pediatr Crit Care Med 2021; 22:380-391. [PMID: 33315755 DOI: 10.1097/pcc.0000000000002628] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To assess whether respiratory variation in aortic blood flow peak velocity can predict preload responsiveness in mechanically ventilated and hemodynamically unstable neonates. DESIGN Prospective observational diagnostic accuracy study. SETTING Third-level neonatal ICU. PATIENTS Hemodynamically unstable neonates under mechanical ventilation. INTERVENTIONS Fluid challenge with 10 mL/kg of normal saline over 20 minutes. MEASUREMENTS AND MAIN RESULTS Respiratory variation in aortic blood flow peak velocity and superior vena cava flow were measured at baseline (T0), immediately upon completion of the fluid infusion (T1), and at 1 hour after fluid administration (T2). Our main outcome was preload responsiveness which was defined as an increase in superior vena cava flow of at least 10% from T0 to T1. Forty-six infants with a median (interquartile range) gestational age of 30.5 weeks (28-36 wk) were included. Twenty-nine infants (63%) were fluid responders, and 17 (37%) were nonresponders Fluid responders had a higher baseline (T0) respiratory variation in aortic blood flow peak velocity than nonresponders (9% [8.2-10.8] vs 5.5% [3.7-6.6]; p < 0.001). Baseline respiratory variation in aortic blood flow peak velocity was correlated with the increase in superior vena cava flow from T0 to T1 (rho = 0.841; p < 0.001). The area under the receiver operating characteristic curve of respiratory variation in aortic blood flow peak velocity to predict preload responsiveness was 0.912 (95% CI, 0.82-1). A respiratory variation in aortic blood flow peak velocity cut-off point of 7.8% provided a 90% sensitivity (95% CI, 71-97), 88% specificity (95% CI, 62-98), 7.6 positive likelihood ratio (95% CI, 2-28), and 0.11 negative likelihood ratio (95% CI, 0.03-0.34) to predict preload responsiveness. CONCLUSIONS Respiratory variation in aortic blood flow velocity may be useful to predict the immediate response to a fluid challenge in hemodynamically unstable neonates under mechanical ventilation. If our results are confirmed, this measurement could be used to guide safe and individualized fluid resuscitation in critically ill neonates.
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16
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Trauzeddel RF, Ertmer M, Nordine M, Groesdonk HV, Michels G, Pfister R, Reuter D, Scheeren TWL, Berger C, Treskatsch S. Perioperative echocardiography-guided hemodynamic therapy in high-risk patients: a practical expert approach of hemodynamically focused echocardiography. J Clin Monit Comput 2021; 35:229-243. [PMID: 32458170 PMCID: PMC7943502 DOI: 10.1007/s10877-020-00534-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/19/2020] [Indexed: 12/15/2022]
Abstract
The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy.
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Affiliation(s)
- R. F. Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - M. Ertmer
- Department of Anesthesiology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - M. Nordine
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - H. V. Groesdonk
- Department of Interdisciplinary Intensive Care Medicine and Intermediate Care, Helios Hospital Erfurt, Erfurt, Germany
| | - G. Michels
- Department of Internal Medicine III, Heart Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - R. Pfister
- Department of Internal Medicine III, Heart Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - D. Reuter
- Department of Anesthesiology and Intensive Care Medicine, University of Rostock, Rostock, Germany
| | - T. W. L. Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - C. Berger
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - S. Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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17
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Balthazar T, Vandenbriele C, Verbrugge FH, Den Uil C, Engström A, Janssens S, Rex S, Meyns B, Van Mieghem N, Price S, Adriaenssens T. Managing Patients With Short-Term Mechanical Circulatory Support: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 77:1243-1256. [PMID: 33663742 DOI: 10.1016/j.jacc.2020.12.054] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/23/2020] [Accepted: 12/07/2020] [Indexed: 12/21/2022]
Abstract
The use of mechanical circulatory support for patients presenting with cardiogenic shock is rapidly increasing. Currently, there is only limited and conflicting evidence available regarding the role of the Impella (a microaxial, continuous-flow, short-term, left or right ventricular assist device) in cardiogenic shock; further randomized trials are needed. Patient selection, timing of implantation, and post-implantation management in the cardiac intensive care unit are crucial elements for success. Particular challenges at the bedside include the practical management of anticoagulation, evaluation of correct device position, and the approach to use in a patient with signs of insufficient hemodynamic support. Profound knowledge of these issues is required to enable the maximal potential of the device. This review provides a comprehensive overview of the short-term assist device and describes a practical approach to optimize care for patients supported with the device.
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Affiliation(s)
- Tim Balthazar
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Department of Adult Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Frederik H Verbrugge
- Department of Cardiovascular Diseases, University Hospitals Brussels, Brussels, Belgium; Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Corstiaan Den Uil
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands; Department of Cardiology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Annemarie Engström
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands; Department of Cardiology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Stefan Janssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Nicolas Van Mieghem
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Susanna Price
- Department of Adult Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Tom Adriaenssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
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18
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Sanfilippo F, Huang S, Herpain A, Balik M, Chew MS, Clau-Terré F, Corredor C, De Backer D, Fletcher N, Geri G, Mekontso-Dessap A, McLean A, Morelli A, Orde S, Petrinic T, Slama M, van der Horst ICC, Vignon P, Mayo P, Vieillard-Baron A. The PRICES statement: an ESICM expert consensus on methodology for conducting and reporting critical care echocardiography research studies. Intensive Care Med 2020; 47:1-13. [PMID: 33275163 DOI: 10.1007/s00134-020-06262-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/25/2020] [Indexed: 01/19/2023]
Abstract
PURPOSE Echocardiography is a common tool for cardiac and hemodynamic assessments in critical care research. However, interpretation (and applications) of results and between-study comparisons are often difficult due to the lack of certain important details in the studies. PRICES (Preferred Reporting Items for Critical care Echocardiography Studies) is a project endorsed by the European Society of Intensive Care Medicine and conducted by the Echocardiography Working Group, aiming at producing recommendations for standardized reporting of critical care echocardiography (CCE) research studies. METHODS The PRICE panel identified lists of clinical and echocardiographic parameters (the "items") deemed important in four main areas of CCE research: left ventricular systolic and diastolic functions, right ventricular function and fluid management. Each item was graded using a critical index (CI) that combined the relative importance of each item and the fraction of studies that did not report it, also taking experts' opinion into account. RESULTS A list of items in each area that deemed essential for the proper interpretation and application of research results is recommended. Additional items which aid interpretation were also proposed. CONCLUSION The PRICES recommendations reported in this document, as a checklist, represent an international consensus of experts as to which parameters and information should be included in the design of echocardiography research studies. PRICES recommendations provide guidance to scientists in the field of CCE with the objective of providing a recommended framework for reporting of CCE methodology and results.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, Policlinico-Vittorio Emanuele University Hospital, Catania, Italy
| | - Stephen Huang
- Intensive Care Unit, Nepean Hospital, The University of Sydney, Sydney, Australia
| | - Antoine Herpain
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Martin Balik
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Michelle S Chew
- Department of Anaesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Fernando Clau-Terré
- Department of Anaesthesiology and Critical Care Medicine, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Carlos Corredor
- Department of Perioperative Medicine, Bart's Heart Centre St. Bartholomew's Hospital, W. Smithfield, London, UK
| | - Daniel De Backer
- CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Nick Fletcher
- Cardiothoracic Critical Care, St Georges Hospital, St Georges University of London, London, UK
| | - Guillaume Geri
- Intensive Care Medicine Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France.,INSERM UMR-1018, CESP, Team Kidney and Heart, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| | - Armand Mekontso-Dessap
- Service de réanimation médicale, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, 51 Avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France
| | - Anthony McLean
- Intensive Care Unit, Nepean Hospital, The University of Sydney, Sydney, Australia
| | - Andrea Morelli
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Viale del Policlinico, Rome, Italy
| | - Sam Orde
- Intensive Care Unit, Nepean Hospital, The University of Sydney, Sydney, Australia
| | - Tatjana Petrinic
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Michel Slama
- Medical Intensive Care Unit, Amiens University Hospital, Amiens, France
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Centre+, University Maastricht, Maastricht, The Netherlands
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, Inserm CIC 1435, Limoges University Hospital, Limoges, France
| | - Paul Mayo
- Division of Pulmonary, Critical Care and Sleep Medicine, Northwell Health LIJ/NSUH Medical Center, Zucker School of Medicine, Hofstra/Northwell, Hempstead, USA
| | - Antoine Vieillard-Baron
- Intensive Care Medicine Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France. .,INSERM UMR-1018, CESP, Team Kidney and Heart, University of Versailles Saint-Quentin en Yvelines, Villejuif, France.
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19
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Vignon P, Evrard B, Asfar P, Busana M, Calfee CS, Coppola S, Demiselle J, Geri G, Jozwiak M, Martin GS, Gattinoni L, Chiumello D. Fluid administration and monitoring in ARDS: which management? Intensive Care Med 2020; 46:2252-2264. [PMID: 33169217 PMCID: PMC7652045 DOI: 10.1007/s00134-020-06310-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/22/2020] [Indexed: 12/22/2022]
Abstract
Modalities of fluid management in patients sustaining the acute respiratory distress syndrome (ARDS) are challenging and controversial. Optimal fluid management should provide adequate oxygen delivery to the body, while avoiding inadvertent increase in lung edema which further impairs gas exchange. In ARDS patients, positive fluid balance has been associated with prolonged mechanical ventilation, longer ICU and hospital stay, and higher mortality. Accordingly, a restrictive strategy has been compared to a more liberal approach in randomized controlled trials conducted in various clinical settings. Restrictive strategies included fluid restriction guided by the monitoring of extravascular lung water, pulmonary capillary wedge or central venous pressure, and furosemide targeted to diuresis and/or albumin replacement in hypoproteinemic patients. Overall, restrictive strategies improved oxygenation significantly and reduced duration of mechanical ventilation, but had no significant effect on mortality. Fluid management may require different approaches depending on the time course of ARDS (i.e., early vs. late period). The effects of fluid strategy management according to ARDS phenotypes remain to be evaluated. Since ARDS is frequently associated with sepsis-induced acute circulatory failure, the prediction of fluid responsiveness is crucial in these patients to avoid hemodynamically inefficient—hence respiratory detrimental—fluid administration. Specific hemodynamic indices of fluid responsiveness or mini-fluid challenges should be preferably used. Since the positive airway pressure contributes to positive fluid balance in ventilated ARDS patients, it should be kept as low as possible. As soon as the hemodynamic status is stabilized, correction of cumulated fluid retention may rely on diuretics administration or renal replacement therapy.
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Affiliation(s)
- 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. .,Réanimation Polyvalente, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France.
| | - Bruno Evrard
- 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
| | - Pierre Asfar
- Service de Médecine Intensive Réanimation, Médecine Hyperbare, CHU Angers, 4 rue Larrey 49933, Angers Cedex 9, France
| | - Mattia Busana
- Department of Anesthesiology and Intensive Care Medicine, University of Göttingen Medical Center, Göttingen, Germany
| | - Carolyn S Calfee
- Departments of Medicine and Anesthesia, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Silvia Coppola
- SC Anestesia e Rianimazione, Ospedale San Paolo, Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Dipartimento di Scienze Della Salute, Università Degli Studi Di Milano, Milan, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Milan, Italy
| | - Julien Demiselle
- Service de Médecine Intensive Réanimation, Médecine Hyperbare, CHU Angers, 4 rue Larrey 49933, Angers Cedex 9, France
| | - Guillaume Geri
- Medical-Surgical Intensive Care Unit, Ambroise Paré University Hospital, APHP, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France.,Paris-Saclay University, Saint-Aubin, France.,Inserm UMR-1018, CESP, Villejuif, France
| | - Mathieu Jozwiak
- Medical Intensive Care Unit, University Hospital, APHP, Centre, Cochin Hospital, 27 rue du faubourg Saint Jacques, 75014, Paris, France.,Paris University, Paris, France
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine and Grady Memorial Hospital, Atlanta, GA, USA
| | - Luciano Gattinoni
- Department of Anesthesiology and Intensive Care Medicine, University of Göttingen Medical Center, Göttingen, Germany
| | - Davide Chiumello
- SC Anestesia e Rianimazione, Ospedale San Paolo, Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Dipartimento di Scienze Della Salute, Università Degli Studi Di Milano, Milan, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Milan, Italy
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20
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Vieillard-Baron A, Prigent A, Repessé X, Goudelin M, Prat G, Evrard B, Charron C, Vignon P, Geri G. Right ventricular failure in septic shock: characterization, incidence and impact on fluid responsiveness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:630. [PMID: 33131508 PMCID: PMC7603714 DOI: 10.1186/s13054-020-03345-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/14/2020] [Indexed: 11/30/2022]
Abstract
Objective Incidence of right ventricular (RV) failure in septic shock patients is not well known, and tricuspid annular plane systolic excursion (TAPSE) could be of limited value. We report the incidence of RV failure in patients with septic shock, its potential impact on the response to fluids, as well as TAPSE values. Design Ancillary study of the HEMOPRED prospective multicenter study includes patients under mechanical ventilation with circulatory failure. Setting This is a multicenter intensive care unit study Patients Two hundred and eighty-two patients with septic shock were analyzed. Patients were classified in three groups based on central venous pressure (CVP) and RV size (RV/LV end-diastolic area, EDA). In group 1, patients had no RV dilatation (RV/LVEDA < 0.6). In group 2, patients had RV dilatation (RV/LVEDA ≥ 0.6) with a CVP < 8 mmHg (no venous congestion). RV failure was defined in group 3 by RV dilatation and a CVP ≥ 8 mmHg. Pulse pressure variation (PPV) was systematically recorded. Interventions None. Measurements and main results In total, 41% of patients were in group 1, 17% in group 2 and 42% in group 3. A correlation between RV size and CVP was only observed in group 3. Higher RV size was associated with a lower response to passive leg raising for a given PPV. A large overlap of TAPSE values was observed between the 3 groups. 63.5% of patients with RV failure had a normal TAPSE. Conclusions RV failure, defined by critical care echocardiography (RV dilatation) and a surrogate of venous congestion (CVP ≥ 8 mmHg), was frequently observed in septic shock patients and negatively associated with response to a fluid challenge despite significant PPV. TAPSE was unable to discriminate patients with or without RV failure.
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Affiliation(s)
- Antoine Vieillard-Baron
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Pare, Boulogne Billancourt, France. .,Faculty of Medicine Simone Veil, Saint Quentin en Yvelines, France. .,Inserm U1018, Center for Research in Epidemiology and Population Health (CESP), Faculty of Paris Saclay, Villejuif, France.
| | - Amélie Prigent
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Pare, Boulogne Billancourt, France.,Faculty of Medicine Simone Veil, Saint Quentin en Yvelines, France
| | - Xavier Repessé
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Pare, Boulogne Billancourt, France
| | - Marine Goudelin
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Pare, Boulogne Billancourt, France
| | - Gwenaël Prat
- Intensive Care Unit, Brest University Hospital, Brest, France
| | - Bruno Evrard
- Intensive Care Unit, Limoges University Hospital, Limoges, France
| | - Cyril Charron
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Pare, Boulogne Billancourt, France
| | - Philippe Vignon
- Intensive Care Unit, Limoges University Hospital, Limoges, France.,INSERM CIC 1435, Limoges University Hospital, Limoges, France.,Faculty of Medicine, University of Limoges, Limoges, France
| | - Guillaume Geri
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Pare, Boulogne Billancourt, France.,Faculty of Medicine Simone Veil, Saint Quentin en Yvelines, France.,Inserm U1018, Center for Research in Epidemiology and Population Health (CESP), Faculty of Paris Saclay, Villejuif, France
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21
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De Backer D, Vincent JL. Noninvasive Monitoring in the Intensive Care Unit. Semin Respir Crit Care Med 2020; 42:40-46. [PMID: 33065744 DOI: 10.1055/s-0040-1718387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
There has been considerable development in the field of noninvasive hemodynamic monitoring in recent years. Multiple devices have been proposed to assess blood pressure, cardiac output, and tissue perfusion. All have their own advantages and disadvantages and selection should be based on individual patient requirements and disease severity and adjusted according to ongoing patient evolution.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
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22
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Algahtani R, Merenda A. Multimorbidity and Critical Care Neurosurgery: Minimizing Major Perioperative Cardiopulmonary Complications. Neurocrit Care 2020; 34:1047-1061. [PMID: 32794145 PMCID: PMC7426068 DOI: 10.1007/s12028-020-01072-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/28/2020] [Indexed: 11/19/2022]
Abstract
With increasing prevalence of chronic diseases, multimorbid patients have become commonplace in the neurosurgical intensive care unit (neuro-ICU), offering unique management challenges. By reducing physiological reserve and interacting with one another, chronic comorbidities pose a greatly enhanced risk of major postoperative medical complications, especially cardiopulmonary complications, which ultimately exert a negative impact on neurosurgical outcomes. These premises underscore the importance of perioperative optimization, in turn requiring a thorough preoperative risk stratification, a basic understanding of a multimorbid patient’s deranged physiology and a proper appreciation of the potential of surgery, anesthesia and neurocritical care interventions to exacerbate comorbid pathophysiologies. This knowledge enables neurosurgeons, neuroanesthesiologists and neurointensivists to function with a heightened level of vigilance in the care of these high-risk patients and can inform the perioperative neuro-ICU management with individualized strategies able to minimize the risk of untoward outcomes. This review highlights potential pitfalls in the intra- and postoperative neuro-ICU period, describes common preoperative risk stratification tools and discusses tailored perioperative ICU management strategies in multimorbid neurosurgical patients, with a special focus on approaches geared toward the minimization of postoperative cardiopulmonary complications and unplanned reintubation.
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Affiliation(s)
- Rami Algahtani
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Amedeo Merenda
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA. .,Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA.
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Affiliation(s)
- Siddharth P Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, United States.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, United States
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States .,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States
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Accuracy of a multiparametric score based on pulse wave analysis for prediction of fluid responsiveness: ancillary analysis of an observational study. Can J Anaesth 2020; 67:1162-1169. [PMID: 32500514 PMCID: PMC7271959 DOI: 10.1007/s12630-020-01736-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/28/2020] [Accepted: 04/01/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose The pressure recording analytical method (PRAM) monitor is a non-invasive pulse contour cardiac output (CO) device that cannot be considered interchangeable with the gold standard for CO estimation. It, however, generates additional hemodynamic indices that need to be evaluated. Our objective was to investigate the performance of a multiparametric predictive score based on a combination of several parameters generated by the PRAM monitor to predict fluid responsiveness. Methods Secondary analysis of a prospective observational study from April 2016 to December 2017 in two French teaching hospitals. We included critically ill patients who were monitored by esophageal Doppler monitoring and an invasive arterial line, and received a 250–500 mL crystalloid fluid challenge. The main outcome measure was the predictive score discrimination evaluated by the area under the receiver operating characteristics curve. Results The three baseline PRAM-derived parameters associated with fluid responsiveness in univariate analysis were pulse pressure variation, cardiac cycle efficiency, and arterial elastance (P < 0.01, P = 0.03, and P < 0.01, respectively). The median [interquartile range] predictive score, calculated after discretization of these parameters according to their optimal threshold value was 3 [2–3] in fluid responders and 1 [1–2] in fluid non-responders, respectively (P < 0.001). The area under the curve of the predictive score was 0.807 (95% confidence interval, 0.662 to 0.909; P < 0.001). Conclusion A multiparametric score combining three parameters generated by the PRAM monitor can predict fluid responsiveness with good positive and negative predictive values in intensive care unit patients. Electronic supplementary material The online version of this article (10.1007/s12630-020-01736-y) contains supplementary material, which is available to authorized users.
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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.
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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
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Teboul JL, Monnet X, Chemla D, Michard F. Arterial Pulse Pressure Variation with Mechanical Ventilation. Am J Respir Crit Care Med 2019; 199:22-31. [PMID: 30138573 DOI: 10.1164/rccm.201801-0088ci] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Fluid administration leads to a significant increase in cardiac output in only half of ICU patients. This has led to the concept of assessing fluid responsiveness before infusing fluid. Pulse pressure variation (PPV), which quantifies the changes in arterial pulse pressure during mechanical ventilation, is one of the dynamic variables that can predict fluid responsiveness. The underlying hypothesis is that large respiratory changes in left ventricular stroke volume, and thus pulse pressure, occur in cases of biventricular preload responsiveness. Several studies showed that PPV accurately predicts fluid responsiveness when patients are under controlled mechanical ventilation. Nevertheless, in many conditions encountered in the ICU, the interpretation of PPV is unreliable (spontaneous breathing, cardiac arrhythmias) or doubtful (low Vt). To overcome some of these limitations, researchers have proposed using simple tests such as the Vt challenge to evaluate the dynamic response of PPV. The applicability of PPV is higher in the operating room setting, where fluid strategies made on the basis of PPV improve postoperative outcomes. In medical critically ill patients, although no randomized controlled trial has compared PPV-based fluid management with standard care, the Surviving Sepsis Campaign guidelines recommend using fluid responsiveness indices, including PPV, whenever applicable. In conclusion, PPV is useful for managing fluid therapy under specific conditions where it is reliable. The kinetics of PPV during diagnostic or therapeutic tests is also helpful for fluid management.
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Affiliation(s)
| | - Xavier Monnet
- 1 Medical Intensive Care Unit, Bicetre Hospital, and
| | - Denis Chemla
- 2 Department of Physiology, Bicetre Hospital, Paris-South University Hospitals, Inserm UMR_S999, Paris-South University, Le Kremlin-Bicêtre, France; and
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Joosten A, Boudart C, Vincent JL, Vanden Eynden F, Barvais L, Van Obbergh L, Rinehart J, Desebbe O. Ability of a New Smartphone Pulse Pressure Variation and Cardiac Output Application to Predict Fluid Responsiveness in Patients Undergoing Cardiac Surgery. Anesth Analg 2019; 128:1145-1151. [PMID: 31094781 DOI: 10.1213/ane.0000000000003652] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pulse pressure variation (PPV) can be used to predict fluid responsiveness in anesthetized patients receiving controlled mechanical ventilation but usually requires dedicated advanced monitoring. Capstesia (Galenic App, Vitoria-Gasteiz, Spain) is a novel smartphone application that calculates PPV and cardiac output (CO) from a picture of the invasive arterial pressure waveform obtained from any monitor screen. The primary objective was to compare the ability of PPV obtained using the Capstesia (PPVCAP) and PPV obtained using a pulse contour analysis monitor (PPVPC) to predict fluid responsiveness. A secondary objective was to assess the agreement and the trending of CO values obtained with the Capstesia (COCAP) against those obtained with the transpulmonary bolus thermodilution method (COTD). METHODS We studied 57 mechanically ventilated patients (tidal volume 8 mL/kg, positive end-expiratory pressure 5 mm Hg, respiratory rate adjusted to keep end tidal carbon dioxide [32-36] mm Hg) undergoing elective coronary artery bypass grafting. COTD, COCAP, PPVCAP, and PPVPC were measured before and after infusion of 5 mL/kg of a colloid solution. Fluid responsiveness was defined as an increase in COTD of >10% from baseline. The ability of PPVCAP and PPVPC to predict fluid responsiveness was analyzed using the area under the receiver-operating characteristic curve (AUROC), the agreement between COCAP and COTD using a Bland-Altman analysis and the trending ability of COCAP compared to COTD after volume expansion using a 4-quadrant plot analysis. RESULTS Twenty-eight patients were studied before surgical incision and 29 after sternal closure. There was no significant difference in the ability of PPVCAP and PPVPC to predict fluid responsiveness (AUROC 0.74 [95% CI, 0.60-0.84] vs 0.68 [0.54-0.80]; P = .30). A PPVCAP >8.6% predicted fluid responsiveness with a sensitivity of 73% (95% CI, 0.54-0.92) and a specificity of 74% (95% CI, 0.55-0.90), whereas a PPVPC >9.5% predicted fluid responsiveness with a sensitivity of 62% (95% CI, 0.42-0.88) and a specificity of 74% (95% CI, 0.48-0.90). When measured before surgery, PPV predicted fluid responsiveness (AUROC PPVCAP = 0.818 [P = .0001]; PPVPC = 0.794 [P = .0007]) but not when measured after surgery (AUROC PPVCAP = 0.645 [P = .19]; PPVPC = 0.552 [P = .63]). A Bland-Altman analysis of COCAP and COTD showed a mean bias of 0.3 L/min (limits of agreement: -2.8 to 3.3 L/min) and a percentage error of 60%. The concordance rate, corresponding to the proportion of CO values that changed in the same direction with the 2 methods, was poor (71%, 95% CI, 66-77). CONCLUSIONS In patients undergoing cardiac surgery, PPVCAP and PPVPC both weakly predict fluid responsiveness. However, COCAP is not a good substitute for COTD and cannot be used to assess fluid responsiveness.
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Affiliation(s)
| | | | | | | | | | | | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, Irvine, California
| | - Olivier Desebbe
- Departments of Anesthesiology and Intensive Care, Clinique de la Sauvegarde, Lyon, France
- Université Lyon 1, EA4169, SFR Lyon-Est Santé - INSERM US 7- CNRS UMS 3453, Lyon, France
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Cholley B. Echocardiography in the intensive care unit: beyond "eyeballing". A plea for the broader use of the aortic velocity-time integral measurement. Intensive Care Med 2019; 45:898-901. [PMID: 30997543 DOI: 10.1007/s00134-019-05618-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 04/06/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Bernard Cholley
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, AP-HP, 20 rue Leblanc, 75015, Paris, France.
- Université PAris Descartes, Sorbonne Paris Cité, Paris, France.
- Unité INSERM UMR_S1140, Paris, France.
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Geri G, Vignon P, Aubry A, Fedou AL, Charron C, Silva S, Repessé X, Vieillard-Baron A. Cardiovascular clusters in septic shock combining clinical and echocardiographic parameters: a post hoc analysis. Intensive Care Med 2019; 45:657-667. [PMID: 30888443 DOI: 10.1007/s00134-019-05596-z] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/06/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Mechanisms of circulatory failure are complex and frequently intricate in septic shock. Better characterization could help to optimize hemodynamic support. METHODS Two published prospective databases from 12 different ICUs including echocardiographic monitoring performed by a transesophageal route at the initial phase of septic shock were merged for post hoc analysis. Hierarchical clustering in a principal components approach was used to define cardiovascular phenotypes using clinical and echocardiographic parameters. Missing data were imputed. FINDINGS A total of 360 patients (median age 64 [55; 74]) were included in the analysis. Five different clusters were defined: patients well resuscitated (cluster 1, n = 61, 16.9%) without left ventricular (LV) systolic dysfunction, right ventricular (RV) failure or fluid responsiveness, patients with LV systolic dysfunction (cluster 2, n = 64, 17.7%), patients with hyperkinetic profile (cluster 3, n = 84, 23.3%), patients with RV failure (cluster 4, n = 81, 22.5%) and patients with persistent hypovolemia (cluster 5, n = 70, 19.4%). Day 7 mortality was 9.8%, 32.8%, 8.3%, 27.2%, and 23.2%, while ICU mortality was 21.3%, 50.0%, 23.8%, 42.0%, and 38.6% in clusters 1, 2, 3, 4, and 5, respectively (p < 0.001 for both). CONCLUSION Our clustering approach on a large population of septic shock patients, based on clinical and echocardiographic parameters, was able to characterize five different cardiovascular phenotypes. How this could help physicians to optimize hemodynamic support should be evaluated in the future.
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Affiliation(s)
- Guillaume Geri
- Medical-Surgical Intensive Care Unit, Ambroise Paré University Hospital, APHP, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France.,UFR des Sciences de la Santé Simone Veil, Université Versailles Saint Quentin, Versailles, France.,INSERM UMR1018, Team Kidney and Heart, CESP, Villejuif, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, Limoges University Hospital, Limoges, France.,Faculty of Medicine, University of Limoges, Limoges, France.,INSERM CIC 1435, Limoges University Hospital, Limoges, France
| | - Alix Aubry
- Medical-Surgical Intensive Care Unit, Ambroise Paré University Hospital, APHP, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France.,UFR des Sciences de la Santé Simone Veil, Université Versailles Saint Quentin, Versailles, France
| | - Anne-Laure Fedou
- Medical-Surgical Intensive Care Unit, Limoges University Hospital, Limoges, France
| | - Cyril Charron
- Medical-Surgical Intensive Care Unit, Ambroise Paré University Hospital, APHP, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France
| | - Stein Silva
- Medical-Surgical Intensive Care Unit, Teaching Hospital of Toulouse, Toulouse, France
| | - Xavier Repessé
- Medical-Surgical Intensive Care Unit, Ambroise Paré University Hospital, APHP, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France
| | - Antoine Vieillard-Baron
- Medical-Surgical Intensive Care Unit, Ambroise Paré University Hospital, APHP, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France. .,UFR des Sciences de la Santé Simone Veil, Université Versailles Saint Quentin, Versailles, France. .,INSERM UMR1018, Team Kidney and Heart, CESP, Villejuif, France.
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Ding X, Liu DW, Cao YG, Zhang HM, Chen H, Zhao H, Wang XT. Ten Things to be Considered in Practicing Critical Care Echocardiography. Chin Med J (Engl) 2018; 131:1738-1743. [PMID: 29998895 PMCID: PMC6048937 DOI: 10.4103/0366-6999.235868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Xin Ding
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yan-Gong Cao
- Department of Critical Care Medicine, Hua Xin Hospital First Hospital of Tsinghua University, Beijing 100016, China
| | - Hong-Min Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Huan Chen
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Hua Zhao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xiao-Ting Wang
- 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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Kovarnik T, Navratil M, Belohlavek J, Mlcek M, Chval M, Chen Z, Jerabek S, Kittnar O, Linhart A. Validation of new marker of fluid responsiveness based on Doppler assessment of blood flow velocity in superior vena cava in mechanically ventilated pigs. Intensive Care Med Exp 2018; 6:36. [PMID: 30251225 PMCID: PMC6153205 DOI: 10.1186/s40635-018-0199-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 09/07/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We studied a novel approach for the evaluation and management of volemia: minimally invasive monitoring of respiratory blood flow variations in the superior vena cava (SVC). We performed an experiment with 10 crossbred (Landrace × large white) female pigs (Sus scrofa domestica). METHODS Hypovolemia was induced by bleeding from a femoral artery, in six stages. This was followed by blood return and then an infusion of 1000 ml saline, resulting in hypervolemia. Flow in the SVC was measured by Flowire (Volcano corp., USA), located in a distal channel of a triple-lumen central venous catheter. The key parameters measured were venous return variation index (VRV)-a new index for fluid responsiveness, calculated from the maximal and minimal velocity time intervals during controlled ventilation-and systolic peak velocity (defined as peak velocity of a systolic wave using the final end-expiratory beat). A Swan-Ganz catheter (Edwards Lifesciences, USA) was introduced into the pulmonary artery to measure pulmonary arterial pressure, pulmonary capillary wedge pressure, and continuous cardiac output measurements, using the Vigilance monitor (Edwards Lifesciences, USA). RESULTS We analyzed 44 VRV index measurements during defined hemodynamic status events. The curves of VRV indexes for volume responders and volume non-responders intersected at a VRV value of 27, with 10% false negativity and 2% false positivity. We compared the accuracy of VRV and pulse pressure variations (PPV) for separation of fluid responders and fluid non-responders using receiver operating characteristic (ROC) curves. VRV was better (AUCROC 0.96) than PPV (AUCROC 0.85) for identification of fluid responders. The VRV index exhibited the highest relative change during both hypovolemia and hypervolemia, compared to standard hemodynamic measurement. CONCLUSIONS The VRV index provides a real-time method for continuous assessment of fluid responsiveness. It combines the advantages of echocardiography-based methods with a direct and continuous assessment of right ventricular filling during mechanical ventilation.
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Affiliation(s)
- Tomas Kovarnik
- 2nd Department of Internal Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic. .,II. interni klinika VFN a 1.LF UK, U nemocnice 2, 128 08, Praha 2, Czech Republic.
| | - Miroslav Navratil
- 2nd Department of Internal Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Jan Belohlavek
- 2nd Department of Internal Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Mikulas Mlcek
- Department of Physiology, 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Martin Chval
- Institute for Research and Development of Education, Faculty of Education, Charles University in Prague, Prague, Czech Republic
| | - Zhi Chen
- Department of Electrical and Computer Engineering and Iowa Institute for Biomedical Imaging, The University of Iowa, Iowa City, IA, USA
| | - Stepan Jerabek
- 2nd Department of Internal Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Otomar Kittnar
- Department of Physiology, 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Ales Linhart
- 2nd Department of Internal Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
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Moitra VK, Einav S, Thies KC, Nunnally ME, Gabrielli A, Maccioli GA, Weinberg G, Bannerjee A, Ruetzler K, Dobson G, McEvoy M, O’Connor MF. Cardiac Arrest in the Operating Room. Anesth Analg 2018; 127:e49-e50. [DOI: 10.1213/ane.0000000000003552] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bloomstone JA, Nathanson BH, McGee WT. Dynamic Indices: Use With Caution in Spontaneously Breathing Patients. Anesth Analg 2018; 127:e47-e48. [PMID: 30044298 DOI: 10.1213/ane.0000000000003550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Joshua A Bloomstone
- Envision Physician Services, Plantation, Florida, OptiStatim, LLC, Longmeadow, Massachusetts University of Massachusetts Medical School, Baystate Medical Center, Springfield, Massachusetts
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Huang SJ, Nalos M, Smith L, Rajamani A, McLean AS. The use of echocardiographic indices in defining and assessing right ventricular systolic function in critical care research. Intensive Care Med 2018; 44:868-883. [PMID: 29789861 DOI: 10.1007/s00134-018-5211-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/05/2018] [Indexed: 01/25/2023]
Abstract
PURPOSE Many echocardiographic indices (or methods) for assessing right ventricular (RV) function are available, but each has its strengths and limitations. In some cases, there might be discordance between the indices. We conducted a systematic review to audit the echocardiographic RV assessments in critical care research to see if a consistent pattern existed. We specifically looked into the kind and number of RV indices used, and how RV dysfunction was defined in each study. METHODS Studies conducted in critical care settings and reported echocardiographic RV function indices from 1997 to 2017 were searched systematically from three databases. Non-adult studies, case reports, reviews and secondary studies were excluded. These studies' characteristics and RV indices reported were summarized. RESULTS Out of 495 non-duplicated publications found, 81 studies were included in our systematic review. There has been an increasing trend of studying RV function by echocardiography since 2001, and most were conducted in ICU. Thirty-one studies use a single index, mostly TAPSE, to define RV dysfunction; 33 used composite indices and the combinations varied between studies. Seventeen studies did not define RV dysfunction. For those using composite indices, many did not explain their choices. CONCLUSIONS TAPSE seemed to be the most popular index in the last 2-3 years. Many studies used combinations of indices but, apart from cor pulmonale, we could not find a consistent pattern of RV assessment and definition of RV dysfunction amongst these studies.
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Affiliation(s)
- Stephen J Huang
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
| | - Marek Nalos
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Louise Smith
- Cardiovascular Ultrasound Laboratory, Intensive Care Unit, Nepean Hospital, Sydney, NSW, Australia
| | - Arvind Rajamani
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Anthony S McLean
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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Vieillard-Baron A, Naeije R, Haddad F, Bogaard HJ, Bull TM, Fletcher N, Lahm T, Magder S, Orde S, Schmidt G, Pinsky MR. Diagnostic workup, etiologies and management of acute right ventricle failure : A state-of-the-art paper. Intensive Care Med 2018; 44:774-790. [PMID: 29744563 DOI: 10.1007/s00134-018-5172-2] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 04/07/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This is a state-of-the-art article of the diagnostic process, etiologies and management of acute right ventricular (RV) failure in critically ill patients. It is based on a large review of previously published articles in the field, as well as the expertise of the authors. RESULTS The authors propose the ten key points and directions for future research in the field. RV failure (RVF) is frequent in the ICU, magnified by the frequent need for positive pressure ventilation. While no universal definition of RVF is accepted, we propose that RVF may be defined as a state in which the right ventricle is unable to meet the demands for blood flow without excessive use of the Frank-Starling mechanism (i.e. increase in stroke volume associated with increased preload). Both echocardiography and hemodynamic monitoring play a central role in the evaluation of RVF in the ICU. Management of RVF includes treatment of the causes, respiratory optimization and hemodynamic support. The administration of fluids is potentially deleterious and unlikely to lead to improvement in cardiac output in the majority of cases. Vasopressors are needed in the setting of shock to restore the systemic pressure and avoid RV ischemia; inotropic drug or inodilator therapies may also be needed. In the most severe cases, recent mechanical circulatory support devices are proposed to unload the RV and improve organ perfusion CONCLUSION: RV function evaluation is key in the critically-ill patients for hemodynamic management, as fluid optimization, vasopressor strategy and respiratory support. RV failure may be diagnosed by the association of different devices and parameters, while echocardiography is crucial.
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Affiliation(s)
- Antoine Vieillard-Baron
- Service de Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France.
- INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France.
| | - R Naeije
- Professor Emeritus at the Université Libre de Bruxelles, Brussels, Belgium
| | - F Haddad
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford, USA
| | - H J Bogaard
- Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - T M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - N Fletcher
- Department of Cardiothoracic Critical Care, St Georges University Hospital NHS Trust, London, SW17 0QT, UK
| | - T Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - S Magder
- Department of Critical Care, McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - S Orde
- Intensive Care Unit, Nepean Hospital, Kingswood, Sydney, NSW, Australia
| | - G Schmidt
- Department of Internal Medicine and Critical Care, University of Iowa, Iowa City, USA
| | - M R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
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Alternatives to the Swan–Ganz catheter. Intensive Care Med 2018; 44:730-741. [DOI: 10.1007/s00134-018-5187-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/18/2018] [Indexed: 12/12/2022]
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Abstract
PURPOSE OF REVIEW It has recently become evident that administration of intravenous fluids following initial resuscitation has a greater probability of producing tissue edema and hypoxemia than of increasing oxygen delivery. Therefore, it is essential to have a rational approach to assess the adequacy of volume resuscitation. Here we review passive leg raising (PLR) and respiratory variation in hemodynamics to assess fluid responsiveness. RECENT FINDINGS The use of ultrasound enhances the clinician's ability to detect and predict fluid responsiveness, whereas enthusiasm for this modality must be tempered by recent evidence that it is only reliable in apneic patients. SUMMARY The best predictor of fluid response for hypotensive patients not on vasopressors is a properly conducted passive leg raise maneuver. For more severely ill patients who are apneic, mechanically ventilated and on vasopressors, point of care echocardiography is the best choice. Increases in vena caval diameter induced by controlled positive pressure breaths are insensitive to arrhythmias and can be performed with relatively brief training. Most challenging are patients who are awake and on vasopressors; we suggest that the best method to discriminate fluid responders is PLR measuring changes in cardiac output.
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Assessment of the effects of inspiratory load on right ventricular function. Curr Opin Crit Care 2018; 22:254-9. [PMID: 27054626 DOI: 10.1097/mcc.0000000000000303] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The right ventricle (RV) plays a pivotal role during respiratory failure because of its high sensitivity to small loading changes during inspiration. Both RVs, preload and afterload, are altered during inspiration, either in spontaneous breathing or during mechanical ventilation. Some clinical situations especially affect RV load during inspiration, for example acute asthma and acute respiratory distress syndrome. The aim of this review is to explain and to summarize the different mechanisms leading to RV failure in these situations. RECENT FINDINGS Research has recently reemphasized the importance to well known physiology of the venous return which is a contributor of RV preload. Authors recently focused on the mean systemic filling pressure which is one of the determinants of venous return. Venous return may change in opposite direction according to the type of ventilation (spontaneous or assisted). Recent works have also demonstrated the crucial impact of lung inflation and driving pressure on RV afterload, and have confirmed the deleterious effect of severe RV failure, described as acute cor pulmonale. In most situations of RV overload induced by inspiration, significant pulse pressure variations are observed, either called 'pulsus paradoxus' in spontaneously breathing patients or 'reverse pulsus paradoxus' in mechanically ventilated patients. SUMMARY RV is very sensitive to abnormal inspiration, which is always responsible for an increase in its afterload. Pulse pressure variations, central venous pressure and especially echocardiography may monitor RV function in abnormal clinical situations. The pulmonary artery catheter was also proposed although now less used.
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Garcia-Montilla R, Imam F, Miao M, Stinson K, Khan A, Heitner S. Optimal right heart filling pressure in acute respiratory distress syndrome determined by strain echocardiography. Echocardiography 2018. [PMID: 28631361 DOI: 10.1111/echo.13546] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Right ventricular (RV) systolic dysfunction is common in acute respiratory distress syndrome (ARDS). While preload optimization is crucial in its management, dynamic fluid responsiveness indices lack reliability, and there is no consensus on target central venous pressure (CVP). We analyzed the utility of RV free wall longitudinal strain (RVFWS) in the estimation of optimal RV filling pressure in ARDS. METHODS A retrospective cross-sectional analysis of clinical data and echocardiograms of patients with ARDS was performed. Tricuspid annular plane systolic excursion (TAPSE), tricuspid peak systolic velocity (S'), RV fractional area change (RVFAC), RVFWS, CVP, systolic pulmonary artery pressure (SPAP), and left ventricular ejection fraction (LVEF) were measured. RESULTS Fifty-one patients with moderate-severe ARDS were included. There were inverse correlations between CVP and TAPSE, S', RVFAC, RVFWS, and LVEF. The most significant was with RVFWS (r:.74, R2 :.55, P:.00001). Direct correlations with creatinine and lactate were noted. Receiver operating characteristic analysis showed that RVFWS -21% (normal reference value) was associated with CVP: 13 mm Hg (AUC: 0.92, 95% CI: 0.83-1.00). Regression model analysis of CVP, and RVFWS interactions established an RVFWS range from -18% to -24%. RVFWS -24% corresponded to CVP: 11 mm Hg and RVFWS -18% to CVP: 15 mm Hg. Beyond a CVP of 15 mm Hg, biventricular systolic dysfunction rapidly ensues. CONCLUSIONS Our data are the first to show that an RV filling pressure of 13±2 mm Hg-as by CVP-correlates with optimal RV mechanics as evaluated by strain echocardiography in patients with moderate-severe ARDS.
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Affiliation(s)
- Romel Garcia-Montilla
- Department of Trauma Surgery and Surgical Critical Care, Marshfield Clinic, Marshfield, WI, USA.,Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Faryal Imam
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Mi Miao
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Kathryn Stinson
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Akram Khan
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Stephen Heitner
- Knight Cardiovascular Institute, Clinical Echocardiography, Oregon Health and Science University, Portland, OR, USA
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Noel-Morgan J, Muir WW. Anesthesia-Associated Relative Hypovolemia: Mechanisms, Monitoring, and Treatment Considerations. Front Vet Sci 2018; 5:53. [PMID: 29616230 PMCID: PMC5864866 DOI: 10.3389/fvets.2018.00053] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/02/2018] [Indexed: 12/14/2022] Open
Abstract
Although the utility and benefits of anesthesia and analgesia are irrefutable, their practice is not void of risks. Almost all drugs that produce anesthesia endanger cardiovascular stability by producing dose-dependent impairment of cardiac function, vascular reactivity, and compensatory autoregulatory responses. Whereas anesthesia-related depression of cardiac performance and arterial vasodilation are well recognized adverse effects contributing to anesthetic risk, far less emphasis has been placed on effects impacting venous physiology and venous return. The venous circulation, containing about 65–70% of the total blood volume, is a pivotal contributor to stroke volume and cardiac output. Vasodilation, particularly venodilation, is the primary cause of relative hypovolemia produced by anesthetic drugs and is often associated with increased venous compliance, decreased venous return, and reduced response to vasoactive substances. Depending on factors such as patient status and monitoring, a state of relative hypovolemia may remain clinically undetected, with impending consequences owing to impaired oxygen delivery and tissue perfusion. Concurrent processes related to comorbidities, hypothermia, inflammation, trauma, sepsis, or other causes of hemodynamic or metabolic compromise, may further exacerbate the condition. Despite scientific and technological advances, clinical monitoring and treatment of relative hypovolemia still pose relevant challenges to the anesthesiologist. This short perspective seeks to define relative hypovolemia, describe the venous system’s role in supporting normal cardiovascular function, characterize effects of anesthetic drugs on venous physiology, and address current considerations and challenges for monitoring and treatment of relative hypovolemia, with focus on insights for future therapies.
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Affiliation(s)
- Jessica Noel-Morgan
- Center for Cardiovascular & Pulmonary Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - William W Muir
- QTest Labs, Columbus, OH, United States.,College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
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Rousset D, Riu-Poulenc B, Silva S. Monitorage hémodynamique dans le SDRA : que savoir en 2018. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Environ deux tiers des patients atteints de syndrome de détresse respiratoire aiguë (SDRA) présenteront une instabilité hémodynamique avec recours aux vasopresseurs. Sous ventilation mécanique, la diminution de précharge du ventricule droit (VD) suite à l’augmentation de la pression pleurale et l’augmentation de la postcharge du VD secondaire à l’élévation de la pression transpulmonaire seront des phénomènes exacerbés en cas de SDRA. Les risques encourus sont une diminution du débit cardiaque global et l’évolution vers un cœur pulmonaire aigu (CPA). Le contrôle de la pression motrice, de la pression expiratoire positive et la lutte contre l’hypoxémie et l’hypercapnie auront un impact autant respiratoire qu’hémodynamique. L’échographie cardiaque tient un rôle central au sein du monitorage hémodynamique au cours du SDRA, à travers l’évaluation du débit cardiaque, des différentes pressions de remplissage intracardiaques et le diagnostic de CPA. Le cathéter artériel pulmonaire est un outil de monitorage complet, indiqué en cas de défaillance cardiaque droite ou hypertension artérielle pulmonaire sévère ; mais le risque d’effets indésirables est élevé. Les moniteurs utilisant la thermodilution transpulmonaire permettent un monitorage du débit cardiaque en temps réel et sont d’une aide précieuse dans l’évaluation du statut volumique. L’évaluation de la précharge dépendance ne doit pas s’effectuer sur les variabilités respiratoires de la pression pulsée ou du diamètre des veines caves, mais à travers l’épreuve de lever de jambe passif, le test d’occlusion télé-expiratoire ou encore les épreuves de remplissage titrées.
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Bunge JJH, Caliskan K, Gommers D, Reis Miranda D. Right ventricular dysfunction during acute respiratory distress syndrome and veno-venous extracorporeal membrane oxygenation. J Thorac Dis 2018; 10:S674-S682. [PMID: 29732186 DOI: 10.21037/jtd.2017.10.75] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Severe ARDS can be complicated by right ventricular (RV) failure. The etiology of RV failure in ARDS is multifactorial. Vascular alterations, hypoxia, hypercapnia and effects of mechanical ventilation may play a role. Echocardiography has an important role in diagnosing RV failure in ARDS patients. Once extracorporeal membrane oxygenation (ECMO) is indicated in these patients, the right ECMO modus needs to be chosen. In this review, the etiology, diagnosis and management of RV failure in ARDS will be briefly outlined. The beneficial effect of veno-venous (VV) ECMO on RV function in these patients will be illustrated. Based on this, we will give recommendations regarding choice of ECMO modus and provide an algorithm for management of RV failure in VV ECMO supported patients.
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Affiliation(s)
- Jeroen J H Bunge
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Dinis Reis Miranda
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Yonis H, Bitker L, Aublanc M, Perinel Ragey S, Riad Z, Lissonde F, Louf-Durier A, Debord S, Gobert F, Tapponnier R, Guérin C, Richard JC. Change in cardiac output during Trendelenburg maneuver is a reliable predictor of fluid responsiveness in patients with acute respiratory distress syndrome in the prone position under protective ventilation. Crit Care 2017; 21:295. [PMID: 29208025 PMCID: PMC5718075 DOI: 10.1186/s13054-017-1881-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/31/2017] [Indexed: 11/10/2022] Open
Abstract
Background Predicting fluid responsiveness may help to avoid unnecessary fluid administration during acute respiratory distress syndrome (ARDS). The aim of this study was to evaluate the diagnostic performance of the following methods to predict fluid responsiveness in ARDS patients under protective ventilation in the prone position: cardiac index variation during a Trendelenburg maneuver, cardiac index variation during an end-expiratory occlusion test, and both pulse pressure variation and change in pulse pressure variation from baseline during a tidal volume challenge by increasing tidal volume (VT) to 8 ml.kg-1. Methods This study is a prospective single-center study, performed in a medical intensive care unit, on ARDS patients with acute circulatory failure in the prone position. Patients were studied at baseline, during a 1-min shift to the Trendelenburg position, during a 15-s end-expiratory occlusion, during a 1-min increase in VT to 8 ml.kg-1, and after fluid administration. Fluid responsiveness was deemed present if cardiac index assessed by transpulmonary thermodilution increased by at least 15% after fluid administration. Results There were 33 patients included, among whom 14 (42%) exhibited cardiac arrhythmia at baseline and 15 (45%) were deemed fluid-responsive. The area under the receiver operating characteristic (ROC) curve of the pulse contour-derived cardiac index change during the Trendelenburg maneuver and the end-expiratory occlusion test were 0.90 (95% CI, 0.80–1.00) and 0.65 (95% CI, 0.46–0.84), respectively. An increase in cardiac index ≥ 8% during the Trendelenburg maneuver enabled diagnosis of fluid responsiveness with sensitivity of 87% (95% CI, 67–100), and specificity of 89% (95% CI, 72–100). The area under the ROC curve of pulse pressure variation and change in pulse pressure variation during the tidal volume challenge were 0.52 (95% CI, 0.24–0.80) and 0.59 (95% CI, 0.31–0.88), respectively. Conclusions Change in cardiac index during a Trendelenburg maneuver is a reliable test to predict fluid responsiveness in ARDS patients in the prone position, while neither change in cardiac index during end-expiratory occlusion, nor pulse pressure variation during a VT challenge reached acceptable predictive performance to predict fluid responsiveness in this setting. Trial registration ClinicalTrials.gov, NCT01965574. Registered on 16 October 2013. The trial was registered 6 days after inclusion of the first patient. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1881-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hodane Yonis
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Laurent Bitker
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Mylène Aublanc
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Sophie Perinel Ragey
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Zakaria Riad
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Floriane Lissonde
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Aurore Louf-Durier
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Sophie Debord
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Florent Gobert
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France
| | - Romain Tapponnier
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université LYON I, Lyon, France.,IMRB, INSERM 955Eq13, Créteil, France
| | - Jean-Christophe Richard
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. .,Université de Lyon, Université LYON I, Lyon, France. .,CREATIS INSERM 1044 CNRS 5220, Villeurbanne, France.
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Acute Right Ventricular Dysfunction in Intensive Care Unit. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8217105. [PMID: 29201914 PMCID: PMC5671685 DOI: 10.1155/2017/8217105] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/13/2017] [Accepted: 09/18/2017] [Indexed: 02/07/2023]
Abstract
The role of the left ventricle in ICU patients with circulatory shock has long been considered. However, acute right ventricle (RV) dysfunction causes and aggravates many common critical diseases (acute respiratory distress syndrome, pulmonary embolism, acute myocardial infarction, and postoperative cardiac surgery). Several supportive therapies, including mechanical ventilation and fluid management, can make RV dysfunction worse, potentially exacerbating shock. We briefly review the epidemiology, pathophysiology, diagnosis, and recommendations to guide management of acute RV dysfunction in ICU patients. Our aim is to clarify the complex effects of mechanical ventilation, fluid therapy, vasoactive drug infusions, and other therapies to resuscitate the critical patient optimally.
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48
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Jeong DM, Ahn HJ, Park HW, Yang M, Kim JA, Park J. Stroke Volume Variation and Pulse Pressure Variation Are Not Useful for Predicting Fluid Responsiveness in Thoracic Surgery. Anesth Analg 2017; 125:1158-1165. [DOI: 10.1213/ane.0000000000002056] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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49
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Garijo JM, Mashari A, Meineri M. Role of Transesophageal Echocardiography in General Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0221-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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50
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Vignon P, Begot E, Mari A, Silva S, Chimot L, Delour P, Vargas F, Filloux B, Vandroux D, Jabot J, François B, Pichon N, Clavel M, Levy B, Slama M, Riu-Poulenc B. Hemodynamic Assessment of Patients With Septic Shock Using Transpulmonary Thermodilution and Critical Care Echocardiography: A Comparative Study. Chest 2017; 153:55-64. [PMID: 28866112 DOI: 10.1016/j.chest.2017.08.022] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/28/2017] [Accepted: 08/01/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND To assess the agreement between transpulmonary thermodilution (TPT) and critical care echocardiography (CCE) in ventilated patients with septic shock. METHODS Ventilated patients in sinus rhythm requiring advanced hemodynamic assessment for septic shock were included in this prospective multicenter descriptive study. Patients were assessed successively using TPT and CCE in random order. Data were interpreted independently at bedside by two investigators who proposed therapeutic changes on the basis of predefined algorithms. TPT and CCE hemodynamic assessments were reviewed offline by two independent experts who identified potential sources of discrepant results by consensus. Lactate clearance and outcome were studied. RESULTS A total of 137 patients were studied (71 men; age, 61 ± 15 years; Simplified Acute Physiologic Score, 58 ± 18; Sequential Organ Failure Assessment, 10 ± 3). TPT and CCE interpretations at bedside were concordant in 87/132 patients (66%) without acute cor pulmonale (ACP), resulting in a moderate agreement (kappa, 0.48; 95% CI, 0.37-0.60). Experts' adjudications were concordant in 100/129 patients without ACP (77.5%), resulting in a good intertechnique agreement (kappa, 0.66; 95% CI, 0.55-0.77). In addition to ACP (n = 8), CCE depicted a potential source of TPT inaccuracy in 8/29 patients (28%). Lactate clearance at H6 was similar irrespective of the concordance of online interpretations of TPT and CCE (55/84 [65%] vs 32/45 [71%], P = .55). ICU and day 28 mortality rates were similar between patients with concordant and discordant interpretations (29/87 [36%] vs 13/45 [29%], P = .60; and 31/87 [36%] vs 16/45 [36%], P = .99, respectively). CONCLUSIONS Agreement between TPT and CCE was moderate when interpreted at bedside and good when adjudicated offline by experts, but without impact on lactate clearance and mortality.
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Affiliation(s)
- Philippe Vignon
- Medical-surgical Intensive Care Unit, Teaching Hospital of Limoges, Limoges, France; INSERM CIC 1435, Teaching Hospital of Limoges, Limoges, France.
| | - Emmanuelle Begot
- Medical-surgical Intensive Care Unit, Teaching Hospital of Limoges, Limoges, France; INSERM CIC 1435, Teaching Hospital of Limoges, Limoges, France
| | - Arnaud Mari
- Medical-Surgical Intensive Care Unit, Teaching Hospital of Toulouse, Toulouse, France
| | - Stein Silva
- Medical-Surgical Intensive Care Unit, Teaching Hospital of Toulouse, Toulouse, France
| | - Loïc Chimot
- Medical Intensive Care Unit, Hospital of Périgueux, Périgueux, France
| | - Pierre Delour
- Medical Intensive Care Unit, Hospital of Périgueux, Périgueux, France
| | - Frédéric Vargas
- Medical Intensive Care Unit, Teaching Hospital of Bordeaux, Bordeaux, France
| | - Bruno Filloux
- Medical Intensive Care Unit, Teaching Hospital of Bordeaux, Bordeaux, France
| | - David Vandroux
- Medical-Surgical Intensive Care Unit, Teaching Hospital of La Réunion, La Réunion, France
| | - Julien Jabot
- Medical-Surgical Intensive Care Unit, Teaching Hospital of La Réunion, La Réunion, France
| | - Bruno François
- Medical-surgical Intensive Care Unit, Teaching Hospital of Limoges, Limoges, France; INSERM CIC 1435, Teaching Hospital of Limoges, Limoges, France
| | - Nicolas Pichon
- Medical-surgical Intensive Care Unit, Teaching Hospital of Limoges, Limoges, France; INSERM CIC 1435, Teaching Hospital of Limoges, Limoges, France
| | - Marc Clavel
- Medical-surgical Intensive Care Unit, Teaching Hospital of Limoges, Limoges, France; INSERM CIC 1435, Teaching Hospital of Limoges, Limoges, France
| | - Bruno Levy
- Medical Intensive Care Unit, Teaching Hospital of Nancy, Nancy, France
| | - Michel Slama
- Medical Intensive Care Unit, Teaching Hospital of Amiens, Amiens, France
| | - Béatrice Riu-Poulenc
- Medical-Surgical Intensive Care Unit, Teaching Hospital of Toulouse, Toulouse, France
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